The Achilles tendon (AT) is the most commonly ruptured tendon in the human body. The incidence of AT ruptures has increased in recent decades, with the number of reported ruptures per 100,000 people in North America now ranging from 5.5 to 9.9. Most acute AT ruptures occur as a result of trauma or athletic activity. Other described mechanisms include unexpected dorsiflexion, push-off with the knee in extension and forced dorsiflexion of a plantarflexed foot. Some studies demonstrate differences in less active individuals, with an increased incidence in the third and fourth decades of life in men and in the sixth decade of life in women.
The AT typically ruptures approximately 3 cm from its calcaneal insertion, likely secondary to decreased vascularity in this region. A 2004 study reported a 6 percent to 26 percent chance of contralateral rupture, with males experiencing a higher rate of rupture than females. A history and physical exam are usually sufficient for diagnosis, with the Thompson test demonstrating the greatest sensitivity. The presence of a palpable gap and loss of plantarflexion strength may also aid in diagnosis but are much less sensitive.

Plain radiographs may be obtained to assess calcaneal avulsion or other concomitant injury. Although ultrasound and MRI are more sensitive and specific for soft tissue injury, they are often not necessary. Acute management typically includes the application of a plantarflexed splint or short-leg cast to promote tendon apposition.

AAOS Clinical Practice Guideline
The 2010 clinical practice guideline published by the AAOS on The Diagnosis and Treatment of Acute Achilles Tendon Rupture was based on a systematic review of published studies on adults (patients older than age 19 years) who had sustained an acute AT rupture, defined as those "treated within the first 6 weeks of injury." (See Table 1.)

The only "Consensus" recommendations were in the areas of physical exam findings and surgical risk factors. Nonsurgical management received a "weak" recommendation, with an "inconclusive" recommendation for or against functional bracing.

Similarly, surgical management and preferred surgical techniques (open, limited open, and percutaneous) also received "weak" recommendations, with an "inconclusive" recommendation for or against the use of allograft, autograft, and biologic adjuncts.

Despite the large body of published research dedicated to acute AT ruptures, the optimal management of this injury remains controversial. The purpose of this "Face Off" is to present compelling arguments in support of surgical (See Fig. 1) and nonsurgical intervention, as appropriate, in the management of acute AT ruptures.

POINT
Surgical treatment decreases incidence of rerupture and improves functional outcomes
Robert L. Parisien, MD, and Christopher C. Dodson, MD

In the debate over surgical versus nonsurgical management of acute AT ruptures, the primary areas of assessment are the rate of rerupture and/or infection, as well as functional outcomes. Proponents of nonsurgical management often cite a 2010 randomized trial involving 118 male and 26 female patients. That study concluded that accelerated functional rehabilitation is a viable treatment option for acute AT ruptures.

However, a closer look at the results found a significant difference in plantarflexion strength in favor of the surgically treated group. The incidence of rerupture and the residual palpable gap, signifying the failure of tendon healing, also favored the surgical group. Although the complication rate was higher in the surgical group, most complications involved the superficial skin and soft tissue with no residual effect at last follow-up. Furthermore, the accelerated rehabilitation protocol may be challenging to consistently reproduce in other settings and across patient populations.

Rerupture and infection
Rates of rerupture have consistently been lower in patients treated surgically for acute AT ruptures compared with patients treated conservatively. A 2002 meta-analysis of six randomized controlled trials (RCTs) reported a statistically significant difference in rerupture rate favoring surgical treatment (3.1 percent versus 13 percent among patients treated nonsurgically). A second meta-analysis further supported these findings, with surgical and nonsurgical rerupture rates of 3.5 percent and 12.6 percent, respectively.

The risk of infection is greater with surgical repair due to the violation of skin and soft tissue, but infection rates have decreased precipitously with less invasive soft-tissue handling due to the advent of short, midline incisions and careful consideration of the highly vascular paratenon. A comparative study published in 2005 evaluated minimally invasive repair and found an overall complication rate of 4.5 percent with no sural nerve injuries or necrosis.

Similar findings were reported in 2014 in a systematic review of 12 studies. It found zero infections and a 0.3 percent rate of necrosis in patients undergoing repair via minimally invasive techniques. An additional retrospective review evaluating surgical versus nonsurgical management of 487 patients found low rates of rerupture and infection in the surgically treated group, (3 percent and 1.5 percent respectively). These reported rates of rerupture and infection remain consistent with the larger body of literature evaluating acute AT rupture management. Finally, in 2012, a quantitative systematic review of seven RCTs (677 patients) comparing surgical and nonsurgical management found that patients who underwent surgical management had a significantly lower rate of rerupture (3.6 percent versus 8.8 percent of patients treated nonsurgically) with an overall deep infection rate of only 2.36 percent.

Functional outcomes
Despite the increasing literature on nonsurgical management, functional outcomes continue to favor surgical repair, with some studies finding that fewer than half of patients treated nonsurgically return to the same level of sport. Although the incidence of functional bracing has increased in recent years, current literature still appears to support surgical intervention with regard to clinical outcomes.

For example, a meta-analysis of 10 studies found a significant difference favoring surgical management, with surgical patients returning to work nearly 20 days sooner than those treated nonsurgically. This is an important finding, as increased rates of return-to-work will decrease direct and indirect costs with regard to lost income and future wages.

Another study comparing surgical versus nonsurgical management reported statistical equivalence in regard to Achilles Tendon Total Rupture Scores, but found a statistically significant difference in the heel-raise test in favor of surgical intervention.

In conclusion, the evidence supporting surgical treatment of acute AT ruptures is compelling, as it demonstrates significantly lower rates of rerupture and superior functional outcomes.

