Non-Surgical Treatment of Achilles Rupture: Does Duration in Functional Weight Bearing Orthosis Matter?

Abstract

Background:
The treatment of acute Achilles tendon ruptures is continually being debated. The success of non-surgical regimes is now evident yet there remains a high rate of surgery in the United States of America and Scandinavia. Recent studies have investigated functional outcome rather than complication rates as primary outcome but the current data are still sparse. We aimed to investigate whether there is any difference in functional outcomes between two dynamic regimes of differing durations for acute Achilles tendon ruptures.

Methods:
The patients in the two groups were matched for age, gender, follow-up duration and mechanism of injury. Forty-four patients were managed in a regime of 11 weeks and another 44 patients for 8 weeks. Demographics, injury details, complications and functional outcome were recorded. The validated Achilles Tendon Rupture Score (ATRS) was used to assess functional outcomes. Minimum follow-up was 1 year.

Results:
The 11-week group had a mean age of 50.8 years (range: 27-80) with 36 (82%) males. The 8-week group had a mean age of 52.0 years (range: 32-77) with 36 (82%) males. The mean ATRS for the 11-week group was 76.0 (range: 8-100). The mean ATRS for the 8-week group was 76.1 (range: 30-100). There were no re-ruptures in the 11-week group and one in the 8-week group. There were three episodes of venous thromboembolism in the 11-week group and four in the 8-week group.

Conclusion:
A reduction in duration of dynamic rehabilitation for non-operative treatment of Achilles tendon rupture from 11 weeks to 8 weeks does not lead to a significant detriment in functional outcomes or complication rates.

Full text

Non-surgical
treatment
of
Achilles
rupture:
Does
duration
in
functional
weight
bearing
orthosis
matter?
Randeep
Aujla
MBChB*,
Amit
Kumar,
Maneesh
Bhatia
Trauma
&
Orthopaedic
Surgery,
University
Hospitals
of
Leicester,
Leicester,
United
Kingdom
1.
Introduction
The
Achilles
tendon
(AT)
remains
the
commonest
tendon
ruptured,
particularly
following
sporting
activity,
and
the
inci-
dence
of
acute
rupture
is
rising
[11,21,25].
The
treatment
of
such
injuries
continues
to
create
debate
with
the
main
decision
algorithm
between
surgical
or
non-surgical
treatment
methods,
albeit
with
recent
trends
away
from
operative
repair
for
acute
primary
ruptures
[12,24,39].
Following
non-surgical
management
there
is
a
plethora
of
treatment
protocols,
each
being
individual-
ised
to
surgeon,
department
or
hospital.
Studies
have
previously
looked
at
surgery
versus
non-surgical
regimes,
use
of
cast
immobilisation
versus
functional
orthosis
and
whether
to
allow
early
weight
bearing
or
not
[5,17,20,37,38].
Overall
no
consensus
has
been
reached
upon
an
ideal
treatment
protocol
but
recent
studies
have
shown
promising
results
from
immediate
weight
bearing
non-surgical
methods
in
functional
rehabilitation
[2,4].
De-
spite
this
there
remains
a
high
rate
of
surgery
in
United
States
of
America
and
Scandinavia
[3].
Systematic
reviews
have
shown
that
overall
complication
rates
are
lower
in
non-surgically
managed
AT
ruptures
compared
to
surgically
treated
AT
ruptures
[20].
Non-surgical
treatment
has
the
benefits
of
avoiding
operative
risks
including
skin
breakdown,
infection
and
nerve
damage.
The
reduced
overall
complication
rate
of
non-surgically
treated
AT
ruptures
is
offset
by
previously
documented
higher
re-rupture
rates.
However,
a
recent
meta-
analysis
showed
no
difference
in
re-rupture
rate
between
surgery
plus
postoperative
functional
bracing
(5%)
and
the
sub-group
of
patients
treated
in
non-operative
accelerated
rehabilitation
regimes
(8%)
[14].
Many
functional
methods
have
been
tried
and
tested
with
varying
devices
and
regimes
[17,19,33].
