Achilles tendon ruptures: let the patient decide

As we age, our collagen loses its elasticity and our tendons weaken. A ruptured Achilles tendon (TA) is often the result. This is a common injury; patients are usually aged 30 – 50 and it normally occurs with a sudden push-off during sport. Now, the initial reaction when anything is torn is to repair it, and while this holds true for inanimate objects, living things are different – 4 billion years of evolution has made some headway in that regard. Many people do not appreciate that as surgeons, when something is broken, cut or torn, all we do is put the ends roughly together and it is nature that does all the healing; we just take the credit. Placing the torn ends of a ruptured TA together is easy: you just flex the ankle. And it turns out that if you do this, and gradually bring the ankle back to normal position over a few weeks, it heals fine – without surgery, and without the complications associated with surgery.

For this topic, there are many randomised trials comparing non-operative treatment to surgical repair, and almost as many systematic reviews of those trials. The fact that these trials are still being done means that we don’t really know what treatment is best. Consequently, surgeons develop their own opinions and either treat TA ruptures surgically, or non-operatively. This means that the treatment choice depends on the preference of the surgeon, not the preference of the patient. It is easy to sell such an operation (“Your tendon is ruptured and we want to sew it back together”), so what happens in many institutions is that patients who present with a ruptured TA simply get scheduled for surgery.

The different treatment preferences between doctors (instead of between patients) can be seen in studies like this one, where they compared the results between two large hospitals in Sweden, because one hospital treated them surgically, and the other treated them non-operatively. They found about half the re-rupture rate in the surgical group (3% vs 6.6%) but a higher infection rate (1.5% vs 0%). This study was a little biased towards surgery, because the surgical hospital tended to operate on the younger ones and leave the older ones out. For better evidence, we should look at the randomised trials.

The studies
In a Cochrane review of randomised trials comparing all forms of non-operative treatment compared to surgical repair, surgery was associated with a lower re-rupture rate (about half), but a higher complication rate (about 5 times higher; things like infection, skin tethering, numbness). Tests of strength tended to favour surgery (though not always), but tests of overall function are usually the same. Two more recent reviews (here and here) found pretty much the same thing.

But those are overall reviews including all forms of non-operative treatment. The more recent studies of functional non-operative treatment (basically letting the patient use the leg and walk on it, but in a special boot) are getting the best results we have seen from non-operative treatment. Recently, there have been studies like this one and this one, which still show a slightly lower re-rupture rate with surgery (about 1 – 2%), but a much higher complication rate. The functional recovery is similar with either treatment. Other studies, like this one, show no difference in the re-rupture rate between the two groups.

The bottom line

Non-operative treatment of Achilles tendon ruptures results in similar functional outcomes compared to surgery, and avoids the surgical complications of wound infection, scar adhesion and numbness. The price you pay for non-operative treatment is a higher re-rupture rate (between 1 and 3% higher). That’s the information you need to make a decision with your surgeon – don’t let them make the decision for you.