Scand J Med Sci Sports 2014: ••: ••–•• doi: 10.1111/sms.12209
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Review
Achilles tendon rupture – treatment and complications: A systematic review C. Holm, M. Kjaer, P. Eliasson Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark Corresponding author: Christina Holm, Bispebjerg Hospital, Building 8, 1st Floor, Bispebjerg Bakke 23, Copenhagen 2400, Denmark. Tel: +45 51 92 25 21, Fax: +45 35 31 27 33, E-mail: [email protected] Accepted for publication 12 February 2014
Achilles tendon rupture is a frequent injury with an increasing incidence. Until now, there is no consensus regarding optimal treatment. The aim of this review was to illuminate and summarize randomized controlled trials comparing surgical and non-surgical treatment of Achilles tendon ruptures during the last 10 years. Seven articles were found and they were all acceptable according to international quality assessment guidelines. Primary outcomes were re-ruptures, other complications, and functional outcomes. There was no significant difference in re-ruptures between the two treatments, but a tendency to favoring surgical treatment. Further, one study found an increased risk of soft-tissue-related com-
plications after surgery. Patient satisfaction and time to return to work were significantly different in favor of surgery in one study, and there was also better functional outcome after surgery in some studies. These seven studies indicate that surgical patients have a faster rehabilitation. However, the differences between surgical and non-surgical treatment appear to be subtle and it could mean that rehabilitation is more important, rather than the actual initial treatment. Therefore, further studies will be needed in regard to understanding the interplay between acute surgical or non-surgical treatment, and the rehabilitation regimen for the overall outcome after Achilles tendon ruptures.
The Achilles tendon is the most frequently ruptured tendon, and this injury type most often occur during soccer, racket games, or basketball (Leppilahti et al., 1996; Gwynne-Jones et al., 2011). Achilles tendon rupture mostly happens at the age of 35–39 years in both men and women, but with predominance for men (Leppilahti et al., 1996; Leppilahti & Orava, 1998; Suchak et al., 2005; Nyyssonen et al., 2008). Tendon healing is a slow process but important as the Achilles tendon is vital for movements. An acute rupture is therefore a complicated injury, and treatment thereof is a controversial subject among medical doctors and scientists, still without consensus regarding optimal treatment. Earlier studies have shown that surgical treatment significantly reduces the risk of re-rupture, but it increases the risk of complications associated with surgery (Nistor, 1981; Moller et al., 2001). Surgery has therefore often been the choice of treatment for athletes and young people, whereas the choice of treatment for elderly has pre-dominantly been non-surgical treatment. During the last decade, the influence of early post-operative rehabilitation has become an aspect of great interest when it comes to understanding the optimal healing of acute Achilles tendon rupture (Speck & Klaue, 1998; Mortensen et al., 1999; Kerkhoffs et al., 2003; Costa
et al., 2006; Suchak et al., 2006, 2008; Schepull & Aspenberg, 2013). Animal and human in vivo studies have shown that early mobilization has had a positive effect on the tendon healing process (Speck & Klaue, 1998; Mortensen et al., 1999; Palmes et al., 2002; Kerkhoffs et al., 2003; Costa et al., 2006; Andersson et al., 2009; Bring et al., 2010). Previously, patients were mostly treated with cast immobilization after both surgery and non-surgery (Nistor, 1981; Cetti et al., 1993). Nowadays, both treatment groups are generally treated with functional braces instead of rigid casts and this allows for earlier mobilization (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013). Newer studies comparing surgical and non-surgical treatment, including early rehabilitation, have not been able to show a significant difference in the occurrence of re-ruptures (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013). The question of surgery vs non-surgery is therefore still open. Furthermore, the functional braces have shown to increase patient satisfaction and return to sport and work (Mortensen et al., 1999). Now that re-rupture rate between the surgery and non-surgery group in many new
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Holm et al. studies has equalized (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013), a new aspect regarding functional outcomes is of great interest in deciding the best acute treatment for acute Achilles tendon rupture. The purpose of this review is to illuminate and summarize randomized controlled trials from the last 10 years, comparing surgical and non-surgical treatment of Achilles tendon ruptures.
According to our inclusion and exclusion criteria we screened the titles, resulting in 22 articles. Further, we screened the abstracts, resulting in 18 articles. By reading each article we ended up with seven (Table 1), which included 577 patients in total. The reference lists from the articles were thereafter screened for other studies of interest, but we found no more relevant articles for inclusion according to our criteria. The quality of the methodology in these seven articles was assessed according to the guidelines by Furlan et al. (2009) (Table 1). Using the criteria in these guidelines, we assessed the risk of bias in each article. Each criterion was assessed with the possibilities of “Yes,” “No,” and “Don’t know.” Articles that achieved more than 6/12 “Yes” were considered to be of “high quality,” whereas articles below 6/12 “Yes” were considered to be of “low quality.” The assessment was performed by C. H. and P. E., and the articles were only evaluated by information written in the paper, no additional information was collected by contacting the authors. Any differences were solved by discussion.
Methods This study analysis includes randomized prospective controlled trials on humans, published in English, which compares surgical and non-surgical treatment of Achilles tendon ruptures during the last 10 years. We excluded retrospective studies, studies with no clear description of randomization, and studies with no report of our selected primary outcomes. In MEDLINE database, the specific search was carried out on Achilles tendon (MeSH terms) OR Achilles (all fields) AND tendon (all fields) OR Achilles tendon (all fields) AND rupture (MeSH terms) OR rupture (all terms) AND randomized controlled trial OR clinical trial. This search resulted in 78 hits. Only those articles that met our inclusion criteria were scrutinized: • • • •
Results All articles assessed were considered to be of a high methodological quality according to the Furlan guidelines (Furlan et al., 2009) (Table 1).
Ipsilateral acute Achilles tendon rupture Complete rupture No previous rupture Study was performed during the last 10 years
Complications and re-ruptures Re-ruptures All of the articles reported the occurrence of re-ruptures (Table 3), and none of them found any statistical significant difference between the two treatment groups (Twaddle & Poon, 2007; Metz et al., 2008; NilssonHelander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013).
Exclusion criteria were studies with delayed diagnostic presentation of rupture (more than 3 weeks after injury). The primary outcomes that we were interested in were re-ruptures, complications of treatment, and functional outcomes of the Achilles tendon (measured with physical tests through rehabilitation). Table 1. Criteria for quality assessment according to Furlan et al. (2009)
Study
A
B
C
D
E
F
G
H
I
J
K
L
Keating and Will (2011) Twaddle and Poon (2007) Nilsson-Helander et al. (2010) Willits et al. (2010) Schepull et al. (2012) Metz et al. (2008)
Yes, blind envelopes Yes, tossing a coin Yes, sealed envelopes
No Don’t know Yes
No No No
No No No
Yes No Yes
Yes, 2.5% Yes, 16% Yes, 3%
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes, computer generated Yes, sealed envelopes Yes, Internet site
No Don’t know No
No No No
No No No
No Yes No
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Olsson et al. (2013)
Yes, sealed envelopes
No
No
No
Yes
Yes, 12% Yes, 17% No, not well described Yes, 6%
Yes
Yes
Yes
Yes
Yes
Yes
Criteria for quality assessment according to Furlan et al. (2009). Criteria were answered with Yes/No/Don’t know: A Was the method of randomization adequate? B Was the treatment allocation concealed? C Was the patient blinded to the intervention? D Was the care provider blinded to the intervention? E Was the outcome assessor blinded to the intervention? F Was the dropout rate described and acceptable? G Were all randomized participants analyzed in the group to which they were allocated? H Are reports of the study free of suggestion of selective outcome reporting? I Were the groups similar at baseline regarding the most important prognostic indicators? J Were co-interventions avoided or similar? K Was the compliance acceptable in all groups? L Was the timing of the outcome assessment similar in all groups?
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Aim: To determine whether surgical treatment was associated with any functional advantages. In particular whether surgical treatment was associated with a faster or a better muscle function recovery. Subjects: 80 patients with acute Achilles tendon rupture. Intervention: A: Surgery (n = 39) and a below knee cast for 6 weeks, non-weightbearing. Full weight-bearing thereafter. B: Non-surgery (n = 41) and a below knee cast for 10 weeks. Non-weightbearing for 8 weeks and partial weight-bearing for last 2 weeks. Evaluation/outcome: Follow-ups were performed at 3, 4, 6 and 12 months. Primary variable was muscle function (measured by isokinetic peak torque, total work, and average power for dorsi- and plantar flexion and range of motion). Primary clinical outcome was re-ruptures. Secondary variables were Short Musculoskeletal Function Assessment Questionnaire (SMFA), pain score, and time to return to work, to sport, and to driving. Other complications besides re-ruptures were also recorded. Aim: To compare surgical vs non-surgical treatment combined with controlled early motion in both groups. Subjects: 50 patients with acute Achilles tendon rupture but 8 patients were excluded. Intervention: A: Surgery (n = 25) B: Non-surgery (n = 25) Both groups had cast for 10 days followed by below knee orthosis, 8 weeks in total, non-weightbearing during the first 6 weeks. Both groups started exercises after 10 days with active dorsiflexion and passive plantar flexion outside the orthosis for 5 min every hour. Evaluation/outcome: Follow-ups were carried out at 10 days and 8, 12, 26 and 52 weeks. Evaluation was performed on range of motion (plantar and dorsiflexion), calf circumference, squeeze test reactivity, Musculoskeletal Functional Assessment Index (MFAI), and re-ruptures and complications were noted.
