Total Hip and Knee Arthroplasties Are Highly Cost-Effective Procedures: The Importance of Duration of Follow-Up.

BACKGROUND: Total hip and knee arthroplasties (THA/TKA) are clinically effective but high cost procedures. The aim of this study is to perform a cost-effectiveness analysis of THA and TKA in the New Zealand (NZ) healthcare system. METHODS: Data were collected from 713 patients undergoing THA and 520 patients undergoing TKA at our local public hospital. SF-6D utility values were obtained from participants preoperatively and 1-year postoperatively, and deaths and any revision surgeries from patient records and the New Zealand Joint Registry at minimum 8-year follow-up. A continuous-time state-transition simulation model was used to estimate costs and health gains to 15 years. Quality-adjusted life years (QALYs), treatment costs, and incremental cost-effectiveness ratios (ICERs) were calculated to determine cost effectiveness. ICERs below NZ gross domestic product (GDP; NZ$60 600) and 0.5 times GDP per capita were considered "cost effective" and "highly cost effective" respectively. RESULTS: Cumulative health gains were 2.8 QALYs (THA) and 2.3 QALYs (TKA) over 15 years. Cost effectiveness improved from ICERs of NZ$74,400 (THA) and NZ$93,000 (TKA) at 1 year to NZ$6000 (THA) and NZ$7500 (TKA) at 15 years. THA and TKA were cost effective after 2 years and highly cost effective after 3 years. QALY gains and cost effectiveness were greater in patients with worse preoperative functional status and younger age. CONCLUSION: THA and TKA are highly cost-effective procedures over longer term horizons. Although preoperative status and age were associated with cost effectiveness, both THA and TKA remained cost effective in patients with less severe preoperative scores and older ages.

The Relationship Between Preoperative Oxford Hip and Knee Score and Change in Health-Related Quality of Life After Total Hip and Total Knee Arthroplasty: Can It Help Inform Rationing Decisions?

BACKGROUND: In countries with publicly funded health care, there is an increasing need for explicit rationing for total joint arthroplasty (TJA). The Oxford Hip and Knee Scores (OHS/OKS) have been used to set access thresholds for TJA despite not being developed for that purpose. The aim of this study was to determine whether preoperative OHS/OKS can aid rationing decisions by investigating the changes in general health-related quality of life after TJA. METHODS: OHS/OKS, Short Form-12, and Short Form-6D (SF-6D) scores were collected preoperatively and at 1 year postoperatively in a cohort of patients undergoing total hip arthroplasty (THA; n = 713) and total knee arthroplasty (TKA; n = 520). The association between preoperative OHS/OKS and postoperative score and the change in OHS/OKS and SF-6D was investigated, adjusting for age and gender. RESULTS: The mean Oxford scores improved from 13.9 to 40.7 (OHS) and 15.6 to 37.4 (OKS). The mean SF-6D improved after THA (0.53 to 0.80) and TKA (0.56 to 0.78) (all P < .0001). Poorer preoperative Oxford scores were associated with poorer postoperative OHS/OKS and SF-6D but larger improvements. For every 5 points lower preoperative OHS/OKS, the postoperative SF-6D score was worse by a margin of 0.019 (THA) and 0.023 (TKA). CONCLUSIONS: Preoperative OHS/OKS can help inform rationing decisions. A lower preoperative OHS/OKS will result in greater gains but a lower final outcome score in general health-related quality of life.

Acetabular Liner Dissociation: A Comparative Study of Two Contemporary Uncemented Acetabular Components.

BACKGROUND: There are a number of reports of polyethylene liner dissociation of third-generation modular acetabular components. This study compares our experience with 2 contemporary systems to determine whether this is an implant- or class-specific problem. METHODS: This is a single-center retrospective study of 961 primary total hip arthroplasties using 2 third-generation modular cementless acetabular shells: Pinnacle (535) and R3 (426) with a polyethylene liner. Details of all revisions were obtained from local databases and the New Zealand Joint Registry. Kaplan-Meier survival curves were calculated for all-cause revision, acetabular reoperation (including liner exchange), and liner dissociation. RESULTS: There were 17 revisions in group 1 (Pinnacle; DePuy Synthes): 17 for recurrent dislocation, 6 for liner dissociations (1.12%), 3 for femoral loosening, and one for deep infection. In group 2 (R3; Smith and Nephew), there were 4 revision procedures: one for infection, 2 for dislocation, and one femoral revision for periprosthetic fracture. There were significantly higher proportions revised in group 1 for all-cause revision, acetabular reoperation, and dissociation (P = .024 to 0.038). The 7-year survival for all-cause revision was 96.1% for Pinnacle and 99.0% for R3 (P = .022), and that in the acetabular reoperation group was 96.9% for Pinnacle and 99.3% for R3 (P = .035). CONCLUSIONS: There was a higher revision rate for the Pinnacle acetabular component than for the R3 at 7 years. This was mainly due to polyethylene liner dissociation that can occur early or late. It appears to be a problem specific to the Pinnacle cup design rather than a feature of similar third-generation acetabular components.

National Referral Prioritization tool for first specialist assessment: results of a pilot study in orthopaedic surgery.

BACKGROUND: Most public hospitals are receiving more referrals for first specialist assessment than they have capacity to see. Traditional priority categories are too broad for effective discrimination. In New Zealand (NZ) explicit prioritization is required by legislation and supported by the Medical Council of NZ. A new generic National Referral Prioritization tool (NRPT) has been developed which includes a patient impact on life score. This study reports its trial implementation in orthopaedic surgery in a single centre. METHODS: Four months of referrals to the orthopaedic department were prioritized using the new NRPT and traditional clinical priority categories. Scores and acceptances were compared across conditions, surgeons and against the traditional categories. RESULTS: The mean NRPT was 60.1 (range 23-99). The correlation with impact on life was 0.59. There was good consistency of scores between surgeons. The NRPT score was significantly different across clinical priority categories (urgent, semi-urgent, routine). A total of 305 referrals (49%) were accepted using the NRPT compared with 493 (79%) if the traditional tool had been used. Patients with foot and ankle, carpal tunnel syndrome and upper limb conditions had the lowest scores and were more likely to be declined. CONCLUSIONS: The NRPT is the first tool designed to prioritize referral letters. It is more discriminating than the clinical priority categories used previously. It allows fine-tuning of a threshold score to balance acceptances and capacity.

The Functional Outcomes of Patients With Knee Osteoarthritis Managed Nonoperatively at the Joint Clinic at 5-Year Follow-Up: Does Surgical Avoidance Mean Success?

BACKGROUND: Nonoperative management of patients with knee osteoarthritis (OA) through multidisciplinary programs may delay or reduce the need for total knee arthroplasty (TKA). However, avoidance of surgery may not represent success for the patient. METHODS: A cohort of 120 patients with knee OA managed with at least 6 months of supervised nonoperative treatment coordinated through the Joint Clinic were reviewed at 5 years. Outcomes including Oxford knee score (OKS), Short Form 12 (SF-12), and SF-6D and other measures including analgesia use, global change, and perception of need for surgery were collected and compared with those from the cohort who had undergone TKA. RESULTS: Seventy (62.5%) surviving patients were still being managed nonoperatively. There was no significant change in any outcome score (OKS, SF-12 physical component score, SF-12 mental component score, SF-6D) (P = .26 to .84). Forty-two patients had undergone TKA with mean time to surgery 29.0 months (range, 9-69 months). In this group, the mean OKS fell from 17.9 at baseline to 10.3 (range, 3-21) preoperatively (P < .0001) and at 5 years there was a significant improvement from baseline in OKS, SF-12 physical component score, and SF-6D scores (P < .0001). All outcome scores and change in scores were significantly higher for the surgical group (all P < .001). CONCLUSION: Although a high proportion of patients with knee OA have avoided surgery at 5 years, their outcomes show no improvement from baseline and are poorer than those who have undergone TKA. Avoidance of surgery should not necessarily be regarded as an indicator of success of nonoperative treatment for the patient.

Cemented or uncemented acetabular fixation in combination with the Exeter Universal cemented stem.

AIMS: To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem. METHODS: Details of 1,086 THAs performed between 1999 and 2005 using the Exeter stem and either a cemented (632) or uncemented acetabular component (454) were collected from local records and the New Zealand Joint Registry. A competing risks regression survival analysis was performed with death as the competing risk with adjustments made for age, sex, approach, and bearing. RESULTS: There were 61 revisions (9.7%; 0.82 revisions/100 observed component years, (OCYs)) in the all-cemented group and 18 (4.0%; 0.30/100 OCYs) in the hybrid group. The cumulative incidence of revision at 18 years was 12.1% for cemented and 5.2% for hybrids. There was a significantly greater risk of revision for all-cemented compared with hybrids (unadjusted sub-hazard ratio (SHR) 2.44; p = 0.001), and of revision for loosening, wear, or osteolysis (unadjusted SHR 3.77; p < 0.001). After adjustment, the increased risk of all-cause revision did not reach significance at age 70 years and above. The advantage for revision for loosening, wear, and osteolysis remained at all ages. CONCLUSION: This study supports the use of uncemented acetabular fixation when used in combination with the Exeter stem with improved survivorship for revision for aseptic loosening, wear, and osteolysis at all ages and for all-cause revision in patients less than 70 years. Cite this article: Bone Joint J 2020;102-B(4):414-422.

The Outcomes of Nonoperative Management of Patients With Hip and Knee Osteoarthritis Triaged to a Physiotherapy-Led Clinic at Minimum 5-Year Follow-Up and Factors Associated With Progression to Surgery.

BACKGROUND: The purpose of this study is to determine outcomes of a nonoperative treatment service for hip and knee osteoarthritis (OA), the "Joint Clinic," at minimum 5-year follow-up, and investigate factors that may influence progression to joint replacement surgery. METHODS: This is an observational cohort study of 337 patients with hip (n = 151, 45%) or knee OA (n = 186, 55%) seen at the Joint Clinic, at 5-7 years of follow-up. Kaplan-Meier survival curves were used to determine survivorship of the affected joint and Cox regression used to determine factors associated with time to surgery. RESULTS: At mean 6-year follow up, 188 (56%) patients had undergone or were awaiting total joint arthroplasty, 127 (38%) were still being managed nonoperatively, and 22 (7%) had died without having surgery. Patients with hip OA were more likely to have required surgery (111/151, 74%) than patients with knee OA (77/186, 41%) (chi-square = 33.6, P < .001). The 7-year surgery-free survival for hip OA was 23.7% and knee OA 55.9% (P < .001). Factors associated with increased likelihood of surgery were joint affected (hip, hazard ratio [HR] 2.80), Kellgren-Lawrence (KL) grade (KL 3, HR 2.02; KL 4, 4.79), and Oxford Hip/Knee Score (HR 1.34 for each 5 points worse at baseline). CONCLUSION: More than 50% of the patients referred to secondary care with mild-moderate knee OA may not need surgery at 7 years. Patients with hip OA and those with severe radiographic changes are more likely to require surgery and should not be delayed if there is not an adequate response to conservative measures.

Mycobacterium bovis infection of total hip arthroplasty after intravesicular Bacillus Calmette-Guérin.

Intravesicular application of Bacillus Calmette-Guérin (BCG), a live attenuated strain of Mycobacterium bovis, is effective in the treatment of bladder cancer. However, systemic dissemination and subsequent infection of implants have been reported. We present a case of M. bovis infection of a total hip arthroplasty 5 years after BCG instillation for bladder cancer. He was treated with debridement, antibiotics, irrigation, and prosthesis retention with appropriate antituberculous therapy. At 4 years after surgery and 3 years after cessation of treatment, he has had no recurrence of infection with a good functional outcome. This case highlights the need to consider Mycobacteria infection in patients who have received intravesicular BCG. Debridement and retention of well-fixed implants can be successful in combination with appropriate antituberculous therapy.

Hybrid Fixation for Total Hip Arthroplasty Showed Improved Survival Over Cemented and Uncemented Fixation: A Single-Center Survival Analysis of 2156 Hips at 12-18 Years.

BACKGROUND: Despite increased use of uncemented and hybrid fixation, there is little evidence of their superiority over cemented implants. The aim of this study is to compare the long-term survivorship of cemented, hybrid and uncemented total hip arthroplasty (THA) at varying ages. METHODS: A total of 2156 hips (1315 cemented, 324 uncemented, and 517 hybrid) were performed in a single center between 1999 and 2005 with follow-up through to 2017. Registry and local databases were used to determine revision rates and cause. Unadjusted and adjusted competing risk survival analysis was performed. RESULTS: The cumulative incidence of all-cause revision at 18 years was cemented 10.9%, uncemented 8.9%, and hybrid 6.5%. Cemented fixation had a statistically significant higher risk of all-cause revision than hybrid in the adjusted model for all ages to 65 years (subhazard ratios [SHRs], 2.28-4.67) and a higher risk of revision for loosening, wear, or osteolysis at all ages (SHRs, 3.25-6.07). Uncemented fixation showed no advantage over hybrid fixation at any age, but did show advantages over cemented at younger ages (≤60 years) for all-cause revision (SHRs, 2.3-4.3). CONCLUSION: Hybrid fixation with conventional polyethylene shows an advantage over cemented hips at all ages. Uncemented THA showed improved survival over cemented only at younger ages and no advantage over hybrid THA.

Outcomes and Factors Influencing Response to an Individualized Multidisciplinary Chronic Disease Management Program for Hip and Knee Osteoarthritis.

BACKGROUND: The objective of the study was to investigate the effectiveness of, and factors associated with, response to a chronic disease management program for patients with hip and knee osteoarthritis (OA). METHODS: Over a 2-year period (2012-2014), 218 patients (97 hip OA; 121 knee OA) were managed with an individualized program of interventions that could include education, physiotherapy, orthotics, occupational therapy, or dietitian referral. Changes in Oxford Hip Score or Oxford Knee Score and Short Form-12 (SF-12) Physical and Mental Component Summary Score (PCS, MCS) were analyzed by joint affected, both unadjusted, and gender and age adjusted. A further analysis also adjusted for body mass index. RESULTS: At mean 12-month follow-up, patients with knee OA had a statistically significant improvement in Oxford Knee Score and PCS, while patients with hip OA had a statistically significant deterioration in all 3 scores. There was evidence that these changes differed between joints for Oxford and PCS scores. Older age was associated with worse outcomes for Oxford scores. Higher body mass index was associated with worse outcomes for Oxford and PCS scores. Patients with hip OA (35%) were more likely to deteriorate to a clinically significant extent (5 points) for Oxford scores than those with knee OA. Gender was not associated with outcomes. Patients with hip OA (54%) were more likely than those with knee OA (24%) to have subsequently had surgery (P < .001). CONCLUSIONS: Patients with knee OA were more likely to improve with a chronic disease management plan than patients with hip OA and efforts should be directed to them.

The Joint Clinic: Managing Excess Demand for Hip and Knee Osteoarthritis Referrals Using a New Physiotherapy-Led Outpatient Service.

BACKGROUND: There are increasing problems with access to both outpatient assessment and joint replacement surgery for patients with hip or knee osteoarthritis. METHODS: Data were collected on all patients seen at the Joint Clinic over a 2-year period with minimum 12-month follow-up. Patients were assessed by a nurse and a physiotherapist, baseline scores and demographic details collected, and an individualized personal care plan developed. Patients could be referred for a first specialist assessment (FSA) if their severity justified surgical assessment. RESULTS: Three hundred fifty-eight patients were seen at Joint Clinic, of whom 150 (44%) had hip and 189 (56%) had knee OA. The mean age was 67.4 years and there were 152 men (45%) and 187 women (55%). The mean baseline Oxford score was 19.8 (standard deviation 8.2). Fifty-four patients were referred directly to FSA (mean Oxford score 13.0, standard deviation 6.7) and 89 after a subsequent review. The scores of patients referred for FSA were significantly worse than those managed in the Joint Clinic (P < .001). Of the 143 referred for FSA, 115 underwent or were awaiting surgery, 18 were recommended surgery but scored below prioritization threshold, and 10 were not recommended surgery. The Oxford scores of the 194 patients managed non-operatively improved from 22.0 to 25.0 (P = .0013). CONCLUSION: This study shows that the Joint Clinic was effective as a triage tool with 93% of those referred for FSA being recommended surgery. This has freed up surgeon time to see only those patients most in need of surgical assessment.

Functional Outcome of Acute Achilles Tendon Rupture With and Without Operative Treatment Using Identical Functional Bracing Protocol.

BACKGROUND: The purpose of this study was to compare the functional results of operative and nonoperative treatment of acute Achilles tendon rupture using an identical rehabilitation program of functional bracing. METHODS: Over a 10-year period, 200 patients (99 operative, 101 nonoperative) aged between 18 and 65 years were treated at our institution's physiotherapy department after acute Achilles tendon rupture. There were 132 patients (62 operative, 70 nonoperative) available for a minimum 2-year follow-up (average 6.5 years; range, 2-13 years). Functional outcome was assessed using the Achilles tendon total rupture score (ATRS). RESULTS: With the numbers available, no significant difference could be detected in ATRS between operative (mean 84.8, median 90) and nonoperative groups (mean 85.3, median 91; P = 0.55). No significant difference could be detected in ATRS between male and female patients however treated ( P = 0.30) or between patients younger and older than 40 years at time of injury ( P = 0.68). There was no correlation between ATRS score and age at injury in all patients (ρ = -0.0168, P = 0.85). In male patients, there was a weak trend with older patients at follow-up having better scores (ρ = 0.21, P = 0.069). However, among female patients, there was a significant negative correlation between ATRS scores and increasing age (ρ = -0.29, P = 0.03). Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS. CONCLUSIONS: This study showed no significant difference detectable in ATRS between operative and nonoperative patients in the treatment of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Enhanced Recovery After Surgery for Hip and Knee Replacements.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs or hip and knee replacements have had a significant effect on streamlining patient care with shorter stays, no increase in complications, and improved outcomes including reduced mortality. PURPOSE: To compare outcomes following the introduction of an ERAS program for hip and knee replacements developed at our institution with a historical cohort of patients. METHODS: ERAS protocols were developed at our institution for patients undergoing hip and knee joint replacements. Key aspects were changes in preadmission, a new education session, improved management of perioperative anemia, standardized anesthetic guidelines, day of surgery mobilization, and improved discharge planning. The results of the first 18 months (528 consecutive patients) were compared with those of a historical cohort of 507 patients from the 18 months prior to their introduction. RESULTS: In the ERAS group, the mean age was 68.3 years for patients who underwent hip replacement and 70.4 years for patients who underwent knee replacement. Thirty-two percent of patients were ASA (American Society of Anesthesiologists) Grades III and IV. The average preoperative Oxford score was 11. The average length of stay (ALOS) fell from 5.6 to 4.3 days for patients who underwent hip replacement and from 5.7 to 4.8 days for patients who underwent knee replacement (p < .001). Ninety-six percent of patients were discharged home. The 30-day readmission rate increased from 3.2% to 5.5% (p = .065). Six-month Oxford knee scores were higher in the ERAS group (39.8 vs. 36.3, p = .03). There was no increase in mortality or early revision rate. CONCLUSIONS: Substantial reductions in ALOS can be gained with the introduction of ERAS protocols, with high patient satisfaction and no increase in complications in a consecutive unselected group of public hospital patients. This requires a multidisciplinary approach and a strong clinical input.

The Morscher Press-Fit Acetabular Component: An Independent Long-Term Review at 18-22 Years.

BACKGROUND: There are relatively few 20-year results of uncemented acetabular components, and most of these are modular designs. This study reports the 20-year results of a monoblock press-fit acetabular component. METHODS: A total of 122 total hip arthroplasties (111 patients) using the Morscher cup were reviewed at a mean of 19.7 years. The average age at implantation was 57.3 years (range, 36-74 years), and 81 (66%) were men. RESULTS: Twenty-two patients (25 hips) had died. Seven hips were revised, including 5 acetabular revisions. Six patients (6 hips) declined to participate but were known not to have been revised. The mean Oxford hip score was 41.1 (range, 22-48), and the mean reduced Western Ontario and McMaster Universities Osteoarthritis Index score was 5.7/48 (range, 0-24). Eccentric wear was seen in 13 (15.7%) and major osteolysis in 14 (17%) of 82 surviving hips with radiographs. The all-cause revision rate was 0.32 per 100 observed component years (95% confidence interval [CI], 0.13-0.66). The 20-year Kaplan-Meier survival was 93.4% (CI, 86.6-96.8) for all-cause revisions, 95.5% (CI, 89.4-98.1) for any acetabular revision, and 97.1% (CI, 91.2-99.1) for acetabular aseptic loosening, wear, or osteolysis. CONCLUSION: The Morscher acetabular component has continued to perform well at 20 years despite using conventional polyethylene with results that match or surpass other cementless acetabulae.

Rationing for Total Hip and Knee Arthroplasty Using the New Zealand Orthopaedic Association Score: Effectiveness and Comparison With Patient-Reported Scores.

BACKGROUND: There is increasing interest in scoring systems to prioritize patients for hip and knee arthroplasty. The purpose of this study was to determine the effectiveness of the New Zealand Orthopaedic Association (NZOA) score and compare it with patient-reported scores of patients listed for hip and knee arthroplasty. METHODS: Over a 1-year period, all patients listed for primary hip and knee arthroplasty were scored by a prioritization nurse. The NZOA score, outcome, preoperative Oxford hip or knee score (OHKS) and reduced Western Ontario McMaster osteoarthritis index (WOMAC) score (RWS) were collected. RESULTS: Overall, 608 patients were listed for hip (319) or knee (289) arthroplasty. The mean scores for knees were all better than hips (P < .001). On initial scoring, 324 patients (53%) were given certainty (mean NZOA, 80.5; OHKS, 10.0; RWS, 35.1), 90 (15%) given clinical over-ride (NZOA, 69.6; OHKS, 12.0; RWS, 33.2), and 194 (32%) returned to general practitioner (NZOA, 64; OHKS, 14.2; RWS, 30.8). Knees (38%) were more likely to be returned than hips (26%; P = .002). Fifty (26%) were re-referred during the study period (mean, 5 months) and given certainty or over-ride. The difference at final outcome between patients with certainty and clinical over-ride was NZOA, 10.3 points; Oxford, 1.6 points; and RWS, 1.4 points. The difference between clinical over-ride and returned to general practitioner was NZOA, 7.2; Oxford, 4.4; RWS, 5.3. CONCLUSION: The NZOA score is an effective tool for rationing for joint arthroplasty. Patients around the threshold score of 70 may not have a clinically important difference compared with those above threshold.

Incidence of Carpal Tunnel Syndrome Requiring Surgical Decompression: A 10.5-Year Review of 2,309 Patients.

PURPOSE: To describe the demographics, neurophysiological grading, and incidence of patients undergoing carpal tunnel decompression (CTD) for carpal tunnel syndrome (CTS) in a single region. METHODS: A retrospective review of 2,313 patients aged greater than 16 years who underwent 3,073 CTDs between January 2000 and August 2010. Crude annual and age- and sex-specific incidences were calculated for the study period. Nerve conduction study grades were recorded and compared with age and sex. RESULTS: Of the 2,313 patients 1,419 (61%) were female and 890 (39%) were male. Mean age at surgery was 56 years (range, 16-93 years). Females had a significantly higher CTD incidence compared with males (161 vs 108/100,000 person-years, respectively). The highest rates of CTD were seen in the 70- to 79-year age group for both men and women (307/100,000 person-years). Neurophysiological grade increased in severity with increasing age despite using an age-adjusted grading system, with higher grades in patients aged greater than 65 years. CONCLUSIONS: This study suggests that carpal tunnel syndrome has the highest incidence in older people who tend to have more severe neurophysiological changes. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Epidemiology and outcomes of acute Achilles tendon rupture with operative or nonoperative treatment using an identical functional bracing protocol.

BACKGROUND: This study reports on the demographics of acute Achilles tendon rupture in our region and compares the results of a selective approach to operative and nonoperative treatment using an identical rehabilitation program with functional bracing. MATERIALS AND METHODS: A consecutive series of 363 patients, aged 15 to 60 years, treated over 8.5 years by either open operative repair (143) or nonoperatively (220) were compared with respect to demographics, re-rupture rate, and major wound complication. RESULTS: There was an almost equal number of males (159) and females (152) up to age 50 years but males comprised 73% of patients aged 51 to 60 years. Netball was the most common cause of injury and explains the relatively high incidence in females. In the 143 patients treated surgically there were two re-ruptures (1.4%) and two reoperations for wound complications (1.4%). In the 220 patients treated nonoperatively there were 19 re-ruptures (8.6%), 13 of 113 males (11.5%) and six of 107 females (5.6%). There was a significantly lower re-rupture rate, and reoperation rate in the surgical group (p < 0.05). In the nonoperative group there was a significantly lower rate of re-rupture in patients over 40 (six of 119) (4.1%) compared with those 40 years and under (13 of 99, 13.1%) and between females over 40 when compared with males 40 years and under. CONCLUSION: In our region there is a high incidence of Achilles tendon rupture among women due to netball and results in a younger age of injury than previously reported. Our results support surgery in patients less than 40 years, particularly males, if there are no contraindications. Functional bracing as part of nonoperative treatment can result in low re-rupture rates in patients over 40, especially in females.