Surgical interventions for treating acute Achilles tendon ruptures: Cochrane systematic review
Assessed as up to date: 2009/10/20
There is a lack of consensus on the best management of the acute Achilles tendon rupture. Treatment can be broadly classified into surgical (open or percutaneous) and non-surgical (cast immobilisation or functional bracing).Objectives
To evaluate the relative effects of surgical versus non-surgical treatment, or different surgical interventions, for acute Achilles tendon ruptures in adults.Search strategy
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 3), MEDLINE (1966 to 20th July 2009), EMBASE (1966 to 2009 week 29), CINAHL (1983 to July 2007) and reference lists of articles.Selection criteria
All randomised and quasi-randomised trials comparing surgical versus non-surgical treatment or different surgical methods for acute Achilles tendon ruptures in adults.Data collection and analysis
Two review authors independently selected potentially eligible trials; trials were then assessed for quality using a 10-item scale. Where possible, data were pooled.Main results
Twelve trials involving 844 participants were included. One trial tested two comparisons.
Quality assessment revealed a poor level of methodological rigour in many studies, particularly with regard to concealment of allocation and the lack of assessor blinding.
Open surgical treatment compared with non-surgical treatment (6 trials, 536 participants) was associated with a statistically significant lower risk of rerupture (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.21 to 0.77), but a higher risk of other complications including infection (RR 4.89, 95% CI 1.09 to 21.91), adhesions and disturbed skin sensibility (numbness). Functional status including sporting activity was variably and often incompletely reported, including frequent use of non standardised outcome measures, and the results were inconclusive.
Open surgical repair compared with percutaneous repair (4 trials, 174 participants) was associated with a higher risk of infection (RR 9.32, 95% CI 1.77 to 49.16). These figures should be interpreted with caution because of the small numbers involved. Similarly, no definitive conclusions could be made regarding different tendon repair techniques (3 trials, 147 participants).Authors' conclusions
Open surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with non-surgical treatment, but produces significantly higher risks of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously.
Khan Riaz JK, Carey Smith Richard L
Surgical interventions for treating acute Achilles tendon ruptures
Rupture of the Achilles tendon is common and said to be increasing. It typically occurs in males in their 30s and 40s who play sport intermittently. People present with severe pain in the tendon, at the back of the ankle. Signs include a palpable gap at the rupture site, and marked weakness of ankle plantar-flexion (movement so toes point downwards). Options for management include non-surgical interventions (plaster of Paris, bracing or splinting) or surgical repair of the tendon. Following either method of treatment, the ankle may be immobilised for up to 12 weeks (in a cast, allowing no movement at the ankle and variable weight-bearing), or mobilised early (in a brace, allowing movement at the ankle and partial to full weight-bearing).
Twelve trials including 794 participants acute Achilles tendon rupture were included. The majority of participants were male, and the average ages of the study populations were between 36 to 41 years. Many of the trials had flawed methods that undermined the reliability of their results.
Open surgical treatment compared with non-surgical treatment (6 studies, 502 participants) was associated with a lower risk of rerupture, but a higher risk of other complications such as infection, adhesions and disturbed skin sensibility (numbness and tingling). There were insufficient and inconclusive data on function and sporting activities.
Percutaneous repair (involving stab incisions through which the repair suture is passed through without direct exposure of the tendon) compared with open repair (4 studies, 174 participants) was associated with a lower risk of infection. These figures should be interpreted with caution because of the small numbers involved. Similarly, no definitive conclusions could be made regarding different tendon repair techniques (3 studies, 141 participants).
Implications for practice
On the basis of the randomised studies reviewed, there is evidence that open surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with non-surgical treatment, but has the drawback of a significantly higher risk of other complications, including wound infection. These complications appear to be reduced by performing surgery percutaneously, but this inference is based upon limited data from a small number of participants.
There is inadequate evidence to comment on different suture techniques, or the use of a more complex (augmented) reconstruction.
Implications for research
Further rigorously conducted randomised controlled trials with larger sample sizes, full reporting of outcomes and blinding of assessors are required to establish the ideal surgical intervention and subsequent rehabilitation regimen. Such studies should be reported using the CONSORT statement. Longer term follow up of functional outcome using standardised validated outcome measures is highly recommended. Increased transparency is needed where the same cohort of participants is reported on in later studies; this will facilitate meaningful data interpretation at meta-analysis. Avoidance of multiple publication and 'salami slicing' (splitting data) is imperative.
Also important is the maintenance of this review in the light of new evidence: we await the publication of the results of the four randomised controlled trials listed in our review ( ; ).Get full text at The Cochrane Library
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