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Contents lists available at ScienceDirect

Foot and Ankle Surgery


journal homepage: www.elsevier.com/locate/fas

Predictors of functional outcome in non-operatively managed Achilles


tendon ruptures
Randeep Aujla* , Shakil Patel, Annette Jones, Maneesh Bhatia
Trauma & Orthopaedic Surgery, University Hospitals of Leicester, Leicester, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Background: Acute Achilles tendon (AT) rupture management remains debatable but non-operative
Received 31 October 2016 functional regimes are beginning to gain popularity. The aim of this study was to identify predictors of
Received in revised form 11 March 2017 functional outcome in patients with AT ruptures treated non-operatively with an immediate weight
Accepted 21 March 2017
bearing functional regime in an orthosis.
Available online xxx
Methods: Analysis of prospectively gathered data from a local database of all patients treated non-
operatively at our institution with an AT rupture was performed. For inclusion in the study patients
Keywords:
required a completed Achilles Tendon Rupture Score (ATRS) at a minimum of 6 months post injury. The
Achilles tendon
Rehabilitation
ATRS score was correlated against age, gender, time following rupture, duration (8 or 11 weeks) of
Non-surgical treatment in a functional orthoses and complications were recorded.
Results: 236 patients of average age 49.5 years were included. The mean ATRS on completion of
rehabilitation was 74 points. The mean ATRS was signicantly lower in the 37 females (65.8) as compared
to the 199 males (75.6) (p = 0.013). Age inversely affected ATRS with a Pearsons correlation of 0.2. There
was no signicant difference in the ATRS score when comparing the two different treatment regime
durations. There were 12 episodes of VTE and 4 episodes of re-rupture. The ATRS does not change
signicantly after 6 months following rupture treatment completion.
Conclusion: Patients with AT ruptures treated non-operatively with a functional rehabilitation regime
demonstrate comparable function to other non-surgical regimes with low re-rupture rates. Increasing
age and female gender demonstrate inferior functional outcomes.
Clinical relevance: Females and increasing age predict poorer functional outcome in acute Achilles tendon
ruptures managed in a dynamic full-weight bearing treatment regime.
2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction bearing or not [711]. Overall no consensus has been reached upon
an ideal treatment protocol but recent studies have shown
The Achilles tendon (AT) remains the most common tendon promising results from non-operatively treated AT ruptures with
ruptured and the incidence of acute ruptures is increasing [13]. immediate weight bearing with functional rehabilitation regimes
The management of these injuries continues to create debate with [12,13]. Despite this, operative repair still seems to be the
the treatment algorithm beginning with deciding between treatment of choice in the United States of America and
operative or non-operative treatment methods, albeit with recent Scandinavia [14].
trends going away from operative repair for acute primary ruptures Multiple studies have shown that non-operative treatment has
[46]. the benet of a reduced complication rate due to avoiding
There are numerous treatment protocols for the non-opera- operative risks such as skin breakdown, infection and nerve
tively managed AT ruptures, each being individualised to surgeon, damage [9]. This benet was offset by earlier documented higher
department or hospital. Studies have previously looked at re-rupture rates [9]. However, a recent meta-analysis showed no
operative versus non-operative regimes, use of cast immobilisa- difference in re-rupture rate between surgery with postoperative
tion versus functional orthosis and whether to allow early weight functional bracing (5%) and the sub-group of patients treated in
non-operative accelerated rehabilitation regimes (8%) [15]. A
Cochrane review demonstrated that patients treated with
functional bracing fared better with regards to less time off
* Corresponding author at: Specialty Registrar Trauma & Orthopaedics, East
Midlands (South) Rotation, United Kingdom. work and quicker return to sporting activities when compared
E-mail address: Randeep.aujla@hotmail.co.uk (R. Aujla). with plaster cast treatment [16]. In addition to this, functional

http://dx.doi.org/10.1016/j.fas.2017.03.007
1268-7731/ 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
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2 R. Aujla et al. / Foot and Ankle Surgery xxx (2017) xxxxxx

treatment with an orthosis is more work and lifestyle compatible


[17,18]. Despite the attention upon functional outcomes following
most orthopaedic injuries, recent meta-analyses have focused on
re-rupture rates and overall complications as primary outcomes
rather than the functional results following AT rupture.
The purpose of this study was to identify predictors of
functional outcome in AT rupture patients treated non-operatively
with an immediate weight bearing functional regime.

