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1362
Controversy surrounds the most appropriate treatment method for patients with a rupture
of the tendo Achillis. The aim of this study was to assess the long term rate of re-rupture
following management with a non-operative functional protocol.
We report the outcome of 945 consecutive patients (949 tendons) diagnosed with a
rupture of the tendo Achillis managed between 1996 and 2008. There were 255 female and
690 male patients with a mean age of 48.97 years (12 to 86). Delayed presentation was
defined as establishing the diagnosis and commencing treatment more than two weeks
after injury. The overall rate of re-rupture was 2.8% (27 re-ruptures), with a rate of 2.9%
(25 re-ruptures) for those with an acute presentation and 2.7% (two re-ruptures) for those
with delayed presentation.
This study of non-operative functional management of rupture of the tendo Achillis is the
largest of its kind in the literature. Our rates of re-rupture are similar to, or better than, those
published for operative treatment. We recommend our regime for patients of all ages and
sporting demands, but it is essential that they adhere to the protocol.
1363
Weeks
1 to 2
14
Remove walker
Final assessment
Fig. 1
Algorithm showing the treatment of ruptures of tendo Achillis
1364
Table I.
Male
Female
Patient characteristics
Number
p-value
690
255
0.12
Rate of
re-rupture
p-value
2.8%
0.46
2.9%
Rate
p-value
2.9%
0.13
2.7%
2.9%
0.17
2.7%
Results
The distribution of ruptures according to gender revealed
no statistically significant difference in the mean age of
patients at time of rupture (p = 0.12) (Table I). Likewise the
rate of re-rupture showed no statistically significant difference in distribution between sporting and non-sporting
individuals (p = 0.46) (Table II).
The orthosis was removed early against medical advice in
five patients, two of whom had a re-rupture. These two
patients completed, from start to finish, a second functional
protocol and all returned to pre-injury activity levels.
All the re-ruptures occurred within three months of diagnosis. There was no significant difference in the rate of rerupture between those with an acute and delayed
presentation or according to gender (p = 0.13 and p = 0.17,
respectively, paired t-test) (Table III).
Good to excellent subjective assessment on discharge
was noted in 939 patients (99.4%; 943 tendons). A total of
six patients (0.6%; six tendons) had a poor score and subsequently underwent operative repair. This was because of
tendon lengthening resulting in weakness of plantar
flexion.
Discussion
These results demonstrate a non-operative approach with a
very low rate of complication. This justifies non-operative
functional treatment if the healing of the tendon is as good
as that achieved with surgery.32
Rates of re-rupture up to 29% following conservative
management have been given as an indication for surgery.33
Some studies documenting increased re-rupture rates have
not used the same immobilisation regime as their surgical
cohort.20 Saleh et al34 were amongst the first to demonstrate that a functional orthosis with early mobilisation can
improve the outcome when compared with cast immobilisation.
The Cochrane Collaboration performed a meta-analysis
to summarise the results of management of patients with a
rupture of tendo Achillis.23 The results of four randomised
controlled trials which looked at operative versus nonoperative techniques were pooled. Only Schroeder et al20
used functional orthosis for their non-operative management, the rest used immobilisation in a cast. At least three
small randomised controlled trials35-37 have subsequently
been published showing improved functional outcome and
lower rates of re-rupture when treatment involved a
functional orthosis and early mobilisation (Table IV).38
These results are encouraging but lack the numbers or long
term follow-up to influence clinical practice.
Our study provides robust information from the largest
number of conservatively treated patients published to
date. The rate of re-rupture amongst our patients includes
two patients who removed their orthosis early. Previous
THE JOURNAL OF BONE AND JOINT SURGERY
Number (%)
30
25
20
15
10
5
0
Total number
% of total
l
ng
/ti
ss
2.2
0.7
in
in
e
bn
1365
a
lp
He
ng
of
o
nd
i
Th
er
lc
te
nn
um
0.5
0.7
on
T
DV
xi
e
ifl
rs
ed
do
0.3
y
ph
PE
lf
Ca
ric
st
Re
0.2
1.1
1.0
ro
at
0.4
0.2
rt
ro
d
ot
Fo
sc
is
di
os
rth
ur
fo
om
2.8
t
up
Re
O
Fig. 2
Bar chart showing complications (DVT, deep-vein thrombosis; PE, pulmonary embolism).
Percentage
5.0
4.0
3.0
Acute pres
Delayed pres
2.0
1.0
0
0.0
g
in
in
/ti
ss
e
bn
l
ng
um
a
lp
ee
of
er
lc
te
ni
in
Th
ng
o
nd
xi
e
ifl
rs
do
T
DV
y
ph
PE
lf
Ca
ct
tri
s
Re
ed
on
tro
rt
op
r
td
o
Fo
i
os
fo
di
sc
om
re
tu
p
-ru
Re
rth
O
Fig. 3
Bar chart showing a comparison of the incidence of complications according to acute or delayed presentation
(DVT, deep-vein thrombosis; PE, pulmonary embolism).
Re-rupture rate
Nistor19*
Cetti et al4*
Mller et al38*
Schroeder et al20
Khan et al23*
Twaddle et al35
Metz et al36
Willits et al37
Current series
Conservative
Surgical
Conservative
Surgical
8.3%
12.7%
20.8%
0%
12.6%
9.1%
15%
4.2%
2.9%
4.5%
5.4%
1.7%
0%
3.5%
15%
4.7%
2.8%
60
55
53
15
183
22
40
72
945
45
56
59
13
173
20
43
72
1366
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