Enhanced recovery after surgery protocols for minimally invasive treatment of Achilles tendon rupture: Prospective single-center randomized study

Abstract

BACKGROUND

Achilles tendon rupture is a common orthopedic injury, with an annual incidence of 11-37 per 100000 people, significantly impacting daily life. Minimally invasive surgery, increasingly favored for its reduced risks and comparable fixation strength to open surgery, addresses these challenges. Despite advantages like accelerated recovery, perioperative care poses emotional support, pain management, and rehabilitation challenges, impacting treatment efficacy and patient experience. To address these gaps, this study investigated the efficacy of a rapid rehabilitation protocol in enhancing recovery outcomes for minimally invasive Achilles tendon surgery, aiming to develop personalized, standardized care guidelines for broader implementation.

AIM

To evaluate a nursing-led rapid rehabilitation program for minimally invasive Achilles tendon repair surgery, providing evidence-based early recovery indicators.

METHODS

This study enrolled 160 patients undergoing channel-assisted minimally invasive Achilles tendon repair randomized into experimental and control groups. The experimental group received perioperative rapid rehabilitation nursing care, while the control group received standard care. The primary outcome measure was the Oswestry disability index score, with secondary outcomes including quality of life, Barthel index, patient satisfaction with nursing, incidence of complications, and rehabilitation adherence. Statistical analysis included appropriate methods to compare outcomes between groups. The study was conducted in a specific setting, utilizing a randomized controlled trial design.

RESULTS

All 160 patients completed the follow-up. The experimental group showed significantly greater improvements in key efficacy indicators: Postoperative Oswestry disability index score (8.688 vs 18.88, P < 0.0001), quality of life score (53.25 vs 38.99, P < 0.0001), and Barthel index (70.44 vs 51.63, P < 0.0001). The experimental group had a lower incidence of deep vein thrombosis (1.25% vs 10.00%, P = 0.0339) with a relative risk of 0.1250 (95% confidence interval: 0.02050-0.7421). Infection rates were lower in the experimental group (2.50% vs 11.25%, P = 0.0564). Hospital stay (5.40 days vs 7.26 days, P < 0.0001) and postoperative bed rest (3.34 days vs 5.42 days, P < 0.0001) were significantly shorter. Patient satisfaction was 100% in the experimental group vs 87.50% in the control group (P = 0.0031).

CONCLUSION

The rapid rehabilitation intervention significantly reduced pain, shortened hospital stays, and lowered complication rates, improving joint function and patient satisfaction.

Key Words: Achilles tendon rupture; Minimally invasive surgery; Perioperative period; Rapid rehabilitation; Orthopedic surgery

Core Tip: This study highlighted the substantial benefits of implementing a nursing-led rapid rehabilitation program for patients undergoing minimally invasive Achilles tendon repair. By integrating rapid rehabilitation strategies, patients experienced faster recovery, reduced pain, shorter hospital stays, and lower complication rates. The program not only improved functional outcomes and quality of life but also enhanced patient satisfaction and adherence to rehabilitation protocols. This approach provides valuable evidence supporting its adoption as a standard practice for optimizing postoperative care and recovery.

INTRODUCTION

Achilles tendon rupture is a common and severe orthopedic injury, with an annual incidence rate of 11-37 per 100000 people[1-3], which has a significant impact on patients’ daily lives[4]. Currently, surgery is the primary treatment for Achilles tendon rupture, and minimally invasive surgery is increasingly favored by researchers due to its ability to significantly reduce surgical risks while providing fixation strength comparable to open surgery[5-7]. According to numerous studies, the re-rupture rate after Achilles tendon repair surgery is approximately 3.1%-3.5%[8].

However, despite the many advantages of minimally invasive surgery in treating Achilles tendon rupture, such as reduced trauma and accelerated recovery, there are still significant challenges in perioperative care[9]. Although the importance of emotional support and pain management is increasingly recognized, individualized and continuous care is often difficult to implement in practice[10,11]. This can result in unnecessary anxiety and pain for patients before and after surgery, affecting their compliance.

