Chou: OKU: Foot and Ankle 7

Chapter 23: Disorders of the Achilles Tendon

the only significant between-group difference was that patients in the surgical group performed better in the heel-rise test. A study reported results on the first 45 of these 97 patients in whom an ultrasonography was per formed before the initiation of treatment. Nonsurgical management of ruptures with more than 10 mm of dias tasis between the tendon ends led to significantly higher rerupture rates than with surgical management. 7 Another randomized study of surgical and nonsurgical treatment in 144 patients evaluated functional outcomes after an accelerated functional rehabilitation program that began 2 weeks after injury. 8 No significant between-group difference was found in range of motion, strength, or rerupture rate. A meta-analysis of 10 randomized studies concluded that the risk of rerupture was equivalent after surgical or nonsurgical treatment of an Achilles tendon rupture if early motion was used during nonsurgical treatment. 9 If early motion was not used, the risk reduc tion with surgery was 8.8%. No significant difference was found in range of motion, strength, calf circumfer ence, or functional outcome. A 2021 network meta-­ analysis of 19 randomized controlled trials compared outcomes of treatment with primary immobilization, function rehabilitation, minimally invasive repair, and open repair. No difference in rerupture risk was found between modern treatment techniques (functional reha bilitation, minimally invasive repair, and open repair), whereas traditional primary immobilization was asso ciated with higher rerupture risk compared with open repair (odds ratio, 4.06). Minimally invasive surgery was associated with a lower risk of complication that resulted in additional procedures. 10 This is a different result than was previously reported in a meta-analysis of level I and level II studies compar ing surgical and nonsurgical treatment of acute Achilles tendon ruptures. 11 A 3.7% rerupture rate in the surgical group and 9.8% in the nonsurgical group were noted. No significant difference was found in return to sport, incidence of deep vein thrombosis, or physical activity scale. These results were similar to those found in a 2022 multicenter randomized controlled trial of 526 patients who were assigned to nonsurgical treatment, open repair, or minimally invasive repair. Although no difference in functional outcomes was reported between groups at 12 months, nonsurgical management was associated with a higher rate of rerupture (6.2% versus 0.6% in each of the surgical groups). 12 With regard to trends in choice of treatment method, there may be geographic variability. A review of a large healthcare database suggested that surgical management is the preferred method of treatment for acute Achilles tendon ruptures in the United States. 13 A review of a Denmark national registry from 1994 to 2013 showed a statistically significant increase in incidence of Achilles

tendon ruptures and a noticeable decline in surgical treat ment from 2009 to 2013. 14 Recent research on the surgical treatment of Achilles tendon ruptures has focused on the use of minimally invasive repair techniques and early mobilization ( Figure 2 ). Historically, minimally invasive and percutaneous techniques have been criticized as leading to relatively high rates of rerupture and sural nerve injury. 15-17 A ret rospective study evaluated the use of immediate weight bearing in 52 patients. 15 After surgery using a modified percutaneous approach, the limb was placed in a cast, and immediate weight bearing was allowed. A boot with a heel lift was substituted after 2 weeks, and exercises were started. At an average 28-month final follow-up, 47 patients (90%) were able to return to their desired level of activity, and the average American Orthopaedic Foot and Ankle Society score was 90. Four patients had sural neuritis, which resolved within 6 months. No reruptures were observed. A study of 15 elite athletes found that all were able to return to their sport after a minimally invasive repair. 17 Thirteen patients had no pain but did have a subjective perception of reduction in calf strength, two had wound-healing difficulty, and none had sural nerve injuries. The study concluded that percutaneous repair is safe and effective for treating Achilles tendon rupture in elite athletes. In a randomized prospective study comparing open repair with the use of a commer cially available percutaneous repair device, all 40 patients regained Achilles tendon function. 16 No between-group difference was found in maximal calf circumference, ankle dorsiflexion, or the ability to perform heel rises. The complication rate was 5% in the patients treated with a percutaneous repair and 35% in those treated with an open repair. No reruptures or sural nerve injuries were found in either group of patients. There were fewer incidences of local tenderness, skin adhesion, and tendon

Section 7: Tendon Disorders and Sports Related Foot and Ankle Injuries

A FIGURE 2 A , Intraoperative photograph showing a mini mally invasive Achilles tendon repair. B , Photograph showing resting tension of the Achilles tendon restored after repair. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023 B

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Orthopaedic Knowledge Update ® : Foot and Ankle 7