Surgical Management of Chronic Achilles Tendon Ruptures: A Systematic Review and Proposed Treatment Algorithm.
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ABSTRACT: Background
As no evidence-based treatment guidelines exist for chronic Achilles tendon rupture (CATR), a systematic review of the literature was performed to compare the different treatment options and recommend a literature-based algorithm.Methods
In June 2022, MEDLINE, Embase, and Cochrane Library databases were systematically reviewed based on the PRISMA guidelines. The level of evidence (LOE) and quality of evidence were evaluated, and statistics on clinical outcomes and complications were calculated.Results
Twenty-seven studies with 614 patients were included. Three studies were LOE III and 25 studies were LOE IV. The mean Achilles tendon rupture score improved from a preoperative weighted mean of 38.8 ± 12.4 to a postoperative score 90.6 ± 4.7. The overall complication rate was 11.4%. Single techniques were used in 23 studies and dual techniques were used in 5 studies. The FHL tendon transfer was the most frequently used technique. We devised an algorithmic approach based on time from injury to surgical intervention and the length of the gap between the tendon stumps: >3 months: FHL transfer; <3 months (a) gap <2 cm, end-to-end repair; (b) gap 2 to 5 cm, gastrocnemius transfer, (c) gap >5 cm, semitendinosus autograft.Conclusion
Surgical management of CATR produced improvements in patient-reported outcome scores at midterm follow up, but a high complication rate (11.4%) was noted. Our proposed treatment algorithm may assist in shared decision making for this complex problem.
SUBMITTER: Azam MT
PROVIDER: S-EPMC10557420 | biostudies-literature | 2023 Oct
REPOSITORIES: biostudies-literature
Publications
Surgical Management of Chronic Achilles Tendon Ruptures: A Systematic Review and Proposed Treatment Algorithm.
Azam Mohammad T MT Butler James J JJ Weiss Matthew B MB Ubillus Hugo A HA Kirschner Noah N Mercer Nathaniel P NP Kennedy John G JG
Foot & ankle orthopaedics 20231005 4
<h4>Background</h4>As no evidence-based treatment guidelines exist for chronic Achilles tendon rupture (CATR), a systematic review of the literature was performed to compare the different treatment options and recommend a literature-based algorithm.<h4>Methods</h4>In June 2022, MEDLINE, Embase, and Cochrane Library databases were systematically reviewed based on the PRISMA guidelines. The level of evidence (LOE) and quality of evidence were evaluated, and statistics on clinical outcomes and comp ...[more]
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Project description:ObjectivesTo compare re-rupture rate, complication rate, and functional outcome after operative versus nonoperative treatment of Achilles tendon ruptures; to compare re-rupture rate after early and late full weight bearing; to evaluate re-rupture rate after functional rehabilitation with early range of motion; and to compare effect estimates from randomised controlled trials and observational studies.DesignSystematic review and meta-analysis.Data sourcesPubMed/Medline, Embase, CENTRAL, and CINAHL databases were last searched on 25 April 2018 for studies comparing operative versus nonoperative treatment of Achilles tendon ruptures.Study selection criteriaRandomised controlled trials and observational studies reporting on comparison of operative versus nonoperative treatment of acute Achilles tendon ruptures.Data extractionData extraction was performed independently in pairs, by four reviewers, with the use of a predefined data extraction file. Outcomes were pooled using random effects models and presented as risk difference, risk ratio, or mean difference, with 95% confidence interval.Results29 studies were included-10 randomised controlled trials and 19 observational studies. The 10 trials included 944 (6%) patients, and the 19 observational studies included 14 918 (94%) patients. A significant reduction in re-ruptures was seen after operative treatment (2.3%) compared with nonoperative treatment (3.9%) (risk difference 1.6%; risk ratio 0.43, 95% confidence interval 0.31 to 0.60; P<0.001; I2=22%). Operative treatment resulted in a significantly higher complication rate than nonoperative treatment (4.9% v 1.6%; risk difference 3.3%; risk ratio 2.76, 1.84 to 4.13; P<0.001; I2=45%). The main difference in complication rate was attributable to the incidence of infection (2.8%) in the operative group. A similar reduction in re-rupture rate in favour of operative treatment was seen after both early and late full weight bearing. No significant difference in re-rupture rate was seen between operative and nonoperative treatment in studies that used accelerated functional rehabilitation with early range of motion (risk ratio 0.60, 0.26 to 1.37; P=0.23; I2=0%). No difference in effect estimates was seen between randomised controlled trials and observational studies.ConclusionsThis meta-analysis shows that operative treatment of Achilles tendon ruptures reduces the risk of re-rupture compared with nonoperative treatment. However, re-rupture rates are low and differences between treatment groups are small (risk difference 1.6%). Operative treatment results in a higher risk of other complications (risk difference 3.3%). The final decision on the management of acute Achilles tendon ruptures should be based on patient specific factors and shared decision making. This review emphasises the potential benefits of adding high quality observational studies in meta-analyses for the evaluation of objective outcome measures after surgical treatment.