2. Methods

A departmental policy was implemented in January 2010 to


standardise the treatment of acute AT ruptures at the University
Hospitals of Leicester. The VACOped1 walking boot orthosis with
immediate full weight bearing mobilisation was used. Initially
there was caution about immediate weight bearing in an orthosis
so a period of 11-weeks of functional mobilisation was used. A
prospective database was created and complications were
recorded as an audit tool by clinic staff. In February 2011 the
Fig. 1. Picture of the VACOped1 boot (Oped Ag Ltd, Germany).
departmental policy changed and the period of functional
mobilisation was reduced to 8-weeks in line with literature at
that time [11,19]. The treatment protocol has remained the same
open injury, patient choice or a high performing athlete these were
since. Both regimes are described in detail in Table 1. Since January
also excluded from functional analysis.
2010, more than 90% of acute AT ruptures have been treated this
The VACOpedJ boot (Oped Ag Ltd, Germany) was used as the
way. The remaining 10% of patients were treated operatively as a
functional orthosis in all cases (Fig. 1). At each time point on return
result of delayed presentation, open injury, patient choice or high
to the clinic, the boot was removed, skin checks were performed
performing athletes. An Achilles Tendon Rupture clinic, led by a
and the liner changed. Boot adjustments were made according to
clinical specialist physiotherapist, has been established in our
the protocol in place by trained staff. All patients were allowed to
department since January 2014. This clinic has aimed to collect
fully weight-bear immediately once their orthosis was applied. The
functional data prospectively to closely monitor progress since
VACOpedJ achieves stability via an inner vacuum cushion that
January 2014January 2015.
conforms to the shape of the leg by evacuating air, while the
All patients with a suspected AT rupture were assessed
external shell provides rigidity. The boot can be locked at a xed
clinically by the Emergency Department or primary care, placed
angle (ranging from 0 to 30 ) or movements can be permitted
into a dorsal plaster slab with the ankle in equinus and referred to
within this range.
the trauma & orthopaedic fracture clinic. The majority of patients
Following completion of the regime, patients returned for a
attended for assessment in the fracture clinic within 3 days, with
clinical review and their boot was removed. Clinical assessment
all attending within one week. Clinical assessment was performed
of the AT was performed, and if felt clinically intact, the
in all patients. This included the calf squeeze test, palpation for
VACOpedJ was discontinued and patients referred to physio-
rupture gap and ability to single leg heel raise. If on clinical
therapy for strengthening exercises. This was the case for all
assessment, the diagnosis was in doubt, then imaging studies
patients involved.
consisting of either a MRI or ultrasound were conducted. Once the
diagnosis was conrmed by a member of the orthopaedic team,
2.1. Outcome measures
patients were placed in the functional VACOpedJ orthosis (Fig. 1)
and the treatment regime initiated (Table 1).
The primary outcome measure was the Achilles Tendon
Inclusion criteria for the study were primary acute AT ruptures
Rupture Score (ATRS). The ATRS is a patient-reported outcome
(as dened by the clinical features above), age >18, presentation
measure developed by Nilsson-Helander et al. in 2007 [20]. It
within 2 weeks of injury, a minimum follow-up of six months, non-
consists of 10 questions based on an 11 point Likert scale, where a
operative treatment, completed functional mobilisation in either
total score of 0 is worst, and 100 is best. This questionnaire is
VACOpedJ regime and completed ATRS questionnaire. Patients
perceived to be the only relevant, validated patient reported
were excluded if they were less than 18 years of age, had a delayed
outcome score for AT ruptures [21]. The ATRS questionnaire was
presentation (>2 weeks) prior to initiation of treatment, other
administered by post a minimum of 6 months after injury. ATRS
injuries in the same limb, poly-trauma, open injury or if they
questionnaire was sent via post for patients treated between
underwent operative repair. The incidence of re-rupture is
January 2010 and January 2014. Following this the outcomes were
presented. However, this group of patients was excluded from
assessed in the dedicated ATR clinic by a research physiotherapist.
the functional analysis of the results. Operative repair was
Secondary outcomes including re-ruptures, venous-thromboem-
performed in patients with a delayed presentation (>2 weeks),
bolic (VTE) events and any other complications were collected

Table 1
A table to show the duration in weeks spent in each position in the VACOPed1 boot for both 11-week and 8-week regimes.