Moreover, specific strategies for early rehabilitation remain controversial. It is challenging to scientifically and effectively carry out ankle joint function exercises and gradual weight-bearing training while ensuring safety, which is a key step in the patient’s recovery process[12-14]. The lack of personalized treatment plans is also a significant issue, as it overlooks the substantial differences between patients in terms of age, physical condition, and extent of injury, thereby limiting the optimization of rehabilitation outcomes. In summary, these issues in perioperative care for minimally invasive Achilles tendon surgery affect both treatment efficacy and the patient’s rehabilitation experience.

There is a greater demand for the understandability and coherence of rehabilitation care guidelines for patients undergoing minimally invasive Achilles tendon surgery. Although the benefits of rapid rehabilitation care have been widely reported, it is still not broadly implemented in most rehabilitation care plans domestically and internationally[15]. Therefore, there is a need to develop personalized and standardized rapid rehabilitation care protocols[16]. This study was a single-center, randomized, double-blind, parallel-controlled clinical trial investigating the efficacy of a rapid rehabilitation surgical care protocol in patients undergoing minimally invasive Achilles tendon surgery with channel-assisted follow-up.

MATERIALS AND METHODS

From January 2023 to December 2023, 160 patients undergoing “channel-assisted minimally invasive Achilles tendon suturing” at the Third Medical Center of the People’s Liberation Army General Hospital were selected as research subjects and randomly divided into a control group and an intervention group using a random number table, with 80 cases in each group. Inclusion criteria were: Patients with a history of Achilles tendon rupture not exceeding 3 weeks before surgery; preoperative risk factor assessments such as American Society of Anesthesiologists Physical Status Classification System score, nutritional assessment, and body mass index; and patients willing to participate in the study and sign an informed consent form. Exclusion criteria included: Calcaneal tuberosity avulsion fractures; autoimmune diseases; rheumatoid arthritis; diabetes; patients with a heavy drinking and smoking history; and those with open Achilles tendon ruptures[7]. After obtaining approval from the hospital Institutional Review Board and securing signed informed consent from the patients, the study was officially initiated. Comparison of general data between the two groups showed no statistically significant differences, indicating rigorous study design and good balance between groups.

Sample size calculation

Using the Oswestry disability index (ODI) as the primary endpoint, the sample size for each group was calculated using the formula:

And a sample size ratio of 1:1. Referencing clinical data from the department for ODI, the calculation yielded 71 cases per group. Considering the loss to follow-up rate and the practical situation of the hospital, the final sample size was determined to be 80 cases per group.

Blinding

To ensure the effectiveness of the study, the following measures were strictly implemented to adhere to the blinding principles: (1) Spatial isolation: Participants receiving different nursing interventions were placed in separate wards to prevent cross-information transmission; (2) Confidentiality mechanism: Except for the directly involved nursing staff, investigators and other relevant personnel were not informed about the details of participants’ nursing assignments; (3) Role division and information barriers: Throughout the trial process, the roles of outcome assessors and intervention implementers were strictly separated. The former were unaware of the participants’ group assignments, while the latter did not participate in the outcome measurement process[8]; (4) Result sealing and awareness limitation: During the trial period, all investigators, staff, and participants were prohibited from accessing any information about measurement results or the trial process; and (5) Interaction restriction: Participants were strictly prohibited from discussing the nursing interventions they received to prevent cross-influence.

Nursing methods

Patients included in the study completed baseline assessments 1 week prior to enrollment and involved ODI scores, quality of life (QOL) scores, and other QOL indicators as well as demographic parameters. On the 7^th postoperative day, the same indicators were re-evaluated, and data on postoperative bed rest duration, hospital stay length, adverse event rates, satisfaction, and compliance were recorded.