| S-EPMC6322065 | biostudies-literature
Project description:BackgroundAchilles tendon ruptures are the most common lower extremity tendinous rupture. While there has been extensive research into the management of mid-substance Achilles tendon ruptures, there is a paucity of literature on the management of myotendinous Achilles tendon ruptures.MethodsThe aim of this systematic review is to compile all available literature on the treatment of myotendinous Achilles tendon tears. A systematic search of Web of Science, Embase, and Medline databases was performed for all studies published from database inception to April 13, 2024. All publications addressing the treatment of myotendinous Achilles ruptures of all levels of evidence were included. The PRISMA Checklist guided the reporting and data abstraction. Descriptive statistics are presented.ResultsA total of five studies with 70 patients were included for analysis. Sixty-seven patients underwent non-operative management with an average age ranging from 40.8 to 51.0 years. Three patients underwent operative management with ages of 16, 36, and 39. The majority of patients tore their Achilles tendon during sports. For nonoperatively treated patients, one group underwent immobilization for a total of 6 weeks and one study treated patients with functional rehabilitation. All patients were able to perform a single heel-raise, had good reported strength, and returned to work or sport. Nonoperative patients reported statistically significant improvements in subjective outcomes and high rates of satisfaction.ConclusionBoth nonoperative and operative management of myotendinous Achilles tendon ruptures demonstrated good outcomes after injury, although there is a limited amount of literature on this topic. Given that nonoperative treatment appears to yield good strength and return to activity, it may be preferred for the majority of patients. Operative management may be indicated in high level athletes. Imaging to determine the exact location of injury, quality of remaining tendon, and gap distance may further aid when considering treatment options. Higher level evidence studies are required to determine the optimal treatment of myotendinous Achilles tendon ruptures.Level of evidenceIV; Systematic review of Level IV-V studies.
| S-EPMC11744937 | biostudies-literature
Project description:BackgroundAchilles tendon ruptures are a common injury and are increasing in incidence. Several management strategies exist for both non-operative and operative care, with each strategy offering unique risks and benefits. Traditional pairwise meta-analyses have been performed to compare management strategies; however, all treatment options have never been integrated in a single analysis. Network meta-analysis (NMA) is a generalization of pairwise meta-analysis, which allows for the comparison of multiple interventions based on all available direct and indirect evidence. The objectives of this review are to synthesize the evidence on the management options for acute Achilles tendon rupture and identify which treatment gives the best functional outcomes.MethodsA systematic review with NMA is planned. An electronic literature search will be performed in conjunction with an experienced information specialist in MEDLINE, EMBASE, CINAHL, PEDro, and the Cochrane Central Register of Controlled Trials. We will include randomized controlled trials with a minimum 6-month follow-up. Two independent reviewers will screen citations for eligibility, extract study data, and perform risk of bias assessments. The primary outcome will be disease-specific functional outcome scores (AOFAS, Leppilahti, modified Leppilahti) at 1 year. Secondary outcomes will include complications (re-rupture, sural nerve injury, wound complications, deep infection, secondary surgeries), strength, range of motion, return to work, return to sport, and quality-of-life measures (including the SF-36 questionnaire). Traditional pairwise meta-analyses will be performed for all direct comparisons where evidence is available, and NMAs will subsequently be performed where possible to compare all management strategies.DiscussionThe data generated from this review will provide health-care providers with a clear evidence synthesis of all Achilles tendon rupture management strategies. Additionally, these data will be incorporated into the development of a patient decision aid to assist patients and clinicians in making a preference-based decision when faced with an Achilles tendon rupture.Systematic review registrationPROSPERO CRD42018093033 .
