the diagnosis and treatment of acute achilles tendon rupture

THE DIAGNOSIS AND TREATMENT OF ACUTE

ACHILLES TENDON RUPTURE

GUIDELINE AND EVIDENCE REPORT

Adopted by the American Academy of Orthopaedic Surgeons Board of Directors December 4, 2009

Disclaimer 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

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Summary of Recommendations 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 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* Description: The supporting evidence is lacking and requires the work group to make a recommendation based on expert opinion by considering the known potential harm and benefits associated with the treatment. A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria of the guideline’s systematic review.

Implications: Practitioners should be flexible in deciding whether to follow a

recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.

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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 Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a

recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role.

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

Strength of Recommendation: Limited Description: Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another. Implications: Practitioners should be cautious in deciding whether to follow a

recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

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

Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm.

Implications: Practitioners should feel little constraint in deciding whether to follow a


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

Strength of Recommendation: Limited Description: Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another. Implications: Practitioners should be cautious in deciding whether to follow a


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 Description: The supporting evidence is lacking and requires the work group to make a recommendation based on expert opinion by considering the known potential harm and benefits associated with the treatment. A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria of the guideline’s systematic review.

Implications: Practitioners should be flexible in deciding whether to follow a

recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.

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.

Strength of Recommendation: Inconclusive Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a


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8. Open, limited open and percutaneous techniques are options for treating patients with acute Achilles tendon rupture.

Strength of Recommendation: Limited Description: Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.

Implications: Practitioners should be cautious in deciding whether to follow a


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.

Strength of Recommendation: Inconclusive Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm.

Implications: Practitioners should feel little constraint in deciding whether to follow a


10. We cannot recommend for or against the use of antithrombotic treatment for

patients with acute Achilles tendon ruptures.

Strength of Recommendation: Inconclusive Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a


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

Strength of Recommendation: Moderate Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. A Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but the strength of the supporting evidence is not as strong. Implications: Practitioners should generally follow a Moderate recommendation but

remain alert to new information and be sensitive to patient preferences.

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

Strength of Recommendation: Moderate Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. A Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but the strength of the supporting evidence is not as strong.

Implications: Practitioners should generally follow a Moderate recommendation but

remain alert to new information and be sensitive to patient preferences.

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


Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a


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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.


Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a


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.

Strength of Recommendation: Limited Description: Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.

Implications: Practitioners should be cautious in deciding whether to follow a


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.

Strength of Recommendation: Inconclusive Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow

a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role.

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* 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.

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Work GroupChristopher P Chiodo MD, Chair Brigham Orthopedic Associates 75 Francis Street Boston MA 02115 Mark Glazebrook MD, Vice-Chair Queen Elizabeth Health Sciences Center Halifax Infirmary Suite 4867 1796 Summer Street Halifax NS B3H 3A7 Canada Eric Michael Bluman MD PhD Madigan Army Medical Center ATTN: MCHJ-SOP (Ortho Clinic) 9040 A Reid Street Tacoma WA 98431-1100 Bruce E Cohen MD 1783 Sterling Road Charlotte NC 28209 John E Femino MD Department of Orthopedics University of Iowa Hospital and Clinics JPP 01022 200 Hawkins Drive Iowa City IA 52242 Eric Giza MD UC Davis Dept of Orthopaedics Ambulatory Care Services Bldg 4860 Y St #3800 Sacramento, CA 95817

Guidelines and Technology Oversight Chair: William C. Watters, III, MD 6624 Fannin #2600 Houston, TX 77030 Guidelines and Technology Oversight Vice-Chair: Michael J. Goldberg, MD Department of Orthopaedics Seattle Children’s Hospital 4800 Sand Point Way NE Seattle, WA 98105 Evidence Based Practice Committee Chair: Michael Keith, MD 2500 Metro Health Drive Cleveland, OH 44109-1900 AAOS Staff: Robert H. Haralson III, MD, MBA AAOS Medical Director 6300 N River Road Rosemont, IL 60018 Charles M. Turkelson, PhD Director of Research and Scientific Affairs Janet L. Wies MPH AAOS Clinical Practice Guideline Mgr AAOS Research Analysts Laura Raymond MA - Lead Analyst Sara Anderson MPH – Lead Analyst Kevin Boyer BS Patrick Sluka MPH

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Peer Review 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 Academy of Physical Medicine and Rehabilitation American College of Foot and Ankle Surgeons American Orthopaedic Foot and Ankle Society American Orthopaedic Society for Sports Medicine American Physical Therapy Association American Podiatric Medical 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

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Table of Contents

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

WORK GROUP ................................................................................................... X

PEER REVIEW ................................................................................................... XI

TABLE OF CONTENTS .................................................................................... XII

LIST OF TABLES ............................................................................................. XVI

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

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

Consensus Development ..............................................................................................................................10

Statistical Methods ......................................................................................................................................10

Peer Review ..................................................................................................................................................11

Public Commentary.....................................................................................................................................11

The AAOS Guideline Approval Process ....................................................................................................12

Revision Plans ..............................................................................................................................................12

Guideline Dissemination Plans ...................................................................................................................12

III. RECOMMENDATIONS AND SUPPORTING EVIDENCE ....................... 13

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 ...............................................................................................................................44 Excluded Articles......................................................................................................................................50 Study Quality ............................................................................................................................................55

Recommendation 6 ......................................................................................................................................59

Recommendation 7 ......................................................................................................................................60

Recommendation 8 ......................................................................................................................................61 Percutaneous vs Open Repair ...................................................................................................................62 Summary of Evidence- Percutaneous vs. Open ........................................................................................63 Limited Open vs Open Repair ..................................................................................................................64

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Summary of Evidence- Limited Open vs. Open .......................................................................................65 Excluded Articles......................................................................................................................................67 Study Quality ............................................................................................................................................69 Study Results ............................................................................................................................................73

Recommendation 9 ......................................................................................................................................77 Autograft Tissue vs Open Repair ..............................................................................................................77 Augmentation with Synthetic Tissue vs Open Repair ..............................................................................78 Summary of Evidence ...............................................................................................................................78 Excluded Articles......................................................................................................................................80 Study Quality ............................................................................................................................................82 Study Results ............................................................................................................................................86

Recommendation 10 ....................................................................................................................................90 Excluded Studies ......................................................................................................................................90

Recommendation 11 ....................................................................................................................................91 Summary of Evidence ...............................................................................................................................94 Summary of Complications ......................................................................................................................99 Excluded Articles....................................................................................................................................101 Study Quality ..........................................................................................................................................102 Study Results ..........................................................................................................................................111

Recommendation 12 ..................................................................................................................................116 Summary of Evidence .............................................................................................................................117 Summary of Complications ....................................................................................................................123 Excluded Articles....................................................................................................................................125 Study Quality ..........................................................................................................................................126 Study Results ..........................................................................................................................................131

Recommendation 13 ..................................................................................................................................136 Summary of Evidence .............................................................................................................................136 Excluded articles .....................................................................................................................................137

Recommendation 14 ..................................................................................................................................138 Summary of Evidence .............................................................................................................................138 Excluded Articles....................................................................................................................................145 Study Quality ..........................................................................................................................................147