These included detailed dietary guidance, scientific rehabilitation training, comprehensive health education, personalized psychological counseling, and proactive prevention and intervention of complications. In terms of pain management, the analgesic regimen was adjusted in real time based on the patient’s specific condition and individual responses[10]. For rehabilitation training, a series of quantifiable and adjustable intensity rehabilitation programs were designed, such as the use of continuous passive motion devices and rehabilitation robots. Regarding psychological support, interventions such as cognitive behavioral therapy and the establishment of support networks were implemented, along with regular assessments using psychological evaluation scales. Professional nurses explained the fast-track plan in detail, including its scientific basis, implementation steps, and expected rehabilitation milestones.

One day before surgery, the responsible nurse introduced the relevant requirements of perioperative fast-track care to the patient. Multimedia formats, such as short videos and PowerPoint presentations, were used to provide perioperative education to the patient, covering aspects such as preoperative and postoperative dietary arrangements, early functional exercises, time to get out of bed, and methods to relieve pain. On the day of surgery, a personalized diet plan and a preventive analgesic strategy was formulated by referring to the consensus guidelines of fast-track surgery experts[16] and the recommendations of the American Society of Anesthesiologists[17] and taking into account the patient’s condition, general comorbidities, nutritional assessment risks, and daily dietary habits: (1) 6 hours preoperative fasting and oral intake of a sugar-electrolyte solution (10% glucose solution 500 mL + 0.9% sodium chloride solution 250 mL) 2 h before surgery; (2) After the patient was safely returned to the ward without nausea or vomiting, drink 50 mL of warm water, observe for 30 min, and then start eating. Adjust to semi-liquid and then normal diet according to the patient’s recovery and use lip balm to relieve dryness and cracking of the lips during the fasting period; (3) To better control postoperative pain, early postoperative local anesthesia combined with small doses of opioid drugs can effectively relieve pain and reduce the side effects of analgesic drugs. In the mid-term, the use of opioid drugs were gradually reduced, increasing the dosage of non-steroidal anti-inflammatory drugs to facilitate pain control and avoid dependency. In terms of psychological intervention, comprehensive psychological assessments were provided during the perioperative period, including measurements of patient anxiety, depression levels, and self-efficacy, and emotional burdens should be alleviated through cognitive-behavioral therapy and family support to enhance their active participation in recovery[18]; and (4) After anesthesia recovery, perform exercises and training to promote the recovery of healthy limbs. This included performing ankle pump exercises with the healthy limb while engaging in isometric muscle contractions of the affected limb and toe flexion and extension exercises.

Regarding the scientific use of Achilles tendon boots and weight-bearing training guidance, it was crucial to emphasize the importance of proper brace usage so that patients and their families could more scientifically engage in medical and rehabilitation care. The decision to use an Achilles tendon boot should be made by a senior orthopedic surgeon. If the boot was used: Postoperative weeks 0-1: The ankle should be strictly fixed in a plantar flexion position of 20°-30°. Postoperative weeks 2-3: The boot should fix the ankle at 30° of plantar flexion. The appropriate weight-bearing levels should be determined based on the patient’s individual differences and tolerance. Postoperative weeks 4-5: The ankle should be fixed at 20° of plantar flexion. At this stage, it was emphasized that the patient should perform active plantar flexion and dorsiflexion exercises while maintaining the ankle in the plantar flexion position. Postoperative weeks 6-7: Free plantar flexion activity within a 0°-30° range is allowed. After 6 weeks, the range of motion for the ankle should be gradually increased to a neutral position, and Achilles tendon massage should be given daily during this period. Postoperative weeks 8-12: The Achilles tendon boot should be gradually removed, and exercises to strengthen the calf muscles should be initiated. Postoperative weeks 13-16: Begin slow jogging with the full foot in contact with the ground, gradually increasing the exercise volume and incorporating small-scale training. For individuals engaged in moderate physical labor, they can gradually return to work. Postoperative weeks 17-20: If no significant discomfort is experienced, athletes can start participating in formal training programs.

Observational indicators

Baseline data: Basic characteristic data, including age, sex, and other indicators, were collected within 7 days prior to patient enrollment.

Primary outcome indicators: The ODI score is used to comprehensively assess the patient’s functional recovery level. Measurements were taken once before treatment and again before discharge.

