Saturday, February 26, 2005
Early motion may be key to Achilles tendon healingBy Carolyn Rogers
Controlled early motion enhances healing for both surgically and nonsurgically treated Achilles tendon ruptures, and may be the important factor in optimizing outcomes in such patients, according to researchers for Paper 207, "Early motion for Achilles tendon ruptures - Is surgery important? A randomized prospective study."
Achilles tendon rupture is a devastating event that is relatively common in the adult population, the investigators say. Yet, there is no universally agreed-upon treatment regimen, nor are there scientifically sustainable guidelines on whether surgical or nonsurgical management is better.
"Recent randomized studies comparing operative and nonoperative treatment of Achilles tendon rupture have suggested improved outcome and superior strength in the operatively treated patients," said Bruce C. Twaddle, FRACS, the lead author of the paper. "However, in all these studies the nonoperatively treated patients have been immobilized for a much greater period of time, and the surgically treated patients have been allowed early motion and weight bearing."
Therefore, the researchers designed a randomized prospective study to compare a group of patients with Achilles tendon rupture treated with surgery and controlled early motion with a similar group of patients treated with controlled early motion without surgery. Between December 1997 and February 2002, 50 patients referred to Auckland Hospital with acute rupture of the Achilles tendon agreed to participate in the study. The patients (between the ages of 18 to 50 years of age at the time of injury) were randomized to surgical and nonsurgical groups. Both groups were comparable for age and sex.
The patients randomized to the nonsurgical group were placed in a hanging equinus plaster-of-paris cast for 10 days. Patients randomized to the surgical group were admitted and operated on within 48 hours. Surgical treatment involved a postero-medial incision and careful reflection of the damaged paratenon. A whip suture was placed in either end of the damaged tendon to re-appose the tendon ends at the normal resting length of the tendon using the noninjured side as a guide, and the paratenon was carefully repaired over the top. The leg was then placed in the hanging cast for 10 days.
Both groups then received early motion controlled in a removable below-knee orthosis, progressing to full, unsupported weight bearing at eight weeks from treatment. Both groups were followed prospectively for 12 months, measuring range of motion, calf circumference, the Musculoskeletal Functional Assessment Instrument (MFAI) outcome score, re-ruptures and any complications.
Results showed no significant differences between the two groups in plantar flexion, dorsiflexion, calf circumference or MFAI scores measured at 2, 8, 12, 26 or 52 weeks. One patient in each group was noncompliant and required surgical re-repair of the tendon before eight weeks. There were no differences in complications and a similar low number of re-ruptures in both groups (two in the surgical group, and one in the nonsurgical group).
"This study supports early motion as an acceptable form of rehabilitation in both surgically and nonsurgically treated patients, with comparable functional results and a low re-rupture rate," said the presenters. "There appears to be no difference between the two groups, suggesting controlled early motion is the important part of treatment of ruptured Achilles tendon."
Dr. Twaddle's co-researcher was Peter C. Poon, FRACS. Both surgeons are from Auckland, New Zealand.