Future Research ........................................................................................................................................166

Appendix I ..................................................................................................................................................168 Work Group ............................................................................................................................................168

Appendix II ................................................................................................................................................169

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Time from rupture to treatment ..............................................................................................................169

Appendix III ...............................................................................................................................................173 AAOS Bodies That Approved This Clinical Practice Guideline ............................................................173 Documentation of Approval ...................................................................................................................174

Appendix IV ...............................................................................................................................................175 Literature Searches for Primary Studies .................................................................................................175

Appendix V ................................................................................................................................................177 Study Attrition Flowchart .......................................................................................................................177

Appendix VI ...............................................................................................................................................178 Data Extraction Elements .......................................................................................................................178

Appendix VII .............................................................................................................................................179 Judging the Quality of Diagnostic Studies ..............................................................................................179 Judging the Quality of Treatment Studies ..............................................................................................180

Appendix VIII ............................................................................................................................................182 Form for Assigning Strength of Recommendation (Interventions) ........................................................182

Appendix IX ...............................................................................................................................................184 Voting by the Nominal Group Technique ..............................................................................................184

Appendix X ................................................................................................................................................185 Structured Peer Review Form .................................................................................................................185

Appendix XI ...............................................................................................................................................188 Peer Review Panel ..................................................................................................................................188 Public Commentary ................................................................................................................................189

Appendix XII .............................................................................................................................................190 Description of Symbols Used in Tables..................................................................................................190

Appendix XIII ............................................................................................................................................191 Conflict of Interest ..................................................................................................................................191

Appendix XIV ............................................................................................................................................192 References ..............................................................................................................................................192 Excluded articles after full text review ...................................................................................................197

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List of Tables Table 1 Strength of Recommendation Descriptions ........................................................... 9 Table 2 AAOS Guideline Language ................................................................................. 10 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 ................................................................ 23 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 .............................................................................. 29 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) ......................................................... 36 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 ............................................................................ 44 Table 42. Open Repair - Return to work........................................................................... 44 Table 43. Open Repair - Activities of daily living ............................................................ 45 Table 44. Open Repair- Mean time until return to athletic activity .................................. 45 Table 45. Open Repair- Percent of patients able to return to activities of daily living .... 46

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Table 46. Open Repair- Percent of patients able to return to work .................................. 46 Table 47. Open Repair- Percent of patients able to return to sports ................................. 46 Table 48: Open Repair- Percent of patients with pain ..................................................... 47 Table 49. Open Repair- Percent of patients able to complete functional activities .......... 47 Table 50. Open Repair- Percent of patients with excellent satisfaction ........................... 47 Table 51. Minimally Invasive Repair- All outcomes ....................................................... 48 Table 52. Minimally Invasive Repair- Percent of Patients able to return to activity........ 48 Table 53. Minimally Invasive Repair - Percent of patients able to return to sports ......... 49 Table 54. Minimally Invasive Repair - Satisfaction ......................................................... 49 Table 55. Minimally Invasive Repair - Mean time until return to activity ....................... 49 Table 56. Minimally Invasive Repair-Percent of patients able to return to sports ........... 49 Table 57. Minimally Invasive Repair-Percent of patients able to return to work ............. 50 Table 58. Minimally Invasive Repair-Pain ....................................................................... 50 Table 59. Excluded Articles .............................................................................................. 50 Table 60. Study Quality .................................................................................................... 55 Table 61. Percutaneous and Limited Open vs. Open - Global Outcomes ........................ 63 Table 62. Percutaneous vs. Open - Return to Activities and Function ............................. 63 Table 63. Percutaneous vs. Open - Satisfaction ............................................................... 63 Table 64. Percutaneous vs. Open- Complications ........................................................... 63 Table 65. Percutaneous vs. Open- Rerupture................................................................... 64 Table 66. Minimally Invasive vs. Open- Pain ................................................................. 65 Table 67. Minimally Invasive vs. Open- Global Outcomes ............................................ 65 Table 68. Limited Open vs. Open- Return to Activity .................................................... 65 Table 69. Mini-Open vs. Open- Symptoms ..................................................................... 65 Table 70. Limited Open Repair vs. Open - Complications............................................... 66 Table 71. Mini-Open vs. Open – Rerupture ..................................................................... 66 Table 72. Excluded Studies - All Operative Techniques .................................................. 67 Table 73. Study Quality - RCTs ....................................................................................... 69 Table 74. Quality of Studies - Comparative Studies......................................................... 71 Table 75. Limited open vs. Open - Global Outcomes .................................................... 73 Table 76. Percutaneous vs. Open - Return to Activities ................................................... 73 Table 77. Percutaneous vs. Open - Satisfaction ................................................................ 73 Table 78. Percutaneous vs. Open - Complications ........................................................... 73 Table 79. Minimally Invasive vs. Open- Pain ................................................................. 74 Table 80. Minimally Invasive vs. Open- Global Outcomes ............................................ 74 Table 81. Minimally Invasive vs. Open - Function .......................................................... 74 Table 82. Minimally Invasive vs. Open - Complications ................................................. 75 Table 83. Minimally Invasive vs. Open - Symptoms ....................................................... 75 Table 84. Minimally Invasive vs. Open - Return to Sport ................................................ 76 Table 85. Minimally Invasive vs. Open - Complications ................................................. 76 Table 86. Autograft vs. Open - Pain and Stiffness ........................................................... 78 Table 87. Autograft vs. Open - Satisfaction ..................................................................... 78 Table 88. Autograft - Return to Activities and Sports ..................................................... 78 Table 89. Autograft vs. Open - Footwear Restrictions ..................................................... 79 Table 90. Autograft vs. Open - Hospitalization and Immobilization ............................... 79 Table 91. Autograft vs. Open - Complications ................................................................. 79

