Postoperative Mobilization
We suggest the use of a protective device that allows mobilization by 2- 4 weeks post operatively.
Rationale
A systematic review identified five Level II 40, 43-45 studies comparing postoperative immobilization to postoperative mobilization following surgical repair of the Achilles tendon. All five studies randomized the patients into two groups with either six weeks in a cast or early motion with a modified splint device. For all studies, patients in the mobilization group had a splint or modified cast device that limited dorsiflexion to protect the repair.
All five studies40, 5, 43-45 found that the weight bearing group had statistical improvement in the mean time to return to activities such as work and normal walking. One44 of three studies found a significantly higher rate in return to sport activities at twelve months, while two40, 39 found no difference. One study 5 found a significantly higher re-rupture rate in the postoperative mobilization group (2 of 23 patients) compared to the immobilization group (0 of 25 patients). Both patients had documented non-compliance with the use of their postoperative splint and fell during the first 4 weeks after surgery. By 12 to 18 months, all five studies40, 5, 43-45 found that there was no significant difference between the two groups in outcomes such as pain and function.
Although the ultimate level of function achieved after operative repair of an Achilles rupture is similar regardless of the postoperative immobilization protocol, early postoperative mobilization allows the patient to achieve a quicker return to activities during the first six months than those patients treated with immobilization. However, treatment decisions should be made in light of all circumstances presented by the patient. Mutual communication between patient and physician should include a discussion of the importance of patient compliance when a program is prescribed for early mobilization. Patient compliance to protocol is important to aid in protection of the incision during the early post-operative period and is also important to prevent wound healing complications.
All five studies40, 5, 43-45 found that the weight bearing group had statistical improvement in the mean time to return to activities such as work and normal walking. One44 of three studies found a significantly higher rate in return to sport activities at twelve months, while two40, 39 found no difference. One study 5 found a significantly higher re-rupture rate in the postoperative mobilization group (2 of 23 patients) compared to the immobilization group (0 of 25 patients). Both patients had documented non-compliance with the use of their postoperative splint and fell during the first 4 weeks after surgery. By 12 to 18 months, all five studies40, 5, 43-45 found that there was no significant difference between the two groups in outcomes such as pain and function.
Although the ultimate level of function achieved after operative repair of an Achilles rupture is similar regardless of the postoperative immobilization protocol, early postoperative mobilization allows the patient to achieve a quicker return to activities during the first six months than those patients treated with immobilization. However, treatment decisions should be made in light of all circumstances presented by the patient. Mutual communication between patient and physician should include a discussion of the importance of patient compliance when a program is prescribed for early mobilization. Patient compliance to protocol is important to aid in protection of the incision during the early post-operative period and is also important to prevent wound healing complications.
- (40) Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med 2003;31(5):692-700.
- (43) Mortensen NHM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon: A prospective, randomized clinical and radiographic study. Journal of Bone and Joint Surgery - Series A 1999;81(7):983-990.
- (44) Cetti R, Henriksen LO, Jacobsen KS. A new treatment of ruptured Achilles tendons. A prospective randomized study. Clin Orthop Relat Res 1994;(308):155-165.
- (45) Kangas J, Pajala A, Siira P, Hamalainen M, Leppilahti J. Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. J Trauma 2003;54(6):1171-1180.
- (5) Costa ML, MacMillan K, Halliday D et al. Randomised controlled trials of immediate weight bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br 2006;88(1):69-77.