Literature

Clinical Pearls & Morning Reports


By Carla Rothaus

Published April 13, 2022

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Was surgery associated with better outcomes than nonoperative treatment for Achilles’ tendon rupture in the trial by Myhrvold et al.? 

An acute Achilles’ tendon rupture is one of the most common musculoskeletal injuries. Myhrvold et al. conducted a randomized trial that compared nonoperative treatment, open repair, and minimally invasive surgery for acute Achilles’ tendon rupture in adults. Read the NEJM Original Article here.

Clinical Pearls

Q: What was the impetus for the trial by Myhrvold et al. about the treatment of Achilles’ tendon rupture?

A: Minimally invasive surgical techniques have been developed to reduce the risk of complications associated with open surgical repair, but randomized, controlled trials that have compared nonoperative treatment, open repair, and minimally invasive surgery are few in number and involved limited sample sizes.

Q: What is the Achilles’ tendon Total Rupture Score?

A: The primary outcome of the trial was the change from baseline in the Achilles’ tendon Total Rupture Score at the 12-month follow-up. The Achilles’ tendon Total Rupture Score is a patient-reported assessment designed to measure outcomes in patients treated for acute Achilles’ tendon rupture. The questionnaire consists of 10 questions to assess symptoms and the level of physical activity; answers are assessed on an 11-point Likert scale (scores range from 0 to 10, with maximum possible score of 100; higher scores represent better health status). The minimal clinically important difference in the score has previously been defined as 8 to 10 points.

Morning Report Questions

Q: Was surgery associated with better outcomes than nonoperative treatment for Achilles’ tendon rupture in the trial by Myhrvold et al.?

A: In this multicenter trial, the authors found no significant differences in changes in the Achilles’ tendon Total Rupture Score among patients who had been randomly assigned to receive nonoperative treatment or undergo open repair or minimally invasive surgery. The change in the Achilles’ tendon Total Rupture Score from baseline to the 12-month follow-up was −17.0 points (95% confidence interval [CI], −20.0 to −14.0) in the nonoperative group, −16.0 points (95% CI, −19.0 to −12.9) in the open-repair group, and −14.7 points (95% CI, −17.9 to −11.6) in the minimally invasive surgery group (P=0.57). Pairwise comparisons provided no evidence of differences between the groups.

Q: Which one of the three treatment groups in the trial had the highest risk of tendon rerupture or nerve injury?

A: There were 11 reruptures in the nonoperative group (in 6.2% of the patients), 1 in the open-repair group (in 0.6%), and 1 in the minimally invasive surgery group (in 0.6%); no patient had more than 1 rerupture. The risk of rerupture was 5.6 percentage points higher in the nonoperative group than in the open-repair group (95% CI, 1.9 to 10.2) and the minimally invasive surgery group (95% CI, 1.8 to 10.2). The risk of rerupture was similar in the two surgical groups (difference in risk, −0.01 percentage points; 95% CI, −2.7 to 2.6). Half the reruptures occurred within the first 10 weeks (range, 2 to 28) after injury. There were 9 nerve injuries in the minimally invasive surgery group (in 5.2% of the patients) as compared with 5 in the open-repair group (in 2.8%) and 1 in the nonoperative group (in 0.6%). The incidence of other adverse events was similar among the groups.

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