Robert L. Parisien, MD, is an orthopaedic surgical resident at Boston University Medical Center in Boston. He can be reached at Robert.L.Parisien@gmail.com

Christopher C. Dodson MD, is head team physician of the Philadelphia 76ers and an associate professor of orthopaedic surgery at the Rothman Institute in Philadelphia.

COUNTERPOINT
Nonsurgical management prevents complications
David P. Trofa, MD, and William N. Levine, MD

The treatment of AT ruptures has rapidly evolved. Historically, the decision to operate involved a risk-benefit assessment between the higher rate of complications and lower rate of reruptures associated with surgery. As such, nonsurgical management was reserved for older, less active patients.

Compelling evidence now shows that nonsurgical management in the form of functional rehabilitation can provide equivalent rerupture rates while avoiding complications and potentially reducing healthcare costs. Supported by a succinct review of the literature from the past decade, we argue that a conservative approach with functional rehabilitation should be the treatment of choice for AT ruptures.

Before comparing rerupture rates and functional outcomes, it is important to highlight the risks associated with AT repair that can be altogether avoided with conservative treatment. Complications other than rerupture are common and include wound infection, scar adhesion, and sural nerve injuries. Recent RCTs have found surgical complication rates ranging from 16 percent to 21 percent, while an older meta-analysis documented complication rates as high as 34.1 percent.

Infection rates in these trials and meta-analyses have ranged from 4.0 percent to 12 percent, although a large national epidemiologic study involving 7,625 patients treated between 2007 and 2011 recently found the infection rate to be lower, at 2.3 percent. When all complications are considered together, one meta-analysis found that surgery was associated with an absolute risk increase of 15.8 percent compared to nonsurgical treatment. Finally, although evidence exists to suggest that percutaneous procedures reduce complication rates, these rates still remain higher than those for nonsurgical treatment.

During the early 2000s, limited evidence supported the role of nonsurgical management for AT ruptures. Two meta-analyses published during that time found rerupture rates of 12.6 percent and 13 percent in nonsurgically treated patients, compared with 3.5 percent and 3.1 percent in surgically managed patients. However, two comparative investigations of functional rehabilitation versus immobilization cited a 2.4 percent rerupture rate in patients treated in a functional brace. Although this did not prove superiority or equivalence of functional rehabilitation to surgery, it was an early predictor for the shift in management.

A number of studies have since highlighted the fundamental role of functional rehabilitation for AT rupture management. The full breadth of these protocols is beyond the scope of this article and varies significantly, but they usually involve early loading of the tendon through range of motion, weight bearing, or both. Comparative studies have proven this to be beneficial to cast immobilization alone as a primary treatment option, as well as postoperatively in preventing rerupture.

The single largest investigation of functional rehabilitation reported a rerupture rate of 2.9 percent in 945 consecutive patients. However, the most significant evidence for success stems from RCTs that show equivalent rerupture rates compared to surgery. For example, a 2008 study found no significant difference in rerupture rates (7.1 percent and 12.2 percent, respectively, in surgical and nonsurgical groups, P = 0.44). Similarly, a 2010 multicenter, randomized trial demonstrated rerupture rates of 2.8 percent and 4.2 percent, respectively, for surgical and nonsurgical treatment arms (P > 0.05). These data have also been supported by a recent meta-analysis that found an insignificant absolute risk difference for rates of rerupture between functional rehabilitation and surgery, compared to an absolute risk reduction of 8.8 percent if a nonfunctional rehabilitation protocol was utilized.

Given the data illustrating equivalent rerupture rates regardless of treatment method, the focus of the debate has shifted to functional outcome measurements, such as tendon strength, return to sports and activities, and quality of life. Data provided from RCTs in this regard are diverse because each RCT each investigated different outcomes.

For instance, one study found no difference between surgery and functional rehabilitation in return to physical activities, quality of life, concentric power, eccentric power, heel-rise repetition, heel-rise height, and heel-rise work; however, the authors did note superiority of surgical management in hopping and the drop counter-movement jump at 12 months. The significance of this finding with respect to the actual functional benefit to patients is questionable, leading the authors to state "there is no conclusive evidence that this treatment (surgery) was superior to nonsurgical treatment with immediate weight bearing in a brace when comparing functional results."

The previously cited 2010 randomized trial also found no clinically important differences in range of motion, calf circumference, or Leppilahti score. In regard to strength, the affected limb in both groups was able to achieve at least 80 percent plantar flexion strength and 100 percent dorsiflexion strength compared to the uninjured contralateral limb, with a small but significant difference in plantar flexion strength favoring surgically repaired tendons. This difference was of unknown significance, leading authors to conclude that they found no clinically important difference in any measured parameter. Finally, a 2008 study found a significant difference in return to work—59 days versus 108 days—in surgically and nonsurgically managed patients. However, no differences were noted in return to sports, subjective pain, and treatment satisfaction.

Fewer complications and near-equivalent outcomes with functional rehabilitation are two of the various reasons to avoid surgical treatment of an acute Achilles rupture. These data have already translated into a decreased rate of surgical treatment for Achilles ruptures, as demonstrated by European database studies, but have not yet been borne out in the United States literature.

The current debate about nonsurgical versus surgical management of AT ruptures is likely to shift toward a focus on determining which patients are least likely to benefit from functional rehabilitation, such that the risk-benefit ratio of surgical intervention is merited.

David P. Trofa, MD, is an orthopaedic surgical resident at Columbia University Medical Center in New York City. William N. Levine, MD, is chairman of the department of orthopaedic surgery and head team physician of Columbia University athletics at Columbia University Medical Center in New York City.

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