Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon

Rupture A Meta-Analysis of Randomized Trials

Alexandra Soroceanu et al

Dalhousie University Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada

J Bone Joint Surg Am. 2012;94:2136-43

• Most commonly ruptured tendon in the body• Risk factors for primary rupture: Male Steroid / floroquinolones use Prior rupture on contralateral side• Diagnosis: Clinical: Gap, Thompson Test Radiology: U/S, MRI

Treatment options• Non Surgical: Cast/ Cast-boot /splint with foot in equinus with /without

early physio• Surgical: Open/Minimally invasive/Percutaneous repair

Physio / Mobilisation:1) Immobilisation for 6-8 weeks prior to start ROM2) Functional bracing with daily active PF from 10 days

Hypothesis of early ROM: Stimulate tendon-healing and may lower rerupture rate

Complications

• Rerupture Non-operative: 10-20% Opertaive: <3%• Post op complications:10-15% (major&minor) Deep infection Skin necrosis Tendon necrosis Draining sinus

Aim

Meta-analysis to compare surgical with non-surgical treatment with regard to

• Rerupture rate (Primary outcome measure)• overall rate of other complications• Return to work• Strength, calf cirucmference• Functional outcomes• Explore the effects of early ROM on rerupture

rate

Materials and Methods

• 2 reviewers independent searched and evaluated by bias tools of Cochrane review

• Studies from Jan 2005 to Dec 2011Inclusion criteria:• All RCT’s comparing Op Vs Non-Op T/T• Acute rupture treated with in 3 weeks• No restriction on WB Status• All language papers included

Results

Ten studies Operative intervention: 418 ptsNon-op : 408 ptsMean age : 398.8 yearsMale predominant

ResultsRerupture:• Absolute risk difference between the two

groups was 5.5% in favour of surgery (p=0.002)• Risk ratio of 0.4% in favor of surgery• Rerupture rate equalient among both surgical

and nonsurgical treatment groups if early ROM.• When functional rehab not used then absolute

rerupture risk reduced by 8.8% in surgical group.

Other Complications

• DVT, PE, Infection, tendon necrosis, fistulas, scar, nerve damage, Stiffness

• Risk difference was 15.8% in favor of nonsurgical treatment

• One additional complication other than rerupture can be expected for every seven patients treated surgically

• Patients retuned to work 19.16 days earlier in OP group (p=0.0014)

• Active PF 10 LESS as compared to other side –No clinical significance (only 3 RCT’s)

• No significant difference in calf circumference• No difference in strength among both groups

(6 RCT’s using different scales)• No difference in std mean difference between

two groups (4 RCT’s)

Conclusion

• Both surgical and nonsurgical treatment were equivalent with rerupture rate when early ROM protocol used.

• If early ROM not used, then surgery reduced the risk of rerupture by 8.8%

• Risk of other complications 4% higher in surgical group with absolute risk increase of 16%

Critique

Strengths:• Level 1 evidence • Robust statistical analysis• Useful conclusions• Included papers of all languages

Critique Strengths

• Level 1 evidence • Robust statistical analysis• Useful conclusions• Included papers of all

languages

Weakness• Early rehab- was it same in all

studies? And how many studies early rehab??

• No comment on Avg follow up of all studies

• No differentiation of major and minor complications

• Return to work- No comment on type of work, criteria to return to work??

• Other complications: DVT / PE rate in OP Vs Non OP