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Nonoperative functional treatment effective for Achilles tendon rupture

Long-term results using a high shaft boot showed a 73.5% success rate with results from 23 surgeons.

Issue: Issue 6 2004

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German investigators recently reported that nonoperative treatment of Achilles tendon rupture using a high shaft boot and hind foot elevation was found to be effective in a large number of patients.

“The first study we published was done by a single surgeon who did all the investigation by ultrasound and decided alone which treatment was appropriate,” co-investigator Martinus Richter, MD, told Orthopaedics Today. “The criticism when we published that study was that the results were not reproducible for other surgeons or other institutions. They doubted that different surgeons could achieve the same results,” said Richter, who is an attending surgeon in the trauma department at Hannover Medical School, Hannover, Germany. He presented the findings at the American Orthopaedic Foot and Ankle Society 20th Annual Summer Meeting.

Second review

The investigators performed the second review as a follow-up, and 23 surgeons performed the nonoperative functional treatment. The study included 168 patients treated from 1990 to 1996, and a mean follow-up of 5.5 years was possible in 125 patients.

The investigators used ultrasound to determine criteria for nonoperative functional treatment. The criteria included a distance of < 10 mm of the tendon’s ends with the ankle in neutral position and an approximation of the tendon’s ends in 20º plantiflexion.

“This [is important] due to the fact that it not only presented a fairly large number of patients, but it also explained the protocol for nonoperative treatment of the Achilles tendon,” said Carol C. Frey, MD, of Manhattan Beach, U.S.A. “These are important parameters that were clearly presented and make this paper very practical.”

Ninety-two patients (73.5% of those available for follow-up) achieved good or excellent results, with complete rehabilitation and full return to sports activity. Of the remaining patients, 9% achieved satisfactory results and 17.5% achieved poor results as a result of Achillodynia, a lengthened Achilles tendon, a reduction in strength or a large reduction in calf size.

“We feel that this study is the basis for justifying nonoperative treatment. Richter said. “I think the key information is that in our institution the contraindication for operative treatment is not automatically an indication for nonoperative functional treatment. To perform a successful nonoperative functional treatment, the tendons need to have contact or it cannot heal.”

Richter added that other studies have attempted to use the same protocol for nonoperative functional treatment, but “they failed because they did not respect the algorithm. It’s really not so easy to do this treatment because if you find out the tendon doesn’t have contact anymore, you have to convert to the operative treatment, and if you don’t, it doesn’t heal. This happened in about 5% of our patients.”

This problem led the researchers to modify the protocol to include a reevaluation of the indication at two to five days using a repeated ultrasound procedure. They also now prolong the 3-cm hind foot elevation treatment in a high shaft boot from six to eight weeks for prolonged protection of the tendon. The patient then wears shoes with a 1-cm hind foot elevation for another three months.

“I want to stress that it is not an easy treatment; you must be an expert in ultrasound, but to [acquire] a sufficient expertise in ultrasound for Achilles tendon assessment takes only five or 10 minutes,” Richter said. “You don’t have to be an experienced sonographer, but you need to learn how to do this. You cannot do this treatment without ultrasound. It’s just not possible.”

For more information:

• Huefner T, Brandes D, Geerling J, et al. Long-term results after nonoperative functional treatment of Achilles tendon rupture. Presented at the American Orthopaedic Foot & Ankle Society 20th Annual Summer Meeting. July 29-31, 2004. Seattle.