OUTCOME OF ACHILLES TENDON RUPTURES OVER 40 YEARS OF AGE

Participants: J.E. Kuhn, D. Weber, P. Thomas

Keywords: ankle, achilles tendon

Introduction

Treatment of ruptures of the Achilles tendon is controversial, with proponents for operative repair and non-operative treatment. Some reserve operative repair for younger patients. The purpose of this report was to prospectively evaluate a group of patients over the age of 40 with Achilles tendon ruptures to provide information regarding the optimal treatment methods.

Materials and Methods

Using ICD-9 codes in a computer search, 26 patients over the age of 40 were treated over a 7 year period (1987-1994) for an acute, isolated, complete, uncomplicated unilateral rupture of the Achilles tendon. Two patients could not be located and one had died, leaving 23 patients for review with greater than two years of follow-up. All of these patients completed a subjective evaluation, which included the American Orthopaedic Foot and Ankle Society ankle and hindfoot scale, and also addressed athletic participation before and after the injury. Physical examinations and Biodex testing of ankle strength in plantar flexion was performed in 21 patients. Patients were divided into two groups based on their treatment. Fourteen patients received non-operative treatment, which consisted of immobilization in an equinus cast for 6 weeks, with subsequent continued immmobilization in a neutral position for an additional 2 weeks. At 8 weeks, active range of motion activities were permitted with partial weight bearing using a 1.5 inch heel lift. Weight bearing increased to full at 12 weeks and an aggressive strengthening program was begun. Nine patients underwent surgical repair, with immobilization in neutral for 6-8 weeks, and partial weight bearing begun at 4 weeks. When the cast was removed, patients used a 1.5 inch heel lift and began a similar physical therapy program. Comparisons between the two groups are presented as descriptive statistics. The re-rupture rate for each group was analyzed using a 2x2 contingency chi-square test.

Results

Re-ruptures of the Achilles tendon occurred in 6/14 (43%) patients treated non-operatively and in 0/9 treated surgically (p<0.001). The ability to return to former levels of athletics was better for the surgical group (6/9 or 67%) than for the non-operative group (5/14, 36%). Patient satisfaction was better for the surgical group as well, with 7/9 (78%) reporting complete satisfaction compared to 6/14 (43%) of the non-operative group satisfied with their outcome. The majority of patients in both groups demonstrated some decrease in strength and endurance with Biodex testing compared to the uninjured side.

Conclusions

The study demonstrates a significant risk for re-ruptures of the Achilles tendon when treated non-operatively using this protocol in patients over 40 years of age. Patients were found to have a decrease in the level of sporting activity, and a decreased level of satisfaction in the non-operative treatment group. Surgical intervention should be strongly considered in patients over 40 years of age with Achilles tendon ruptures.