Achilles Tendon Rupture- Orthopedics
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Achilles tendon rupture is when the achilles tendon tears. The achilles is the most commonly injured tendon. Rupture can occur while performing actions requiring explosive acceleration, such as pushing off or jumping. The male to female ratio for Achilles tendon rupture varies between 7:1 and 4:1 across various studies.
Treatment options for an Achilles tendon rupture include surgical and non-surgical approaches. Among the medical profession opinions are divided what is to be preferred.
Non-surgical management traditionally was selected for minor ruptures, less active patients, and those with medical conditions that prevent them from undergoing surgery. It traditionally consisted of restriction in a plaster cast for six to eight weeks with the foot pointed downwards (to oppose the ends of the ruptured tendon). But recent studies have produced superior results with much more rapid rehabilitation in fixed or hinged boots.
Some surgeons feel an early surgical repair of the tendon is beneficial. The surgical option was long thought to offer a significantly smaller risk of re-rupture compared to traditional non-operative management (5% vs 15%) Of course, surgery imposes higher relative risks of perioperative mortality and morbidity, e.g., infection including MRSA, bleeding, deep vein thrombosis and lingering anesthesia effects.
However, three recent studies have scientifically tested the benefits of surgery, using randomized streaming of patients into surgical and non-surgical protocols, and applying virtually identical (and aggressive) rehabilitation protocols to both types of patients. None of the three studies found statistically significant benefits from the surgery, separated from the other confounding variables. They all produced reasonably comparable results in re-rupture rates (with each study adding a cautious note about small sample size, one study showing 12% re-rupture in non-surgical treatment versus 4% re-rupture in surgical treatment, which is statistically insignificant), strength, and range of motion, while most have reaffirmed the greater complication rate from surgery. Although the study met the sample size dictated by the authors’ a priori power calculation, the difference in the rerupture rate might be considered clinically important by some. Two studies showed small, but statistically significant differences in plantarflexion strength: The surgical group had significantly better results in the heel-rise work, heel-rise height, concentric power, and hopping tests at the 6-month evaluation than did the nonsurgical group. However, at the 12-month evaluation, there was a significant between-groups difference only in one test, the heel-rise work test.
The relative benefits of surgical and nonsurgical treatments remains a subject of debate; authors of studies are cautious about the preferred treatment. It should be noted that in centers that do not have early range of motion rehabilitation available, surgical repair is preferred to decrease re-rupture rates.