2 the diagnosis and treatment of acute achilles tendon ...€¦ · patients with acute achilles...

1

2 3

4 5 6 7 8

THE DIAGNOSIS AND TREATMENT OF ACUTE ACHILLES TENDON RUPTURE

GUIDELINE AND EVIDENCE REPORT

CONFIDENTIAL DRAFT

Disclaimer 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49

This Clinical Practice Guideline was developed by an AAOS physician volunteer Work Group based on a systematic review of the current scientific and clinical information and accepted approaches to treatment and/or diagnosis. This Clinical Practice Guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s clinical circumstances. Disclosure Requirement In accordance with AAOS policy, all individuals whose names appear as authors or contributors to Clinical Practice Guideline filed a disclosure statement as part of the submission process. All panel members provided full disclosure of potential conflicts of interest prior to voting on the recommendations contained within this Clinical Practice Guidelines. Funding Source This Clinical Practice Guideline was funded exclusively by the American Academy of Orthopaedic Surgeons who received no funding from outside commercial sources to support the development of this document. FDA Clearance Some drugs or medical devices referenced or described in this Clinical Practice Guideline may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice. Copyright All rights reserved. No part of this Clinical Practice Guideline may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the AAOS. Published 2009 by the American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018 First Edition Copyright 2007 by the American Academy of Orthopaedic Surgeons

ii

Summary of Recommendations 50 51 52 53 54 55 56 57 58 59 60 61 62 63

64 65 66 67

68 69 70 71 72 73 74 75 76 77

78 79 80 81

82 83 84 85 86

87

88

The following is a summary of the recommendations in the AAOS’ clinical practice guideline, The Diagnosis and Treatment of Acute Achilles Tendon Rupture. The scope of this guideline is specifically limited to acute Achilles tendon rupture. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician and other healthcare practitioners.

1. In the absence of the reliable evidence, it is the opinion of this work group that a detailed history and physical exam be performed. The physical examination should include two or more of the following tests to establish the diagnosis of acute Achilles tendon rupture:

o Clinical Thompson test (Simmonds squeeze test) o Decreased ankle plantar flexion strength o Presence of a palpable gap (defect, loss of contour) o Increased passive ankle dorsiflexion with gentle manipulation

Strength of Recommendation – Consensus* 2. We are unable to recommend for or against the routine use of magnetic resonance

imaging (MRI), ultrasound (ultrasonography), and radiograph (roentgengrams, x-rays) to confirm the diagnosis of acute Achilles tendon rupture.

Strength of Recommendation – Inconclusive

3. Non-operative treatment is an option for all patients with acute Achilles tendon rupture.

Strength of Recommendation: Weak

4. For patients treated non-operatively, we are unable to recommend for or against the use of immediate functional bracing for patients with acute Achilles tendon rupture

Strength of Recommendation: Inconclusive

iii

5. Operative treatment is an option in patients with acute Achilles tendon rupture. 89

90 91 92 93 94 95 96

97 98 99

100 101

102 103 104 105 106 107

108 109

110 111 112

113 114 115 116

117 118 119 120

121 122 123 124

125 126


6. In the absence of reliable evidence, it is the opinion of the work group that although operative treatment is an option, it should be approached more cautiously in patients with diabetes, neuropathy, immunocompromised states, age above 65, tobacco use, sedentary lifestyle, obesity (BMI >30), peripheral vascular disease or local/systemic dermatologic disorders.

Strength of Recommendation: Consensus

7. For patients who will be treated operatively for an acute Achilles tendon rupture, we are unable to recommend for or against preoperative immobilization or restricted weight-bearing.


8. We suggest that patients with an acute Achilles tendon rupture who are treated operatively undergo a minimally invasive technique rather than an open technique.

Strength of Recommendation: Moderate

9. We cannot recommend for or against the use of allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts in all acute Achilles tendon ruptures that are treated operatively.


10. We cannot recommend for or against the use of antithrombotic treatment for patients with acute Achilles tendon ruptures.


11. We suggest early (≤ 2 weeks) post-operative protected weight-bearing for patients with acute Achilles tendon rupture who have been treated operatively


12. We suggest the use of a protective device that allows mobilization by 2- 4 weeks post operatively.


iv

v

127 128 129 130 131 132 133 134

135 136 137 138 139 140 141 142 143 144 145 146

147 148 149 150 151 152

13. 13 We are unable to recommend for or against post-operative physiotherapy for patients with acute Achilles tendon rupture


14. In all patients with acute Achilles tendon rupture, irrespective of treatment type,

we are unable to recommend a specific time at which patients can return to activities of daily living.

Strength of Recommendation: Inconclusive 15. In patients who participate in sports it is an option to return them to sports within

3-6 months after operative treatment for acute Achilles tendon rupture.


16. In patients with acute Achilles tendon rupture treated non-operatively, we are unable to recommend a specific time at which patients can return to athletic activity.


* While we strongly encourage reviewers to read the full guideline, please refer to the sections titled “Judging the Quality of Evidence” and “Defining the Strength of the Recommendations Table 1” for a detailed description of the link between the evidence supporting the Strength of a Recommendation and the language of the guideline.

Work Group153 154 Blinded for review

vi

Peer Review 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189

Participation in the AAOS peer review process does not constitute an endorsement of this guideline by the participating organization or the individuals listed below nor does it is any way imply the reviewer supports this document. The following organizations participated in peer review of this clinical practice guideline and gave explicit consent to be listed as a peer review organization of this document: American Academy of Family Practitioners American Podiatric Medical Association American Orthopaedic Society for Sports Medicine American College of Foot and Ankle Surgeons American Academy of Physical Medicine and Rehabilitation American Physical Therapy Association Individuals who participated in the peer review of this document and gave their explicit consent to be listed as reviewers of this document are: Avrill Roy Berkman, MD Christopher R. Carcia, MD Michael Heggeness, MD Harvey Insler, MD John Kirkpatrick, MD Michael S. Lee, DPM, FACFA Angus McBryde Jr., MD Ariz R. Mehta, MD Lawrence Oloff, DPM Steven Raikin, MD Charles Reitman, MD John Richmond, MD Kevin Shea, MD Naomi Sheilds, MD Nelson F. Soohoo, MD Glenn Weinraub, DPM, FACFAS

vii

Table of Contents 190

191

192

193

194

195

196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

SUMMARY OF RECOMMENDATIONS ..............................................................III

WORK GROUP .................................................................................................. VI

PEER REVIEW.................................................................................................. VII

TABLE OF CONTENTS ................................................................................... VIII

LIST OF TABLES.............................................................................................. XII

I. INTRODUCTION ...........................................................................................1

Overview ....................................................................................................................................................... 1

Goals and Rationale ..................................................................................................................................... 1

Intended Users .............................................................................................................................................. 1

Patient Population ........................................................................................................................................ 2

Incidence ....................................................................................................................................................... 2

Burden of Disease ......................................................................................................................................... 2

Etiology.......................................................................................................................................................... 2

Risk Factors .................................................................................................................................................. 2

Emotional and Physical Impact of Achilles Tendon Rupture .................................................................. 2

Potential Benefits, Harms, and Contraindications .................................................................................... 2

II. METHODS.....................................................................................................3

Formulating Preliminary Recommendations............................................................................................. 3

Study Inclusion Criteria............................................................................................................................... 4

Outcomes Considered .................................................................................................................................. 4

Literature Searches ...................................................................................................................................... 5

Data Extraction............................................................................................................................................. 6

Judging the Quality of Evidence ................................................................................................................. 6

viii

214

215

216

217

218

219

220

221

222

223 224 225 226 227

228 229 230 231 232

233 234 235 236 237

238 239 240 241

242 243 244 245

246

247

248 249 250 251

Defining the Strength of the Recommendations ........................................................................................ 7

Consensus Development............................................................................................................................... 8

Statistical Methods ....................................................................................................................................... 9

Peer Review................................................................................................................................................... 9

Public Commentary.................................................................................................................................... 10

The AAOS Guideline Approval Process................................................................................................... 10

Revision Plans ............................................................................................................................................. 10

Guideline Dissemination Plans .................................................................................................................. 10

III. RECOMMENDATIONS AND SUPPORTING EVIDENCE .......................12

Recommendation 1 ..................................................................................................................................... 13 Summary of Evidence.............................................................................................................................. 13 Excluded Articles..................................................................................................................................... 14 Study Quality ........................................................................................................................................... 15 Study Results ........................................................................................................................................... 16



Recommendation 4 ..................................................................................................................................... 34 Summary of Evidence.............................................................................................................................. 35 Excluded Articles..................................................................................................................................... 38 Study Quality ........................................................................................................................................... 39

Recommendation 5 ..................................................................................................................................... 42 Summary of Evidence.............................................................................................................................. 43 Excluded Articles..................................................................................................................................... 49 Study Quality ........................................................................................................................................... 53

Recommendation 6 ..................................................................................................................................... 57

Recommendation 7 ..................................................................................................................................... 58

Recommendation 8 ..................................................................................................................................... 59 Percutaneous vs Open Repair .................................................................................................................. 60 Limited Open vs Open Repair ................................................................................................................. 60 Summary of Evidence.............................................................................................................................. 60

ix

252 253 254

255 256 257 258 259 260 261

262 263

264 265 266 267 268 269

270 271 272 273 274 275

276 277 278

279 280 281 282

283 284 285 286

287 288 289 290

291

292

293 294

Excluded Articles..................................................................................................................................... 63 Study Quality ........................................................................................................................................... 65 Study Results ........................................................................................................................................... 68

Recommendation 9 ..................................................................................................................................... 71 Autograft Tissue vs Open Repair............................................................................................................. 71 Augmentation with Synthetic Tissue vs Open Repair ............................................................................. 71 Summary of Evidence.............................................................................................................................. 72 Excluded Articles..................................................................................................................................... 74 Study Quality ........................................................................................................................................... 77 Study Results ........................................................................................................................................... 81

Recommendation 10 ................................................................................................................................... 85 Excluded Studies ..................................................................................................................................... 85

Recommendation 11 ................................................................................................................................... 86 Summary of Evidence.............................................................................................................................. 88 Summary of Complications ..................................................................................................................... 91 Excluded Articles..................................................................................................................................... 92 Study Quality ........................................................................................................................................... 93 Study Results ........................................................................................................................................... 98

Recommendation 12 ................................................................................................................................. 102 Summary of Evidence............................................................................................................................ 103 Summary of Complications ................................................................................................................... 109 Excluded Articles................................................................................................................................... 111 Study Quality ......................................................................................................................................... 112 Study Results ......................................................................................................................................... 117

Recommendation 13 ................................................................................................................................. 122 Summary of Evidence............................................................................................................................ 122 Excluded articles.................................................................................................................................... 123

Recommendation 14 ................................................................................................................................. 124 Summary of Evidence............................................................................................................................ 124 Excluded Articles................................................................................................................................... 131 Study Quality ......................................................................................................................................... 133



Future Research ....................................................................................................................................... 151

IV. APPENDIXES .............................................................................................152

Appendix I................................................................................................................................................. 153 Work Group........................................................................................................................................... 153

x

295 296 297

298 299

300 301

302 303

304 305 306

307 308

309 310

311 312

313 314 315

316 317

318 319

320 321 322 323

Appendix II ............................................................................................................................................... 154 AAOS Bodies That Approved This Clinical Practice Guideline ........................................................... 154 Documentation of Approval .................................................................................................................. 155

Appendix III.............................................................................................................................................. 156 Literature Searches for Primary Studies ................................................................................................ 156

Appendix IV.............................................................................................................................................. 158 Study Attrition Flowchart ...................................................................................................................... 158

Appendix V ............................................................................................................................................... 159 Data Extraction Elements ...................................................................................................................... 159

Appendix VI.............................................................................................................................................. 160 Judging the Quality of Diagnostic Studies............................................................................................. 160 Judging the Quality of Treatment Studies ............................................................................................. 161

Appendix VII ............................................................................................................................................ 163 Form for Assigning Strength of Recommendation (Interventions) ....................................................... 163

Appendix VIII........................................................................................................................................... 165 Voting by the Nominal Group Technique ............................................................................................. 165

Appendix IX.............................................................................................................................................. 166 Structured Peer Review Form................................................................................................................ 166

Appendix X ............................................................................................................................................... 169 Peer Review Panel ................................................................................................................................. 169 Public Commentary ............................................................................................................................... 169

Appendix XI.............................................................................................................................................. 171 Description of Symbols Used in Tables................................................................................................. 171

Appendix XII ............................................................................................................................................ 172 Conflict of Interest................................................................................................................................. 172

Appendix XIII........................................................................................................................................... 173 References ............................................................................................................................................. 173 Excluded articles after full text review .................................................................................................. 178

xi

List of Tables 324 325

326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368

Table 1 Defining the Strength of the Recommendation ..................................................... 8 Table 2 AAOS Guideline Language ................................................................................... 8 Table 3. Excluded Articles................................................................................................ 14 Table 4. Study Quality ...................................................................................................... 15 Table 5. Sensitivity and specificity of Palpation, Calf Squeeze and Matles tests ............ 16 Table 6. Excluded Articles................................................................................................ 18 Table 7. Study Quality ...................................................................................................... 19 Table 8. Sensitivity and Specificity .................................................................................. 20 Table 9. Operative vs. Cast – Function............................................................................. 22 Table 10. Operative vs. Cast – Pain.................................................................................. 22 Table 11. Operative vs. Cast – Return to Work................................................................ 22 Table 12. Operative vs. Cast - Return to Sport ................................................................ 23 Table 13. Operative vs. Cast - Rerupture.......................................................................... 23 Table 14. Operative vs. Cast - Satisfaction....................................................................... 24 Table 15. Operative vs. Cast – Complications.................................................................. 24 Table 16. Systematic Review Summary ........................................................................... 25 Table 17. Excluded Articles.............................................................................................. 26 Table 18. Study Quality .................................................................................................... 27 Table 19. Open vs. Cast - Function................................................................................... 28 Table 20. Cast vs. Open Repair - Pain .............................................................................. 28 Table 21. Operative vs. Cast - Return to Work................................................................. 30 Table 22. Operative vs. Cast - Return to Sport ................................................................. 31 Table 23. Operative vs. Cast - Rerupture.......................................................................... 31 Table 24 Cast vs. Open - Complications .......................................................................... 32 Table 25. Cast + Functional Brace vs. Cast - Rerupture................................................... 35 Table 26. Summary of Results - Case Series.................................................................... 35 Table 27. Summary of Systematic Reviews ..................................................................... 35 Table 28. Functional Bracing – Satisfaction (VAS) ......................................................... 35 Table 29. Functional Bracing - Satisfaction (%) .............................................................. 36 Table 30. Functional Bracing - Pain ................................................................................. 36 Table 31. Functional Bracing - Function .......................................................................... 36 Table 32. Functional Bracing - Strength........................................................................... 37 Table 33. Functional Bracing - Return to Work and Sports ............................................. 37 Table 34. Functional Bracing - Return to Work and Sports (days) .................................. 37 Table 35. Functional Bracing - Complications ................................................................. 38 Table 36. Functional Bracing - Rerupture ........................................................................ 38 Table 37. Functional Bracing - Excluded Studies ............................................................ 38 Table 38. Study Quality - Randomized Control Trials ..................................................... 39 Table 39. Study Quality - Non-Randomized Comparative Study .................................... 39 Table 40. Study Quality - Case Series .............................................................................. 40 Table 41. Open Repair – All Outcomes............................................................................ 43 Table 42. Open Repair - Return to work........................................................................... 43 Table 43. Open Repair - Activities of daily living............................................................ 44

xii

369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414

Table 44. Open Repair- Mean time until return to athletic activity.................................. 44 Table 45. Open Repair- Percent of patients able to return to activities of daily living .... 45 Table 46. Open Repair- Percent of patients able to return to work .................................. 45 Table 47. Open Repair- Percent of patients able to return to sports ................................. 45 Table 48: Open Repair- Percent of patients with pain..................................................... 46 Table 49. Open Repair- Percent of patients able to complete functional activities.......... 46 Table 50. Open Repair- Percent of patients with excellent satisfaction ........................... 46 Table 51. Minimally Invasive Repair- All outcomes....................................................... 47 Table 52. Minimally Invasive Repair- Percent of Patients able to return to activity........ 47 Table 53. Minimally Invasive Repair - Percent of patients able to return to sports ......... 48 Table 54. Minimally Invasive Repair - Satisfaction ......................................................... 48 Table 55. Minimally Invasive Repair - Mean time until return to activity....................... 48 Table 56. Minimally Invasive Repair-Percent of patients able to return to sports ........... 48 Table 57. Minimally Invasive Repair-Percent of patients able to return to work............. 49 Table 58. Excluded Articles.............................................................................................. 49 Table 59. Study Quality .................................................................................................... 53 Table 60. Percutaneous vs. Open - Global Outcomes ...................................................... 60 Table 61. Percutaneous and Limited Open vs. Open - Return to Activities and Function61 Table 62. Percutaneous vs. Open - Satisfaction............................................................... 61 Table 63. Percutaneous Repair and Limited Open Repair vs. Open - Complications...... 61 Table 64. Percutaneous and Limited Open vs. Open – Rerupture.................................... 62 Table 65. Excluded Studies - All Operative Techniques.................................................. 63 Table 66. Study Quality - RCTs ....................................................................................... 65 Table 67. Quality of Studies - Comparative Studies......................................................... 66 Table 68. Percutaneous vs. Open - Global Outcomes ..................................................... 68 Table 69. Percutaneous vs. Open - Return to Activities ................................................... 68 Table 70. Percutaneous vs. Open - Satisfaction................................................................ 68 Table 71. Percutaneous vs. Open - Complications ........................................................... 68 Table 72. Minimally Invasive vs. Open - Function .......................................................... 69 Table 73. Minimally Invasive vs. Open - Complications ................................................. 69 Table 74. Minimally Invasive vs. Open - Symptoms ....................................................... 70 Table 75. Minimally Invasive vs. Open - Return to Sport................................................ 70 Table 76. Minimally Invasive vs. Open - Complications ................................................. 70 Table 77. Autograft vs. Open - Pain and Stiffness ........................................................... 72 Table 78. Autograft vs. Open - Satisfaction ..................................................................... 72 Table 79. Autograft - Return to Activities and Sports ..................................................... 72 Table 80. Autograft vs. Open - Footwear Restrictions ..................................................... 73 Table 81. Autograft vs. Open - Hospitalization and Immobilization ............................... 73 Table 82. Autograft vs. Open - Complications................................................................. 73 Table 83. Excluded Studies - Allograft............................................................................. 74 Table 84. Excluded Studies - Autograft............................................................................ 74 Table 85. Excluded Studies - Synthetic Tissue................................................................. 75 Table 86- Biologic Adjuncts............................................................................................. 76 Table 87. Study Quality – Autograft RCTs ...................................................................... 77 Table 88. Study Quality - Autograft Comparative Studies.............................................. 78 Table 89. Study Quality - Synthetic Tissue Case Series.................................................. 80

xiii

415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460

Table 90 Autograft vs. Open Pain and Stiffness............................................................... 81 Table 91. Autograft vs. Open - Satisfaction ..................................................................... 81 Table 92. Autograft vs. Open - Return to Sports .............................................................. 82 Table 93. Autograft vs. Open - Return to Activities......................................................... 82 Table 94. Autograft vs. Open - Footwear Restrictions ..................................................... 82 Table 95. Autograft vs. Open - Hospitalization vs. Immobilization................................. 83 Table 96. Autograft vs. Open - Complications................................................................. 83 Table 97. Synthetic Tissue - Results................................................................................. 84 Table 98. Antithrombotic Treatment - Excluded Studies ................................................. 85 Table 99: Description of treatment groups ...................................................................... 87 Table 100 Time until return to activity ............................................................................. 88 Table 101 Pain .................................................................................................................. 88 Table 102 Function ........................................................................................................... 89 Table 103 EuroQoL, Rand-36........................................................................................... 90 Table 104 Patient Subjective Results................................................................................ 90 Table 105 Reruptures........................................................................................................ 90 Table 106 Reported Complications .................................................................................. 91 Table 107 Systematic Reviews ......................................................................................... 91 Table 108 Article Inclusion List- Early weight-bearing vs. non-weight bearing ............. 92 Table 109. Quality- Weight-bearing vs. non-weight bearing ........................................... 93 Table 110 Study Data: Weight Bearing vs. Non-Weight Bearing.................................... 98 Table 111. Description of Treatment Groups ................................................................. 103 Table 112. Time to Return to Activity............................................................................ 103 Table 113. Pain .............................................................................................................. 105 Table 114. Function ........................................................................................................ 105 Table 115. EuroQoL, E5D, Ankle Performance Score................................................... 106 Table 116. Patient opinion of results .............................................................................. 107 Table 117. Footwear restrictions..................................................................................... 108 Table 118. Re-rupture ..................................................................................................... 108 Table 119. Early Motion vs. Cast - Complications......................................................... 109 Table 120. Systematic Reviews ...................................................................................... 109 Table 121. Mobilization vs. Immobilization Included Articles...................................... 111 Table 122. Mobilization vs. Immobilization Quality...................................................... 112 Table 123. Mobilization vs. Immobilization Study Data................................................ 117 Table 124. Post Operative Physiotherapy Regiments.................................................... 122 Table 125. Excluded Articles.......................................................................................... 123 Table 126. Non-Operative treatment - Percent of patients able to return to work.......... 124 Table 127. Non-Operative Treatment -Percent of patients able to return to ADL ......... 125 Table 128. Operative Treatment - Percent of patients returning to ADL ....................... 125 Table 129. Operative Treatment - Percent of patients able to return to work ................ 126 Table 130. Non-Operative Treatment - Mean time until return to work ........................ 128 Table 131. Non-Operative Treatment - Mean time until return to walking.................... 128 Table 132. Operative Treatment - Mean time to return to ADL..................................... 129 Table 133. Operative Treatment - Mean time until return to work ................................ 130 Table 134. Excluded Articles.......................................................................................... 131 Table 135. Patient return to activities of daily living...................................................... 133

xiv

xv

461 462 463 464 465 466 467 468 469 470 471

Table 136. Operative Treatment - Return to Recreational Activity................................ 137 Table 137. Operative Treatment - Return to sports ........................................................ 137 Table 138. Operative Treatment - Mean time to return to athletic activity .................... 139 Table 139. Excluded Articles.......................................................................................... 139 Table 140. Return to sports............................................................................................. 141 Table 141. Non-Operative Treatment - Percent of patients returning to athletic activity......................................................................................................................................... 146 Table 142. Non-Operative Treatment - Mean time until patients return to athletic activity......................................................................................................................................... 147 Table 143. Excluded studies ........................................................................................... 148 Table 144. Study Quality ................................................................................................ 148

I. INTRODUCTION 472

473 474 475 476 477 478 479

480 481 482 483

484 485 486 487 488 489 490 491 492 493 494 495

496 497 498 499 500 501 502 503

504 505 506 507 508 509 510 511 512 513

OVERVIEW This clinical practice guideline is based on a systematic review of published studies on the treatment of acute Achilles tendon rupture in adults. Adults were defined as older than 19 years of age for this guideline. Acute Achilles tendon ruptures are defined as those treated within the first six weeks of injury. In addition to providing practice recommendations, this guideline also highlights gaps in the literature and areas that require future research.

This guideline is intended to be used by all appropriately trained surgeons and all qualified physicians diagnosing and treating Achilles tendon ruptures. It is also intended to serve as an information resource for decision makers and developers of practice guidelines and recommendations.

GOALS AND RATIONALE The purpose of this clinical practice guideline is to help improve treatment based on the current best evidence. Current evidence-based practice (EBP) standards demand that physicians use the best available evidence in their clinical decision making. To assist in this, this clinical practice guideline consists of a systematic review of the available literature regarding the treatment of Achilles tendon ruptures. The systematic review detailed herein was conducted between December 2008 and June 2009 and demonstrates where there is good evidence, where evidence is lacking, and what topics future research must target in order to improve the treatment of patients with acute Achilles tendon ruptures. AAOS staff and the physician work group systematically reviewed the available literature and subsequently wrote the following recommendations based on a rigorous, standardized process.

Musculoskeletal care is provided in many different settings by many different providers. We created this guideline as an educational tool to guide qualified physicians through a series of treatment decisions in an effort to improve the quality and efficiency of care. This guideline should not be construed as including all proper methods of care or excluding methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment must be made in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.

INTENDED USERS This guideline is intended to be used by orthopaedic surgeons and all qualified physicians managing patients with acute Achilles tendon rupture. Typically, orthopaedic surgeons will have completed medical training, a qualified residency in orthopaedic surgery, and some may have completed additional sub-specialty training. It is also intended to serve as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. Diagnosis and treatment for patients with acute Achilles tendon rupture are based on the assumption that decisions are predicated on patient and physician mutual communication including discussion of available treatments and procedures applicable to the individual patient. Once the patient has been informed of

AAOS Guideline Unit v0.3 10.12.09 1

514 515 516 517

518 519 520

521 522 523 524 525

526 527 528 529

530 531 532

533 534 535

536 537 538 539 540 541 542 543 544

546 547 548 549 550 551 552 553

available therapies and has discussed these options with his/her physician, an informed decision can be made. Clinician input based on experience with both conservative management and surgical skills increases the probability of identifying patients who will benefit from specific treatment options.

PATIENT POPULATION This document addresses the diagnosis and treatment of acute Achilles tendon rupture in adults (defined as patients 19 years of age and older).

INCIDENCE The incidence of Achilles tendon ruptures has been estimated to range from an annual average of 5.5 ruptures to 9.9 ruptures per 100,000 people in North America (Edmonton, Canada).1 Studies of European communities report comparable values ranging from 6 to 18 ruptures per 100,000 people.1-4

BURDEN OF DISEASE Those afflicted with an acute Achilles tendon rupture face a healing period that requires time away from work and limited athletic activity. Time away from work may impact the patient financially and limiting activity may impact the patient’s health.5

ETIOLOGY Most acute Achilles tendon ruptures are traumatic in origin. Some studies have shown that ruptured Achilles tendons have occult degeneration.3

RISK FACTORS Most ruptures of the Achilles tendons occur during sports activities, are more common in males in the third or fourth decade of life, and occur more frequently on the left side.1

EMOTIONAL AND PHYSICAL IMPACT OF ACHILLES TENDON RUPTURE Acute Achilles tendon rupture often results in sudden pain in the affected leg, the inability to bear weight and noticeable weakness of the affected ankle.3 The injury often results in the patient’s inability to walk or perform their regular activities of daily living. Patients face possible deformity if the tendon does not heal correctly and a substantial recovery period. Possible complications associated with Achilles tendon rupture include rerupture and, in cases of surgical repair, infection. POTENTIAL BENEFITS, HARMS, AND CONTRAINDICATIONS 545 The aim of treatment is pain relief and improvement or maintenance of the patient’s functional status. Long term results were often not available and complications varied by study (frequently they were not reported) in the literature available for this guideline. Most treatments are associated with some known risks, especially invasive and operative treatments. In addition, contraindications vary widely based on the treatment administered. Therefore, discussion of available treatments and procedures applicable to the individual patient rely on mutual communication between the patient and physician, weighing the potential risks and benefits for that patient.


II. METHODS 554

555 556 557 558 559 560

561 562 563 564 565 566 567 568

569 570 571 572 573 574 575 576 577 578 579

580 581 582 583 584 585 586

587 588 589 590 591 592 593 594

Each recommendation in this clinical practice guideline is based on a systematic review of the relevant medical literature. We developed systematic reviews for this guideline because these reviews employ specific processes designed to minimize bias in the selection, summary, and analysis of this literature.6, 7 In referring to bias, we explicitly mean both the biases that can arise from financial conflicts of interest and biases that can arise from intellectual conflicts if interest.

This section of the present document describes how we conducted our systematic reviews and how the guideline was developed. Accordingly, in this section we describe our strategies for finding relevant literature, our criteria for selecting articles to include in this guideline, how we extracted data, how we appraised and graded the evidence, our methods of statistical analysis, and the review and approval steps this guideline went through. Elsewhere in this document, we provide extensive documentation so that interested readers can assure themselves that we attempted to combat bias wherever possible.

This guideline and the underlying systematic reviews were prepared by an AAOS physician work group with the assistance of the AAOS Clinical Practice Guidelines Unit in the Department of Research and Scientific Affairs at the AAOS (Appendix I). The work group met on December 13, 2008 to establish the guideline’s scope. The work group met again on July 31 and August 1, 2009 to write and vote on the final recommendations and rationales for each recommendation. The resulting draft guidelines were then peer-reviewed, subsequently sent for public commentary, and then sequentially approved by the AAOS Evidence Based Practice Committee, AAOS Guidelines and Technology Oversight Committee, AAOS Council on Research, Quality Assessment, and Technology, and the AAOS Board of Directors (see Appendix II for a description of the AAOS bodies involved in the approval process)

FORMULATING PRELIMINARY RECOMMENDATIONS The work group began work on this guideline by constructing a set of preliminary recommendations. These recommendations specify [what] should be done in [whom], [when], [where], and [how often or how long]. They function as questions for the systematic review that underpins each preliminary recommendation, and they do not function as final recommendations or conclusions. Preliminary recommendations do not need to be true.

Once established, these a priori preliminary recommendations cannot be modified until the final work group meeting. The a priori and inviolate nature of the preliminary recommendations combats bias by preventing a “change in course” if a systematic review yields results that are not to someone’s liking. The results of each systematic review are presented and discussed at the final work group meeting. At this time the preliminary recommendations are modified in response to the evidence in the systematic review. All of the systematic reviews conducted for a given guideline are presented in it and, in general, all preliminary recommendations are modified.


STUDY INCLUSION CRITERIA 595

601 602 603

604 605

606

607

608 609 610

611 612

613

614 615

616

617 618

619 620

621 622 623 624 625 626

627 628 629 630 631

We developed a priori article inclusion criteria for our review. These criteria are our 596 “rules of evidence” and articles that do not meet them are, for the purposes of this 597 guideline, not evidence. 598

To be included in our systematic reviews (and hence, in this guideline) an article had to 599 be a report of a study that: 600

• Evaluated a treatment for acute Achilles tendon rupture. Acute Achilles tendon rupture is defined as a rupture treated within zero to six weeks post injury.

• Was a full report of a clinical study and was published in the peer reviewed literature

• Was an English language article published after 1965

• Was not a cadaveric, animal, in vitro, or biomechanical study

• Was not a retrospective case series, medical records review, meeting abstract, unpublished study report, case report, historical article, editorial, letter, or commentary

• Was the most recent report of a study or the report with the largest number of enrolled patients in a study with multiple publications

• Enrolled ≥ 10 patients in each of its study groups

• Enrolled a patient population comprised of at least 80% of patients with acute Achilles tendon rupture

• Reported quantified results

• Must have followed 50% or more of its patients on at least one outcome; if less than 80% follow up the outcome was down graded.

• Study must use validated outcome measures

When considering studies for inclusion, we included only the best available evidence. Accordingly, we first included Level I evidence. In the absence of two or more studies of this Level, we sequentially searched for and included Level II through Level IV evidence, and did not proceed to a lower level if there were two or more studies of a higher level. For example, if there were two Level II studies that addressed a recommendation, we did not include Level III or IV studies.

OUTCOMES CONSIDERED Clinical studies often report many different outcomes. We included only patient-oriented outcomes when they were available. As the term implies, patient-oriented outcomes are outcomes that matter to the patient. “They tell clinicians, directly and without the need for extrapolation, that a diagnostic, therapeutic, or preventive procedure helps patients


live longer or live better.”8 Examples of patient-oriented outcomes include pain and quality of life.

632 633

634 635 636 637

638 639 640 641 642 643 644 645 646

647 648 649 650 651

652 653 654 655

656 657 658 659 660

661 662 663 664 665

666 667 668

We included surrogate outcomes only when patient-oriented outcomes were not available. Surrogate outcomes are laboratory or other measurements that are used as substitutes for how a patient feels, functions, or survives.9 Radiographic results are an example of a surrogate outcome.

We only included data for an outcome if ≥ 50% of the patients were followed for that outcome. For example, some studies report short-term outcomes data on nearly all enrolled patients, and report longer-term data on less than half of the enrolled patients. In such cases, we did not include the longer-term data. Additionally, we downgraded the Level of Evidence by one in instances where 50% to ≤80% of patients were followed. For example, if an otherwise perfect randomized controlled trial reported data on all enrolled patients one week after patients received a treatment but reported data on only 60% of patients one year later, we considered data from the later follow-up time as Level II evidence.

We only included data for outcomes reporting the average length of time to return to an activity if >80 % of the patients were included in the calculation. For example, some studies report the mean time for return to work as 6 weeks but are only including data for patients who have actually returned to work and are ignoring patients who are unable to return. An outcome such as this would not be included.

LITERATURE SEARCHES We attempted to make our searches for articles comprehensive. Using comprehensive literature searches ensures that the evidence we considered for this guideline is not biased for (or against) any particular point of view.

We searched for articles published from January 1966 to June 2009. Strategies for searching electronic databases were constructed by a Medical Librarian and reviewed by the work group. The search strategies we used are provided in Appendix III. We searched six electronic databases; PubMed, EMBASE, CINAHL, The Cochrane Library, The National Guidelines Clearinghouse and TRIP database.

All searches of electronic databases were supplemented with manual screening of bibliographies of all retrieved publications. We also searched the bibliographies of recent systematic reviews and other review articles for potentially relevant citations. Finally, a list of potentially relevant studies not identified by our searches was provided by the work group members. Fifty-six studies met the inclusion criteria and were included.

A study attrition diagram (provided in Appendix IV) documents, for each recommendation, the number of articles we identified, where we identified these articles, the number of articles we included, and the number of articles we excluded.


DATA EXTRACTION 669 670 671 672 673 674

675 676 677 678

679 680 681 682 683

684 685 686 687

688 689 690 691 692 693 694 695

696 697 698 699 700 701 702 703 704 705

706 707 708 709

Data elements extracted from studies were defined in consultation with the physician work group. Two analysts completed data extraction independently for all studies. The evidence tables were audited by the work group. Disagreements about the accuracy of extracted data were resolved by consensus. The elements extracted are provided in Appendix V.

The use of extracted data in our systematic reviews is another of our methods to combat bias. It ensures that our results are based on the numerical results reported in published articles and not on the authors’ conclusions in the “Discussion Sections” of their articles. Such author conclusions can be influenced by bias.

JUDGING THE QUALITY OF EVIDENCE Determining the quality of the included evidence is vitally important when preparing any evidence-based work product. Doing so conveys the amount of confidence one can have in any study’s results. One has more confidence in high quality evidence than in low quality evidence.

We assessed the quality of the evidence for each outcome at each time point reported in a study. We did not simply assess the overall quality of a study. Our approach follows the recommendations of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) working group10 as well as others.11

We evaluated quality on a per outcome basis rather than a per study basis because quality is not necessarily the same for all outcomes and all follow-up times reported in a study. For example, a study might report results immediately after patients received a given treatment and after some period of time has passed. Often, nearly all enrolled patients contribute data at early follow-up times but, at much later follow-up times, only a few patients may contribute data. One has more confidence in the earlier data than in the later data. The fact that we would assign a higher quality score to the earlier results reflects this difference in confidence.

We assessed the quality of treatment studies using a two step process. First, we assigned a Level of Evidence to all results reported in a study based solely on that study’s design. Accordingly, all data presented in randomized controlled trials were initially categorized as Level I evidence, all results presented in non-randomized controlled trials and other prospective comparative studies were initially categorized as Level II, all results presented in retrospective comparative and case-control studies were initially categorized as Level III, and all results presented in case-series reports were initially categorized as Level IV. We next assessed each outcome at each reported time point using a quality questionnaire and, when quality standards were not met, downgraded the Level of evidence (for this outcome at this time point) by one level (Appendix VI).

