Why do emergency clinicians need to know about this paper? Afterall, we will not be making treatment decisions about to operate or not…
Two
reasons.
First, we need
to know the “next step” and be able to inform our patients of what the
treatment options are likely to be.
Second, this
was an RCT published in the New England Journal of Medicine. This is the
highest impact medical journal on the planet. Papers published here set the
guidelines about how we practice medicine.
These authors
from Norway randomized 554 patients with acute Achilles tendon rupture
to one of three treatment arms: conservative, open repair, or minimally
invasive surgery.
The primary
outcome was the change in the Achilles tendon Total Rupture Score at
12 months. They also looked at incidence of tendon re-rupture.
They standardized
the aftercare & rehabilitation in all groups. They required casts and weight
bearing as tolerated using an ankle-food orthosis with heel wedges for 6-8
weeks. They did not report on earlier return to functional status between
groups.
Results?
At 12
months, there was no difference in the rupture score. As expected, there
were more re-ruptures in the conservative vs. surgical arms (6.2%
vs. 0.6%). And there were more nerve injuries in the surgical groups.
All studies
have limitations and this one is no exception. An RCT is only as good as
the measuring tool of its primary outcome. I’m not sure what to make of the rupture
score and self-reporting may have led to bias.
What are we
to make of this?
In the long
term, there probably is no big difference between conservative vs.
surgical management.
Nevertheless,
there is probably enough wiggle room with the interpretation of this study for orthopedists
to continue doing whatever they like. Conservative seems fine in the long run,
but there are higher rates of re-rupture. Surgical treatment is about the same
but comes with the potential for nerve injury and infection.
Seems like
we are right back where we started!
Covering:
Myhrvold S,
Brouwer E, Andresen T, et al. Nonoperative or Surgical Treatment of Acute
Achilles’ Tendon Rupture. N Engl J Med 2022;386:1409-20. [link to article]