Patient-specific Factors Should Guide Treatment of Acute Achilles Tendon Rupture
Key findings
- According to a meta-analysis that included observational studies, open or minimally invasive surgery was associated with a statistically significant reduction in re-rupture of Achilles tendon, compared with cast immobilization or functional bracing
- However, surgery resulted in a significantly higher rate of other complications, notably infection
- The re-rupture rate was significantly better with surgery than with nonoperative treatment, whether weight-bearing was allowed early (up to four weeks after treatment) or later
- There was no significant difference in re-rupture rate between surgery and nonoperative treatment when an accelerated functional rehabilitation program was used
A longstanding controversy in orthopedics is whether the management of acute Achilles tendon ruptures should be operative or nonoperative. In the latest systematic review and meta-analysis of this issue reported in BMJ, Yassine Ochen, MD, research fellow in the Department of Orthopaedic Surgery, and Marilyn Heng, MD, MPH, orthopaedic trauma surgeon of Massachusetts General Hospital, and colleagues from Utrecht University determined that operative treatment reduces the risk of re-rupture, but results in a higher risk of other complications.
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The reviewers included prospective and retrospective observational studies in the meta-analysis published up to April 25, 2018. That increased the sample size, but more importantly, provided insight into a greater variety of populations than those typically selected for randomized, controlled trials (RCTs).
The inclusion criteria were:
- The study concerned treatment of initial acute Achilles tendon rupture
- The study compared open or minimally invasive surgery with cast immobilization or functional bracing
- Ruptures were treated within four weeks
- Patient age was ≥16 years
- The paper reported the re-rupture rate, complication rate or functional outcome
Ten RCTs and 19 observational studies met these criteria. They included 15,862 patients, 9,375 treated operatively and 6,487 treated nonoperatively. Overall, 74% of patients were male, the weighted average age was 41 and follow-up ranged from 10 to 95 months.
Re-rupture Rate
The primary outcome measure, the re-rupture rate, was reported in all 29 studies. Re-rupture occurred in 2.3% of patients after operative treatment compared with 3.9% after nonoperative treatment, for a risk difference of 1.6%. The risk ratio was 0.43 (95% CI, 0.31–0.60; < .001). There was no significant difference between effect estimates from RCTs and those from observational studies.
Complication Rate
The complication rate was reported in 10 RCTs and 16 observational studies. The incidence of complications was 4.9% after operative treatment and 1.6% after nonoperative treatment, for a risk difference of 3.3%. The risk ratio was 2.76 (95% CI, 1.84–4.13; < .001) in favor of nonoperative treatment.
The main complication after operative treatment was infection (2.8% of patients). The main complication after nonoperative treatment was deep vein thrombosis (1.2% of patients vs. 1.0% after operative treatment). There was no significant difference between effect estimates from RCTs and observational studies.
Functional Outcome
Short-term functional outcome according to Achilles Tendon Rupture Score (ATRS) was reported in two RCTs and an observational study. In both RCTs, the differences between operative and nonoperative treatment were non-significant. In the observational study, the median ATRS was 94 in the operative group, which is significantly higher than the 84 in the nonoperative group.
Long-term functional outcome using the ATRS score was assessed in two observational studies. No significant difference between operative and nonoperative treatment was evident in either study.
Primary Sensitivity Analyses
The researchers conducted two sensitivity analyses for the primary outcome. In the first, they divided studies according to the timing of full weight bearing after treatment: early (≤4 weeks) or late (>4 weeks).
Early weight bearing was allowed in five RCTs and four observational studies. This group of studies showed a significant reduction in re-rupture rate after operative treatment compared with nonoperative treatment (risk ratio, 0.49; 95% CI, 0.26–0.93; = .03).
Late weight bearing was reported in four RCTs and 11 observational studies. This group of studies, too, showed a significant reduction in re-rupture rate in favor of operative treatment (RR, 0.33; 95% CI, 0.21–0.50; = .001).
The other sensitivity analysis included three RCTs and three observational studies in which the functional rehabilitation protocol was accelerated (free range of motion started ≤3 weeks after nonoperative treatment). In this analysis, there was no significant difference between operative and nonoperative treatment regarding the re-rupture rate.
Clinical Implications
Dr. Heng and her colleagues believe the final decision about operative or nonoperative management should be based on patient-specific factors and shared decision-making. They suggest counseling patients that operative treatment reduces the risk of re-rupture compared with nonoperative treatment, but re-rupture rates are low and surgery presents a higher risk of other complications, mostly infections.
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