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Table 92. Excluded Studies - Allograft............................................................................. 80 Table 93. Excluded Studies - Autograft ............................................................................ 80 Table 94. Excluded Studies - Synthetic Tissue ................................................................. 81 Table 95- Biologic Adjuncts ............................................................................................. 81 Table 96. Study Quality – Autograft RCTs ...................................................................... 82 Table 97. Study Quality - Autograft Comparative Studies .............................................. 83 Table 98. Study Quality - Synthetic Tissue Case Series .................................................. 85 Table 99 Autograft vs. Open Pain and Stiffness ............................................................... 86 Table 100. Autograft vs. Open - Satisfaction ................................................................... 86 Table 101. Autograft vs. Open - Return to Sports ............................................................ 87 Table 102. Autograft vs. Open - Return to Activities ....................................................... 87 Table 103. Autograft vs. Open - Footwear Restrictions ................................................... 87 Table 104. Autograft vs. Open - Hospitalization vs. Immobilization ............................... 88 Table 105. Autograft vs. Open - Complications ............................................................... 88 Table 106. Synthetic Tissue - Results ............................................................................... 89 Table 107. Antithrombotic Treatment - Excluded Studies ............................................... 90 Table 108: Description of treatment groups .................................................................... 92 Table 109 Time until return to activity ............................................................................. 94 Table 110 Pain .................................................................................................................. 94 Table 111 Function ........................................................................................................... 96 Table 112 EuroQoL, Rand-36 ........................................................................................... 97 Table 113 Patient Subjective Results ................................................................................ 97 Table 114 Reruptures ........................................................................................................ 98 Table 115 Reported Complications .................................................................................. 99 Table 116 Systematic Reviews ....................................................................................... 100 Table 117 Article Inclusion List- Early weight bearing vs. non-weight bearing ............ 101 Table 118. Quality- Weight bearing vs. non-weight bearing- RCT ............................... 102 Table 119. Quality- Weight bearing vs. non-weight bearing- Comparative.................. 105 Table 120 Study Data: Weight Bearing vs. Non-Weight Bearing .................................. 111 Table 121. Description of Treatment Groups ................................................................. 117 Table 122. Time to Return to Activity ............................................................................ 117 Table 123. Pain .............................................................................................................. 119 Table 124. Function ........................................................................................................ 119 Table 125. EuroQoL, E5D, Ankle Performance Score ................................................... 120 Table 126. Patient opinion of results .............................................................................. 121 Table 127. Footwear restrictions..................................................................................... 122 Table 128. Rerupture ...................................................................................................... 122 Table 129. Early Motion vs. Cast - Complications ......................................................... 123 Table 130. Systematic Reviews ...................................................................................... 124 Table 131. Mobilization vs. Immobilization Included Articles ...................................... 125 Table 132. Mobilization vs. Immobilization Quality...................................................... 126 Table 133. Mobilization vs. Immobilization Study Data ................................................ 131 Table 134. Post Operative Physiotherapy Regiments .................................................... 136 Table 135. Excluded Articles .......................................................................................... 137 Table 136. Non-Operative treatment - Percent of patients able to return to work .......... 138 Table 137. Non-Operative Treatment -Percent of patients able to return to ADL ......... 139

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Table 138. Operative Treatment - Percent of patients returning to ADL ....................... 139 Table 139. Operative Treatment - Percent of patients able to return to work ................ 140 Table 140. Non-Operative Treatment - Mean time until return to work ........................ 142 Table 141. Non-Operative Treatment - Mean time until return to walking .................... 142 Table 142. Operative Treatment - Mean time to return to ADL ..................................... 143 Table 143. Operative Treatment - Mean time until return to work ................................ 144 Table 144. Excluded Articles .......................................................................................... 145 Table 145. Patient return to activities of daily living ...................................................... 147 Table 146. Operative Treatment - Return to Recreational Activity................................ 151 Table 147. Operative Treatment - Return to sports ........................................................ 151 Table 148. Operative Treatment - Mean time to return to athletic activity .................... 153 Table 149. Excluded Articles .......................................................................................... 153 Table 150. Return to sports ............................................................................................. 155 Table 151. Non-Operative Treatment - Percent of patients returning to athletic activity......................................................................................................................................... 160 Table 152. Non-Operative Treatment - Mean time until patients return to athletic activity......................................................................................................................................... 162 Table 153. Excluded studies ........................................................................................... 163 Table 154. Study Quality ................................................................................................ 163 Table 155. Time from injury to treatment ..................................................................... 169

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I. INTRODUCTION 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 were defined for the literature search as those treated within the first six weeks of injury to capture all applicable literature; the patient population of the majority of studies included in this guideline are patients treated within the first two weeks of injury (See Appendix II). 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

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patient and physician mutual communication including discussion of available treatments and procedures applicable to the individual patient. Once the patient has been informed of 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 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

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the individual patient rely on mutual communication between the patient and physician, weighing the potential risks and benefits for that patient.

II. METHODS 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 III 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

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of the systematic reviews conducted for a given guideline are presented in it and, in general, all preliminary recommendations are modified.

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

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

• Evaluated a treatment for acute Achilles tendon rupture. Acute Achilles tendon ruptures are 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

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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.

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 IV. 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 V) 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.

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DATA EXTRACTION 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 VI.

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 VII).

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

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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 (Appendix VII). 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 “limited”.

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 VIII. 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

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the basis of these considerations.

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1 The AAOS will issue a consensus-based recommendation only when the service in question has virtually no associated harm and is of low cost (e.g. a history and physical) or when not establishing a recommendation could have catastrophic consequences.

Table 1 Strength of Recommendation Descriptions

Statement Rating

Description of Evidence Strength Implication for Practice

Strong

Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the benefits of the recommended approach clearly exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a strong negative recommendation), and that the strength of the supporting evidence is high.

Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

Moderate

Evidence from two or more “Moderate” strength studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. A Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but the strength of the supporting evidence is not as strong.

Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

Limited

Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single Moderate quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.

Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

Inconclusive Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm.

Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role.

Consensus1

The supporting evidence is lacking and requires the work group to make a recommendation based on expert opinion by considering the known potential harm and benefits associated with the treatment. A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.

Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.

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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

Guideline Language Strength of Recommendation

We recommend Strong

We suggest Moderate

Is an option Limited

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

opinion of this work group Consensus

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 . 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 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

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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 X).

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 (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, 4 returned public comments.

For this guideline, outside specialty societies could post the confidential draft of the guideline to their “member only” website. The responses garnered from these postings were compiled by the specialty society and submitted as one succinct public commentary.

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In addition, members of the AAOS Board of Specialties (BOS) and Board of Councilors (BOC) were encouraged to provide input; including encouragement to seek input from colleagues not necessarily members of the BOS or BOC. As a result, the opportunity to comment on this guideline exceeds the number of public commentators for previously published AAOS guidelines as well as the numbers listed above.

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 III.

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.

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, 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.

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

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.

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

III. RECOMMENDATIONS AND SUPPORTING EVIDENCE RECOMMENDATION 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

AAOS Strength of Recommendation – Consensus Description: The supporting evidence is lacking and requires the work group to make a recommendation based on expert opinion by considering the known potential harm and benefits associated with the treatment. A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria of the guideline’s systematic review. Implications: Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role. 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

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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.

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

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STUDY QUALITY Table 4. Study Quality

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

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

With

draw

als e

xpla

ined

Author N Index Test Reference Standard

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 ○ ● ● ● ○ ● ● ● ● ○ ● ● ○

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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)

‡ AAOS Calculation

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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.

AAOS Strength of Recommendation – Inconclusive Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role. 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.

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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

v1.0 12.04.09 18


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

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Author N Index Test Reference Standard

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 ○ ● ● ● ○ ● ● ● ○ ○ ● ● ○

v1.0 12.04.09 19

STUDY RESULTS 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)

v1.0 12.04.09 20

RECOMMENDATION 3 Non-operative treatment is an option for patients with acute Achilles tendon rupture. AAOS Strength of Recommendation: Limited Description: Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another. Implications: Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role. 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 limited.

