From the Guidelines
Surgery is generally recommended for complete Achilles tendon ruptures, especially in younger, active individuals or athletes who require full strength and function, as it offers potentially better restoration of tendon length and reduced re-rupture rates 1. The decision to surgically repair an Achilles tendon rupture typically depends on several factors rather than a single threshold.
Key Factors Influencing the Decision
- Complete ruptures, especially in younger, active individuals or athletes who require full strength and function, often warrant surgical intervention
- Non-surgical management may be considered for partial tears (less than 50% of the tendon diameter), older or less active patients, or those with significant surgical risks
- The gap between tendon ends is also important; gaps greater than 1 cm often warrant surgical intervention as they may not heal properly with conservative treatment
Timing of Surgical Repair
Surgical repair is typically performed within 1-2 weeks of injury for optimal outcomes, as delayed repairs (beyond 4-6 weeks) become technically more difficult and may have poorer functional results.
Individualized Decision Making
The decision should be individualized based on the patient's age, activity level, comorbidities, and personal preferences after discussing the risks and benefits with their orthopedic surgeon.
Risks and Benefits
Surgery offers potentially better restoration of tendon length and reduced re-rupture rates (2-5% versus 10-20% with non-surgical management), but carries risks including infection, wound complications, and nerve damage, as noted in a systematic review of the literature, including eight studies that addressed the efficacy of open repair and six studies that addressed the efficacy of minimally invasive techniques 1.
From the Research
Threshold for Achilles Surgery
The decision to surgically repair an Achilles tendon rupture depends on various factors, including the patient's age, activity level, and overall health.
- According to 2, operative repair of a ruptured Achilles tendon is associated with a faster return to activity/sport compared to nonoperative alternatives.
- The study by 3 found that surgical technique lowers the risk of rerupture rate but is associated with a higher complication rate.
- However, there is no specific threshold mentioned in the provided studies for when Achilles surgery will be surgically repaired.
Treatment Options
There are different treatment options available for Achilles tendon ruptures, including:
- Open surgical repair: This involves making an incision in the skin to repair the tendon 2, 4, 5, 6.
- Percutaneous/minimally invasive repair: This involves making small incisions in the skin to repair the tendon 4, 5, 6.
- Non-surgical treatment: This involves using functional rehabilitation to treat the rupture 2, 3, 6.
Patient Selection
Appropriate patient selection is critical in determining the best treatment option.
- Younger patients hoping to return to highly competitive athletics should consider operative repair 2.
- Patients with no contraindications should consider open surgical repair as the gold standard 6.
Complications and Outcomes
The studies found that:
- Operative repair is associated with a higher risk of wound complications, but a lower risk of rerupture 2, 3, 5, 6.
- Minimally invasive surgery is associated with a lower risk of wound complications, but a higher risk of sural nerve injury 5.
- Non-surgical treatment is associated with a higher risk of rerupture and deep vein thrombosis/pulmonary embolism 6.