In studies investigating a diagnostic test, we used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) instrument to identify potential bias and assess variability and the quality of reporting in studies reporting the effectiveness of diagnostic techniques. We utilized a two step process to assess the quality of diagnostic studies. All


studies enrolling a prospective cohort of patients are initially categorized as Level I studies. Any study that did not enroll the appropriate spectrum of patients (e.g. case-control studies) was initially categorized as a Level IV study. A study that we determined contained methodological flaws (i.e. QUADAS question answered ‘no’) that introduce bias were downgraded in a cumulative manner for each known bias (

710 711 712 713 714 715 716 717 718 719

720 721 722 723 724 725 726

727 728 729 730 731 732 733 734

735 736 737 738 739 740 741 742 743

744 745 746 747 748 749 750 751

Appendix VI). For example, a study that is determined by the QUADAS instrument to have two biases is downgraded to Level III and a study that is determined to have four or more biases is downgraded to a Level V study. Those studies that do not sufficiently report their methods for a potential bias are downgraded to Level II since we are unable to determine if the bias did or did not bias the results of the study.

Assigning a Level of Evidence on the basis of study design plus other quality characteristics ties the Levels of Evidence we report more closely to quality than Levels of Evidence based only on study design. Because we tie quality to Levels of Evidence, we are able to characterize the confidence one can have in their results. Accordingly, we characterize the confidence one can have in Level I evidence as high, the confidence one can have in Level II and III evidence as moderate, and the confidence one can have in Level IV and V evidence as low.

DEFINING THE STRENGTH OF THE RECOMMENDATIONS Judging the quality of evidence is only a stepping stone towards arriving at the strength of the guideline recommendation. Unlike Levels of Evidence (which apply only to a given result at a given follow-up time in a given study) strength of the recommendation takes into account the quality, quantity, and applicability of the available evidence. Strength of the recommendation also takes into account the trade-off between the benefits and harms of a treatment or diagnostic procedure, and the magnitude of a treatment’s effect.

The strength of a recommendation expresses the degree of confidence one can have in a recommendation. As such, the strength expresses how possible it is that a recommendation will be overturned by future evidence. It is very difficult for future evidence to overturn a recommendation that is based on many high quality randomized controlled trials that show a large effect. It is much more likely that future evidence will overturn recommendations derived from a few small case series. Consequently, recommendations based on the former kind of evidence are rated as “strong” and recommendations based on the latter kind of evidence are given strength of recommendation of “weak”.

To develop the strength of a recommendation, AAOS staff first assigned a preliminary strength rating for each recommendation that took only the quality and quantity of the available evidence into account (see Table 1). Work group members then modified the preliminary strength rating using the ‘Form for Assigning Grade of Recommendation (Interventions)’ shown in Appendix VII. This form is based on recommendations of the GRADE Working group10 and requires the work group to consider the harms, benefits, and critical outcomes associated with a treatment. It also requires the work group to evaluate the applicability of the evidence. The final strength of the recommendation is


assigned by the physician work group, which modifies the preliminary strength rating on the basis of these considerations.

752 753

754 Table 1 Defining the Strength of the Recommendation

Strength Overall

Quality of Evidence

Description of Evidence

Strong Good Quality Evidence

Level I evidence from more than one study with consistent findings for recommending for or against the intervention or diagnostic.

Moderate Fair Quality Evidence

Level II or III evidence from more than one study with consistent findings, or Level I evidence from a single study for recommending for or against the intervention or diagnostic.

Weak Poor Quality Evidence

Level IV or V evidence from more than one study with consistent findings, or Level II or III evidence from a single study for recommending for against the intervention or diagnostic.

Inconclusive No Evidence or Conflicting

Evidence

The evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention or diagnostic.

Consensus There is no supporting evidence. In the absence of reliable evidence, the work group is making a recommendation based on their clinical opinion considering the known harms and benefits associated with the treatment.

No Evidence

755 756 757 758

759

Each recommendation was written using language that accounts for the final strength of the recommendation. This language, and the corresponding strength of recommendation, is shown in Table 2.

Table 2 AAOS Guideline Language Strength of

Recommendation Guideline Language

We recommend Strong

We suggest Moderate

Is an option Weak

We are unable to recommend for or against Inconclusive In the absence of reliable evidence, it is the

opinion of this work group Consensus

760 761 762 763 764 765 766

CONSENSUS DEVELOPMENT The recommendations and their strength were voted on using a structured voting technique known as the nominal group technique.12 We present details of this technique in Appendix VIII. Voting on guideline recommendations was conducted using a secret ballot and work group members were blinded to the responses of other members. If disagreement between work group members was significant, there was further discussion


767 768 769 770

771 772 773 774 775 776 777 778 779

780 781 782 783 784 785 786 787

788 789

790 791

792 793 794 795 796

797 798 799 800

801 802 803 804 805

to see whether the disagreement(s) could be resolved. Up to three rounds of voting were held to attempt to resolve disagreements. If disagreements were not resolved following three voting rounds, no recommendation was adopted. Lack of agreement is a reason that the strength for some recommendations is labeled “Inconclusive.”

STATISTICAL METHODS When possible, we report the results of the statistical analyses conducted by the authors of the included studies. In some circumstances, statistical testing was not conducted; however, the authors reported sufficient quantitative data, including measures of dispersion or patient level data for statistical testing. In these circumstances we used the statistical program STATA (StatCorp LP, College Station, Texas) to conduct our own analysis to interpret the results of a study. P-values < 0.05 were considered statistically significant. Any statistical analysis conducted by the AAOS authors is denoted in the tables.

STATA was also used to determine 95% confidence intervals, using the method of Wilson, when authors of the included studies reported counts or proportions. The program was also used to determine the magnitude of the treatment effect. For data reported as means (and associated measures of dispersion) we calculated a standardized mean difference by the method of Hedges and Olkin.13 For proportions, we calculated the odds ratio as a measure of treatment effect. When no events occur (“zero event”) in a proportion, the variance of the arcsine difference was used to determine statistical significance (p < 0.05).14

We used the program TechDig 2.0 (Ronald B. Jones, Mundelein, Illinois) to estimate means and variances from studies presenting data only in graphical form.

When published studies only reported the median, range, and size of the trial, we estimated their means and variances according to a published method.15

PEER REVIEW The draft of the guideline and evidence report were peer reviewed by outside specialty organizations that were nominated by the physician work group prior to the development of the guideline. Peer review was accomplished using a structured peer review form (Appendix IX).

In addition, the physician members of the AAOS Guidelines and Technology Oversight Committee, the Evidence Based Practice Committee and the Chairpersons of the AAOS Occupational Health and Workers’ Compensation Committee and the Medical Liability Committee were given the opportunity to provide peer review of the draft document.

We forwarded the draft guideline to a total of 38 peer reviewers and 17 returned reviews. The disposition of all non-editorial peer review comments was documented and the guideline was modified in response to peer review. The peer reviews and the responses to them accompanied this guideline through the process of public commentary and the subsequent approval process. Peer reviewing organizations and peer reviewing


individuals are listed in this document if they explicitly agree to allow us to publish this information (

806 807

808 809 810 811 812 813 814 815 816

817 818 819 820 821 822 823

Appendix X).

Peer review of an AAOS guideline does not imply endorsement. This is clearly stated on the structured review form sent to all peer reviewers and is also posted within the guideline. Endorsement cannot be solicited during the peer review process because the documents may still undergo substantial change as a result of both the peer review and public commentary processes. In addition, no guideline can be endorsed by specialty societies outside of the Academy until the AAOS Board of Directors has approved it. Organizations that provide members who participate on the work group or peer review of a draft guideline will be solicited for endorsement once the document has completed the full review and approval processes.

PUBLIC COMMENTARY After modifying the draft in response to peer review, the guideline was submitted for a thirty day period of “Public Commentary.” Commentators consist of members of the AAOS Board of Directors (BOD), members of the Council on Research, Quality Assessment, and Technology (CORQAT), members of the Board of Councilors (BOC), and members of the Board of Specialty Societies (BOS). Based on these bodies, up to 185 commentators had the opportunity to provide input into the development of this guideline. Of these, XX returned public comments. 824

825 826 827 828 829 830 831 832

833 834 835 836 837 838

839 840 841 842

THE AAOS GUIDELINE APPROVAL PROCESS In response to the non-editorial comments submitted during the period of public commentary, the draft was again modified by the AAOS Clinical Practice Guidelines Unit and physician work group members. The AAOS Guidelines and Technology Oversight Committee, the AAOS Evidence-based Practice Committee, the AAOS Council on Research, Quality Assessment, and Technology, and the AAOS Board of Directors approved the final guideline draft. Descriptions of these bodies are provided in Appendix II

REVISION PLANS This guideline represents a cross-sectional view of current treatment and/or diagnosis and may become outdated as new evidence becomes available. This guideline will be revised in accordance with this new evidence, changing practice, rapidly emerging treatment options, and new technology. This guideline will be updated or withdrawn in five years in accordance with the standards of the National Guideline Clearinghouse.

GUIDELINE DISSEMINATION PLANS The primary purpose of the present document is to provide interested readers with full documentation about not only our recommendations, but also about how we arrived at those recommendations. This document is also posted on the AAOS website at http://www.aaos.org/research/guidelines/guide.asp. 843

844 845 846

Shorter versions of the guideline are available in other venues. Publication of most guidelines is announced by an Academy press release, articles authored by the work group and published in the Journal of the American Academy of Orthopaedic Surgeons,


http://www.aaos.org/research/guidelines/guide.asp

and articles published in AAOS Now. Most guidelines are also distributed at the AAOS Annual Meeting in various venues such as on Academy Row and at Committee Scientific Exhibits.

847 848 849

854 855 856

Selected guidelines are disseminated by webinar, an Online Module for the Orthopeadic 850 Knowledge Online website, Radio Media Tours, Media Briefings, and by distributing 851 them at relevant Continuing Medical Education (CME) courses and at the AAOS 852 Resource Center. 853

Other dissemination efforts outside the AAOS include submitting the guideline to the National Guideline Clearinghouse and distributing the guideline at other medical specialty societies’ meetings.


III. RECOMMENDATIONS AND SUPPORTING EVIDENCE 857


858

863 864 865 866 867 868 869 870 871 872 873 874 875

876 877 878 879 880

881

882 883

884 885 886 887 888 889 890 891 892 893

894 895 896 897 898

RECOMMENDATION 1 859 In the absence of the reliable evidence, it is the opinion of this work group that a detailed 860 history and physical exam be performed. The physical examination should include two 861 or more of the following tests to establish the diagnosis of acute Achilles tendon rupture: 862

o Clinical Thompson test (Simmonds squeeze test) o Decreased ankle plantar flexion strength o Presence of a palpable gap (defect, loss of contour) o Increased passive ankle dorsiflexion with gentle manipulation

Strength of Recommendation - Consensus Rationale: A systematic review of the literature did not identify adequate evidence for or against the use of specific history and physical examination findings to confirm the diagnosis of acute Achilles tendon rupture. There was only one level V study16 identified that did not provide adequate data in support of any individual or combination of the physical tests.

The prompt and accurate diagnosis of acute Achilles tendon rupture is essential to providing patients with timely, effective, and appropriate care. A history and physical examination adds no cost or risk to patients. The work group therefore agreed that an opinion-based recommendation is warranted.

Supporting Evidence:

One Level V prospective study that enrolled patients with unilateral complete Achilles tendon tears was included.16

SUMMARY OF EVIDENCE The study16 used visual inspection at surgery as the gold standard for the diagnosis in patients who had open repair. The study author also used clinical exam, ultrasound and MRI as the reference standard for diagnosis when deciphering if patients had an Achilles tendon tear and to confirm the extent of the tear in patients treated non-operatively. Healthcare providers were not routinely blinded to the results of any given test. All patients received a physical examination; palpation (presence of a gap) and the calf squeeze test (Thompson/Simmonds squeeze test) were performed by the author in all patients. The author performed the Matles test (increased passive ankle dorsiflexion) on 107 of 174 patients.

The study author reported sensitivities and specificities for the tests based on the 133 patients treated with open repair and the 28 patients treated who did not have an Achilles tendon rupture. The author reported these test results individually. He did not consider if incremental value exists for any combination of the given physical tests when the tests are all performed during the physical examination.



899 900

EXCLUDED ARTICLES Table 3. Excluded Articles

Author Title Exclusion Reason

Copeland SA; Rupture of the Achilles tendon: a new clinical test Not relevant

Matles AL Rupture of the tendo achilles: another diagnostic sign Commentary

STUDY QUALITY 901 902 Table 4. Study Quality

● = Yes ○ = No X = Not Reported n/a = not applicable

Author N

Spec

trum

bia

s avo

ided

Sele

ctio

n cr

iteria

des

crib

ed

App

ropr

iate

refe

renc

e st

anda

rd

Dis

ease

pro

gres

sion

bia

s avo

ided

Parti

al v

erifi

catio

n bi

as a

void

ed

Diff

eren

tial v

erifi

catio

n bi

as a

void

ed

Inco

rpor

atio

n bi

as a

void

ed

Inde

x te

st e

xecu

tion

desc

ribed

Ref

eren

ce st

anda

rd e

xecu

tion

desc

ribed

Test

revi

ew b

ias a

void

ed

Dia

gnos

tic re

view

bia

s avo

ided

Clin

ical

revi

ew b

ias a

void

ed

Uni

nter

rupt

able

/Inte

rmed

iate

test

re

sult(

s) re

porte

d

Reference Standard Index Test

With

draw

als e

xpla

ined

Maffulli 161 Palpation

Open Repair,Ultrasound or MRI or Clinical tests

X ○ ● ● ● ○ ● ● ● ● ○ ● ● ●

Maffulli 161

Calf Squeeze Test (Thompson test/Simmonds squeeze test)

Open Repair, Ultrasound or MRI or Clinical tests

X ○ ● ● ● ○ ● ● ● ● ○ ● ● ●

Maffulli 105

Matles Test (increased passive ankle dorsiflexion)

Open Repair, Ultrasound or MRI or Clinical tests

X ○ ● ● ● ○ ● ● ● ● ○ ● ● ○


903

904 905

STUDY RESULTS Table 5. Sensitivity and specificity of Palpation, Calf Squeeze and Matles tests

Author N Test Sensitivity‡ (95% CI)

Specificity‡ (95% CI)

Maffulli 161 Palpation (presence of a gap)

0.73 (0.65, 0.80)

0.89 (0.72, 0.98)

Maffulli 161 Calf Squeeze Test (Thompson test /

Simmonds squeeze test)

0.96 (0.91, 0.99)

0.93 (0.76, 0.99)

Maffulli 105 Matles Test (increased passive ankle dorsiflexion)

0.88 (0.79, 0.95)

0.86 (0.67, 0.96)

906 ‡ AAOS Calculation


907 908 909 910 911 912 913 914 915 916 917 918 919 920 921 922 923 924 925

926 927 928 929 930 931

932 933 934 935 936 937

938

RECOMMENDATION 2 We are unable to recommend for or against the routine use of magnetic resonance imaging (MRI), ultrasound (ultrasonography), and radiograph (roentgengrams, x-rays) to confirm the diagnosis of acute Achilles tendon rupture.

Strength of Recommendation – Inconclusive Rationale:

A systematic review of the literature failed to identify adequate evidence to make a recommendation for or against the routine use of MRI, ultrasound, or radiographs to confirm the diagnosis of acute Achilles tendon rupture. There were no studies that address MRI or radiographs as confirmatory tests and there were only two level V studies16, 17 that addressed ultrasound. These two studies contain unreliable data and cannot be combined to provide adequate evidence.


No studies were identified to adequately answer this recommendation. To answer this recommendation the ideal study must investigate the incremental benefit added by one of the specified technologies (MRI, Ultrasound or plain radiograph). We found no studies that addressed MRI or plain radiographs as a confirmatory test. Studies were found that addressed ultrasound but they did not adequately address the recommendation using the necessary study design.

The ideal study design required to address this recommendation compares two groups of patients. Group one patients undergo the Thompson test and then surgery (gold standard). Group two patients undergo the Thompson test and the test of interest (MRI, ultrasound, or plain radiographs) and then surgery. Sensitivity, specificity and likelihood ratios would be calculated and compared between groups to determine the incremental benefit added by the technology. No study included both of the groups.



939 940 941 942 943 944 945

946 947

SUMMARY OF EVIDENCE Two Level V prospective studies that enrolled patients with complete Achilles tendon tears were found.16, 17 The studies used visual inspection at surgery as the gold standard for the diagnosis. One study had patients that underwent the Thompson test and then surgery. Patients in the second study underwent the Thompson test and Ultrasound and then surgery. The authors of the studies reported sensitivities and specificities or provided enough information for these parameters to be determined.



Fornage, 1986 Achilles tendon: US examination Less than 10 patients per group

Haims, et al. 2000

MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic

individuals

Does not investigate the diagnostic test

Hartgerink, et al. 2001

Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26

cases with surgical correlation

Retrospective Chart Review

Hollenberg, et al. 2000

Sonographic appearance of nonoperatively treated Achilles tendon ruptures

Does not investigate the diagnostic test

Kabbani, et al. 1993

Magnetic resonance imaging of tendon pathology about the foot and ankle. Part I. Achilles tendon Commentary

Kalebo, et al. 1992

Diagnostic value of ultrasonography in partial ruptures of the Achilles tendon

Chronic/neglected Achilles tendon rupture

Kayser, et al. 2005

Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound

imaging Partial Rupture

Kuwada, 2008 Surgical correlation of preoperative MRI findings of

trauma to tendons and ligaments of the foot and ankle

Less than 10 patients per group

Lehtinen, et al. 1994

Sonography of Achilles tendon correlated to operative findings

Chronic/neglected Achilles tendon rupture

Marshall, et al. 2002

Contrast-enhanced magic-angle MR imaging of the Achilles tendon


Mathieson, et al. 1988

Sonography of the Achilles tendon and adjacent bursae


Paavola, et al. 1998

Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. A

comparison between pre-operative ultrasonography and surgical findings

Retrospective Chart Review

948 949 950

STUDY QUALITY 951 952 953

Table 7. Study Quality

● = Yes ○ = No X = Not Reported n/a = not applicable

Author N

Uni

nter

rupt

able

/Inte

rmed

iate

test

resu

lt(s)

re

porte

d

Spec

trum

bia

s avo

ided

Sele

ctio

n cr

iteria

des

crib

ed

App

ropr

iate

refe

renc

e st

anda

rd

Dis

ease

pro

gres

sion

bia

s avo

ided

Parti

al v

erifi

catio

n bi

as a

void

ed

Diff

eren

tial v

erifi

catio

n bi

as a

void

ed

Inco

rpor

atio

n bi

as a

void

ed

Inde

x te

st e

xecu

tion

desc

ribed

Ref

eren

ce st

anda

rd e

xecu

tion

desc

ribed

Test

revi

ew b

ias a

void

ed

Dia

gnos

tic re

view

bia

s avo

ided

Clin

ical

revi

ew b

ias

avoi

ded

Reference Standard Index Test

With

draw

als

expl

aine

d

Maffulli 161

Calf Squeeze Test (Thompson test/Simmonds squeeze test)

Open Repair X ○ ● ● ● ○ ● ● ● ● ○ ● ● ●

Margetic 88

Calf Squeeze Test (Thompson test/Simmonds squeeze test) plus Ultrasound

Surgery X ○ ● ● ● ○ ● ● ● ○ ○ ● ● ○


STUDY RESULTS 954 955 Table 8. Sensitivity and Specificity

Author N Test Sensitivity (95% CI)

Specificity (95% CI)

Maffulli 161 Calf Squeeze Test (Thompson test /

Simmonds squeeze test)

0.96 (0.91, 0.99)

0.93 (0.76, 0.99)

Margetic et. al. 88

Calf Squeeze Test (Thompson test /

Simmonds squeeze test) plus ultrasound

0.91 (0.83, 0.96)

1.00 (0.16, 1.00)


956 957 958 959 960 961 962 963 964 965 966 967

968 969 970 971 972 973

974 975 976 977

978 979 980

981 982 983

984

985 986 987 988

989 990 991 992 993 994 995

RECOMMENDATION 3 Non-operative treatment is an option for patients with acute Achilles tendon rupture. Strength of Recommendation: Weak Rationale: A systematic review of non-operative treatment compared to operative treatment of acute Achilles tendon ruptures identified four level II studies including all operative techniques.18-21 Three studies included standard open treatment and one included a minimally invasive technique. Increased complications were noted in the open operative group.

When the outcomes of open and minimally invasive techniques were considered separately, the preliminary strength of recommendation was moderate. The group agreed that it was important to evaluate both functional outcomes and complications comparing non-operative and all operative treatment groups. When these heterogeneous groups were separated into non-operative and operative (including minimally invasive) treatments, the strength of recommendation was downgraded to weak.

The functional outcomes were favorable in the operative group in 1 of 2 level II studies and the return to activity and sport in 1 of 3 level II studies. Only 1 of 4 studies demonstrated improvement in the rerupture rate in the operative group. The remainder of the studies demonstrated no difference between the groups.

Higher complication rates, primarily due to impaired wound healing in the operative group, demonstrate the importance of awareness of surgical risk factors in the decision making of operative versus non-operative treatment (see Recommendation 6).

With acceptable functional results and lower complication rates than operative treatment, non-operative treatment of acute Achilles tendon ruptures is an option in all patients, especially those with increased surgical risk factors.


To address this recommendation, we analyzed studies that made two different comparisons. Three level II studies compared patients treated non-operatively (with casting) to patients treated with open repair and one level II study compared casting to minimally invasive open repair.18-21

Two studies examined functional outcomes and both found non-significant results (Table 9). Based on AAOS calculations, one of these studies did have significant results at two, three, and six months measured by the Musculoskeletal Functional Assessment Index (MFAI) in which patients with operative treatment had better functional ability than those treated non-operatively; our results differ from the authors because a higher powered statistical test was used. Two studies reported no significant difference in the number of patients with pain (see Table 10).


Three studies reported patients treated non-operatively did not significantly differ in the amount of time to return to work (see

996 997 998 999

1000 1001 1002 1003 1004 1005 1006 1007

Table 11). Three studies examined return to sports and one reported significant results in favor of patients treated with operative repair (see Table 12). One study reported significantly less reruptures in patients treated operatively (see Table 13).The occurrence of extreme residual tendon lengthening, DVT, and “major” complications were not significantly different between patients treated operatively or non-operatively. Minor complications reported in the included studies were related to the surgical intervention and therefore occurred less in patients treated non-operatively (see Table 15). SUMMARY OF EVIDENCE Table 9. Operative vs. Cast – Function

Duration (Months) Author Comparison Outcome LOE N 2

weeks 2 3 6 12

Twaddle Open vs. Cast MFAI* II 42 ○ ●Op ●Op ●Op ○

Cetti Open vs. Cast Function II 111 ○

1008 1009 1010 1011 1012 1013

*Musculoskeletal Functional Assessment Index ●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 10. Operative vs. Cast – Pain

Duration (Months) Author Comparison Outcome LOE N 2 3 12

Möller Open vs. Cast % w/ Pain* III 85 ○

Metz Minimally Invasive vs. Cast Pain (VAS) II 83 ○ ○ ○

1014 1015 1016 1017 1018 1019

*Level III evidence due to less than 80% of patients at follow-up ●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 11. Operative vs. Cast – Return to Work

Duration (Months)

Author Comparison Outcome LOE N 12 24

Cetti Open vs. Cast Sick Leave II 111 ○


Duration (Months)

Author Comparison Outcome LOE N 12 24

Möller Open vs. Cast Sick Leave II 112 ○

Metz Minimally

Invasive vs. Cast

Return to Work II 78 ○

1020 1021 1022 1023 1024

●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 12. Operative vs. Cast - Return to Sport

Duration (Months) Author Comparison Outcome LOE N 12 24

Cetti Open vs. Cast Return to Sport II 111 ●Op

Möller Open vs. Cast Return to Sport II 112 ○

Metz Minimally

Invasive vs. Cast

Return to Sport (%) II 69 ○

1025 1026 1027 1028 1029

●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 13. Operative vs. Cast - Rerupture

Duration (Months) Author Outcome LOE N

12

Twaddle Rerupture II 42 ○

Cetti Rerupture II 111 ○

Möller Rerupture II 112 ●Op

Metz Rerupture II 83 ○

1030 1031 1032 1033

●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance


Table 14. Operative vs. Cast - Satisfaction 1034

Duration (Months) Author Comparison Outcome LOE N 2 3 6 12 24

Möller Open Repair vs. Cast Satisfaction* (VAS) III 85 ●Op ●Op ●Op ●Op

Metz Minimally Invasive vs. Cast

Satisfaction (VAS) II 83 ○ ○ ○

1035 1036 1037 1038 1039

1040

*Level III evidence due to less than 80% of patients at follow-up ●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance

Table 15. Operative vs. Cast – Complications

Duration (Months) Author Adverse event/

Complication LOE N 12

Cetti Major Complications - (not including rerupture) II 111 ○

Metz Total Complications II 83 ○

Möller Extreme Residual Tendon Lengthening II 112 ○

Möller DVT II 112 ○

Cetti Total - Minor Complications* II 111 ●Non-Op

Metz Partial Sensibility II 83 ●Non-Op

Cetti Disturbances of Sensibility II 111 ○

Möller Disturbance of Sensitivity II 112 ○

Metz Scar Adhesions II 83 ●Non-Op

Möller Scar Adhesions II 112 ●Non-Op

Cetti Suture granuloma II 111 ○

Möller Superficial infection II 112 ○

1041 1042 1043 1044

*As defined by the author: “Differences between major/minor complications is that major complications give functional discomfort.” Minor Complications include: Scar adhesions, superficial infection, disturbances of sensibility, suture granuloma, delayed wound healing. ●Op: Statistically Significant in Favor of Operative Repair


1045 1046 1047 1048

1049

●Non-Op: Statistically Significant in Favor of Non-Operative treatment with Cast ○ No statistical significance Summary of Systematic Reviews

Table 16. Systematic Review Summary

Author Conclusion Bhandari, M et al. 2002

"Deep venous thrombosis is more common after nonoperative treatment of Achilles tendon ruptures" (p. 195)."…The current group of randomized trials suggests a benefit to surgical repair of acute Achilles tendon ruptures in younger, active patients" (p. 199).

Bhandari, M et al. 2002

"Pooled analysis of studies did not reveal any difference in the risk of minor complaints or return to normal function between surgical repair and conservatively treated groups" (p. 190).


"Surgical treatment significantly reduces the risk of Achilles tendon re-ruptures, but increases the risk of infection, when compared with conservative therapy" (p. 190).


"In conclusion, open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of re-rupture compared with nonoperative treatment but has the drawback of a significantly higher risk of other complications, including wound infection" (p.2209).

Khan, RJK, et al. 2005

"Although operative treatment provides a reduced re-rupture rate over nonoperative treatment, the rate of moderate and mild complications in operative treatment is 20 times greater" (p. 211).

Lo, IKY, et al. 1997

"Presently, we favor non-operative treatment in patients with poor healing potential (i.e., smokers, diabetics, and patients with peripheral vascular disease)" (p. 211).


"For healthy active individuals, we offer both forms of treatment, providing the patients with the estimates of treatment success and complication rates" (p. 211).


"Surgical treatment is preferable to non-surgical treatment, produces better functional outcomes, and therefore appears to be the treatment of choice" (p. 156).

Lynch, RM 2004

"The incidence of re-rupture following non-surgical treatment is significantly higher than for surgical treatment" (p. 156).

Lynch, RM 2004

"The number of patients that need to be treated surgically to prevent one re-rupture if these patients were treated non-surgically is 5 (3-13, 95% confidence intervals)" (p.156).

Lynch, RM 2004

Lynch, RM 2004 "The incidence of minor complications following surgical treatment is large, but these do not appear to affect functional outcome" (p. 156).


Author Conclusion "Non-surgical treatment should be reserved for patients who refuse or who are unfit for operative repair" (p. 156). Lynch, RM 2004

1050 1051 1052


Author Title Exclusion Reason Doral, et al.

2009 Percutaneous suturing of the ruptured

Achilles tendon with endoscopic control Not best available evidence - not

comparative Neumayer,

et al. 2009

A new conservative-dynamic treatment for the acute ruptured Achilles tendon

Not best available evidence - not comparative

Ebinesan, et al.

2008

Conservative, open or percutaneous repair for acute rupture of the Achilles tendon

Not best available evidence - retrospective comparative

Lorkowski, et al. 2007

Evaluation of long term therapy outcomes for Achilles tendon ruptures

Combines operative and non-operative patients

Kotnis, et al. 2006

Dynamic ultrasound as a selection tool for reducing Achilles tendon re-ruptures Not best available evidence

van, et al. 2004

Results of surgical versus non-surgical treatment of Achilles tendon rupture Not best available evidence

Weber, et al. 2003

Non-operative treatment of acute rupture of the Achilles tendon. results of a new

protocol and comparison with operative treatment

Not best available evidence - retrospective comparative

Follak, et al. 2002

The utility of gait analysis in the rehabilitation of patients after surgical treatment of Achilles tendon rupture


Moller, et al. 2002

Calf muscle function after Achilles tendon rupture. A prospective, randomised study

comparing surgical and non-surgical treatment

Duplicate - Data reported in prior study

Rumian, et al.

2001

Surgical repair of the Achilles tendon. The lateral approach


Horstmann, et al. 2000

Isokinetic strength and strength endurance of the lower limb musculature ten years after

Achilles tendon repair


Rowley, et al.

1982

Rupture of the Achilles tendon treated by a simple operative procedure No patient oriented outcome

Inglis, et al. 1976

Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical

treatment Less than 10 patients per group

Nistor, et al. 1981

Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective

randomized study Not best available evidence



Jacobs, et al. 1978

Combines acute and neglected/chronic Achilles

tendon tear patients

A new conservative-dynamic treatment for the acute ruptured Achilles tendon

1053 1054 1055

STUDY QUALITY Table 18. Study Quality

● = Yes ○ = No × = Not Reported

Author

Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

Follo

w U

p - 8

0% o

r m

ore

Outcome N Level of EvidenceTreatment(s)

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at e

ntry

Twaddle MFAI 42 Operative vs.

Cast Level II ● ● ○ ● ● ×

Twaddle Re-rupture 42 Operative vs.


Moller Re-rupture 112 Operative vs.

Cast Level II ● ● ○ ● ● ●

Moller Return to work 112 Operative vs.


Moller Quality of Life

(VAS) 112 Operative vs.


Moller Treatment

Results (VAS) 112 Operative vs.


Moller Pain 85 Operative vs.

Cast Level III ● ● ○ ● ○ ●

Cetti Return to Work 111 Operative vs.

Cast Level II × × ○ ● ● ●

Cetti Return to Sports 111 Operative vs.


Cetti Hospitalization 111 Operative vs.


Metz Re-rupture 83 Operative vs.

Cast Level II ○ ○ × × ● ×

Metz Return to work 83 Operative vs.


Metz Return to sport 83 Operative vs.


Metz Pain- VAS 83 Operative vs.


Metz Satisfaction -

VAS 83 Operative vs.



1056 1057 1058

STUDY RESULTS Table 19. Open vs. Cast - Function

Open Repair Cast

Author Comparison Outcome LOE N Durati

on mean (SD)

% mean (SD)

%

Results

Twaddle Open vs. Cast MFAI* II 42 2 weeks 42.4 (2.7)‡ 43 (2.7)‡ p = 0.48‡

Twaddle Open vs. Cast MFAI* II 42 2 months 23.7 (2.6)‡ 27.6 (3.4)‡ p = 0.002‡

Twaddle Open vs. Cast MFAI* II 42 3 months 15.2 (2.1)‡ 17 (2.6)‡ p = 0.02‡



Cetti Open vs. Cast Function - Abnormal

Gait II 111 12

months 5.4% 3.6% NS

Cetti Open vs. Cast Function – Abnormal

Run II 111 12

months 12.5% 18.2% NS

Cetti Open vs. Cast Function - Abnormal Toe Stand

II 111 12 months 8.9% 9.1% NS

1059 1060 1061 1062 1063

‡ AAOS Calculation NS: No statistical significance; authors do not report p-value. Table 20. Cast vs. Open Repair - Pain

Open Repair

Minimally Invasive Cast

Author Comparison Outcome LOE N Duration mean (SD) %

mean (SD) %

mean (SD) %

Results

Möller Open vs. Cast

Pain - None III 85 12

months 92% n/a 88% p = .69‡


Pain - Moderate III 85 12

months 6% n/a 3% p = .55‡


Pain - During

Walking III 85 12

months 2% n/a 9% p = .129‡


Pain (VAS)‡ II 83 2 months n/a 1.80

(1.40)‡ 1.56

(1.25)‡ p =

0.20‡



Open Repair


Author Comparison Outcome LOE N Duration mean (SD) %

mean (SD) %

Results mean (SD)

%


Pain (VAS)‡ II 83 3 months n/a 1.53

(1.71)‡ 1.80

(1.40)‡ p = 0.78‡


Pain (VAS)‡ II 83 12

months n/a 0.40 (0.93)‡ 0.78(1.40)‡ p =

0.92‡

‡ AAOS Calculation 1064 1065 1066 1067 1068

NS: No statistical significance; authors do not report p-value. n/a: not applicable

Table 21. Operative vs. Cast - Return to Work 1069

Open Repair


Author Comparison Outcome LOE N Duration mean (SD) mean (SD) mean (SD)

Results

Cetti Open vs. Cast Return to Work (days) II 111 12 months

43.4 (15.05) n/a 56 (25.2) NS

Möller Open vs. Cast Sick Leave (days) II 111 24 months 54.9 (47.9) n/a 73.4 (56.5) p =

0.06

Möller Open vs. Cast Return to heavy work (days) II 24 24

months 102.2 (52.7) n/a 108.1(34.7) NS

Möller Open vs. Cast Return to light work (days) II 54 24 months 35.7 (38) n/a 67.2 (65.9) p =

0.03

Möller Open vs. Cast Return to Work – Sedentary (days) II 34 24

months 30.8 (36.5) n/a 33.2 (54.7) NS

Metz Minimally Invasive vs. Cast Return to Work (days) II 78 12

months n/a 59 (82) p < 0.05 108 (115)

1070 1071 1072 1073 1074

‡ AAOS Calculation NS: No statistical significance; authors do not report p-value. n/a: not applicable


Table 22. Operative vs. Cast - Return to Sport 1075

Minimally Invasive Author Comparison Outcome LOE N Duration

Open Repair

%

Cast%

% Results

Cetti Open vs. Cast

Return to Sports- Total

II 111 12 months 79% n/a 64% p =

.21‡

Cetti Open vs. Cast

Return to Sport - Same Level

II 111 12 months 57% n/a 29% p =.005


Return to Sport - Same Level

II 112 12 months 54% n/a 54% NS

Cetti Open vs. Cast

Return to Sport -

DiminishedII 111 12

months 21% n/a 35% NS

Cetti Open vs. Cast

Return to Sport -

Stopped II 111 12

months 14% n/a 22% NS


Return to Sport -

Stopped II 112 12

months 16% n/a 14% p = .620‡


Return to Sport II 69 12

months n/a 67% 81% p = 0.16

1076 1077 1078 1079 1080

‡ AAOS Calculation NS: No statistical significance; authors do not report p-value. n/a: not applicable Table 23. Operative vs. Cast - Rerupture

Open Repair

Minimally Invasive Cast Author Complication LOE N Duration

% % % Results

Cetti Rerupture II 111 12 months 5.4% n/a 12.7% p = .167‡

Möller Rerupture II 112 12 months 1.7% n/a 20.8% p = < .001

Twaddle Rerupture II 42 6 months 10.0% n/a 4.5% p = .49‡

Metz Rerupture II 83 12 months n/a 7.1% 12.2% p = 0.44‡

Cetti Second Rerupture II 111 12

months 0.0% n/a 1.8% p = .154‡

1081 1082 1083

‡ AAOS Calculation n/a: not applicable


Table 24 Cast vs. Open - Complications 1084

Open Repair


Author Complications LOE N Duration% % %

Results

Metz Total Complications II 83 12

months n/a 28.6% 48.8% p = 0.06

Cetti

Major Complications (not including

rerupture)

II 111 12 months 9.0% n/a 16.3% NS

Metz

Total Complications

Other Than Rerupture

II 83 12 months n/a 21.4% 36.6% p = 0.13

Metz Sural Nerve Injury II 83 12 months n/a 7.1% 2.4% p = 0.30‡

Cetti Deep Infection II 111 12 months 3.6% n/a 0% p = 0.05

Metz Deep Wound Infection II 83 12

months n/a 0 0.0% NS

Cetti Delayed Wound Healing II 111 12

months 1.8% n/a 0% p = 0.158‡

Cetti Disturbances of Sensibility II 111 12

months 12.5% n/a 1.8% p = 0.017‡

Möller Disturbance of Sensitivity II 112 24

months 1.7% n/a 0% p = 0.16‡

Metz Partial Sensibility II 83 12 months n/a 9.5% 0.0% p = 0.01‡

Metz DVT - lower leg II 83 12 months n/a 0.0% 2.4% p = 0.15‡

Möller DVT II 112 24 months 0.0% n/a 1.9% p = 0.14‡

Cetti Necrosis of the Skin II 112 12

months 0.0% n/a 0% NS

Cetti Extreme Residual

Tendon Lengthening

II 111 12 months 0.0% n/a 1.8% p = 0.15‡

Möller Extreme Residual

Tendon Lengthening

II 112 24 months 0.0% n/a 1.9% p = 0.14‡

Cetti Total - Minor Complications II 111 12

months 26.8% n/a 5.4% p = 0.004

Metz Skin Related Complications II 83 12

months n/a 4.8% 31.7% p = .001‡

Cetti Scar Adhesions II 111 12 months 10.7% n/a 3.6% p = 0.136‡

Metz Scar Adhesions II 83 12 months n/a 7.1% 0.0% p = 0.01‡


Open Repair


Author Complications LOE N Duration% %

Results %

Möller Scar Adhesions II 112 24 months 13.6% n/a 0% p = <.001‡

Cetti Suture Granuloma II 111 12 months 1.8% n/a 0% p = 0.158‡

Möller Superficial Infection II 112 24

months 1.7% n/a 0% p = 0.16‡

1085 1086 1087 1088 1089 1090

‡ AAOS Calculation NS: No statistical significance; authors do not report p-value. n/a: not applicable


RECOMMENDATION 4 1091 1092 1093

1094

1095 1096 1097 1098 1099 1100

1101 1102

1103 1104 1105 1106

1107

1108 1109 1110 1111 1112 1113

1114 1115 1116

1117 1118 1119 1120

1121 1122 1123 1124 1125 1126 1127

For patients treated non-operatively, we are unable to recommend for or against the use of immediate functional bracing for patients with acute Achilles tendon rupture.


