Management of Achilles tendon rupture: surgical versus conservative method

Introduction Current therapy for managing achilles tendon rupture are classified into surgical and conservative method. Randomized controlled trials were performed in multiple healthcare facilities in multiple centers across the world yet functional outcomes, re-rupture rate and complications are still indecisive.

The aim of this study is to compare surgical versus conservative methods for the treatment of acute Achilles tendon rupture; including functional outcome, re-rupture rate, and complications to provide better guidance in selecting therapeutic method.

Materials and Methods We conducted a comprehensive electronic database. Original articles until November 2023 were screened, focusing on randomized controlled trials with at least 12 months follow up. Our protocol has been registered at PROSPERO ID (CRD42023486152).

Results and Discussion The initial search yielded 354 studies. Twelve randomized controlled trials study with a  total of 1525 participants were assessed. Surgical treatment has better outcomes for preventing: re‑rupture (p ≤ 0.001), abnormal ankle movement (p ≤ 0.001), and calf muscle atrophy (p = 0.005). Functional outcomes at 6 months follow-up were better for hopping (p ≤ 0.001), heel-rise height (p ≤ 0.001), and heel‑rise work (p = 0.007) in surgical treatment. Functional outcomes at 12 months of follow-up were better only for heel‑rise work test (p ≤ 0.001) in surgical treatment. However, incidence of sural nerve injury (p = 0.006) was found lower in the conservative group. Complications other than re-rupture (p = 0.08) had no significant difference between two groups. At 6-month follow-up, functional outcome tends to be better compared to conservative management of Achilles tendon rupture. At 12-month follow-up, functional outcomes was comparable between two groups. However, the risk of re- rupture rate is higher in the conservative management.

Conclusion Reduced rates of re-rupture and quicker functional recovery are benefits of surgical repair. Conservative treatment can yield good results in terms of functional outcomes and re-rupture rates in  long‑term follow up, particularly when combined with contemporary rehabilitation procedures. Conservative treatment eliminates the hazards associated with surgery, but it may have a slightly higher chance of re‑rupture and a shorter initial recovery of some functional outcomes. Both of these treatment methods are good for treating Achilles tendon rupture.

Level of Evidence: I.

1. Holm C, Kjaer M, Eliasson P. Achilles tendon rupture--treatment and complications: a systematic review. Scand J Med Sci Sports. 2015;25(1):e1-10. doi: 10.1111/sms.12209.

2. Yasui Y, Tonogai I, Rosenbaum AJ, et al. The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States. Biomed Res Int. 2017;2017:7021862. doi: 10.1155/2017/7021862.

3. Meulenkamp B, Stacey D, Fergusson D, et al. Protocol for treatment of Achilles tendon ruptures; a systematic review with network meta-analysis. Syst Rev. 2018;7(1):247. doi: 10.1186/s13643-018-0912-5.

4. Carmont MR, Rossi R, Scheffler S, et al. Percutaneous & Mini Invasive Achilles tendon repair. Sports Med Arthrosc Rehabil Ther Technol. 2011;3:28. doi: 10.1186/1758-2555-3-28.

5. Ochen Y, Beks RB, van Heijl M, et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019 Jan 7;364:k5120. doi: 10.1136/bmj.k5120.

6. Lantto I, Heikkinen J, Flinkkila T, et al. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med. 2016 Sep;44(9):2406-2414. doi: 10.1177/0363546516651060.

7. Cetti R, Christensen SE, Ejsted R, et al. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;21(6):791-799. doi: 10.1177/036354659302100606.

8. Fischer S, Colcuc C, Gramlich Y, et al. Prospective randomized clinical trial of open operative, minimally invasive and conservative treatments of acute Achilles tendon tear. Arch Orthop Trauma Surg. 2021;141(5):751-760. doi: 10.1007/s00402-020-03461-z.

9. Keating JF, Will EM. Operative versus non-operative treatment of acute rupture of tendo Achillis: a prospective randomised evaluation of functional outcome. J Bone Joint Surg Br. 2011;93(8):1071-1078. doi: 10.1302/0301-620X.93B8.25998.

