Surgical versus non-surgical treatment for acute Achilles’ tendon rupture. A systematic review of literature and meta-analysis

Reda, Y.; Farouk, Amr; Abdelmonem, Ibrahim M; Shazly, Ossama El

doi:10.1016/j.fas.2019.03.010

Cited by 63 publications

(64 citation statements)

References 27 publications

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“…This may be due to the study being underpowered to detect differences in rerupture rate and is a feature of many randomized controlled trials in the field of ATR, where differences in rerupture rate are often not detected in individual studies 20,26,41 but become apparent when data are pooled into meta-analyses. 28,32 A post hoc power calculation was performed according to the rerupture rates observed between the groups, with an alpha of .05, which confirmed that the current study was underpowered (43%) to demonstrate a statistical difference in rerupture rates; this may have resulted in a type II error. It has been postulated that functional rehabilitation may significantly reduce the rate of tendon rerupture 35 ; however, this conclusion has been criticized, as it was not based on direct comparison of rerupture rates in functional and traditional rehabilitation regimens.…”

Section: Complicationssupporting

confidence: 59%

A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures

et al. 2020

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Background: There has been a shift toward functional nonoperative rehabilitation in the treatment of Achilles tendon rupture (ATR) despite a shortage of studies directly comparing nonoperative functional rehabilitation with traditional nonoperative immobilization. Purpose: To compare patient-reported outcome measures and functional outcomes for nonoperatively treated ATR with traditional cast immobilization or functional rehabilitation in a walking boot. Study Design: Randomized controlled clinical trial; Level of evidence, 2. Methods: In a single-center nonblinded study, 140 patients were randomized to compare treatment for acute ATR in (1) an immobilizing cast in reducing degrees of equinus over a 10-week period with 8 weeks of nonweightbearing mobilization or (2) a walking boot for 8 weeks with reducing equinus and immediate full weightbearing. Exclusion criteria were delayed presentation >2 weeks after injury, tendon reruptures, and latex allergy. Analysis was undertaken on an intention-to-treat basis. Results: A total of 69 patients (median age, 41 years [interquartile range, 33-50.5 years]) were randomized to walking boot treatment and 71 patients (41 [32-49]) to cast treatment. At 6 months, patients treated in a walking boot reported better Short Musculoskeletal Function Assessment (SMFA) dysfunction index (6.62 [2.21-12.50] vs 10.66 [4.96-13.42]; P = .050), SMFA bother index (7.29 [2.08-14.58] vs 10.42 [5.73-19.27]; P = .04), Achilles Tendon Total Rupture Score (71.5 [53.50-84.25] vs 54.0 [37-76]; P = .01), and Foot and Ankle Questionnaire core score (91 [81.89-97.55] vs 85 [78.25-92.09]; P = .04). At 1 year, there was no difference in SMFA dysfunction index (2.21 [0.74-5.88] vs 2.94 [1.47-6.62]; P = .25), SMFA bother index (2.08 [0-9.38] vs 5.21 [0.52-11.98]; P = .25), Achilles Tendon Total Rupture Score (92 [72.50-96] vs 87.5 [66.0-94.75]; P = .21), or Foot and Ankle Questionnaire core score (97.75 [89.46-99.00] vs 95.50 [90.88-97.50]; P = .18). Rerupture occurred in 5 and 11 patients ( P = .075) and venous thromboembolism in 2 and 3 patients ( P = .67) in the boot and cast groups, respectively. Fifteen patients in the boot group but none in the cast group had skin problems ( P < .001). Patients treated in a boot returned to driving at a median 12 weeks (vs 13 weeks for cast; P = .045), but there was no difference in time to return to work ( P = .48). Conclusion: Functional rehabilitation with early weightbearing is a safe alternative to traditional immobilizing treatment for ATR, giving better early functional outcomes, albeit with a higher incidence of transient minor skin complications. Registration: NCT02598843 (ClinicalTrials.gov identifier).

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Section: Complicationssupporting

confidence: 59%

A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures

et al. 2020

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“…To the best of our knowledge, treatment on ATR should be focused on optimal functional recovery accompanied with the least complication. Combined with the novel primary outcome of return to sport included in this study, similar functional recovery was observed between surgical and conservative treatment group, even though surgical treatment was recommended owing to lower rerupture rate according to previous studies [37,38]. Moreover, conservative management accompanied with early weightbearing of the injured tendon was reported to be capable of stimulating collagen and healing process, leading similar re-rupture rate as surgical treatment [10,[39][40][41].…”

Section: Discussion Innovationsupporting

confidence: 68%

Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture: A Comprehensive Meta-Analysis of RCTs