Rationale: Non-operative treatment for Achilles tendon ruptures was evaluated by comparing the use of immediate functional bracing or a combination of casting with functional bracing (for a period of 0-12 weeks) to casting alone. One level II and one level IV comparative study were analyzed. The only outcome that could be adequately determined in these studies was rerupture rate which was not significantly different. 22, 22

Functional outcomes of the functional bracing group were analyzed with three studies (level IV and V) and no case series of cast treatment alone was identified. 23-25

With the lack of functional data demonstrating improved outcomes with functional bracing and the lack of demonstrable difference in rerupture rates, we are unable to recommend for or against the use of immediate functional bracing for patients treated non-operatively for acute Achilles tendon rupture.


We analyzed one level II and one level IV study that compared patients treated with cast plus a functional brace vs. patients treated with a cast only. 26 22 We reported the rerupture rates of both comparative studies but other outcomes were considered due to the reliability of the evidence reported in both studies (See Methods Section – Outcomes considered). We then examined three studies (Level IV and V) that reported results for patients treated with functional bracing. 23-25

In both comparative studies, rerupture rates did not significantly differ between patients treated with cast plus orthosis vs. cast (see Table 25). See Table 36 for case series re-rupture rates.

Seventy-eight percent of patients treated with a functional brace had no pain, 55% reported no stiffness, 56% had no weakness, 98% of patients returned to full level of employment and 37% returned to the same level of sports at 2.9 years. The average time to return to work was 7 days (range 21 – 52) (see Table 26).

One study reported 2% of patients had a pulmonary embolism and another study reported 1% of patients with a DVT and “temporary drop foot”(see Table 35).


SUMMARY OF EVIDENCE 1128 1129 1130

Table 25. Cast + Functional Brace vs. Cast - Rerupture

Cast Author Outcome LOE N Duration

Cast + orthosis

(%) (%) Results

Saleh, et al. 1992 Rerupture II 31

12 months 6% 7% p=.96‡

Ingvar, et al. 2005 Rerupture IV 194 4 years 7% 10% p=.51‡

‡ AAOS calculation 1131 1132 Table 26. Summary of Results - Case Series

Results Author Outcome LOE N Duration (%) Wallace Pain - none IV 140 2.9 years 78%

Wallace Stiffness –

none IV 140 2.9 years 55%

Wallace Weakness –


Wallace

Return to Full Preinjury Level of Employment IV 122 2.9 years 98%

Wallace, et al. 2004

Return to Sports - same or better level IV 101 2.9 years 37%

1133

1134 Table 27. Summary of Systematic Reviews

Author Conclusion "Early functional mobilisation is more acceptable to patients than plaster cast immobilisation and results in improved functional outcomes" (p. 156).

Lynch, RM 2004

1135

1136

Table 28. Functional Bracing – Satisfaction (VAS)

Author Outcome LOE N Duration Results (mean ± SD)

Neumayer, et al. 2009

Satisfaction (VAS) IV 46 5 years 8.1 ± 2

1137


Table 29. Functional Bracing - Satisfaction (%) 1138

Author Outcome LOE N Duration Results (%)


Satisfaction – very satisfied IV 140 2.9 years 83%


Satisfaction –satisfied with

minor reservations IV 140 2.9 years 15%


Satisfaction –satisfied with

major reservations IV 140 2.9 years 1%


Satisfaction –dissatisfied IV 140 2.9 years 1%

1139 1140

Table 30. Functional Bracing - Pain


Wallace, et al. 2004 Pain - none IV 140 2.9 years 78%

Wallace, et al. 2004 Pain - mild IV 140 2.9 years 13%

Wallace, et al. 2004 Pain - moderate IV 140 2.9 years 8%

Wallace, et al. 2004 Pain – severe IV 140 2.9 years 1%

1141 1142

Table 31. Functional Bracing - Function


Wallace, et al. 2004 Stiffness – none IV 140 2.9 years 55%

Wallace, et al. 2004 Stiffness – mild IV 140 2.9 years 41%


Stiffness – moderate IV 140 2.9 years 3%

Wallace, et al. 2004 Stiffness – severe IV 140 2.9 years 1%

1143


Table 32. Functional Bracing - Strength 1144


Wallace, et al. 2004 Weakness – none IV 140 2.9 years 56%

Wallace, et al. 2004 Weakness - mild IV 140 2.9 years 33%


Weakness - moderate IV 140 2.9 years 10%

Wallace, et al. 2004 Weakness -severe IV 140 2.9 years 1%

1145 1146

Table 33. Functional Bracing - Return to Work and Sports



Return to Full Preinjury Level of

Employment IV 122 2.9 years 98%


Return to Sports - same or better

level IV 101 2.9 years 37%


Return to Sports - diminished or


McComis, et al. 1997

Return to Sports - same level V 15 26 weeks 67%


Return to Sports - diminished V 15 26 weeks 33%

1147 1148

Table 34. Functional Bracing - Return to Work and Sports (days)

Author Outcome LOE N Results (mean)


Time to Return to Work IV 122 7 days

(max: 52 days) McComis, et al. 1997

Time to Return to Work V 15 4 days

(max: 3 weeks)


Time to Return to Sports IV 101

8 weeks (range 2 weeks

- 6 months) 1149


Table 35. Functional Bracing - Complications 1150

Cast

Author Outcome LOE N Duration

Cast + orthosis

(%) (%)

Results


Pulmonary embolism IV 57

12 months n/a 2% n/a

Wallace, et al. 2004 DVT IV 140

2.9 years (0.4-8.2) n/a 1% n/a


Temporary Drop foot IV 140

2.9 years (0.4-8.2) n/a 1% n/a

1151 1152 1153

n/a: not applicable Table 36. Functional Bracing - Rerupture

Author Outcome LOE N Duration Cast (%)

Cast + orthosis

(%) Results


Complete rerupture IV 57 12 months n/a 9% n/a


Complete rerupture IV 140 2.9 years

(0.4-8.2) n/a 2% n/a

Neumayer, et al. 2009 Partial rerupture IV 57 12 months n/a 4% n/a

Wallace, et al. 2004 Partial rerupture IV 140 2.9 years

(0.4-8.2) n/a 4% n/a

1154 1155 1156 1157

n/a: not applicable EXCLUDED ARTICLES Table 37. Functional Bracing - Excluded Studies

Author Title Exclusion Reason Edna TH; Non-operative treatment of Achilles tendon ruptures case series cast only

Fruensgaard S, et al.

Conservative treatment for acute rupture of the Achilles tendon casting only

Hufner TM, et al. Long-term results after functional non-operative treatment of Achilles tendon rupture cast only case series

Inglis AE, et al. Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment Less than 10 patients per arm

Josey RA, et al. Immediate, full weight bearing cast treatment of acute Achilles tendon ruptures: a long-term follow-up study cast only case series

Keller J, et al Closed treatment of Achilles tendon rupture case series cast only


Author Title Exclusion Reason Lea RB; Smith L; Non-surgical treatment of tendo achillis rupture casting only

Lildholdt T, et al Conservative treatment to Achilles tendon rupture. A follow-up study of 14 cases cast only case series

Nistor L; Conservative treatment of fresh subcutaneous rupture of the Achilles tendon casting only case series

Pendleton H, et al. Residual functional problems after non-operative treatment of Achilles tendon rupture cast only case series

Persson A, et al. The treatment of total ruptures of the Achilles tendon by plaster immobilisation cast only case series

Roberts CP, et al Dynamised cast management of Achilles tendon ruptures retrospective case series

1158 1159 1160

STUDY QUALITY Table 38. Study Quality - Randomized Control Trials


Author Outcome N

Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Thos

e ra

ting

outc

ome

Blin

ded

Follo

w U

p - 8

0% o

r mor

e

Level of Evidence Treatment(s) A

ll gr

oups

hav

e si

mila

r ou

tcom

e pe

rfor

man

ce a

t ent

ry

Saleh, et al. 1992 Rerupture 31 Cast vs. Cast +

Orthosis Level II × × ○ ○ ● ●

1161 1162 Table 39. Study Quality - Non-Randomized Comparative Study


Author Outcome N

Com

plet

ion

rate

- le

ss th

an 2

0%

diff

eren

ce b

etw

een

grou

ps

All

grou

ps c

oncu

rren

tly

tre

ated

All

grou

ps re

ceiv

e sa

me

treat

men

t

All

grou

ps e

valu

ated

usi

ng

sam

e ou

tcom

e m

easu

res

All

grou

ps h

ave

appr

oxim

atel

y eq

ual

follo

w-u

p tim

es

Follo

w U

p - 8

0% o

r mor

e

Sam

e ce

nter

for e

xper

imen

tal a

nd

cont

rol g

roup

dat

a Si

mila

r per

form

ance

on

outc

ome

at

base

line

Treatment(s) Level of Evidence Pa

tient

cha

ract

eris

tics c

ompa

rabl

e at

ba

selin

e

Ingvar, et al. 2005 Re-rupture 194

Cast vs. Cast + Orthosis Level IV × ○ ● ● × ● ● ● ×


Table 40. Study Quality - Case Series 1163


Author Outcome N Treatment(s) Level of Evidence

Con

secu

tive

enro

llmen

t

of

pat

ient

s

Follo

w U

p - 8

0% o

r mor

e

All

patie

nts e

valu

ated

usi

ng

sa

me

outc

ome

mea

sure

s

All

patie

nts r

ecei

ve sa

me

treat

men

t

All

patie

nts h

ave

appr

oxim

atel

y eq

ual

follo

w-u

p tim

es

Neumayer, et al. 2009 Satisfaction (VAS) 46 Cast + Orthosis Level IV ● ● ● ● ●

Wallace, et al. 2004 Satisfaction 140 Cast + Orthosis Level IV ● ● ● ● ●

Wallace, et al. 2004 Pain 140 Cast + Orthosis Level IV ● ● ● ● ●

Wallace, et al. 2004 Stiffness 140 Cast + Orthosis Level IV ● ● ● ● ●

Wallace, et al. 2004 Weakness 140 Cast + Orthosis Level IV ● ● ● ● ●


Return to Full Preinjury Level of

Employment 122 Cast + Orthosis Level IV ● ● ● ● ●


Return to Sports - same or better level 101 Cast + Orthosis Level IV ● ● ● ● ●


Return to Sports - diminished or none 101 Cast + Orthosis Level IV ● ● ● ● ●


Return to Sports - same level 15 Cast + Orthosis Level V ● ○ ● ● ●


Return to Sports - diminished 15 Cast + Orthosis Level V ● ○ ● ● ●


Time to Return to Work 122 Cast + Orthosis Level IV ● ● ● ● ●


Time to Return to Work 15 Cast + Orthosis Level V ● ○ ● ● ●


Time to Return to Sports 140 Cast + Orthosis Level IV ● ● ● ● ●


Complete re-rupture 57 Cast + Orthosis Level IV ● ● ● ● ●




Con

secu

tive

enro

llmen

t

of

pat

ient

s

Follo

w U

p - 8

0% o

r mor

e

All

patie

nts e

valu

ated

usi

ng

sa

me

outc

ome

mea

sure

s

All

patie

nts h

ave

appr

oxim

atel

y eq

ual

follo

w-u

p tim

es

All

patie

nts r

ecei

ve sa

me

treat

men

t


Complete re-rupture 140 Cast + Orthosis Level IV ● ● ● ● ●

Neumayer, et al. 2009 Partial rerupture 57 Cast + Orthosis Level IV ● ● ● ● ●

Wallace, et al. 2004 Partial rerupture 140 Cast + Orthosis Level IV ● ● ● ● ●


Pulmonary embolism 57 Cast + Orthosis Level IV ● ● ● ● ●

Wallace, et al. 2004 DVT 140 Cast + Orthosis Level IV ● ● ● ● ●


Temporary Drop foot 140 Cast + Orthosis Level IV ● ● ● ● ●

1164


RECOMMENDATION 5 1165 1166 1167 1168 1169 1170 1171 1172 1173 1174 1175 1176 1177 1178 1179

1180 1181 1182 1183 1184

1185 1186

1187

1188 1189 1190 1191 1192 1193 1194 1195 1196 1197

1198

Operative treatment is an option in patients with acute Achilles tendon rupture. AAOS Strength of Recommendation: Weak Rationale: To answer this recommendation, we reviewed studies addressing the efficacy of operative treatment. A systematic review of the literature included seven studies20, 19, 27, 28, 29, 30,31 that addressed the efficacy of open repair and five studies32, 29, 33, 21, 27 addressing the efficacy of minimally invasive techniques. This systematic review addressed only the efficacy of operative treatment and therefore did not consider the comparisons made in the studies. Please refer to Recommendation 3 and its rationale for a comparison of non-operative and operative treatment of acute Achilles tendon ruptures. In addition, relevant comparative information about operative techniques can be found in Recommendation 8 and its rationale.

A systematic review of the literature included seven studies20, 19, 27, 28, 29, 30,31 that addressed the efficacy of open repair and five studies32, 29, 33, 21, 27 addressing the efficacy of minimally invasive techniques. By six months the return to activity ranged from 73% to 100% after operative treatment (see Table 42 through Table 57). After twelve months, 92% of patients reported they had no pain (see Table 48).

All studies relevant to this Recommendation were Level IV (see Table 59) because this is non comparative data.


To determine the efficacy of open repair and/or minimally invasive repair we need a study with preoperative and postoperative data. However, the data we identified only provides postoperative measures and is therefore unreliable. We have tabled the postoperative data from seven studies20, 19, 27, 28, 29, 30,31 that address efficacy of open repair and five studies 32, 29, 33, 21, 27 that address minimally invasive techniques. Table 42 through Table 57 demonstrate the wide variety of patient-oriented outcome measures and duration to follow-up used to evaluate patients receiving operative treatment for Achilles tendon rupture. The inconsistency of these outcome measures makes comparisons between studies difficult. Because the body of evidence is weak, it does not allow for additional statistical analysis.

Please see Recommendation 7 for results of operative treatment comparisons.


SUMMARY OF EVIDENCE 1199 1200 Table 41. Open Repair – All Outcomes

Result (Efficacy) Outcome

Time until Return to Work ?

Time until Return to Stair Climbing ?

Time until Return to Walking ?

Time until Return to Sports ?

Return to work (%) ?

Return to ADL (%) ?

Return to Final Functional Activities (%) ?

Pain (%) ?

Function- Abnormal ankle movement (%) ?

Abnormal Run (%) ?

Abnormal toe stand (%) ?

Satisfaction (%) ? 1201

1202 Table 42. Open Repair - Return to work

Author LOE N Outcome Mean time Mean (SD)

Moller, et al. 2001 IV 59 Return to work (days) 54.9 (nr)

Cetti, et al. 1993 IV 56 Return to work (weeks) 6.2 (SD 2.15)

Moller, et al. 2001 IV 59 Return to heavy work (days) 102.2 (nr)

Moller, et al. 2001 IV 59 Return to sedentary work (days) 30.8 (nr)

Moller, et al. 2001 IV 59 Return to light, mobile work (days) 35.7 (nr)

1203 nr: not reported


Table 43. Open Repair - Activities of daily living 1204

Author LOE N Outcome

Mean time Mean

(SD)/(range) Bhattacharyya, et al.

2009 IV 53 Return to Normal Stair Climbing (weeks) 19 (3.5)‡

Bhattacharyya, et al. 2009 IV 53 Return to Normal Walking

(weeks) 17 (3)‡

Uchiyama, et al. 2007 IV 84 Return to same level of sports (months) (high level athletes) 5 (17-26 weeks)

Uchiyama, et al. 2007 IV 84 12.3 (range 8-21) Return to jogging (weeks)

1205

1206

1207

‡AAOS Calculation

Table 44. Open Repair- Mean time until return to athletic activity

Author LOE N Outcome Mean time

Mean (range)

Uchiyama, et al. 2007 IV 84 Return to same level of sports (months) (high level athletes) 5 (17-26 weeks)

Uchiyama, et al. 2007 IV 84 Return to jogging (weeks) 12.3 (8-21)


1208

1209 Table 45. Open Repair- Percent of patients able to return to activities of daily living

Author LOE N Outcome Follow-up

% of Patients

Lim, et al. 2001 IV 33 Return to ADL 2 months 6%



Lim, et al. 2001 IV 33 Return to final functional activity*

3 months 36%

Lim, et al. 2001 IV 33 Return to final functional activity*

6 months 64%

1210 1211 1212

1213

* Final functional activity defined as “patient is unhindered in all his or her activities apart from active sports”

Table 46. Open Repair- Percent of patients able to return to work


% of Patients

Moller, et al. 2001 IV 59 Return to work (days) nr 100%

Moller, et al. 2001 IV 59 Return to sedentary work (days) nr 22%

Moller, et al. 2001 IV 59 Return to light, mobile work (days) nr 54%

Moller, et al. 2001 IV 59 Return to heavy work (days) nr 24%

1214 1215

1216

Nr: not reported

Table 47. Open Repair- Percent of patients able to return to sports


% of Patients

Coutts, et al 2002 IV 22 Return to pre-injury sporting level nr 91%

Moller, et al. 2001 IV 47 Return to sports - same level 12 months 54%

Cetti, et al. 1993 IV 52 Return to sports - same level 12 months 62%

Lim, et al. 2001 IV 33 Return to active sporting/outdoor activities

3 months 9%

Lim, et al. 2001 IV 33 Return to active sporting/outdoor activities

6 months 48%

Moller, et al. 2001 IV 47 Return to sports - stopped 12 months 16%


Follow-up Author LOE N Outcome % of

Patients

Cetti, et al. 1993 IV 52 Return to sports - stopped 12 months 15%

Cetti, et al. 1993 IV 52 Return to sports - diminished level

12 months 23%

1217

1218 Table 48: Open Repair- Percent of patients with pain

Author LOE N Outcome Follow-up % of PatientsAktas, et al. 2007 IV 30 Pain - Mild w/ maximal exertion 6 months 14%

Aktas, et al. 2007 IV 30 Pain - Absent 6 months 86%

Moller, et al. 2001 IV 52 Pain-during walking 12 months 2%

Moller, et al. 2001 IV 52 Pain-moderate 12 months 6%

Moller, et al. 2001 IV 52 Pain-none 12 months 92%

1219

1220 Table 49. Open Repair- Percent of patients able to complete functional activities

Author LOE N Outcome Follow-up % of Patients

Cetti, et al. 1993 IV 56 Function-Abnormal ankle movement 4 months 52%

Cetti, et al. 1993 IV 56 Function-Abnormal ankle movement 12 months 18%

Cetti, et al. 1993 IV 56 Function-Abnormal gait 4 months 27%

Cetti, et al. 1993 IV 56 Function-Abnormal gait 12 months 5%

Cetti, et al. 1993 IV 56 Function-Abnormal run 4 months 52%

Cetti, et al. 1993 IV 56 Function-Abnormal run 12 months 13%

Cetti, et al. 1993 IV 56 Function-Abnormal toe stand 4 months 21%

Cetti, et al. 1993 IV 56 Function-Abnormal toe stand 12 months 9%

1221

1222 Table 50. Open Repair- Percent of patients with excellent satisfaction

Author LOE N Outcome Follow-up % of Patients

Lim, et al. 2001 IV 33 Satisfaction - Excellent 6 months 42%

1223


Table 51. Minimally Invasive Repair- All outcomes 1224 Result

(Efficacy) Outcome

Return to Work (%) ?

Return to Stair Climbing (%) ?

Return to Walking (%) ?

Return to Sports (%) ?

Return to work (%) ?

Return to ADL (%) ?

Return to Final Functional Activities (%) ?

Satisfaction (%) ?

Function- Abnormal ankle movement (%) ?

Return to same level of activity (%) ?

Able to walk without limitations (%) ?

Return to sports (%) ? 1225

1226 Table 52. Minimally Invasive Repair- Percent of Patients able to return to activity

Author LOE N Treatment Outcome Follow-up % of Patients

ES Ng, et al. 2007 IV 25 percutaneous Return to activity -

same level 65.5

months 96%

Lim, et al. 2001 IV 33 percutaneous Return to ADL 2 months 6%



Lim, et al. 2001 IV 33 percutaneous Return to final

functional activity 3 months 27%

Lim, et al. 2001 IV 33 percutaneous Return to final

functional activity 6 months 73%

Chillemi, et al. 2002 IV 38 percutaneous Able to walk

without limitation 6 months 100%

1227 1228

1229

1230


Table 53. Minimally Invasive Repair - Percent of patients able to return to sports 1231

Author LOE N Treatment Outcome Follow-up % of Patients

Lim, et al. 2001 IV 33 percutaneous

Return to active sporting/outdoor

activities 3 months 0%

Lim, et al. 2001 IV 33 percutaneous

Return to active sporting/outdoor

activities 6 months 67%

Chillemi, et al. 2002 IV 14 percutaneous

Return to sports activity (frequent

participant 2-3 times per week)

nr 57%

1232 1233

1234

nr: not reported

Table 54. Minimally Invasive Repair - Satisfaction

Author LOE Treatment N Outcome Follow-up %

Lim, et al. 2001

IV percutaneous 33 Satisfaction - Excellent 6 months 52%

1235 1236 1237

Table 55. Minimally Invasive Repair - Mean time until return to activity

Author LOE Treatment N Outcome Mean Time (Days)Mean (SD)

Metz, et al. 2008 IV minimally-invasive 40 Return to work 59 (82)

Bhattacharyya, et al. 2009 IV minimally-invasive 53 Return to Normal

Walking (weeks) 12.5 (3)‡

Bhattacharyya, et al. 2009 IV minimally-invasive 53

Return to Normal Stair Climbing

(weeks) 14 (3)‡

1238 1239 1240

‡= AAOS Calculation

Table 56. Minimally Invasive Repair-Percent of patients able to return to sports

Author LOE Treatment N Outcome Follow-up % of

Patients Metz, et al.

2008 IV minimally-invasive 36 Return to sports 12 months 67%

Metz, et al. 2008

IV minimally-invasive 36 Change sports 12 months 11%

Metz, et al. 2008

IV minimally-invasive 36 Stop sports 12 months 22%

Metz, et al. 2008

IV minimally-invasive 40 Return to work nr 98%

1241 nr: not reported


Table 57. Minimally Invasive Repair-Percent of patients able to return to work 1242

Author LOE Treatment N Outcome Follow-up % of

Patients Metz, et al.

2008 IV minimally-invasive 40 Return to work nr 98%

1243 1244 1245 1246

nr: not reported EXCLUDED ARTICLES Table 58. Excluded Articles


Leppilahti J;Forsman K;Puranen J;Orava S;

Outcome and prognostic factors of Achilles rupture repair using a new scoring method

Not best available evidence

Chiodo CP;Wilson MG;

Current concepts review: acute ruptures of the Achilles tendon


Weber M;Niemann M;Lanz R;Muller T;

Nonoperative treatment of acute rupture of the Achilles tendon: results of a new protocol and

comparison with operative treatment Retrospective

Maffulli N;Tallon C;Wong J;Lim

KP;Bleakney R;

Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the Achilles

tendon Not Relevant

Halasi T;Tallay A;Berkes I;

Percutaneous Achilles tendon repair with and without endoscopic control Retrospective

Costa ML;Shepstone L;Darrah C;Marshall

T;Donell ST;

Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study


Maffulli N;Tallon C;Wong J;Peng LK;Bleakney R;

No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon

Duplicate - Data reported in prior

study van der Linden-van der

Zwaag HM;Nelissen RG;Sintenie JB;

Results of surgical versus non-surgical treatment of Achilles tendon rupture


Steele GJ;Harter RA;Ting AJ;

Comparison of functional ability following percutaneous and open surgical repairs of acutely

ruptured Achilles tendons

No patient- oriented outcome

Cretnik A;Kosanovic M;Smrkolj V;

Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study


Goren D;Ayalon M;Nyska M;

Isokinetic strength and endurance after percutaneous and open surgical repair of Achilles tendon ruptures

No patient -oriented outcome

Wagnon R;Akayi M; The Webb-Bannister percutaneous technique for acute

Achilles' tendon ruptures: a functional and MRI assessment




Mortensen HM;Skov O;Jensen PE;

Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective,

randomized clinical and radiographic study


Hufner TM;Brandes DB;Thermann

H;Richter M;Knobloch K;Krettek C;

Long-term results after functional nonoperative treatment of Achilles tendon rupture


Kauranen K;Kangas J;Leppilahti J;

Recovering motor performance of the foot after Achilles rupture repair: a randomized clinical study

about early functional treatment vs. early immobilization of Achilles tendon in tension

No patient oriented outcome

Majewski M;Rohrbach M;Czaja S;Ochsner P;

Avoiding sural nerve injuries during percutaneous Achilles tendon repair


Attinger CE;Ducic I;Hess CL;Basil A;Abbruzzesse M;Cooper P;

Outcome of skin graft versus flap surgery in the salvage of the exposed Achilles tendon in diabetics

versus nondiabetics Not relevant

Kotnis R;David S;Handley R;Willett

K;Ostlere S;

Dynamic ultrasound as a selection tool for reducing Achilles tendon re-ruptures

Combines open and

percutaneous repair

Schonberger TJ;Janzing HM;Morrenhof JW;de Visser AC;Muitjens P;

Operative treatment of acute Achilles tendon rupture: Open end-to-end-reconstruction versus reconstruction

with Mitek-anchors

Retrospective case series

Metz R;Verleisdonk EJ;van der Heijden

GJ;Clevers GJ;Hammacher

ER;Verhofstad MH;van der WC;

Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate

full weightbearing--a randomized controlled trial Not Relevant

Suchak AA;Bostick GP;Beaupre

LA;Durand DC;Jomha NM;

The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the

Achilles tendon

All patients do not receive same

treatment

Blankstein A;Israeli A;Dudkiewicz

I;Chechik A;Ganel A;

Percutaneous Achilles tendon repair combined with real-time sonography


Maffulli N;Longo UG;Ronga M;Khanna

A;Denaro V;

Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly


Twaddle BC;Poon P; Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study

No relevant outcomes

Fujikawa A;Kyoto Y;Kawaguchi M;Naoi

Y;Ukegawa Y;

Achilles tendon after percutaneous surgical repair: serial MRI observation of uncomplicated healing




Costa ML;MacMillan K;Halliday D;Chester

R;Shepstone L;Robinson AH;Donell

ST;

Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis Not Relevant

Carter TR;Fowler PJ;Blokker C;

Functional postoperative treatment of Achilles tendon repair Retrospective

Perez TA; Traumatic rupture of the Achilles Tendon.

Reconstruction by transplant and graft using the lateral peroneus brevis

Insufficient Quantitative

Data

Martinelli B; Percutaneous repair of the Achilles tendon in athletes Not best available evidence

Gorschewsky O;Pitzl M;Putz A;Klakow

A;Neumann W; Percutaneous repair of acute Achilles tendon rupture


Data Mullaney MJ;McHugh MP;Tyler TF;Nicholas

SJ;Lee SJ;

Weakness in end-range plantar flexion after Achilles tendon repair


Rumian AP;Molloy S;Solan M;Newman

KJ;Elliott D;

Surgical repair of the Achilles tendon: The lateral approach


Ebinesan AD;Sarai BS;Walley GD;Maffulli

N;

Conservative, open or percutaneous repair for acute rupture of the Achilles tendon

Retrospective comparative

Chan SK;Chung SC;Ho YF; Minimally invasive repair of ruptured Achilles tendon Retrospective

Lildholdt T;Munch-Jorgensen T;

Conservative treatment to Achilles tendon rupture. A follow-up study of 14 cases

No description of surgery

Nistor L; Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study


Haggmark T;Liedberg H;Eriksson

E;Wredmark T;

Calf muscle atrophy and muscle function after non-operative vs operative treatment of Achilles tendon

ruptures


Kangas J;Pajala A;Siira P;Hamalainen

M;Leppilahti J;

Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles

rupture repair: a prospective, randomized, clinical study

Not Relevant

Synder M;Zwierzchowski H;

Post-operative results in fresh injuries the Achilles tendon


Data



Therbo M;Petersen MM;Nielsen PK;Lund

B;

Loss of bone mineral of the hip and proximal tibia following rupture of the Achilles tendon


Solveborn SA;Moberg A;

Immediate free ankle motion after surgical repair of acute Achilles tendon ruptures

Surgeons did not follow same

technique

Kakiuchi M; A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair


Buchgraber A;Passler HH;

Percutaneous repair of Achilles tendon rupture. Immobilization versus functional postoperative

treatment No baseline data

Speck M;Klaue K; Early full weightbearing and functional treatment after surgical repair of acute Achilles tendon rupture No baseline data

Aoki M;Ogiwara N;Ohta T;Nabeta Y;

Early active motion and weightbearing after cross-stitch Achilles tendon repair

Insufficient Data

Dargel J;Ninck J;Koebke J;Appell

HJ;Pennig D;Hillekamp J;

Influence of knee flexion on plantarflexion moments after open or percutaneous Achilles tendon repair

Retrospective comparative

Follak N;Ganzer D;Merk H;

The utility of gait analysis in the rehabilitation of patients after surgical treatment of Achilles tendon

rupture

No relevant patient oriented

outcomes Horstmann T;Lukas C;Mayer F;Winter

E;Ambacher T;Heitkamp

H;Dickhuth H;

Isokinetic strength and strength endurance of the lower limb musculature ten years after Achilles tendon repair

All patients did not receive

exact surgery

Kerkhoffs GM;Struijs PA;Raaymakers EL;Marti RK;

Functional treatment after surgical repair of acute Achilles tendon rupture: wrap vs walking cast Not Relevant

Soldatis JJ;Goodfellow DB;Wilber JH; End-to-end operative repair of Achilles tendon rupture Retrospective

Cetti R; Ruptured Achilles tendon--preliminary results of a new treatment No baseline data

Cetti R;Henriksen LO;Jacobsen KS;

A new treatment of ruptured Achilles tendons. A prospective randomized study Not Relevant


STUDY QUALITY 1247 1248 Table 59. Study Quality


Author Outcome Measure N

Sam

e T

reat

men

ts

LoE

Con

secu

tive

Enr

ollm

ent

Follo

w u

p <8

0%

Sam

e O

utco

mes

Treatment

Equ

al F

ollo

w u

p T

ime

Aktas, et al. 2007 Pain - Mild w/ maximal exertion*

30 Open Repair IV ● ● ● ● ●

Aktas, et al. 2007 Pain - Absent* 30 Open Repair IV ● ● ● ● ●

Bhattacharyya, et al. 2009

Return to Normal Walking (weeks) 53 Open Repair IV ● ● ● ● ●


Return to Normal Stair Climbing (weeks)



Return to Normal Walking (weeks) 53 Minimally

Invasive Repair IV ● ● ● ● ●


Return to Normal Stair Climbing (weeks)

53 Minimally Invasive Repair IV ● ● ● ● ●

Cetti, et al. 1993 Return to work (weeks) 56 Open Repair IV ● ● ● ● ●

Cetti, et al. 1993 Return to sports - diminished level 56 Open Repair IV ● ● ● ● ●

Cetti, et al. 1993 Return to sports - same level 56 Open Repair IV ● ● ● ● ●

Cetti, et al. 1993 Return to sports - stopped 56 Open Repair IV ● ● ● ● ●

Cetti, et al. 1993 Function-Abnormal ankle movement


Cetti, et al. 1993 Function-Abnormal ankle movement


Cetti, et al. 1993 Function-Abnormal gait 56 Open Repair IV ● ● ● ● ●

Cetti, et al. 1993 Function-Abnormal gait 56 Open Repair IV ● ● ● ● ●

Cetti, et al. 1993 Function-Abnormal run 56 Open Repair IV ● ● ● ● ●



Author Outcome Measure N Treatment LoE

Con

secu

tive

Enr

ollm

ent

Follo

w u

p <8

0%

Sam

e O

utco

mes

Equ

al F

ollo

w u

p Sa

me

Tre

atm

ents

Tim

e

Cetti, et al. 1993 Function-Abnormal run 56 Open Repair IV ● ● ● ● ●

Cetti, et al. 1993 Function-Abnormal toe stand


Cetti, et al. 1993 Function-Abnormal toe stand


Chillemi, et al. 2002

Able to walk without limitation 38 Percutaneous

Repair IV ● ● ● ● ●


Return to sports activity (frequent participant 2-3 times per week)

14 Percutaneous Repair IV ● ● ● ● ●

Coutts, et al 2002 Return to pre-injury sporting level

22 Open Repair IV ○ ● ● ● ●

ES Ng, et al. 2007

Return to activity - same level 25 Percutaneous


Gigante, et al. 2008

SF-12 - Physical Component Score 19 Percutaneous



SF-12 - Mental Component Score 19 Percutaneous


Lim, et al. 2001 Return to active sporting/outdoor activities




Lim, et al. 2001 Return to ADL 33 Open Repair

IV ● ● ● ● ●

Lim, et al. 2001 Return to final functional activity

33 Open Repair

IV ● ● ● ● ●

Lim, et al. 2001 Satisfaction - Excellent 33

Open Repair IV ● ● ● ● ●

Lim, et al. 2001 Return to final functional activity





Con

secu

tive

Enr

ollm

ent

Follo

w u

p <8

0%

Sam

e O

utco

mes

Equ

al F

ollo

w u

p Sa

me

Tre

atm

ents

Tim

e





Lim, et al. 2001 Satisfaction - Excellent 33 Percutaneous


Metz, et al. 2008 Return to work 40 Minimally Invasive Repair IV ● ● ● ● ●

Metz, et al. 2008 Return to sports 40 Minimally Invasive Repair IV ● ● ● ● ●

Metz, et al. 2008 Change sports 40 Minimally Invasive Repair IV ● ● ● ● ●

Metz, et al. 2008 Stop sports 40 Minimally Invasive Repair IV ● ● ● ● ●

Moller, et al. 2001

Return to sedentary work (days)


Moller, et al. 2001

Return to light, mobile work (days)


Moller, et al. 2001

Return to work (days) 59 Open Repair IV ● ● ● ● ●

Moller, et al. 2001

Return to heavy work (days) 59 Open Repair IV ● ● ● ● ●

Moller, et al. 2001

Return to sports - same level 59 Open Repair IV ● ● ● ● ●

Moller, et al. 2001

Return to sports - stopped 59 Open Repair IV ● ● ● ● ●

Moller, et al. 2001

Return to sedentary work (days)


Moller, et al. 2001

Return to light, mobile work (days)


Moller, et al. 2001

Return to work (days) 59 Open Repair IV ● ● ● ● ●

Moller, et al. 2001

Return to heavy work (days) 59 Open Repair IV ● ● ● ● ●




Con

secu

tive

Enr

ollm

ent

Follo

w u

p <8

0%

Sam

e O

utco

mes

Equ

al F

ollo

w u

p Sa

me

Tre

atm

ents

Tim

e

Moller, et al. 2001

Pain-during walking 59 Open Repair IV ● ● ● ● ●

Moller, et al. 2001 Pain-moderate 59 Open Repair IV ● ● ● ● ●

Moller, et al. 2001 Pain-none 59 Open Repair IV ● ● ● ● ●

Uchiyama, et al. 2007

Return to jogging (weeks) 84 Open Repair IV ○ ● ● ● ●


Return to same level of sports (months) (high level athletes)

84 Open Repair IV ○ ● ● ● ●


RECOMMENDATION 6 1249 1250 1251 1252 1253 1254

1255 1256 1257

1258 1259 1260 1261 1262

1263 1264 1265 1266

1267

1268

1269

1270

1271

1272

1273

1274

1275

1276

1277

1278

In the absence of reliable evidence, it is the opinion of the work group that although operative treatment is an option , it should be approached more cautiously in patients with diabetes, neuropathy, immunocompromised states, age above 65, tobacco use, sedentary lifestyle, obesity (BMI >30), peripheral vascular disease or local/systemic dermatologic disorders.

