Treatment of Tendo Achilles (TA) ruptures can result in considerable morbidity and has significant socio-economic implications. The ideal management of these injuries has yet to be defined. Recent studies have demonstrated that non-surgical treatment with accelerated rehabilitation may have comparable outcomes to surgery. The aim of this study was to evaluate current management and outcomes of TA ruptures at a tertiary referral centre, with a view to developing contemporary treatment guidelines.

A retrospective review of TA ruptures over a 12-month period was undertaken. Patients were managed on an individual based approach with no strict management algorithm followed. Data collection included pre-injury activity level, ultrasound findings and treatment methodology. Outcome data collected included return to activity, incidence of DVT and re-rupture. Patients were followed up for an average of 2 years.

Data was collected in 49 patients. 31 (63%) of these were managed non-surgically. Ruptures were most common in men (65%) at an average age of 44 yrs. Ultrasound scan at initial diagnosis was performed in 28 patients. There was an average gap in equinus of 34mm in the surgical group, while the average gap within the non-surgical group was 24mm (p=0.23). There was no association between the gap observed on ultrasound and re-rupture rate.

At a median of 2 year follow up, there was no significant reduction in average time spent immobilised in a below knee splint in the surgically treated group (10.2 weeks) compared to non-surgical group (10.9 weeks, p=0.35). 86.3% of patients returned to pre-injury level of activity in the non-surgical group and 86.7% in the surgery group (p=1.0). Complications within this patient cohort consisted of one superficial wound infection and one re-rupture, both occurring within the surgical group. Within the surgical group patients were treated with direct primary repair or primary reconstruction using FHL augmentation in cases of delayed presentation. DVT was not observed in either group. Only 22.6% received thromboprophylaxis in non-surgical group compared to 61.1% in surgical group.

We observed that patients within the non-surgical group demonstrated the same return to pre-injury activity as the surgically treated group and had fewer complications. The time spent immobilised was also comparable. Based on these findings, we modified guidelines and now recommend that surgery should be limited to patients with gap of greater than 20 mm in full equinus on ultrasound and in those with delayed diagnosis. We also recommend thromboprophylaxis for 2 weeks in non-surgical group.

Background

It has been suggested that routine follow-up of primary THR patients could be performed by GPs in primary care, rather than by orthopaedic specialists. Essential radiographic follow-up would likely be based on radiographic reports, rather than on inspection of the radiographs themselves.