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treatment of Achilles tendon rupture

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.

Share your views on the research.

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.

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.

Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis

Published on 9 January 2019

Ochen, Y.,Beks, R. B.,van Heijl, M.,Hietbrink, F.,Leenen, L. P. H.,van der Velde, D.,Heng, M.,van der Meijden, O.,Groenwold, R. H. H.,Houwert, R. M.

Bmj Volume 364 , 2019

OBJECTIVES: To compare re-rupture rate, complication rate, and functional outcome after operative versus nonoperative treatment of Achilles tendon ruptures; to compare re-rupture rate after early and late full weight bearing; to evaluate re-rupture rate after functional rehabilitation with early range of motion; and to compare effect estimates from randomised controlled trials and observational studies. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed/Medline, Embase, CENTRAL, and CINAHL databases were last searched on 25 April 2018 for studies comparing operative versus nonoperative treatment of Achilles tendon ruptures. STUDY SELECTION CRITERIA: Randomised controlled trials and observational studies reporting on comparison of operative versus nonoperative treatment of acute Achilles tendon ruptures. DATA EXTRACTION: Data extraction was performed independently in pairs, by four reviewers, with the use of a predefined data extraction file. Outcomes were pooled using random effects models and presented as risk difference, risk ratio, or mean difference, with 95% confidence interval. RESULTS: 29 studies were included-10 randomised controlled trials and 19 observational studies. The 10 trials included 944 (6%) patients, and the 19 observational studies included 14 918 (94%) patients. A significant reduction in re-ruptures was seen after operative treatment (2.3%) compared with nonoperative treatment (3.9%) (risk difference 1.6%; risk ratio 0.43, 95% confidence interval 0.31 to 0.60; P<0.001; I(2)=22%). Operative treatment resulted in a significantly higher complication rate than nonoperative treatment (4.9% v 1.6%; risk difference 3.3%; risk ratio 2.76, 1.84 to 4.13; P<0.001; I(2)=45%). The main difference in complication rate was attributable to the incidence of infection (2.8%) in the operative group. A similar reduction in re-rupture rate in favour of operative treatment was seen after both early and late full weight bearing. No significant difference in re-rupture rate was seen between operative and nonoperative treatment in studies that used accelerated functional rehabilitation with early range of motion (risk ratio 0.60, 0.26 to 1.37; P=0.23; I(2)=0%). No difference in effect estimates was seen between randomised controlled trials and observational studies. CONCLUSIONS: This meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.

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