Keating and Will (2011)
Twaddle and Poon (2007)
Summary
Study
Table 2. Summary of each study, results between and within groups
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The non-injured side had a greater range of dorsi- and plantar flexion in both groups at all time points (but very little difference at 52 weeks).
No significant differences in range of motion, calf circumference, and MFAI at any time points. There was also no difference in re-ruptures or other complications.
9/12 No significant difference in re-ruptures or any other complications. No significant difference in range of motion, except an increased mean range of plantar flexion compared with the non-injured leg in the surgical-treated group at 26 weeks. The difference in peak torque of plantar flexion between injured and uninjured side was significantly lower in the surgical group at 3 months (47% vs 61%). No other significant results on strength tests. Significantly better results in SMFA score in the surgical group at 3 months – otherwise no significant differences. No significant differences in pain score.
None statistically described differences compared with normal side.
Quality assessment
Between-group results
Within-group results
Treatment of Achilles tendon ruptures
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4
Summary
Aim: To compare patients treated with surgery and accelerated functional rehabilitation, with patients treated with accelerated functional rehabilitation alone. Subjects: 144 patients with acute Achilles tendon rupture. Intervention: A: Surgery (n = 72) B: Non-surgery (n = 72) Both groups had accelerated functional rehabilitation with a below knee orthosis for 8 weeks. Protective weight-bearing at 2 weeks and weight-bearing as tolerated at 4 weeks. Outcome/evaluation: Follow-ups were carried out at 3, 6, 12 and 24 months. Primary outcome was re-ruptures. Secondary outcomes were isokinetic strength (dorsi- and plantar flexion), Leppilahti score, range of motion, and calf circumference.
Aim: To investigate if different treatments (surgical and non-surgical) influence modulus of elasticity of the tendon. The second aim was to study if early elastic modulus correlates with late tendon function. Subjects: 30 patients with acute Achilles tendon rupture. Intervention: A: Surgery (n = 15) B: Non-surgery (n = 15) Both groups had a cast on for a total of 7 weeks. They were allowed full weight-bearing from the beginning. Evaluation/outcome: Follow-ups were performed at 7 weeks, and 6 and 18 months. Primary variable was an estimate for the modulus of elasticity at 7 weeks. Secondary variables were strain per force, heel-raise index, tendon cross-sectional area, tendon elongation, and ATRS.
Willits et al. (2010)
Schepull et al. (2012)
Nilsson-Helander Aim: To compare outcomes of patients treated with or without surgery, using early mobilization and identical rehabilitation protocols. et al. Subjects: 100 patients with acute Achilles tendon rupture. (2010) Intervention: A: Surgery (n = 49) B: Non-surgery (n = 48) Both groups received a below knee cast followed by an adjustable brace for a total of 8 weeks, then rehabilitation protocol Evaluation/outcome: Follow-ups were carried out at 2, 8, 12 weeks and 6 and 12 months. Primary variable was re-ruptures. Secondary variables were Achilles Tendon Total Rupture Score (ATRS), physical activity scale (PAS), functional tests (two jumps, two strengths, and one endurance test).
Study
Table 2. Continued.
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No significant difference in re-ruptures; however, the difference might be of clinical importance (4% vs 12%). Concentric strength (82% vs 71%), heel-rise work (65% vs 54%) and height (75% vs 68%), and hopping tests (90% vs 75%) were significantly better in the surgical group at the 6-month evaluation. There was only a difference in the endurance test (heel-rise work) at 12 months where the surgical group performed significantly better (78% vs 68%). No significant differences on ATRS or PAS score at 6- and 12-month evaluation. Eccentric strength and drop countermovement jump test did not differ between the groups at any time point.
Both groups improved significantly over time in ATRS and PAS score. Also the functional tests improved over time, all tests except for concentric power in the surgery group. Both groups had significantly lower values for the injured leg compared with the uninjured leg at all functional tests at 6 and 12 months, except for hopping at 12 months. In both groups, the affected limb achieved at least 80% of the plantar flexion strength, and 100% of the dorsiflexion strength of the unaffected limb at all test velocities, 12 and 24 months. Greater range of motion on the unaffected limb in both groups during the entire time. No significant change in strength at any velocity in both groups between 12and 24-month follow-up. In both groups there was a significant correlation between the modulus of elasticity at 7 weeks and the heel-raise index at 18 months. There was also an elongation of the tendon between 3–7 weeks and 7–19 weeks, but not between 7 weeks and 18 months. No significant differences at any time in the elastic modulus between the two groups. No significant differences in strain per force, heel-raise index, ATRS score, tendon lengthening, or tendon cross-sectional area between the groups at any time point. A significant higher variation in strain per force in the non-surgical group.
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8/12 Only significant difference at the plantar strength ratio at 240 °/s at 12 and 24 months, in favor of the surgical group (21% higher). No significant difference in the dorsiflexion strength at any test velocity or any time point. A greater side-to-side difference for non-surgical group in plantar flexion range of motion at 24-month follow-up (15% higher). Otherwise no significant differences in range of motion between the two groups. No significant difference in re-ruptures, calf circumference, or Leppilahti score at any time point. Increased risk of complication in the surgical group (18% vs 8%).
Quality assessment
Between-group results
Within-group results
Holm et al.
Aim: To compare minimally invasive surgical repair with non-surgical treatment by functional bracing. Subjects: 83 patients with acute Achilles tendon rupture. Interventions: A: Minimally invasive surgery (n = 42) and cast for 1 week, followed by a tape bandage supported with heel raise for 6 weeks. B: Non-surgery (n = 41), cast for 1 week, followed by a functional bracing system for 6 weeks. Full weight-bearing was allowed after 1 week for both groups. Outcome/evaluation: Follow-ups were performed at 1, 3, 5, 7 weeks and at 3, 6 and 12 months. Primary variable was complications (besides re-ruptures). Secondary variables were time to work, time to sports, patient satisfaction and pain (measured by VAS), re-ruptures, and Leppilahti score. Aim: To compare outcomes of patients treated with surgery, early loading, and range of motion with patients treated without surgery and with a more traditional rehabilitation. Subjects: 101 patients with acute Achilles tendon rupture. Intervention: A: Surgery (n = 49) B: Non-surgery (n = 51) Both groups received a pneumatic walker brace including three heel pads and were allowed full weight-bearing. The surgical group started early active rehabilitation (range of motion and strength training exercises) after 2 weeks, and were mobilized in the walker for 6 weeks. The non-surgical group was immobilized in the walker for 8 weeks. Evaluation/outcome: Follow-ups were carried out at 2, 6/8, 12, 26 and 52 weeks. Primary variable was ATRS. Secondary variables were re-ruptures, other complications, PAS, Foot and Ankle Outcome Score (FAOS), EuroQol group’s questionnaires (EQ-5D), functional tests (two jumps, two strengths, and one endurance test).
VAS, visual analog scale.
Olsson et al. (2013)
Metz et al. (2008)
7/12
9/12
No statistically significant differences in the risk of re-ruptures or overall complications. A clinical difference is although described with an increased risk of complications after non-surgical treatment (49% vs 29%). There was significant difference in time to return to work, in favor of surgical treatment (59 vs 108 days). No significant difference in time to return to sport, pain, or patient satisfaction between the two groups. No significant difference in Leppilahti outcome scores.
No significant difference at any time point in ATRS. No significant difference in PAS, FAOS, or EQ-5D between the groups. Significant difference in the jumping tests at 12 months in favor of surgical treatment (10% vs 21%). No statistically significant differences (P = 0.06) in the risk of re-ruptures (2% vs 10%). No significant difference in the occurrence of deep vein thrombosis between the two groups. 12% of the patients in the surgical group suffered from superficial wound infections. 26% of the surgical-treated patients and 4% of the non-surgical-treated patients experienced temporary nerve disturbances.
None described.
Improved ATRS and FAOS over time in both groups. No significant difference in PAS compared with baseline in either group. Significant decrease in EQ-5D in both groups at 12 months compared with pre-injury values. Significantly lower values on the injured side compared with the non-injured side on all functional tests at 6 months. The surgical group improved in one jumping test and concentric power at 12 months and the non-surgical group also improved in one jumping test at 12 months.
