Athletic Training and Sports Health Care

Sports Medicine Digest 

Evaluation of Conservative Treatment and Surgical Intervention for Achilles Tendon Rupture in Athletes

Stuart Wright, DAT, ATC, CSCS; Christopher Anderson, DAT, ATC, SCAT; Cailee E. Welch Bacon, PhD, ATC

Abstract

Holm C, Kjaer M, Eliasson P. Achilles tendon rupture–treatment and complications: a systematic review. Scand J Med Sci Sports. 2015;25:e1–e10.

Clinical Question: To evaluate a systematic review to determine whether surgical intervention is more effective at reducing Achilles tendon re-rupture rates and improving functional outcomes of patients compared with conservative treatment.

Study Selection: Studies published between 2005 and 2015 were identified. Inclusion criteria were studies published in English and patients suffering from ipsilateral acute Achilles tendon ruptures, complete tendon rupture, and no previous rupture. Studies were excluded if the patients had a delayed presentation of rupture (more than 3 weeks after injury). The main outcomes of interest were re-rupture rates, complications, and functional outcomes of the Achilles tendon. A total of 7 articles met the inclusion criteria and were included in the systematic review.

Main Results: Overall re-rupture rates ranged from 0% to 10%, with a mean of 4.47% for the surgical intervention group. Re-rupture rates for the non-surgical intervention group averaged 7.52%. No difference was reported regarding the Achilles Tendon Rupture Score between surgical and non-surgical interventions. Higher plantar flexion peak torque at 3 months and increased heel raise work, plantar strength, and jump scores were associated with the surgical intervention group at 12 months. There was no difference in heel raise index at 18 months. In addition, there was no reported difference in calf circumference. Increased minor complications were associated with surgical intervention.

Conclusions: No statistical significance exists between surgical and non-surgical interventions for Achilles tendon rupture regarding re-rupture rates. Surgical intervention may be associated with increased strength; however, this improved outcome is not in agreement with the results of patient-reported outcome measures.

Summary: The Achilles tendon is the most frequently ruptured tendon, occurring predominantly in males between 35 and 39 years of age.1 Research has illustrated a shift in the efficacy of intervention, with recent evidence suggesting equitable re-rupture rates between surgical and non-surgical interventions.1 However, minor complications are associated with surgical intervention.1 In addition to the initial treatment, bracing and rehabilitation may influence functional outcomes of patients.1

Holm et al.1 completed a systematic review of randomized controlled trials comparing the surgical and non-surgical treatment of Achilles tendon ruptures. Re-rupture rates were higher in the non-surgical intervention group compared to the surgical intervention group in 6 of the 7 studies. Although none were statistically significant, 2 studies reviewed may be of clinical significance in favor of surgical intervention.1 Because the results were not statistically significant, a strong recommendation cannot be made on this systematic review alone. However, it may be worth considering these differences when deciding the optimal course of treatment for Achilles tendon ruptures, especially when taking into account the increased demands of athletic populations.

Deep vein thrombosis (DVT) was examined in 6 of the 7 studies, with each noting a higher but not statistically significant incidence in non-surgical intervention groups. Infection was also reported as a potential complication following surgery, although direct comparison with non-surgical intervention was not reported in each individual study.1 Clinicians should understand the minor risks associated with surgery,1 but this should be weighed against the increased incidence of DVT in non-surgical interventions.1

A significant difference in range of motion (ROM) in favor of the unaffected versus the affected limb was reported.1 This highlights an area of focus for clinicians during rehabilitation of an Achilles tendon rupture. Increased strength was associated with surgical intervention at 3, 6, and 12 months.1 However, these results should be interpreted with caution because strength as an outcome measure is disease oriented and does not directly reflect a patient's functional ability. These results also demonstrate the importance…

Holm C, Kjaer M, Eliasson P. Achilles tendon rupture–treatment and complications: a systematic review. Scand J Med Sci Sports. 2015;25:e1–e10.

Clinical Question: To evaluate a systematic review to determine whether surgical intervention is more effective at reducing Achilles tendon re-rupture rates and improving functional outcomes of patients compared with conservative treatment.

Study Selection: Studies published between 2005 and 2015 were identified. Inclusion criteria were studies published in English and patients suffering from ipsilateral acute Achilles tendon ruptures, complete tendon rupture, and no previous rupture. Studies were excluded if the patients had a delayed presentation of rupture (more than 3 weeks after injury). The main outcomes of interest were re-rupture rates, complications, and functional outcomes of the Achilles tendon. A total of 7 articles met the inclusion criteria and were included in the systematic review.

Main Results: Overall re-rupture rates ranged from 0% to 10%, with a mean of 4.47% for the surgical intervention group. Re-rupture rates for the non-surgical intervention group averaged 7.52%. No difference was reported regarding the Achilles Tendon Rupture Score between surgical and non-surgical interventions. Higher plantar flexion peak torque at 3 months and increased heel raise work, plantar strength, and jump scores were associated with the surgical intervention group at 12 months. There was no difference in heel raise index at 18 months. In addition, there was no reported difference in calf circumference. Increased minor complications were associated with surgical intervention.

Conclusions: No statistical significance exists between surgical and non-surgical interventions for Achilles tendon rupture regarding re-rupture rates. Surgical intervention may be associated with increased strength; however, this improved outcome is not in agreement with the results of patient-reported outcome measures.

