Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation

Background: To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treatedwithsurgicalrepairwiththerateinpatientstreatednonoperativelyhavebeeninconclusivebutthepooledrelativerisk ofrerupture favoredsurgical repair. Inall but one study,thelimbwas immobilized for sixtoeight weeks.Published studiesof animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of the present study wastocomparetheoutcomesofpatientswithanacuteAchillestendonrupturetreatedwithoperativerepairandaccelerated functional rehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone. Methods: Patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. All patients underwent an accelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The primary outcome was the rerupture rate as demonstrated by a positive Thompson squeeze test, the presence of a palpable gap, and loss of plantar flexion strength. Secondary outcomes included isokinetic strength, the Leppilahti score, range of motion, and calf circumference measured at three, six, twelve, and twenty-four months after injury. Results: A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized.Therewere118malesandtwenty-sixfemales,andthemeanage(andstandarddeviation)was40.4±8.8years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. Therewere thirteencomplications intheoperative groupandsix in thenonoperative group, with themain difference being the greater number of soft-tissue-related complications in the operative group. Conclusions: This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. All measured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management. Level of Evidence: Level I. See Instructions to Authors for a complete description of levels of evidence.