AAOS Grade of Recommendation: Consensus Rationale:

Rupture of the Achilles tendon occurs not only in healthy active individuals, but also in those with substantial medical histories. We were unable to find any published studies that addressed the effects of co-morbid conditions on the success of operative repair. Therefore, this recommendation is based on expert opinion, and is consistent with current clinical practice.

The consensus of the work group is that consideration of non-operative treatment should occur before performing operative repair of Achilles tendon ruptures in those individuals with conditions that may impair wound healing. These individuals may be at increased risk for wound problems and infection with subsequent detrimental effect on outcome.


We did not identify any studies to address this recommendation.


RECOMMENDATION 7 1279 1280 1281 1282 1283

1284

1285 1286 1287 1288 1289 1290 1291 1292

1293

For patients who will be treated operatively for an acute Achilles tendon rupture, we are unable to recommend for or against preoperative immobilization or restricted weight-bearing.

AAOS Strength of Recommendation: Inconclusive

Rationale: We were unable to find any published studies that addressed the effects of preoperative immobilization or restricted weight-bearing on the success of operative repair of acute rupture of this tendon. Supporting Evidence:

We did not identify any studies to address this recommendation.


RECOMMENDATION 8 1294 1295 1296 1297 1298 1299 1300

1301

We suggest that patients with an acute Achilles tendon rupture who are treated operatively undergo a minimally invasive technique rather than an open technique. AAOS Grade of Recommendation: Moderate Rationale:

We defined the following operative repairs:

1302 1303 1304

Open – procedure utilizing an extended incision for exposure allowing visualization of the rupture and tendon to allow direct placement of sutures for the repair.

1305 1306

Limited-Open – procedure utilizing a small incision for exposure allowing direct visualization of the ruptured ends.

1307 1308 1309

1310 1311 1312 1313

1314 1315 1316

1317 1318 1319 1320 1321

1322 1323 1324 1325 1326 1327

1328 1329 1330

1331

Percutaneous – procedure without direct exposure of the tendon rupture site. Both the limited-open and percutaneous techniques are considered “minimally invasive.”

A systematic review identified two level II comparative trials investigating percutaneous repair and three level II comparative trials studying limited-open repairs.27, 29, 32, 34, 35 In these studies, there was no significant difference in return to activities, rerupture or satisfaction between open and minimally invasive techniques.

Three studies show that complications are less likely using minimally invasive techniques.27, 32, 35 One study comparing percutaneous to open repairs demonstrated better SF-12 global outcomes in the percutaneous group.34

The literature reviewed refers primarily to non insertional ruptures in which there is sufficient distal tendon for repair. It is acknowledged that a small subset of ACTR consist of purely insertional injuries, often with a segment of bone attached. The latter group is beyond the scope of this GL. However, the reader should be aware of the fact that the repair techniques reviewed may not be compatible with these distal ruptures.

Consideration should also be given to the location of the tear when performing a repair in a percutaneous or limited-open fashion. Tears located at the proximal or distal ends of the tendon may compromise the ability to successfully complete a limited open repair. The orthopaedic surgeon performing the repair may need to extend the incision, converting it to an open technique if unable to obtain good suture fixation with a limited-open or percutaneous technique.

We suggest the use of minimally invasive techniques for acute Achilles tendon repair because of the lower incidence of complications with these techniques compared to open repair.


Supporting Evidence: 1332

1333 1334 1335

1336 1337 1338 1339 1340

1341 1342 1343 1344 1345 1346

s repair had significantly fewer superficial infections (see Table 63). Wound 1347 puckering occurred significantly more in patients treated with percutaneous repair (see 1348

1349

1350 in 1351

1352

1353 1354

epair (see 1355

in the number of reruptures 1356 d with limited open repair had 1357

signif tly fewer com tions than ts tr ate n repair (see Table 63). 1358 SUMMARY OF EVIDENCE 1359 T Perc en - Gl al O omes1360

Duration

We examined studies that made two different comparisons. Two level II studies compared percutaneous repair to open repair.29, 34 One level II study and two level III studies compared limited open to open repair.32 27, 35

PERCUTANEOUS VS OPEN REPAIR Patients treated with percutaneous repair scored significantly higher on the SF-12 physical and mental component scores (see Table 60). There was no significant difference in the amount of patients who returned to functional activities, activities of daily living, (see

Table 61) or patient satisfaction (see Table 62). The amount of reruptures did not significantly differ between treatment groups (see Table 64) One study reported no significant difference in the number of sural nerve injuries (Table 63). Patients treated with percutaneous repair had significantly less wound breakdown/delay of healing as well as less scar adhesions (see Table 63). No significant difference in the amount of deep infections was reported. Patients treated with percutaneou

Table 63).

LIMITED OPEN VS OPEN REPAIR Patients treated with limited open repair returned to normal walking and stair climbingsignificantly less time than patients treated with standard open repair (see

Table 61). A significantly larger percentage of patients treated with limited open repair returned to sports and activities and had fewer symptoms compared to patients treated with open r

Table 61). Two studies reported no significant differencebetween treatment groups (see Table 64). Patients treate

ican plica patien e d with ope

able 60. utaneous vs. Op ob utc

Author Outcome LOE N 24 months

Gigante Component Score II 39 ● P SF-12 - Physical

Gigante SF-12 - MeComponent S

ntal core II 39 ● P

● P: Statistically Significant in Favor of Percutaneous Repair 1361 Op: Statistically Significant in Favor of Open Repair 1362

○ No statistical significance 1363 1364

●


1365

Table 61. Percutaneous and Limited Open vs. Open - Return to Activities and 1366 Function 1367

D ationOutcome ur (months) Author LOE N 6 12 63.5 Treatment

%

Lim

Percutaneous vs.

D II 66 ○

Open

Return to Activities of

aily Living

Lim

Percutaneous vs. Open

Retu nal

○

rned to FiFunctional

Activity II 66

Bhattacharyya Limited Open vs.

Open Return to Normal

Walking III 53

● L

Bhattacharyya Ret al

Sta g ● Limited Open vs.

Open urn to Normir Climbin III 53 L

ES Ng Limited Open vs.

Open Return to Activity II 68 ○

Kakiuchi Limited Open vs.

Open Return to Sports III 22

● L

KakLimited Open vs.

iuchi Open Symptoms III 22 ●L * Final Functional Activity: “When patient was unhindered in all his or her activities apart from 1368

1369 epair 1370

in Favor of Limited Open Repair 1371 Op: Statistically Significant in Favor of Open Repair 1372

1373 1374 Tab ercutane en - S t 1375

Outcome Duration

sports.” ● P: Statistically Significant in Favor of Percutaneous R● L: Statistically Significant ●○ No statistical significance

le 62. P ous vs. Op atisfac ion

Author LOE N ths% 6 mon

Lim Satisfaction II 66 ○ ● P: Statistically Significant in Favor of Percutaneous Repair 1376

Op: Statistically Significant in Favor of Open Repair 1377 1378

1379 Tab rcutan d Li O Repa ations 1380

uration months)

●○ No statistical significance

le 63. Pe eous Repair an mited pen ir vs. O - Compen plic

D (Author Complications LOE N 12 63.5 6

Lim

Sural Nerve Problems II 66 ○

Lim Deep Infection II 66 ○


Duration (months) Author Complications LOE N 12 6 63.5

Lim Adhesions II 66 ●P

Lim Superficial Infection II 66 ●P

Lim Keloid Formation II 66 ○

Lim Wound Puckering II

66 ● Op Delayed Wound

Healing Bhattacharyya III 53

● L

Bhattacharyya Severe Wound Infection and Dehiscence

III 53

● L

Bhattacharyya Minor Surgical Site Infection III 53

● L

Ng Wound Breakdown II 68 ● L

Ng Sural Nerve Injury II 68 ○

Ng Scar Adhesion II 68 ● L

Ng Superficial Infection II 68 ○

Ng Hypertrophic Scar II 68 ○ ● P: Statistically Significant in Favor of Percutaneous Repair 1381

1382 1383 1384 1385 1386

● L: Statistically Significant in Favor of Limited Open Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance Table 64. Percutaneous and Limited Open vs. Open – Rerupture

Duration (months) Author Outcome LOE N

6 63.5 65.5 Lim Rerupture II 66 ○ Ng Rerupture II 68 ○

Kakiuchi Rerupture III 22 ○ 1387 1388 1389 1390

1391

● P: Statistically Significant in Favor of Percutaneous Repair ● L: Statistically Significant in Favor of Limited Open Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance


1392 1393 1394

EXCLUDED ARTICLES Table 65. Excluded Studies - All Operative Techniques


Cretnik A, et al Percutaneous versus open repair of the ruptured Achilles tendon. a comparative study


Wagnon R, et al The Webb-Bannister percutaneous technique for acute

Achilles' tendon ruptures. a functional and MRI assessment


Atkas S, et al Open Versus Minimal Invasive Repair with Achillon Device


Assal M, et al Limited open repair of Achilles tendon ruptures. a technique with a new instrument and findings of a

prospective multicenter study


Halasi T, et al Percutaneous Achilles tendon repair with and without endoscopic control


Cretnik A, et al Percutaneous suturing of the ruptured Achilles tendon under local anesthesia


Coutts A, et al Clinical and functional results of open operative repair for Achilles tendon rupture in a non-specialist surgical unit


Calder JD, et al Independent evaluation of a recently described Achilles tendon repair technique


Uchiyama E, et al A modified operation for Achilles tendon ruptures Not best available

evidence - not comparative

Maes R, et al; Is percutaneous repair of the Achilles tendon a safe technique? A study of 124 cases


Amlang MH, et al The percutaneous suture of the Achilles tendon with the Dresden instrument


Tang KL, et al Arthroscopically assisted percutaneous repair of fresh closed Achilles tendon rupture by Kessler's suture


Fortis AP, et al Repair of Achilles tendon rupture under endoscopic control


Schonberger TJ, et al

Operative treatment of acute Achilles tendon rupture. Open end-to-end-reconstruction versus reconstruction with

Mitek-anchors Retrospective case series

Hohendorff B, et al Long-term results after operatively treated Achilles tendon rupture. fibrin glue versus suture suture technique



Kuwada GT; Critical analysis of tendo Achillis repair using Achilles tendon rupture classification system and repair


Lansdaal JR, et al The results of 163 Achilles tendon ruptures treated by a

minimally invasive surgical technique and functional after treatment


Blankstein A, et al Percutaneous Achilles tendon repair combined with real-time sonography


Majewski M, et al Avoiding sural nerve injuries during percutaneous Achilles tendon repair


Jung HG, et al Outcome of Achilles tendon ruptures treated by a limited open technique


Scarfi G, et al Percutaneous repair of Achilles tendon Not best available


Crnica S, et al Follow-up results of Achilles tendon rupture treatment by the method of modified percutaneous suture


Perez TA; Traumatic rupture of the Achilles Tendon. Reconstruction by transplant and graft using the lateral peroneus brevis


Ma GW;Griffith TG;

Percutaneous repair of acute closed ruptured Achilles tendon. a new technique


Boyden EM, et al; Late versus early repair of Achilles tendon rupture. Clinical and biomechanical evaluation


Soldatis JJ, et al End-to-end operative repair of Achilles tendon rupture Not best available


Martinelli B; Percutaneous repair of the Achilles tendon in athletes Not best available


Mellor SJ;Patterson MH; Tendo Achillis rupture; surgical repair is a safe option


Bruggeman NB, et al

Wound complications after open Achilles tendon repair. an analysis of risk factors


Webb JM;Bannister GC; Percutaneous repair of the ruptured tendo Achillis


Gillespie HS;George EA;

Results of surgical repair of spontaneous rupture of the Achilles tendon




Jessing P;Hansen E; Surgical treatment of 102 tendo achillis ruptures-- suture or tenontoplasty?


Kiviluoto O, et al Surgical repair of subcutaneous rupture of the Achilles tendon


Haggmark T, et al Calf muscle atrophy and muscle function after non-operative vs. operative treatment of Achilles tendon

ruptures


Bomler J;Sturup J; Achilles tendon rupture. An 8-year follow up Not best available


Hogsaa B, et al Surgical treatment of Achilles tendon ruptures Not best available


FitzGibbons RE, et al Percutaneous Achilles tendon repair


Chillemi C, et al Percutaneous repair of Achilles tendon rupture. Ultrasonographical and isokinetic evaluation


Gorschewsky O, et al


Percutaneous repair of acute Achilles tendon rupture

1395 1396 1397

STUDY QUALITY Table 66. Study Quality - RCTs


Author Outcome N

Follo

w U

p - 8

0% o

r m

ore

Stoc

hast

ic

Ran

dom

izat

ion

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

Level of EvidenceTreatment(s)

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entr

y


SF-12. Physical

Component 39

Open Repair vs.

Percutaneous Repair

Level II ● × × ● ● ×


SF-12. Mental Component 39

Open Repair vs.

Percutaneous Repair

Level II ● × × ● ● ×

Lim, et al.

2001 Complications 66

Open Repair vs.

Percutaneous Level II ○ ● ● × ● ×




Stoc

hast

ic

Ran

dom

izat

ion

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entr

y

Follo

w U

p - 8

0% o

r m

ore

Repair

Lim, et al.

2001

Duration of Immobilization 66

Open Repair vs.

Percutaneous Repair

Level II ○ ● ● × ● ×

Lim, et al.

2001

Return to activities of daily living

66

Open Repair vs.

Percutaneous Repair

Level II ○ ● ● × ● ×

Lim, et al.

2001

Return to functional

activity 66

Open Repair vs.

Percutaneous Repair

Level II ○ ● ● × ● ×

1398

1399 Table 67. Quality of Studies - Comparative Studies


Author Outcome N Treatment(s) Level of Evidence A

ll gr

oups

hav

e si

mila

r ch

arac

teris

tics a

t ent

ry

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entry

All

grou

ps c

oncu

rren

tly

tre

ated

Follo

w U

p - 8

0% o

r mor

e

Sam

e ce

nter

for

expe

rimen

tal a

nd c

ontro

l gr

oup

data

Kakiuchi, et al. 1995

Return to Sports 22

Percutaneous and Minimally

Invasive vs. Open Repair

Level III × × ● ○ ●


Symptoms - None 22





Symptoms - Stiffness 22







ll gr

oups

hav

e si

mila

r ch

arac

teris

tics a

t ent

ry

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entry

All

grou

ps c

oncu

rren

tly

tre

ated

Sam

e ce

nter

for

expe

rimen

tal a

nd c

ontro

l gr

oup

data

Follo

w U

p - 8

0% o

r mor

e


Symptoms - Discomfort 22





Symptoms - Pain 22




Kakiuchi, et al. 1995 Re-rupture 22




Ng, et al. 2006 Return to Activity -

Same Level 68

Percutaneous vs. Open Repair

Level II ● × ● ● ●

Ng, et al. 2006 Complications 68 Percutaneous

vs. Open Repair

Level II ● × ● ● ●


Return to Normal Walking

53 Minimally


Level III ○ × ● ● ●


Return to Normal Stair

Climbing 53

Minimally Invasive vs. Open Repair



Severe Wound

Infection and Dehiscence

53 Minimally




Minor Surgical Site

Infection 53

Minimally Invasive vs. Open Repair



Delayed Wound Healing

53 Minimally




STUDY RESULTS 1400 1401 Table 68. Percutaneous vs. Open - Global Outcomes

Percutaneous Open Author Outcome LOE N Duration

mean (SD) mean (SD) Results

SF-12 - Physical Component Score II 39 24 months 52.6 (2.31) 50.7 (2.57) p = 0.02‡ Gigante, et al.

2008 SF-12- Mental Component Score II 39 24 months 52.2 (1.91) 50.4 (2.75) p = 0.02‡

1402 1403 1404

‡ AAOS calculation Table 69. Percutaneous vs. Open - Return to Activities

Author Outcome LOE N Duration Percutaneous (%)

Open (%) Results

Lim, et al. 2001 Return to

Activities of Daily Living

II 66 6 months 100% 100% NS

Lim, et al. 2001 Returned to Final

Functional Activity

II 66 6 months 100% 100% NS

NS: not significant; authors do not report p-value

Table 70. Percutaneous vs. Open - Satisfaction 1405

Author Outcome LOE N Duration Percutaneous (%)

Open (%) Results

Lim, et al. 2001 Satisfaction - Excellent II 66 6 months 52% 42% NS

NS: not significant; authors do not report p-value 1406

1407

1408

Table 71. Percutaneous vs. Open - Complications

Author Complications LOE N Duration Percutaneous(%)

Open (%) Results

Lim, et al 2001 Re-rupture II 66 6 months 3% 6% p = .55‡

Lim, et al. 2001

Sural Nerve Problems II 66 6 months 3% 0% p = .15‡

Lim, et al. 2001 Infections II 66 6 months 0% 21% p <

.001‡ Lim, et al.

2001 Keloid

Formation II 66 6 months 0% 3% p = .15‡

Lim, et al. 2001 Adhesions II 66 6 months 0% 6% p = .043


Author Complications LOE N Duration Percutaneous(%)

Open (%) Results

Lim, et al. 2001

Wound Puckering II 66 6 months 9% 0% p =

.013‡ ‡ AAOS calculation

Table 72. Minimally Invasive vs. Open - Function 1409

Author Outcome LOE N Duration Minimally

Invasive mean (SD)

Open Repair

mean (SD) Results

Return to Normal Walking (weeks) III 53 12 months 12.5 (3)‡ 17 (3)‡ p ≤ .001‡

Bhattacharyya, et al. 2009 Return to Normal

Stair Climbing (weeks)

III 53 12 months 14 (3)‡ 19 (3.5)‡ p ≤ .001‡

Ng, et al 2006 Return to

Activity - Same Level

II 68 65.5 months 96% 88% p = 0.244

‡ AAOS calculation

Table 73. Minimally Invasive vs. Open - Complications 1410

Author Complications LOE N Duration

Minimally Invasive Open

Repair (%)

Open (%) Results


Delayed Wound Healing III 53 12 months 0% 10% p <.001‡


Severe Wound Infection and Dehiscence

III 53 12 months 0% 10% p =.034‡


Minor Surgical Site Infection III 53 12 months 0% 25% p = .001‡

Ng, et al. 2006 Re-rupture II 68 65.5

months 0% 2% p = .223‡

Ng, et al. 2006

Sural Nerve Injury II 68 65.5

months 0% 2% p = .22‡

Ng, et al. 2006

Superficial Infection II 68 65.5

months 8% 5% p = .58‡

Ng, et al. 2006

Hypertrophic Scar II 68 65.5

months 4% 19% p = .052‡

Ng, et al. 2006 Scar Adhesion II 68 65.5

months 0% 9% p = .014‡

Ng, et al. 2006

Wound Breakdown/delay II 68 65.5

months 0% 12% p = .005‡

1411 ‡ AAOS calculation


Table 74. Minimally Invasive vs. Open - Symptoms 1412

Author Outcome LOE N Duration Minimally Invasive (%)

Open (%) Results

Kakiuchi, et al. 1995 Symptoms - Pain III 22 63.5

months 0% 20% p = .05‡

Kakiuchi, et al. 1995 Symptoms- None III 22 63.5

months 83% 40% p <.001‡


Symptoms - Stiffness III 22 63.5

months 17% 30% p =.78‡


Symptoms - Discomfort III 22 63.5

months 0% 10% p = .17‡


Table 75. Minimally Invasive vs. Open - Return to Sport 1413


Minimally Invasive (%)

Open (%) Results

Return to Sport - Same or

increased level III 22 63.5

months 75% 10% p < .001‡

Return to Sport - Decreased III 22 63.5

months 8% 40% p = .17‡ Kakiuchi, et al. 1995

Return to Sport - No participation for other reasons

III 22 63.5 months 17% 50% p = .27‡

1414 1415 1416


Table 76. Minimally Invasive vs. Open - Complications

Minimally Invasive (%) Open

Author Complications LOE N Duration % %

Results

Kakiuchi, et al. 1995 Rerupture III 22 63.5

months 0% 0% NS

1417 NS: not significant; authors do not report p-value



1421

1422

1423 1424 1425

1426 1427

1428 1429 1430 1431

1432

1433 1434 1435 1436 1437

1438 1439 1440 1441

1442 1443 1444 1445 1446 1447 1448 1449

1450 1451 1452 1453 1454

We cannot recommend for or against the use of allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts in acute Achilles tendon ruptures that are treated operatively.


Rationale

A systematic review failed to identify adequate evidence to make a recommendation for or against the use of allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts in acute Achilles tendon ruptures that are treated operatively.

No studies addressed adjunctive augmentation with allograft, xenograft, or biologic adjuncts.

Three level II studies36-38 compared open repair alone and autograft augmentation. One level IV study39 compared patients treated with synthetic tissue augmentation to open repair alone. All four of these studies failed to demonstrate significant improvement in outcomes or complications.


No studies were identified that address adjunctive augmentation with allograft (see Table 83), xenograft, or biologic adjuncts (see Table 86). We examined three level II studies that compared patients given adjunctive augmentation with autograft tissue vs. open repair.36-38 One Level IV study that compared patients given adjunctive augmentation with synthetic tissue vs. open repair.39

AUTOGRAFT TISSUE VS OPEN REPAIR Three studies reported that patients given adjunctive augmentation did not significantly differ in pain, stiffness, satisfaction, return to daily activities, return to sport, or footwear restrictions (see Table 77 - Table 80).

One study reported one patient given adjunct augmentation had a pulmonary embolism; no significant difference was found between treatment groups (see Table 82). In two studies, DVT rates did not significantly differ in patients given augmentation with autograft tissue vs. open repair. Two studies reported patients with deep infection. One study found patients treated with open repair had significantly less deep infections and the other study reported no significant difference. No significant differences were found in patients given augmentation with superficial infections, dysesthesia, Keloid, and dehiscence (see Table 82).

AUGMENTATION WITH SYNTHETIC TISSUE VS OPEN REPAIR We analyzed one non-comparative study that analyzed patients treated with synthetic tissue (polypropylene braid). All patients reported excellent results and all patients returned to previous activity (see Table 97). There were no reruptures and no healing impairment (see Table 97). One patient underwent a PB removal procedure 1 year after


surgery because of the distal heat-sealed end of the PB device stuck out of the tendon, causing an impingement on the shoe (see

1455 1456

1457 1458

Table 97).

SUMMARY OF EVIDENCE Table 77. Autograft vs. Open - Pain and Stiffness

Duration (months) Author LOE N Outcome 6 12 42

Pajala II 59 Pain ○

Aktas II 30 Pain ○

Taglialavoro II 46 Pain ○

Pajala II 59 Stiffness ○

1459 1460 1461 1462

1463

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance

Table 78. Autograft vs. Open - Satisfaction Duration (months) Author LOE N Outcome 12 42

Taglialavoro II 46 Satisfaction ○

Pajala II 59 Satisfaction ○

1464 1465 1466 1467

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 79. Autograft - Return to Activities and Sports

Duration (months)

Author LOE N Outcome 6 42

Taglialavoro II 46 Recovery of Daily

Activities (days) ○

Taglialavoro II 46

Return to Sports – Complaints during normal

activity ○

Aktas, et al II 30 Return to Sports – Same

Level / Pre-injury ○

Taglialavoro II 46 Return to Sports ○ 1468 1469 1470



1471 1472 Table 80. Autograft vs. Open - Footwear Restrictions

Duration (months) Author LOE N Outcome

12 42

Pajala II 59 Footwear Restrictions ○

Taglialavoro II 46 Conflict with shoes ○

1473 1474 1475 1476 1477

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 81. Autograft vs. Open - Hospitalization and Immobilization

Author Outcome (Days) LOE N Duration

42 months

Taglialavoro Hospitalization II 46 ●Op

Taglialavoro Immobilization II 46 ●Op

1478 1479 1480 1481 1482

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 82. Autograft vs. Open - Complications

Duration (months) Author LOE N Outcome 6 12 42

Taglialavoro II 46 PE ○ Taglialavoro II 46 DVT ○

Pajala II 60 DVT ○ Aktas II 30 Deep Infection ○ Pajala II 60 Deep Infection ●Op

Pajala II 60 Superficial Infection ○

Pajala II 60 Re-rupture ○

Aktas II 30 Re-rupture ○ Taglialavoro II 46 Dysesthesia ○ Taglialavoro II 46 Cheloid ○ Taglialavoro II 46 Dehiscence ○

1483 1484 1485 1486



EXCLUDED ARTICLES 1487 1488 Table 83. Excluded Studies - Allograft


Bleakney, et al. 2005 Imaging of the Achilles tendon Commentary

Lee, et al. 2007

Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures

Neglected/chronic Achilles tear patients

1489 1490 Table 84. Excluded Studies - Autograft


Bradley, et al. 1990

Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study


Coull, et al. 2003

Flexor hallucis longus tendon transfer: evaluation of postoperative morbidity


Cretnik, et al. 2004 Incidence and outcome of rupture of the Achilles tendon Not best available

evidence Dekker, et al.

1977 Results of surgical treatment of rupture of the Achilles

tendon with use of the plantaris tendon Not best available

evidence

Elias, et al. 2007

Reconstruction for missed or neglected Achilles tendon rupture with V-Y lengthening and flexor hallucis longus

tendon transfer through one incision


Garabito, et al. 2005

Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia


Hahn, et al. 2008

Treatment of chronic Achilles tendinopathy and ruptures with flexor hallucis tendon transfer: clinical outcome and

MRI findings


Jessing, et al. 1975

Surgical treatment of 102 tendo achillis ruptures-- suture or tenontoplasty?


Kiviluoto, et al. 1985

Surgical repair of subcutaneous rupture of the Achilles tendon cast only

Leppilahti, et al. 1998

Outcome and prognostic factors of Achilles rupture repair using a new scoring method


Lynn, et al. 1966

Repair of the torn Achilles tendon, using the plantaris tendon as a reinforcing membrane

Less than 50% follow-up

Maffulli, et al. 2005

Free gracilis tendon graft in neglected tears of the Achilles tendon


Roberts, et al. 1989

Team physician #6. Surgical treatment of Achilles tendon rupture


Schedl, et al. 1979

Achilles tendon repair with the plantaris tendon compared with repair using polyglycol threads


Stein, et al. 2005 Duthie's biological repair of ruptured Achilles tendons Insufficient

Quantitative Data



Winter, et al. 1998

Surgical repair of Achilles tendon rupture. Comparison of surgical with conservative treatment

Retrospective case series

Wong, et al. 2005

Modified flexor hallucis longus transfer for Achilles insertional rupture in elderly patients


1491 1492 Table 85. Excluded Studies - Synthetic Tissue

Author Title Exclusion Reason Fernandez-Fairen, et

al. 1997

Augmented repair of Achilles tendon ruptures Retrospective case series

Hohendorff, et al. 2008

Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture Suture Technique

Parsons, et al. 1984

Achilles tendon repair with an absorbable polymer-carbon fiber composite

Combines acute and neglected/chronic

Achilles tendon tear patients

Parsons, et al. 1989

Patients had prior surgical or

conservative treatment

Long-term follow-up of Achilles tendon repair with an absorbable polymer carbon fiber composite

1493


Table 86- Biologic Adjuncts 1494


Aspenberg, et al. 2007

Stimulation of tendon repair: mechanical loading, GDFs and platelets. A mini-review Review

Sanchez, et al. 2007

Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices


1495


1496 1497 1498

STUDY QUALITY Table 87. Study Quality – Autograft RCTs


Author

Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

Follo

w U

p - 8

0% o

r m

ore

Outcome N Level of EvidenceTreatment(s) A

ll gr

oups

hav

e si

mila

r ou

tcom

e pe

rfor

man

ce a

t ent

ry

Pajala, et al.

2009 Stiffness 60 Open vs. Autograft

Augmentation Level II ● ● ● ○ ● ×

Pajala, et al.

2009

Footwear Restrictions 60 Open vs. Autograft


Pajala, et al.

2009 Pain 60 Open vs. Autograft


Pajala, et al.

2009 Satisfaction 60 Open vs. Autograft


Pajala, et al.

2009 Re-rupture 60 Open vs. Autograft


Pajala, et al.

2009 Deep Infection 60 Open vs. Autograft


Pajala, et al.

2009 DVT 60 Open vs. Autograft


Pajala, et al.

2009

Superficial Infection 60 Open vs. Autograft


Aktas, et al.

2007 Return to sport 30 Open vs. Autograft

Augmentation Level II × × ● ○ ● ×

Aktas, et al.

2007 Pain 30 Open vs. Autograft

Augmentation Level II ○ ● ● ○ ● ×




Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at e

ntry

Follo

w U

p - 8

0% o

r m

ore

Aktas, et al.

2007 Deep Infection 30 Open vs. Autograft


Aktas, et al.

