Interventions for treating acute Achilles tendon ruptures

Abstract

Background: There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace.

Objectives: To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures.

Search strategy: We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries.

Selection criteria: All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures.

Data collection and analysis: Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale.

Main results: Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes. Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28). Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved. Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76). Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients).

Reviewers' conclusions: Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.