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NIHR Signal Torn Achilles tendons have similar outcomes if treated with or without surgery

Published on 19 March 2019

doi: 10.3310/signal-000750

Outcomes for ruptured Achilles tendons appear similar irrespective of the choice of intervention. This systematic review and meta-analysis found that while the risk of re-rupture with corrective surgery was small at 2.3%, with conservative management (immobilisation in a cast), the rate was only 3.9%.

The complication rate at 4.9% was three times higher in those who had surgery.

Nearly all of the included studies were observational in this review, and no information was provided on the severity of the tears. It is possible that surgery was reserved for the more severe cases, but this evidence is broadly supportive of current practice.

The pros and cons of each strategy should continue to be discussed, and decision shared with patients.

  •   Musculo-skeletal disorders, Orthopaedics, Surgery, Physical therapy
Torn Achilles tendons have similar outcomes if treated with or without surgery

Why was this study needed?

The Achilles tendon runs down the back of the calf to the heel. Approximately 5 to 10 people in every 100, 000 will tear (rupture) their Achilles tendon, and as many as 80% of these injuries will happen while playing sport.

Treatment can be conservative, usually immobilisation by plaster cast and/or a specialised boot. Alternatively, the tendon can be surgically repaired. This operation can either be open or in certain cases, a less invasive option may be performed.  

There is currently considerable debate as to the best treatment for this condition. Both options carry their risks and benefits, and the final decision is often made taking into account the nature of the injury and patient factors such as lifestyle and age.

This study sought to clarify the situation by bolstering the results of existing systematic reviews with evidence from observational studies, which have more participants.

What did this study do?

This systematic review and meta-analysis included 29 studies with a total of 15,862 patients. Of these, 9,375 were treated operatively and 6,487 non-operatively (cast immobilisation or functional bracing). Nineteen studies were observational contributing 94% of patients, including one large US study of 12,570 participants.

Most surgery was open rather than minimally invasive, and many studies were old, with 18 of them spanning from 1969 to 2005.  There was no information on the severity of tendon tear.

A further limitation of the review is the variation in rehabilitation protocols, and very few studies looked at the ability to return to exercise.

What did it find?

  • Re-rupture was less common after surgery, occurring in 2.3% of cases compared to 3.9% after conservative treatment (risk ratio [RR] 0.43, 95% confidence interval [CI] 0.31 to 0.60).  
  • Complications, such as wound infection, sural nerve injury, deep vein thrombosis, and pulmonary embolism occurred in 4.9% of people undergoing surgery compared to 1.6% of those with conservative management (RR 2.76, 95% CI 1.84 to 4.13; 26 studies).
  • Functional outcomes proved harder to measure as there was considerable variation in outcome measures between studies. The Achilles Tendon Rupture Scores (ATRS) were not pooled, but most studies showed no significant difference between operative and non-operative treatment groups.

What does current guidance say on this issue?

No current national guidance on the topic exists, but most orthopaedic units in the UK offer conservative and surgical options.

Regardless of treatment chosen, a below the knee cast with toes pointing downwards is required for two to four weeks. If surgery does take place, wound assessment and removal of sutures will occur after two weeks.

Once the cast is removed, it is replaced with a removable boot, which restricts the range of ankle movement, for about six weeks. The patient will then usually be referred for physiotherapy.

What are the implications?

This information may help patients and surgeons to reach better-informed treatment decisions.

Future research is needed focussing on functional outcomes and attempting to define better the group who might benefit from surgery. An agreed set of important outcomes would allow researchers to design studies with results that can be compared more readily.

Citation and Funding

Ochen Y, Beks RB, van Heijl M et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019;364:k5120.

No funding information was provided for this study.

Bibliography

Maughan K, Boggess B. Achilles tendinopathy and tendon rupture. Waltham, MA: UpToDate; updated 2018.

North Bristol NHS Trust. Achilles tendon rupture. Bristol: North Bristol NHS Trust; 2014.

Expert commentary

The authors have confirmed the clinical understanding that there is little difference in the primary outcomes (re-rupture rate/complication rate) of Achilles tendon rupture with either operative or non-operative treatment. We have to be slightly cautious due to the varied protocols in each study and the weighting of the operative studies to open surgery rather than percutaneous/minimally invasive techniques.

Unfortunately, very few of the included studies looked at functional scoring and early rehabilitation. There were no studies comparing the size of the tendon gap before treatment commenced and long term functional outcome.

As such the paper is not able to guide us on how to risk stratify the management of individual patients.

Mr Howard Davies, Consultant Orthopaedic Surgeon (Foot & Ankle), Northern General Hospital, Sheffield

The commentator declares no conflicting interests