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 ABSTRACT

Treatment for Achilles tendon ruptures in athletes iscontroversial. Surgical xation has lower rates of re-rupture and confers increased strength and function,whereas conservative treatment has lower risks ofwound complications. We review the literature onthe optimal treatment for Achilles tendon rupture inathletes.

Key words: Ach il les tendon; athletes

introduction

Achilles tendon rupture was rst reported in 1575.1 Itsincidence has increased since then.2 75% of Achillestendon ruptures occur during sporting activities,particularly those involving jumping or twistingmotions.3–6 The ruptures used to occur in men in their40s,7  and the male-to-female ratio was about 6:1.8,9

In a more recent study in athletes,10 age and sex no

Review article: Treatment for Achilles tendonruptures in athletes

Maria Stavrou, Andreas Seraphim, Nawfal Al-Hadithy, Simon C MordecaiLister General Hospital, Stevenage, United Kingdom

Address correspondence and reprint requests to: Maria Stavrou, 6 Nevern Square, Flat 3, SW5 9NN, London, United Kingdom.

Email: mrstavrou1@gmail.com

 Journal of Orthopaedic Surgery 2013;21(2):232-5

longer had as strong inuence on the rupture rate.This could be due to increased participation in sports

 by females and older people.11 The optimal treatment for Achilles tendon

rupture remains controversial. Conservativetreatment involves early application of an equinuscast for 6 to 8 weeks to approximate the edges of theruptured tendon together to promote healing. It hasa higher rate of re-rupture and is reserved for lessactive patients. Operative (open and percutaneous)treatment is usually for younger, more activepatients, and has more favourable functionaloutcomes, with lower re-rupture rates but highercomplication rates.  Before the 20th century, treatment for Achillestendon ruptures was primarily conservative. In the

60s, open surgery achieved better outcome but withhigher complication rates.12  In the 70s, this trendshifted toward conservative treatment, owing toincreasing complications and wound infections withoperative techniques.13 Poor wound healing remainsthe most common complication of open repair, andis likely to be due to incision on poorly vascularisedtissue.14  Athletes have higher expectations and

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Vol. 21 No. 2, August 2013  Achilles tendon ruptures in athletes 233

demands, higher re-rupture rates after conservativetreatment are therefore unacceptable. Percutaneoustechniques enable lower rates of wound infectionswhile maintaining lower re-rupture rates. In recentstudies, non-operative intervention is advocated.15,16

We reviewed the literature on the optimal treatmentfor Achilles tendon rupture in athletes.

literature reVieW

In a study of 92 Achilles tendon ruptures,17 outcomesin terms of function and range of motion were similarafter surgical (n=86) and non-surgical (n=6) treatment,

 but complications were signicantly more frequentin the surgical group. It was concluded that the riskof surgery and anaesthesia was not worthwhile,

given the similar outcome. Nonetheless, there werelimitations in the study, as the patients were notrandomised, the distribution of patients was uneven,and prophylaxis for deep vein thrombosis was notroutinely used.  In a study comparing 6 non-operative to 7operative patients in terms of plantar exion strengthafter treatment,18  conservative management offresh ruptures and old unhealed ruptures offeredadvantages over surgical intervention. One woundcomplication occurred in the operative group. Theweakness of this study included the small patient

number and no evaluation of functional level beforeand after injury.In a study of 79 patients with Achilles tendon

ruptures treated operatively (n=48) and non-operatively (n=31),19  there were 2 wound infectionsin the operative group, and 7 re-ruptures in the non-operative group. 31 of the 79 patients had playedsports competitively, 9 of them were treated non-operatively and could not return to sports, whereasthe remaining 22 were treated operatively andhad returned to competitive sports. Surgery wasrecommended for more active patients. Nonetheless,

the study was not randomised, and the non-operativecases were from another hospital. Some of theAchilles tendon ruptures were misdiagnosed andearly application of the equinus cast (essential forsuccessful non-operative treatment) may not have

 been undertaken.20

  In a prospective randomised study of 105 patientstreated non-operatively (n=60) and operatively(n=45),6  most patients were young (mean age, 41years) and active. 80% of the ruptures occurredduring sports. Re-ruptures were signicantly morecommon in the non-operative group (8% vs. 4%), but

the operative group had higher rates of complications,

pain, and stiffness, whereas strength and functionwere similar in both groups. Non-operativetreatment was recommended owing to the higherrates of complications after surgery. Nonetheless,randomisation was based on which orthopaedic

team was on-call, which may have introducedselection bias. The grade of the surgeon was also notmentioned, nor was the delay in treatment for thenon-operative group.  Failure to apply the equinus cast within 48hours of injury results in poor outcome.20  Re-rupture rates were comparable in 73 patients withAchilles tendon rupture treated surgically or non-surgically. Patients treated non-operatively hadquicker return to work and sporting activities,whereas patients treated operatively had higher re-rupture rates (3.9% vs. 1.9%) and wound infection

rates. Nonetheless, a standardised surgical techniquewas not used; different suture materials were usedand immobilisation periods varied. This may haveintroduced variables and accounted for a higherre-rupture rate in the operative group. Thus, non-operative treatment was recommended if the injurywas diagnosed and treated within 48 hours.

