You have probably heard of the "seven deadly sins" and if you watched Mickey Mouse cartoons, you may have even seen Disney's version of "killing seven with one blow." But you probably haven't seen the results of seven level I random controlled trials evaluating treatment of acute Achilles tendon ruptures. That's what we bring to you from this quantitative systematic review presented by the Department of Orthopaedic Surgery at the State University of New York at Buffalo.
For quite some time, there has been debate and controversy over the optimal way to approach management of the acute Achilles tendon rupture. Should it be treated surgically? Can the complications of surgery be avoided by going with a more conservative treatment plan? What is the best way to measure results?
The Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon, causing your foot to point down and helping you rise on your toes. This powerful muscle group helps when you sprint, jump, or climb.
Achilles tendon ruptures seem to be on the rise among athletes. The risk of rerupture is the primary concern when evaluating which treatment plan works the best. Other ways to assess outcomes can include strength, time to return to work or play, and complications. Besides re-rupture, postoperative problems (not likely with conservative care) can include infection, nerve damage, unacceptable cosmetic appearance (due to fibrosis and scarring), and blood clots.
In each of the seven studies included, patient results were compared from conservative to operative care. The main goal was to see what the re-rupture rate was for operative care versus conservative (nonoperative) care. Secondary measures were as described above (strength, return to work/sports, and complications).
By combining the number of patients together from all seven studies, there were 677 people (and outcomes) to examine and analyze. This type of study is both a systematic review (finding and reviewing all studies comparing these two treatments) and a meta-analysis (combining all patients together to form a larger pool).
There were four major findings. First, open repair had a significantly lower rate of reruptures compared with conservative care. There were almost three times as many reruptures in the conservative care group compared with the surgical group.
Second, the number of deep infections was much higher in the group that had surgery. No one had infection in the conservative care group. Almost three per cent of the surgical group developed a deep infection that required additional medical care and delayed recovery.
Third, nerve damage and dissatisfaction with the scar were never problems in the nonoperative group but were reported in the surgical group. The number of blood clots was not significantly different between the two groups. And the time to return to work or play was shorter for the surgical group but the statistical values did not reach significance.
And fourth, strength could not be used as an outcome measure because the way strength was assessed was different from study to study. As a result, the strength measurements were not considered "standardized."
The authors pointed out that there were more than seven studies available. In fact, there were over 1,000 articles on the topic of acute Achilles tendon ruptures. But with the strict criteria they used to ensure the best analysis with the most reliable results, only these seven articles could be included.
They advise that future studies are needed -- especially to answer the question of treatment effect on muscle strength. This information would be very valuable for athletes who depend on return of full strength needed for jumping and running. But such studies would also provide high-quality research that yields meaningful, trustworthy data.
On the basis of this systematic review and meta-analysis, surgeons can expect to reduce a patient's risk of rerupture with surgical treatment of acute Achilles tendon ruptures. But the higher risk of postoperative complications must be taken into consideration. Athletes and active patients may prefer the stronger tendon that comes with surgical repair. Less active and older adults with fewer biomechanical demands on the damaged tendon may opt for the nonoperative approach.
Reference: Ryan Wilkins, MD, and Leslie J. Bisson, MD. Operative Versus Nonoperative Management of Acute Achilles Tendon Ruptures. In The American Journal of Sports Medicine. September 2012. Vol. 40. No. 9. Pp. 2154-2160.