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

v1.0 12.04.09 21

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 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

Author Comparison Outcome LOE N Duration (Months)

2 weeks 2 3 6 12

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

Cetti Open vs. Cast Function II 111 ○

‡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

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

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

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

‡Level III evidence due to less than 80% of patients at follow-up ●Op: Statistically Significant in Favor of Operative Repair

v1.0 12.04.09 22

●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 11. Operative vs. Cast – Return to Work

Author Comparison Outcome LOE N

Duration (Months)

12 24

Cetti Open vs. Cast Sick Leave II 111 ○

Möller Open vs. Cast Sick Leave II 112 ○

Metz Minimally

Invasive vs. Cast

Return to Work II 78 ○

●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

Author Comparison Outcome LOE N Duration (Months)

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 ○

●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

Author Outcome LOE N Duration (Months)

12

Twaddle Rerupture II 42 ○

Cetti Rerupture II 111 ○

Möller Rerupture II 112 ●Op

v1.0 12.04.09 23

Metz Rerupture II 83 ○

●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

Author Comparison Outcome LOE N Duration (Months) 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 ○ ○ ○

‡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

Author Adverse event/ Complication LOE N

Duration (Months)

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

v1.0 12.04.09 24

Cetti Suture granuloma II 111 ○

Möller Superficial infection II 112 ○

‡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 ●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).

Bhandari, M et al. 2002

"…The current group of randomized trials suggests a benefit to surgical repair of acute Achilles tendon ruptures in younger, active patients" (p. 199).


"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).

Khan, RJK, et al. 2005

"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).

Lo, IKY, et al. 1997

"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).

Lo, IKY, et al. 1997 "For healthy active individuals, we offer both forms of treatment, providing the patients with the estimates of treatment success and complication rates" (p. 211).

Lynch, RM 2004 "Surgical treatment is preferable to non-surgical treatment, produces better functional outcomes, and therefore appears to be the treatment of choice" (p. 156).

v1.0 12.04.09 25

Author Conclusion

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

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


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.

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


v1.0 12.04.09 26

Author Title Exclusion Reason 2000 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

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

Combines acute and neglected/chronic Achilles

tendon tear patients STUDY QUALITY Table 18. Study Quality

● = Yes ○ = No × = Not Reported

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 e

ntry

Author Outcome N Treatment(s) Level of Evidence

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.

Cast Level II × × ○ ● ● ● Cetti Hospitalization 111 Operative vs. Level II × × ○ ● ● ●

v1.0 12.04.09 27


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 e

ntry


Cast

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.

Cast Level II ● ● ○ ● ● × STUDY RESULTS Table 19. Open vs. Cast - Function

Author Comparison Outcome LOE N Durati

on

Open Repair Cast

Results mean (SD)

% mean (SD)

%

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

v1.0 12.04.09 28

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

Author Comparison Outcome LOE N Duration

Open Repair

Minimally Invasive Cast

Results mean (SD) %

mean (SD) %

mean (SD) %

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‡


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

v1.0 12.04.09 29

Table 21. Operative vs. Cast - Return to Work

Author Comparison Outcome LOE N Duration

Open Repair


Results mean (SD) mean (SD) mean (SD)

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) 108 (115) p < 0.05


v1.0 12.04.09 30

Table 22. Operative vs. Cast - Return to Sport

Author Comparison Outcome LOE N Duration Open

Repair %


% 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 -

Diminished II 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

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

Author Complication LOE N Duration Open

Repair Minimally Invasive Cast 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‡

‡ AAOS Calculation n/a: not applicable

v1.0 12.04.09 31

Table 24 Cast vs. Open - Complications

Author Complications LOE N Duration

Open Repair


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‡

v1.0 12.04.09 32


Open Repair


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‡


v1.0 12.04.09 33

RECOMMENDATION 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.

AAOS Strength of Recommendation: Inconclusive

Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role. 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).

v1.0 12.04.09 34

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

Author Outcome LOE N Duration Cast

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

Table 26. Summary of Results - Case Series

Author Outcome LOE N Duration Results

(%) 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%

Table 27. Summary of Systematic Reviews

Author Conclusion

Lynch, RM 2004 "Early functional mobilisation is more acceptable to patients than plaster cast immobilisation and results in improved functional outcomes" (p. 156).

v1.0 12.04.09 35

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

Table 29. Functional Bracing - Satisfaction (%)

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%

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%

Table 31. Functional Bracing - Function


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

v1.0 12.04.09 36

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%

Table 32. Functional Bracing - Strength


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%

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%

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

Author Outcome LOE N Results (mean)

v1.0 12.04.09 37


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) Table 35. Functional Bracing - Complications

Author Outcome LOE N Duration

Cast 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

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

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

v1.0 12.04.09 38


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 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

STUDY QUALITY Table 38. Study Quality - Randomized Control Trials


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

All

grou

ps h

ave

sim

ilar

outc

ome

perf

orm

ance

at e

ntry

Author Outcome N Treatment(s) Level of

Evidence

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

Orthosis Level II × × ○ ○ ● ●

Table 39. Study Quality - Non-Randomized Comparative Study


th

an 2

0%

diff

eren

ce

All

grou

ps

conc

urre

ntly

treat

ed

All

grou

ps

rece

ive

sam

e tre

atm

ent

eval

uate

d us

ing

sam

e ou

tcom

e

have

ap

prox

imat

ely

equa

l fol

low

Follo

w U

p -

80%

or m

ore

for

expe

rimen

tal

and

cont

rol

perf

orm

ance

on

out

com

e at

char

acte

ristic

s co

mpa

rabl

e at

v1.0 12.04.09 39


Ingvar, et al. 2005 Re-rupture 194

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

Table 40. Study Quality - Case Series


Con

secu

tive

enro

llmen

t

of p

atie

nts

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

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 ● ○ ● ● ●

v1.0 12.04.09 40


Con

secu

tive

enro

llmen

t

of p

atie

nts

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

All

patie

nts h

ave

appr

oxim

atel

y eq

ual

follo

w-u

p tim

es



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 ● ● ● ● ●


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 ● ● ● ● ●

v1.0 12.04.09 41

RECOMMENDATION 5 Operative treatment is an option in patients with acute Achilles tendon rupture. AAOS Strength of Recommendation: Limited Description: Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another. Implications: Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role. Rationale: To answer this recommendation, we reviewed studies addressing the efficacy of operative treatment. A systematic review of the literature included eight studies20, 19, 27, 28, 29, 30,31,

32that addressed the efficacy of open repair and six studies33, 29, 34, 21, 27, 31, 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 eight studies20, 19, 27, 28, 29, 30,31, 32 that addressed the efficacy of open repair and six studies33, 29, 34, 21, 27, 31 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 58). 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 60) 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 eight studies20, 19, 27, 28, 29, 30,31,32 that address efficacy of open repair and six studies 33, 29, 34, 21, 27, 31 that address minimally invasive techniques. Table 42 through Table 58 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 limited, it does not allow for additional statistical analysis.

v1.0 12.04.09 42

Please see Recommendation 7 for results of operative treatment comparisons.

v1.0 12.04.09 43

SUMMARY OF EVIDENCE Table 41. Open Repair – All Outcomes

Outcome Result

(Efficacy) 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 (%) ?