A
Cochrane
review
demonstrated
that
patients
treated
with
Foot
and
Ankle
Surgery
xxx
(2015)
xxx–xxx
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
8
July
2015
Received
in
revised
form
1
November
2015
Accepted
7
November
2015
Keywords:
Achilles
tendon
Rehabilitation
Non-surgical
A
B
S
T
R
A
C
T
Background:
The
treatment
of
acute
Achilles
tendon
ruptures
is
continually
being
debated.
The
success
of
non-surgical
regimes
is
now
evident
yet
there
remains
a
high
rate
of
surgery
in
the
United
States
of
America
and
Scandinavia.
Recent
studies
have
investigated
functional
outcome
rather
than
complication
rates
as
primary
outcome
but
the
current
data
are
still
sparse.
We
aimed
to
investigate
whether
there
is
any
difference
in
functional
outcomes
between
two
dynamic
regimes
of
differing
durations
for
acute
Achilles
tendon
ruptures.
Methods:
The
patients
in
the
two
groups
were
matched
for
age,
gender,
follow-up
duration
and
mechanism
of
injury.
Forty-four
patients
were
managed
in
a
regime
of
11
weeks
and
another
44
patients
for
8
weeks.
Demographics,
injury
details,
complications
and
functional
outcome
were
recorded.
The
validated
Achilles
Tendon
Rupture
Score
(ATRS)
was
used
to
assess
functional
outcomes.
Minimum
follow-up
was
1
year.
Results:
The
11-week
group
had
a
mean
age
of
50.8
years
(range:
27–80)
with
36
(82%)
males.
The
8-
week
group
had
a
mean
age
of
52.0
years
(range:
32–77)
with
36
(82%)
males.
The
mean
ATRS
for
the
11-
week
group
was
76.0
(range:
8–100).
The
mean
ATRS
for
the
8-week
group
was
76.1
(range:
30–100).
There
were
no
re-ruptures
in
the
11-week
group
and
one
in
the
8-week
group.
There
were
three
episodes
of
venous
thromboembolism
in
the
11-week
group
and
four
in
the
8-week
group.
Conclusion:
A
reduction
in
duration
of
dynamic
rehabilitation
for
non-operative
treatment
of
Achilles
tendon
rupture
from
11
weeks
to
8
weeks
does
not
lead
to
a
significant
detriment
in
functional
outcomes
or
complication
rates.
!
2015
European
Foot
and
Ankle
Society.
Published
by
Elsevier
Ltd.
All
rights
reserved.
*Corresponding
author.
E-mail
address:
Randeep.aujla@hotmail.co.uk
(R.
Aujla).
G
Model
FAS-873;
No.
of
Pages
5
Please
cite
this
article
in
press
as:
Aujla
R,
et
al.
Non-surgical
treatment
of
Achilles
rupture:
Does
duration
in
functional
weight
bearing
orthosis
matter?
Foot
Ankle
Surg
(2015),
http://dx.doi.org/10.1016/j.fas.2015.11.003
Contents
lists
available
at
ScienceDirect
Foot
and
Ankle
Surgery
jou
r
nal
h
o
mep
age:
w
ww.els
evier
.co
m/lo
c
ate/fas
http://dx.doi.org/10.1016/j.fas.2015.11.003
1268-7731/!
2015
European
Foot
and
Ankle
Society.
Published
by
Elsevier
Ltd.
All
rights
reserved.

functional
bracing
fared
better
with
regards
to
less
time
off
work
and
quicker
return
to
sporting
activities
when
compared
with
plaster
cast
treatment
[19].
In
addition
to
this
functional
treatment
with
an
orthosis
is
more
work
and
lifestyle
compatible
[9,36].
De-
spite
the
attention
upon
functional
outcomes
following
orthopae-
dic
injuries,
recent
meta-analyses
have
focused
on
re-rupture
rate
and
overall
complications
as
outcomes
rather
than
the
functional
results
following
AT
rupture.
To
date,
no
study
has
examined
the
optimum
duration
of
functional
mobilisation
in
a
weight
bearing
orthosis
in
the
management
of
acute
AT
ruptures.
