Question: In patients having repair of Achilles tendon ruptures,
does early motion or immobilization after surgery reduce Achilles tendon
elongation?
Design: Randomized (allocation concealed), unblinded, controlled
trial with 60-week follow-up.
Setting: A university hospital in Oulu, Finland.
Patients: 50 patients who were 21 to 55 years of age (mean age 36 y,
92% men) and treated for an acute, complete, closed Achilles tendon rupture.
Exclusion criteria included an age of >60 years, a delay in treatment of
=1 week, systemic or local corticosteroid treatment, a previous Achilles
tendon rupture on the contralateral side, and diabetes mellitus.
Intervention: All patients had the same operative repair technique
including a central gastrocnemius aponeurosis flap for repairing the Achilles
tendon rupture. 25 patients were allocated to early motion and 25 to
immobilization. On the first postoperative day, patients in the early-motion
group received a below-the-knee, dorsal-blocking, rigid plaster splint, which
they wore for 6 weeks. The splint allowed active free plantar flexion of the
ankle with dorsiflexion restricted to neutral. Patients in the immobilization
group received a below-the-knee plaster splint with the ankle held in a
neutral position for 6 weeks. Full weight-bearing was permitted in both groups
after 3 weeks. Patients were given a standard rehabilitation program of
exercises to perform postoperatively. Jogging was begun at 12 weeks, and
swimming and cycling exercises were recommended. Full-speed running and other
sports were allowed at 6 months.
Main outcome measures: Achilles tendon elongation (assessed by
radiography) and functional outcomes (ankle performance and isokinetic
calf-muscle strength scores).
Main results: Achilles tendon elongation was less in the early
motion group than in the immobilization group at a mean of 60 weeks (median, 2
vs 5 mm; p = 0.05 [borderline significance]). Ankle performance and isokinetic
calf-muscle strength scores did not differ between groups.
Conclusion: In patients who have had surgical repair of an Achilles
tendon rupture, elongation of the Achilles tendon occurred slightly less after
early motion than after immobilization.
The conclusions of the study by Kangas and colleagues support other
research showing that early protected motion during postoperative
rehabilitation after operative repair does not result in clinically
significant tendon elongation compared with traditional cast
immobilization1. The
current study adds radiographic analysis to previously published clinical
data2.
The technique employed in this paper, involving use of a dorsalblocking
splint and early plantar-flexion exercises for 6 weeks, was described by
Carter and colleagues in a consecutive series of standard Achilles tendon
repairs3.
Kangas and colleagues, as well as Mortensen and
colleagues1,
measured elongation radiographically using metallic markers implanted after
tendon repair at the time of surgery. Mortensen and colleagues found more
elongation in the early motion group, whereas the current study found less
elongation in that group. However, in both studies, the outcomes had a
tendency to be clinically better in the early motion group. As the authors
noted in their discussion, the tendency could have been better evaluated with
more patients in the study.
The operative technique used in this study included a gastrocnemius flap
turndown over the repair site. This technique varies from those described in
most other acute repair studies and may add initial strength to the repair,
and thus prevent elongation.
Despite these issues, this study provides further evidence that protected
early motion in the postoperative regimen following open repair is not
detrimental and is more likely to be beneficial. More research is necessary to
ensure these principles are applicable to all types of repairs, including
minimally invasive techniques.
Mortensen HM, Skov O, Jensen PE. Early
motion of the ankle after operative treatment of a rupture of the Achilles
tendon. A prospective, randomized clinical and radiographic study. J
Bone Joint Surg Am. 1999;81:
983-90.81983
1999
[PubMed]
Kangas J, Pajala A, Siira P, Hamalainen
M, Leppilahti J. Early functional treatment versus early immobilization in
tension of the musculotendinous unit after Achilles rupture repair: a
prospective, randomized, clinical study. J Trauma.
2003;54:
1171-81.541171
2003
[PubMed][CrossRef]
Carter TR, Fowler PJ, Blokker C.
Functional postoperative treatment of Achilles tendon repair. Am J
Sports Med. 1992;20:
459—62.20459
1992
[CrossRef]