Regime 30 Plantarexion (static) 15 Plantarexion (static) 1530 (dynamic) 030 (dynamic)
11 weeks (January 2010January 2011) 5 3 2 1
8 weeks (February 2011January 2015) 4 0 2 2

Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
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R. Aujla et al. / Foot and Ankle Surgery xxx (2017) xxxxxx 3

3.1. Gender

The mean ATRS score for all patients was 74.0 (SD 22.0, range 8
100, 95% CI 71.276.8). The mean ATRS score was signicantly
better (p = 0.013) in male patients (75.6, range 8100, SD 21.5, 95%
CI 72.678.6) as compared to female patients (65.8, range 21100,
SD 22.7, 95% CI 58.273.4).

3.2. Age

Functional outcomes were inversely related to age, Pearsons


correlation of 0.2 (p = 0.002). The negative correlation remained
for both male (Pearson correlation 0.175, p = 0.014) and female
patients ( 0.245, p = 0.143), although did not reach statistical
signicance in females.

3.3. Length of functional rehabilitation

There was no signicant difference (p = 0.546) in the mean ATRS


Fig. 2. A owchart to demonstrate the passage of patients through the inclusion/ scores between the 194 patients treated in the 8-week regime
exclusion criteria. (mean 73.6, range 18100, SD 21.9) as compared to the 42 patients
treated in the 11-week regime (mean 75.9, range 8100, SD 22.5).
prospectively. The ATRS was assessed against age, gender,
complications, time following rupture, and duration of functional 3.4. Length of follow-up
rehabilitation regime.
Local ethics approval was obtained via our hospital research Length of follow-up did not signicantly affect ATRS with a
and audit department. Pearson correlation of 0.076 (p = 0.247). There was no signicant
difference in the ATRS scores when comparing those patients
2.2. Statistical methods assessed at 6 months post rupture as compared to those who were
followed up for longer (Fig. 3) (One-Way Anova Post Hoc test p = 1).
The Fishers exact test was used to compare complications
between groups. Correlations were calculated using Pearson 3.5. Complications
correlation. Parametric data is presented as mean and the
independent Student t-test was used for analysis. A one-way The overall incidence of venous thromboembolic events was 5%
ANOVA with a Bonferroni correction was used to assess ATRS (n = 12). 2.7% of such cases occurred in females (n = 1) and 5.5% in
outcomes and duration of follow up. Statistical signicance was males (n = 11) with no statistically signicant difference between
dened as p < 0.05. The sample size was calculated using 10-points the two (Fishers Exact test p = 0.697). The length of functional
on the Achilles Tendon Rupture Score as being signicantly rehabilitation was also not related to the incidence of VTE episodes
different. Standard deviation from the original study involving (p = 0.549).
82 patients was 21.4 [20]. With an alpha error of 0.05, a power of The incidence of re-rupture was 2.6% in females (n = 1) as
80% the sample size was calculated to be 38 per group. compared to 1.5% in males (n = 3), without any signicant
differences between the two (p = 0.501). Length of functional
3. Results rehabilitation also failed to show any signicant difference in the
re-rupture rate (p = 0.549). Patients with re-rupture were excluded
345 AT ruptures were treated at our hospital, after exclusion from all of the analysis above. Three of these patients were treated
criteria, between January 2010 and January 2015. Complete data successfully with a further functional rehabilitation regime and
was available in 70% (n = 240) of patients. 4 patients had re- one underwent surgical repair. The ATRS score in these 4 patients
ruptures whose ATRS scores were post completion of re-rupture following successful treatment for re-rupture was 54.5 as com-
treatment and were therefore excluded from the analysis of ATRS pared to the 74 in the 236 patients who did not. Due to the small
outcomes. This left 236 patients for the nal analysis (Fig. 2). number statistical analysis was not performed.
There were 199 (84%) male patients with a mean age 49.0 years
(SD 13.7) and 37 (16%) females of average age 52.7 years (SD 16.8). 4. Discussion
Patients were followed up for a mean of 24 months (range 658)
following completion of the regime. Results are summarised in Debate remains as to the optimal treatment for acute AT
Table 2. ruptures. More evidence is available supporting non-operative

Table 2
A table to show the affect of variable of nal Achilles Tendon Rupture Score in non-surgically managed Achilles tendon ruptures.

