The Achilles’ Heals…Without Surgery? Non-op vs Operative Management RCT

May 12, 2022

Written by Vivian Lei

Spoon Feed
Patients with Achilles’ tendon rupture undergoing surgical repair, either open or minimally-invasive, did not have better outcomes at 12 months compared to non-operative treatment. However, those managed nonoperatively had a higher rate of tendon rerupture.

Why does this matter?
Achilles’ tendon rupture is common and can be managed with non-operative and operative treatment approaches. This trial shed light on what considerations might inform treatment decisions when patients choose to proceed with surgery or not, since functional outcomes appear to be similar.

The Achilles’ heals with or without surgery
This was a Norwegian multicenter, randomized controlled trial comparing adults with Achilles’ tendon rupture treated with surgical (open or minimally-invasive) or nonoperative treatment. Patients were excluded if they had a previous Achilles’ tendon rupture, were high anesthesia risk (>ASA II), had received quinolones or local glucocorticoid injections in the 6 months before the injury, or had baseline walking disabilities. All patients were placed in equinus casts in plantar flexion for 2 weeks after injury, followed by 6 weeks of gradual dorsiflexion with weight bearing as tolerated. The surgery groups had 2 weeks of additional casting after surgery, followed by the gradual dorsiflexion protocol.

At the 12-month follow-up, the change from baseline of a validated patient-reported 100-point functional score was similar in all 3 groups: -17.0 in the nonoperative group, -16.0 in the open-repair group, and -14.7 in the minimally invasive surgery group. The rate of rerupture was higher in the nonoperative group at 6.2% vs. 0.6% in each of the operative groups. Nerve injuries were more common in the minimally invasive group, at 5.2% compared with 2.8% of open repair patients and 0.6% of non-operative patients. This is useful information to share with patients who are weighing the risks of tendon rerupture against the benefits of avoiding surgery.

Source
Nonoperative or Surgical Treatment of Acute Achilles’ Tendon Rupture. N Engl J Med. 2022 Apr 14;386(15):1409-1420. doi: 10.1056/NEJMoa2108447.