How to Decide When Not to Operate on Achilles Tendon Ruptures

The debate about surgery or not for this injury continues, but this algorithm seems intuitively sensible and useful

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Smart Practice: If you’re contemplating nonsurgical treatment of an Achilles tendon rupture, consider evaluating that tendon using ultrasound according to the CARTA algorithm.

What’s the Claim?

A small, three-armed randomized trial compared selective repair of Achilles tendon ruptures to surgery as well as to nonsurgical care and found no differences among the groups in terms of gait dynamics or outcomes scores. Which patients got surgery in the selective repair group was decided according to CARTA (the Copenhagen Achilles Rupture Treatment Algorithm) results from two ultrasound examinations.

But there was an interesting finding hidden among the reruptures (which also did not differ statistically among the groups): had the patients randomized to nonsurgical treatment who reruptured been evaluated using the CARTA algorithm, three of the four would have received surgical repair. The authors did not emphasize this point, but we thought it was a neat, practical discovery that would cause us to consider using CARTA in practice in patients who are considering nonsurgical management, since it otherwise seems to have no downsides and it may be informative.

How’s It Stack Up?

The “definitive” trial on surgical versus nonsurgical management of this injury was an RCT in the NEJM, which we covered a few months back. It found that surgery for patients with Achilles tendon ruptures (whether traditional or minimally invasive repair) doesn’t result in better patient-reported outcomes at 12 months, but about 6% of the patients treated nonsurgically with serial casting had reruptures (compared with <1% of those in the surgical groups), while about 5% of those treated with open surgery had nerve injuries (compared 0.6% in the nonsurgical group). We learned after covering that study that it censored the data from reruptures (that fact was buried in a 41-page online protocol document), effectively burying its worst nonoperative results, while retaining patients who had surgical complications. (Full disclosure: CORRelations Foot & Ankle Advisor, Gregory Guyton, MD, is working on a re-analysis of the NEJM dataset, which we’ll cover here when it’s available.) The RCT we’re covering here is too small to support grandiose claims, but we liked how intuitively sensible CARTA is, and that it seemingly would have helped surgeons pick which patients would go on to rerupture if managed nonsurgically.

What’s Our Take?