2007 Re-rupture 30 Open vs. Autograft


1499 1500

1501

Table 88. Study Quality - Autograft Comparative Studies


Author

Outcome N Level of Evidence A

ll gr

oups

hav

e si

mila

r cha

ract

eris

tics

at e

ntry

A

ll gr

oups

hav

e si

mila

r out

com

e pe

rfor

man

ce a

t ent

ry

All

grou

ps c

oncu

rren

tly

treat

ed

Follo

w U

p - 8

0% o

r mor

e

Treatment(s) Sam

e ce

nter

for e

xper

imen

tal a

nd

cont

rol g

roup

dat

a

Taglialavoro, et al 2004 Pain 46 Open vs. Autograft

Augmentation Level II ● ● ● ● ●

Taglialavoro, et al 2004

Recovery of Daily Activities 46 Open vs. Autograft


Taglialavoro, et al 2004 Return to Sports 46 Open vs. Autograft


Taglialavoro, et al 2004 Satisfaction 46 Open vs. Autograft


Taglialavoro, et al 2004 Hospitalization 46 Open vs. Autograft





ll gr

oups

hav

e si

mila

r cha

ract

eris

tics

at e

ntry

A

ll gr

oups

hav

e si

mila

r out

com

e pe

rfor

man

ce a

t ent

ry

All

grou

ps c

oncu

rren

tly

treat

ed

Sam

e ce

nter

for e

xper

imen

tal a

nd

cont

rol g

roup

dat

a

Follo

w U

p - 8

0% o

r mor

e

Taglialavoro, et al 2004 Immobilization 46 Open vs. Autograft


Taglialavoro, et al 2004 DVT 46 Open vs. Autograft


Taglialavoro, et al 2004 PE 46 Open vs. Autograft


Taglialavoro, et al 2004 Dysesthesia 46 Open vs. Autograft


Taglialavoro, et al 2004 Shoe conflict 46 Open vs. Autograft


Taglialavoro, et al 2004 Cheloid 46 Open vs. Autograft


Taglialavoro, et al 2004 Dehiscence 46 Open vs. Autograft


1502


Table 89. Study Quality - Synthetic Tissue Case Series 1503


Author

Con

secu

tive

enro

llmen

t

of

pat

ient

s

Follo

w U

p - 8

0% o

r mor

e

All

patie

nts e

valu

ated

usi

ng

sam

e ou

tcom

e m

easu

res

All

patie

nts r

ecei

ve sa

me

treat

men

t

Level of EvidenceOutcome N Treatment(s)

All

patie

nts h

ave

appr

oxim

atel

y eq

ual f

ollo

w-u

p tim

es

Giannini et al, 1994 Return to Sports 15 Synthetic Adjunctive

Augmentation Level IV ● ● ● ● ●

Giannini et al, 1994

Return to Previous Activity

15 Synthetic Adjunctive Augmentation Level IV ● ● ● ● ●


Subjective Results-

Excellent 15 Synthetic Adjunctive



Full weight-bearing (weeks) 15 Synthetic Adjunctive


Giannini et al, 1994 Re-rupture 15 Synthetic Adjunctive



Healing Impairment 15 Synthetic Adjunctive



Return to Swimming 15 Synthetic Adjunctive


1504


STUDY RESULTS 1505 1506 Table 90 Autograft vs. Open Pain and Stiffness

Adjunctive Augmentation Open Author Outcome LOE N Duration

% % Results

Pajala, et al. 2009 No Pain vs. Pain II 59 12

months 79% (4%) 90% (0%) p = 0.35

Aktas, et al. 2007 Pain - Absent* II 30 6 months 94% 86% NS

Aktas, et al. 2007

Pain - Mild w/ maximal exertion* II 30 6 months 6% 14% NS

Taglialavoro, et al 2004 Pain - Absentª II 46 42

months 83% 73% NS


Pain - During Intense Trainingª II 46 42

months 17% 18% NS


Pain - During Moderate Trainingª II 46 42

months 0% 5% NS

Taglialavoro, et al 2004 Pain - Continuousª II 46 42

months 0% 5% NS

Pajala, et al. 2009 No stiffness vs. stiffness II 59 12

months 46% (36% 72% (16%) p = .10

*American Orthopaedic Foot and Ankle Score NS: not significant; authors do not report p-value

Table 91. Autograft vs. Open - Satisfaction 1507

Author Outcome LOE N Duration Adjunctive

Augmentation (%)

Open (%) Results

Pajala, et al. 2009

Very satisfied vs. all other satisfaction levels II 59 12

months 71% (11%) 71% (19%) p = 0.55

Taglialavoro, et al 2004 Satisfaction - Very Goodª II 46 42

months 46% 46% p = .98‡

Taglialavoro, et al 2004 Satisfaction - Goodª II 46 42

months 42% 46% p = .8‡

Taglialavoro, et al 2004 Satisfaction - Fairª II 46 42

months 13% 0% p = .01‡

Taglialavoro, et al 2004 Satisfaction - Poorª II 46 42

months 0% 9% p = .04‡

ª Modified McCormis Score ‡ AAOS Calculation

1508


1509 1510 Table 92. Autograft vs. Open - Return to Sports


Augmentation (%)

Open (%) Results

Aktas, et al. 2007

Return to Sports - Same Level / Pre-injury II 30 6 months 85% 89% p = .620‡


Return to Sports - Complete II 46 42

months 38% 32% NS


Return to Sports - Low Loss II 46 42

months 50% 55% NS


Return to Sports - Decreased II 46 42

months 8% 9% NS


Return to Sports - Not Recovered II 46 42

months 4% 0% NS


Return to Sports - Complaints during

normal activity II 46 42

months 0% 5% NS

1511 1512 1513 1514

‡ AAOS Calculation NS: not significant; authors do not report p-value Table 93. Autograft vs. Open - Return to Activities


Adjunctive Augmentation

mean (SD)

Open mean(SD) Results


Recovery of Daily Activities(days) II 46 42

months 128 (39) 106 (66) p = .17‡

1515 1516 1517 1518

‡ AAOS Calculation Table 94. Autograft vs. Open - Footwear Restrictions


Augmentation (%)

Open (%) Results

Pajala, et al. 2009

No footwear restrictions vs. footwear restrictions II 60 12

months 79% (4%) 90% (0%) p = 0.35

Taglialavoro, et al 2004 Shoe conflict II 46 42

months 38% 23% NS

1519 1520 1521

1522

1523

‡ AAOS Calculation NS: not significant; authors do not report p-value


Table 95. Autograft vs. Open - Hospitalization vs. Immobilization 1524


Augmentation mean (SD)

Open mean(SD) Results

Taglialavoro, et al 2004 Hospitalization (days) II 46 42

months 8.2 (2.3) 5.0 (1.9) p <.001‡

Taglialavoro, et al 2004 Immobilization (days) II 46 42

months 63.9 (15.8) 49.5 (10.6) p <.001‡

‡ AAOS Calculation 1525

1526 Table 96. Autograft vs. Open - Complications

Adjunctive Augmentation

Open Repair

Author Complication LOE N Duration % % Results

Taglialavoro, et al 2004 PE II 46 42 months 4% 0% NS

Taglialavoro, et al 2004 DVT II 46 42 months 4% 14% NS

Pajala, et al. 2009 DVT II 60 3 weeks 4% 0% NS

Pajala, et al. 2009 Deep Infection II 60 12 months 7% 0% p = .04‡

Aktas et al. 2007 Deep Infection II 30 6 months 6% 0% NS

Pajala, et al. 2009

Superficial Infection II 60 12 months 4% 13% NS

Pajala, et al. 2009 Re-rupture* II 60 12 months 11% 9% NS

Aktas et al. 2007 Re-rupture II 30 6 months 0% 0% NS

Taglialavoro, et al 2004 Dysesthesia II 46 42 months 13% 14% NS

Taglialavoro, et al 2004 Cheloid II 46 42 months 8% 5% NS

Taglialavoro, et al 2004 Dehiscence II 46 42 months 13% 9% NS

* Three of the patients with reruptures had obvious new injury during recovery period. One re-rupture occurred at ten weeks when patient was cycling up a steep hill. Two re-ruptures occurred at twelve weeks with minimum trauma; these patients were in the Open repair group and recalled having sustained a slight injury during the first three weeks. ‡ AAOS calculation NS: Non-Significant; Authors did not report p-value

1527


Table 97. Synthetic Tissue - Results 1528

Adjunctive AugmentationAuthor Outcome LOE N Duration mean (SD) %

Giannini et al, 1994 Subjective Results- Excellent IV 15 18

months 100%

Giannini et al, 1994 Return to Previous Activity IV 15 18

months 100%

Giannini et al, 1994 Re-rupture IV 15 18

months 0%

Giannini et al, 1994 Healing Impairment IV 15 18

months 0%

1529 1530


RECOMMENDATION 10 1531 1532 1533 1534

1535 1536 1537 1538

1539 1540 1541

We cannot recommend for or against the use of antithrombotic treatment for patients with acute Achilles tendon ruptures. Strength of Recommendation: Inconclusive

Rationale: A systematic review was conducted to determine if prophylaxis for thromboembolic events is warranted for patients with acute Achilles tendon rupture. No studies were identified that address this issue.

EXCLUDED STUDIES Table 98. Antithrombotic Treatment - Excluded Studies


Nilsson-Helander, et al. 2009

High Incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study

Not Relevant; Does not answer the

recommendation. Lapidus, et al.

2007 Prolonged thromboprophylaxis with dalteparin after surgical treatment

of Achilles tendon rupture: a randomized, placebo-controlled study Less than 50%

follow up

Lassen, et al. 2002

Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization

Less than 80% Achilles tendon tear

patients



1545

1546 1547 1548 1549 1550 1551 1552 1553 1554 1555 1556 1557 1558 1559 1560 1561 1562 1563 1564 1565 1566 1567 1568 1569 1570 1571 1572 1573 1574 1575 1576 1577 1578

1579 1580

1581 1582

We suggest early (≤ 2 weeks) post-operative protected weight bearing for patients with acute Achilles tendon rupture who have been treated operatively.


Rationale: A systematic review identified three Level II studies40, 5, 41that compared early postoperative weight bearing to non-weight bearing following surgical repair of the Achilles tendon. All studies randomized the patients into two groups with either six weeks of non-weight bearing in a cast or early weight bearing with a modified splint device. One study40 permitted immediate toe-touch weight bearing starting the day of surgery in a cast. The second study5 allowed the weight bearing group to begin immediate rehabilitation on the first post-operative day in a modified splint. The patients in the third study41 began weight bearing two weeks after surgery. By two weeks, all investigators used a splint device that limited dorsiflexion to prevent compromise of the repair. After four weeks, Maffulli et al.40 allowed the non-weight bearing group to begin full weight bearing in a cast, while the other two studies5, 41 kept the non-weight bearing group on crutches for six weeks. One study5, found a significantly higher re-rupture rate in the early postoperative weight bearing group (2 of 23 patients) compared to non-weight bearing group (0 of 25 patients). Both patients had documented non-compliance with the use of their postoperative splint and fell during the first four weeks after surgery. Two studies40, 5 found that the weight bearing group had statistical improvement in the time to return to activities including work, sports, and normal walking. Suchak et al.41 found significantly better scores in physical functioning and reported fewer limitations of daily living six weeks after the operation. By 12 months, all three studies found that there was no significant difference between the two groups in outcomes such as pain and function. Although the ultimate level of function achieved after operative repair of an Achilles rupture is similar regardless of the post-operative weight bearing protocol, early post-operative weight bearing allows the patient to achieve a quicker return to activities during the first six months than those patients treated with traditional postoperative casting. Treatment decisions should be made in light of all circumstances presented by the patient. Mutual communication between patient and physician should include a discussion of the importance of patient compliance when a program is prescribed for the use of early weight bearing. Patient compliance to protocol is important to prevent re-rupture.


Three Level II studies 40, 5, 41 compare early postoperative weight-bearing to non-weight bearing following surgical repair of the Achilles tendon. The post-operative regimes in


1583 1584

1585 1586 1587 1588 1589 1590 1591 1592 1593 1594 1595 1596 1597 1598 1599

1600 1601 1602

1603

1604

the three studies are detailed in Table 99. For results of early weight-bearing versus non-weight bearing see Table 100 though Table 106.

Of thirty-two outcome measures comparing early weight-bearing to non-weight bearing, thirteen were statistically significant in favor of early weight bearing, while zero were in favor of non-weight bearing. Seven of the fifteen results in favor of early weight bearing measured time until returning to activity (return to sports, return to normal walking, return to stair climbing, return to work, return to full weight bearing, number of physical therapy visits, and time until release from physical therapy) (see Table 100). A second study5 that measured time until return to work did not find a statistically significant difference between groups. At one and a half months, the early weight-bearing group reported statistically significantly fewer limitations and scored statistically significantly higher on the physical function, social function, vitality, and emotion components of the Rand-36 scale. One study reported that statistically significantly more patients returned to sports at 12 months. However, two other studies reported no statistically significant difference in return to sports at six or twelve months. There was no statistically significant difference in pain, satisfaction, return to work, limitations, or footwear restrictions at twelve months (see Table 101 through Table 104).

One study5, reported significantly more re-ruptures in the early weight-bearing group. Of the two patients with re-ruptures, one patient did not follow the written rehabilitation protocol and the second patient suffered a fall on ice and forcibly dorsiflexed his ankle.

There were no statistically significant differences between groups in complications.

Table 99: Description of treatment groups Author Post operative Instructions

Maffulli, et al.

Early weight-bearing group: Bear weight on the tip toes of the operated leg as tolerated but keep leg elevated for the first two weeks. Begin weight-bearing as tolerated. Non-weight-bearing group: No weight bearing and keep leg elevated for first two weeks. Increase weight bearing at 4 weeks.

Costa, et al. Early weight-bearing group: Immediate weight-bearing and mobilization using carbon fibre orthosis with 1.5 cm heal raises. Non-weight-bearing group: Traditional plaster cast.

Suchak, et al.

Early weight-bearing group: Two weeks of non-weight-bearing followed by weight-bearing. Non-weight-bearing group: 6 weeks of non-weight bearing using auxiliary crutches.

1605


SUMMARY OF EVIDENCE 1606 1607 Table 100 Time until return to activity

Author Outcome LoE N Time to Return to Activity

Maffulli, et al 2003 Return to Sports (months) II 53 ●wb

Costa, et al 2006 Return to Normal Walking (weeks) II 48** ●wb

Costa, et al 2006 Return to Normal Stair Climbing (weeks) II 48** ●wb

Costa, et al 2006 Return to Work (weeks) II 48** ○

Maffulli, et al 2003 Return to Work (weeks) II 53 ●wb

Maffulli, et al 2003 Full weight-Bearing (wks) II 53 ●wb

Maffulli, et al 2003 Physiotherapy sessions (visits) II 53 ●wb

Maffulli, et al 2003 Discharged from Physiotherapy (months) II 53 ●wb

1608 1609 1610 1611 1612 1613 1614

Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks Table 101 Pain

Result (months)

Author Outcome LoE N 1.5 2 3 6 12

Maffulli, et al 2003 Pain- None II 53 ○*

Maffulli, et al 2003 Pain- Mild, Occasional II 53 ○*

Maffulli, et al 2003 Pain- Moderate II 53 ○*

1615 1616 1617 1618 1619

Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks


1620

1621 Table 102 Function

Author Outcome Result (months)

Suchak, et al 2008

No Limitations or Limitations only in recreation LoE N 1.5 6 12

Maffulli, et al 2003 No Limitations II 110 ●wb

Maffulli, et al 2003

Activity Limitation - Limited Recreational but not Daily Activities II 53 ○

Suchak, et al 2008 Return to at least partial sports II 53 ○*

Maffulli, et al 2003 Return to Sports II 110 ○*

Costa, et al 2006 Return to Sports II 38 ○*

Maffulli, et al 2003 Return to Work II 48** ●wb

Maffulli, et al 2003 Changed Jobs II 49 ○*


Experience Problems at work due to injury II 49 ○*


Footwear restrictions- None, mild (most shoes tolerated) II 49 ○*


Footwear restrictions- Moderate (unable to tolerate fashionable shoes,

with or without insert) II 53 ○*

Wb= weight bearing 1622 1623 1624 1625

**= Open cast group converted to orthosis at 3 weeks 1626

○= no statistically significant difference ●= statistically significant difference * AAOS calculations


Table 103 EuroQoL, Rand-36 1627

Results (Months) Author Outcome LoE N

1.5 2 6 12 Costa, et al

2006 EuroQoL - Health

Score II 48** ○ ○ ○

Costa, et al 2006 EuroQoL - E5D II 48** ○ ○ ○

Suchak, et al 2008

Rand-36 Physical Functioning II 110 ●wb

Suchak, et al 2008

Rand-36 Social Functioning II 110 ●wb

Suchak, et al 2008 Rand-36 Vitality II 110 ●wb

Suchak, et al 2008

Rand-36 Role-Emotional II 110 ●wb

1628 1629 1630 1631 1632 1633 1634

Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks Table 104 Patient Subjective Results

Results (Months)

Author Outcome LoE N 12 months


Patient opinion of results- Excellent

II 53 ○*


Percent satisfied with results of surgery

II 53 ○*

1635 1636 1637 1638 1639 1640

1641

Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks

Table 105 Reruptures

Author LoE Duration N Weight Bearing

Non-Weight Bearing

Statistically Significant Difference

Costa, et al 2006

II 1 year 48** 8.69% 0% ●* nwb

1642 1643 1644

**= Open cast group converted to orthosis at 3 weeks; ●* nwb= statistically significant difference in favor of non-weight-bearing


SUMMARY OF COMPLICATIONS 1645 1646 Table 106 Reported Complications

Author Complication LoE Duration N Weight Bearing

Non-Weight Bearing


Suchak, et al 2008 DVT II 6

months 110 0% 2% ○*

Suchak, et al 2008 Necrosis of the skin II 6

months 110 0% 2% ○*

Suchak, et al 2008

Sural nerve dysesthesias, superficial

infections, delayed wound healing, scar

adhesions.

II 6 months 110 15% 16% ○*

Maffulli, et al 2003 Superficial Infection II 12

months 53 7.69% 7.40% ○*


Hypersensitivity of surgical wounds II 10-12

wks 53 15.38% 18.51% ○*

Maffulli, et al 2003 Hypertrophic Scar II 10-12

weeks 53 3.84% 0% ○*

Costa, et al 2006

Minor wound complications II Nr 48** 26% 21% ○*

Costa, et al 2006

Percsistent paraethesiae II Nr 48** 0% 4.3% ○*

1647 1648 1649 1650 1651 1652 1653 1654

Wb= weight bearing Nwb= non-weight-bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks

Table 107 Systematic Reviews Author Conclusion

"Postoperative splinting in a cast followed by a functional brace rather than a cast alone reduces the overall complication rate" (p. 2209).


"Early functional mobilisation is more acceptable to patients than plaster cast immobilisation and results in improved functional outcomes" (p. 156).

Lynch, RM 2004

Suchak, AA et al. 2006 "An early functional rehabilitation protocol for Achilles tendon ruptures improves patient satisfaction with reduction in minor complications and no increase in rerupture rate or infection rate" (p. 220).


EXCLUDED ARTICLES 1655 1656 Table 108 Article Inclusion List- Early weight-bearing vs. non-weight bearing

Author Title Exclusion Reason Maffulli, et

al. 2003

No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon Data reported previously

Costa, et al. 2003



Wagnon, et al.

2005

The Webb-Bannister percutaneous technique for acute Achilles' tendon ruptures: a functional and MRI

assessment

No patient-oriented outcome

Aoki, et al. 1998

Early active motion and weight-bearing after cross-stitch Achilles tendon repair


Speck, et al. 1998

Early full weight-bearing and functional treatment after surgical repair of acute Achilles tendon rupture


Solveborn, et al. 1994



1657


STUDY QUALITY 1658 1659 Table 109. Quality- Weight-bearing vs. non-weight bearing

● = Yes ○ = No × = Not Reported n/a = not applicable

Author

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

ent

r

Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

Follo

w U

p - 8

0% o

r m

ore

y

Outcome N Treatment(s) LoE

Costa, et al.

2006 Return to Sports 43

Weight-bearing vs. Non-

weight-bearing II ● ● × × ● ●

Costa, et al.

2006

Return to Sport (weeks)** 43



Costa, et al.

2006

Return to Normal Walking (weeks) 43



Costa, et al.

2006

Return to Normal Stair Climbing

(weeks) 43



Costa, et al.

2006

Return to Work (weeks) 43



Costa, et al.

2006

EuroQoL - Health Score** 43


weight-bearing II ● ● × × ● ×

Costa, et al.

2006 EuroQoL - E5D* 43


weight-bearing II ● ● × × ● ×

Suchak, et al. 2008

RAND-36: Physical Function 109

Weight bearing vs. Non-weight

bearing II ● ● × × ● ×



Author Outcome N Treatment(s) LoE

Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

ent

r

Follo

w U

p - 8

0% o

r m

ore

y

Suchak, et al. 2008

RAND-36: Mental health 109



Suchak, et al. 2008

Complications 110Weight bearing vs. Non-weight


Suchak, et al. 2008

RAND-36: Social Functioning 109



Suchak, et al. 2008

RAND-36: Role-physical 109



Suchak, et al. 2008

RAND-36: Bodily pain 109



Suchak, et al. 2008

RAND-36: General health 109



Suchak, et al. 2008

RAND-36: Vitality 109Weight bearing vs. Non-weight


Suchak, et al. 2008

RAND-36: Role-emotional 109






Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

ent

r

Follo

w U

p - 8

0% o

r m

ore

y


Pain- None 53

Weight Bearing vs. Non-Weight

Bearing

II ○ ○ ○ ● ● ×


Pain- Mild, Occasional 53

Weight Bearing vs. Non-Weight

Bearing

II ○ ○ ○ ● ● ×


Pain- Moderate 53

Weight Bearing vs. Non-weight-bearing

II ○ ○ × × ● ×


Return to Sports 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ×


Return to Sports (months) 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●




II ○ ○ × × ● ●


Return to Work 53


II ○ ○ × × ● ●


Changed Jobs 53


II ○ ○ × × ● ●




Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

ent

r

Follo

w U

p - 8

0% o

r m

ore

y


Experience Problems at work

due to injury 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●


Full weight-Bearing (wks) 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●


Activity Limitation - None 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●


Activity Limitation - Limited

Recreational but not Daily Activities

53 Weight

Bearing vs. Non Weight

II ○ ○ × × ● ●


Discharged from Physiotherapy

(months) 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●


Physiotherapy sessions (visits) 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●


Footwear restrictions- None, mild (most shoes

tolerated)

53

Weight Bearing vs. Non Weight

Bearing

II ○ ○ × × ● ●




Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

ent

r

Follo

w U

p - 8

0% o

r m

ore

y


Footwear restrictions-

Moderate (unable to tolerate

fashionable shoes, with or without

insert)

53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●


Percent satisfied with results of

surgery 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●


Patient opinion of results- Excellent 53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●

1660


1661 1662 1663

STUDY RESULTS Table 110 Study Data: Weight Bearing vs. Non-Weight Bearing

Author Outcome LoE Duration N Weight Bearing

Non-Weight Bearing Result

Suchak, et al 2008

Rand-36 Physical Functioning II 6 week 110 61.4 (SD

29.4) 47.6 (SD

34.4) p = 0.03

Suchak, et al 2008

Rand-36 Social Functioning II 6 week 110 72.7 (SD

28.5) 60.7 (SD

26.8) p = 0.03

Suchak, et al 2008 Rand-36 Vitality II 6 week 110 69.4 (SD

23.7) 60.6 (SD

21.1) p = 0.04

Suchak, et al 2008

Rand-36 Role-Emotional II 6 week 110 84.6 (SD

32.0) 67.3 (SD

43.1) p = 0.02

Suchak, et al 2008

No Limitations or Limitations only in

recreation II 6 week 110 43% 9% p = <.001

Suchak, et al 2008

Return to at least partial sports II 6 months 110 67% 63%

OR 1.08 (95% CI .46, 2.54)


Full weight-Bearing (wks) II 12

months 53 2.5 (SD 0.4) 5.5 (SD 2.2) p = 0.021


Physiotherapy sessions (visits) II 12

months 53 6.1 (SD 3.1) 13.6 (SD 4.8) p = 0.03


Discharged from Physiotherapy (months) II 12

months 53 2.1 (SD 1.1) 4.6 (SD 2) p = <.0001

Maffulli, et al 2003 Pain- None II 12

months 53 88% 89% OR .95

(95% CI .12, 7.92)*

Maffulli, et al 2003 Pain- Mild, Occasional II 12

months 53 8% 7% OR 1.04 (95% CI

.07, 15.43)*

Maffulli, et al 2003 Pain- Moderate II 12

months 53 4% 4%

OR 1.04 (95% CI

.01, 84.73) *


Activity Limitation - None II 12

months 53 92% 93%

OR .96 (95% CI .0647975

14.24349*





Activity Limitation - Limited Recreational

but not Daily ActivitiesII 12

months 53 8% 7%

OR 1.041667 (95% CI

.07, 15.43)

Maffulli, et al 2003 Return to Sports II 12

months 38 89% 89% OR 1 (95%

CI .35, 2.78)*


Return to Sports (months) II 12

months 53 5.1 (SD 2.8) 6 (SD 3) p= 0.04


Footwear restrictions-None, mild (most shoes

tolerated) II 12

months 53 96% 93%

OR 1.08(95%

CI .46 2.50)


Footwear restrictions-Moderate (unable to tolerate fashionable

shoes, with or without insert)

II 12 months 53 4% 7%

OR .48 (95% CI .01, 9.92)


Percent satisfied with results of surgery II 12

months 53 88% 85% 1.04 (95%

CI .44, 2.47)*

Maffulli, et al 2003 Excellent II 12

months 53 88% 81% OR 1.08 (95% CI

.45, 2.59)*

Maffulli, et al 2003 Return to Work (weeks) II 12

months 53 9.2 (SD 2.5) 13.2 (SD 3) p= 0.05

Maffulli, et al 2003 Return to Work II 12

months 49 100% 100% 1

Maffulli, et al 2003 Changed Jobs II 12

months 49 1 2 OR .5

(95% CI .01, 10.31)


Experience Problems at work due to injury II 12

months 49 2 4 .5 (95% CI .04, 4.15)

Costa, et al 2006 Return to Sports II 1 year 48** 83% 68% p= 0.04

Costa, et al 2006

Return to Normal Walking (weeks) II 1 year 48** 12.5 (CI

10-18) 18 (CI 18-22) p= 0.03

Costa, et al 2006

Return to Normal Stair Climbing (weeks) II 1 year 48** 13 (CI 10-

18) 22 (CI 18-22) p= 0.02




Costa, et al 2006 Return to Work (weeks) II 1 year 48** 8 (CI 2-13) 4(CI 1-13) p= 0.59

Costa, et al 2006

EuroQoL - Health Score II 2 months 48** 75 (IQR

70-85) 75 (IQR 65-

80) p= 0.85

Costa, et al 2006

EuroQoL - Health Score II 6 months 48** 85 (IQR

80-90) 81 (IQR 75-

95) p= 0.96

Costa, et al 2006

EuroQoL - Health Score** II 1 year 48** 84 (IQR

75-95) 90 (IQR 85-

95) p= 0.14

Costa, et al 2006 EuroQoL - E5D II 2 months 48** 0.69 (IQR

0.6-0.9) 0.69 (IQR 0.6-0.7) p= 0.45

Costa, et al 2006 EuroQoL - E5D II 6 months 48** 0.8 (IQR

0.7-1.0) 0.8 (IQR 0.8-

1.0) p= 0.96

Costa, et al 2006 EuroQoL - E5D II 1 year 48** 1 (IQR

0.9-1.0) 1(IQR 0.8-

1.0) p= 0.15

Costa, et al 2006 Re-rupture II 1 year 48** 8.69% 0 p= 0.03*

Suchak, et al 2008 DVT II 6 months 110 0 2% p= 0.14*

Suchak, et al 2008 Necrosis of the skin II 6 months 110 0 2% p= 0.14*

Suchak, et al 2008

Sural nerve dysesthesias, superficial

infections, delayed wound healing, scar

adhesions.

II 6 months 110 15% 16% p= 0.89*

Maffulli, et al 2003 Superficial Infection II 12

months 53 7.69% 7.40% p= 0.97*

Costa, et al 2006 Minor wound

complications II Nr 48** 26% 21% p=0.17*

Costa, et al 2006 Persistent paraethesiae II Nr 48** 0% 4.3% p= 0.60*


Hypersensitivity of surgical wounds II 10-12

wks 53 15.38% 18.51% p= 0.76*




Maffulli, et al 2003 Hypertrophic Scar II 10-12

weeks 53 3.84% 0% p= 0.15*

1664 1665

*= AAOS calculations **= Open cast group converted to orthosis at 3 weeks


RECOMMENDATION 12 1666 1667 1668 1669 1670

1671 1672 1673 1674 1675 1676 1677 1678 1679 1680 1681 1682 1683 1684 1685 1686 1687 1688 1689 1690 1691 1692 1693 1694 1695 1696 1697

1698

1699 1700 1701 1702

1703 1704 1705 1706 1707 1708

We suggest the use of a protective device that allows mobilization by 2- 4 weeks post operatively. Strength of Recommendation: Moderate

Rationale: A systematic review identified five Level II 40, 42-44 studies comparing postoperative immobilization to postoperative mobilization following surgical repair of the Achilles tendon. All five studies randomized the patients into two groups with either six weeks in a cast or early motion with a modified splint device. For all studies, patients in the mobilization group had a splint or modified cast device that limited dorsiflexion to protect the repair. All five studies40, 5, 42-44 found that the weight bearing group had statistical improvement in the mean time to return to activities such as work and normal walking. One43 of three studies found a significantly higher rate in return to sport activities at twelve months, while two40, 39 found no difference. One study 5 found a significantly higher re-rupture rate in the postoperative mobilization group (2 of 23 patients) compared to the immobilization group (0 of 25 patients). Both patients had documented non-compliance with the use of their postoperative splint and fell during the first 4 weeks after surgery. By 12 to 18 months, all five studies40, 5, 42-44 found that there was no significant difference between the two groups in outcomes such as pain and function. Although the ultimate level of function achieved after operative repair of an Achilles rupture is similar regardless of the postoperative immobilization protocol, early postoperative mobilization allows the patient to achieve a quicker return to activities during the first six months than those patients treated with immobilization. However, treatment decisions should be made in light of all circumstances presented by the patient. Mutual communication between patient and physician should include a discussion of the importance of patient compliance when a program is prescribed for early mobilization. Patient compliance to protocol is important to aid in protection of the incision during the early post-operative period and is also important to prevent wound healing complications.

Supporting Evidence

Five Level II studies40, 5, 42-44 compare postoperative immobilization to postoperative mobilization. The post operative mobilization and immobilization regimes are detailed in Table 111. Please see Table 112 through Table 119 for results of mobilization versus immobilization.

Of the forty outcomes reported, sixteen were statistically significant in favor of early motion. Nine of the sixteen statistically significant results measured time until return to activity, sports, walking, stair climbing, work, weight bearing, discharge from physiotherapy, number of physiotherapy sessions, and sick leave (see Table 112). However, another study that reported time until return to sport and work did statistically significantly differ between groups (see Table 112). Patients in the early motion group


1709 1710 1711 1712 1713 1714 1715 1716 1717

1718 1719 1720

1721 1722 1723

1724

reported statistically significantly less pain at one month but no statistically significant difference in pain at three, six, or twelve months (see Table 113). One of seven outcome measures found a statistically significant difference in the percent of patients able to return to sports in favor of the motion group. Statistically significantly more patients were able to stand on their toes and walk as far as they could before surgery in the early motion group at three and six months. Patients in the early motion group were more satisfied with their cast at one year. There was no statistically significant difference between groups in regard to: patient opinion of results, footwear restrictions, EuroQoL, E5D, or Ankle Performance Score (see Table 114).

Costa, et al5, reported significantly more re-ruptures in the early weight-bearing group. Of the two patients with re-ruptures, one patient did not follow the written rehabilitation protocol and the second patients suffered a fall on ice and forcibly dorsiflexed his ankle.

Abnormal sensibility was significantly more prevalent in the immobilized group than in the motion group. There were no other statistically significant differences between groups in complications.

Table 111. Description of Treatment Groups Author Post operative Instructions

Costa, et al. Mobilization group: Immediate weight-bearing and mobilization using carbon fibre orthosis with 1.5 cm heal raises. Immobilization group: Traditional plaster cast.

Mortensen, et al. Mobilization group: Below the knee dorsal plaster splint followed by walker brace. Immobilization group: Below the knee plaster cast

Cetti, et al. Mobilization group. Mobile cast Immobilization group. Rigid below the knee cast

Kangas, et al Mobilization group. Below the knee dorsal cast for 6 weeks, this allowed for free plantar flexion. Immobilization group. Below the knee plaster cast

Maffulli, et al.

Early weight-bearing group: Bear weight on the tip toes of the operated leg as tolerated but keep leg elevated for the first two weeks. Begin weight-bearing as tolerated. Non-weight-bearing group: No weight bearing and keep leg elevated for first two weeks. Increase weight bearing at 4 weeks.

1725

1726 1727

SUMMARY OF EVIDENCE Table 112. Time to Return to Activity

Author Outcome LoE Comparison N Time to return


Return to Sports

(months) II

Early Motion vs.

Immobilization53 ●em


Author Outcome LoE Comparison N Time to return

Costa, et al 2005

Time in weeks taken to return to

sport

II Early Motion

vs. Cast

48** ○

Cetti, et al. 1994

Return to same level of

sports activities

II Early Motion

vs. Cast

60 ●em

Costa, et al 2005

Time in weeks until

return to stair climbing

II Early Motion

vs. Cast

48** ●em

Costa, et al 2005


walking

II Early Motion

vs. Cast

48** ●em

Costa, et al 2005


work.

II Early Motion

vs. Cast

48** ○

Cetti, et al. 1994

Mean Sick leave (days) II

Early Motion vs.

Cast 60 ●em


Return to Work (weeks) II

Early Motion Vs.



Full weight-Bearing (wks) II

Early Motion Vs.



Physiotherapy sessions (visits)

II Early Motion

Vs. Immobilization

53 ●em


Discharged from

Physiotherapy (months)

II Early Motion

Vs. Immobilization

53 ●em

1728 1729 1730 1731 1732 1733

em= early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks


Table 113. Pain 1734 Duration (Months) Author Outcome LoE Comparison N

1 3 6 12

Kangas, et al 2002 Vas Pain II

Early Motion vs.

Cast 50 ●em ○ ○

Maffulli, et al 2003 Pain- None II

Early Motion vs.

Immobilization 53

○


Pain- Mild, Occasional II

Early Motion Vs.

Immobilization 53

○

Maffulli, et al 2003 Pain- Moderate II

Early Motion Vs.

Immobilization 53

○

1735 1736 1737 1738 1739 1740 1741 1742


Table 114. Function

Duration (Months) Author Outcome LoE Comparison N

3 6 12 18

Costa, et al 2005

Return to sports II

Early Motion vs.

Cast

48** ○

Mortensen, et al 1999

Return to sports II

Early Motion vs.

Cast 61 ○


Return to Sports II Early Motion vs.

Immobilization 38 ○

Cetti, et al. 1994

Return sports

activities II

Early Motion vs.

Cast 60 ●e

m


Reached pre-injury

level II

Early Motion vs.

Cast 61 ○

Cetti, et al. 1994

Return to lesser level of sports activities

II Early Motion

vs. Cast

60 ○


Duration (Months) Author Outcome LoE Comparison

3 6 N

12 18

Cetti, et al. 1994

Stopped sports

activities II

Early Motion vs.

Cast 60 ○


No Limitations II

Early Motion Vs.

Immobilization 53 ○


Activity Limitation - Limited

Recreational but not

Daily Activities

II Early Motion

Vs. Immobilization

53 ○


Able to walk as far

before surgery

II Early Motion

vs. Cast

71 ●em

Cetti, et al. 1994

Able to stand on

toes II

Early Motion vs.

Cast 60 ●em ●em ○


Sick Leave (days) II

Early Motion vs.

Cast ●em


Return to Work II 49 ○


Changed Jobs II 49 ○

1743 1744 1745 1746 1747 1748 1749

em= early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks Table 115. EuroQoL, E5D, Ankle Performance Score

Duration (Months)

Author Outcome LoE Comparison N 3.5 4 12 15

Costa, et al 2006

EuroQoL - Health

Score** II

Early Motion

vs. Cast

48** ○ ○ ○


Costa, et al 2006

E5D (Dimension of Health

Score)

II

Early Motion

vs. Cast

48** ○ ○ ○

Kangas, et al 2002

Ankle Performance

Score - Excellent

II

Early Motion

vs. Cast

50 ○

1750 1751 1752 1753 1754 1755 1756

1757


Table 116. Patient opinion of results

Author Outcome LoE 3 m 6 m 12m 16m

Cetti, et al. 1994

Patient opinion of cast-

excellent II

●em

Mortensen, et al. 1999

Subjective Result-

Excellent II ○

Cetti, et al. 1994 Complaints II ●em ○ ●em



II ○



surgery II ○

1758 1759 1760 1761 1762 1763 1764




1765 Table 117. Footwear restrictions

Duration (Months)

Author Outcome LoE Comparison N 12 16 Kangas,

et al 2002

Footwear Restrictions II

Early Motion vs.

Cast 50 ○


Footwear restrictions- None, mild (most shoes tolerated)

II Early Motion

vs. Cast

53 ○


Footwear restrictions- Moderate (unable to

tolerate fashionable


II Early Motion

vs. Cast

53 ○

em= early motion 1766 1767 1768 1769 1770 1771 1772

○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks Table 118. Re-rupture

Author LoE Duration N Early Motion

Immobilization


Cetti, et al. 1994

Re-rupture II 3% 7% ○

Costa, et al 2006 II 1 year 48

** 8.69% 0% ●* nwb

em= early motion 1773 1774 1775 1776 1777 1778 1779

○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks

SUMMARY OF COMPLICATIONS 1780 1781 Table 119. Early Motion vs. Cast - Complications

Author Complication LoE N Early Motion

Rigid Cast Group


Cetti, et al. 1994 Infection II 60 0% 3% ○

Cetti, et al. 1994 Scar Adhesion II 60 3% 13% ○

Cetti, et al. 1994 Suture Granuloma II 60 3% 0% ○

Cetti, et al. 1994

Abnormal Sensibility II 60 3% 17% ●em

Cetti, et al. 1994 Keloid Scar II 60 10% 23% ○

Cetti, et al. 1994 Re-rupture II 60 3% 7% ○

Mortensen Deep Infection II 61 3% 0% ○

Mortensen Failed Repair II 61 3% 7% ○

Costa, et al 2006

Minor Wound Complications II 60 23% 20% ○


Superficial Infection II 53 7.69% 7.40% ○


Hypersensitivity of surgical wounds II 53 15.38% 18.51% ○

Maffulli, et al 2003 Hypertrophic Scar II 53 3.84% 0% ○

1782 1783 1784 1785 1786 1787

1788

em= early motion nem= not early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculated

Table 120. Systematic Reviews

Author Conclusion "Postoperative splinting in a cast followed by a functional brace rather than a cast alone reduces the overall complication rate" (p. 2209).


Lynch, RM 2004 "Early functional mobilisation is more acceptable to patients than plaster cast immobilisation and results in improved functional outcomes" (p. 156).


Suchak, AA et al. 2006

"An early functional rehabilitation protocol for Achilles tendon ruptures improves patient satisfaction with reduction in minor complications and no increase in rerupture rate or infection rate" (p. 220).