Treatment of Achilles tendon ruptures
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Although two studies found differences, which could be of clinical importance, in favor of surgery, 2–4% vs 10–12% after non-surgical treatment (Nilsson-Helander et al., 2010; Olsson et al., 2013) (Table 2).
Non-surgery 4%
Skin-related complications
Surgery 4.8% Non-surgery 32%†
Holm et al.
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Surgery 7.1% Non-surgery 2.4% Surgery 1.4% Surgery 1.4%
Surgery 7.1%
Surgery 27% Surgery 2%
Surgery 12%
Surgery 5.6%
Six out of the seven articles reported the incidence of DVT (Table 3) (Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013). None of them found any significant differences between surgery and non-surgery. Four of the articles reported an incidence of 1–5% (Metz et al., 2008; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013), and these were only the patients with symptoms of DVT. Nilsson-Helander et al. (2010) screened all patients with color duplex sonography and showed that the actual incidence of DVT is far greater than the incidence reported by symptoms, 29% after surgical treatment and 39% after nonsurgical treatment. Schepull et al. (2012) reported an incidence of 27% after non-surgical treatment compared with none after surgical treatment; however, they did not do a statistical test on their findings.
Olsson et al. (2013)
Metz et al. (2008)
Schepull et al. (2012)
Nilsson-Helander et al. (2010) Willits et al. (2010)
Twaddle and Poon (2007)
*Color duplex sonography on all patients. † Including superficial wound infection.
Surgery 29% Non-surgery 39%* Surgery 1.4% Non-surgery 1.4% Surgery 0% Non-surgery 27% Surgery 0% Non-surgery 2.4% Surgery 2% Non-surgery 4%
Surgery 2%
Surgery 0% Surgery 0%
Surgery 5.1% Surgery 0% Non-surgery 5% Keating and Will (2011)
Surgery 5.4% Non-surgery 10% Surgery 10% Non-surgery 4.5% Surgery 4% Non-surgery 12% Surgery 2.8% Non-surgery 4.2% Surgery 0% Non-surgery 6.7% Surgery 7.1% Non-surgery 12% Surgery 2% Non-surgery 10%
Surgery 2.6%
DVT
DVT
Superficial infections
Metz et al. (2008) found no statistical significant difference in other complications [nerve injuries, deep venous thrombosis (DVT), regional pain, skin-related complications, and scar adhesions] between surgical and non-surgical-treated patients, although they found a difference that could be of clinical importance in favor of surgical treatment, 21% vs 36% after non-surgical treatment (Table 3). Willits et al. (2010) found, on the other hand, an increased risk of complications (DVT, pulmonary embolus, infections, scar, and wound complications) after surgical treatment, 18% vs 8% after non-surgical treatment. Olsson et al. (2013) found that superficial wound infections (12%) and temporal nerve disturbance (2%) occurred after surgical treatment but not after non-surgical treatment. Two other studies found no statistical difference in the occurrence of complication after different treatments (Twaddle & Poon, 2007; Keating & Will, 2011).
Re-ruptures
Table 3. Summary of the occurrence of re-ruptures and other types of complications in each study
Deep infections
Scar complications
Surgery 4.1%
Nerve disturbances
Other complications including infections
Muscle strength, tendon stiffness, and tendon elongation Four articles measured different functional tests (plantar flexion, heel-rise work, heel-rise height, hopping, drop countermovement jump, concentric power, eccentric power) (Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013) (Table 2). Nilsson-Helander et al. (2010) found a significant difference in concentric power (82% vs 71%), heelrise height (75% vs 68%), heel-rise work (65% vs 54%),
Treatment of Achilles tendon ruptures and hopping tests (90% vs 75%) after 6 months, in favor of surgical treatment. Furthermore at 12-month evaluation, the surgical group performed significantly better in the endurance test, heel-rise work (75% vs 68%). Olsson et al. (2013) found that surgery significantly improved the results in two jumping tests after 12 months (10% and 21% higher after surgery compared with nonsurgical treatment, but they did not find any difference in heel-rise work). Willits et al. (2010) found that the plantar strength ratio at 240 °/s (240 °/s means the velocity of the dynamometer during isokinetic testing) was significantly better for the surgical group at 12-month (21% higher for the surgical group) and 24-month (15% higher for the surgical group) evaluation. Furthermore, they found that the affected limb on average achieved at least 80% of the plantar flexion strength, and 100% of the dorsiflexion strength of the unaffected limb at all three test velocities. Keating and Will (2011) found a significantly better result in plantar flexion peak torque for the surgical group at 3-month follow-up (47% vs 61%), but no difference between groups at 12-month follow-up. Schepull et al. (2012) reported an estimate for the e-modulus (tendon stiffness normalized to the size of the tendon) at 7 weeks, and found no difference between surgery and non-surgery. Neither did they find any difference in heel-raise index at 18 months. However, they did find a significant correlation between e-modulus at 7 weeks and the heel-raise index (r = 0.75). This was also the only study that reported on tendon elongation, and they found no significant difference between the two treatments. Two studies also measured calf circumference and found no significant difference (Twaddle & Poon, 2007; Willits et al., 2010). Range of motion Three articles investigated range of motion (Twaddle & Poon, 2007; Willits et al., 2010; Keating & Will, 2011). Willits et al. (2010) found a significantly greater side-toside difference (–2,2 mean difference between groups) in the non-surgical group in range of motion at plantar flexion after 2 years. In addition both Willits et al. (2010) and Twaddle and Poon (2007) found a greater range of motion on the unaffected limb in both groups at each follow-up, although none of them found any significant difference between surgical and non-surgical treatment. Return to work and sports Two papers reported time to return to work and sports (Metz et al., 2008; Keating & Will, 2011). Metz et al. (2008) found a significant difference in return to work in favor of surgical treatment (59 vs 108 days), but they found no significant difference between groups regarding returning to former level of sports. Keating and Will (2011) found no statistical difference in neither of these two variables. Olsson et al. (2013) did not report on time
to return to sports; however, they did find that there were no difference in physical activity in either of the two groups at 12 months compared with baseline. Patient satisfaction, pain sensation, and Achilles Tendon Rupture Score (ATRS) Metz et al. (2008) found no statistical significant difference in pain sensation or treatment satisfaction. However, there was a clinical difference between the two groups at 7 weeks, where the surgical group had more pain and was less satisfied. This was shifted after 3 months and 1 year, where the non-surgical group had more pain and was less satisfied. Keating and Will (2011) found no significant differences in pain between groups at any time point. Three studies reported on ATRS and found no difference between the two treatments (Nilsson-Helander et al., 2010; Schepull et al., 2012; Olsson et al., 2013). Discussion We found seven randomized studies according to our inclusion and exclusion criteria during the last 10 years, which compared surgical and non-surgical treatment of acute Achilles tendon ruptures (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013). All of the articles were considered to be of high quality, according to the guidelines by Furlan et al. (2009). None of the studies had the care provider or the patient blinded; however, four out of seven papers had blinded outcome assessors (NilssonHelander et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013), which is of greater importance when it comes to bias. None of the papers in the present review found any significant difference in the occurrence of re-ruptures between surgical and non-surgical treatment. Earlier research has found that surgical treatment after acute Achilles tendon rupture significantly reduces the risk of re-rupture (Nistor, 1981; Moller et al., 2001). Newer studies show a reduced risk of re-ruptures after both treatments, and especially after non-surgical treatment (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013). However, the lack of a significant difference could also be a question of lack of power. To study differences in re-ruptures between the two treatments one would need a very large cohort. This has also been shown in several meta-analyses, which includes a lot more patients (Bhandari et al., 2002; Khan et al., 2005; Zhao et al., 2011; Jiang et al., 2012; Soroceanu et al., 2012; Wilkins & Bisson, 2012; van der Eng et al., 2013). Most of these meta-analyses have found that the risk of re-rupture is higher after non-surgical treatment