Secondary outcome indicators: The QOL score and Barthel index, along with the occurrence of postoperative complications, including but not limited to infections, deep vein thrombosis, and poor wound healing, were reported. Additionally, patient satisfaction and adherence to rehabilitation training were evaluated. These indicators help assess the practical value and effectiveness of rapid recovery care interventions in the rehabilitation process of patients undergoing minimally invasive Achilles tendon repair.

Statistical analysis

We used the Statistical Package for the Social Sciences (SPSS, version 24.0; IBM Corp., Armonk, NY, United States) for data analysis. For measurement data that followed a normal distribution, we expressed the data as mean ± standard deviation. For measurement data that did not follow a normal distribution, we described the data using the median and interquartile range. Categorical data were presented as n (%), where n represents the number of observations and% indicates the proportion relative to the total sample size. The Shapiro-Wilk test was used to assess the normality of the data distribution. Continuous variables between groups were compared using t-tests or analysis of variance, and categorical variables were compared using the χ² test. A P value of less than 0.05 was considered statistically significant (Figure 1).

Figure 1 Clinical trial design. The primary outcome measure for comparison between the two groups was the Oswestry disability index (ODI) score. Secondary outcome measures included the quality of life (QOL) score, the Barthel index, patient satisfaction with nursing services, incidence of postoperative complications, and adherence to rehabilitation. ERAS: Enhanced recovery after surgery; ICF: Informed consent form.

RESULTS

Baseline

In the design and implementation of this randomized controlled clinical trial, we placed a high priority on ensuring that the experimental group and the control group were well-matched in baseline characteristics to minimize the impact of potential confounding variables on subsequent efficacy and safety evaluations. Baseline data for all participants included in the study were systematically and comprehensively collected and organized before they were assigned to each group and received the corresponding interventions, thereby ensuring the reliability of the data with respect to its prospective nature and reference benchmark. Detailed baseline characteristic data are provided in Table 1.

Table 1 Patient data summary.

Parameter	Experimental group	Control group	χ2/t	P value
Sex			0.63	0.43
Male	38	33	-	-
Female	42	47	-	-
Age	37.46	36.00	0.29	0.75
BMI	23.76	23.44	0.74	0.46
Before surgery ODI	30.31	30.69	0.11	0.90
Before surgery QOL	18.16	18.83	0.34	0.74
Before surgery Barthel	30.75	31.13	0.16	0.91

Barthel: Barthel index; ODI: Oswestry disability index; QOL: Quality of life.

Efficacy

Compared to the conventional care group, we found that the experimental group showed significant improvements in ODI scores, QOL scores, and Barthel index after implementing the accelerated rehabilitation external care plan.

The ODI scores revealed that both groups had similar preoperative values, with the control group at 30.69 [95% confidence interval (CI): 25.95-35.43] and the experimental group at 30.31 (95%CI: 25.78-34.85). However, a significant postoperative improvement was observed in the experimental group, whose ODI score dropped to 8.688 (95%CI: 6.249-11.13) compared to a decrease of 18.88 (95%CI: 15.51-22.24) in the control group.

In terms of QOL, preoperative scores were also comparable, with the control group scoring 18.83 (95%CI: 15.96-21.69) and the experimental group 18.16 (95%CI: 15.51-20.82). After surgery, the QOL of the control group improved to 38.99 (95%CI: 35.42-42.55), whereas the experimental group saw a more pronounced increase to 53.25 (95%CI: 51.53-54.97), underscoring the benefits of the Enhanced Recovery After Surgery (ERAS) care plan.

Barthel index scores followed a similar pattern, showing no significant difference preoperatively: 31.13 (95%CI: 26.16-36.09) for the control group vs 30.75 (95%CI: 26.63-34.87) for the experimental group. Postoperatively, the score of control group increased to 51.63 (95%CI: 46.86-56.39), while the experimental group achieved a noteworthy score of 70.44 (95%CI: 65.99-74.89), highlighting their improved capacity for daily activities (Figure 2).