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)

nr: not reported

v1.0 12.04.09 44

Table 43. Open Repair - Activities of daily living

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 Return to jogging (weeks) 12.3 (range 8-21)

‡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)

v1.0 12.04.09 45

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%

‡ 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%

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%

v1.0 12.04.09 46


% 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%

Table 48: Open Repair- Percent of patients with pain

Author LOE N Outcome Follow-up % of Patients Aktas, 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%

Aktas, et al. 2009 IV 23 Pain- mild during exertion 22 months 13%

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%

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%

v1.0 12.04.09 47

Table 51. Minimally Invasive Repair- All outcomes

Outcome Result

(Efficacy)

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 (%) ?

Pain (%) ? 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%

v1.0 12.04.09 48

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

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%

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%

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)‡

‡= 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%

nr: not reported

v1.0 12.04.09 49

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


Patients Metz, et al.

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

nr: not reported

Table 58. Minimally Invasive Repair-Pain


Patients

Aktas, et al.2009

IV minimally-invasive 23

Percent of patient with mild pain during exertion

22 months 4.5%



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

Not relevant- looks at effect

of weight bearing

following surgery

van der Linden-van der Zwaag HM;Nelissen

RG;Sintenie JB;

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


v1.0 12.04.09 50


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

v1.0 12.04.09 51


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 Insufficient Quantitative

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

v1.0 12.04.09 52


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

Insufficient Quantitative

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

v1.0 12.04.09 53


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

v1.0 12.04.09 54



Con

secu

tive

Enr

ollm

ent

Follo

w u

p <8

0%

Sam

e O

utco

mes

Sam

e T

reat

men

ts

Equ

al F

ollo

w u

p T

ime

Author Outcome Measure N Treatment LoE

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 ● ● ● ● ●

v1.0 12.04.09 55


Con

secu

tive

Enr

ollm

ent

Follo

w u

p <8

0%

Sam

e O

utco

mes

Sam

e T

reat

men

ts

Equ

al F

ollo

w u

p T

ime


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


v1.0 12.04.09 56


Con

secu

tive

Enr

ollm

ent

Follo

w u

p <8

0%

Sam

e O

utco

mes

Sam

e T

reat

men

ts

Equ

al F

ollo

w u

p T

ime






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 ● ● ● ● ●

v1.0 12.04.09 57


Con

secu

tive

Enr

ollm

ent

Follo

w u

p <8

0%

Sam

e O

utco

mes

Sam

e T

reat

men

ts

Equ

al F

ollo

w u

p T

ime


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 ○ ● ● ● ●

Uchiyama, et al. 2007

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

84 Open Repair IV ○ ● ● ● ●

Aktas, et al.Aktas, et al.2009 Pain 46 Minimally

Invasive Repair IV ● ● ● ● ●

Aktas, et al.Aktas, et al.2009 Pain 46 Open Repair IV ● ● ● ● ●

v1.0 12.04.09 58

RECOMMENDATION 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.

AAOS Strength of Recommendation: Consensus Description: The supporting evidence is lacking and requires the work group to make a recommendation based on expert opinion by considering the known potential harm and benefits associated with the treatment. A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria of the guideline’s systematic review. Implications: Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role. 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.

v1.0 12.04.09 59

RECOMMENDATION 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.


Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role. 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.

v1.0 12.04.09 60

RECOMMENDATION 8 Open, limited open and percutaneous techniques are options for treating patients with acute Achilles tendon rupture. AAOS Strength of Recommendation: Limited Description: Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another. Implications: Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role. Rationale:

We defined the following operative repairs:

Open – procedure utilizing an extended incision for exposure allowing visualization of the rupture and tendon to allow direct placement of sutures for the repair. Limited-Open – procedure utilizing a small incision for exposure allowing direct visualization of the ruptured ends. Percutaneous – procedure without direct exposure of the tendon rupture site.

A systematic review identified three level II comparative trials29, 33, 35 investigating percutaneous repair and one level II and two level III comparative trials studying limited-open repairs.27, 36, 31 In both these comparisons, there was no significant difference in reruptures between open and minimally invasive techniques.

Two studies 29, 33 that compared percutaneous to open repairs found no statistically significant difference in return to activity. Two studies27, 36 comparing limited open to open repair found that patients treated with a limited open technique returned to activity sooner than those treated with an open repair. There is no statistically significant difference in satisfaction in patients treated with percutaneous or open repairs.29 Patients treated with limited open repair techniques have statistically significantly fewer symptoms than those treated with open technique but no statistically significant differences in pain. One study33 showed a statistically significant difference in the short term in favor of the percutaneous group for wound breakdown/delayed healing. Two studies29, 33 showed statistically significantly less scar adhesion in the percutaneous repair group compared with the open repair. Similarly, patients treated with limited open groups had statistically

v1.0 12.04.09 61

significantly fewer minor surgical site infections leading to delayed wound healing and in one study fewer severe wound infections.27 Beyond short term wound complications, there is no identified added benefit when comparing long term adverse events between open repair and minimally invasive repair. While in some studies33, 31 there were an increased number of superficial infections in the open repair group, there was no statistically significant difference between groups for deep infections31. One study29 reported a statistically significant difference in superficial infections between the open group and percutaneous groups, however, the authors29 did not administer IV antibiotics to the open control group. Based on these considerations, we downgraded this body of evidence to limited. 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 examined studies that made two different comparisons. Two level II studies compared percutaneous repair to open repair.29, 35 Two level II studies and two level III studies compared limited open to open repair.31,33 27, 36

PERCUTANEOUS VS OPEN REPAIR Patients treated with percutaneous repair scored significantly higher on the SF-12 physical and mental component scores (see Table 61). There was no significant difference in the amount of patients who returned to functional activities, activities of daily living, (see Table 62) or patient satisfaction (see Table 63). The amount of reruptures did not significantly differ between treatment groups (see Table 65)

Studies29, 33 reported no significant difference in the number of sural nerve injuries, superficial infection with staphalococcus, hypertonic scars, or keloid formation (Table 64). Patients treated with percutaneous repair had significantly less wound breakdown/delay of healing as well as less scar adhesions (see Table 64). No significant difference in the amount of deep infections was reported. One study29 reported a statistically significant difference in superficial infection, while another study33 did not report a difference(see Table 64). However, the study which did report more superficial infections in the open repair group, did not administer IV antibiotics. Wound puckering occurred significantly more in patients treated with percutaneous repair (see Table 64).

v1.0 12.04.09 62

SUMMARY OF EVIDENCE- PERCUTANEOUS VS. OPEN Table 61. Percutaneous and Limited Open vs. Open - Global Outcomes


24 months

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

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

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

Table 62. Percutaneous vs. Open - Return to Activities and Function

Author Outcome

LOE N Duration (months)

% 6 65.5

ES Ng Return to Activity II 68 ○

Lim Return to Activities of Daily Living II 66 ○

Lim Returned to Final Functional Activity‡ II 66 ○

● 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 ‡ Final Functional Activity: “When patient was unhindered in all his or her activities apart from sports.” Table 63. Percutaneous vs. Open - Satisfaction

Author Outcome

LOE N Duration

% 6 months Lim Satisfaction II 66 ○

● P: Statistically Significant in Favor of Percutaneous Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance Table 64. Percutaneous vs. Open- Complications