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Holm et al. compared with surgical. However, the most recent meta-analysis by van der Eng et al. (2013) did not show any statistically significant difference in re-ruptures occurrence between the treatments. Two of the most recent meta-analyses have also started to divide the studies into studies with early range of motion or delayed (Soroceanu et al., 2012; van der Eng et al., 2013), and Soroceanu et al. (2012) found that with delayed range of motion, there was a decreased risk of re-ruptures by 9% after surgical treatment. Surgery is, on the other hand, often shown to increase the risk of other complications (Cetti et al., 1993; Moller et al., 2001; Bhandari et al., 2002; Khan et al., 2005; Soroceanu et al., 2012; Wilkins & Bisson, 2012). Soroceanu et al. (2012) reported that the risk of complications was 15% higher after surgical treatment. In the studies covered in this review, Metz et al. (2008) found a tendency to increased risk of complications after non-surgical treatment, whereas Willits et al. (2010) found an increased risk of complications after surgical treatment. Olsson et al. (2013) found that both superficial wound infections as well as temporal nerve disturbances were more commonly occurring after surgery; however, they did not find any differences in the occurrence of DVT between the treatments. Besides re-rupture and wound complications, DVT is the most common complication after Achilles tendon rupture (Table 3). There appears to be no significant difference in the occurrence between surgical and non-surgical treatment in most studies. This was also seen in the meta-analyses by Wilkins and Bisson (2012) where they reported that surgical treatment lead to 7% risk of DVT compared with 10% after non-surgical treatment. However, Schepull et al. (2012) only found DVT on patients treated non-surgically (27%). Most DVTs are only reported after symptoms occurring. Nilsson-Helander et al. (2010) scanned all of their patients and found that the incidence of DVT was as high as 34% after Achilles tendon rupture. This indicates that DVTs are the most common complication and might therefore need more attention. Several studies have shown that most complications related to surgery resolve and that they appear to have no influence on functional outcome (Kellam et al., 1985; Wills et al., 1986; Leppilahti & Orava, 1998; Olsson et al., 2013). The most common complications after open surgery are adhesive scars, infections, and wound healing problems (Gigante et al., 2008). To reduce the rate of complications from surgery, percutaneous and minimally invasive repair techniques have become more used. These techniques have however been shown to increase the risk of sural nerve lesion (Bhandari et al., 2002; Khan et al., 2005; Nilsson-Helander et al., 2010). Gigante et al. (2008) found no significant difference in risk of complications or clinical outcome between open and percutaneous surgery, but recommends percutaneous surgery because of the minor cutaneous complications and reduction in operation time, which might give faster recovery. The
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only study in this review using minimal invasive surgery was Metz et al. (2008), and they found no significant differences in complications between surgical and nonsurgical treatment. Previous studies, which have found a significant increased risk of re-rupture with non-surgical treatment, used immobilization during the entire cast period for the non-surgical group (Cetti et al., 1993; Moller et al., 2001). These studies were included in the meta-analyses by Khan et al. (2005), Bhandari et al. (2002), and Wilkins and Bisson (2012), which concluded a higher re-rupture risk for non-surgical treatment and a higher risk for other complications for surgical patients. Newer results in the randomized controlled trials in this review as well as a newer meta-analysis show that early mobilization and/or early weight-bearing does not cause a significantly higher risk for complications including re-rupture (Khan et al., 2005; Twaddle & Poon, 2007; Metz et al., 2008; Willits et al., 2010; Schepull et al., 2012; Soroceanu et al., 2012; Olsson et al., 2013; van der Eng et al., 2013). Early mobilization during rehabilitation also appears to level out the functional outcomes for patients treated with either surgery or non-surgery. Studies comparing post-operative immobilization with early mobilization have shown that early mobilization and/or early weight-bearing gives better functional outcome, higher quality of life and patient satisfaction, and also shortens the time for rehabilitation (Mortensen et al., 1999; Suchak et al., 2006, 2008; Olsson et al., 2013). Another known risk after Achilles tendon rupture is tendon elongation. Previous studies have shown that tendon elongation has the tendency to correlate with poorer functional outcome (Leppilahti & Orava, 1998; Kangas et al., 2007; Nilsson-Helander et al., 2010). In the studies covered by this review, only Schepull et al. (2012) studied tendon elongation. They found that tendon elongation occurred during the first 19 weeks, but they found no difference between surgical and non-surgical treatment. There was also no correlation between heel-raise index and elongation, besides one patient with an abnormal lengthening, which performed very poorly. This study also mentions that the variation (standard deviation) in their test results is significantly lower in the surgical group compared with the non-surgical group. This could indicate that surgery might not improve the healing outcome on group level, but it removes the outliers on group level by improving the healing greatly in people who would normally have a bad course of healing after non-surgical treatment. It might therefore mainly be these patients who will benefit from surgical treatment. The problem today is that we have no idea who will have a good or a bad course of healing when we are about to choose between the two treatment options. Two papers in this review found a significant difference in some of the functional outcomes (in jumping tests or heel-raise work) at late time points, favoring surgery (Nilsson-Helander et al., 2010; Olsson et al.,
Treatment of Achilles tendon ruptures 2013). There was however also differences in functional outcomes at 6 months after injury in one study (Nilsson-Helander et al., 2010). Keating and Will (2011) also showed a better result in short musculo-skeletal assessment questionnaire. One study also showed that the time to return to work was shorter after surgical treatment (Metz et al., 2008). Soroceanu et al. (2012) also showed in their meta-analyses that this was 19 days shorter after surgery. However, Wilkins and Bisson (2012) did not find any statistical difference in return to work in their meta-analysis. This review indicates that treatment alone after an acute Achilles tendon rupture might not determine the best functional outcome. It is possible that early rehabilitation after surgical as well as after non-surgical treatment is crucial for functional outcome. Patients treated with surgery appears to return to work (Metz et al., 2008; Soroceanu et al., 2012) and sport earlier, and they might have the possibility to start rehabilitation quicker, which is preferable regarding functional outcome. Also, given the fact that most complications related to surgery resolves and has no impact on functional outcome, surgery is preferable due to patient satisfaction and early functional outcome (Olsson et al., 2013). Furthermore, although no significant difference in re-rupture rates was seen in this review, there was still a clinical difference in favor of surgery treatment, which also advocates for surgery. Alternatively, minimally invasive surgery is recommendable, but more research is needed. Also, because rehabilitation is likely the determinant factor next to treatment, studies investigating whether early range of motion and/or early weight-bearing is recommendable are needed. We found no significant differences in re-rupture rate between surgical and non-surgical treatment of Achilles tendon rupture, although a tendency to favoring surgery that could be of clinical importance was presented. Sur-
gical patients had significantly better early functional outcomes and also returned to work earlier, which could be related to the fact that their rehabilitation is faster combined with early mobilization. However, surgical patients more often suffer from minor complications. Finally, randomized controlled trials will be needed in regard to understanding the interplay between acute surgical or non-surgical treatment and the rehabilitation regimen for the overall outcome of Achilles tendon treatment.
Perspectives Achilles tendon rupture frequently occurs during sports activities, and it has a long rehabilitation afterward. Most active athletes are recommended surgery to get a faster recovery and in some cases this is true, because there are studies that have shown time to return to sports is decreased after surgery. However, this review shows that today the choice of surgery/non-surgery might not be as important anymore, because the differences between initial treatments are less pronounced. This is likely due to the improved rehabilitation with functional braces and earlier motion and loading after each treatment. However, we have still not found the optimal rehabilitation protocol for Achilles tendon rupture. The patients still suffer from major deficits 1–2 years after rupture, irrespective of treatment (Nilsson-Helander et al., 2010; Olsson et al., 2011). Many of these patients will therefore most likely never return to their pre-injury sports level. An even better understanding on how rehabilitation can improve the functional outcomes after Achilles tendon rupture needs to be found. Key words: Surgery, conservative treatment, re-rupture, randomized controlled trials, functional outcomes.
