Achilles Tendon Rupture - Surgery vs. Conservative Treatment

Non-surgical repair may have fewer complications but higher risk of re-rupture

The Achilles tendon.
The Achilles tendon. SEBASTIAN KAULITZKI/Getty Images

Is conservative treatment of an Achilles tendon rupture a good alternative to surgical repair? This has been analyzed further since a study published in the issue of Journal of Bone and Joint Surgery recommended conservative treatment for Achilles tendon ruptures rather than surgical repair for many patients.

Since the publication of that study, other studies have compared the two and most conclude that surgery has a lower rate of re-rupture, but a higher rate of complications for deep infections, non-cosmetic scar complaints, and sural nerve dysfunctions.

Conservative treatment may be best for patients who are in a functional rehab program with early range-of-motion therapy and who are older. This will continue to be a topic of debate. Here are the details of the studies so you can discuss this with your doctor if you have an Achilles tendon rupture.

Nonoperative Treatment of Achilles Tendon Rupture

The 2004 study followed the three-year outcome of patients with complete ruptures of the Achilles tendon that were treated with non-surgical methods. Eighty-six percent of them reported "excellent" or "good" results. These results were better than a similar group who had surgical repair.

The non-surgical treatment had patients wear a hard cast for a short time, and then switch to a lighter cast and finally to a functional, removable brace that was worn for one month. Traditional treatment for a complete Achilles tear has always been surgery immobilizing the ankle with a cast during healing.

In the study, patients were immobilized for a shorter period of time and then were able to take off the brace and do rehab exercises.

Researchers found that nearly all (91 percent) of those patients who participated in sports before their injury were able to return to sports. They also reported a lower rate of complications than with surgical repair.

Their conclusion is that this new nonoperative treatment should be the treatment of choice when physicians and therapists are trained and experienced in this protocol.

Which is Better - Surgical or Nonoperative Repair for Achilles Tendon Rupture?

A meta-analysis of 10 randomized controlled trials from 1980-2011 found the operative treatment to be better than the nonoperative treatment of preventing re-rupture and an earlier return to work, but it had more risk of complications. But both operative and nonoperative patients had the same rate of return to the sports they enjoyed before their injuries.

Another meta-analysis of eight trials found the same results. They concluded that the operative treatment would be better for patients who were in good physical condition while the nonoperative treatment is a good alternative for older patients.

Functional Rehabilitation May Make a Difference for Choosing Conservative Treatment

If you have your Achilles tendon rupture treated at a center that uses functional rehabilitation, the conservative non-surgical intervention may be a good choice.

A meta-analysis of 10 studies found that when treated conservatively with early-range-of-motion protocols, the re-rupture risk was the same as for surgical patients, without the increased risk of complications seen in surgical treatment. If a functional rehab program isn't available, then surgery is probably a better choice.

Sources:

Wallace RG, et. al. "Combined conservative and orthotic management of acute ruptures of the Achilles tendon." J Bone Joint Surg Am. 2004 Jun;86-A(6):1198-202.

Jiang N, Wang B, Chen A, Dong F, Yu B. "Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence." International Orthopaedics 2012; 36(4): 765-773.

Zhao HM, Yu GR, Yang YF, Zhou JQ, Aubeeluck A. Outcomes and complications of operative versus non-operative treatment of acute Achilles tendon rupture: a meta-analysis. Chinese Medical Journal 2011; 124(23): 4050-4055

Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute achilles tendon rupture: A meta-analysis of randomized trials. Journal of Bone and Joint Surgery. American volume 2012; 94(23): 2136-2143

Wilkins R, Bisson LJ. Operative versus nonoperative management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. American Journal of Sports Medicine 2012; 40(9): 2154-2160.

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