Study examines which treatment method reduces complications

Which method of treating an acute Achilles tendon (AT) rupture has fewer complications—minimally invasive surgery or functional bracing?

According to a randomized, controlled, multicenter clinical trial conducted in the Netherlands, surgical treatment resulted in fewer complications and reruptures. The results of this study were published in the September 2008 American Journal of Sports Medicine.

Randomized for treatment
Patients included in the study were randomized to either minimally invasive surgery (42 patients) or functional bracing system (41 patients); treatment started within 72 hours following the AT rupture. Baseline characteristics—average age, gender, mean body mass index, cause (sports), and side (left)—were similar for both groups. One patient in the surgical treatment group opted for nonsurgical treatment; two patients in the nonsurgical treatment group opted for surgery.

Surgical treatment consisted of a minimally invasive repair procedure, followed by casting (1 week) and tape bandage (6 weeks). Nonsurgical treatment consisted of casting (1 week) and a new type of functional bracing system (6 weeks).

Both groups used crutches for the first week, and afterward at the direction of the treating physician. Full weight-bearing was allowed when patients were walking on flat surfaces.

Fewer complications with surgery
Researchers based their data analysis on the intention-to-treat principle, which resulted in 12 complications for surgical treatment and 20 complications for functional bracing. Complications ranged from rerupture and sural nerve injury to lower leg deep vein thrombosis and skin-related issues—fungal infections, pressure sores, and blisters. Skin-related complications were attributed to the brace or tape bandage and resolved quickly when the bracing system or tape bandages were removed.

Patients in the surgical group reported more pain and had lower patient satisfaction at 7 weeks than those who received nonsurgical treatment. But by 3 months postsurgery, these findings were reversed. Surgical patients reported higher levels of satisfaction and less pain at 3 months and 1 year than those in the nonsurgical treatment group (Fig. 1). Patients in the surgical treatment group also took less time off from work than patients in the nonsurgical treatment group.

Conclusions
“Our data show that minimally invasive surgical treatment of acute AT rupture appears to have a lower risk of complications than does nonoperative treatment using functional bracing,” wrote the authors, “although this difference is not statistically significant. Surgery does result in earlier return to work.”

The authors of “Acute Achilles tendon rupture: Minimally invasive surgery versus nonoperative treatment with immediate full weightbearing—A randomized controlled trial” are Roderick Metz, MD; Egbert-Jan M.M. Verleisdonk, MD, PhD; Geert J.-M.-G. van der Heijden, MD, PhD; Geert-Jan Clevers, MD, PhD; Erik R. Hammacher, MD, PhD; Michiel H.J. Verhofstad, MD, PhD; and Christiaan van der Werken, MD, PhD; they reported no potential conflicts of interest.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org