| S-EPMC6304227 | biostudies-literature
Project description:PurposeThis scoping review aims to systematically map and summarise the available evidence on the management of chronic Achilles ruptures, whilst identifying prognostic factors and areas of future research.MethodsA scoping review was performed according to the frameworks of Arksey and O'Malley, Levac and Peters. A computer-based search was performed in PubMed, Embase, EmCare, CINAHL, ISI Web of Science and Scopus, for articles reporting treatment of chronic Achilles ruptures. Two reviewers independently performed title/abstract and full text screening according to pre-defined selection criteria.ResultsA total of 747 unique articles were identified, of which 73 (9.8%) met all inclusion criteria. A variety of methods are described, with flexor hallucis longus tendon transfer being the most common. The most commonly reported outcome is the American Orthopaedic Foot and Ankle Society (AOFAS) score, although 16 other measures were reported in the literatures. All studies comparing pre- and post-operative outcomes reported significant post-treatment improvement. Complications were reported in 50 studies, with an overall pooled complication rate of 168/1065 (15.8%).ConclusionAlthough beneficial results were reported following a variety of techniques, comparison between these is challenging due to the low-level study designs used and confounding factors such as treatment delay and tendon gap size. Further research comparing the efficacy of different techniques is required in order to facilitate the development of an evidence-based treatment protocol. Such work would allow clinicians to better understand the suitability of the large variety of reported techniques and select the optimal strategy for each individual patient.
| S-EPMC8514369 | biostudies-literature
Project description:BackgroundDespite the literature on acute Achilles tendon ruptures, there remains a lack of consensus regarding the optimal treatment. The purpose of this survey study was to investigate treatment preferences among Army orthopaedic surgeons when presented with a standardized case of an acute Achilles rupture and determine if surgeon factors correlated with treatment preference.MethodsA hypothetical case of a 37-year-old male with history, physical exam, and imaging consistent with an Achilles rupture was sent to board-certified Army orthopaedic surgeons to determine their preferred management. Demographic data was collected to include: practice setting, years from residency graduation, and completion of fellowship. Correlations analyzed between demographics and treatment preferences.ResultsSixty-two surgeons responded. 62% of respondents selected surgical intervention. Of these, 59% chose a traditional open technique. 50% of respondents were general orthopaedic. There was a correlation between fellowship training and operative management (P = 0.042). Within the operative management group there was no statistical difference (P > 0.05) in need for further imaging, technique used, post-operative immobilization, length of immobilization, weight-bearing protocol, and time to release to running. The majority of non-operative responders would splint/cast in plantarflexion or CAM boot with heel lift for < 3 weeks (50%) and keep non-weight bearing for < 4 weeks (63%). Only 38% of respondents would use DVT chemoprophylaxis.ConclusionWhen provided with a hypothetic case of an acute Achilles tendon rupture, queried Army orthopaedic surgeons would more often treat with a surgical procedure. This difference in treatment is secondary to training, fellowship or other. This propensity of surgical management, likely stems from the highly active population and the desire to return to duty.
