Three Part Question
In [active patients with complete achilles tendon rupture] is [operative treatment better than conservative management] in [speeding time to recovery and improving functional outcome]?
A 35 year old man presents with acute onset of difficulty walking which came on while paying sport. He describes sudden onset of pain at the back of the ankle. Clinical examination reveals complete rupture of the achilles tendon. You wonder whether operative treatment is better than conservative management in this case.
Medline 1966-10/03 using the OVID interface. Including MEDLINE in progress and other non-indexed citations
[exp Achilles Tendon OR achilles.mp] AND [exp Rupture OR rupture$.mp) LIMIT to human, English language and abstracts
494 papers found. A systematic review was found from 2000. Since 2000 an additional 2 papers were found.
|Author, date and country
||Study type (level of evidence)
|Meta analysis of 6 papers. Adult patients. 273 citations were examined. 11 were potentially eligible. 6 were methodologically sound and used in the final analysis.||Meta analysis||Risk of rerupture (448 patients)||3.1% with surgery vs. 13% non-operative. p=0.005||Different surgical methods between trials (not necessarilly weakness of metaanalysis). Search strategy could have been wider to include a greater part of the grey literature.|
|Infection rates (421 patients)||4.7% in surgical patients|
|Return to normal function (421 patients)||71% for surgery vs. 63% for non-operative (p=NS)|
|23 patients treated non-operatively compared against 15 operatively treated patients.||Retrospective cohort||rerupture rate||4 in the non-operative group, 1 in the operative group||Not randomised. Authors conclusion consider outcome to be equivalent which is not suggested by the rerupture rate. Retrospective study. Very small numbers.|
A good Metanalysis supports the use of operative treatment for fit patients. There is a significant reduction in rerupture rate and a trend towards improved functional outcome. The advantages are at the expense of the possibility of wound infection.
Clinical Bottom Line
On current evidence operative repair is preferable.
Level of Evidence
Level 1 - Recent well-done systematic review was considered or a study of high quality is available.
- Bhandari M. Treatment of acute achilles tendon ruptures a systematic overview and metaanalysis Clinical Orthopaedics & Related Research 2002;400:190-200.
- Weber M Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative management. Am J Sports Med 2003;31:685-691