Author Adverse Event LOE N Duration (months) 6 65.5

v1.0 12.04.09 63


Ng Wound breakdown/ delay healing II 68 ●P

Ng Sural Nerve Injury II 68 ○ Lim Sural Nerve Problems II 66 ○

Lim Deep Infection with staphalococcus II 66 ○

Lim Adhesions II 66 ●P Ng Scar Adhesion II 68 ●P Ng Superficial Infection II 68 ○ Lim Superficial Infection II 66 ●P

Lim Superficial Infection with staphalococcus ○

Ng Hypertrophic Scar II 68 ○ Lim Keloid Formation II 66 ○ Lim Wound Puckering II 66 ● Op

● P: Statistically Significant in Favor of Percutaneous Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance Table 65. Percutaneous vs. Open- Rerupture


Lim et al 2001 Rerupture II 66 ○

Ng, et al 2006 Rerupture II 68 ○ ● 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

LIMITED OPEN VS OPEN REPAIR Patients treated with limited open repair did not have less pain or score higher on the AOFAS scale than patients treated with open repair (see Table 66 and Table 67). Patients treated with limited open repair returned to normal walking, stair climbing, and sports in significantly less time than patients treated with standard open repair (seeTable 68). A significantly larger percentage of patients treated with limited open repair had fewer symptoms compared to patients treated with open repair (seeTable 69). There was no significant difference in the number of reruptures between treatment groups (see Table 71). There was no statistically significant difference in DVT, large hematoma,

v1.0 12.04.09 64

stiffness of ankle, insertional tendinopathy, or deep infection between the open and limited repair groups (see Table 70). However, patients treated with limited open repair had significantly fewer severe wound infections, superficial infections, and minor surgical site infections than patients treated with open repair (see Table 70). SUMMARY OF EVIDENCE- LIMITED OPEN VS. OPEN Table 66. Minimally Invasive vs. Open- Pain

Author Outcome

LOE N Duration

% 6 months Aktas Pain II 46 ○

● P: Statistically Significant in Favor of Percutaneous Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance Table 67. Minimally Invasive vs. Open- Global Outcomes


24 months

Aktas AOFAS II 40 ○

● P: Statistically Significant in Favor of Percutaneous Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance Table 68. Limited Open vs. Open- Return to Activity

Author Outcome

LOE N Duration

(weeks) 12 months

63.5 months

Bhattacharyya Return to Normal Walking III 53 ●Mini

Bhattacharyya Return to Normal Stair Climbing III 53 ●Mini

Kakiuchi Return to Sports III 22 ● Mini

● Mini: Statistically Significant in Favor of Minimally Invasive (mini-open) Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance Table 69. Mini-Open vs. Open- Symptoms

Author Outcome

LOE N Duration

(%) 63.5 months

Kakiuchi Symptoms III 22 ● Mini

● Mini: Statistically Significant in Favor of Minimally Invasive Repair

v1.0 12.04.09 65

● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance Table 70. Limited Open Repair vs. Open - Complications

Author Complication LOE N Duration

6 Months

12 months

Bhattacharyya

Minor Surgical Site Infection with

Delayed Wound Healing

III 53 ● Mini

Bhattacharyya Severe Wound Infection and Dehiscence

III 53 ● Mini

Aktas, 2009 Deep Infection II 40 ○

Aktas, 2009 Superficial Infection II 40 ● Mini

Aktas, 2009 Insertional Tendinopathy II 40 ○

Aktas, 2009 Stiffness of the ankle II 40 ○

Aktas, 2009 Large Hematoma II 40 ○

Aktas, 2009 DVT II 40 ○

● 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 Table 71. Mini-Open vs. Open – Rerupture

Author Adverse Events LOE N Duration

63.5 months Kakiuchi Rerupture III 22 ○

● 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

v1.0 12.04.09 66

EXCLUDED ARTICLES Table 72. 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


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


v1.0 12.04.09 67


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?


v1.0 12.04.09 68


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


STUDY QUALITY Table 73. Study Quality - RCTs


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

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



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 Repair

Level II ○ ● ● × ● ×

Lim, et al.

Duration of Immobilization 66 Open Repair

vs. Level II ○ ● ● × ● ×

v1.0 12.04.09 69


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

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


2001 Percutaneous Repair

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 ○ ● ● × ● ×

Aktas, et al. 2009

AOFAS 40 Minimally

Invasive vs. Open

Level II × × × ○ ● ●

v1.0 12.04.09 70

Table 74. Quality of Studies - Comparative Studies


All

grou

ps h

ave

sim

ilar

char

acte

ristic

s at e

ntry

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





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 53



v1.0 12.04.09 71


All

grou

ps h

ave

sim

ilar

char

acte

ristic

s at e

ntry

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


Dehiscence


Minor Surgical Site

Infection 53




Delayed Wound Healing

53 Minimally



v1.0 12.04.09 72

STUDY RESULTS Table 75. Limited open vs. Open - Global Outcomes

Author Outcome LOE N Duration Minimally Invasive Open

Results mean (SD) mean (SD)


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

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

‡ AAOS calculation Table 76. 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 77. Percutaneous vs. Open - Satisfaction


Open (%) Results

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

NS: not significant; authors do not report p-value Table 78. 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

Deep infection with wound

breakdown and staphalococcus

infection

II 66 6 months 0% 3% p = 0.155‡

Lim, et al. 2001

Superficial Infection with staphalococcus

infection

II 66 6 months 0% 3% p = 0.155‡

v1.0 12.04.09 73

Author Complications LOE N Duration Percutaneous (%)

Open (%) Results

Lim, et al. 2001

Superficial Infection II 66 6 months 0% 15% p=0.001‡

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

Lim, et al. 2001

Wound Puckering II 66 6 months 9% 0% p = .013‡

Aktas, et al. 2009 Deep Infection II 40 Post

operative 0% 5% p=0.15‡

Aktas, et al. 2009

Superficial Infection II 40 Post

operative 0% 15% p=0.011‡

Aktas, et al. 2009

Insertional Tendinopathy II 40 Post

operative 5% 0 p=0.15‡ Aktas, et al.

2009 Stiffness of the

ankle II 40 Post operative 0% 5% p=0.15‡

Aktas, et al. 2009

Large Hematoma II 40 Post

operative 0% 5% p=0.15‡ Aktas, et al.

2009 DVT II 40 Post operative 0% 5% p=0.15‡


Table 79. Minimally Invasive vs. Open- Pain


Open (%) Results

Aktas, et al. 2009 Pain II 46 22 months 4.5% 13% P=0.3

Table 80. Minimally Invasive vs. Open- Global Outcomes


Open (%) Results

Aktas, et al. 2009 Pain II 46 22 months 4.5% 13% P=0.3

Table 81. Minimally Invasive vs. Open - Function

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‡


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

v1.0 12.04.09 74

Author Outcome LOE N Duration Minimally

Invasive mean (SD)

Open Repair

mean (SD) Results

Ng, et al 2006 Return to

Activity - Same Level

II 68 65.5 months 96% 88% p = 0.244


Table 82. Minimally Invasive vs. Open - Complications


Minimally Invasive Open

Repair (%)

Open (%) Results


Minor Surgical Site Infection with Delayed

Wound Healing

III 53 12 months 0% 17% p <.001‡


Severe Wound Infection and Dehiscence

III 53 12 months 0% 7% p =.034‡

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‡


Table 83. Minimally Invasive vs. Open - Symptoms

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‡


v1.0 12.04.09 75

Table 84. Minimally Invasive vs. Open - Return to Sport


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‡

Return to Sport - No participation for other reasons

III 22 63.5 months 17% 50% p = .27‡


Table 85. Minimally Invasive vs. Open - Complications

Author Complications LOE N Duration Minimally

Invasive (%) Open Results

% % Kakiuchi, et al.

