Summary

This multicentric retrospective and prospective study is the largest on acute Achilles tendon rupture and evaluates practices and outcomes in general and athlete populations.

Abstract

Introduction

Achilles tendon rupture is one of the most common injuries. There is no current consensus on treatment and rehabilitation.
Therefore, the study goals were to assess patients following a recent Achilles tendon rupture at a min 6-month follow-up, to compare the results between surgery and orthopaedic treatment, between the surgical techniques, to determine the recurrence rate and their risk factors and, to evaluate the time and level of sport activities.

Material And Methods

This is a multicentric, retrospective and prospective study, including acute Achilles tendon ruptures. The minimum follow-up was 6 months. The evaluation criteria were clinical exam, delay to sport and competition, complications, scores ATRS, Visa-A, EFAS, SF 12.
Athletes had a specific follow-up.

Results

The study included 405 patients retrospectively and 128 prospectively. Both groups were similar. The median age was 40. It was mostly sport related. Surgery, particularly open techniques, was the main treatment. Usually, patients were strictly immobilized in equinus, then in neutral for more than a month. The rehabilitation was long, 3 to 5 months. Amyotrophy and tendon increase thickness were systematic. There was no discrepancy in dorsiflexion. Tiptoeing on 5 m was usually possible after 6 months but 30% showed an asymmetry. One-quarter of the patients could not achieve a unipodal jump at 6 months.
The rerupture rate was 5-10% and the complication rate was 30%. Sedentary patients doubled their risk of complications.
At 1 year, quality of life scores recovered before daily activities and sports.
Training was usually possible at 7 months in 76% of cases. Only 61 % of the patients could practice sports at the same level at 8.3 months. Only 42% started competition after 8.7 months.

Discussion

Firstly, the prospective group had fewer patients due to the pandemic.
Although the literature showed few discrepancies between treatments, Tenolig ? seems to increase the risk of rerupture. Moreover, open techniques demonstrate less tendon lengthening. While mini-open seem to generate fewer rerupture and better scores.
Furthermore, compared to the literature, orthopaedic treatments showed worse outcomes: algoneurodystrophy, rerupture, lengthening, amyotrophy, longer rehabilitation and inferior scores.
In addition, as in the literature, a short period of immobilization, early weight-bearing, and early rehabilitation did not increase the risk of complications. Thus, we propose a rehabilitation protocol: non-weight-bearing immobilization in equinus for 3 weeks then weight-bearing in a boot with gradual correction of the equinus for 3 weeks then removal of the boot and rehabilitation intensified.
Finally, like in the literature, it can be a life-changing injury, 25 to 40% of athletes stopped competition. Half of the patients practising a jump impulse sport could not resume their activity. Notwithstanding, international athletes had better results than national or regional.

Conclusion

This study is the largest on this topic.
Tenolig and orthopaedic treatments are not recommended for athletes. The rehabilitation must start at 3 weeks.
We need to gain more understanding of the Achilles tendon biomechanics and its remodelling process.
Finally, new mini-open techniques using braided sutures and calcaneal anchorage may show benefits in early recovery.