EXCLUDED ARTICLES 1789 1790 Table 121. Mobilization vs. Immobilization Included Articles


Sorrenti SJ; Achilles tendon rupture: effect of early mobilization in rehabilitation after surgical repair Not relevant

Buchgraber A;Passler HH;

Percutaneous repair of Achilles tendon rupture. Immobilization versus functional postoperative

treatment


Kerkhoffs GM;Struijs PA;Raaymakers EL;Marti RK;

Functional treatment after surgical repair of acute Achilles tendon rupture: wrap vs. walking

cast Not relevant

Kauranen K;Kangas J;Leppilahti J;

Recovering motor performance of the foot after Achilles rupture repair: a randomized clinical

study about early functional treatment vs. early immobilization of Achilles tendon in tension


Maffulli N;Tallon C;Wong J;Lim

KP;Bleakney R;

Early weight-bearing and ankle mobilization after open repair of acute midsubstance tears of

the Achilles tendon Not relevant

Kangas J;Pajala A;Ohtonen

P;Leppilahti J;

Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative

regimens

Duplicate - Data reported in prior

study Majewski M;Schaeren S;Kohlhaas U;Ochsner

PE;

Postoperative rehabilitation after percutaneous Achilles tendon repair: Early functional therapy

versus cast immobilization


Solveborn SA;Moberg A;



1791


STUDY QUALITY 1792 1793 Table 122. Mobilization vs. Immobilization Quality


Author

Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

Follo

w U

p - 8

0% o

r m

ore


All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entr

y

Costa, et al.

2006 Sport 43

Mobilization vs.

ImmobilizationII ● ● × × ● ×

Costa, et al.

2006 Walking 43

Mobilization vs.


Costa, et al.

2006

Stair Climbing 43

Mobilization vs.


Costa, et al.

2006 Work 43

Mobilization vs.


Kangas, et al.

2003

VAS Pain 50

Mobilization vs.

ImmobilizationII × ● ○ ○ ● ●

Kangas, et al.

2003

VAS Pain 50

Mobilization vs.


Kangas, et al.

2003

VAS Pain 50

Mobilization vs.


Kangas, et al.

2003

VAS Pain 50

Mobilization vs.


Kangas, et al.

2003

VAS Pain 50

Mobilization vs.


1794


1795


Author

Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

Follo

w U

p - 8

0% o

r m

ore

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entr

y


Kangas, et al.

2003 Stiffness 50

Mobilization vs.


Kangas, et al.

2003

subjective calf muscle weakness

50 Mobilization

vs. Immobilization

II × ● ○ ○ ● ●

Kangas, et al.

2003

footwear restrictions 50

Mobilization vs.


Kangas, et al.

2003

Ankle performance

score 50

Mobilization vs.



Sick Leave 61 Mobilization

vs. Immobilization

II ● ○ ○ ○ ○ ●


Subjective assessment 61

Mobilization vs.

ImmobilizationII ● ○ ○ ○ ○ ●


Sports Activity 61

Mobilization vs.

ImmobilizationII ● ○ ○ ○ ○ ●


Pain 61 Mobilization

vs. Immobilization

II ● ○ ○ ○ ○ ●

1796


1797


Author

Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

Follo

w U

p - 8

0% o

r m

ore


All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entr

y


Stiffness 61

Mobilization vs.

Immobilization

II ● ○ ○ ○ ○ ●


Able to walk as far as pre surgery

-61

Mobilization vs.

Immobilization

II ● ○ ○ ○ ○ ●

Cetti, et al.

1994

Resumption of sports activity 111

Mobilization vs.

Immobilization

II × × × × × ○

Cetti, et al.

1993 Return to sport 111

Mobilization vs.

Immobilization

II × × ○ ● ● ●

Cetti, et al.

1993 Return to work 111

Mobilization vs.

Immobilization

II × × ○ ● ● ●

Cetti, et al.

1993 Re-rupture 111

Mobilization vs.

Immobilization

II × × ○ ● ● ●


Pain- None 53

Mobilization vs.

Immobilization

II ○ ○ ○ ● ● ×


Pain- Mild, Occasional 53

Mobilization vs.

Immobilization II ○ ○ ○ ● ● ×


Pain- Moderate 53 Mobilization

vs. Immobilization

II ○ ○ × × ● ×


Return to Sports 53

Mobilization vs.

Immobilization II ○ ○ × × ● ×




Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entr

y

Follo

w U

p - 8

0% o

r m

ore


Return to Sports (months) 53

Mobilization vs.

Immobilization II ○ ○ × × ● ●



Mobilization vs.

Immobilization

II ○ ○ × × ● ●


Return to Work 53 Mobilization

vs. Immobilization

II ○ ○ × × ● ●


Changed Jobs 53 Mobilization

vs. Immobilization

II ○ ○ × × ● ●


Experience Problems at work due to

injury

53 Mobilization

vs. Immobilization

II ○ ○ × × ● ●


Full weight-Bearing (wks) 53

Mobilization vs.



Activity Limitation -

None 53

Mobilization vs.




Limited Recreational but not Daily

Activities

53 Mobilization

vs. Immobilization

II ○ ○ × × ● ●


Discharged from

Physiotherapy (months)

53 Mobilization

vs. Immobilization

II ○ ○ × × ● ●


Physiotherapy sessions (visits) 53

Mobilization vs.



Footwear restrictions- None, mild

53 Mobilization

vs. Immobilization

II ○ ○ × × ● ●




Stoc

hast

ic R

ando

miz

atio

n

Allo

catio

n C

once

alm

ent

Patie

nts B

linde

d

Tho

se r

atin

g ou

tcom

e B

linde

d

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at

entr

y

Follo

w U

p - 8

0% o

r m

ore


Footwear restrictions- Moderate (unable to


shoes)

53 Mobilization

vs. Immobilization

II ○ ○ × × ● ●


Percent satisfied with

results of surgery

53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●



53

Weight Bearing vs.

Non-weight-bearing

II ○ ○ × × ● ●

1798


STUDY RESULTS 1799 1800 Table 123. Mobilization vs. Immobilization Study Data

Results Author

Outcome

LoE

Duration

N Early Motion Cast Results

Cetti, et al. 1994

Return to same level of sports

activities II 1 year 60 80% 50% p=

0.0292

Cetti, et al. 1994

Return to lesser level of sports

activities II 1 year 60 7% 13% p= 0.616

Cetti, et al. 1994

Stopped sports activities II 1 year 60 3% 13% p= 0.141

Cetti, et al. 1994

Patient opinion of cast- excellent II 1 year 60 77% 20% p=

0.0005

Cetti, et al. 1994

Mean Sick leave (days) II NA 60 20.2

(Range 3-75)

53.4 (Range 1-182)

p= 0.0009

Cetti, et al. 1994

Able to stand on toes II 3 months 60 83% 53% p= 0.025

Cetti, et al. 1994

Able to stand on toes II 6 months 60 100% 77% p= 0.011

Cetti, et al. 1994

Able to stand on toes II 12

months 60 100% 97% p= 0.15*

Cetti, et al. 1994 Re-rupture II NA 60 3% 7% p= 0.55*

Cetti, et al. 1994 Complaints II 3 months 60 17.0 25.00 p= 0.047

Cetti, et al. 1994 Complaints II 6 months 60 10.00 14.00 p=

0.290* Cetti, et al.

1994 Complaints II 12 months 60 3.00 11.00 p= 0.03


Able to walk as far as they could

before surgery II 12 weeks 61 19% 40% p= 0.06


Subjective Result - excellent II 16

months 61 84% 63%

OR 3.01 (95 % CI

.785-12.76)*


Returned to sports II 16 months 61 73% 76% OR =1

1801 1802 1803



1804 Results Author Outcome LoE Duration N Early Motion Cast Results Mortensen,

et al 1999

Reached pre-injury level II 16 months 61 57% 55% 1


Time until pre-injury level

reached (months)

II NA 61 6 (2.5-13)

9 (6-14) P <0.01

Kangas, et al

2002 Vas Pain II 1 week 50 2.17± 2.7 2.02 ±

1.7 p= 0.08

Kangas, et al

2002 Vas Pain II 3 weeks 50 .83 ± 1.2 .82 ±

1.3 p= 0.797

Kangas, et al

2002 Vas Pain II 6 weeks 50 .65 ± 1.4 .60 ±

.09 p= 0.9

Kangas, et al

2002 No Stiffness II 60 weeks 50 44% 68%

OR .369 (95% CI

0.09-1.34)*

Kangas, et al

2002 Mild Stiffness II 60 weeks 50 56% 32%

OR .369 (95% CI

0.09-1.34)*

Kangas, et al

2002

No footwear restrictions II 60 weeks 50 68% 92%

OR .369 (95% CI

0.09-1.34)*

Kangas, et al

2002

Ankle Performance

Score - Excellent II 60 weeks 50 88% 92%

OR 1 (95% CI

0.27-3.59)*

Kangas, et al

2002 Re-rupture II 5 months 50 4% 8% 1.000

Costa, et al 2006

Return to Normal

Walking** II Time

measurement 48 18 (95% CI 12-22)

18 (95% CI 18-

22)

p= 0.027

Costa, et al 2006

Return to Normal Stair Climbing**

II Time measurement 48 17 (95% CI 11-

18)

18 (95% CI 14-

22)

p= 0.023

Cetti, et al. 1994 Infection II Not Reported 60 0 3.3 p= 0.155*


Results Author Outcome LoE Duration N Early Motion Cast Results Cetti, et al.

1994 Scar Adhesion II Not Reported 60 3.3 13.3 0.141*

Cetti, et al. 1994

Suture Granuloma II Not Reported 60 3.3 0 0.155*


Full weight-Bearing (wks) II 12 months 53 2.5 (SD 0.4) 5.5 (SD

2.2) p= 0.021


Physiotherapy sessions (visits) II 12 months 53 6.1 (SD 3.1)

13.6 (SD 4.8)

p= 0.03


Discharged from Physiotherapy

(months) II 12 months 53 2.1 (SD 1.1) 4.6 (SD

2) p<.0001

Maffulli, et al 2003 Pain- None II 12 months 53 88% 89%

OR .95 (95% CI

.12, 7.92)*


Pain- Mild, Occasional II 12 months 53 8% 7%

OR 1.04 (95% CI

.07, 15.43)*

Maffulli, et al 2003 Pain- Moderate II 12 months 53 4% 4%

OR 1.04 (95% CI

.01, 84.73) *



None II 12 months 53 92% 93%

OR .96 (95% CI .0647975

14.24349*



Limited Recreational but

not Daily Activities

II 12 months 53 8% 7%

OR 1.041667 (95% CI

.07, 15.43)

Maffulli, et al 2003 Return to Sports II 12 months 38 89% 89%

OR 1 (95% CI

.35, 2.78)* Maffulli, et

al 2003 Return to Sports

(months) II 12 months 53 5.1 (SD 2.8) 6 (SD 3) 0.04


Footwear restrictions-None, mild

II 12 months 53 96% 93%

OR 1.08(95%

CI .46 2.50)


Results Author Outcome LoE Duration N Early Motion Cast Results


Footwear restrictions-Moderate (unable to



II 12 months 53 4% 7% OR .48 (95% CI .01, 9.92)



surgery II 12 months 53 88% 85%

1.04 (95% CI .44, 2.47)*

Maffulli, et al 2003 Excellent II 12 months 53 88% 81%

OR 1.08 (95% CI

.45, 2.59)*


Return to Work (weeks) II 12 months 53 9.2 (SD 2.5) 13.2

(SD 3) p= 0.05

Maffulli, et al 2003 Return to Work II 12 months 49 100% 100% 1

Maffulli, et al 2003 Changed Jobs II 12 months 49 1 2

OR .5 (95% CI

.01, 10.31)


Hypersensitivity of surgical

wounds II 10-12 wks 53 15.38% 18.51% p= 0.76*


Hypertrophic Scar II 10-12 weeks 53 3.84% 0% p= 0.15*

1805 1806 1807



1808 Results

Author Outcome LoE Duration N Early Motion Cast ResultsCetti, et

al. 1994

Abnormal Sensibility II Not

Reported 60 3.3 16.7 p= 0.066*

Cetti, et al.

1994 Keloid Scar II Not

Reported 60 10 23.3 p= 0.157*

Mortensen Deep Infection II 6 weeks 3% 0% p=

0.154*

Mortensen Failed Repair II 6 weeks 3% 7% p= 0.52*

Costa Minor Wound Complications II Varying Tie 23% 20% p=

0.79* Kangas, et

al 2002

Re-rupture II 5 months 4% 8% p= 0.545*

Costa, et al

2005


work.

II Time measurement 48 22 26 p=

0.593*

Costa, et al 2006

EuroQoL - Health

Score** II 10 weeks 48 75 (IQR 70-85) 75 (IQR 65-80) p=

0.854

Costa, et al 2006

EuroQoL - Health

Score** II 6months 48 85 (IQR 80-90) 81 (IQR 75-95) p=

0.956

Costa, et al 2006

EuroQoL - Health

Score** II 12 months 48 84 (IQR 75-95) 90 (IQR 85-95) p= .138

Costa, et al 2006

E5D (Dimension of Health Score)

II 10 weeks 48 0.69 (IQR 0.6-0.9) 0.69 (IQR 0.6-0.7) p= 0.450

Costa, et al 2006


II 6months 48 0.8 (IQR 0.7-1.0) 0.8 (IQR 0.8-1.0) p= 0.956

Costa, et al 2006


II 12 months 48 1 (IQR 0.9-1.0) p= 0.146 1(IQR 0.8-1.0)

1809 1810 1811



RECOMMENDATION 13 1812 1813 1814 1815 1816

1817

1818 1819 1820

1821 1822 1823 1824 1825 1826 1827

We are unable to recommend for or against post-operative physiotherapy for patients with acute Achilles tendon rupture. AAOS Strength of Recommendation: Inconclusive

Rationale:

A systematic review did not identify any studies that met the inclusion criteria. Supporting Evidence:

We searched for any studies addressing post operative physical therapy including supervised and unsupervised physical therapy. The only studies that we identified did not specifically study whether physical therapy was effective. Therefore, it is not possible to draw evidence-based conclusions for this recommendation. SUMMARY OF EVIDENCE Table 124. Post Operative Physiotherapy Regiments

Author LOE Treatment N Post Treatment PT Regimen

15Cast followed

by walking cast Majewski III Percutaneous

Repair Combination splint and shoe 88

Both groups received same PT at 8 weeks

Calder IV Mini-Open Repair 46 Functional

Brace "Active physiotherapy programme"

at 2 weeks

Troop IV Open Repair 13 Cast (5) Splint (8)

All had supervised PT. Authors do not report details of PT regimen.

Saw IV Open Repair 19Cast followed

by walking boot

All patients began supervised active ankle dorsiflexion at 1 week. Neutral

position of the ankle at 2 weeks. Active non-weight bearing exercises at 6 weeks. Normal walking allowed

at 8 weeks.

Moberg IV Operative Repair 17 Mobile plaster

cast

Immediate free ankle joint movement. Free weightbearing and

mobilization at 6 weeks.

II Open Repair 25Dorsal rigid splint at 6

weeks

Both groups performed "standard rehabilitation program;" Authors do not specify details of PT program Kangas

II Open Repair 25Both groups performed "standard

rehabilitation program;" Authors do not specify details of PT program

Plaster splint

1828


EXCLUDED ARTICLES 1829 1830 Table 125. Excluded Articles


Majewski M, et al

Postoperative rehabilitation after percutaneous Achilles tendon repair: Early functional therapy versus cast

immobilization

Does not answer the recommendation

Calder JD, et al.

Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study


Troop RL, et al. Early motion after repair of Achilles tendon ruptures Does not answer the

recommendation Saw Y, et

al. Early mobilization after operative repair of ruptured

Achilles tendon Does not answer the

recommendation

Moberg A, et al.

Surgically repaired Achilles tendon ruptures with postoperative mobile ankle cast: A 12-month follow-up study with an isokinetic and a dynamic muscle function

test


Kangas J, et al.

Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens



RECOMMENDATION 14 1831 1832 1833 1834 1835 1836

1837

1838 1839 1840 1841 1842

1843

1844 1845 1846 1847 1848 1849 1850 1851 1852 1853 1854

1855 1856

In patients with acute Achilles tendon rupture, irrespective of treatment type, we are unable to recommend a specific time at which patients can return to activities of daily living. Strength of Recommendation: Inconclusive

Rationale:

A systematic review identified 18 studies that reported on return to low impact activities. Our meta-analysis suggested the results of these studies were very different from each other and this is confirmed by examining their individual results (See supporting evidence below).


Eighteen studies5, 45, 46, 47, 48, 49, 20,41, 50, 30,21,51,52, 25,48, 19, 40 are included that report data on return to low impact activity. We have tabled the mean length of time to return to activity and the percent of patients able to return after either non-operative or operative treatments (see Table 126 through Table 133). We attempted meta-analysis for the following patient groups and outcomes: mean time for non-operative patients to return to work (I^2 95%), mean time for operative patients to return to work (I^2 >90%), and the percent of operative patients able to return to work at three months (I^2 at 3 months >75%). The results of these studies are so different from each other, as demonstrated by the high heterogeneity, that it is difficult to draw any conclusions about the time to return to recreational or athletic activity. There were too few studies included for each outcome to investigate the reasons for heterogeneity.

SUMMARY OF EVIDENCE Table 126. Non-Operative treatment - Percent of patients able to return to work

Author LOE Treatment N Outcome Duration (months)

% of Patients

Costa, et al. 2006 IV

immediate weight-bearing

mobilization 22 Return to work 12 59%

Costa, et al. 2006 IV plaster cast

immobilization 26 Return to work 12 65%

Hufner, et al. 2006 IV cast and boot 125 Return to work 0.6 45%

1857


Table 127. Non-Operative Treatment -Percent of patients able to return to ADL 1858


% of Patients


immediate weight-bearing

mobilization 22 Return to normal

walking 12 73%


immobilization 26 Return to normal walking 12 85%

1859

1860 Table 128. Operative Treatment - Percent of patients returning to ADL

Author LOE Treatment N Outcome Duration (months) %

Scarfi, et al. 2002 IV percutaneous repair 20 Return to ADL 2 100%

Tang, et al. 2007 IV arthroscopically assisted

percutaneous 20 Resume walking 3 100%


open end-to-end (immediate weight-

bearing mobilisation) 23 Return to normal

walking 12 96%

Costa, et al. 2006 IV open end-to-end (plaster

cast immobilisation) 25 Return to normal walking 12 100%



bearing mobilisation) 23 Return to stair

climbing 12 96%


cast immobilisation) 25 Return to stair climbing (months) 12 96%

1861


Table 129. Operative Treatment - Percent of patients able to return to work 1862


Kiviluoto, et al. 1985

IV open repair 70 Return to work 1-3 70%

Hogsaa, et al. 1990

IV open repair 68 Return to work -

same employment (weeks)

1.5-3 35%

Moller, et al. 2001 IV end-to-end suture w/o

augmentation 32 Return to light, mobile work 1 100%


augmentation 13 Return to sedentary work 1 100%

Hogsaa, et al. 1990



< 1 29%

Suchak, et al. 2008

IV open repair 103 Return to work 1.7 65%

Jung, et al. 2008 IV limited open 27 Return to work 2 100%

Hogsaa, et al. 1990



> 3 15%

Suchak, et al. 2011

IV open repair 103 Return to work 3 82%


augmentation 14 Return to heavy work 3.5 100%

Kuskucu, et al. 2005

IV fibrin sealant 32 Return to daily work 6 97%

Hogsaa, et al. 1990



< 6 18%

Suchak, et al. 2008

IV open repair 103 Return to work 6 97%

Lansdaal, et al. 2007

IV minimally-invasive 150 Return to work - same work 12 98%


Duration (months) Author LOE Treatment N Outcome %



bearing mobilisation) 23 Return to work 12 87%


cast immobilisation) 25 Return to work 12 100%


IV open repair (non-weight-bearing) 26 Return to work -

same job 12 92%


IV open repair (non-weight-bearing) 26 Return to work 12 100%


IV open repair (weight-bearing) 23 Return to work -

same job 12 96%


IV open repair (weight-bearing) 23 Return to work 12 100%

1863


Table 130. Non-Operative Treatment - Mean time until return to work 1864 Author LOE Treatment N Outcome Duration (weeks)

Metz, et al. 2008 IV functional brace 33 Return to work 15.4 (SD 16.42)

Costa, et al. 2006 IV immediate weight-

bearing mobilisation 22 Return to work 1 (95% CI 1-13)*


bearing mobilisation 22 Return to normal walking 18 (95% CI 12-22)*

Moller, et al. 2001 IV Below the knee plaster

cast 53 Return to work 10.48 (SD 8.07)

Wallace, et al. 2004 IV cast 122 Return to work 2.36 (SD 1.19)

Cetti, et al. 1993 IV below-knee plaster cast 55 Return to work 8 (SD 3.6)


immobilisation 26 Return to work 10 (95% CI 2-22)*


cast 22 Return to light, mobile work 9.6 (SD 9.4)


cast 22 Return to sedentary work 4.7 (SD7.8)


immobilisation 26 Return to normal walking 18 (95% CI 18-22)*

1865 1866

1867

* AAOS Calculation

Table 131. Non-Operative Treatment - Mean time until return to walking Author LOE Treatment N Outcome Duration (weeks)


bearing mobilisation 22 Return to normal walking 18 (95% CI 12-22)*


immobilisation 26 Return to normal walking 18 (95% CI 18-22)*


Table 132. Operative Treatment - Mean time to return to ADL 1868 Author LOE Treatment N Outcome Duration (Weeks)



bearing mobilisation) 23 Return to normal

walking 12.5 (95% CI 10-

18)*


cast immobilisation) 25 Return to normal walking

18 (95% CI 18-22)*

Maffulli, et al. 2003 IV open repair (non-weight-

bearing) 27 Walk w/o crutches 5.5 (SD 2.2; range 4.6-8.1)

Maffulli, et al. 2003 IV open repair (weight-

bearing) 26 Walk w/o crutches 2.5 (SD 0.4; range 1.2-3.1)



bearing mobilisation) 23 Return to stair

climbing 13 (95% CI 10-

18)*


cast immobilisation) 25 Return to stair climbing

22 (95% CI 18-22)*

Calder, et al. 2006 IV percutaneous repair 25 Return to driving 4.14 (range .7-9)

1869 1870

* AAOS Calculation


1871

1872 Table 133. Operative Treatment - Mean time until return to work Author LOE Treatment N Outcome Duration (Weeks)


augmentation 14 Return to heavy work 14.6 (SD 7.5)

Coutts, et al. 2002 IV open repair 15 Return to work -

manual 11.1 (range 8-24)


augmentation 32 Return to light, mobile work 5.1 (SD 5.4)


augmentation 13 Return to sedentary work 4.4(SD 5.2)


augmentation 59 Return to work 7.8(SD 68.4)

Cetti, et al. 1993 IV end-to-end suture 56 Return to work 6.2 (SD 2.15)

Metz, et al. 2008 IV minimally-invasive 40 Return to work 8.4 (SD 11.71)

Lansdaal, et al. 2007 IV minimally-invasive 15

0 Return to work 4 (range .14-52.57)*

Calder, et al. 2005 IV

mini-open repair w/ early active

rehabilitation 46 Return to work 3.12 (range .57-11)



bearing mobilisation) 23 Return to work 8 (95% CI 2-13)*


open end-to-end (plaster cast

immobilisation) 25 Return to work 4 (95% CI 1-13)*

Calder, et al. 2006 IV percutaneous repair 25 Return to work 2.7 (range .85-11)

Majewski, et al. 2008 IV percutaneous w/ shoe 14 Return to work 5.2 (range .7-18.85)

Wagnon, et al. 2005 IV percutaneous repair

(Webb-Bannister) 22 Return to work (months) 1.07

Doral, et al. 2009 IV endoscopy assisted

percutaneous 62 Return to work 11.7 (range 10-13)

1873 1874

1875

* AAOS Calculation


EXCLUDED ARTICLES 1876 1877 Table 134. Excluded Articles

Author Title Reason for Exclusion Costa ML;Shepstone L;Darrah C;Marshall

T;Donell ST;

Immediate full-weight-bearing mobilisation for repaired Achilles

tendon ruptures: a pilot study

Less than 80% follow up


Isokinetic strength and endurance after percutaneous and open surgical

repair of Achilles tendon ruptures


van der Linden-van der Zwaag HM;Nelissen

RG;Sintenie JB;

Results of surgical versus non-surgical treatment of Achilles tendon

rupture Not 80% follow

Kakiuchi M; A combined open and percutaneous

technique for repair of tendo Achilles. Comparison with open repair

Not 80% time follow up

Hufner TM;Brandes DB;Thermann H;Richter M;Knobloch K;Krettek

C;

Long-term results after functional nonoperative treatment of Achilles

tendon rupture


Roberts C;Rosenblum S;Uhl R;Fetto J;




Early motion of the ankle after operative treatment of a rupture of the

Achilles tendon. A prospective, randomized clinical and radiographic

study


Maes R;Copin G;Averous C;

Is percutaneous repair of the Achilles tendon a safe technique? A study of

124 cases



Percutaneous versus open repair of the ruptured Achilles tendon: a

comparative study


Chiodo CP;Wilson MG; Current concepts review: acute ruptures of the Achilles tendon


Fernandez-Fairen M;Gimeno C;

Augmented repair of Achilles tendon ruptures


Wagnon R;Akayi M;

The Webb-Bannister percutaneous technique for acute Achilles' tendon

ruptures: a functional and MRI assessment


Martinelli B; Percutaneous repair of the Achilles tendon in athletes


Park HG;Moon DH;Yoon JM;

Limited open repair of ruptured Achilles tendons with Bunnel-type

sutures


Edna TH; Non-operative treatment of Achilles tendon ruptures


Jessing P;Hansen E; Surgical treatment of 102 tendo achillis ruptures-- suture or



Author Title Reason for Exclusion tenontoplasty?

Closed treatment of Achilles tendon rupture Keller J;Rasmussen TB; Not best available

evidence Majewski M;Rohrbach M;Czaja S;Ochsner P;



Jennings AG;Sefton GK;Newman RJ;

Repair of acute rupture of the Achilles tendon: a new technique

using polyester tape without external splintage


Suchak AA;Bostick GP;Beaupre LA;Durand

DC;Jomha NM;

The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles

tendon

Does not report relevant outcomes

Pendleton H;Resch S;Stenstrom A;Astrom I;

Residual functional problems after non-operative treatment of Achilles

tendon rupture Retrospective


Nonoperative treatment of acute rupture of the Achilles tendon: results

of a new protocol and comparison with operative treatment

Retrospective


STUDY QUALITY 1878 1879 1880

Table 135. Patient return to activities of daily living

●= yes ○= no x= not reported

Author Outcome Measure

Sam

e T

reat

men

t

N LoE

Con

secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equ

al F

ollo

w u

p T

ime

Calder, et al. 2005 Return to previous sporting activities 46 IV ● ● ● ● x


Cetti, et al. 1993 Return to sports - same level 47 IV ● ● ● ● ●



Return to sports - frequent* (months) 14 IV ● ● ● ● ●

Costa, et al. 2006 Return to sports 23 IV x ● ● ● ● Costa, et al. 2006 Return to sports 25 IV x ● ● ● ●

Costa, et al. 2006 Return to stair climbing (weeks) 26 IV x ● ● ● ●


Costa, et al. 2006 Return to sports (weeks) 23 IV x ● ● ● ●

Coutts, et al. 2002 Return to pre-injury level of sporting participation 22 IV x ● ● ● ●

Coutts, et al. 2002 Return to sports 20 IV x ● ● ● ●

Doral, et al. 2009 Return to previous sporting activities 62 IV ● ● ● ● ●

Doral, et al. 2009 Rehabilitation training 62 IV ● ● ● ● ●

Fortis, et al. 2008 Return to previous activity levels 20 IV x ● ● ● ●


Return to sports - pre-injury level 54 IV ● ● ● ● ●

Giannini, et al. 1994

Return to pre-injury level of activity 15 IV ● ● ● ● ●

Hogsaa, et al. 1990 Resumption of recreational activities 63 IV ● ● ● ● ●

Hogsaa, et al. 1990 Resumption of recreational activities 63 IV ● ● ● ● x




Author Outcome Measure N LoE

Con

secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equ

al F

ollo

w u

p T

ime

Sam

e T

reat

men

t

Jung, et al. 2008 Resume light exercise 27 IV x ● ● ● ●

Jung, et al. 2008 Return to previous sporting activities 27 IV x ● ● ● ●


Return to amateur sports activity 32 IV x ● ● ● ●

Lansdaal, et al. 2007 Return to sports - same level 152 IV x ● ● ● ●

Lansdaal, et al. 2007 Return to sports 152 IV x ● ● ● ●

Maffulli, et al. 2003 Activity limitations - none 27 IV ● ● ● ● ●


Maffulli, et al. 2003 Return to sports 19 IV ● ● ● ● ●





Metz, et al. 2008 Return to sports 33 IV ● ● ● ● ● Metz, et al. 2008 Return to sports 36 IV ● ● ● ● ●

Moller, et al. 2001 Return to sports - same level 47 IV ● ● ● ● ●

Scarfi, et al. 2002 Return to sports activities 20 IV x ● ● ● ●


Return to previous sports activity w/o any difficulty 16 IV ● ● ● ● ●

Solveborn, et al. 1994 Return to sports 16 IV ● ● ● ● ●

Taglialavoro, et al. 2004 Return to sports - complete 24 IV ● ● ● ● ●


Tang, et al. 2007 Return to sports level 6 IV x ● ● ● ● Troop, et al. 1995 Resume jogging/running 13 IV ● ● ● ● ● Troop, et al. 1995 Resume jogging/running 13 IV ● ● ● ● ●




Con

secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equ

al F

ollo

w u

p T

ime

Sam

e T

reat

men

t

Uchiyama, et al. 2007 Resume jogging (weeks) 84 IV x ● ● ● ●


Return to sports for high-level athletes - original game level 21 IV x ● ● ● ●

Wallace, et al. 2004 Return to sports (weeks) 101 IV ● ● ● ● x


RECOMMENDATION 15 1881 1882 1883 1884 1885

1886

1887 1888 1889 1890 1891

1892 1893

1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906

In patients who participate in sports it is an option to return them to sports within 3-6 months after operative treatment for acute Achilles tendon rupture. Strength of Recommendation: Weak

Rationale:

A systematic review identified 23 level IV studies providing data on return to sports after operative treatment. Two studies53, 50 reported return to jogging at three months. One study 46 reported return to sport at four months. Five studies54, 37,53, 50,55 reported that 83%-100% of patient returned to sports at six months. Ten studies19,56, 57, 52, 56, 54 , 40, 5, 21,

20 reported that 32-100% of patients returned to sports at 12 months or more.


Twenty-three21,5,20, 19, 49,39, 58,53,50,46,37,56, 57,38,25, 59,52,28,30,33, 54, 40studies are included that report data on return to athletic activity. We have tabled the percent of patients able to return to recreational and sports activities after operative treatments and the mean length of time to return to athletic activity (see Table 136 through Table 138 ). We attempted meta-analysis for the following patient groups and outcomes: percent operative patients able to return to activity at ≥ 12 months (I^2 >80%) (see Table 136 ) percent of operative patients able to return to sports at 6 and at 12 months (I ^2 >90%) (see Table 137), and mean time for operative patients to return to sports (I ^2 >95%) (see Table 138). The results of these studies are so different from each other, as demonstrated by the high heterogeneity, that it is difficult to draw any conclusions about the time to return to recreational or athletic activity. There were too few studies included for each outcome to investigate the reasons for heterogeneity. The remainder of outcomes and patient groups do not include enough studies to attempt meta-analysis.


SUMMARY OF EVIDENCE 1907 1908 Table 136. Operative Treatment - Return to Recreational Activity

Author LOE Treatment N Outcome Duration (months) % Hogsaa, et al.

