Question: In patients with acute, complete rupture
of the tendo Achillis, is surgical or nonsurgical treatment more
effective for improving clinical outcome?
Design: Randomized (unclear allocation concealment),
unblinded, controlled trial with 2-year follow-up.
Setting: University hospitals in Sweden.
Patients: 112 patients (mean age, 39 years [range,
21 to 63 years]; 88% men) who had had a closed
rupture within the previous 7 days. Exclusion criteria were previous injury
to the same tendon, functional impairment on the contralateral side,
diabetes mellitus, neurovascular disease, or immunosuppression.
Follow-up was 100% for rate of rerupture, 83% for
patient-generated quality-of-life ratings at 8 weeks, and 80% for
patient-generated treatment ratings at 2 years.
Intervention: Patients were allocated to surgical
(n = 59) or nonsurgical treatment (n = 53). Surgery
consisted of a short medial skin incision (6 to 8 cm), an end-to-end
suture without augmentation with use of a modified Kessler technique, and
closure of the paratenon. The foot was initially placed in a below-the-knee
plaster cast in equinus; at 12 days after surgery, the cast was
replaced with an articulated brace that allowed a graduated increase
in dorsiflexion over 8 weeks. Nonsurgical treatment consisted of
immobilization in a below-the-knee plaster cast with the ankle in
equinus for 4 weeks, followed by cast immobilization with the ankle
in a neutral position for another 4 weeks. Both groups received
a bilateral heel-raise of 15 mm for an additional 4 to 8 weeks.
Main outcome measures: Rate of rerupture, sick leave duration,
and patient ratings of the results of treatment and of the quality
of life on visual analog scales. Other functional outcomes were
assessed but the rate of follow-up was <80%.
Results: More patients in the nonsurgical treatment
group (11/53) had a rerupture than did those in the surgical
treatment group (1/59) (P < 0.001) (table). Patients
who had surgery reported a better quality of life during the 8-week treatment
period (P < 0.001) and rated the result of treatment more highly
than did patients in the nonsurgical treatment group (P < 0.001)
(table). The groups did not differ with regard to the duration of
sick leave (table).
Conclusion: In patients with acute, complete rupture
of the tendo Achillis, surgery led to a lower rate of rerupture
and higher patient ratings of the result of treatment and their
quality of life than did nonsurgical treatment.