Figure 2 Outcomes before and after operation. A: Oswestry disability index (ODI) score before and after operation for the control and experimental groups; B: Preoperative and postoperative quality of life (QOL) scores for the control and experimental groups; C: Barthel index scores for the control and experimental groups before and after surgery. ERAS: Enhanced recovery after surgery.

Complications and adverse events

In the comparative analysis, the experimental group demonstrated significant postoperative recovery advantages over the control group. Specifically, the experimental group had an average postoperative bed rest duration of only 3.34 days, which was notably shorter than the 5.42 days for the control group. Additionally, their hospital stay was significantly reduced to 5.40 days, well below the 7.26 days of the control group. These results indicate that patients in the experimental group were able to recover more quickly from the surgical effects and reduce the hospital burden.

More notably, in terms of complications control, the incidence of deep vein thrombosis in the experimental group was only 1 case (0.01%), and the infection rate was 2 cases (0.02%). In contrast, the control group had an incidence of deep vein thrombosis in 8 cases (10.00%) and infections in 9 cases (11.25%). These data strongly demonstrated that the accelerated recovery care measures are significantly more effective than traditional care plans in preventing postoperative complications, particularly deep vein thrombosis and infections, thereby greatly enhancing patient recovery quality and safety (Table 2).

Table 2 Comparison of clinical indicators and complication rates between the two groups.

Group	Number of cases	Postoperative bed rest duration	Length of hospital stay	Deep vein thrombosis	Infection
Control group	80	5.42 ± 2.46	7.26 ± 2.70	8 (10.00)	9 (11.25)
Experimental group	80	3.34 ± 1.77	5.40 ± 2.76	1 (0.01)	2 (0.02)
χ²	-	4.339	3.440	5.769	4.783
P value	-	0.009	0.000	0.001	0.001

Data were presented as n (%).

Satisfaction and compliance

In evaluating patient satisfaction and compliance, the experimental group achieved significantly better results compared to the control group. Regarding satisfaction, 53 patients (66.25%) in the experimental group reported being satisfied, far exceeding the 11 patients (13.75%) in the control group. Additionally, none of the patients in the experimental group reported poor satisfaction, whereas 20 patients (25.00%) in the control group expressed lower satisfaction levels. In terms of compliance, the experimental group also showed superior performance, with 79 patients (98.75%) meeting the standard for excellent compliance, including 59 patients (73.75%) rated as excellent. In contrast, only 20 patients (25.00%) in the control group had good compliance, with an excellent rate of just 65.00%. The experimental group had only 1 case (1.25%) of poor compliance, while the control group had a significantly higher rate of 35.00%. These data clearly demonstrated that our accelerated recovery care program not only greatly improved patient satisfaction but also significantly optimized adherence to treatment plans, further validating the effectiveness of this strategy in enhancing patient satisfaction and ensuring treatment outcomes (Table 3 and Table 4).

Table 3 Comparison of nursing satisfaction between the two groups.

Group	Number of cases	Satisfied	Better	General	Inferior	Overall satisfaction
Control group	80	11 (13.75)	38 (47.50)	11 (13.75)	20 (25.00)	60 (87.50)
Experimental group	80	53 (66.25)	20 (25.00)	7 (8.75)	0 (0.00)	80 (100.00)
χ²	-	-	-	-	-	7.786
P value	-	-	-	-	-	0.005

Data were presented as n (%).

Table 4 Comparison of the rate of excellent compliance with rehabilitation exercises between the two groups.