The
purpose
of
our
study
was
to
compare
the
functional
outcome,
in
AT
rupture
patients
treated
non-surgically
with
an
immediate
weight
bearing
func-
tional
orthosis,
using
two
different
regimes.
Our
hypothesis
is
that
there
is
no
difference
in
functional
outcomes
between
rehabilita-
tion
duration
of
11
or
8
weeks
in
an
immediate
weight
bearing
functional
regime
after
a
minimum
of
1-year
follow-up.
2.
Methods
A
departmental
policy
was
implemented
in
January
2010
to
standardise
the
treatment
of
acute
AT
rupture
at
our
hospital.
We
used
the
VACOped
1
walking
boot
orthosis
with
immediate
full
weight
bearing
mobilisation.
Initially
there
was
caution
about
immediate
weight
bearing
in
an
orthosis
so
a
period
of
11
weeks
of
functional
mobilisation
was
used.
A
database
was
created
and
complications
were
recorded
prospectively.
In
February
2011
the
departmental
policy
was
changed
and
the
period
of
functional
mobilisation
was
reduced
to
8
weeks
in
line
with
literature
at
that
time
[27,38].
Both
regimes
are
described
in
detail
in
Table
1.
No
significance
was
given
to
gap
size
between
proximal
and
distal
ends
of
the
tendon
to
ration
whether
operative
or
functional
treatment
was
best.
This
was
due
to
the
limited
knowledge
at
the
time
about
whether
rupture
gap
affects
decision-making.
More
recent
research
has
shown
little
correlation
between
gap
size
and
ATRS
at
1
year
following
AT
rupture
[32].
All
patients
with
a
suspected
AT
rupture
were
assessed
clinically
by
the
Emergency
Department,
placed
into
a
dorsal
plaster
slab
and
referred
to
the
trauma
&
orthopaedic
team
at
the
time
of
presentation.
Patients
usually
attended
within
3
days
but
all
attended
within
1
week.
Clinical
assessment
was
performed
which
included
calf
squeeze
test,
palpation
for
rupture
gap
and
ability
to
singe
heel
raise
on
examination
in
the
orthopaedic
out-
patient
clinic.
If
there
was
any
clinical
doubt
regarding
the
rupture
then
radiological
investigation
(ultrasound
or
MRI)
was
used
to
confirm
diagnosis.
Once
diagnosis
was
confirmed,
by
a
member
of
the
orthopaedic
department,
patients
were
placed
in
the
functional
VACOped
W
orthosis
(Fig.
1)
and
the
treatment
protocol
initiated.
Inclusion
criteria
for
the
study
were
primary
acute
AT
ruptures
(as
defined
by
the
clinical
features
above),
a
minimum
follow
up
of
12
months,
non-operative
treatment,
completed
functional
mobilisation
in
either
VACOped
W
regime
and
completed
ATRS
form.
Patients
were
excluded
if
they
had
a
delayed
presentation
(>1
week)
prior
to
institution
of
treatment,
other
injury
in
same
limb,
poly-trauma,
open
injury
or
underwent
surgical
repair.
Surgical
repair
was
undertaken
for
patients
who
wished
to
have
surgery
despite
counselling
by
a
foot
and
ankle
surgeon
or
if
there
was
a
delay
in
presentation
of
>2
weeks.
During
this
time
period
only
six
patients
underwent
surgical
treatment.
We
used
the
VACOped
W
boot
(Oped
Ag
Ltd,
Germany)
as
the
functional
orthosis
in
all
cases
(Fig.
1).
At
each
time
point
on
return
to
the
clinic,
the
boot
was
removed,
skin
checks
were
made
and
the
liner
was
changed.
Boot
adjustments
were
made
according
to
the
protocol
in
place
by
trained
staff.
All
patients
were
allowed
to
fully
weight-bear
immediately
once
their
orthosis
was
applied.
The
VACOped
W
achieves
stability
via
an
inner
vacuum
cushion
that
conforms
to
the
shape
of
the
leg
by
evacuating
air,
while
the
external
shell
provides
rigidity.
The
boot
can
be
locked
at
a
fixed
degree
(ranging
from
0
to
308)
or
movements
can
be
permitted
within
this
range.
