The Achilles Heel of Geriatrics: A systematic review comparing outcomes of operative and nonoperative management of Achilles tendon ruptures in patients aged 65 years and older

Introduction Achilles tendon ruptures (ATR) are increasingly common in the geriatric population. Recent literature reports a 50% decline in operative procedures among individuals aged 30 to 70, despite a rising overall incidence of orthopedic surgeries. Evaluating standardized outcome measures, such as the Achilles Tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot & Ankle Society (AOFAS) score, along with objective “return to baseline” metrics, is essential for guiding treatment decisions between operative and nonoperative management. This systematic review aims to synthesize current evidence on outcomes following both operative and nonoperative treatment modalities in patients aged 65 and older, to aid clinical decision making. Methods A comprehensive literature search was performed using the following literature databases: PubMed, Embase, SCOPUS, and CINAHL. The search was conducted under the direction of a research librarian. Analogous search strategies were employed across all databases, with filters applied to include only English language studies involving patients aged 65 or older, published between December 2018 and December 2024. The review followed PRISMA 2020 guidelines and was managed using Covidence software (Melbourne, Australia). Of the 752 studies identified, 392 remained after removing duplicate studies, and five met the criteria for data extraction. Two independent reviewers extracted data, requiring a consensus decision for inclusion. Study quality was assessed using the Downs and Black checklist. Results Five studies, involving 18 patients, met inclusion criteria. 13 patients underwent operative treatment and five received nonoperative management. Post treatment, 16 patients demonstrated improved ATRS or AOFAS scores; two patients lacked reported outcome scores. 17 patients returned to their pre-rupture functional baseline, while one operative patient reported ongoing restrictions. Overall, the quality of evidence was rated as low to moderate. Conclusions In patients aged 65 and older, both operative and nonoperative treatments for Achilles tendon rupture appear to yield comparable outcomes in terms of patient satisfaction and return to baseline function. Given the low to moderate quality of available evidence, further high-quality studies are warranted to strengthen treatment recommendations.