SLR - February 2013 - S. Hoffman
Reference: Wilkins R, Bisson LJ, Am J Sports Med. 2012 Sep;40(9):2154-60.
Scientific Literature Review
Reviewed by: Scott Hoffman, DPM
Residency Program: St. John Hospital and Medical Center - Detroit, Michigan
Podiatric Relevance:
Despite the fact that Achilles tendon rupture is frequently encountered by the podiatric surgeon, there is no clear consensus regarding optimal management. The primary goal of treatment remains tendon healing with restoration of function. While increased risk of re-rupture is commonly cited as a concern with nonoperative management, recent level I evidence studies suggest that the re-rupture rate is not significantly different between operative and nonoperative management. The authors performed a meta-analysis of the data from all randomized controlled trials comparing operative and nonoperative management of Achilles tendon ruptures.
Methods:
Multiple online databases (including MEDLINE, PubMed, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials) were searched to identify English-language, prospective randomized controlled trials comparing open surgical repair of acute Achilles tendon ruptures to nonoperative management. Coleman methodology scores were calculated for each included study with a perfect score of 100 representing a study that ‘‘largely avoids the influence of chance, different biases and confounding factors.’’ A meta-analysis was performed from pooled data extracted from the qualifying studies. The primary outcome was re-rupture. Secondary outcomes included strength, time to return to work, deep infections, sural nerve sensory disturbances, noncosmetic scar complaints, and deep venous thrombosis. To statistically assess observed differences with regard to complications, the exact Cochran-Mantel-Haenszel test was used in conjunction with a .05 nominal significance level.
Results:
Seven level I trials (677 total patients) met inclusion criteria with calculated Coleman scores of 95, 95, 95, 89, 78, 97, and 92. All groups were similar in terms of gender distribution and age at the time of the injury. The mean duration of follow-up ranged from 10 to 36 months. Open repair was associated with a significantly lower re-rupture rate compared with nonoperative treatment (3.6 percent vs. 8.8 percent; odds ratio, 0.425; 95 percent confidence interval, 0.222-0.815).
The overall deep infection rate was 2.36 percent among patients treated with surgical repair (six out of 254) versus 0 percent with nonoperative management (P = .0113). The overall rate of noncosmetic scar complaints was 13.1 percent in the surgical group and 0.62 percent in the nonoperative group (P<.001). Sural nerve sensory disturbances occurred in 8.76 percent of patients treated surgically (22/251) compared with 0.78 percent of patients treated nonoperatively (P<.001). The overall deep vein thrombosis rate was not significantly different when the surgical (7.08 percent) and nonoperative (10.24 percent) groups were compared (P = .1706). With regard to the time it took patients to return to work after the initiation of treatment, the point estimate of the mean difference favored surgical management, but this was not statistically significant (mean difference, 7.453 days; 95 percent CI, –4.959 to 19.864). Strength measurements were not able be meta-analyzed due to lack of standardization.
Conclusions:
Open surgical repair of acute Achilles tendon rupture significantly reduces the risk of re-rupture when compared with nonoperative management. The predominant role of intrinsic tendon healing after primary repair may explain the decreased risk of rerupture. Intrinsic healing has been shown to result in a tendon with less scar tissue, less adhesions, and with more favorable biomechanics. Extrinsic healing predominates in tendon ruptures treated with nonoperative management, where a greater diastasis between tendon ends is often present.
Known risk factors for deep infection include age >60 years, diabetes, corticosteroid therapy, smoking, delay in treatment of seven days or more, and pain in the tendon prior to injury. Nonoperative management should be strongly considered in patients with multiple risk factors. Other complications (i.e. noncosmetic scar, sural nerve sensory disturbance), which are avoided with nonoperative treatment, occur with a significantly higher incidence when surgical repair is performed. Future studies may focus on testing strength in a more functional (rapid eccentric loading) and reproducible manner than isokinetic testing.