Following
completion
of
the
regime,
patients
returned
for
a
clinical
review
and
their
boot
was
removed.
Clinical
assessment
of
the
AT
was
performed,
and
if
felt
clinically
intact,
patients
were
referred
to
physiotherapy
for
strengthening
exercises.
This
was
the
case
for
all
patients
involved.
The
primary
outcome
measure
was
the
Achilles
tendon
rupture
score
(ATRS).
The
ATRS
questionnaire
was
administered
by
post
a
minimum
of
12
months
after
the
patient’s
regime
was
completed.
The
ATRS
is
a
patient-reported
outcome
measure
developed
by
Nilsson-Helander
in
2007
[29].
It
consists
of
10
questions
based
on
an
11
point
Likert
scale,
where
a
total
score
of
0
is
worst,
and
100
is
best.
This
questionnaire
is
perceived
to
be
the
only
relevant,
validated
patient
reported
outcome
score
for
AT
ruptures
[16].
We
also
prospectively
collected
data
regarding
secondary
outcomes
including
re-ruptures,
venous-thromboembolic
(VTE)
events
or
any
other
significant
complication.
In
total
there
were
88
patients
treated
in
both
regimes
with
the
VACOped
W
boot.
72
(82%)
were
males.
There
were
44
patients
treated
for
11
weeks
prior
to
the
change
in
policy.
Patients
were
only
included
in
analysis
if
they
returned
a
completed
question-
naire.
An
age,
sex
and
injury
mechanism
group
were
identified
from
patients
treated
in
the
8-week
regime.
These
patients
were
then
contacted
to
be
involved
in
the
study.
Table
2
shows
the
patient
demographics
and
mechanism
of
injury
of
all
cases
in
both
groups.
Table
1
A
table
to
show
the
duration
in
weeks
spent
in
each
position
in
the
VACOPed
1
boot
for
both
11-week
and
8-week
regimes.
Regime
308
plantarflexion
(static)
158
plantarflexion
(static)
15–308
(dynamic)
0–308
(dynamic)
11
weeks
(January
2010
to
January
2011)
5
3
2
1
8
weeks
(February
2011
to
February
2012)
4
0
2
2
Fig.
1.
Picture
of
the
VACOped
1
boot
(Oped
Ag
Ltd,
Germany).
R.
Aujla
et
al.
/
Foot
and
Ankle
Surgery
xxx
(2015)
xxx–xxx
2
G
Model
FAS-873;
No.
of
Pages
5
Please
cite
this
article
in
press
as:
Aujla
R,
et
al.
Non-surgical
treatment
of
Achilles
rupture:
Does
duration
in
functional
weight
bearing
orthosis
matter?
Foot
Ankle
Surg
(2015),
http://dx.doi.org/10.1016/j.fas.2015.11.003

2.1.
Statistical
methods
A
sample
size
was
calculated
using
10-points
on
the
ATRS
as
being
significantly
different.
Standard
deviation
from
the
original
study
involving
82
patients
was
21.4
[29].
With
an
alpha
error
of
0.05,
a
power
of
80%
the
minimum
sample
size
was
calculated
to
be
38
per
group.
This
number
was
surpassed
to
ensure
loss
to
follow-
up
did
not
affect
results.
Statistical
analysis
was
performed
using
the
statistical
software
(SPSS
16.0
for
Windows
–
SPSS
Inc.,
IL,
United
States).
Parametric
data
are
presented
as
mean
and
the
independent
Student’s
t-test
was
used
for
analysis.
Statistical
significance
is
defined
as
p
<
0.05.
3.
Results
3.1.
Achilles
tendon
rupture
score
Received
questionnaires
were
all
fully
completed.
Re-rupture
patients
were
excluded
from
the
final
ATRS
calculation.
The
mean
ATRS
in
the
11-week
group
was
76.0
points
(range:
8–100,
44
patients,
SD:
22.3),
and
76.1
in
the
8-week
group
(range:
30–
100,
43
patients,
SD:
22.0).