1990 IV open repair 63 Resumption of recreational activities 6-12 30%

Hogsaa, et al. 1990 IV open repair 63 Resumption of recreational

activities 3-6 33%


activities < 3 10%

Maffulli, et al. 2003 IV open repair (non-

weight-bearing) 27 Activity limitations - none 12 93%

Maffulli, et al. 2003 IV open repair

(weight-bearing) 26 Activity limitations - none 12 92%


activities > 12 51%

Giannini, et al. 1994 IV

adjunctive augmentation

(synthetic graft) 15 Return to pre-injury level

of activity 18 100%

Fortis, et al. 2008 IV

endoscopically assisted

percutaneous 20 Return to previous activity

levels 30 100%

1909

1910 Table 137. Operative Treatment - Return to sports


Troop, et al. 1995 IV end-to-end w/

early motion 13 Resume jogging/running 3 92%

Jung, et al. 2008 IV limited open 27 Resume light exercise 3 100%

Troop, et al. 1995 IV end-to-end w/

early motion 13 Resume jogging/running 3 92%

Scarfi, et al. 2002 IV percutaneous

repair 20 Return to sports activities 4 100%

Kuskucu, et al. 2005 IV fibrin sealant 32 Return to amateur sports

activity 6 97%

Aktas, et al. 2007 IV


(autograft) 16 Return to sports - pre-injury

level of activity 6 85%

Tang, et al. 2007 IV

arthroscopically assisted

percutaneous 6 Return to sports level 6 83%

Jung, et al. 2008 IV limited open 27 Return to previous sporting

activities 6 100%


Duration (months) Author LOE Treatment N Outcome %

Calder, et al. 2005 IV

mini-open repair w/ early active rehabilitation

46 Return to previous sporting activities 6 100%

Aktas, et al. 2008 IV open repair 14 Return to sports - pre-injury

level of activity 6 89%

Calder, et al. 2006 IV percutaneous

repair 25 Return to previous sporting activities 6 100%

Cetti, et al. 1993 IV end-to-end suture 52 Return to sports - same level 12 62%

Solveborn, et al. 1994 IV

end-to-end suture w/ below-knee transport splint

cast

16 Return to previous sports activity w/o any difficulty 12 81%

Solveborn, et al. 1994 IV

end-to-end suture w/ below-knee transport splint

cast

16 Return to sports 12 100%

Moller, et al. 2001 IV end-to-end suture

w/o augmentation 47 Return to sports - same level 12 54%

Metz, et al. 2008 IV minimally-

invasive 36 Return to sports 12 67%

Lansdaal, et al. 2007 IV minimally-

invasive 152 Return to sports - same level 12 64%


open end-to-end (immediate

weight-bearing mobilisation)

23 Return to sports 12 83%


open end-to-end (plaster cast

immobilisation) 25 Return to sports 12 68%


weight-bearing) 19 Return to sports 12 89%

Maffulli, et al. 2003 IV open repair

(weight-bearing) 19 Return to sports 12 89%

Taglialavoro, et al. 2004 IV


(autograft) 24 Return to sports - complete 42 38%

Taglialavoro, et al. 2004 IV open repair 22 Return to sports - complete 42 32%

Doral, et al. 2009 IV

endoscopy assisted

percutaneous 62 Return to previous sporting

activities 46 95%

Garabito, et al. 2004 IV


(autograft) 54 Return to sports - pre-injury

level 96 43%


1911

1912 Table 138. Operative Treatment - Mean time to return to athletic activity


Doral, et al. 2009 IV endoscopy assisted

percutaneous 62 Rehabilitation training 11.7 (SD 0.75)

Troop, et al. 1995 IV end-to-end w/ early

motion 13 Resume jogging/running 3 (SD 0.75)

Lansdaal, et al. 2007 IV minimally-invasive 152 Return to sports 7.1 (SD 3.8)



bearing mobilisation)

23 Return to sports (weeks)

11.14 (95% CI 5-17)*

Uchiyama, et al. 2007 IV open repair 84 Resume jogging

(weeks) 3.5(SD .9)

Coutts, et al. 2002 IV open repair 22

Return to pre-injury level of sporting

participation 40.8 (SD 25.2)

Coutts, et al. 2002 IV open repair 20 Return to sports 4.5 (SD 2.14)

Uchiyama, et al. 2007 IV open repair 21

Return to sports for high-level athletes - original game level

5 (SD .35)


weight-bearing) 19 Return to sports 6 (SD 3)

Maffulli, et al. 2003 IV open repair (weight-

bearing) 19 Return to sports 5.1 (SD 2.8)

Gorschewsky, et al. 2004 IV percutaneous repair 66 Return to original

sport 5.46 (SD 1.5)

Maffulli, et al. 2009 IV percutaneous repair 24 Return to sports 88 (SD 14.5)

Chillemi, et al. 2002 IV percutaneous repair 14 Return to sports -

frequent* (months) 8 (SD 1.5)

1913

1914 1915


Author Title Reason for Exclusion

Suchak AA;Bostick GP;Beaupre LA;Durand

DC;Jomha NM;

The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the

Achilles tendon

No relevant outcomes

Majewski M;Rohrbach M;Czaja S;Ochsner P;





Wagnon R;Akayi M; The Webb-Bannister percutaneous technique for acute Achilles' tendon ruptures: a functional and

MRI assessment

Time of return to sports not reported


Isokinetic strength and endurance after percutaneous and open surgical repair of Achilles

tendon ruptures

No patient-oriented outcome




Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study


Jennings AG;Sefton GK;Newman RJ;

Repair of acute rupture of the Achilles tendon: a new technique using polyester tape without external

splintage



RG;Sintenie JB;




T;Donell ST;




Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective,

randomized clinical and radiographic study


Kakiuchi M; A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open

repair


Roberts C;Rosenblum S;Uhl R;Fetto J;



Keller J;Rasmussen TB; Closed treatment of Achilles tendon rupture Not best available evidence

Martinelli B; Percutaneous repair of the Achilles tendon in athletes


Fernandez-Fairen M;Gimeno C; Augmented repair of Achilles tendon ruptures Not best available

evidence Park HG;Moon DH;Yoon

JM; Limited open repair of ruptured Achilles tendons

with Bunnel-type sutures Not best available

evidence


STUDY QUALITY 1916 1917 Table 140. Return to sports



Sam

e T

reat

men

t

N LoE Con

secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equ

al F

ollo

w u

p T

ime

Aktas, et al. 2007 Return to sports - pre-injury level of activity 16 IV ● ● ● ● ●

Aktas, et al. 2008 Return to sports - pre-injury level of activity 14 IV ● ● ● ● ●






Return to sports - frequent* (months) 14 IV ● ● ● ● ●

Costa, et al. 2006 Return to sports 23 IV x ● ● ● ●




Costa, et al. 2006 Return to sports (weeks) 23 IV x ● ● ● ●

Coutts, et al. 2002 Return to pre-injury level of sporting participation 22 IV x ● ● ● ●

Coutts, et al. 2002 Return to sports 20 IV x ● ● ● ●

Doral, et al. 2009 Return to previous sporting activities 62 IV ● ● ● ● ●

Doral, et al. 2009 Rehabilitation training 62 IV ● ● ● ● ●



Author Outcome Measure N LoE Con

secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equ

al F

ollo

w u

p T

ime

Sam

e T

reat

men

t

Fortis, et al. 2008 Return to previous activity levels 20 IV x ● ● ● ●


Return to sports - pre-injury level 54 IV ● ● ● ● ●

Giannini, et al. 1994

Return to pre-injury level of activity 15 IV ● ● ● ● ●





Jung, et al. 2008 Resume light exercise 27 IV x ● ● ● ●

Jung, et al. 2008 Return to previous sporting activities 27 IV x ● ● ● ●


Return to amateur sports activity 32 IV ● ● ● ● ●

Lansdaal, et al. 2007 Return to sports - same level 152 IV x ● ● ● ●

Lansdaal, et al. 2007 Return to sports 152 IV x ● ● ● ●

Metz, et al. 2008 Re-rupture 33 IV ● ● ● ● ●

Metz, et al. 2008 Absence from work 33 IV ● ● ● ● ●

Metz, et al. 2008 Return to sport 33 IV ● ● ● ● ●

Metz, et al. 2008 Pain - VAS 33 IV ● ● ● ● ●





secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equ

al F

ollo

w u

p T

ime

Sam

e T

reat

men

t


Metz, et al. 2008 Satisfaction - VAS 33 IV ● ● ● ● ●



Metz, et al. 2008 Return to sedentary work

(days) 59 IV ● ● ● ● ●

Moller, et al. 2001 Return to light, mobile work (days) 59 IV ● ● ● ● ●

Moller, et al. 2001 Return to work (days) 59 IV ● ● ● ● ●

Moller, et al. 2001 Return to heavy work (days) 59 IV ● ● ● ● ●


Moller, et al. 2001 Return to sports - stopped 59 IV ● ● ● ● ●

Moller, et al. 2001 Return to sedentary work (days) 59 IV ● ● ● ● ●


Scarfi, et al. 2002 Return to sports activities 20 IV x ● ● ● ●


Return to previous sports activity w/o any difficulty 16 IV ● ● ● ● ●

Solveborn, et al. 1994 Return to sports 16 IV ● ● ● ● ●






secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equ

al F

ollo

w u

p T

ime

Sam

e T

reat

men

t


Return to sports for high-level athletes - original game level 21 IV ● ● ● ● ●

Cetti, et al. 1993 Return to work (weeks) 56 IV ● ● ● ● ●

Cetti, et al. 1993 Return to sports - diminished level 56 IV ● ● ● ● ●


Cetti, et al. 1993 Return to sports - stopped 56 IV ● ● ● ● ●

Cetti, et al. 1993 Function-Abnormal ankle movement 56 IV ● ● ● ● ●


Cetti, et al. 1993 Function-Abnormal gait 56 IV ● ● ● ● ●


Cetti, et al. 1993 Function-Abnormal run 56 IV ● ● ● ● ●


Cetti, et al. 1993 Function-Abnormal toe stand 56 IV ● ● ● ● ●



Able to walk without limitation 38 IV ● ● ● ● ●


Return to sports activity (frequent participant 2-3 times

per week) 14 IV ● ● ● ● ●




secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equ

al F

ollo

w u

p T

ime

Sam

e T

reat

men

t

Coutts, et al 2002 Return to pre-injury sporting level 22 IV x ● ● ● ●








Troop, et al. 1995 Resume jogging/running 13 IV ● ● ● ● ●

Troop, et al. 1995 Resume jogging/running 13 IV ● ● ● ● ●

Tang, et al. 2007 Return to sports level 6 IV x ● ● ● ●


RECOMMENDATION 16 1918 1919 1920 1921 1922

1923

1924 1925 1926 1927 1928 1929

1930 1931 1932 1933 1934 1935

1936 1937 1938

In patients with acute Achilles tendon rupture treated non-operatively, we are unable to recommend a specific time at which patients can return to athletic activity. Strength of Recommendation: Inconclusive

Rationale:

A systematic review identified 5 level IV studies21,5,20, 19,25 providing data on return to sports after non-operative treatment. These studies did not provide adequate evidence to make a recommendation for the specific time patients can return to athletic activity following non-operative treatment for Achilles tendon rupture. Supporting Evidence:

Five Level IV studies21,5,20, 19,25 that provided data on return to sports after non-operative treatment were identified. We have tabled the percent of patients and the mean length of time to return to athletic activity reported by the authors of these studies (see Table 141 and Table 142). The lack of studies, variation in treatments and variation in reported outcomes makes it difficult to draw any conclusions about the time to return to athletic activity following non-operative treatment.

SUMMARY OF EVIDENCE Table 141. Non-Operative Treatment - Percent of patients returning to athletic activity


Metz, et al. 2008 IV functional brace 33 Return to sports 12 82%


bearing mobilisation 18 Return to sports (months) 12 56%


immobilisation 21 Return to sports (months) 12 52%

Moller, et al. 2001 IV below the knee

plaster cast 38 Return to sports - same level (months) 12 54%

Cetti, et al. 1993 IV below-knee plaster

cast 47 Return to sports-same level 12 34 %

1939


1940 1941 1942

Table 142. Non-Operative Treatment - Mean time until patients return to athletic activity

Author LOE Treatment N Outcome Duration (weeks)

Wallace, et al. 2004 IV cast 101 Return to sports (weeks) 10 (SD 4.9)

Costa, et al. 2006 IV plaster cast immobilisation 26 Return to stair climbing

(weeks) 18 (95% CI

14-22)*


bearing mobilisation

22 Return to stair climbing (weeks)

17 (95% CI 11-18)*

1943


1944 1945 1946

EXCLUDED ARTICLES Table 143. Excluded studies





RG;Sintenie JB;




T;Donell ST;




Nonoperative treatment of acute rupture of the Achilles tendon: results of a new protocol and

comparison with operative treatment Retrospective

Pendleton H;Resch S;Stenstrom A;Astrom I;

Residual functional problems after non-operative treatment of Achilles tendon rupture Retrospective

1947

1948 1949

STUDY QUALITY Table 144. Study Quality



Sam

e Tr

eatm

ent

N LoE

Con

secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equa

l Fol

low

up

Tim

e Cetti, et al. 1993 Return to sports - same level 47 IV ● ● ● ● ●






Metz, et al. 2008 Re-rupture 33 IV ● ● ● ● ●




Con

secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equa

l Fol

low

up

Tim

e

Sam

e Tr

eatm

ent

Metz, et al. 2008 Absence from work 33 IV ● ● ● ● ●

Metz, et al. 2008 Return to sport 33 IV ● ● ● ● ●







Metz, et al. 2008 Return to sedentary work

(days) 59 IV ● ● ● ● ●


Moller, et al. 2001 Return to work (days) 59 IV ● ● ● ● ●

Moller, et al. 2001 Return to heavy work (days) 59 IV ● ● ● ● ●


Moller, et al. 2001 Return to sports - stopped 59 IV ● ● ● ● ●

Moller, et al. 2001 Return to sedentary work (days) 59 IV ● ● ● ● ●


Wallace, et al. 2004 Return to sports (weeks) 101 IV x ● ● ● ●




Con

secu

tive

Follo

w u

p 80

Sam

e O

utco

mes

Equa

l Fol

low

up

Tim

e

Sam

e Tr

eatm

ent


Cetti, et al. 1993 Return to sports - stopped 56 IV ● ● ● ● ●









1950


FUTURE RESEARCH 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967

While the current guideline is instructive in many ways, it also demonstrates a substantial need for future research. Wherever the strength of a specific Recommendation is weak or inconclusive, there exists a need for well-designed studies and high-level evidence. As such, the most obvious need is for further, high-level investigations into the fundamental question of whether or not surgical management is superior to non-operative management of acute Achilles ruptures. There are hundreds of studies that are centered on this question, but too few are high-level randomized control trials. Beyond this, there are several other areas of needed research. Does the clinician routinely need MRI or an ultrasound for the diagnosis of an Achilles rupture? Probably not. However, there are no high-level studies to help answer this question. For non-operative treatment, low-level evidence supports the use of immediate functional bracing, but again more randomized trials are necessary. Post-operatively, is DVT prophylaxis necessary? Does the patient really need physical therapy? These are very important questions that so far remain unanswered.


IV. APPENDIXES 1968


APPENDIX I 1969 1970 1971

WORK GROUP Blinded for peer review


APPENDIX II 1972 1973 1974 1975 1976 1977 1978 1979

1980 1981 1982 1983 1984

1985 1986 1987 1988 1989 1990 1991 1992 1993

1994 1995 1996 1997 1998 1999 2000 2001 2002

2003 2004 2005

AAOS BODIES THAT APPROVED THIS CLINICAL PRACTICE GUIDELINE Guidelines and Technology Oversight Committee The AAOS Guidelines and Technology Oversight Committee (GTOC) consist of sixteen AAOS members. The overall purpose of this Committee is to oversee the development of the clinical practice guidelines, performance measures, health technology assessments and utilization guidelines.

Evidence Based Practice Committee The AAOS Evidence Based Practice Committee (EBPC) consists of ten AAOS members. This Committee provides review, planning and oversight for all activities related to quality improvement in orthopaedic practice, including, but not limited to evidence-based guidelines, performance measures, and outcomes.

Council on Research, Quality Assessment, and Technology To enhance the mission of the AAOS, the Council on Research, Quality Assessment, and Technology promotes the most ethically and scientifically sound basic, clinical, and translational research possible to ensure the future care for patients with musculoskeletal disorders. The Council also serves as the primary resource to educate its members, the public, and public policy makers regarding evidenced-based medical practice, orthopaedic devices and biologics, regulatory pathways and standards development, patient safety, occupational health, technology assessment, and other related areas of importance.

The Council is comprised of the chairs of the AAOS Biological Implants, Biomedical Engineering, Evidence Based Practice, Guidelines and Technology Oversight, Occupational Health and Workers’ Compensation, Patient Safety, Research Development, and US Bone and Joint Decade committees. Also on the Council are the AAOS second vice-president, representatives of the Diversity Advisory Board, the Women's Health Issues Advisory Board, the Board of Specialty Societies (BOS), the Board of Councilors (BOC), the Communications Cabinet, the Orthopaedic Research Society (ORS), the Orthopedic Research and Education Foundation (OREF), and three members at large.

Board of Directors The 17 member AAOS Board of Directors manages the affairs of the AAOS, sets policy, and determines and continually reassesses the Strategic Plan.


DOCUMENTATION OF APPROVAL 2006 2007

2008

2009

2010

2011

2012

2013 2014

2015

AAOS Work Group Draft Completed August 18, 2009

Peer Review Completed September 18, 2009

Public Commentary Completed November 12, 2009

AAOS Guidelines and Technology Oversight Committee _________________

AAOS Evidence Based Practice Committee _________________

AAOS Council on Research, Quality Assessment, _________________ and Technology

AAOS Board of Directors _________________


APPENDIX III 2016

2020 2021 2022 2023 2024 2025 2026 2027 2028 2029

2030

2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052

2053

2054 2055 2056 2057

LITERATURE SEARCHES FOR PRIMARY STUDIES 2017 The literature searches were performed using the following databases. The full search 2018 strategies are listed below: 2019

• PubMed • EMBASE • CINAHL • The Cochrane Library • The National Guidelines Clearinghouse • TRIP Database - Guidelines

All literature searches were supplemented with manual screening of bibliographies in publications accepted for inclusion into the evidence base. In addition, the bibliographies of recent review articles were searched for potentially relevant citations.

PubMed was searched using the following strategy:

(("Achilles Tendon"[mh] OR Achilles[tw]) AND ((("Tendon Injuries"[mh] OR injuries[sh] OR injur*[tiab] OR ruptur*[tiab] OR re-ruptur*[tiab] OR tears[tiab] OR torn[tiab] OR tear[tiab]) AND (diagnosis[sh] OR diagnos*[tw] OR "Magnetic Resonance Imaging"[mh] OR MRI[tiab] OR Ultrasonography[mh] OR sonograph*[tiab] OR ultrasound[tiab] OR radiograph*[tiab] OR Radiography[mh] OR x-ray[tiab] OR imaging[tiab] OR gap[tiab] OR "Thompson test"[tw] OR therapy[sh] OR treated[tiab] OR treatment*[tiab] OR brace[tiab] OR bracing[tiab] OR cast[tiab] OR casting[tiab] OR casts[tw] OR "Casts, Surgical"[mh] OR immobiliz*[tiab] OR surgery[tiab] OR surgical*[tiab] OR operati*[tiab] OR repair*[tiab] OR reconstruct*[tiab] OR non-operativ*[tiab] OR nonoperativ*[tiab] OR "weight bearing"[tiab] OR "Recovery of Function"[mh] OR "Physical Therapy Modalities"[mh] OR physiotherapy[tiab] OR Anticoagulants[pa])) OR ((repair*[tiab] OR surgery[tiab] OR surgery[sh] OR surgical*[tiab] OR operati*[tiab] OR repair*[tiab] OR reconstruct*[tiab] OR post-operative*[tiab] OR postoperative*[tiab]) AND ("Physical Therapy Modalities"[mh] OR physiotherapy[tiab] OR brace[tiab] OR bracing[tiab] OR cast[tiab] OR casting[tiab] OR casts[tw] OR "Casts, Surgical"[mh] OR immobiliz*[tiab] OR low-impact[tiab] OR activity[tiab] OR activities[tiab] OR "weight bearing"[tiab] OR weight-bearing[tiab] OR "Recovery of Function"[mh])))) AND "1966"[PDat]:"2008"[PDat] AND “1”[EDat]:”2008/12/21”[EDAT] AND English[lang] AND (human[mh] OR in process[sb] OR publisher[sb]) NOT (comment[pt] OR editorial[pt] OR letter[pt] OR addresses[pt] OR news[pt] OR "newspaper article"[pt] OR “historical article”[pt] OR "case reports"[pt] OR "retrospective case study"[tw])

EMBASE was searched using the following strategy:

('Achilles tendon rupture'/de OR (('Achilles tendon'/de OR Achilles) AND ('tendon reconstruction'/de OR ((('tendon injury'/de OR injur* OR ruptur* OR reruptur* OR tears OR torn OR tear) AND (diagnos* OR 'nuclear magnetic resonance imaging'/exp OR mri OR 'ultrasound'/de OR ultrasound OR sonograph* OR radiograph* OR 'radiography'/de


2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068

2069

2070 2071 2072

2073

2074

2075

2076

2077

2078

OR imaging OR gap OR 'thompson test' OR treated OR treatment* OR brace OR bracing OR cast OR casts OR 'plaster cast'/de OR 'walking aid'/de OR immobiliz* OR surgery OR surgical* OR operati* OR repair* OR reconstruct* OR nonoperativ* OR 'weight bearing'/de OR 'weight bearing' OR 'convalescence'/de OR 'physiotherapy'/exp OR physiotherapy OR 'anticoagulant agent'/exp)) OR ((repair* OR surgery OR surgical* OR operti* OR reconstruct* OR postoperative*) AND ('physiotherapy'/de OR physiotherapy OR brace OR bracing OR case OR casting OR casts OR 'plaster cast'/de OR 'walking aid'/de OR immobiliz* OR 'low impact' OR activity OR activities OR 'weight bearing'/de OR 'weight bearing' OR convalescence/de)))))) AND ([article]/lim OR [conference paper]/lim OR [review]/lim) AND [english]/lim AND [humans]/lim AND [embase]/lim NOT [22-12-2008]/sd

CINAHL was searched using the following strategy:

MM "Achilles Tendon" or Achilles and MM "tendon injuries" or ruptur* and ( PT “research” and LA English and PY 1966-2008 ) not (PT “editorial” or PT “letter” or PT “case study” or MM “case studies”)

The Cochrane Library was searched using the following strategy:

Achilles AND (injur* OR ruptur* OR re-ruptur* OR tears OR torn OR tear)

The National Guidelines Clearinghouse was searched using the following strategy:

Achilles tendon rupture

The TRIP Database - Guidelines was searched using the following strategy:

Achilles tendon rupture


APPENDIX IV 2079 2080

2081

STUDY ATTRITION FLOWCHART

2481 abstracts screened for inclusion

1766 citations excluded

281 articles recalled for full text review

2200 abstracts excluded

237 articles excluded

44 articles included

4247 citations identified by literature search


APPENDIX V 2082 2083 2084 2085 2086

7

2089 2090 2091 2092 2093 2094

5

2097 2098 2099 2100

1

2103 2104 2105 2106 2107 2108 2109 2110

DATA EXTRACTION ELEMENTS The data elements below were extracted into electronic forms in Microsoft® Access and Microsoft® Excel. The extracted information includes: 208 Study Characteristics (for all relevant outcomes in a study) 2088

• methods of randomization and allocation • use of blinding (patient, caregiver, evaluator) • funding source/conflict of interest • duration of the study • number of subjects and follow-up percentage • experimental and control groups

209 Patient Characteristics (for all treatment groups in a study) 2096

• patient inclusion/exclusion criteria • co-interventions (if used) and co-morbidities (if present) • measures of disease severity • Complications

210 Results (for all relevant outcomes in a study) 2102

• outcome measure • is the outcome measure patient-oriented? validated? objective/subjective? • duration at which outcome measure was evaluated • statistic reported (for dichotomous results) • mean value and measure and value of dispersion (continuous results) • statistical test used, value of test statistic, and p-value • verification of calculations


APPENDIX VI 2111 2112 2113 2114 2115 2116

2117 2118

2119

2120

2121 2122

2123 2124

2125

2126 2127

2128 2129

2130 2131

2132 2133

2134 2135

2136 2137

2138

2139

JUDGING THE QUALITY OF DIAGNOSTIC STUDIES The QUADAS tool is used to identify sources of bias, variability, and the quality of reporting in studies of diagnostic accuracy. Fourteen questions answered “yes”, “no”, or “unclear” contribute to the QUADAS tool. There is no score derived from the use of the QUADAS tool.

Was the spectrum of patient’s representative of the patients who will receive the test in practice?

Were selection criteria clearly described?

Is the reference standard likely to correctly classify the target condition?

Is the time period between ref. standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

Did the whole sample or a random selection of the sample, receive verification using a reference standard of diagnosis?

Did patients receive the same reference standard regardless of the index test result?

Was the reference standard independent of the index test (i.e. the index test did not form part of the reference standard)?

Was the execution of the index test described in sufficient detail to permit replication of the test?

Was the execution of the reference standard described in sufficient detail to permit its replication?

Were the index test results interpreted without knowledge of the results of the reference standard?

Were the reference standard results interpreted without knowledge of the results of the index test?

Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

Were uninterpretable/intermediate test results reported?

Were withdrawals from the study explained?


JUDGING THE QUALITY OF TREATMENT STUDIES 2140 2141

2142

2143

2144

2145 2146

2147 2148

2149 2150

2151 2152

2153 2154

RANDOMIZED CONTROLLED TRIALS

Did the study employ stochastic randomization?

Was there concealment of allocation?

Were subjects blinded to the treatment they received?

Were those who assessed/rated the patient’s outcomes blinded to the group to which the patients were assigned?

Was there more than 80% follow-up for all patients in the control group and the experimental group on the outcome of interest?

Did patients in the different study groups have similar levels of performance on ALL of the outcome variables at the time they were assigned to groups?

For randomized crossover studies, was there evidence that the results obtained in the study’s two experimental groups (in period 1 and 2) did not differ?

For randomized crossover studies, was there evidence that the results of the two control groups (in period 1 and 2) did not differ?

2155

2156 2157

2158 2159

2160

2161 2162

2163 2164

2165 2166

2167 2168

2169

2170

PROSPECTIVE NON- RANDOMIZED CONTROLLED STUDIES

Were the characteristics of patients in the different study groups comparable at the beginning of the study?

Did patients in the different study groups have similar levels of performance on ALL of the outcome variables at baseline?

Were all of the study’s groups concurrently treated?


Did the study avoid collecting control group data from one center and experimental group data from another?

For crossover studies, was there evidence that the results obtained in the study’s two experimental groups (in period 1 and 2) did not differ?

For crossover studies, was there evidence that the results of the two control groups (in period 1 and 2) did not differ?


2171

2172

2173

2174

2175 2176

2177

2178 2179

2180 2181

2182 2183

2184 2185

RETROSPECTIVE COMPARATIVE STUDIES

Was there less than 20% difference in completion rates in the study’s groups?

Were all of the study’s groups concurrently treated?

Was the same treatment given to all patients enrolled in the experimental and

Were the same laboratory tests, clinical findings, psychological instruments, etc. used to measure the outcomes in all of the study’s groups?

Were the follow-up times in all of the study’s relevant groups approximately equal?


Did the study avoid collecting control group data from one center and experimental group data from another?

Did patients in the different study groups have similar levels of performance on ALL of the outcome variables at the time they were assigned to groups?

Were the characteristics of patients in the different study groups comparable at the beginning of the study?

2186

2187

2188

2189 2190

2191

2192

CASE SERIES

Was enrollment in the study consecutive?

Was there more than 80% follow-up for all patients on the outcome of interest?

Were the same laboratory tests, clinical findings, psychological instruments, etc. used to measure the outcomes in all patients?

Were the patients instructed/not given concomitant or adjuvant treatments?

Were the follow-up times for all patients approximately equal?


APPENDIX VII 2193 2194 2195 2196 2197

2198 2199

2200

2201

2202

2203

2204

2205

2206 2207

2208 2209

2210

2211

2212 2213

2214

2215

2216

2217

2218 2219

2220

2221

FORM FOR ASSIGNING STRENGTH OF RECOMMENDATION (INTERVENTIONS) GUIDELINE RECOMMENDATION___________________________________

PRELIMINARY STRENGTH OF RECOMMENDATION:________________________________________

STEP 1: LIST BENEFITS AND HARMS

Please list the benefits (as demonstrated by the systematic review) of the intervention

Please list the harms (as demonstrated by the systematic review) of the intervention

Please list the benefits for which the systematic review is not definitive

Please list the harms for which the systematic review is not definitive

STEP 2: IDENTIFY CRITICAL OUTCOMES

Please circle the above outcomes that are critical for determining whether the intervention is beneficial and whether it is harmful

Are data about critical outcomes lacking to such a degree that you would lower the preliminary strength of the recommendation?

What is the resulting strength of recommendation?

STEP 3: EVALUATE APPLICABILITY OF THE EVIDENCE

Is the applicability of the evidence for any of the critical outcomes so low that substantially worse results are likely to be obtained in actual clinical practice?

Please list the critical outcomes backed by evidence of doubtful applicability:

Should the strength of recommendation be lowered because of low applicability?


STEP 4: BALANCE BENEFITS AND HARMS

Are there trade-offs between benefits and harms that alter the strength of recommendation obtained in STEP 3?



2222

2223 2224

2225

2226 2227

STEP 5 CONSIDER STRENGTH OF EVIDENCE

Does the strength of the existing evidence alter the strength of recommendation obtained in STEP 4?


NOTE: Because we are not performing a formal cost analyses, you should only consider costs if their impact is substantial.


APPENDIX VIII 2228 2229 2230 2231 2232 2233 2234 2235 2236 2237 2238 2239 2240

VOTING BY THE NOMINAL GROUP TECHNIQUE Voting on guideline recommendations will be conducted using a modification of the nominal group technique (NGT), a method previously used in guideline development.12 Briefly each member of the guideline work group ranks his or her agreement with a guideline recommendation on a scale ranging from 1 to 9 (where 1 is “extremely inappropriate” and 9 is “extremely appropriate”). Consensus is obtained if the number of individuals who do not rate a measure as 7, 8, or 9 is statistically non-significant (as determined using the binomial distribution). Because the number of work group members who are allowed to dissent with the recommendation depends on statistical significance, the number of permissible dissenters varies with the size of the work group. The number of permissible dissenters for several work group sizes is given in the table below:

Number of Permissible Dissenters Work group Size

Not allowed, statistical significance cannot be

obtained ≤ 3

4-5 0

6-8 1

9 1 or 2

2241 2242 2243 2244 2245 2246 2247

2248

The NGT is conducted by first having members vote on a given recommendation without discussion. If the number of dissenters is “permissible”, the recommendation is adopted without further discussion. If the number of dissenters is not permissible, there is further discussion to see whether the disagreement(s) can be resolved. Three rounds of voting are held to attempt to resolve disagreements. If disagreements are not resolved after three voting rounds, no recommendation is adopted.


APPENDIX IX 2249 2250 2251

STRUCTURED PEER REVIEW FORM Review of any AAOS confidential draft allows us to improve the overall guideline but does not imply endorsement by any given individual or any specialty society who participates in our review processes. The AAOS review process may result in changes to the documents; therefore, endorsement cannot be solicited until the AAOS Board of Directors officially approves the final guideline.

2252 2253 2254 2255 2256 2257 2258 2259 2260 2261 2262 2263 2264 2265 2266 2267 2268

Reviewer Information: Name of Reviewer_________________________________________ Address_________________________________________________ City___________________ State_________________ Zip Code___________ Phone _____________________Fax ________________________ E-mail_______________________ Specialty Area/Discipline: _______________________________________ Work setting: _________________________________________________ Credentials: _________________________________________________

2269 2270

May we list you as a Peer Reviewer in the final Guidelines? Yes No

2271 2272 2273

Are you reviewing this guideline as Yes No a representative of a professional society?

2274 2275 2276 2277 2278 2279 2280 2281 2282 2283 2284 2285 2286 2287 2288 2289 2290 2291 2292

If yes, may we list your society as a reviewer Yes No of this guideline? Reviewer Instructions Please read and review this Draft Clinical Practice Guideline and its associated Technical Report with particular focus on your area of expertise. Your responses are confidential and will be used only to assess the validity, clarity, and accuracy of the interpretation of the evidence. If applicable, please specify the draft page and line numbers in your comments. Please feel free to also comment on the overall structure and content of the guideline and Technical Report. If you need more space than is provided, please attach additional pages. Please complete and return this form electronically to [email protected] or fax the form back to Jan Weis at (847) 823-9769. Thank you in advance for your time in completing this form and giving us your feedback. We value your input and greatly appreciate your efforts. Please send the completed form and comments by Month, Day, Year



2293

COMMENTS 2294 2295 2296 2297 2298 2299 2300 2301 2302 2303 2304 2305 2306 2307 2308 2309 2310 2311 2312 2313 2314 2315 2316 2317

Please provide a brief explanation of both your positive and negative answers in the preceding section. If applicable, please specify the draft page and line numbers in your comments. Please feel free to also comment on the overall structure and content of the guideline and Technical Report

OVERALL ASSESSMENT Would you recommend these guidelines for use in practice? (check one) Strongly recommend _______ Recommend (with provisions or alterations) _______ Would not recommend _______ Unsure _______ COMMENTS: Please provide the reason(s) for your recommendation.


APPENDIX X 2318 2319

2320 2321 2322 2323 2324 2325 2326 2327 2328 2329 2330 2331 2332

2333 2334 2335 2336 2337 2338

PEER REVIEW PANEL

Participation in the AAOS peer review process does not constitute an endorsement of this guideline by the participating organization. Peer review of the draft guideline is completed by an outside Peer Review Panel. Outside peer reviewers are solicited for each AAOS guideline and consist of experts in the guideline’s topic area. These experts represent professional societies other than AAOS and are nominated by the guideline Work group prior to beginning work on the guideline. For this guideline, eleven outside peer review organizations were invited to review the draft guideline and all supporting documentation. Seven societies participated in the review of this guideline draft and six explicitly consented to be listed as a peer review organization in this appendix. One organizations did not give explicit consent that the organization name could be listed in this publication. The organizations that reviewed the document and consented to publication are listed below:

Individuals who participated in the peer review of this document and gave their consent to be listed as reviewers of this document are: 2339

2340 2341 2342 2343 2344 2345 2346 2347 2348 2349 2350 2351 2352 2353

2354 2355 2356 2357 2358 2359 2360 2361

Again, participation in the AAOS guideline peer review process does not constitute an endorsement of the guideline by the participating organizations or the individuals listed above. PUBLIC COMMENTARY A period of public commentary follows the peer review of the draft guideline. If significant non-editorial changes are made to the document as a result of public


2362 2363 2364 2365 2366 2367 2368 2369 2370 2371 2372 2373 2374

2375 2376 2377 2378 2379 2380

commentary, these changes are also documented and forwarded to the AAOS bodies that approve the final guideline. Public commentators who gave explicit consent to be listed in this document include the following:

Participation in the AAOS guideline public commentary review process does not constitute an endorsement of the guideline by the participating organizations or the individual listed nor does it is any way imply the reviewer supports this document.


APPENDIX XI 2381 2382 DESCRIPTION OF SYMBOLS USED IN TABLES

Symbol Description Odds Ratio = The odds in Group B divided by the odds in Group A, where the odds is the probability of the outcome occurring divided by the probability of the outcome not occurring.

OR

95% Confidence Interval = A measure of uncertainty of the point estimate: if the trial were repeated an infinite number of times, then the 95% CI calculated for each trial would contain the true effect 95% of the time.

95% CI

An open circle in a Summary of Evidence Table indicates that the result is not statistically significant. ○

A filled-in circle in a Summary of Evidence Table indicates that the result is statistically significant in favor of the listed treatment (in this example, in favor of op = operative treatment)

● op

2383


APPENDIX XII 2384 2385 2386

CONFLICT OF INTEREST Blinded for peer review


APPENDIX XIII 2387 2388 2389 2390 2391

2392 2393 2394

2395 2396

2397 2398

2399 2400 2401

2402 2403

2404 2405

2406 2407

2408 2409

2410 2411

2412 2413

2414 2415 2416

2417 2418

2419 2420 2421

REFERENCES (1) Suchak AA, Bostick G, Reid D, Blitz S, Jomha N. The incidence of Achilles

tendon ruptures in Edmonton, Canada. Foot and Ankle International 2005;26(11):932-936.

(2) Nyyssonen T, Luthje P. Achilles tendon ruptures in South-East Finland between 1986-1996, with special reference to epidemiology, complications of surgery and hospital costs. Ann Chir Gynaecol 2000;89(1):53-57.

(3) Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81(7):1019-1036.

(4) Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthopaedica Scandinavica 1996;67(3):277-279.

(5) Costa ML, MacMillan K, Halliday D et al. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg Br 2006;88(1):69-77.

(6) Cook D.J., Mulrow CD, Haynes RB. Systematic Reviews:synthesis of best evidence for clinical decisions. Ann Intern Med 1997;126(5):376-380.

(7) Mulrow C.D., Cook D.J., Davidoff F. Systematic Reviews:critical links in the great chain of evidence. Ann Intern Med 1997;126(5):389-391.

(8) Shaughnessy AF, Slawson DC. What happened to the valid POEMs? A survey of review articles on the treatment of type 2 diabetes. BMJ 2003;327(7409):266.

(9) Bucher H.C., Guyatt G.H., Cook D.J., Holbrook A., McAlister F.A. Users' Guides to the Medical Literature. JAMA 1999;282(8).

(10) GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328.

(11) Treadwell JR, Tregear SJ, Reston JT, Turkelson CM. A system for rating the stability and strength of medical evidence. BMC Med Res Methodol 2006;6:52.

(12) Murphy MK, Black LA, Lamping DL, McKee CM, Sanderson C.F., Askam J. Consensus development methods, and their use in clinical guideline development. Health Technol Assess 1998.

(13) Hedges L V., Olkin I. Statistical Methods for Meta-Analysis. Orlando: Academic Press; 1985.

(14) Rucker G, Schwarzer G, Carpenter J, Olkin I. Why add anything to nothing? The arcsine difference as a measure of treatment effect in meta-analysis with zero cells. Stat Med 2009;28(5):721-738.


2422 2423

2424 2425

2426 2427 2428

2429 2430 2431

2432 2433 2434

2435 2436 2437

2438 2439 2440 2441

2442 2443 2444

2445 2446 2447

2448 2449 2450

2451 2452 2453

2454 2455 2456 2457

(15) Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 2005;5(1):13.

(16) Maffulli N. The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med 1998;26(2):266-270.

(17) Margetic P, Miklic D, Rakic-Ersek V, Doko Z, Lubina ZI, Brkljacic B. Comparison of ultrasonographic and intraoperative findings in Achilles tendon rupture. Coll Antropol 2007;31(1):279-284.

(18) Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med 2007;35(12):2033-2038.

(19) Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med 1993;21(6):791-799.

(20) Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 2001;83(6):843-848.

(21) Metz R, Verleisdonk EJ, van der Heijden GJ et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial. Am J Sports Med 2008;36(9):1688-1694.

(22) Ingvar J, Tagil M, Eneroth M. Nonoperative treatment of Achilles tendon rupture: 196 consecutive patients with a 7% re-rupture rate. Acta Orthop 2005;76(4):597-601.

(23) Neumayer F, Mouhsine E, Arlettaz Y, Gremion G, Wettstein M, Crevoisier X. A new conservative-dynamic treatment for the acute ruptured Achilles tendon. Arch Orthop Trauma Surg 2009.

