Outcomes of open surgery versus nonoperative management of acute achilles tendon rupture

Abstract

Objective: To compare the outcomes (reruptures and other complications, strength, and return to work) of open surgical repair of acute Achilles tendon ruptures with nonoperative management, by means of a meta-analysis of the results of randomized controlled trials (RCTs).

Data sources: The online search using words related to management of Achilles tendon rupture included MEDLINE, PubMed, the Cochrane Database of Systematic Reviews, and the American College of Physicians Journal Club. Reference lists of relevant articles were searched for further studies.

Study selection: Inclusion criteria were RCTs, published in English, that compared open surgery with nonoperative management of acute Achilles tendon ruptures, and that reported the rate of reruptures as an outcome. Of 1163 articles identified, 44 were read in full, and 7 met inclusion criteria.

Data extraction: Data on samples, management of the rupture, outcomes, and length of follow-up were extracted. The methods of the trials were assessed using the 10 criteria of the Coleman methodology score.

Main results: Among patients followed for 10 to 36 months, the pooled rate of tendon reruptures was lower in those treated surgically, 3.6% (n = 15), compared with 8.8% (n = 38) for patients managed nonoperatively (odds ratio [OR] favoring open surgical repair, 0.425; 95% confidence interval [CI], 0.222-0.815). Other complications were mostly higher in the open surgery group. In 5 studies reporting deep infection rates, there were none in the nonsurgically managed group versus 6 in 254 patients (2.36%) among the open surgery patients (P = 0.0113). In 6 studies reporting noncosmetic scar complaints, the pooled rate was 13.1% for patients treated with surgery and 0.62% for patients treated nonoperatively (P < 0.001). In 5 studies reporting sural nerve sensory disturbances, the pooled rate was 8.76% of surgical patients compared with 0.78% of patients treated nonoperatively (P < 0.001). In 4 studies, the pooled rate of deep vein thrombosis did not differ significantly between the surgery group (7.08%) and the nonoperative group (10.24%; P = 0.1706). Time to return to work after the beginning of treatment did not differ between groups (pooled mean difference favoring surgical management, 7.453 days; 95% CI, -4.959 to 19.864) in 4 studies. Measurements of strength were too heterogeneous to be pooled. The mean age of the 677 patients was approximately 40 years, and ≥70% of each group was male.

Conclusions: Rates of reruptures after open surgical treatment of acute Achilles tendon ruptures were lower than those among patients managed nonsurgically. However, the rates of complications of surgery, such as deep infections, noncosmetic scarring, and sural nerve disturbances, should cause concern.