Effect of Time to Repair of Acute Achilles Rupture on Clinical Outcomes

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Achilles tendon ruptures are common injuries that are often treated with surgical repair due to the decreased incidence of re-rupture. Few studies have examined how time between injury to surgical repair impacts patient outcomes. The purpose of this retrospective study is to compare the outcomes of three groups of patients with variable timing between injury and surgical repair (0-1 week, 1-2 weeks, and 2-4 weeks). Isokinetic strength assessments, ankle motion, and patient reported outcome were compared. Incidence of post-operative infection and re-rupture were also recorded. It is hypothesized that there will be no difference between the 0-1 week and 1-2 week cohorts, but there may be differences in outcomes after >2 weeks have elapsed. Methods: Patients who underwent primary operative repair of an acute Achilles tendon rupture with a minimum one year follow up were retrospectively identified from a single institutional database over a five year period (2011-2015). Patients who underwent both open and minimally invasive repairs were included. Exclusion criteria included surgery > 4 weeks post injury, surgical reconstruction other than direct repair, patients < 18 years old, history of ipsilateral intra-articular trauma, incomplete PRO or isokinetic data, or a patient declining participation. Outcome measures included calf circumference, ATRS score, VAS score, PROMIS pain interference and physical function scores, radiographic and clinically measured plantarflexion and dorsiflexion, isokinetic (BTE PrimusRS) and subjectively measured plantarflexion strength, and return to work. We also recorded incidence of post operative complications (wound infection, re-rupture.) Categorical variables were compared using Fischer exact tests, while numerical variables were evaluated using an unpaired t-test and one way ANOVA (p < 0.05). Results: 35 patients were included with mean age of 43 +/- 13 years. Mean follow up was 4.3 +/- 1.9 years 11 patients underwent open repair, and 24 patients underwent minimally invasive repair. Tendon repair was performed for 15 patients < 1 week from injury, for 12 patients between 1-2 weeks, and for 8 patients between 2-4 weeks. There was a statistically significant increase in the difference in plantarflexion on lateral radiograph between the operative & non-operative limb with delayed repair. Other variables recorded (PROs, strength) did not achieve statistical significance. There was one post-operative infection in a patient who was repaired ten days after injury. Three patients experienced a re-rupture fixed at 2, 14, and 28 days from injury. All patients returned to preinjury work. Conclusion: Our data suggests that if Achilles tendon ruptures are repaired less than 4 weeks from injury, time to repair does not have a significant effect on objective strength measurements or functional outcome measures. This suggests that a good clinical outcome is attainable any time within the first four weeks from injury. Out study is limited by a small sample size, power, and retrospective analysis. Further investigation with larger numbers is required to clarify the optimal timing for surgical repair of Achilles tendon ruptures.