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Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon RuptureA Meta-Analysis of Randomized Trials
Alexandra Soroceanu, MD, CM, MPH1; Feroze Sidhwa, MD, MPH2; Shahram Aarabi, MD, MPH3; Annette Kaufman, MPH, PhD4; Mark Glazebrook, MD, PhD1
1 Division of Orthopaedic Surgery, QEII Health Sciences Center, 1796 Summer Street, Halifax, NS B3H 4M8, Canada. E-mail address for M. Glazebrook: markglazebr@ns.sympatico.ca
2 1005 East Roy Street, Apartment 11, Seattle, WA 9810
3 596 Tremont Street #5, Boston, MA 02118
4 Cancer Prevention Fellowship Program, National Cancer Institute, 6130 Executive Boulevard, Suite 4051A, Rockville, MD 20852
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Investigation performed at Dalhousie University Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Dec 05;94(23):2136-2143. doi: 10.2106/JBJS.K.00917
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Abstract

Background: 

Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate.

Methods: 

A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion.

Results: 

Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226).

Conclusions: 

The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mark Glazebrook MSc., PhD. MD, F.R.C.S.(C), Dip Sports Med.
    Posted on January 09, 2013
    Nonoperative Treatment of Achilles Ruptures
    Dalhousie University and Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada

    [Editor's note: The author of this comment is one of the authors of this article.]

     Two very recent papers provided evidence for effectiveness of Non-op Rx of Achilles Ruptures and the Non-op Rx Accelerated Rehabilitation Protocol[1,2].

    Please note the following: (1) Non-op Rx does not equal no treatment!! A proven accelerated rehab protocol must be administered and supervised closely1,2.  (2) The same protocol is used for Operative Treatment[1].  (3) Patients must be careful with non-op Rx!!! Operative Rx is more robust given sutures to provide extra protection to slip or sudden unexpected contraction. (4) It is important to avoid overstretching the Achilles tendon at the repair site, thus it is recommended that physio does not allow ankle to go past neutral position in the early phase of functional rehab (prior to ~ 12-16 weeks). (5) Between 8 and 16 weeks, ensure patients understand that tendon is still very vulnerable and patients need to be diligent with activities of ADL and exercises. Any sudden loading of the Achilles (e.g. trip, step up stairs etc.) may result in a re-rupture. (6) Gradual return to sports may commence at 6 months post rupture but return to aggressive sports (e.g. soccer, football, rugby etc.) is not recommended until 9 months post rupture and gradual.

    REFERENCES
    1. Willits, K., et al., Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 92(17): p. 2767-75.

    2. Soroceanu, A., et al., Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 94(23): p. 2136-43.

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