Achilles tendon rupture: Less frequent with surgical treatment

Controversy rages within the medical community. Should an Achilles tendon rupture be performed systematically? If so, what methods should be preferred? If not, what immobilization and rehabilitation protocol should be chosen?

To assess the benefits and risks of these different treatments, a large, multicenter, randomized, Norwegian study, published in the “New England Journal of Medicine,” compared the efficacy of three commonly used types of management in acute Achilles tendon rupture: orthopedic treatment, open surgery, and minimally invasive surgery. The percutaneous only technique is not included.

Acute Achilles tendon rupture is a common disease (31 cases per 100,000 cases per year), preferentially affecting male athletes aged 30–50 years whose management can be surgical or surgical (open, minimally invasive technique or via Skin).

This condition, the diagnosis of which is primarily clinical (hematoma, physiological loss of equilibrium and positive Thomson’s sign) in the context of acute pain with sudden sensation, unfortunately is not always well defined in time. When this is the case, the surgical option is preferred due to better reconstructed tendon stiffness and presumed early resumption of athletic activity. Orthopedic treatment is sometimes preferred because of the lower risk of complications.

Paralysis and rehabilitation

To reach these conclusions, 554 adults underwent either open surgery, consisting of direct suturing of the torn tendon after an incision of more than 10 cm, or minimally invasive surgery with suturing of the tendon fragments at a distance and incision of 3 cm, i.e. a simple orthopedic treatment.

For each of the three treatments, patients wore a shoe made from a horse’s foot for two weeks, then an ankle orthosis for six weeks with three heel wedges removed one at a time every two weeks. Rehabilitation, common to all alike, was based on a dynamic protocol beginning with the removal of the plaster cast and extending over a period of three months.

The authors of this publication selected the variance, between study start and at one year, from the ATRS score, a 100-point scale assessing pain sensation, strength, fatigue, stiffness, and limitations in physical activities, as the main end point related to the affected tendon. Secondary outcomes included physical performance and mental health assessment at 6 and 12 months, incidence of complications, and incidence of new tendon rupture at 1 year, among others.

Improvement in all three groups

Finally, the one-year improvement in the ATRS score was similar in the three treatment groups and also at the three- and six-month follow-up. Furthermore, secondary outcomes were equally similar between groups. The only exceptions were the risk of a new rupture, which was higher in patients treated with orthopedic surgery than in patients treated with open or minimally invasive repair (6.2% versus 0.6% in both surgical groups), and the incidence of superficial nerve damage, affecting On 2.8% of patients in the open repair group and 5.2% in the minimally invasive surgery group compared to only 0.6% in the non-operative group.

The main conclusion of this study, Intended by Dr. Antoine Jerometa, orthopedic surgeon at the Clinique du Sport in Paris, is that surgery clearly reduces the risk of a second tendon rupture compared to conventional treatment. » Indeed, as confirmed by previous experiences on this topic, surgical management makes it possible to obtain better rigidity of the affected tendon in the long term, which effectively reduces the occurrence of a new fracture, regardless of the technique chosen – open or minimally invasive.

group of surgical techniques

“Personally , Surgeon warns, I use open surgery because it allows me to precisely sew the torn tendon to the appropriate length. However, the minimally invasive technique also has good results. »

Moreover, the latter should not be confused with the percutaneous Tenolig technique, absent from the Norwegian study, which consists in closed suturing of the affected tendon. This method, without a genuine surgical approach, and the purpose of which is to protect the skin and promote rapid healing and early mobilization of the tendon, is now widely questioned due to the high risk of nerve damage and recurrence of rupture. A note shared by Dr Jerometa who regularly returns to the operating room for patients initially operated on by Tenolig whose tendon has ruptured again or appears with secondary elongation.

Regarding orthopedic treatment, surgeon says, Rather, it should be intended for patients who are non-athletic, smokers, or have comorbidities such as obesity or diabetes, given the risk of potential complications associated with surgery such as infections or healing defects, which are more common in this population. illness. » In the endThis study confirms the superiority of the surgical option – open or minimally invasive – over conservative treatment, due to the long-term strength of the tendons. Thus, surgery enhances its gold standard status in the event of an acute Achilles tendon rupture in an active patient without comorbidities.

S. Myhrvold et al, New Engl J of Med, April 2022. DOI: 10.1056/NEJMoa2108447

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