1995 Rerupture III 22 63.5 months 0% 0% NS

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

v1.0 12.04.09 76

RECOMMENDATION 9 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.


Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role.

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 studies32, 37, 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.

Supporting Evidence: No studies were identified that address adjunctive augmentation with allograft (see Table 92), xenograft, or biologic adjuncts (see Table 95). We examined three level II studies that compared patients given adjunctive augmentation with autograft tissue vs. open repair.32, 37, 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 86 - Table 89).

One study reported one patient given adjunct augmentation had a pulmonary embolism; no significant difference was found between treatment groups (see Table 91). 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

v1.0 12.04.09 77

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 91).

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 106). There were no reruptures and no healing impairment (see Table 106). 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 Table 106).

SUMMARY OF EVIDENCE Table 86. Autograft vs. Open - Pain and Stiffness

Author LOE N Outcome Duration (months) 6 12 42

Pajala II 59 Pain ○

Aktas II 30 Pain ○

Taglialavoro II 46 Pain ○

Pajala II 59 Stiffness ○

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 87. Autograft vs. Open - Satisfaction

Author LOE N Outcome Duration (months) 12 42

Taglialavoro II 46 Satisfaction ○

Pajala II 59 Satisfaction ○

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 88. Autograft - Return to Activities and Sports


Taglialavoro II 46 Recovery of Daily Activities (days) ○

v1.0 12.04.09 78


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 ○ ●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 89. Autograft vs. Open - Footwear Restrictions

Author LOE N Outcome Duration (months)

12 42

Pajala II 59 Footwear Restrictions ○

Taglialavoro II 46 Conflict with shoes ○

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 90. Autograft vs. Open - Hospitalization and Immobilization

Author Outcome (Days) LOE N Duration

42 months

Taglialavoro Hospitalization II 46 ●Op

Taglialavoro Immobilization II 46 ●Op

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 91. Autograft vs. Open - Complications


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 ○

v1.0 12.04.09 79


Infection

Pajala II 60 Re-rupture ○

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

●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance EXCLUDED ARTICLES Table 92. 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

Table 93. 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?


v1.0 12.04.09 80


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 Less than 10 patients

per group Table 94. 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

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

Patients had prior surgical or

conservative treatment Table 95- Biologic Adjuncts


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


v1.0 12.04.09 81

STUDY QUALITY Table 96. Study Quality – Autograft RCTs


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 e

ntry


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 ○ ● ● ○ ● ×

v1.0 12.04.09 82


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 e

ntry


Aktas, et al.

2007 Deep Infection 30 Open vs. Autograft


Aktas, et al.

2007 Re-rupture 30 Open vs. Autograft


Table 97. Study Quality - Autograft Comparative Studies


All

grou

ps h

ave

sim

ilar c

hara

cter

istic

s at

ent

ry

All

grou

ps h

ave

sim

ilar o

utco

me

perf

orm

ance

at e

ntry

A

ll gr

oups

con

curr

ently

treat

ed

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


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


v1.0 12.04.09 83


All

grou

ps h

ave

sim

ilar c

hara

cter

istic

s at

ent

ry

All

grou

ps h

ave

sim

ilar o

utco

me

perf

orm

ance

at e

ntry

A

ll gr

oups

con

curr

ently

treat

ed

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


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 Keloid 46 Open vs. Autograft


Taglialavoro, et al 2004 Dehiscence 46 Open vs. Autograft


v1.0 12.04.09 84

Table 98. Study Quality - Synthetic Tissue Case Series


Con

secu

tive

enro

llmen

t

of p

atie

nts

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

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 Rerupture 15 Synthetic Adjunctive



Healing Impairment 15 Synthetic Adjunctive



Return to Swimming 15 Synthetic Adjunctive


v1.0 12.04.09 85

STUDY RESULTS Table 99 Autograft vs. Open Pain and Stiffness

Author Outcome LOE N Duration Adjunctive

Augmentation Open 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 100. Autograft vs. Open - Satisfaction


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 McComis Score ‡ AAOS Calculation

v1.0 12.04.09 86

Table 101. 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

‡ AAOS Calculation NS: not significant; authors do not report p-value Table 102. 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‡

‡ AAOS Calculation Table 103. 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

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

v1.0 12.04.09 87

Table 104. Autograft vs. Open - Hospitalization vs. Immobilization


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 Table 105. Autograft vs. Open - Complications

Author Complication LOE N Duration Adjunctive

Augmentation Open

Repair

% % 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 Keloid 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

v1.0 12.04.09 88

Table 106. Synthetic Tissue - Results


Augmentation 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 Rerupture IV 15 18

months 0%

Giannini et al, 1994 Healing Impairment IV 15 18

months 0%

v1.0 12.04.09 89

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



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 107. 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

v1.0 12.04.09 90

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

AAOS Strength of Recommendation: Moderate

Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. A Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but the strength of the supporting evidence is not as strong. Implications: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences. Rationale: A systematic review identified four Level II studies40, 5, 41,42 that compared early postoperative weight bearing to non-weight bearing following surgical repair of the Achilles tendon. All studies compared patients with either six weeks of non-weight bearing in a cast to early weight bearing. Two studies40, 42 permitted immediate weight bearing starting the day of surgery in a cast, defined as toe-touch weight bearing in one study.40 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, three investigators40, 5, 41 used a splint device that limited dorsiflexion to prevent compromise of the repair. After four weeks, Maffulli et al.40, 42 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 study,5 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. Three studies40, 5, 42 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 four 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.

v1.0 12.04.09 91

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.


Four Level II studies 40, 5, 41, 42 compare early postoperative weight bearing to non-weight bearing following surgical repair of the Achilles tendon. The post-operative regimes in the three studies are detailed in Table 108. For results of early weight bearing versus non-weight bearing see Table 109 through Table 115.

Of forty-nine outcome measures comparing early weight bearing to non-weight bearing, seventeen were statistically significant in favor of early weight bearing, while one was in favor of non-weight bearing. Eleven of the seventeen 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 109). A third 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 had no limitation 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 (see Table 109).. 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, or footwear restrictions at twelve months (see Table 110 through Table 113).

One study5, reported significantly more reruptures 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 108: Description of treatment groups Author Post operative Instructions

Maffulli, et al.(a)

Early weight bearing group: Bear weight on the tiptoes 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.

