Functional rehab avoids surgery for Achilles rupture

Conservative nonsurgical treatment of acute Achilles tendon rupture is as good as surgery, provided the nonsurgical protocol includes functional rehabilitation, Canadian research shows.

"This resulted in re-rupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications," report Alexandra Soroceanu (Dalhousie University Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia) and colleagues in the Journal of Bone and Joint Surgery.

However, if early range-of-motion rehabilitation is not used, surgery reduces the risk for re-rupture by 8.8%, leaving the researchers to suggest that surgical repair should be preferred at centers that do not employ functional rehabilitation protocols.

Surgery was associated with an absolute 15.8% increased risk for complications other than re-rupture. One complication would be expected for every seven patients treated with surgery, say the researchers.

The team performed a meta-analysis of 10 studies that included 418 patients treated surgically and 408 patients who underwent nonsurgical treatment.

The absolute difference in the re-rupture rate in the pooled analysis was 5.5% favoring surgical repair, a difference that translated into a significant 60% lower relative risk for re-rupture among those treated with surgery.

If a functional rehabilitation protocol with early range-of-motion was used, however, the absolute difference in the re-rupture rate was just 1.7%, a nonsignificant difference between the two treatment approaches.

By contrast, if the treatment protocol included a prolonged period of immobilization after the Achilles rupture, the absolute reduction in the re-rupture risk obtained with surgery was 8.8%, a statistically significant difference.

Without functional rehabilitation, just 12 patients would require treatment with surgery to prevent one tendon re-rupture. Patients treated with surgery returned to work 19 days sooner than those who underwent conservative nonsurgical therapy.

Treatment of the ruptured Achilles tendon without surgery requires the use of a cast, a cast-boot, or a splint with the foot placed in plantar flexion. Surgery, on the other hand, may include open, minimally invasive, or percutaneous repair of the tendon.

Given that not all complications are major, some surgeons and patients "may consider the increased rate of other complications following surgical treatment to be an acceptable trade-off for the reduced re-rupture rate," write Soroceanu and colleagues.

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