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Holm et al. Keating JF, Will EM. Operative versus non-operative treatment of acute rupture of tendo Achillis: a prospective randomised evaluation of functional outcome. J Bone Joint Surg Br 2011: 93: 1071–1078. Kellam JF, Hunter GA, McElwain JP. Review of the operative treatment of Achilles tendon rupture. Clin Orthop Relat Res 1985: 201: 80–83. Kerkhoffs GM, Struijs PA, Marti RK, Blankevoort L, Assendelft WJ, van Dijk CN. Functional treatments for acute ruptures of the lateral ankle ligament: a systematic review. Acta Orthop Scand 2003: 74: 69–77. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute Achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am 2005: 87: 2202–2210. Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med 1998: 25: 79–100. Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand 1996: 67: 277–279. Metz R, Verleisdonk EJ, van der Heijden GJ, Clevers GJ, Hammacher ER, Verhofstad MH, van der Werken C. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing – a randomized controlled trial. Am J Sports Med 2008: 36: 1688–1694. Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 2001: 83: 843–848. Mortensen HM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. J Bone Joint Surg Am 1999: 81: 983–990. Nilsson-Helander K, Silbernagel KG, Thomee R, Faxen E, Olsson N, Eriksson BI, Karlsson J. Acute Achilles tendon rupture: a randomized, controlled study comparing surgical
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and nonsurgical treatments using validated outcome measures. Am J Sports Med 2010: 38: 2186–2193. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. A prospective randomized study. J Bone Joint Surg Am 1981: 63: 394–399. Nyyssonen T, Luthje P, Kroger H. The increasing incidence and difference in sex distribution of Achilles tendon rupture in Finland in 1987–1999. Scand J Surg 2008: 97: 272–275. Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Thomee R, Faxen E, Silbernagel KG. Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2011: 19: 1385–1393. Olsson N, Silbernagel KG, Eriksson BI, Sansone M, Brorsson A, Nilsson-Helander K, Karlsson J. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med 2013: 41: 2867–2876. Palmes D, Spiegel HU, Schneider TO, Langer M, Stratmann U, Budny T, Probst A. Achilles tendon healing: long-term biomechanical effects of postoperative mobilization and immobilization in a new mouse model. J Orthop Res 2002: 20: 939–946. Schepull T, Aspenberg P. Early controlled tension improves the material properties of healing human Achilles tendons after ruptures: a randomized trial. Am J Sports Med 2013: 41: 2550–2557. Schepull T, Kvist J, Aspenberg P. Early E-modulus of healing Achilles tendons correlates with late function: similar results with or without surgery. Scand J Med Sci Sports 2012: 22: 18–23. 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. Speck M, Klaue K. Early full weightbearing and functional treatment
after surgical repair of acute Achilles tendon rupture. Am J Sports Med 1998: 26: 789–793. Suchak AA, Bostick G, Reid D, Blitz S, Jomha N. The incidence of Achilles tendon ruptures in Edmonton, Canada. Foot Ankle Int 2005: 26: 932–936. Suchak AA, Bostick GP, Beaupre LA, Durand DC, Jomha NM. The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am 2008: 90: 1876–1883. Suchak AA, Spooner C, Reid DC, Jomha NM. Postoperative rehabilitation protocols for Achilles tendon ruptures: a meta-analysis. Clin Orthop Relat Res 2006: 445: 216–221. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med 2007: 35: 2033–2038. 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. Wilkins R, Bisson LJ. Operative versus nonoperative management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. Am J Sports Med 2012: 40: 2154–2160. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 2010: 92: 2767–2775. Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture. A review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop Relat Res 1986: 207: 156–163. Zhao HM, Yu GR, Yang YF, Zhou JQ, Aubeeluck A. Outcomes and complications of operative versus non-operative treatment of acute Achilles tendon rupture: a meta-analysis. Chin Med J 2011: 124: 4050–4055.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Review
Achilles tendon rupture – treatment and complications: A systematic review C. Holm, M. Kjaer, P. Eliasson Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark Corresponding author: Christina Holm, Bispebjerg Hospital, Building 8, 1st Floor, Bispebjerg Bakke 23, Copenhagen 2400, Denmark. Tel: +45 51 92 25 21, Fax: +45 35 31 27 33, E-mail: [email protected] Accepted for publication 12 February 2014
Achilles tendon rupture is a frequent injury with an increasing incidence. Until now, there is no consensus regarding optimal treatment. The aim of this review was to illuminate and summarize randomized controlled trials comparing surgical and non-surgical treatment of Achilles tendon ruptures during the last 10 years. Seven articles were found and they were all acceptable according to international quality assessment guidelines. Primary outcomes were re-ruptures, other complications, and functional outcomes. There was no significant difference in re-ruptures between the two treatments, but a tendency to favoring surgical treatment. Further, one study found an increased risk of soft-tissue-related com-
plications after surgery. Patient satisfaction and time to return to work were significantly different in favor of surgery in one study, and there was also better functional outcome after surgery in some studies. These seven studies indicate that surgical patients have a faster rehabilitation. However, the differences between surgical and non-surgical treatment appear to be subtle and it could mean that rehabilitation is more important, rather than the actual initial treatment. Therefore, further studies will be needed in regard to understanding the interplay between acute surgical or non-surgical treatment, and the rehabilitation regimen for the overall outcome after Achilles tendon ruptures.
The Achilles tendon is the most frequently ruptured tendon, and this injury type most often occur during soccer, racket games, or basketball (Leppilahti et al., 1996; Gwynne-Jones et al., 2011). Achilles tendon rupture mostly happens at the age of 35–39 years in both men and women, but with predominance for men (Leppilahti et al., 1996; Leppilahti & Orava, 1998; Suchak et al., 2005; Nyyssonen et al., 2008). Tendon healing is a slow process but important as the Achilles tendon is vital for movements. An acute rupture is therefore a complicated injury, and treatment thereof is a controversial subject among medical doctors and scientists, still without consensus regarding optimal treatment. Earlier studies have shown that surgical treatment significantly reduces the risk of re-rupture, but it increases the risk of complications associated with surgery (Nistor, 1981; Moller et al., 2001). Surgery has therefore often been the choice of treatment for athletes and young people, whereas the choice of treatment for elderly has pre-dominantly been non-surgical treatment. During the last decade, the influence of early post-operative rehabilitation has become an aspect of great interest when it comes to understanding the optimal healing of acute Achilles tendon rupture (Speck & Klaue, 1998; Mortensen et al., 1999; Kerkhoffs et al., 2003; Costa
et al., 2006; Suchak et al., 2006, 2008; Schepull & Aspenberg, 2013). Animal and human in vivo studies have shown that early mobilization has had a positive effect on the tendon healing process (Speck & Klaue, 1998; Mortensen et al., 1999; Palmes et al., 2002; Kerkhoffs et al., 2003; Costa et al., 2006; Andersson et al., 2009; Bring et al., 2010). Previously, patients were mostly treated with cast immobilization after both surgery and non-surgery (Nistor, 1981; Cetti et al., 1993). Nowadays, both treatment groups are generally treated with functional braces instead of rigid casts and this allows for earlier mobilization (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013). Newer studies comparing surgical and non-surgical treatment, including early rehabilitation, have not been able to show a significant difference in the occurrence of re-ruptures (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013). The question of surgery vs non-surgery is therefore still open. Furthermore, the functional braces have shown to increase patient satisfaction and return to sport and work (Mortensen et al., 1999). Now that re-rupture rate between the surgery and non-surgery group in many new
1
Holm et al. studies has equalized (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013), a new aspect regarding functional outcomes is of great interest in deciding the best acute treatment for acute Achilles tendon rupture. The purpose of this review is to illuminate and summarize randomized controlled trials from the last 10 years, comparing surgical and non-surgical treatment of Achilles tendon ruptures.
According to our inclusion and exclusion criteria we screened the titles, resulting in 22 articles. Further, we screened the abstracts, resulting in 18 articles. By reading each article we ended up with seven (Table 1), which included 577 patients in total. The reference lists from the articles were thereafter screened for other studies of interest, but we found no more relevant articles for inclusion according to our criteria. The quality of the methodology in these seven articles was assessed according to the guidelines by Furlan et al. (2009) (Table 1). Using the criteria in these guidelines, we assessed the risk of bias in each article. Each criterion was assessed with the possibilities of “Yes,” “No,” and “Don’t know.” Articles that achieved more than 6/12 “Yes” were considered to be of “high quality,” whereas articles below 6/12 “Yes” were considered to be of “low quality.” The assessment was performed by C. H. and P. E., and the articles were only evaluated by information written in the paper, no additional information was collected by contacting the authors. Any differences were solved by discussion.
Methods This study analysis includes randomized prospective controlled trials on humans, published in English, which compares surgical and non-surgical treatment of Achilles tendon ruptures during the last 10 years. We excluded retrospective studies, studies with no clear description of randomization, and studies with no report of our selected primary outcomes. In MEDLINE database, the specific search was carried out on Achilles tendon (MeSH terms) OR Achilles (all fields) AND tendon (all fields) OR Achilles tendon (all fields) AND rupture (MeSH terms) OR rupture (all terms) AND randomized controlled trial OR clinical trial. This search resulted in 78 hits. Only those articles that met our inclusion criteria were scrutinized: • • • •
Results All articles assessed were considered to be of a high methodological quality according to the Furlan guidelines (Furlan et al., 2009) (Table 1).
Ipsilateral acute Achilles tendon rupture Complete rupture No previous rupture Study was performed during the last 10 years
Complications and re-ruptures Re-ruptures All of the articles reported the occurrence of re-ruptures (Table 3), and none of them found any statistical significant difference between the two treatment groups (Twaddle & Poon, 2007; Metz et al., 2008; NilssonHelander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013).
Exclusion criteria were studies with delayed diagnostic presentation of rupture (more than 3 weeks after injury). The primary outcomes that we were interested in were re-ruptures, complications of treatment, and functional outcomes of the Achilles tendon (measured with physical tests through rehabilitation). Table 1. Criteria for quality assessment according to Furlan et al. (2009)
Study
A
B
C
D
E
F
G
H
I
J
K
L
Keating and Will (2011) Twaddle and Poon (2007) Nilsson-Helander et al. (2010) Willits et al. (2010) Schepull et al. (2012) Metz et al. (2008)
Yes, blind envelopes Yes, tossing a coin Yes, sealed envelopes
No Don’t know Yes
No No No
No No No
Yes No Yes
Yes, 2.5% Yes, 16% Yes, 3%
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes, computer generated Yes, sealed envelopes Yes, Internet site
No Don’t know No
No No No
No No No
No Yes No
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Yes Yes Yes
Olsson et al. (2013)
Yes, sealed envelopes
No
No
No
Yes
Yes, 12% Yes, 17% No, not well described Yes, 6%
Yes
Yes
Yes
Yes
Yes
Yes
Criteria for quality assessment according to Furlan et al. (2009). Criteria were answered with Yes/No/Don’t know: A Was the method of randomization adequate? B Was the treatment allocation concealed? C Was the patient blinded to the intervention? D Was the care provider blinded to the intervention? E Was the outcome assessor blinded to the intervention? F Was the dropout rate described and acceptable? G Were all randomized participants analyzed in the group to which they were allocated? H Are reports of the study free of suggestion of selective outcome reporting? I Were the groups similar at baseline regarding the most important prognostic indicators? J Were co-interventions avoided or similar? K Was the compliance acceptable in all groups? L Was the timing of the outcome assessment similar in all groups?