In a prospective randomised study of 111 patientstreated operatively (n=56) and non-operatively(n=55),21  83% of the patients were sportsmen whoplayed an average of 3.6 hours per week. Surgeryinvolved suturing of the tendon using the Bunnell

method and repair of the paratendon. The operativegroup had 3 (5.4%) re-ruptures and 2 infections,whereas the non-operative group had 7 (13.4%)re-ruptures, one further re-rupture, and one caseof extreme residual lengthening. Calf and ankleplantarexion strength was signicantly better in theoperative group. 57% of the operative group returnedto sports at the same level, compared with 29.1% inthe non-operative group. Thus, operative treatmentwas recommended for all active patients.

In 196 consecutive patients with Achilles tendonruptures treated with an equinus cast for 8 weeks

(n=173) or an operation (n=23),22

  no re-ruptureoccurred in the operative group. In the non-operativegroup, the re-rupture rate was 7%, which was almost50% less than in another study.23 Early application ofthe equinus cast could have accounted for the lowerre-rupture rate. Nonetheless, the activity level of thepatients (hours per week) was not mentioned.  In a review of 125 papers (5056 Achilles tendonruptures) published between 1966 and 2000,24  datawere extracted using a standardised scoring system.Main outcome measures included complication rate(including re-rupture rate), strength, time to return

to work, and rate of return to sports. The re-rupture

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234 M Stavrou et al.  Journal of Orthopaedic Surgery 

rate was 9.8% in the conservative group and 2.2%in the operative group. The overall postoperativecomplication rate was as high as 20%. This was dueto poor surgical techniques in early papers. Patientsin the operative group were more likely to return to

sports and work. Older studies tended to recommendnon-operative treatment and score lower. In highdemand patients, operative intervention was thetreatment of choice. In addition, percutaneousxation resulted in high rates of sural nerve injury andwound complications.25 The percutaneous techniquewas inferior to open end-to-end Bunnel suturing, andhad higher rates of complication (sural nerve injuries

 being the most common) and re-rupture (33%).26

  In a prospective randomised study of 40recreational sportsmen (mean age, 40.7 years)undergoing open (end-to-end Bunnel suturing) or

percutaneous repair,27

 outcome was similar in termsof subjective satisfaction and isokinetics. There were2 (10%) cases of delayed healing in the open group,and one re-rupture (5%) in the percutaneous group.All diagnoses were made using ultrasonography.

In a meta-analysis of 800 patients in 12 trialscomparing operative (open or percutaneous) withnon-operative (casting or functional brace) treatmentsfor Achilles tendon rupture,28  operative treatmentconferred lower risks of re-rupture (relative risk[RR]=0.27; 95% condence interval [CI], 0.11–0.64) buthigher rates of other complications (RR=10.60; 95%

CI, 4.82–23.28). These included infection, adhesions,and disturbed skin sensibility. Percutaneous repairconferred a lower complication rate than open repair(RR=2.84; 95% CI, 1.06–7.62).  In another meta-analysis of 777 patients in 8

randomised controlled trials,29  the non-operativegroup had signicantly higher re-rupture rates(Z=3.33, RR=0.4, p<0.01). The operative group hadhigher rates in terms of moderate complications(Z=4.27, RR=8.95, p<0.01) and minor complications

(Z=5.59, RR=13.38, p<0.01). Moderate and minorcomplications included delayed wound healing,infection, granuloma, sural nerve injury, and adhesionof the skin to the Achilles tendon. Nonetheless, therewas no signicant difference in terms of total or majorcomplications, which included pulmonary embolism,deep vein thrombosis, pneumonia, deep woundinfection, and any complication necessitating re-operation (including tendon lengthening). Functionaloutcome in terms of return to previous levels ofsporting activities and ankle joint range of movementin the 2 groups was not signicantly different, except

that the operative group returned to work earlier.

conclusion

Elderly and low-demand patients with risk factorsfor infection (e.g. diabetes or smoking) should betreated non-operatively. For patients who partakein sporting activities and wish to return to similarlevels of function, operative intervention is superiorin terms of strength and returning to sports, with alower risk of re-rupture.

disclosure

No conicts of interest were declared by the authors.

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C o p y r i g h t o f J o u r n a l o f O r t h o p a e d i c S u r g e r y ( 1 0 2 2 5 5 3 6 ) i s t h e p r o p e r t y o f J o u r n a l o f      

O r t h o p a e d i c S u r g e r y a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d      

t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y      

 p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .