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2202
COPYRIGHT 2005
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Treatment of Acute
Achilles Tendon Ruptures
A META-ANALYSIS
OF
BY RIAZ J.K. KHAN, FRCS(TR&ORTH), DAN FICK, MBBS, ANGUS KEOGH, MBBS,
JOHN CRAWFORD, FRCS(TR&ORTH), TIM BRAMMAR, FRCS(TR&ORTH), AND MARTYN PARKER, MD
Investigation performed at Perth Orthopaedic Institute, Department of Surgery and Pathology, University of Western Australia, Perth, Australia
Background: There is a lack of consensus regarding the best option for the treatment of acute Achilles tendon rupture. Treatment can be broadly classified as operative (open or percutaneous) or nonoperative (casting or functional
bracing). Postoperative splinting can be performed with a rigid cast (proximal or distal to the knee) or a more mobile
functional brace. The aim of this meta-analysis was to identify and summarize the evidence from randomized, controlled trials on the effectiveness of different interventions for the treatment of acute Achilles tendon ruptures.
Methods: We searched multiple databases (including EMBASE, CINAHL, and MEDLINE) as well as reference lists of
articles and contacted authors. Keywords included Achilles tendon, rupture, and tendon injuries. Three reviewers extracted data and independently assessed trial quality with use of a ten-item scale.
Results: Twelve trials involving 800 patients were included. There was a variable level of methodological rigor and reporting of outcomes. Open operative treatment was associated with a lower risk of rerupture compared with nonoperative treatment (relative risk, 0.27; 95% confidence interval, 0.11 to 0.64). However, it was associated with a higher
risk of other complications, including infection, adhesions, and disturbed skin sensibility (relative risk, 10.60; 95%
confidence interval, 4.82 to 23.28). Percutaneous repair was associated with a lower complication rate compared
with open operative repair (relative risk, 2.84; 95% confidence interval, 1.06 to 7.62). Patients who had been managed with a functional brace postoperatively (allowing for early mobilization) had a lower complication rate compared
with those who had been managed with a cast (relative risk, 1.88; 95% confidence interval, 1.27 to 2.76). Because
of the small number of patients involved, no definitive conclusions could be made regarding different nonoperative
treatment regimens.
Conclusions: Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture
compared with nonoperative treatment, but operative treatment is associated with a significantly higher risk of other
complications. Operative risks may be reduced by performing surgery percutaneously. Postoperative splinting with
use of a functional brace reduces the overall complication rate.
Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
topical corticosteroids5,6, fluoroquinolone antibiotics (e.g., ciprofloxacin)7, exercise-induced hyperthermia8, and mechanical
abnormalities of the foot9.
Treatment of acute Achilles tendon ruptures can be
broadly classified as operative (open or percutaneous) or nonoperative (cast immobilization or functional bracing). Generally, open operative treatment has been used for athletes and
young, fit patients; percutaneous operative treatment has been
used for those who do not wish to have an open repair (e.g.,
for cosmetic reasons); and nonoperative treatment has been
used for the elderly10-13.
Previous reviews have examined the relative advantages
of operative and nonoperative treatment14-17. However, to our
knowledge, there has not been a systematic review of different
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Fig. 1
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and manual search results. In MEDLINE (OVID-WEB), the following subject-specific search was combined with all three levels of the optimal trial search strategy18: Achilles Tendon,
(achill#s or tendoachill#s).tw., or/1-2, Rupture/, rupture$.tw.,
or/4-5, and/3,6, Tendon Injuries/, and/3,8, or/7,9. Articles in all
languages were considered for inclusion and were translated
when necessary. We excluded retrospective studies, studies with
insufficient reporting of primary outcomes, studies with inadequate methods of randomization, and unique randomized,
controlled trials (where pooling of data was not possible, making them unsuitable for meta-analysis).
Participants included adults with acute ruptures of the
Achilles tendon. Patients with delayed presentation (more than
three weeks after the injury) and rerupture were excluded. The
types of interventions included operative repair (open and percutaneous) and nonoperative treatment (cast immobilization
and functional bracing). The primary outcomes were complications of treatment and rerupture. Other outcomes, such as the
level of sporting activity, patient satisfaction, and the length of
hospital stay, were omitted because they lack quantity and uniformity to support rigorous meta-analysis.
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Fig. 2
Flowchart depicting the method by which the twelve randomized, controlled studies were chosen.
Total Score
(Maximum, 12)
Cetti et al.21
1110110010
Cetti et al.25
1110010011
3110100111
0110110011
0100010101
0110111010
3110110111
10
2110110010
0010010011
3110010010
Saleh et al.
1100110011
Schroeder et al.24
1100100000
Study
Kangas et al.
29
Kerkhoffs et al.26
Lim et al.
30
Maffulli et al.28
Moller et al.
22
Mortensen et al.27
Nistor
23
Petersen et al.32
31
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Fig. 3
Illustration indicating the prevalence of rerupture associated with open operative and nonoperative treatment. The values are given as the number of patients with a rerupture (n)/number of patients in the group (N), with a summation of the totals and the relative risk (RR) and 95% confidence intervals (95% CI).
Fig. 4
Illustration indicating the prevalence of complications other than rerupture associated with open operative and nonoperative treatment. The values are given as the number of patients with a complication (n)/number of patients in the group (N), with a summation of the totals and the relative risk (RR) and 95% confidence intervals (95% CI).
Fig. 5
Illustration indicating the prevalence of wound infection associated with open operative and nonoperative treatment. The values are given as the
number of patients with a wound infection (n)/number of patients in the group (N), with a summation of the totals and the relative risk (RR) and
95% confidence intervals (95% CI).
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Fig. 6
Illustration indicating the prevalence of rerupture associated with open surgery and percutaneous surgery. The values are given as the number of
patients with a rerupture (n)/number of patients in the group (N), with a summation of the totals and the relative risk (RR) and 95% confidence
intervals (95% CI).
Fig. 7
Illustration indicating the prevalence of complications other than rerupture associated with open surgery and percutaneous surgery. The values
are given as the number of patients with a complication (n)/number of patients in the group (N), with a summation of the totals and the relative
risk (RR) and 95% confidence intervals (95% CI).
Fig. 8
Illustration indicating the prevalence of wound infection associated with open surgery and percutaneous surgery. The values are given as the
number of patients with an infection (n)/number of patients in the group (N), with a summation of the totals and the relative risk (RR) and 95%
confidence intervals (95% CI).
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Fig. 9
Illustration indicating the prevalence of rerupture associated with postoperative splinting with casting alone and casting followed by functional
bracing. The values are given as the number of patients with a rerupture (n)/number of patients in the group (N), with a summation of the totals
and the relative risk (RR) and 95% confidence intervals (95% CI).
val, 0.59 to 21.76). The mean duration of follow-up used for the
calculation of the rerupture rates was twelve months for both
studies. The results are summarized in Figure 11.
Discussion
welve prospective randomized studies involving the treatment of acute Achilles tendon rupture fulfilled the inclusion criteria for this meta-analysis. Quality assessment scores
were calculated for each study in order to assess the level of
methodological rigor. They were not used as a criterion for exclusion or to weight the pooled data. However, the findings of
studies with higher methodological quality should naturally
be considered to be of greater importance. The scores indicate
a variable level of methodological rigor, particularly with regard to the method of randomization and concealment of allocation. The quality of the primary study used for pooled
analysis influences the results of a meta-analysis33. The inclusion of poorly randomized trials can lead to over-reporting of
treatment effect, and thus all recommendations should be
critically appraised. Recommendations have been made on the
basis of analysis of pooled data extracted from what were believed to be the most rigorously conducted studies.
The rate of rerupture was consistently higher among
nonoperatively treated patients as compared with operatively
treated patients. The most methodologically sound study22 provided the most favorable rerupture rate with operative interven-
Fig. 10
Illustration indicating the prevalence of complications other than rerupture associated with postoperative splinting with casting alone and casting
followed by functional bracing. The values are given as the number of patients with a complication (n)/number of patients in the group (N), with a
summation of the totals and the relative risk (RR) and 95% confidence intervals (95% CI).
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Fig. 11
Illustration indicating the prevalence of rerupture associated with nonoperative treatment (casting alone and casting followed by functional bracing). The values are given as the number of patients with a rerupture (n)/number of patients in the group (N), with a summation of the totals and
the relative risk (RR) and 95% confidence intervals (95% CI).
Using a technique of analysis not previously applied to rupture of the Achilles tendon, Kocher et al.37 performed an expected-value decision analysis of operative and nonoperative
management. Expected-value decision analysis involves allocating utility scores to outcomes and allows quantitative analysis of decision-making. A decision tree was constructed, and
prospective patients progressed through the various alternatives. Article selection for the generation of outcome probabilities followed the criteria of Lo et al.14. With use of this
technique, operative treatment was found to be the optimal
strategy. However, the authors stressed that the decisionmaking process should be shared between doctor and patient.
In our analysis of studies comparing open and percutaneous repair, we noted a tendency for a lower overall rate of
complications (particularly infection) in the percutaneously
treated group. However, this finding is based on pooled data
from a small number of patients, and there is some discrepancy between studies with regard to the rate of infection in the
open treatment group. In a previous review of prospective and
retrospective studies regarding operative and nonoperative
treatment, Wong et al.17 reported a lower rate of wound complications in patients undergoing percutaneous repair. However, they also noted that patients in the percutaneous group
had relatively high rates of complications (notably sural nerve
injury), particularly when the procedure was combined with
early active mobilization.
One of the most important aspects of the present review
is that pertaining to postoperative splintage. This subject has
not been previously evaluated with use of meta-analysis. The
functional bracing group had a significantly lower rate of
complications (p = 0.001), particularly with regard to adhesion formation. The early mobilization group also tended to
have a lower rerupture rate. Conclusions made on the basis of
the pooled data must be interpreted with caution because of
the variety of regimens used.
Limited conclusions can be drawn from the two studies
comparing nonoperative treatment in a cast and functional
bracing because of the small numbers involved (ninety patients),
differences in regimens, and minimal reporting of outcomes31,32.
It is interesting to note, however, that the pooled rate of rerupture in the functional bracing group (2.4%) was lower than that
for patients managed with operative treatment (3.5%). Indeed, it
was almost equivalent to that seen for patients managed with
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doi:10.2106/JBJS.D.03049
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