2
Aim: To determine whether surgical treatment was associated with any functional advantages. In particular whether surgical treatment was associated with a faster or a better muscle function recovery. Subjects: 80 patients with acute Achilles tendon rupture. Intervention: A: Surgery (n = 39) and a below knee cast for 6 weeks, non-weightbearing. Full weight-bearing thereafter. B: Non-surgery (n = 41) and a below knee cast for 10 weeks. Non-weightbearing for 8 weeks and partial weight-bearing for last 2 weeks. Evaluation/outcome: Follow-ups were performed at 3, 4, 6 and 12 months. Primary variable was muscle function (measured by isokinetic peak torque, total work, and average power for dorsi- and plantar flexion and range of motion). Primary clinical outcome was re-ruptures. Secondary variables were Short Musculoskeletal Function Assessment Questionnaire (SMFA), pain score, and time to return to work, to sport, and to driving. Other complications besides re-ruptures were also recorded. Aim: To compare surgical vs non-surgical treatment combined with controlled early motion in both groups. Subjects: 50 patients with acute Achilles tendon rupture but 8 patients were excluded. Intervention: A: Surgery (n = 25) B: Non-surgery (n = 25) Both groups had cast for 10 days followed by below knee orthosis, 8 weeks in total, non-weightbearing during the first 6 weeks. Both groups started exercises after 10 days with active dorsiflexion and passive plantar flexion outside the orthosis for 5 min every hour. Evaluation/outcome: Follow-ups were carried out at 10 days and 8, 12, 26 and 52 weeks. Evaluation was performed on range of motion (plantar and dorsiflexion), calf circumference, squeeze test reactivity, Musculoskeletal Functional Assessment Index (MFAI), and re-ruptures and complications were noted.
Keating and Will (2011)
Twaddle and Poon (2007)
Summary
Study
Table 2. Summary of each study, results between and within groups
8/12
The non-injured side had a greater range of dorsi- and plantar flexion in both groups at all time points (but very little difference at 52 weeks).
No significant differences in range of motion, calf circumference, and MFAI at any time points. There was also no difference in re-ruptures or other complications.
9/12 No significant difference in re-ruptures or any other complications. No significant difference in range of motion, except an increased mean range of plantar flexion compared with the non-injured leg in the surgical-treated group at 26 weeks. The difference in peak torque of plantar flexion between injured and uninjured side was significantly lower in the surgical group at 3 months (47% vs 61%). No other significant results on strength tests. Significantly better results in SMFA score in the surgical group at 3 months – otherwise no significant differences. No significant differences in pain score.
None statistically described differences compared with normal side.
Quality assessment
Between-group results
Within-group results
Treatment of Achilles tendon ruptures
3
4
Summary
Aim: To compare patients treated with surgery and accelerated functional rehabilitation, with patients treated with accelerated functional rehabilitation alone. Subjects: 144 patients with acute Achilles tendon rupture. Intervention: A: Surgery (n = 72) B: Non-surgery (n = 72) Both groups had accelerated functional rehabilitation with a below knee orthosis for 8 weeks. Protective weight-bearing at 2 weeks and weight-bearing as tolerated at 4 weeks. Outcome/evaluation: Follow-ups were carried out at 3, 6, 12 and 24 months. Primary outcome was re-ruptures. Secondary outcomes were isokinetic strength (dorsi- and plantar flexion), Leppilahti score, range of motion, and calf circumference.
Aim: To investigate if different treatments (surgical and non-surgical) influence modulus of elasticity of the tendon. The second aim was to study if early elastic modulus correlates with late tendon function. Subjects: 30 patients with acute Achilles tendon rupture. Intervention: A: Surgery (n = 15) B: Non-surgery (n = 15) Both groups had a cast on for a total of 7 weeks. They were allowed full weight-bearing from the beginning. Evaluation/outcome: Follow-ups were performed at 7 weeks, and 6 and 18 months. Primary variable was an estimate for the modulus of elasticity at 7 weeks. Secondary variables were strain per force, heel-raise index, tendon cross-sectional area, tendon elongation, and ATRS.
Willits et al. (2010)
Schepull et al. (2012)
Nilsson-Helander Aim: To compare outcomes of patients treated with or without surgery, using early mobilization and identical rehabilitation protocols. et al. Subjects: 100 patients with acute Achilles tendon rupture. (2010) Intervention: A: Surgery (n = 49) B: Non-surgery (n = 48) Both groups received a below knee cast followed by an adjustable brace for a total of 8 weeks, then rehabilitation protocol Evaluation/outcome: Follow-ups were carried out at 2, 8, 12 weeks and 6 and 12 months. Primary variable was re-ruptures. Secondary variables were Achilles Tendon Total Rupture Score (ATRS), physical activity scale (PAS), functional tests (two jumps, two strengths, and one endurance test).
Study
Table 2. Continued.
10/12
No significant difference in re-ruptures; however, the difference might be of clinical importance (4% vs 12%). Concentric strength (82% vs 71%), heel-rise work (65% vs 54%) and height (75% vs 68%), and hopping tests (90% vs 75%) were significantly better in the surgical group at the 6-month evaluation. There was only a difference in the endurance test (heel-rise work) at 12 months where the surgical group performed significantly better (78% vs 68%). No significant differences on ATRS or PAS score at 6- and 12-month evaluation. Eccentric strength and drop countermovement jump test did not differ between the groups at any time point.
Both groups improved significantly over time in ATRS and PAS score. Also the functional tests improved over time, all tests except for concentric power in the surgery group. Both groups had significantly lower values for the injured leg compared with the uninjured leg at all functional tests at 6 and 12 months, except for hopping at 12 months. In both groups, the affected limb achieved at least 80% of the plantar flexion strength, and 100% of the dorsiflexion strength of the unaffected limb at all test velocities, 12 and 24 months. Greater range of motion on the unaffected limb in both groups during the entire time. No significant change in strength at any velocity in both groups between 12and 24-month follow-up. In both groups there was a significant correlation between the modulus of elasticity at 7 weeks and the heel-raise index at 18 months. There was also an elongation of the tendon between 3–7 weeks and 7–19 weeks, but not between 7 weeks and 18 months. No significant differences at any time in the elastic modulus between the two groups. No significant differences in strain per force, heel-raise index, ATRS score, tendon lengthening, or tendon cross-sectional area between the groups at any time point. A significant higher variation in strain per force in the non-surgical group.
9/12
8/12 Only significant difference at the plantar strength ratio at 240 °/s at 12 and 24 months, in favor of the surgical group (21% higher). No significant difference in the dorsiflexion strength at any test velocity or any time point. A greater side-to-side difference for non-surgical group in plantar flexion range of motion at 24-month follow-up (15% higher). Otherwise no significant differences in range of motion between the two groups. No significant difference in re-ruptures, calf circumference, or Leppilahti score at any time point. Increased risk of complication in the surgical group (18% vs 8%).
Quality assessment
Between-group results
Within-group results
Holm et al.
Aim: To compare minimally invasive surgical repair with non-surgical treatment by functional bracing. Subjects: 83 patients with acute Achilles tendon rupture. Interventions: A: Minimally invasive surgery (n = 42) and cast for 1 week, followed by a tape bandage supported with heel raise for 6 weeks. B: Non-surgery (n = 41), cast for 1 week, followed by a functional bracing system for 6 weeks. Full weight-bearing was allowed after 1 week for both groups. Outcome/evaluation: Follow-ups were performed at 1, 3, 5, 7 weeks and at 3, 6 and 12 months. Primary variable was complications (besides re-ruptures). Secondary variables were time to work, time to sports, patient satisfaction and pain (measured by VAS), re-ruptures, and Leppilahti score. Aim: To compare outcomes of patients treated with surgery, early loading, and range of motion with patients treated without surgery and with a more traditional rehabilitation. Subjects: 101 patients with acute Achilles tendon rupture. Intervention: A: Surgery (n = 49) B: Non-surgery (n = 51) Both groups received a pneumatic walker brace including three heel pads and were allowed full weight-bearing. The surgical group started early active rehabilitation (range of motion and strength training exercises) after 2 weeks, and were mobilized in the walker for 6 weeks. The non-surgical group was immobilized in the walker for 8 weeks. Evaluation/outcome: Follow-ups were carried out at 2, 6/8, 12, 26 and 52 weeks. Primary variable was ATRS. Secondary variables were re-ruptures, other complications, PAS, Foot and Ankle Outcome Score (FAOS), EuroQol group’s questionnaires (EQ-5D), functional tests (two jumps, two strengths, and one endurance test).
