Clinical Question

Is open repair or minimally invasive surgery better than nonoperative management for adults with acute Achilles tendon rupture?

Bottom Line

There is no clear benefit to surgery over nonoperative management for adults with acute Achilles tendon rupture. Symptomatic improvement is the same, and surgery trades more nerve injuries for a lower risk of re-rupture. (Level of Evidence = 1b)

Synopsis

The Achilles heel of orthopedic surgery appears to be that when surgeons compare surgical to nonoperative management, they find that nonoperative management is effective for many, if not all, patients. In this Norwegian study, adults 18 to 60 years of age with an acute Achilles tendon rupture were randomized to receive open surgical repair, minimally invasive repair, or nonoperative management. The injury had to be assessed and casted within three days of injury, and surgery had to be completed within seven days of injury. Nonoperative management involved a below-the-knee equinus cast for two weeks, followed by six weeks of weight-bearing as tolerated with heel wedges and ankle-foot orthoses. Patients had gradually decreasing plantar flexion with progressive removal of heel lifts in the six weeks following the equinus cast. The brace was worn day and night for the first two weeks but was removed at night for weeks 3 through 6. Postoperative management was similar.

Groups were similar at baseline, with a mean age of 40 years and a body mass index of approximately 27 kg per m². About 75% of the patients were men. Analysis was by intention to treat, and allocation was appropriately concealed, although the study was not masked to the intervention. At one year, there was no difference in the primary outcome of a change in the Achilles tendon Total Rupture Score compared with baseline status pre-injury: −17 points for nonoperative management, −16 points for open repair, and −14.7 points for minimally invasive surgery. In this case, smaller negative numbers are better, but the minimum clinically important difference is estimated to be 8 to 10 points. There was no difference in the broader 36-item Short Form Health Survey quality of life scale. Nerve injuries were less common with nonoperative management (0.6% vs. 2.8% with open repair and 5.2% with minimally invasive surgery). Re-ruptures were more common with nonoperative management (6.2% vs. 0.6% in each of the surgery groups; number needed to harm = 18), with most occurring in the 10 weeks following the index injury.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Reference: Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or surgical treatment of acute Achilles' tendon rupture. N Engl J Med. 2022;386(15):1409-1420.

Editor's Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell.