Why do emergency clinicians need to know about this paper? Afterall, we will not be making treatment decisions about to operate or not…
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.
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!
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]