| S-EPMC7953566 | biostudies-literature
Project description:PurposeThe aim of this systematic review and meta-analysis was to compare re-rupture rates, complication rates, functional outcomes, as well as return to work (RTW)/sport (RTS) among different rehabilitation protocols following operative treatment of acute Achilles tendon ruptures.MethodsSystematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were searched for randomized controlled trials (RCTs) comparing at least two rehabilitation protocols following surgical repair of acute Achilles tendon ruptures. Rehabilitation protocols were classified as a variation of either non-weightbearing (NWB) or weightbearing (WB) and immobilization (IM) or mobilization (M). The data collection consisted of re-ruptures, complications, and RTW/RTS.ResultsOut of 2760 studies screened, 20 RCTs with 1007 patients were eligible. Fourteen studies included a group consisting of WB + M (Group 1), 11 of WB + IM (Group 2), 3 of NWB + M (Group 3), and 13 of NWB + IM (Group 4). Outcome parameters available for a meta-analysis were re-ruptures, complications, RTW, and RTS. Re-ruptures overall occurred in 2.7%, with prevalences ranging between 0.04 and 0.08. Major complications occurred in 2.6%, with prevalences ranging between 0.02 and 0.03. Minor complications occurred in 11.8% with prevalances ranging between 0.04 to 0.17. Comparing the odds-ratios between the four different groups revealed no significant differences with overall favourable results for group 1 (WB+M).ConclusionEarly functional rehabilitation protocols with early ankle M and WB following surgical repair of acute Achilles tendon ruptures are safe and they apparently allow for a quicker RTW and RTS and seem to lead to favourable results.
| S-EPMC9619394 | biostudies-literature
Project description:BackgroundThe management of acute Achilles tendon ruptures is controversial, and most injuries are treated with surgery in the USA. The cost utility of operative versus non-operative treatment of acute Achilles tendon injury is unclear.Questions/purposesThe purpose of this study was to compare the cost-effectiveness of operative versus functional non-operative treatment of acute Achilles tendon ruptures.MethodsA Markov cost-utility analysis was conducted from the societal perspective using a 2-year time horizon. Hospital costs were derived from New York State billing data, and physician and rehabilitation costs were derived from the Medicare physician fee schedule. Indirect costs of missed work were calculated using estimates from the US Bureau of Labor Statistics. Rates of re-rupture, major and minor complications, and the associated costs were obtained from the literature. Effectiveness was expressed in quality-adjusted life years (QALYs). For the base-case analysis, operative and non-operative patients were assumed to have the same utilities (quality of life) following surgery. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of model assumptions.ResultsIn the base-case model, non-operative management of acute Achilles tendon ruptures dominated operative management, resulting in both lower costs and greater QALY gains. The differences in costs and effectiveness were relatively small. The benefit of non-operative treatment was 1.69 QALYs, and the benefit of operative treatment was 1.67 QALYs. Similarly, the total cost of operative and non-operative management was $13,936 versus $13,413, respectively. In sensitivity analyses, surgical costs and days of missed work were important drivers of cost-effectiveness. If hospitalization costs dropped below $2621 (compared with $3145) or the hourly wage rose above $29 (compared with $24), then operative treatment became a cost-effective strategy at the willingness-to-pay threshold of $50,000/QALY. The model results were also highly sensitive to the relative utilities for operative versus non-operative treatment. If non-operative utilities decreased relative to operative utilities by just 2%, then operative management became the dominant treatment strategy.ConclusionFor acute Achilles tendon ruptures, non-operative treatment provided greater benefits and lower costs than operative management in the base case; however, surgical costs and the economic impact associated with return to work are important determinants of the preferred cost-effective strategy.