The
difference
in
scores
between
the
two
groups
was
less
than
one
point
and
this
was
not
statistically
significant
(p
=
0.977;
unpaired
t-test).
In
patients
under
the
age
of
40
there
was
a
mean
ATRS
of
75.5
in
the
8-week
group
and
75.6
in
the
11-week
group,
at
mean
follow-
up
of
2.1
and
2.3
years,
respectively.
This
was
not
statistically
significant
(p
=
0.99;
unpaired
t-test).
There
were
no
re-ruptures
in
these
age
groups.
Table
3
shows
the
sub-group
analysis
for
various
age
groups.
3.2.
Re-rupture
rate
There
were
no
re-ruptures
in
the
11-week
group
and
one
(2.3%)
in
the
8-week
group.
This
difference
was
not
statistically
significant
(p
=
1.0;
Chi-square
test).
The
re-rupture
in
the
8th
week
was
treated
with
surgical
repair
and
had
a
final
ATRS
of
42
at
over
2
years
follow-up.
3.3.
Thromboembolism
In
the
11-week
group
the
venous
thromboembolism
(VTE)
rate
was
6.8%.
In
this
group
there
were
3
episodes
of
deep
vein
thrombosis
(DVT;
all
below
knee)
and
no
pulmonary
emboli
(PE).
All
were
treated
with
anticoagulation
following
input
from
haematology.
The
8-week
group
had
a
venous
VTE
rate
of
9.1%.
In
this
group
there
were
four
episodes
of
DVT
(all
below
knee)
and
no
PE’s.
There
was
no
statistical
significance
between
these
results
(p
=
1.0;
Chi-square
test).
4.
Discussion
We
present
the
comparison
between
two
different
dynamic
rehabilitation
regimes
for
the
non-operative
treatment
of
acute
AT
ruptures
looking
specifically
at
duration
of
the
protocol.
There
was
no
statistical
difference
in
functional
outcomes,
re-rupture
rate
or
VTE
events
between
the
groups
treated
in
a
functional
orthosis
for
11
or
8
weeks.
Historically
AT
ruptures
have
been
treated
in
various
plaster
cast
immobilisation
protocols.
Two
randomised
controlled
trials
have
compared
plaster
cast
alone
versus
plaster
cast
then
bracing
[31,33].
They
trended
towards
a
lower
re-rupture
rate
in
the
functionally
braced
group
but
this
did
not
reach
statistical
significance.
Neither
study
looked
at
functional
outcomes
but
Saleh
et
al.
found
that
patients
preferred
the
orthosis
over
plaster
cast
treatment
[33].
Various
orthoses
have
been
used
in
recent
years.
Olsson
et
al.
used
a
pneumatic
walker
brace
(Aircast
XP
Diabetic
Walker,
DJO,
Vista,
CA)
for
the
non-surgical
management
of
51
patients
in
their
randomised
controlled
trial
[30].
They
used
a
standardised
protocol,
described
by
Ingvar
et
al.,
which
consisted
of
removal
of
heel
wedges
over
8
weeks.
They
demonstrated
a
mean
ATRS
of
80
at
12-month
evaluation
[30].
Similar
orthosis
with
heel
wedges
were
used
in
non-surgical
management
during
other
randomised
controlled
trials
[37,38].
The
use
of
the
VACOped
W
orthosis
has
significant
advantages
over
these
regimes.
There
is
no
need
to
remove
heel
wedges
and
plantarflexion
can
be
integrated
into
the
orthosis
and
adjusted
easily
without
removing
the
boot.
The
ankle
hinge
also
allows
the
ability
to
provide
controlled
movements
at
the
ankle
joint,
which
may
reduce
post-
treatment
complications.
AT
ruptures
most
commonly
occur
in
recreational
sports
people
of
working
age.
So
the
effect
of
immobilisation
on
society
can
be
significant
with
respect
to
driving
and
returning
to
work.
An
extension
of
3
weeks
in
the
boot
can
have
a
significant
impact
on
socio-economics
but
it
is
important
to
note,
from
our
findings,
that
long-term
functional
outcomes
are
unaffected.
An
animal
model
has
shown
healed
Achilles
tendons
having
a
re-rupture
force
of
56.7%
of
normal
at
12
months
following
transection.
