Surgery may not be necessary for Achilles tendon rupture

The two ends of a ruptured Achilles tendon are often stitched together before the leg is put in plaster, in order to reduce the risk of the tendon rupturing again. However, Katarina Nilsson Helander, MD, PhD at the Sahlgrenska Academy, University of Gothenburg, Sweden, now suggests that surgery may be unnecessary. Patients who do not undergo surgery have just as good a chance of recovery.

The Achilles tendon, which attaches the calf muscle to the heel, is the body's strongest tendon. The tendon may rupture on sudden tensing of the muscle, something that affects middle-aged men in particular, typically when playing badminton or tennis.

"When the Achilles tendon ruptures, it feels like a sudden, violent and intensely painful snap in the calf or tendon above the heel. It is an injury that has become increasingly common in recent years, probably because exercise is increasingly popular. But whether or not one should operate has been the subject of debate for quite some time," says orthopaedic surgeon Katarina Nilsson Helander, MD, PhD.

When the Achilles tendon has ruptured, the foot is put in plaster with the toes pointing downwards, so that the torn ends of the tendon come into contact and join together as they heal. The torn ends of the tendon are often stitched together before the foot is put in plaster, to make sure they stay in place. In recent times, a removable orthosis has begun to replace plaster casts, making it possible for the patient to start to move the foot sooner. Other studies have shown that early motion stimulates healing.

Surgery increases the risk of infections and sores but is often carried out anyway, as studies have shown that the operation reduces the risk of the tendon rupturing again.

One hundred patients were randomly assigned to surgery with early mobilisation or to early mobilisation alone with the removable orthosis and without prior surgery. In every other respect, all the patients in the study had the same treatment. The thesis shows that there is no difference in the re-rupture rate. A year after the injury, there was no difference in the patients' own impression of symptoms and function, but irrespective of which treatment the patient received, the function tests showed that there remained a substantial difference between the healthy and the injured foot.

"I have concluded that not everybody needs to have surgery, but it is important that those who suffer an Achilles tendon rupture discuss the treatment options with their orthopaedic surgeon," says Katarina Nilsson Helander.

May 14, 2009