SLR - December 2018 - Woojung M. Lee
Reference: Simon Svedman, Robin Juthberg, Gunnar Edman, Paul W. Ackermann. Reduced Time to Surgery Improves Patient-Reported Outcome After Achilles Tendon Rupture. Am J Sports Med. 2018 Oct;46(12):2929–2934.Scientific Literature Review
Reviewed By: Woojung M. Lee, DPM
Residency Program: Hunt Regional Medical Center, Greenville, TX
Podiatric Relevance: Treatment strategies for Achilles tendon rupture vary considerably, and discussions for optimizing its repair have been mostly focused on surgical versus nonsurgical treatment. The purpose of this retrospective cohort study is to determine whether patient outcomes and adverse events after surgical repair of acute Achilles tendon rupture are related to delayed time to surgery. Patient-reported outcome at one year was assessed with the validated Achilles Tendon Total Rupture Score (ATRS) along with the incidences of adverse events and deep venous thrombosis.
Methods: A level III retrospective cohort study was performed on 228 patients who had undergone surgery after acute Achilles tendon rupture injury with uniform anesthetic and surgical techniques. These patients were included from two prospectively designed randomized controlled trials. All patients sustained an acute unilateral Achilles rupture at the midsubstance level and had received surgery within 10 days from injury. Time to surgery depended on availability of the operating theater, and neither surgeon nor patient could influence this. Patients were further divided to one of three groups: short (<48 hours), intermediate (48–72 hours) and long time to surgery (>72 hours). The prevalence of good subjective outcome was assessed at one year follow-up with the validated ATRS. A score higher than 80 (out of 100) was considered an overall good subjective outcome. The incidence of adverse events (perioperative and postoperative) and deep venous thrombosis were also assessed.
Results: Short time to surgery was significantly associated with increased rate of good subjective outcome (ATRS >80) and reduced incidence of adverse events. A good subjective outcome was observed in 71 percent (95 percent CI, 60–83 percent) in the short time to surgery group compared to 44 percent (95 percent CI, 33–56 percent) in the group with long time to surgery. The patients with intermediate time to surgery had good subjective outcome of 63 percent (95 percent CI, 47–78 percent). The incidence of adverse events was also significantly reduced among patients in the short time to surgery group, 1.4 percent (95 percent CI, 1–4 percent) compared with those in intermediate group, 11 percent (95^ CI, 2–21 percent) and those with long time to surgery, 14.8 percent (95 percent CI, 7–23 percent). There was no statistically significant difference among the three groups for incidence of deep venous thrombosis.
Conclusions: This study established that there is poorer patient-reported outcomes one year after surgery for an acute Achilles tendon rupture with delayed time to surgery (>72 hours). Prolonged time to surgery was further associated with higher occurrence of adverse events. According to current literature, the first 72 hours from the time of Achilles tendon rupture injury are considered the induction phase of tendon healing. If a second trauma caused by surgery occurs after this induction phase is over, there may be a lack of healing-inducing factors, which may be contributing to poorer outcomes on those with delayed time to surgery. Further studies are needed to determine the exact mechanisms underlying the effects of time to surgery. The authors propose not to delay acute Achilles tendon rupture surgery more than 72 hours.