Clinical Question

Is open repair or minimally invasive surgery better than nonoperative management for adults with acute Achilles tendon rupture?

Bottom Line

There is no clear benefit to surgery over nonoperative management for adults with acute Achilles tendon rupture. Symptomatic improvement is the same, and surgery trades more nerve injuries for a lower risk of re-rupture. (Level of Evidence = 1b)

Synopsis

The Achilles heel of orthopedic surgery appears to be that when surgeons compare surgical to nonoperative management, they find that nonoperative management is effective for many, if not all, patients. In this Norwegian study, adults 18 to 60 years of age with an acute Achilles tendon rupture were randomized to receive open surgical repair, minimally invasive repair, or nonoperative management. The injury had to be assessed and casted within three days of injury, and surgery had to be completed within seven days of injury. Nonoperative management involved a below-the-knee equinus cast for two weeks, followed by six weeks of weight-bearing as tolerated with heel wedges and ankle-foot orthoses. Patients had gradually decreasing plantar flexion with progressive removal of heel lifts in the six weeks following the equinus cast. The brace was worn day and night for the first two weeks but was removed at night for weeks 3 through 6. Postoperative management was similar.