VAS, visual analog scale.
Olsson et al. (2013)
Metz et al. (2008)
7/12
9/12
No statistically significant differences in the risk of re-ruptures or overall complications. A clinical difference is although described with an increased risk of complications after non-surgical treatment (49% vs 29%). There was significant difference in time to return to work, in favor of surgical treatment (59 vs 108 days). No significant difference in time to return to sport, pain, or patient satisfaction between the two groups. No significant difference in Leppilahti outcome scores.
No significant difference at any time point in ATRS. No significant difference in PAS, FAOS, or EQ-5D between the groups. Significant difference in the jumping tests at 12 months in favor of surgical treatment (10% vs 21%). No statistically significant differences (P = 0.06) in the risk of re-ruptures (2% vs 10%). No significant difference in the occurrence of deep vein thrombosis between the two groups. 12% of the patients in the surgical group suffered from superficial wound infections. 26% of the surgical-treated patients and 4% of the non-surgical-treated patients experienced temporary nerve disturbances.
None described.
Improved ATRS and FAOS over time in both groups. No significant difference in PAS compared with baseline in either group. Significant decrease in EQ-5D in both groups at 12 months compared with pre-injury values. Significantly lower values on the injured side compared with the non-injured side on all functional tests at 6 months. The surgical group improved in one jumping test and concentric power at 12 months and the non-surgical group also improved in one jumping test at 12 months.
Treatment of Achilles tendon ruptures
5
Although two studies found differences, which could be of clinical importance, in favor of surgery, 2–4% vs 10–12% after non-surgical treatment (Nilsson-Helander et al., 2010; Olsson et al., 2013) (Table 2).
Non-surgery 4%
Skin-related complications
Surgery 4.8% Non-surgery 32%†
Holm et al.
6
Surgery 7.1% Non-surgery 2.4% Surgery 1.4% Surgery 1.4%
Surgery 7.1%
Surgery 27% Surgery 2%
Surgery 12%
Surgery 5.6%
Six out of the seven articles reported the incidence of DVT (Table 3) (Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013). None of them found any significant differences between surgery and non-surgery. Four of the articles reported an incidence of 1–5% (Metz et al., 2008; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013), and these were only the patients with symptoms of DVT. Nilsson-Helander et al. (2010) screened all patients with color duplex sonography and showed that the actual incidence of DVT is far greater than the incidence reported by symptoms, 29% after surgical treatment and 39% after nonsurgical treatment. Schepull et al. (2012) reported an incidence of 27% after non-surgical treatment compared with none after surgical treatment; however, they did not do a statistical test on their findings.
Olsson et al. (2013)
Metz et al. (2008)
Schepull et al. (2012)
Nilsson-Helander et al. (2010) Willits et al. (2010)
Twaddle and Poon (2007)
*Color duplex sonography on all patients. † Including superficial wound infection.
Surgery 29% Non-surgery 39%* Surgery 1.4% Non-surgery 1.4% Surgery 0% Non-surgery 27% Surgery 0% Non-surgery 2.4% Surgery 2% Non-surgery 4%
Surgery 2%
Surgery 0% Surgery 0%
Surgery 5.1% Surgery 0% Non-surgery 5% Keating and Will (2011)
Surgery 5.4% Non-surgery 10% Surgery 10% Non-surgery 4.5% Surgery 4% Non-surgery 12% Surgery 2.8% Non-surgery 4.2% Surgery 0% Non-surgery 6.7% Surgery 7.1% Non-surgery 12% Surgery 2% Non-surgery 10%
Surgery 2.6%
DVT
DVT
Superficial infections
Metz et al. (2008) found no statistical significant difference in other complications [nerve injuries, deep venous thrombosis (DVT), regional pain, skin-related complications, and scar adhesions] between surgical and non-surgical-treated patients, although they found a difference that could be of clinical importance in favor of surgical treatment, 21% vs 36% after non-surgical treatment (Table 3). Willits et al. (2010) found, on the other hand, an increased risk of complications (DVT, pulmonary embolus, infections, scar, and wound complications) after surgical treatment, 18% vs 8% after non-surgical treatment. Olsson et al. (2013) found that superficial wound infections (12%) and temporal nerve disturbance (2%) occurred after surgical treatment but not after non-surgical treatment. Two other studies found no statistical difference in the occurrence of complication after different treatments (Twaddle & Poon, 2007; Keating & Will, 2011).
Re-ruptures
Table 3. Summary of the occurrence of re-ruptures and other types of complications in each study
Deep infections
Scar complications
Surgery 4.1%
Nerve disturbances
Other complications including infections
Muscle strength, tendon stiffness, and tendon elongation Four articles measured different functional tests (plantar flexion, heel-rise work, heel-rise height, hopping, drop countermovement jump, concentric power, eccentric power) (Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Olsson et al., 2013) (Table 2). Nilsson-Helander et al. (2010) found a significant difference in concentric power (82% vs 71%), heelrise height (75% vs 68%), heel-rise work (65% vs 54%),
Treatment of Achilles tendon ruptures and hopping tests (90% vs 75%) after 6 months, in favor of surgical treatment. Furthermore at 12-month evaluation, the surgical group performed significantly better in the endurance test, heel-rise work (75% vs 68%). Olsson et al. (2013) found that surgery significantly improved the results in two jumping tests after 12 months (10% and 21% higher after surgery compared with nonsurgical treatment, but they did not find any difference in heel-rise work). Willits et al. (2010) found that the plantar strength ratio at 240 °/s (240 °/s means the velocity of the dynamometer during isokinetic testing) was significantly better for the surgical group at 12-month (21% higher for the surgical group) and 24-month (15% higher for the surgical group) evaluation. Furthermore, they found that the affected limb on average achieved at least 80% of the plantar flexion strength, and 100% of the dorsiflexion strength of the unaffected limb at all three test velocities. Keating and Will (2011) found a significantly better result in plantar flexion peak torque for the surgical group at 3-month follow-up (47% vs 61%), but no difference between groups at 12-month follow-up. Schepull et al. (2012) reported an estimate for the e-modulus (tendon stiffness normalized to the size of the tendon) at 7 weeks, and found no difference between surgery and non-surgery. Neither did they find any difference in heel-raise index at 18 months. However, they did find a significant correlation between e-modulus at 7 weeks and the heel-raise index (r = 0.75). This was also the only study that reported on tendon elongation, and they found no significant difference between the two treatments. Two studies also measured calf circumference and found no significant difference (Twaddle & Poon, 2007; Willits et al., 2010). Range of motion Three articles investigated range of motion (Twaddle & Poon, 2007; Willits et al., 2010; Keating & Will, 2011). Willits et al. (2010) found a significantly greater side-toside difference (–2,2 mean difference between groups) in the non-surgical group in range of motion at plantar flexion after 2 years. In addition both Willits et al. (2010) and Twaddle and Poon (2007) found a greater range of motion on the unaffected limb in both groups at each follow-up, although none of them found any significant difference between surgical and non-surgical treatment. Return to work and sports Two papers reported time to return to work and sports (Metz et al., 2008; Keating & Will, 2011). Metz et al. (2008) found a significant difference in return to work in favor of surgical treatment (59 vs 108 days), but they found no significant difference between groups regarding returning to former level of sports. Keating and Will (2011) found no statistical difference in neither of these two variables. Olsson et al. (2013) did not report on time
to return to sports; however, they did find that there were no difference in physical activity in either of the two groups at 12 months compared with baseline. Patient satisfaction, pain sensation, and Achilles Tendon Rupture Score (ATRS) Metz et al. (2008) found no statistical significant difference in pain sensation or treatment satisfaction. However, there was a clinical difference between the two groups at 7 weeks, where the surgical group had more pain and was less satisfied. This was shifted after 3 months and 1 year, where the non-surgical group had more pain and was less satisfied. Keating and Will (2011) found no significant differences in pain between groups at any time point. Three studies reported on ATRS and found no difference between the two treatments (Nilsson-Helander et al., 2010; Schepull et al., 2012; Olsson et al., 2013). Discussion We found seven randomized studies according to our inclusion and exclusion criteria during the last 10 years, which compared surgical and non-surgical treatment of acute Achilles tendon ruptures (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013). All of the articles were considered to be of high quality, according to the guidelines by Furlan et al. (2009). None of the studies had the care provider or the patient blinded; however, four out of seven papers had blinded outcome assessors (NilssonHelander et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013), which is of greater importance when it comes to bias. None of the papers in the present review found any significant difference in the occurrence of re-ruptures between surgical and non-surgical treatment. Earlier research has found that surgical treatment after acute Achilles tendon rupture significantly reduces the risk of re-rupture (Nistor, 1981; Moller et al., 2001). Newer studies show a reduced risk of re-ruptures after both treatments, and especially after non-surgical treatment (Twaddle & Poon, 2007; Metz et al., 2008; Nilsson-Helander et al., 2010; Willits et al., 2010; Keating & Will, 2011; Schepull et al., 2012; Olsson et al., 2013). However, the lack of a significant difference could also be a question of lack of power. To study differences in re-ruptures between the two treatments one would need a very large cohort. This has also been shown in several meta-analyses, which includes a lot more patients (Bhandari et al., 2002; Khan et al., 2005; Zhao et al., 2011; Jiang et al., 2012; Soroceanu et al., 2012; Wilkins & Bisson, 2012; van der Eng et al., 2013). Most of these meta-analyses have found that the risk of re-rupture is higher after non-surgical treatment