She

Teng

et al. 2020

Preprint

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Background Achilles tendon is the strongest tendon in human and frequently injured mainly in young to middle age active population. Increasing incidence of Achilles tendon rupture (ATR) is still reported in several studies. Surgical repair and conservative treatment are two major management strategy widely adopted in ATR patients but the consensus of optimal treatment strategy is still debated. We aimed at fully reviewing the ATR topic with additional assessments and performed a most comprehensive meta-analysis of randomized controlled trials (RCTs).Method We comprehensively searched database of PubMed, Embase, Cochrane and ClinicalTrial.gov and retrieved all randomized controlled trials comparing surgical and conservative treatment on achilles tendon rupture for further analysis. Data extraction was performed by two independent reviewer and random effect model was adopted when I2 > 50%, with data presentation of risk ratio, risk difference or mean difference and 95% confidence interval. Results A total of 13 randomized control trials were included in this meta-analysis. Significant difference was observed in events of re-rupture, complication rate, adhesion to underlying tendon, sural nerve injury and superficial infection. For surgical treatment, significant reduction in re-rupture rate could be observed while complication rate was higher compared with conservative treatment. Conclusion Surgical treatment was revealed significance in reduction of re-rupture rate but associated with higher complication rate while conservative treatment showed similar outcomes with lower complication rate. Collectively, we recommend conservative treatment if patients’ status and expectation are suitable, but surgeon as well as physician’s discretion is also important in decision making.

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“…6 Surgical repair has been reported to predict a reduced risk of rerupture, increased power, and a quicker return to sports compared with nonoperative modalities. 9,11,13 High variability is found between surgeons regarding postoperative management of surgically repaired Achilles tendons. Historically, because of concern for tendon lengthening, most surgeons immobilized patients in plantarflexion for 6 weeks before allowing weightbearing.…”

mentioning

confidence: 99%

Comparison of Tendon Lengthening With Traditional Versus Accelerated Rehabilitation After Achilles Tendon Repair: A Prospective Randomized Controlled Trial

et al. 2020

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Background: Early weightbearing protocols after Achilles tendon repair promote mobilization, yet little is known about their effect on tendon lengthening. Purpose: To evaluate tendon lengthening after Achilles tendon repair with accelerated rehabilitation. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients undergoing primary repair for acute Achilles tendon ruptures consented to have tantalum beads placed within the tendon. Patients were randomized into either a traditional (weightbearing at 6 weeks) or accelerated (graduated weightbearing at 2 weeks) rehabilitation group. The primary outcome of the study was postoperative tendon elongation as measured by radiostereometric beads. Secondary outcomes included Achilles Tendon Total Rupture Score (ATRS) and Patient-Reported Outcomes Measurement Information System Pain Interference Short Form (PROMIS PI-SF) score. Results: All 18 patients included in the final analysis were found to have significant tendon lengthening after surgery, with a mean lengthening of 15.9 mm. No significant differences were found in overall lengthening between the traditional and accelerated rehabilitation groups (15.3 ± 4.5 vs 16.4 ± 4.7 mm, respectively; P = .33) at final follow-up. The repair site in each group was found to lengthen more than the intratendinous site (traditional group, 13.2 vs 2.1 mm; accelerated group, 16.8 vs −0.4 mm); however, no difference in lengthening was seen between groups ( P = .82 and P = .31, respectively). The greatest amount of lengthening occurred between 2 and 6 weeks, and the least amount of lengthening occurred between 6 and 12 weeks, with no difference between the traditional and accelerated groups at these time points ( P = .84 and P = .38, respectively). No differences were noted in ankle range of motion (dorsiflexion, P = .16; plantarflexion, P = .08) or outcome scores (ATRS, P = .56; PROMIS PI-SF, P = .54). Conclusion: This study’s findings demonstrate that all patients undergoing operative repair of Achilles tendon ruptures had lengthening after surgery. No difference was found in tendon lengthening (repair site or intratendinous) at any time point between patients undergoing traditional versus accelerated rehabilitation postoperatively. The greatest amount of lengthening was found to occur between 2 and 6 weeks postoperatively, and tendon lengthening decreased significantly after 6 weeks. Registration: NCT04050748 (ClinicalTrials.gov identifier).

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Surgical versus non-surgical treatment for acute Achilles’ tendon rupture. A systematic review of literature and meta-analysis

Cited by 63 publications

References 27 publications

A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures

A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures

Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture: A Comprehensive Meta-Analysis of RCTs

Comparison of Tendon Lengthening With Traditional Versus Accelerated Rehabilitation After Achilles Tendon Repair: A Prospective Randomized Controlled Trial

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