Group	Number of cases	Good compliance	Moderate compliance	Poor adherence	Compliance rate
Control group	80	20 (25.00)	32 (40.00)	28 (35.00)	52 (65.00)
Experimental group	80	59 (73.75)	20 (25.00)	1 (1.25)	79 (98.75)
χ²	-	-	-	-	6.44
P value	-	-	-	-	0.015

DISCUSSION

The findings from this study demonstrated that the fast-track surgical care model applied to minimally invasive Achilles tendon rupture surgeries yielded superior patient outcomes compared to traditional care methods. Patients who received fast-track care showed significant improvements in functional recovery, as evidenced by higher Barthel index scores, lower ODI scores, and enhanced QOL post-surgery. Additionally, these patients exhibited better adherence to rehabilitation exercises and greater satisfaction with nursing services. Quantitative indicators such as shorter postoperative bed rest duration, reduced hospital stays, and a lower incidence of complications like deep vein thrombosis and infections further underscored the effectiveness of the fast-track care approach.

These findings aligned with previous studies that highlight the benefits of fast-track surgery in promoting faster recovery, reducing complications, and shortening hospital stays for various surgical procedures[17,18]. Similar results have been observed in fast-track programs for orthopedic surgeries, where early mobilization, personalized rehabilitation, and efficient pain management contribute to improved outcomes[19,20]. For example, studies on fast-track protocols for knee and hip replacements have shown analogous benefits in terms of reduced hospital stays and enhanced recovery, underscoring the generalizability of the fast-track model across surgical domains[21]. However, the present study is unique in its focus on Achilles tendon rupture, an area that has not been extensively explored in the context of fast-track care. Existing literature on Achilles tendon repair emphasizes the importance of early rehabilitation and individualized care, both of which are key components of the fast-track protocol used in this study[22]. By integrating early mobilization strategies with personalized care, our results contributed to the growing evidence supporting fast-track protocols as an effective approach for orthopedic conditions. It is crucial to delve into the challenges and future directions of ERAS[16].

Despite these positive outcomes, this study had several limitations. First, the time points for data collection were limited to the admission and discharge phases, potentially overlooking important intermediate progressions in patient recovery. This lack of continuous monitoring restricts a deeper understanding of the dynamic changes in patient recovery throughout the treatment process. Future studies should incorporate more frequent data collection to capture trends and fluctuations during the perioperative period. Second, although efforts were made to control potential biases, residual biases related to sample selection, data collection, and analysis could have influenced the results. Non-random errors may have affected the internal validity of the study. Third, although our study further confirmed that ERAS can shorten hospital stays, the reasons why patients stay longer were ignored. Fourth, the complexity of the ERAS protocol may lead to “partial ERAS” instead of full implementation. Further studies are necessary to further subdivide the effectiveness of each component in ERAS. Finally, the statistical methods employed were relatively basic, limiting the exploration of more complex relationships between variables. The use of advanced techniques such as multivariate regression or machine learning algorithms could provide greater insight into the intricate factors influencing recovery outcomes[23-25].

The findings from this study have several important implications for clinical practice, health policy, and future research. In terms of practice, the fast-track care model presents an effective and patient-centered approach that can be integrated into existing perioperative care strategies[26-28], particularly for minimally invasive orthopedic surgeries. This model promotes early rehabilitation, personalized care plans, and proactive pain management, all of which contribute to faster recovery and higher patient satisfaction. From a policy perspective, adopting fast-track protocols can help optimize healthcare resources by reducing hospital stays and lowering the incidence of postoperative complications[17,23,29], ultimately leading to cost savings and improved patient throughput.

Future research should focus on refining ERAS protocols through personalized interventions, leveraging advanced statistical models to tailor care strategies to individual patient profiles[30]. Large-scale randomized controlled trials are crucial for validation of the universal applicability of recommended elements and for ensuring consistent implementation effectiveness[31,32]. Detailed observational studies complement RCTs by exploring specific impacts of preoperative, intraoperative, and postoperative elements on recovery outcomes, providing nuanced data for optimizing ERAS pathways across diverse clinical contexts.

CONCLUSION

The fast-track surgical care model offers significant advantages for patients undergoing minimally invasive Achilles tendon rupture repair. By addressing the current challenges in perioperative care, such as the need for personalized rehabilitation plans and efficient pain management, this model has the potential to improve both clinical outcomes and patient satisfaction. Further research is needed to refine these protocols and expand their application across different surgical procedures and patient populations.