Summary: The Achilles tendon is the most frequently ruptured tendon, occurring predominantly in males between 35 and 39 years of age.1 Research has illustrated a shift in the efficacy of intervention, with recent evidence suggesting equitable re-rupture rates between surgical and non-surgical interventions.1 However, minor complications are associated with surgical intervention.1 In addition to the initial treatment, bracing and rehabilitation may influence functional outcomes of patients.1

Holm et al.1 completed a systematic review of randomized controlled trials comparing the surgical and non-surgical treatment of Achilles tendon ruptures. Re-rupture rates were higher in the non-surgical intervention group compared to the surgical intervention group in 6 of the 7 studies. Although none were statistically significant, 2 studies reviewed may be of clinical significance in favor of surgical intervention.1 Because the results were not statistically significant, a strong recommendation cannot be made on this systematic review alone. However, it may be worth considering these differences when deciding the optimal course of treatment for Achilles tendon ruptures, especially when taking into account the increased demands of athletic populations.

Deep vein thrombosis (DVT) was examined in 6 of the 7 studies, with each noting a higher but not statistically significant incidence in non-surgical intervention groups. Infection was also reported as a potential complication following surgery, although direct comparison with non-surgical intervention was not reported in each individual study.1 Clinicians should understand the minor risks associated with surgery,1 but this should be weighed against the increased incidence of DVT in non-surgical interventions.1

A significant difference in range of motion (ROM) in favor of the unaffected versus the affected limb was reported.1 This highlights an area of focus for clinicians during rehabilitation of an Achilles tendon rupture. Increased strength was associated with surgical intervention at 3, 6, and 12 months.1 However, these results should be interpreted with caution because strength as an outcome measure is disease oriented and does not directly reflect a patient's functional ability. These results also demonstrate the importance of using patient-oriented evidence in research to avoid false conclusions through surrogate end points.

It has been suggested that minimally invasive surgery, including the percutaneous technique, is comparable to open surgical techniques, and may even display reduced re-rupture rates and complications at a lower cost.4 Understanding this variance allows clinicians to play a pivotal role in patient education. Clinicians should communicate the technique options so their patients can make a more informed treatment choice. In addition, an important consideration for the treatment of Achilles tendon ruptures is the impact of rehabilitation.

Brumann et al.5 investigated early mobilization, early weight bearing, and combined (early weight bearing and ROM) treatment. They concluded that the combined treatment group displayed higher satisfaction, reduced the rehabilitation resources used, promoted an earlier return to previous activities, and increased strength, with no increase in re-rupture rates. These findings agree with those of Huang et al.,6 who reported better satisfaction (from shorter recovery time as opposed to impact on daily life), improved strength, and reduced complications, with no increase in the re-rupture rates for the combined functional treatment group compared to the immobilization treatment group. No difference was found when comparing functional assessment scales (ie, Achilles Rupture Performance Score and Modified Rupture Score) between immobilization treatment groups and functional treatment groups.

Based on the current evidence, surgical versus conservative treatment results in no significant difference in re-rupture rates, although a clinical difference has been reported.1 The impact of rehabilitation has been highlighted as a major contributor to the success of both conservative and surgical treatments.5,6 Early ROM and weight bearing may improve patient outcomes following an Achilles tendon rupture, although it is important for the clinician to understand that heterogeneity between studies and rehabilitation protocols may affect the interpretation of results.

No significant difference exists for return to previous level of sport.1 Return to sport was reported to be between 56 days and 9 months5; therefore, a clinician must understand that return to participation should be based on the individual's progress. Regardless of the course of care chosen, a thorough evidence-based rehabilitation protocol for an Achilles tendon rupture is still lacking, and more research is needed in this area.

Finally, the authors used the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 to appraise the quality of the systematic review by Holm et al.1 Two authors individually appraised the systematic review, but ties were broken by a third author. The review was met with approval for items 1, 5, 8, 9, 13, and 14. The systematic review received a “no” on all remaining items. Therefore, the review by Holm et al.1 should be rated as critically low because there is more than one critical flaw,7 which means that clinicians should interpret the results of this study with caution.

References

  1. Holm C, Kjaer M, Eliasson P. Achilles tendon rupture–treatment and complications: a systematic review. Scand J Med Sci Sports. 2015;25:e1–e10. doi:10.1111/sms.12209 [CrossRef]
  2. Van der eng DM, Schepers T, Goslings JC, Schep NW. Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis. J Foot Ankle Surg. 2013;52:622–628. doi:10.1053/j.jfas.2013.03.027 [CrossRef]
  3. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94:2136–2143. doi:10.2106/JBJS.K.00917 [CrossRef]
  4. Del Buono A, Volpin A, Maffulli N. Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review. Brit Med Bull. 2014;109:45–54. doi:10.1093/bmb/ldt029 [CrossRef]
  5. Brumann M, Baumbach S, Mutschler W, Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture–development of an evidence-based treatment protocol. Injury. 2014;45:1782–1790. doi:10.1016/j.injury.2014.06.022 [CrossRef]
  6. Huang J, Wang C, Ma X, Wang X, Zhang C, Chen L. Rehabilitation regimen after surgical treatment of acute Achilles tendon ruptures: a systematic review with meta-analysis. Am J Sport Med. 2015;43:1008–1016. doi:10.1177/0363546514531014 [CrossRef]
  7. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of health care interventions, or both. BMJ. 2017;358:j4008. doi:10.1136/bmj.j4008 [CrossRef]
Authors

From the Athletic Training Program, A. T. Still University, Mesa, Arizona (SW, CA, CEWB); the Department of Physical Education and Athletic Training, Limestone College, Gaffeny, South Carolina (SW); and Venesco LLC, Fort Jackson, South Carolina (CA).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Stuart Wright, DAT, ATC, CSCS, 122 Margie Road, Gaffney, SC 29340. E-mail: swright@atsu.edu

10.3928/19425864-20181002-04

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