(24) McComis GP, Nawoczenski DA, DeHaven KE. Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data. J Bone Joint Surg Am 1997;79(12):1799-1808.

(25) Wallace RG, Traynor IE, Kernohan WG, Eames MH. Combined conservative and orthotic management of acute ruptures of the Achilles tendon. J Bone Joint Surg Am 2004;86-A(6):1198-1202.

(26) Saleh M, Marshall PD, Senior R, MacFarlane A. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon: A prospective, randomised comparison with plaster treatment. Journal of Bone and Joint Surgery - Series B 1992;74(2):206-209.


2458 2459

2460 2461

2462 2463 2464

2465 2466 2467

2468 2469

2470 2471

2472 2473 2474

2475 2476 2477 2478

2479 2480

2481 2482 2483

2484 2485 2486

2487 2488

2489 2490 2491

(27) Bhattacharyya M, Gerber B. Mini-invasive surgical repair of the Achilles tendon-does it reduce post-operative morbidity? Int Orthop 2008.

(28) Uchiyama E, Nomura A, Takeda Y, Hiranuma K, Iwaso H. A modified operation for Achilles tendon ruptures. Am J Sports Med 2007;35(10):1739-1743.

(29) Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon--a prospective randomized controlled study. Foot Ankle Int 2001;22(7):559-568.

(30) Coutts A, MacGregor A, Gibson J, Maffulli N. Clinical and functional results of open operative repair for Achilles tendon rupture in a non-specialist surgical unit. J R Coll Surg Edinb 2002;47(6):753-762.

(31) Aktas S, Kocaoglu B. Open versus minimal invasive repair with Achillon device. Foot Ankle Int 2009;30(5):391-397.

(32) Ng ES, Ng YO, Gupta R, Lim F, Mah E. Repair of acute Achilles tendon rupture using a double-ended needle. J Orthop Surg (Hong Kong) 2006;14(2):142-146.

(33) Chillemi C, Gigante A, Verdenelli A et al. Percutaneous repair of Achilles tendon rupture: Ultrasonographical and isokinetic evaluation. Foot and Ankle Surgery 2002;8(4):267-276.

(34) Gigante A, Moschini A, Verdenelli A, Del TM, Ulisse S, de PL. Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study. Knee Surg Sports Traumatol Arthrosc 2008;16(2):204-209.

(35) Kakiuchi M. A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair. J Bone Joint Surg Br 1995;77(1):60-63.

(36) Pajala A, Kangas J, Siira P, Ohtonen P, Leppilahti J. Augmented compared with nonaugmented surgical repair of a fresh total Achilles tendon rupture. A prospective randomized study. J Bone Joint Surg Am 2009;91(5):1092-1100.

(37) Aktas S, Kocaoglu B, Nalbantoglu U, Seyhan M, Guven O. End-to-end versus augmented repair in the treatment of acute Achilles tendon ruptures. J Foot Ankle Surg 2007;46(5):336-340.

(38) Taglialavoro G, Stecco C. The subcutaneous Achilles tendon rupture: Comparison of three surgical techniques. Foot and Ankle Surgery 2004;10(4):187-194.

(39) Giannini S, Girolami M, Ceccarelli F, Catani F, Stea S. Surgical repair of achilles tendon ruptures using polypropylene braid augmentation. Foot Ankle Int 1994;15(7):372-375.


2492 2493 2494

2495 2496 2497

2498 2499 2500 2501

2502 2503 2504

2505 2506 2507 2508

2509 2510 2511

2512 2513

2514 2515 2516

2517 2518 2519

2520 2521

2522 2523

2524 2525 2526

(40) Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med 2003;31(5):692-700.

(41) Suchak AA, Bostick GP, Beaupre LA, Durand DC, Jomha NM. The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am 2008;90(9):1876-1883.

(42) Mortensen NHM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon: A prospective, randomized clinical and radiographic study. Journal of Bone and Joint Surgery - Series A 1999;81(7):983-990.

(43) Cetti R, Henriksen LO, Jacobsen KS. A new treatment of ruptured Achilles tendons. A prospective randomized study. Clin Orthop Relat Res 1994;(308):155-165.

(44) Kangas J, Pajala A, Siira P, Hamalainen M, Leppilahti J. Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. J Trauma 2003;54(6):1171-1180.

(45) Hufner TM, Brandes DB, Thermann H, Richter M, Knobloch K, Krettek C. Long-term results after functional nonoperative treatment of achilles tendon rupture. Foot Ankle Int 2006;27(3):167-171.

(46) Scarfi G, Veneziani C, Bigazzi P. Percutaneous repair of Achilles tendon. Foot and Ankle Surgery 2002;8(2):105-110.

(47) Tang KL, Thermann H, Dai G, Chen GX, Guo L, Yang L. Arthroscopically assisted percutaneous repair of fresh closed achilles tendon rupture by Kessler's suture. Am J Sports Med 2007;35(4):589-596.

(48) Kiviluoto O, Santavirta S, Klossner O, Sandelin J, Hakkinen S. Surgical repair of subcutaneous rupture of the Achilles tendon. Arch Orthop Trauma Surg 1985;104(5):327-329.

(49) Hogsaa B, Nohr M, Lass P, Kaalund S. Surgical treatment of Achilles tendon ruptures. Unfallchirurg 1990;93(1):40-43.

(50) Jung HG, Lee KB, Cho SG, Yoon TR. Outcome of achilles tendon ruptures treated by a limited open technique. Foot Ankle Int 2008;29(8):803-807.

(51) Wagnon R, Akayi M. The Webb-Bannister percutaneous technique for acute Achilles' tendon ruptures: a functional and MRI assessment. J Foot Ankle Surg 2005;44(6):437-444.


2527 2528 2529

2530 2531 2532

2533 2534

2535 2536 2537

2538 2539

2540 2541 2542

2543 2544

2545 2546 2547

2548 2549 2550 2551

(52) Doral MN, Bozkurt M, Turhan E et al. Percutaneous suturing of the ruptured Achilles tendon with endoscopic control. Arch Orthop Trauma Surg 2009;129(8):1093-1101.

(53) Troop RL, Losse GM, Lane JG, Robertson DB, Hastings PS, Howard ME. Early motion after repair of Achilles tendon ruptures. Foot Ankle Int 1995;16(11):705-709.

(54) Kuskucu M, Mahirogullari M, Solakoglu C et al. Treatment of rupture of the Achilles tendon with fibrin sealant. Foot Ankle Int 2005;26(10):826-831.

(55) Calder JD, Saxby TS. Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study. Br J Sports Med 2005;39(11):857-859.

(56) Solveborn SA, Moberg A. Immediate free ankle motion after surgical repair of acute Achilles tendon ruptures. Am J Sports Med 1994;22(5):607-610.

(57) Lansdaal JR, Goslings JC, Reichart M et al. The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment. Injury 2007;38(7):839-844.

(58) Fortis AP, Dimas A, Lamprakis AA. Repair of achilles tendon rupture under endoscopic control. Arthroscopy 2008;24(6):683-688.

(59) Garabito A, Martinez-Miranda J, Sanchez-Sotelo J. Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia. Int Orthop 2005;29(1):42-46.

(60) Gorschewsky O, Pitzl M, Putz A, Klakow A, Neumann W. Percutaneous repair of acute Achilles tendon rupture. Foot Ankle Int 2004;25(4):219-224.


EXCLUDED ARTICLES AFTER FULL TEXT REVIEW 2552 2553

2554 2555

2556 2557 2558

2559 2560 2561

2562 2563 2564

2565 2566 2567

2568 2569 2570

2571 2572 2573

2574 2575

2576 2577

2578 2579

2580 2581 2582

2583 2584

Achilles rupture. Tending to tendon health. Mayo Clin Health Lett 2005;23(4):7.

Ajis A, Maffulli N. Management of acute tendo Achillis ruptures. Foot and Ankle Surgery 2007;13(3):132-135.

Akizuki KH, Gartman EJ, Nisonson B, Ben-Avi S, McHugh MP. The relative stress on the Achilles tendon during ambulation in an ankle immobiliser: implications for rehabilitation after Achilles tendon repair. Br J Sports Med 2001;35(5):329-333.

Aroen A, Helgo D, Granlund OG, Bahr R. Contralateral tendon rupture risk is increased in individuals with a previous Achilles tendon rupture. Scand J Med Sci Sports 2004;14(1):30-33.

Attinger CE, Ducic I, Hess CL, Basil A, Abbruzzesse M, Cooper P. Outcome of skin graft versus flap surgery in the salvage of the exposed achilles tendon in diabetics versus nondiabetics. Plast Reconstr Surg 2006;117(7):2460-2467.

Bergqvist D, Lowe G. Venous thromboembolism in patients undergoing laparoscopic and arthroscopic surgery and in leg casts. Archives of Internal Medicine 2002;162(19):2173-2176.

Bhattacharyya M, Gerber B. Minimally-invasive surgical repair of ruptured Achilles tendon as a day case procedure with early full weight bearing. Journal of One-Day Surgery /20;17(3):70-75.

Bibbo C, Anderson RB, Davis WH, Agnone M. Repair of the Achilles tendon sleeve avulsion: quantitative and functional evaluation of a transcalcaneal suture technique. Foot Ankle Int 2003;24(7):539-544.

Blankstein A, Israeli A, Dudkiewicz I, Chechik A, Ganel A. Percutaneous Achilles tendon repair combined with real-time sonography. Isr Med Assoc J 2007;9(2):83-85.

Bleakney RR, White LM. Imaging of the Achilles tendon. Foot Ankle Clin 2005;10(2):239-254.

Caceres JM, Beano A, Ruiz M, de LP. Percutaneous suture in achilles tendon tears. The Journal of Bone and Joint Surgery 2005;87-B:82.

Canete AC, Deiparine HP. Treatment of chronic Achilles tendon rupture with triple bundle suturing technique and early rehabilitation: Early results. Techniques in Orthopaedics 2006;21(2):134-142.

Carmont MR, Maffulli N. Modified percutaneous repair of ruptured Achilles tendon. Knee Surg Sports Traumatol Arthrosc 2008;16(2):199-203.


2585 2586 2587

2588 2589

2590 2591 2592

2593 2594

2595 2596

2597 2598

2599 2600

2601 2602

2603 2604 2605

2606 2607

2608 2609

2610 2611

2612 2613

2614 2615

2616 2617

Cetti R, Junge J, Vyberg M. Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients. Acta Orthop Scand 2003;74(1):78-84.

Chan SK, Chung SC, Ho YF. Minimally invasive repair of ruptured Achilles tendon. Hong Kong Med J 2008;14(4):255-258.

Chester R, Costa ML, Shepstone L, Donell ST. Reliability of isokinetic dynamometry in assessing plantarflexion torque following Achilles tendon rupture. Foot Ankle Int 2003;24(12):909-915.

Chiodo CP, Wilson MG. Current concepts review: acute ruptures of the achilles tendon. Foot Ankle Int 2006;27(4):305-313.

Chiodo CP, Den HB. Surgical strategies: acute Achilles rupture-open repair. Foot Ankle Int 2008;29(1):114-118.

Clayton RAE, Court-Brown. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 2008;39(12):1338-1344.

Coombs RRH. Prospective trial of conservative and surgical treatment of Achilles tendon rupture [abstract]. Journal of Bone and Joint Surgery British Volume 1981;63:288.

Copeland SA. Rupture of the Achilles tendon: a new clinical test. Ann R Coll Surg Engl 1990;72(4):270-271.

Costa ML, Shepstone L, Darrah C, Marshall T, Donell ST. Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study. Injury 2003;34(11):874-876.

Costa ML, Kay D, Donell ST. Gait abnormalities following rupture of the tendo Achillis: a pedobarographic assessment. J Bone Joint Surg Br 2005;87(8):1085-1088.

Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med 2005;33(9):1369-1379.

de PL, Gigante A, Rapali S. Physiopathology of the repair process of lesions of Achilles tendon. Foot and Ankle Surgery 2006;12(1):5-11.

Doral MN, Bozkurt M, Turhan E et al. Percutaneous suturing of the ruptured Achilles tendon with endoscopic control. Arch Orthop Trauma Surg 2009;129(8):1093-1101.

Ebinesan AD, Sarai BS, Walley GD, Maffulli N. Conservative, open or percutaneous repair for acute rupture of the Achilles tendon. Disabil Rehabil 2008;30(20):1721-1725.

Edna TH. Non-operative treatment of Achilles tendon ruptures. Acta Orthop Scand 1980;51(6):991-993.


2618 2619

2620

2621 2622 2623

2624

2625 2626

2627 2628 2629

2630 2631

2632 2633 2634

2635 2636 2637

2638 2639 2640

2641 2642

2643 2644 2645

2646 2647 2648

2649 2650

Elliot RR, Calder JD. Percutaneous and mini-open repair of acute Achilles tendon rupture. Foot Ankle Clin 2007;12(4):573-82, vi.

Ellis JRC, Teh JL, Scott PM. Ultrasound of tendons. Imaging 2002;14(3):223-228.

Follak N, Ganzer D, Merk H. The utility of gait analysis in the rehabilitation of patients after surgical treatment of Achilles tendon rupture. European Journal of Orthopaedic Surgery and Traumatology 2002;12(2):90-95.

Fornage BD. Achilles tendon: US examination. Radiology 1986;159(3):759-764.

Forni I. Pedicled tendon transfer in the repair of subcutaneous rupture of the Achilles tendon. Ital J Orthop Traumatol 1981;7(3):299-303.

Fredberg U, Bolvig L, Andersen NT. Prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in Achilles and patellar tendons: the Danish Super League Study. Am J Sports Med 2008;36(3):451-460.

Fruensgaard S, Helmig P, Riis J, Stovring JO. Conservative treatment for acute rupture of the Achilles tendon. Int Orthop 1992;16(1):33-35.

Fujikawa A, Kyoto Y, Kawaguchi M, Naoi Y, Ukegawa Y. Achilles tendon after percutaneous surgical repair: serial MRI observation of uncomplicated healing. AJR Am J Roentgenol 2007;189(5):1169-1174.

Gilpin T. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Treatment of ruptured Achilles tendon. J Accid Emerg Med 1999;16(3):215-216.

Girish G, Finlay K, Landry D et al. Musculoskeletal disorders of the lower limb - Ultrasound and magnetic resonance imaging correlation. Canadian Association of Radiologists Journal 2007;58(3):152-166.

Goren D, Ayalon M, Nyska M. Isokinetic strength and endurance after percutaneous and open surgical repair of Achilles tendon ruptures. Foot Ankle Int 2005;26(4):286-290.

Hahn F, Maiwald C, Horstmann T, Vienne P. Changes in plantar pressure distribution after Achilles tendon augmentation with flexor hallucis longus transfer. Clin Biomech (Bristol , Avon ) 2008;23(1):109-116.

Haims AH, Schweitzer ME, Patel RS, Hecht P, Wapner KL. MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic individuals. Skeletal Radiol 2000;29(11):640-645.

Halasi T, Tallay A, Berkes I. Percutaneous Achilles tendon repair with and without endoscopic control. Knee Surg Sports Traumatol Arthrosc 2003;11(6):409-414.


Hamel R. Achilles tendon ruptures: Making the diagnosis. Physician and Sportsmedicine 1992;20(9):189-190+193.

2651 2652

2653 2654

2655 2656 2657

2658 2659 2660

2661 2662

2663 2664 2665

2666 2667 2668

2669

2670 2671 2672

2673 2674

2675 2676 2677

2678 2679

2680 2681 2682

2683 2684 2685

Hart TJ, Napoli RC, Wolf JA, Cangiano S. Diagnosis and treatment of the ruptured Achilles tendon. Journal of Foot Surgery 1988;27(1):30-39.

Hartgerink P, Fessell DP, Jacobson JA, van Holsbeeck MT. Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation. Radiology 2001;220(2):406-412.

Hohendorff B, Siepen W, Spiering L, Staub L, Schmuck T, Boss A. Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture. J Foot Ankle Surg 2008;47(5):392-399.

Hollenberg GM, Adams MJ, Weinberg EP. Sonographic appearance of nonoperatively treated Achilles tendon ruptures. Skeletal Radiol 2000;29(5):259-264.

Horstmann T, Lukas C, Mayer F et al. Isokinetic strength and strength endurance of the lower limb musculature ten years after achilles tendon repair. Isokinetics and Exercise Science 2000;8(3):141-145.

Hufner TM, Brandes DB, Thermann H, Richter M, Knobloch K, Krettek C. Long-term results after functional nonoperative treatment of achilles tendon rupture. Foot Ankle Int 2006;27(3):167-171.

Inglis AE. Achilles tendon rupture. Lancet 1973;1(7808):884.

Inglis AE, Scott WN, Sculco TP, Patterson AH. Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment. J Bone Joint Surg Am 1976;58(7):990-993.

Inglis AE, Sculco TP. Surgical repair of ruptures of the tendo Achillis. Clin Orthop Relat Res 1981;(156):160-169.

Jacob KM, Paterson R. Surgical repair followed by functional rehabilitation for acute and chronic achilles tendon injuries: excellent functional results, patient satisfaction and no reruptures. ANZ J Surg 2007;77(4):287-291.

Jacobs D, Martens M, Van AR, Mulier JC, Mulier F. Comparison of conservative and operative treatment of Achilles tendon rupture. Am J Sports Med 1978;6(3):107-111.

Jennings AG, Sefton GK, Newman RJ. Repair of acute rupture of the Achilles tendon: a new technique using polyester tape without external splintage. Ann R Coll Surg Engl 2004;86(6):445-448.

Josey RA, Marymont JV, Varner KE, Borom A, O'Connor D, Oates JC. Immediate, full weightbearing cast treatment of acute Achilles tendon ruptures: a long-term follow-up study. Foot Ankle Int 2003;24(10):775-779.


2686 2687

2688 2689

2690 2691 2692

2693 2694 2695 2696

2697 2698 2699

2700 2701 2702

2703 2704 2705

2706 2707

2708 2709 2710 2711 2712

2713 2714 2715

2716 2717

2718 2719 2720

Kabbani YM, Mayer DP. Magnetic resonance imaging of tendon pathology about the foot and ankle. Part I. Achilles tendon. J Am Podiatr Med Assoc 1993;83(7):418-420.

Kalebo P, Allenmark C, Peterson L, Sward L. Diagnostic value of ultrasonography in partial ruptures of the Achilles tendon. Am J Sports Med 1992;20(4):378-381.

Kangas J, Pajala A, Leppilahti J. Acute achilles tendon rupture postoperative treatment with a below knee cast the ankle in neutral position compared to early restricted motion of the ankle. Suomen Ortopedia ja Traumatologia 2000;23:295-298.

Kangas J, Pajala A, Ohtonen P, Leppilahti J, Amendola A. Elongation of the Achilles tendon after rupture repair occurred slightly less with postoperative early motion than with postoperative immobilization. Journal of Bone and Joint Surgery Series A 2007;89:1873-Series.

Kaseta M, Mourikis A, Kostopoulos N, Papadopoulos CH, Baltopoulos P. Comparison of surgical and no surgical treatment of Achilles tendon rupture in athletes. Journal of Sports Sciences 2000;18(7):493-494.

Kauranen K, Kangas J, Leppilahti J. Recovering motor performance of the foot after Achilles rupture repair: a randomized clinical study about early functional treatment vs. early immobilization of Achilles tendon in tension. Foot Ankle Int 2002;23(7):600-605.

Kayser R, Mahlfeld K, Heyde CE. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med 2005;39(11):838-842.

Keller J, Rasmussen TB. Closed treatment of Achilles tendon rupture. Acta Orthop Scand 1984;55(5):548-550.

Khan RJK, Fick D, Brammar TJ, Crawford J, Parker MJ. Surgical interventions for treating acute Achilles tendon ruptures. Khan RJK , Fick D , Brammar TJ, Crawford J, Parker MJ Surgical interventions for treating acute Achilles tendon ruptures Cochrane Database of Systematic Reviews: Reviews 2004 Issue 3 John Wiley & Sons , Ltd Chichester, UK DOI : 10 1002 /14651858 CD00367 2004.

Konecny J, Veverkova L, Reska M. Current possibilities of treatment of achilles tendon rupture. A review. Scripta Medica Facultatis Medicae Universitatis Brunensis Masarykianae 2006;79(2):75-84.

Kotnis R, David S, Handley R, Willett K, Ostlere S. Dynamic ultrasound as a selection tool for reducing achilles tendon reruptures. Am J Sports Med 2006;34(9):1395-1400.

Krolo I, Viskovic K, Ikic D, Klaric-Custovic R, Marotti M, Cicvara T. The risk of sports activities--the injuries of the Achilles tendon in sportsmen. Coll Antropol 2007;31(1):275-278.


2721 2722

2723 2724

2725 2726

2727 2728

2729 2730 2731

2732 2733

2734 2735

2736 2737 2738

2739 2740 2741

2742 2743

2744 2745

2746 2747 2748

2749 2750

2751 2752

2753 2754

Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med 2005;15(3):133-135.

Kumta SM, Maffulli N. Local flap coverage for soft tissue defects following open repair of Achilles tendon rupture. Acta Orthop Belg 2003;69(1):59-66.

Kuskucu M, Mahirogullari M, Solakoglu C et al. Treatment of rupture of the Achilles tendon with fibrin sealant. Foot Ankle Int 2005;26(10):826-831.

Kuwada GT. Surgical correlation of preoperative MRI findings of trauma to tendons and ligaments of the foot and ankle. J Am Podiatr Med Assoc 2008;98(5):370-373.

Lapidus LJ, Rosfors S, Ponzer S et al. Prolonged thromboprophylaxis with dalteparin after surgical treatment of achilles tendon rupture: a randomized, placebo-controlled study. J Orthop Trauma 2007;21(1):52-57.

Lawrence SJ, Grau GF. Management of acute Achilles tendon ruptures. Orthopedics 2004;27(6):579-581.

Lea RB, Smith L. Non-surgical treatment of tendo achillis rupture. J Bone Joint Surg Am 1972;54(7):1398-1407.

Lee SJ, Goldsmith S, Nicholas SJ, McHugh M, Kremenic I, Ben-Avi S. Optimizing Achilles tendon repair: effect of epitendinous suture augmentation on the strength of achilles tendon repairs. Foot Ankle Int 2008;29(4):427-432.

Lee YS, Lin CC, Chen CN, Chen SH, Liao WY, Huang CR. Reconstruction for neglected Achilles tendon rupture: the modified Bosworth technique. Orthopedics 2005;28(7):647-650.

Lehtinen A, Peltokallio P, Taavitsainen M. Sonography of Achilles tendon correlated to operative findings. Ann Chir Gynaecol 1994;83(4):322-327.

Lildholdt T, Munch-Jorgensen T. Conservative treatment to Achilles tendon rupture. A follow-up study of 14 cases. Acta Orthop Scand 1976;47(4):454-458.

Lo IK, Kirkley A, Nonweiler B, Kumbhare DA. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review. Clin J Sport Med 1997;7(3):207-211.

Lorkowski J, Brongel L, Hladki W et al. Evaluation of long term therapy outcomes for achilles tendon ruptures. Polski Przeglad Chirurgiczny 2007;79(6):745-756.

Lundberg GD. What is the best way to treat and rehabilitate a ruptured achilles tendon? Medscape J Med 2008;10(2):37.

Lynch RM. Achilles tendon rupture: surgical versus non-surgical treatment. Accid Emerg Nurs 2004;12(3):149-158.


2755 2756 2757

2758 2759 2760

2761 2762 2763

2764 2765

2766 2767 2768

2769 2770

2771 2772

2773 2774

2775 2776 2777 2778 2779

2780 2781

2782 2783 2784 2785

2786 2787 2788

Maffulli N, Tallon C, Wong J, Lim KP, Bleakney R. Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med 2003;31(5):692-700.

Maffulli N, Tallon C, Wong J, Peng LK, Bleakney R. No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon. J Sports Med Phys Fitness 2003;43(3):367-379.

Maffulli N, Longo UG, Ronga M, Khanna A, Denaro V. Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly. Clin Orthop Relat Res 2009.

Majewski M, Rohrbach M, Czaja S, Ochsner P. Avoiding sural nerve injuries during percutaneous Achilles tendon repair. Am J Sports Med 2006;34(5):793-798.

Marshall H, Howarth C, Larkman DJ, Herlihy AH, Oatridge A, Bydder GM. Contrast-enhanced magic-angle MR imaging of the Achilles tendon. AJR Am J Roentgenol 2002;179(1):187-192.

Marti RK, van der WC, Schutte PR, Bast TJ. Operative repair of ruptured achilles tendon and functional after-treatment--I. Acute rupture. Neth J Surg 1983;35(2):61-64.

Mathieson JR, Connell DG, Cooperberg PL, Lloyd-Smith DR. Sonography of the Achilles tendon and adjacent bursae. AJR Am J Roentgenol 1988;151(1):127-131.

Matles AL. Rupture of the tendo achilles: another diagnostic sign. Bull Hosp Joint Dis 1975;36(1):48-51.

Mandelbaum BR, Myerson MS, Forster R. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med 1995 Jul-Aug;23(4):392-5. Mehdizade A, Adler RS. Sonographically guided flexor hallucis longus tendon sheath injection. J Ultrasound Med 2007;26(2):233-237.

Mellor SJ, Patterson MH. Tendo Achillis rupture; surgical repair is a safe option. Injury 2000;31(7):489-491.

Metz R, Kerkhoffs GM, Verleisdonk EJ, van der Heijden GJ. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial. BMC Musculoskelet Disord 2007;8:108.

Metz R, Verleisdonk EJ, van der Heijden GJ et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing--a randomized controlled trial. Am J Sports Med 2008;36(9):1688-1694.


2789 2790 2791

2792 2793 2794

2795 2796 2797

2798 2799 2800

2801 2802

2803 2804 2805

2806 2807

2808

2809 2810 2811

2812 2813 2814

2815 2816

2817 2818

2819 2820

2821 2822 2823

Moller M, Lind K, Movin T, Karlsson J. Calf muscle function after Achilles tendon rupture. A prospective, randomised study comparing surgical and non-surgical treatment. Scand J Med Sci Sports 2002;12(1):9-16.

Mortensen HM, Skov O, Jensen PE. Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. J Bone Joint Surg Am 1999;81(7):983-990.

Mortensen NH, Saether J, Steinke MS, Staehr H, Mikkelsen SS. Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study. Orthopedics 1992;15(8):899-903.

Mortensen NHM, Skov O, Jensen PE. Early mobilisation of operatively treated achilles tendon ruptures: 1 to 2 years follow-up [abstract]. Journal of Bone and Joint Surgery British Volume 1995;77 Suppl 2:195.

Movin T, Ryberg A, McBride DJ, Maffulli N. Acute rupture of the Achilles tendon. Foot Ankle Clin 2005;10(2):331-356.

Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am 2003;85-A(8):1436-1445.

Mullaney MJ, McHugh MP, Tyler TF, Nicholas SJ, Lee SJ. Weakness in end-range plantar flexion after Achilles tendon repair. Am J Sports Med 2006;34(7):1120-1125.

Murtagh J. Ruptured Achilles tendon. Aust Fam Physician 1991;20(10):1509.

Neumayer F, Mouhsine E, Arlettaz Y, Gremion G, Wettstein M, Crevoisier X. A new conservative-dynamic treatment for the acute ruptured Achilles tendon. Arch Orthop Trauma Surg 2009.

Nilsson-Helander K, Thomee R, Gravare-Silbernagel K et al. The Achilles tendon Total Rupture Score (ATRS): development and validation. Am J Sports Med 2007;35(3):421-426.

Nistor L. Conservative treatment of fresh subcutaneous rupture of the Achilles tendon. Acta Orthop Scand 1976;47(4):459-462.

Nistor L. Choice of treatment in subcutaneous Achilles tendon rupture [abstract]. Acta Orthopaedica Scandinavica 1979;50:112.

Nistor L. Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study. J Bone Joint Surg Am 1981;63(3):394-399.

Nyyssonen T, Luthje P, Kroger H. The increasing incidence and difference in sex distribution of Achilles tendon rupture in Finland in 1987-1999. Scand J Surg 2008;97(3):272-275.


Ostlere S. Imaging the ankle and foot. Imaging 2003;15(4):242-269. 2824

2825 2826 2827

2828 2829

2830 2831

2832 2833

2834 2835 2836

2837 2838

2839 2840 2841

2842 2843 2844

2845 2846

2847 2848

2849 2850

2851 2852

2853 2854

2855 2856 2857

Paavola M, Paakkala T, Kannus P, Jarvinen M. Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. A comparison between pre-operative ultrasonography and surgical findings. Acta Radiol 1998;39(6):612-619.

Palmer DM. Assessment and management of patients with achilles tendon rupture. Advanced Emergency Nursing Journal 2007;29(3):249-259.

Park HG, Moon DH, Yoon JM. Limited open repair of ruptured Achilles tendons with Bunnel-type sutures. Foot Ankle Int 2001;22(12):985-987.

Pearsall AW, Bryant GK. Technique tip: a new technique for augmentation of repair of chronic Achilles tendon rupture. Foot Ankle Int 2006;27(2):146-147.

Pendleton H, Resch S, Stenstrom A, Astrom I. Residual functional problems after non-operative treatment of Achilles tendon rupture. Foot and Ankle Surgery 1997;3(3):131-135.

Persson A, Wredmark T. The treatment of total ruptures of the Achilles tendon by plaster immobilisation. Int Orthop 1979;3(2):149-152.

Petersen W, Pufe T, Zantop T, Tillmann B, Tsokos M, Mentlein R. Expression of VEGFR-1 and VEGFR-2 in degenerative Achilles tendons. Clin Orthop Relat Res 2004;(420):286-291.

Porter DA, Mannarino FP, Snead D, Gabel SJ, Ostrowski M. Primary repair without augmentation for early neglected Achilles tendon ruptures in the recreational athlete. Foot Ankle Int 1997;18(9):557-564.

Rippstein PF, Jung M, Assal M. Surgical repair of acute Achilles tendon rupture using a "mini-open" technique. Foot Ankle Clin 2002;7(3):611-619.

Roberts CP, Palmer S, Vince A, Deliss LJ. Dynamised cast management of Achilles tendon ruptures. Injury 2001;32(5):423-426.

Rowley DI, Scotland TR. Rupture of the Achilles tendon treated by a simple operative procedure. Injury 1982;14(3):252-254.

Rumian AP, Molloy S, Solan M, Newman KJ, Elliott D. Surgical repair of the Achilles tendon: The lateral approach. Foot 2001;11(3):136-139.

Schilders E, Bismil Q, Metcalf R, Marynissen H. Clinical tip: Achilles tendon repair with accelerated rehabilitation program. Foot Ankle Int 2005;26(5):412-415.

Schonberger TJ, Janzing HM, Morrenhof JW, de Visser AC, Muitjens P. Operative treatment of acute Achilles tendon rupture: Open end-to-end-reconstruction versus reconstruction with Mitek-anchors. Acta Chir Belg 2008;108(2):236-239.


2858 2859 2860

2861 2862 2863

2864 2865 2866

2867 2868 2869

2870 2871 2872

2873 2874 2875

2876 2877

2878 2879 2880

2881 2882 2883

2884 2885

2886 2887

2888 2889

2890 2891

Schroeder D, Lehmann M, Steinbrueck K. Treatment of acute achilles tendon ruptures: open vs. percutaneous repair vs. conservative treatment. A prospective randomized study [Abstract]. Orthopaedic Transactions 1997;21:1228.

Skiba K, Rutowski R, Wiacek R, Reichert P, Dudek K. Treatment of subcutaneous ruptures of the Achilles tendon in own material. Advances in Clinical and Experimental Medicine 2006;15(3):471-480.

Sode J, Obel N, Hallas J, Lassen A. Use of fluroquinolone and risk of Achilles tendon rupture: A population-based cohort study. European Journal of Clinical Pharmacology 2007;63(5):499-503.

Steele GJ, Harter RA, Ting AJ. Comparison of functional ability following percutaneous and open surgical repairs of acutely ruptured Achilles tendons. Journal of Sport Rehabilitation 1993;2(2):115-127.

Suchak AA, Bostick GP, Beaupre LA, Durand DC, Jomha NM. The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am 2008;90(9):1876-1883.

Syed S, Bhatti A, Shah MM. Spontaneous atraumatic Achilles tendon rupture in healthy individuals: Biomechanical aspect. Journal of the College of Physicians and Surgeons Pakistan 2009;19(3):195-197.

Synder M, Zwierzchowski H. Post-operative results in fresh injuries the Achilles tendon. Beitr Orthop Traumatol 1988;35(10):503-508.

Therbo M, Petersen MM, Nielsen PK, Lund B. Loss of bone mineral of the hip and proximal tibia following rupture of the Achilles tendon. Scand J Med Sci Sports 2003;13(3):194-199.

Thermann H, Zwipp H, Tscherne H, Hoffmann R, Sudkamp N. Operative versus conservative functional treatment of acute achilles tendon rupture. International journal of sports medicine 1988;9:397.

Thermann H, Zwipp H, Tscherne H, Sudkamp N. Functional concepts of treatment in acute achilles tendon rupture. International journal of sports medicine 1991;12:153.

Thermann H, Tibesku CO, Mastrokalos DS, Passler HH. Endoscopically assisted percutaneous achilles tendon suture. Foot Ankle Int 2001;22(2):158-160.

Tokmakov P. Treatment of ruptures of Achilles' tendons by an external fixator. Folia Med (Plovdiv ) 1995;37(4A Suppl):92.

Tumilty S. Achilles tendon rupture: rising incidence in New Zealand follows international trends. Physical Therapy Reviews /20;12(1):59-65.



2892 2893 2894

2895 2896

2897 2898 2899

2900 2901 2902

2903 2904 2905

2906 2907 2908

2909 2910 2911

2912 2913

2914 2915

2916 2917 2918 2919

2920 2921

2922 2923

2924

Twaddle BC, Poon P, Monnig J. Randomised prospective study of surgical vs. non-surgical treatment of achilles tendon rupture - clinical results. The Journal of Bone and Joint Surgery 2005;87-B:30-3f.

van der Linden-van der Zwaag HM, Nelissen RG, Sintenie JB. Results of surgical versus non-surgical treatment of Achilles tendon rupture. Int Orthop 2004;28(6):370-373.

van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HM, Rowlands S, Stricker BH. Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids. Arch Intern Med 2003;163(15):1801-1807.

Wagnon R, Akayi M. The Webb-Bannister percutaneous technique for acute Achilles' tendon ruptures: a functional and MRI assessment. J Foot Ankle Surg 2005;44(6):437-444.

Weber M, Niemann M, Lanz R, Muller T. Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative treatment. Am J Sports Med 2003;31(5):685-691.

White DW, Wenke JC, Mosely DS, Mountcastle SB, Basamania CJ. Incidence of major tendon ruptures and anterior cruciate ligament tears in US Army soldiers. Am J Sports Med 2007;35(8):1308-1314.

Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture. A review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop Relat Res 1986;(207):156-163.

Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of achilles tendon ruptures. Am J Sports Med 2002;30(4):565-575.

Worth N, Ghosh S, Maffulli N. Management of acute Achilles tendon ruptures in the United Kingdom. J Orthop Surg (Hong Kong) 2007;15(3):311-314.

Xu Y-Q, Zhu Y-L, Yang J, Li J, Ding J, Lu S. Bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing Achilles tendon and overlying skin defect: The anatomic basis and clinical application. Chinese Journal of Traumatology - English Edition 2007;10(2):78-81.

Young J, Sayana MK, McClelland D, Maffulli N. Percutaneous repair of acute rupture of achilles tendon. Techniques in Foot and Ankle Surgery 2006;5(1):9-14.

Zell RA, Santoro VM. Augmented repair of acute Achilles tendon ruptures. Foot Ankle Int 2000;21(6):469-474.

2 the diagnosis and treatment of acute achilles tendon ...€¦ · patients with acute achilles...

Documents