Is operative treatment of delayed Achilles tendon rupture presentation essential? Mid and long-term follow-up of conservatively treated patients

D. Winson, R. Macnair, N. Owen, R. Evans, A.-M. Hutchinson, P. Williams

Introduction: Surgical treatment of delayed Achilles tendon rupture is strongly advised in the literature, but is it always required? The purpose of this study was to report the outcomes of patients with a delayed presentation of Achilles tendon rupture treated conservatively via a dedicated treatment pathway.

Methods: All Patients with a delayed presentation who had been conservatively treated between 2008 - 2014 were identified. The conservative management pathway was the Swansea Morriston Achilles Rupture Treatment (SMART protocol) as used for the acute ruptures. Following ultrasound diagnosis, patients were immobilised in equinus and followed up in a dedicated Achilles tendon clinic along strict rehabilitation guidelines. Outcome measures included complication rates; Achilles Tendon Total Rupture Score (ATRS) and Achilles Repair Score (ARS) repeated at mid (mean of 3 years) and long follow-up (mean of 6 years); and muscle function dynamometry assessing plantarflexion torque of the ankle. MRI of ruptured and non-ruptured legs allowed measurement of Achilles tendon length. Comparisons between the two sides were made (2-tailed t-test).

Results: 19 patients with a mean age of 60 years and a mean delay to treatment of 61 days were identified. The mean ATRS at mid-term follow-up was 65/100 and ARS was 71/100. The mean plantarflexion torque for the injured side was 19.5 N.m compared to 25.7 N.m on the uninjured side, with a significant difference between the two sides (p = 0.001). The mean length of the injured Achilles tendon was 104.9mm and uninjured 97.3mm, with no significant difference (p= 0.111). At long-term follow-up ATRS was 81/100 and ARS was 73/100. There were no re-ruptures. One patient had a pulmonary embolus. One patient went on to surgery.

Conclusions: A conservative management regime for patients with a delayed presentation Achilles tendon rupture provides a satisfactory outcome in the majority of cases.