Dr. Lewis Responds to Recent Article on the Best Postoperative Management of Acute Achilles Tendon Rupture

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The original artcile, featured below, says that Achilles tears can be treated nonsurgically. Dr. Lewis agrees and found the article compelling. Read her response to the article below.

"Studies have shown that early functional rehabilitation, early mobilization, and weight-bearing following acute achilles tendon fixation improves patient satisfaction. Compared to the study group that was immobilzed and nonweight-bearing for 6 weeks, there was no significant difference between the groups' return to work, return to sports, rerupture rate, and long-term ankle strength and motion.  

Patients, however, definitely "felt better" with decreased immobilization and earlier walking. They had an increased likelihood of rating their experience as good or excellent. 

In a motivated, extremely compliant patient, I definitely agree that early rehabilitation is sound. Although long-term results do not differ between the two postoperative philosophies, a happier patient is important. 

It is crucial to remember that we still have to be cognizant of the soft-tissue envelope, and that early mobilization could increase the incidence of wound-healing problems.

I would recommend at least two weeks of immobilization, and in select patients, proceed with early functional rehabilitation in their third week."


Full Article: What's the Best Postoperative Management of Acute Achilles Tendon Rupture?

NEW YORK (Reuters Health) - For acute Achilles tendon rupture, early dynamic functional rehabilitation is just as safe as the traditional ankle mobilization, and with greater patient satisfaction, according to a new meta-analysis.

"It is safe to be more aggressive with earlier rehab and this approach results in improved results for patients," Dr. Robert G. McCormack from the University of British Columbia in New Westminster, Canada, told Reuters Health by email.

Traditionally, operative repair of ruptured Achilles tendon was followed by a prolonged period of ankle immobilization in a rigid cast. Several studies, however, have suggested that early postoperative ankle motion and functional rehabilitation did not increase the rerupture rate and may improve motor performance.

Dr. McCormack and Dr. James Bovard investigated whether one approach was superior to the other in their systematic review and meta-analysis of 10 published randomized controlled trials including 570 patients: 281 assigned to early functional rehabilitation and 289 assigned to postoperative casting.

Early functional rehabilitation involved early mobilization and weight bearing between 24 hours and two weeks after surgery, either in a dynamic brace, rigid dorsal splint, removable cast boot, or semirigid wrap. The casting group received a non-weight bearing rigid cast or cast boot that immobilized the ankle for six to eight weeks after surgery. All patients underwent physical therapy after brace or cast removal.

There was no significant difference between the groups in the time to return to employment and sports activities, although five of six trials indicated a nominally faster return in the bracing group.

In six trials that reported patient satisfaction, the bracing group had three times the odds of rating their satisfaction as "good" or "excellent" compared with the casting group.

In the only trial that used RAND-36 to assess health-related quality of life, the bracing group reported significantly better scores for physical functioning, social functioning, vitality, and role-emotional domains than did the casting group.

Major complication rates did not differ between the groups, and reruptures were uncommon, occurring in fewer than 3% of patients in both groups, the researchers report in the British Journal of Sports Medicine, online August 17.

Ankle strength and range of motion in the injured leg tended to be closer to normal in the bracing group early on, but these differences disappeared with longer follow-up. Calf atrophy differed little between the groups.

"Postoperative immobilization is not necessary or helpful," the researchers conclude.

Dr. McCormack said that bracing should become the standard of care for postoperative management of these patients. He added, "The value of a systematic review like this is that the consistency of results gives confidence to the clinician that the conclusions are valid."

SOURCE: http://bit.ly/1PWQLte

Br J Sports Med 2015.