10. Maempel JF, Clement ND, Wickramasinghe NR, et alF. Operative repair of acute Achilles tendon rupture does not give superior patient-reported outcomes to nonoperative management. Bone Joint J. 2020;102-B(7):933-940. doi: 10.1302/0301-620X.102B7.BJJ2019-0783.R3.

11. Metz R, Verleisdonk EJ, van der Heijden GJ, et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial. Am J Sports Med. 2008;36(9):1688-1694. doi: 10.1177/0363546508319312.

12. Möller M, Movin T, Granhed H, et al. Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br. 2001;83(6):843-848. doi: 10.1302/0301-620x.83b6.11676.

13. Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386(15):1409-1420. doi: 10.1056/NEJMoa2108447.

14. Nilsson-Helander K, Silbernagel KG, Thomeé R, et al. Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med. 2010;38(11):2186-2193. doi: 10.1177/0363546510376052.

15. Olsson N, Silbernagel KG, Eriksson BI, et al. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2013;41(12):2867-2876. doi: 10.1177/0363546513503282.

16. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. 2007;35(12):2033-2038. doi: 10.1177/0363546507307503.

17. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-2775. doi: 10.2106/JBJS.I.01401.

18. Zhang H, Tang H, He Q, et al. Surgical Versus Conservative Intervention for Acute Achilles Tendon Rupture: A PRISMA-Compliant Systematic Review of Overlapping Meta-Analyses. Medicine (Baltimore). 2015;94(45):e1951. doi: 10.1097/MD.0000000000001951.

19. She G, Teng Q, Li J, et al. Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture: A Comprehensive MetaAnalysis of RCTs. . 2021;8:607743. doi: 10.3389/fsurg.2021.607743.

20. El-Akkawi AI, Joanroy R, Barfod KW, et al. Effect of Early Versus Late Weightbearing in Conservatively Treated Acute Achilles Tendon Rupture: A Meta-Analysis. J Foot Ankle Surg. 2018;57(2):346-352. doi: 10.1053/j.jfas.2017.06.006.

21. Deng S, Sun Z, Zhang C, et al. Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg. 2017;56(6):1236-1243. doi: 10.1053/j.jfas.2017.05.036.

22. Khan RJ, Fick D, Keogh A, et al. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005;87(10):2202-2210. doi: 10.2106/JBJS.D.03049.

23. Zhou K, Song L, Zhang P, et al. Surgical Versus Non-Surgical Methods for Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Controlled Trials. J Foot Ankle Surg. 2018;57(6):1191-1199. doi: 10.1053/j.jfas.2018.05.007.

24. Seow D, Yasui Y, Calder JDF, et al. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. Am J Sports Med. 2021;49(13):3728-3748. doi: 10.1177/0363546521998284

25. Soroceanu A, Sidhwa F, Aarabi S, et al. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94(23):2136-2143. doi: 10.2106/JBJS.K.00917.

26. van der Eng DM, Schepers T, Goslings JC, Schep NW. Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis. J Foot Ankle Surg. 2013;52(5):622-628. doi: 10.1053/j.jfas.2013.03.027.

27. Westin O, Sjögren T, Svedman S, et al. Treatment of acute Achilles tendon rupture - a multicentre, non-inferiority analysis. BMC Musculoskelet Disord. 2020;21(1):358. doi: 10.1186/s12891-020-03320-3.

28. Yang X, Meng H, Quan Q, et al. Management of acute Achilles tendon ruptures: A review. Bone Joint Res. 2018;7(10):561-569. doi: 10.1302/2046-3758.710.BJR-2018-0004.R2.

29. Metz R, Kerkhoffs GM, Verleisdonk EJ, van der Heijden GJ. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial. BMC Musculoskelet Disord. 2007;8:108. doi: 10.1186/1471-2474-8-108.

30. Wallace RG, Heyes GJ, Michael AL. The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture. J Bone Joint Surg Br. 2011;93(10):1362-1366. doi: 10.1302/0301-620X.93B10.26187.

31. Del Buono A, Volpin A, Maffulli N. Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review. Br Med Bull. 2014;109:45-54. doi: 10.1093/bmb/ldt029.

32. Li Y, Jiang Q, Chen H, et al. Comparison of mini-open repair system and percutaneous repair for acute Achilles tendon rupture. BMC Musculoskelet Disord. 2021;22(1):914. doi: 10.1186/s12891-021-04802-8.