Variable Sub-category ATRS Statistical result


Gender Male 75.6 (SD 21.5) p = 0.013
Female 65.8 (SD 22.7)
Age Continuous variable Pearsons 0.2 (p = 0.002)
Length of treatment 8-week regime 73.6 (SD 21.9) p = 0.546
11-week regime 75.9 (SD 22.5)
Length of follow-up Contnuous variable Pearsons 0.076 (p = 0.247)

Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007
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4 R. Aujla et al. / Foot and Ankle Surgery xxx (2017) xxxxxx

Fig. 3. A gure to show how duration of follow-up affected functional outcome results in acute Achilles tendon ruptures.

treatment with immediate full weight bearing in a functional treated AT ruptures. They showed males had a 13 point superiority
rehabilitation regime over operative repair. However, variables over females when operatively managed. However, there was no
that may affect outcomes through this method of treatment are not difference shown for non-operatively treated AT ruptures [26].
yet known. This cohort study of acute AT ruptures treated in a Bostick et al. evaluated predictors of calf muscle endurance at one
dynamic immediate full-weight bearing regime has attempted to year following AT rupture repair. They showed better calf
identify factors that may affect functional outcome. endurance in females at 3 months in a 73 patient cohort [27].
This is currently the largest cohort of functional results for non- There has been no gender difference noted in Achilles tendinop-
operatively treated AT ruptures using the ATRS outcome score. athy or capillary blood ow but there is clearly a higher proportion
Bergkvist et al. showed a mean ATRS of 79 (SD  20.8) in 189 non- of rupture in males in studies [28]. This study currently represents
operatively managed AT ruptures, at a mean follow-up of 3.3 years, the largest series in a functional weight bearing orthoses of
who were managed in functional bracing [13]. Kearney et al. conservatively managed AT ruptures. These results would there-
demonstrated a mean ATRS of 78 (SD  20) at 9 months following fore be most accurate in establishing the inuence of gender on
eight weeks of functional non-operative rehabilitation following outcomes following AT rupture.
AT rupture in 38 patients [22]. These published scores are slightly The second strong inuence on functional outcome identied
better than those demonstrated in this study (ATRS 74). Similar to was age. Increasing age negatively affected functional outcomes in
other studies, a high standard deviation was also demonstrated non-operatively managed AT rupture. Olsson et al. also demon-
(22). The difference is likely to be due to natural geographical strated that an increasing age strongly correlated with a reduced
variation between the groups. However, all patients including heel-rise height. They also showed that increasing BMI by 5 points
those who had complications, such at VTE, were included in the lead to a reduction in ATRS by 10 points [24].
nal results. In operatively managed AT ruptures ATRS scores tend Bergkvist et a. concluded that older female patients may benet
to be higher and range from 82 to 89 [13,2324]. Percutaneous from surgical intervention and the ndings of this study do show a
minimally invasive repair methods have demonstrated an ATRS of similar trend, although failed to reach statistical signicance [13].
89 at 12-month follow-up [23]. Percutaneous repair with This may be due to the smaller number of female patients as
functional rehabilitation may provide the best functional outcome compared to males in this study. Older females do have the poorer
but there are few studies to conrm this theory. The minimally functional results following non-operative treatment. However, it
clinically important difference for ATRS has yet to be established may be worth considering the functional demands of this cohort
and this may facilitate future study comparisons. before subjecting them to surgery.
Inferior results in females compared to males were identied Complications were too infrequent to allow accurate analysis
with a 9.7 point difference (p = 0.013). A similar nding has also into the impact upon function. Barfod et al. showed in a
been shown by Olsson et al. who demonstrated a 12 point randomised controlled trial that immediate weight bearing has
difference favouring males [25]. Sibernagel et al. focussed on no detrimental effect on ATRS, re-rupture rates or health related
gender differences for 94 operatively and 88 non-operatively quality of life [12]. The overall rate of a VTE following

Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
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conservatively managed AT ruptures in this study is 5%. This is Ethical approval


comparable to recent literature having VTE rates of 1.411% for
similar non-operative regimes [11,2932]. Ethical approval was conrmed by local committee.
Soroceanu et al. showed that if functional rehabilitation were
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Please cite this article in press as: R. Aujla, et al., Predictors of functional outcome in non-operatively managed Achilles tendon ruptures, Foot
Ankle Surg (2017), http://dx.doi.org/10.1016/j.fas.2017.03.007