Comparative Effectiveness of Operative and Nonoperative Management Strategies for Acute Achilles Tendon Rupture: A Narrative Review

Acute Achilles tendon ruptures (AATRs), an extremely prevalent injury amongst adults who remain active, have been treated with surgical intervention for decades. This choice was made due to several decades-old studies demonstrating reduced re-rupture rates as opposed to nonsurgical interventions utilizing casts; however, numerous surgeons and researchers acknowledged potential complications such as wound problems and nerve damage. Functional braces and early weight-bearing now challenge this 'surgical by default' model. An evidence-based, focused review of randomized clinical trials, conventional and network meta-analysis, and large cohorts was conducted for the comparison of operative and nonoperative treatment for AATRs or the evaluation of various rehabilitation approaches. Operative management provides a lower rate of re-rupture in comparison to traditional cast-based nonoperative treatment; however, operative management also results in increased wound complications and sural nerve injuries. Nonoperative management employing functional bracing and early weight-bearing provides re-rupture rates approaching those of operative management, and the long-term functional outcome data are generally comparable. Differences in structural changes continue to exist between the two management groups, with longer tendon length and atrophy of the soleus muscle seen after conservative treatment, although for the majority of patients, the resultant strength and endurance deficits will be minimal. Both treatment options may provide optimal results if implemented through structured rehabilitation pathways. Treatment should be individualized based on the patient's specific factors, injury characteristics, and available resources. The use of current comparative effectiveness research to assist in making decisions regarding treatment with the patient is recommended.