7
Holm et al. compared with surgical. However, the most recent meta-analysis by van der Eng et al. (2013) did not show any statistically significant difference in re-ruptures occurrence between the treatments. Two of the most recent meta-analyses have also started to divide the studies into studies with early range of motion or delayed (Soroceanu et al., 2012; van der Eng et al., 2013), and Soroceanu et al. (2012) found that with delayed range of motion, there was a decreased risk of re-ruptures by 9% after surgical treatment. Surgery is, on the other hand, often shown to increase the risk of other complications (Cetti et al., 1993; Moller et al., 2001; Bhandari et al., 2002; Khan et al., 2005; Soroceanu et al., 2012; Wilkins & Bisson, 2012). Soroceanu et al. (2012) reported that the risk of complications was 15% higher after surgical treatment. In the studies covered in this review, Metz et al. (2008) found a tendency to increased risk of complications after non-surgical treatment, whereas Willits et al. (2010) found an increased risk of complications after surgical treatment. Olsson et al. (2013) found that both superficial wound infections as well as temporal nerve disturbances were more commonly occurring after surgery; however, they did not find any differences in the occurrence of DVT between the treatments. Besides re-rupture and wound complications, DVT is the most common complication after Achilles tendon rupture (Table 3). There appears to be no significant difference in the occurrence between surgical and non-surgical treatment in most studies. This was also seen in the meta-analyses by Wilkins and Bisson (2012) where they reported that surgical treatment lead to 7% risk of DVT compared with 10% after non-surgical treatment. However, Schepull et al. (2012) only found DVT on patients treated non-surgically (27%). Most DVTs are only reported after symptoms occurring. Nilsson-Helander et al. (2010) scanned all of their patients and found that the incidence of DVT was as high as 34% after Achilles tendon rupture. This indicates that DVTs are the most common complication and might therefore need more attention. Several studies have shown that most complications related to surgery resolve and that they appear to have no influence on functional outcome (Kellam et al., 1985; Wills et al., 1986; Leppilahti & Orava, 1998; Olsson et al., 2013). The most common complications after open surgery are adhesive scars, infections, and wound healing problems (Gigante et al., 2008). To reduce the rate of complications from surgery, percutaneous and minimally invasive repair techniques have become more used. These techniques have however been shown to increase the risk of sural nerve lesion (Bhandari et al., 2002; Khan et al., 2005; Nilsson-Helander et al., 2010). Gigante et al. (2008) found no significant difference in risk of complications or clinical outcome between open and percutaneous surgery, but recommends percutaneous surgery because of the minor cutaneous complications and reduction in operation time, which might give faster recovery. The
8
only study in this review using minimal invasive surgery was Metz et al. (2008), and they found no significant differences in complications between surgical and nonsurgical treatment. Previous studies, which have found a significant increased risk of re-rupture with non-surgical treatment, used immobilization during the entire cast period for the non-surgical group (Cetti et al., 1993; Moller et al., 2001). These studies were included in the meta-analyses by Khan et al. (2005), Bhandari et al. (2002), and Wilkins and Bisson (2012), which concluded a higher re-rupture risk for non-surgical treatment and a higher risk for other complications for surgical patients. Newer results in the randomized controlled trials in this review as well as a newer meta-analysis show that early mobilization and/or early weight-bearing does not cause a significantly higher risk for complications including re-rupture (Khan et al., 2005; Twaddle & Poon, 2007; Metz et al., 2008; Willits et al., 2010; Schepull et al., 2012; Soroceanu et al., 2012; Olsson et al., 2013; van der Eng et al., 2013). Early mobilization during rehabilitation also appears to level out the functional outcomes for patients treated with either surgery or non-surgery. Studies comparing post-operative immobilization with early mobilization have shown that early mobilization and/or early weight-bearing gives better functional outcome, higher quality of life and patient satisfaction, and also shortens the time for rehabilitation (Mortensen et al., 1999; Suchak et al., 2006, 2008; Olsson et al., 2013). Another known risk after Achilles tendon rupture is tendon elongation. Previous studies have shown that tendon elongation has the tendency to correlate with poorer functional outcome (Leppilahti & Orava, 1998; Kangas et al., 2007; Nilsson-Helander et al., 2010). In the studies covered by this review, only Schepull et al. (2012) studied tendon elongation. They found that tendon elongation occurred during the first 19 weeks, but they found no difference between surgical and non-surgical treatment. There was also no correlation between heel-raise index and elongation, besides one patient with an abnormal lengthening, which performed very poorly. This study also mentions that the variation (standard deviation) in their test results is significantly lower in the surgical group compared with the non-surgical group. This could indicate that surgery might not improve the healing outcome on group level, but it removes the outliers on group level by improving the healing greatly in people who would normally have a bad course of healing after non-surgical treatment. It might therefore mainly be these patients who will benefit from surgical treatment. The problem today is that we have no idea who will have a good or a bad course of healing when we are about to choose between the two treatment options. Two papers in this review found a significant difference in some of the functional outcomes (in jumping tests or heel-raise work) at late time points, favoring surgery (Nilsson-Helander et al., 2010; Olsson et al.,
Treatment of Achilles tendon ruptures 2013). There was however also differences in functional outcomes at 6 months after injury in one study (Nilsson-Helander et al., 2010). Keating and Will (2011) also showed a better result in short musculo-skeletal assessment questionnaire. One study also showed that the time to return to work was shorter after surgical treatment (Metz et al., 2008). Soroceanu et al. (2012) also showed in their meta-analyses that this was 19 days shorter after surgery. However, Wilkins and Bisson (2012) did not find any statistical difference in return to work in their meta-analysis. This review indicates that treatment alone after an acute Achilles tendon rupture might not determine the best functional outcome. It is possible that early rehabilitation after surgical as well as after non-surgical treatment is crucial for functional outcome. Patients treated with surgery appears to return to work (Metz et al., 2008; Soroceanu et al., 2012) and sport earlier, and they might have the possibility to start rehabilitation quicker, which is preferable regarding functional outcome. Also, given the fact that most complications related to surgery resolves and has no impact on functional outcome, surgery is preferable due to patient satisfaction and early functional outcome (Olsson et al., 2013). Furthermore, although no significant difference in re-rupture rates was seen in this review, there was still a clinical difference in favor of surgery treatment, which also advocates for surgery. Alternatively, minimally invasive surgery is recommendable, but more research is needed. Also, because rehabilitation is likely the determinant factor next to treatment, studies investigating whether early range of motion and/or early weight-bearing is recommendable are needed. We found no significant differences in re-rupture rate between surgical and non-surgical treatment of Achilles tendon rupture, although a tendency to favoring surgery that could be of clinical importance was presented. Sur-
gical patients had significantly better early functional outcomes and also returned to work earlier, which could be related to the fact that their rehabilitation is faster combined with early mobilization. However, surgical patients more often suffer from minor complications. Finally, randomized controlled trials will be needed in regard to understanding the interplay between acute surgical or non-surgical treatment and the rehabilitation regimen for the overall outcome of Achilles tendon treatment.
Perspectives Achilles tendon rupture frequently occurs during sports activities, and it has a long rehabilitation afterward. Most active athletes are recommended surgery to get a faster recovery and in some cases this is true, because there are studies that have shown time to return to sports is decreased after surgery. However, this review shows that today the choice of surgery/non-surgery might not be as important anymore, because the differences between initial treatments are less pronounced. This is likely due to the improved rehabilitation with functional braces and earlier motion and loading after each treatment. However, we have still not found the optimal rehabilitation protocol for Achilles tendon rupture. The patients still suffer from major deficits 1–2 years after rupture, irrespective of treatment (Nilsson-Helander et al., 2010; Olsson et al., 2011). Many of these patients will therefore most likely never return to their pre-injury sports level. An even better understanding on how rehabilitation can improve the functional outcomes after Achilles tendon rupture needs to be found. Key words: Surgery, conservative treatment, re-rupture, randomized controlled trials, functional outcomes.
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