Postoperative Rehabilitation Protocols May Affect Rates of Achilles Tendon Re-Rupture after Acute Surgical Repair: A Systematic Review

Abstract

Category: Ankle; Hindfoot Introduction/Purpose: Acute achilles tendon ruptures (AATR) are the most common tendon rupture in the lower limb with an incidence of up to 37 patients per 100,000 patient population annually. Several different guidelines exist on time to full weight bearing after AATR repair. Advantages of surgical management of AATR repairs are to maximize function of the tendon and reduce post-operative complications such as re-ruptures. A systematic review of the literature was performed which evaluated post-operative rehabilitation protocols, their complications and if an optimal post-operative treatment algorithm can be determined. Methods: In October 2022, MEDLINE, EMBASE and Cochrane Library databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The level of evidence (LOE) and quality of evidence (QOE) were evaluated, and statistics on clinical outcomes, post-operative management and complications were calculated. Results: Eleven studies with 437 patients were included. Two studies were LOE I, three were LOE II, three were LOE III and three studies were LOE IV. Mean post-operative follow-up was 33.4 ± 31.2 months. Weighted mean post-operative return to full-weight bearing (FWB) was 4.8 ± 6.4 weeks. Post-operative return to neutral ankle position was achieved at an average of 4.6 ± 3.9 weeks. The overall complication rate was 3.0% (16 of 420 patients) with surgical wound infection (1.9%) and re-rupture (1.2%) the most common. Seven studies described an early rehabilitation protocol that commenced within 4 weeks from surgery. Subgroup analysis showed that early full weight-bearing (≤4 weeks) was associated with a higher re-rupture rate: 1.5% versus 0.7%. Conclusion: This systematic review demonstrated marked heterogenicity in reported rehabilitation protocols after AATR repair. While the risk of re-ruptures after surgical repair are low, we found that rehabilitation protocols that incorporate early weight- bearing within 4 weeks have a markedly increased risk of re-rupture. While there is increasing use of early rehabilitation after surgical repair of achilles tendon ruptures, further study is required to determine the optimal protocol to optimise outcome while decreasing the risk of failure.