| S-EPMC6974171 | biostudies-literature
Project description:PurposeThis study aimed to describe and analyse usual care of Achilles tendon ruptures (ATRs) by orthopaedic surgeons and trauma surgeons in the Netherlands.MethodsA nationwide online survey of ATR management was sent to all consultant orthopaedic and trauma surgeons in the Netherlands, requesting participation of those involved in ATR management. Data on individual characteristics and the entire ATR management (from diagnosis to rehabilitation) were gathered. Consensus was defined as ≥ 70% agreement on an answer.ResultsA total of 91 responses (70 orthopaedic surgeons and 21 trauma surgeons) were analysed. There was consensus on the importance of the physical examination in terms of diagnosis (> 90%) and a lack of consensus on diagnostic imaging (ultrasound/MRI). There was consensus that non-surgical treatment is preferred for sedentary and systemically diseased patients and surgery for patients who are younger and athletic and present with larger tendon gap sizes. There was consensus on most of the non-surgical methods used: initial immobilisation in plaster cast with the foot in equinus position (90%) and its gradual regression (82%) every 2 weeks (85%). Only length of immobilisation lacked consensus. Surgery was generally preferred, but there was a lack of consensus on the entire followed protocol. Orthopaedic and trauma surgeons differed significantly on their surgical (p = 0.001) and suturing techniques (p = 0.002) and methods of postoperative immobilisation (p < 0.001). Orthopaedic surgeons employed open repair and Bunnell sutures more often, whereas trauma surgeons used minimally invasive approaches and bone anchors. Rehabilitation methods and advised time until weight-bearing and return to sport varied. Orthopaedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment (p = 0.001) and surgery (p = 0.002) than trauma surgeons.ConclusionThis is the first study to describe the entire ATR management. The results show a lack of consensus and wide variation in management of ATRs in the Netherlands. This study shows that especially the methods of the perioperative and rehabilitation phases were inconclusive and differed between orthopaedic and trauma surgeons. Further research into optimal ATR management regimens is recommended. In addition, to achieve uniformity in management more multidisciplinary collaboration between Dutch and international surgeons treating ATRs is needed.Level of evidenceCross-sectional survey, Level V.
| S-EPMC6706364 | biostudies-literature
Project description:Achilles tendon ruptures are a common tendon injury, usually occurring in middle-aged men during recreational sporting activities. Both nonoperative and operative management are employed to treat these injuries. Several operative treatments are described in the literature, including percutaneous Achilles repair, mini-open repair, and open repair. Open Achilles repair is associated with higher rates of impaired wound healing and infection, whereas minimally invasive techniques have been reported to have an increased risk of iatrogenic sural nerve injury. More recently, low complication rates, improved cosmetic appearance, reduced operating times, and improved clinical outcomes have been reported for the percutaneous Achilles repair technique. In this Technical Note, we present our preferred technique using the Percutaneous Achilles Repair System (Arthrex, Naples, FL), which has been reported to have minimal wound and nerve complications, and early return to activity.
| S-EPMC5851437 | biostudies-literature
Project description:In correlation with a growing body of evidence regarding nonoperative management for Achilles tendon rupture (ATR), studies from Europe and Canada have displayed a decreasing incidence in surgical management, which has not been noted in the United States. The primary objective of this study is to evaluate the US trend in ATR repair volume. The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination Case List Database was used. All cases using Current Procedural Terminology codes for primary ATR repair were requested from the years 2006-2020. Total submitted Achilles repair volume, the number of candidates submitting an Achilles repair case, and the overall submitted case volume per examination year was analyzed. Poisson and linear regressions were used to determine statistically significant trends. The total number of Achilles repair cases submitted for the ABOS Part II Oral Examination significantly increased from 2006 to 2011 and then decreased until 2020. Taking Achilles repair cases as a proportion of total orthopaedic cases submitted, the same trend was seen. The number of candidates submitting an Achilles repair case increased from 2006 to 2009 and then decreased until 2020. Foot and Ankle fellowship-trained candidates submitted an increasing number of ATR repair cases per candidate during the time period studied. This is the first study to demonstrate a decline in the volume of ATR repair in the United States. The decline in ATR repair volume seen in the ABOS Part II Case Lists does not match previously published US surgeon practice patterns but is not necessarily generalizable to beyond this period. Although the overall ATR repair volume in the ABOS Part II Case Lists is decreasing, we found Foot and Ankle fellowship-trained surgeons are operating on an increasing number of ATRs during their board collection period. Level III, retrospective cohort study.
| S-EPMC11292698 | biostudies-literature