One
theory
behind
this
is
the
absence
of
mechanical
loading
during
the
period
of
immobilisation
in
this
study
[6].
Early
tendon
healing
takes
place
over
6
weeks
before
the
remodelling
phase
begins.
The
remodelling
phase
has
an
initial
consolidation
stage
that
continues
for
up
to
10
weeks.
It
is
during
this
time
that
repair
tissue
changes
from
cellular
to
fibrous.
After
this,
the
maturation
phase
begins
in
which
the
fibrous
tissue
gradually
changes
to
scar-like
tissue
over
the
course
of
1-year
post
injury
[34].
This
would
suggest
that
tendon
use
should
begin
between
6
and
10
weeks
post
injury,
prior
to
the
maturation
phase,
to
orientate
the
collagen
fibres
position
in
order
to
optimise
unidirectional
strength
that
is
required
by
the
AT.
Table
2
A
table
to
show
patient
demographics
and
mode
of
injury
in
the
two
groups
treated
with
VACOped
1
boot.
Patients
11-week
regime
8-week
regime
No.
of
patients
44
44
Mean
age
at
rupture
(years)
50.8
52.0
Range
27–80
32–77
Mean
follow
up
(months)
26.6
29.2
Range
24–33
12–44
Gender
mix
Male
36:
female
8
Male
36:
female
8
Laterality
Right
21
Right
23
Left
23
Left
21
Mechanism
of
injury:
Sports
28
33
Walking/running
10
3
Heavy
push
2
2
Fall
3
6
Unknown
1
0
Local
ethics
approval
was
obtained
via
our
hospital
research
and
audit
department.
Table
3
A
table
to
show
the
results
for
Achilles
tendon
rupture
scores
for
varying
age
brackets.
Patient
age
(years)
11
week
regime
ATRS
8
week
regime
ATRS
Unpaired
t-test
result
<40
75.6
(n
=
10)
75.5
(n
=
10)
P
=
0.99
40–60
79.1
(n
=
24)
73.1
(n
=
24)
P
=
0.31
>60
68.7
(n
=
10)
84.8
(n
=
9)
P
=
0.20
There
was
no
statistical
difference
between
males
or
females
for
either
regime,
p
=
0.90
and
p
=
0.25,
respectively.
However
there
were
a
low
number
of
female
patients
for
this
statistical
analysis.
R.
Aujla
et
al.
/
Foot
and
Ankle
Surgery
xxx
(2015)
xxx–xxx
3
G
Model
FAS-873;
No.
of
Pages
5
Please
cite
this
article
in
press
as:
Aujla
R,
et
al.
Non-surgical
treatment
of
Achilles
rupture:
Does
duration
in
functional
weight
bearing
orthosis
matter?
Foot
Ankle
Surg
(2015),
http://dx.doi.org/10.1016/j.fas.2015.11.003

Controlled
early
motion
in
healing
tendons
has
been
shown
to
even
propagate
healing
through
the
release
of
local
growth
factors
[1].
Animal
studies
have
demonstrated
a
3-fold
increase
in
strength
of
AT
with
dynamic
rehabilitation
but
clinical
research
have
failed
to
demonstrate
this
link
in
human
studies
[8,9,15,26,33].
There
are
few
non-originator
studies
using
the
ATRS
to
assess
non-operatively
managed
AT
ruptures.
Bergkvist
et
al.
showed
a
mean
ATRS
(SD)
of
79
(
!20.8)
in
227
non-operatively
managed
AT
ruptures,
at
a
mean
follow-up
of
3.3
years,
who
were
managed
in
functional
bracing
[4].
Kearney
et
al.
demonstrated
a
mean
ATRS
(SD)
of
78
(!20)
at
9
months
following
8
weeks
of
functional
non-
operative
rehabilitation
following
AT
rupture
in
38
patients
[18].
These
scores
are
comparable
to
that
of
ours
for
both
the
11
and
8
weeks
cohorts,
with
ATRS
of
76.0
and
76.1,
respectively.
In
surgically
managed
AT
ruptures
ATRS
scores
tend
to
be
higher
and
range
from
82–89
[4,7,30].
Percutaneous
minimally
invasive
repair
methods
have
demonstrated
an
ATRS
of
89
at
12-month
follow-up
[7].
Percutaneous
repair
with
functional
rehabilitation
may
provide
the
best
functional
outcome
but
there
are
few
studies
to
confirm
this
theory.
The
minimally
clinically
important
difference
for
ATRS
has
yet
to
be
established
and
this
may
facilitate
future
study
comparisons.
Barfod
et
al.
showed
in
a
randomised
controlled
trial
that
immediate
weight
bearing
has
no
detrimental
effect
on
ATRS,
re-
rupture
rates
or
health
related
quality
of
life
[2].
A
2012
Cochrane
review,
including
meta-analysis,
showed
no
difference
in
re-
rupture
rate
between
surgery
and
the
sub-group
of
patients
treated
in
accelerated
rehabilitation
regimes
[14].
We
concur,
and
add
the
fact
that
longer
than
8
weeks
treatment
protocols
do
not
improve
functional
outcomes.
No
previous
study
has
looked
at
duration
of
regimes
and
functional
outcomes
following
AT
ruptures.
There
remains
an
unexplained
high
VTE
rate
in
patients
sustaining
AT
ruptures
with
no
proven
reduction
with
the
use
of
prophylactic
low-molecular
weight
heparin
[22,28].
Our
VTE
rate
was
higher
than
other
reported
studies
at
8.0%
for
both
regimes
combined.
We
felt
this
can
be
explained
by
selection
bias.
In
our
own
larger,
unpublished
cohort
of
293
patients
treated
for
8
weeks
there
is
a
VTE
rate
of
6.8%.
We
feel
this
probably
reflects
a
more
realistic
clinical
VTE
rate
for
non-operatively
managed
AT
ruptures
and
is
comparable
to
other
studies
[10,13].
Soroceanu
et
al.
showed
that
if
functional
rehabilitation
were
employed
then
the
re-rupture
rate
was
equal
in
operative
and
non-operative
patients
(risk
difference
1.7%;
p
=
0.45)
[35].
Duration
of
immo-
bilisation
did
not
affect
the
VTE
or
re-rupture
incidence
in
our
study
but
this
is
likely
to
be
due
to
an
under-powering
as
this
was
a
secondary
outcome
measure.
We
are
aware
of
the
limitations
of
this
study.
Patient
inclusion
was
dependent
of
a
completed
ATRS
being
available.
This
was
not
a
truly
prospective
data
collection
either
as
the
ATRS
was
obtained
via
postal
questionnaire
at
unspecified
time
points
in
the
patient’s
rehabilitation.
Retrospectively
identifying
complications
can
cause
some
cases
to
be
missed
and
reduce
accuracy.
However,
we
feel
our
findings
are
significant
and
may
provide
evidence
to
stimulate
a
randomised
controlled
trial
into
different
non-surgical
treatment
protocols
to
optimise
functional
outcome.
There
is
a
certain
amount
of
selection
bias
as
the
patients
included
were
involved
in
a
change
in
local
protocol.
5.
Conclusion
A
reduction
in
duration
of
dynamic
rehabilitation
after
non-
operative
treatment
of
Achilles
tendon
rupture
from
11
weeks
to
8
weeks
does
not
lead
to
a
detriment
in
long-term
functional
outcome
or
complication
rates.
Conflict
of
interest
No
benefits
in
any
form
have
been
received
or
will
be
received
from
a
commercial
party
related
directly
or
indirectly
to
the
subject
of
this
article.
Funding
None.
Ethical
approval
Ethical
approval
was
confirmed
by
local
committee.
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Foot
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xxx
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xxx–xxx
4
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Model
FAS-873;
No.
of
Pages
5
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this
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in
press
as:
Aujla
R,
et
al.
Non-surgical
treatment
of
Achilles
rupture:
Does
duration
in
functional
weight
bearing
orthosis
matter?
Foot
Ankle
Surg
(2015),
http://dx.doi.org/10.1016/j.fas.2015.11.003

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