Maffulli, et al (b)

Early weight bearing group: Bear weight on 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

v1.0 12.04.09 92

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.

v1.0 12.04.09 93

SUMMARY OF EVIDENCE Table 109 Time until return to activity

Author Outcome LoE N Time to

Return to Activity

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

Maffulli, et al 2003 (b) Return to Sports (months) II 56‡ ●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 (a) Return to Work (weeks) II 53 ●wb

Maffulli, et al 2003 (a) Full weight bearing (wks) II 53 ●wb

Maffulli, et al 2003 (b) Full weight bearing (wks) II 56‡ ●wb

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

Maffulli, et al 2003 (b) Physiotherapy sessions (visits) II 56‡ ●wb

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

Maffulli, et al 2003 (b) Discharged from Physiotherapy (months) II 56‡ ●wb

Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference ‡ AAOS calculations ‡‡= Number of patients is unclear. The authors state both 56 and 53 as the number of patients enrolled Table 110 Pain

Result (months)

Author Outcome LoE N 1.5 2 3 6 12

Maffulli, et al 2003 (a) Pain- None II 53 ○‡

Maffulli, et al 2003 (a) Pain- Mild, Occasional II 53 ○‡

Maffulli, et al 2003 (a) Pain- Moderate II 53 ○‡

Maffulli, et al 2003 (b) Pain- None II 53 ○‡

v1.0 12.04.09 94

Result (months)

Author Outcome LoE N 1.5 2 3 6 12

Maffulli, et al 2003 (b) Pain- Mild, Occasional II 53 ○‡

Maffulli, et al 2003 (b) Pain- Moderate II 53 ○‡

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

v1.0 12.04.09 95

Table 111 Function

Author Outcome Result (months)

LoE N 1.5 6 12

Suchak, et al 2008

No Limitations or Limitations only in recreation II 110 ●wb

Maffulli, et al 2003 (a) No Limitations II 53 ○‡

Maffulli, et al 2003 (b) No Limitations II 53 ○

Maffulli, et al 2003 (a)

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

Maffulli, et al 2003 (b)

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

Suchak, et al 2008 (a) Return to at least partial sports II 38 ○‡

Maffulli, et al 2003 (a) Return to Sports II 48 ○‡

Maffulli, et al 2003 (b) Return to Sports II 53 ○‡

Costa, et al 2006 Return to Sports II 48‡‡ ●wb

Maffulli, et al 2003 (a) Return to Work II 49 ○‡

Maffulli, et al 2003 (b) Return to Work II 53 ○‡

Maffulli, et al 2003 (a) Changed Jobs II 49 ○‡

Maffulli, et al 2003 (b) Changed Jobs ○‡


Experience Problems at work due to injury II 49 ○‡


Experience Problems at work due to injury II 53 ○‡


Footwear restrictions- None, mild (most shoes tolerated) II 53 ○‡


Footwear restrictions- None, mild (most shoes tolerated) II 53 ○‡


Footwear restrictions- Moderate (unable to tolerate fashionable shoes,

with or without insert) II

53 ○‡


Footwear restrictions- Moderate (unable to tolerate fashionable shoes,

with or without insert) II 53 ○‡

Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference

v1.0 12.04.09 96

‡ AAOS calculations ‡‡= Open cast group converted to orthosis at 3 weeks Table 112 EuroQoL, Rand-36

Author Outcome LoE N Results (Months)

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

Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference ‡ AAOS calculations ‡‡= Open cast group converted to orthosis at 3 weeks Table 113 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 ○‡



II 53 ○‡



surgery II 53 ○‡

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

v1.0 12.04.09 97

Table 114 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

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

v1.0 12.04.09 98

SUMMARY OF COMPLICATIONS Table 115 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 (a)

Superficial Infection II 12 months 53 7.69% 7.40% ○‡

Maffulli, et al

2003 (a)

Hypersensitivity of surgical

wounds II 10-12 wks 53 15.38% 18.51% ○‡

Maffulli, et al

2003 (a)

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

Persistent paraethesiae II Nr 48‡‡ 0% 4.3% ○‡

Maffulli, et al

2003 (b)


wounds II 10-12 wks 53‡‡‡ 12% 4% ○‡

Maffulli, et al

2003 (b)

Hypertrophic Scar II 10-12 weeks 53‡‡‡ 4% 4% ○‡

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 ‡‡‡= Number of patients is unclear. The authors state both 56 and 53 as the number of patients enrolled

v1.0 12.04.09 99

Table 116 Systematic Reviews Author Conclusion

Khan, RJK, et al. 2005 "Postoperative splinting in a cast followed by a functional brace rather than a cast alone reduces the overall complication rate" (p. 2209).


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).

v1.0 12.04.09 100

EXCLUDED ARTICLES Table 117 Article Inclusion List- Early weight bearing vs. non-weight bearing

Author Title Exclusion Reason Costa, et al.

2003 Immediate full-weight bearing mobilisation for repaired Achilles tendon ruptures: a pilot study


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



v1.0 12.04.09 101

STUDY QUALITY Table 118. Quality- Weight bearing vs. non-weight bearing- RCT

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

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

bas

elin

e

Author 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


(weeks) 43



Costa, et al.

2006

Return to Work (weeks) 43



Costa, et al.

2006

EuroQoL - Health Score‡‡ 43


bearing II ● ● × × ● ×

Costa, et al.

2006 EuroQoL - E5D‡ 43



v1.0 12.04.09 102


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

bas

elin

e


Suchak, et al.

2008

RAND-36: Physical Function 109



Suchak, et al.

2008

RAND-36: Mental health 109



Suchak, et al.

2008 Complications 110



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 109



v1.0 12.04.09 103


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

bas

elin

e


Suchak, et al.

2008

RAND-36: Role-emotional 109



v1.0 12.04.09 104

Table 119. Quality- Weight bearing vs. non-weight bearing- Comparative


All

grou

ps h

ave

sim

ilar c

hara

cter

istic

s at e

ntry

All

grou

ps h

ave

sim

ilar o

utco

me

perf

orm

ance

at e

ntry

All

grou

ps c

oncu

rren

tly

treat

ed

Follo

w U

p - 8

0% o

r mor

e

Sam

e ce

nter

for e

xper

imen

tal a

nd c

ontro

l gro

up d

ata


Maffulli, et al.

2003 (a) Pain- None 53

Weight Bearing vs. Non-Weight

Bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)

Pain- Mild, Occasional 53


Bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a) Pain- Moderate 53

Weight Bearing vs. Non-weight bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a) Return to Sports 53

Weight Bearing vs. Non-weight

bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)

Return to Sports (months) 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)



II ● ● x ● ●

v1.0 12.04.09 105


All

grou

ps h

ave

sim

ilar c

hara

cter

istic

s at e

ntry

All

grou

ps h

ave

sim

ilar o

utco

me

perf

orm

ance

at e

ntry

All

grou

ps c

oncu

rren

tly

treat

ed

Follo

w U

p - 8

0% o

r mor

e

Sam

e ce

nter

for e

xper

imen

tal a

nd c

ontro

l gro

up d

ata


Maffulli, et al.

2003 (a) Return to Work 53


II ● ● x ● ●

Maffulli, et al.

2003(a) Changed Jobs 53


II ● ● x ● ●

Maffulli, et al.

2003 (a)

Experience Problems at work

due to injury 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)

Full weight bearing (wks) 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)

Activity Limitation - None 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003(a)

Activity Limitation - Limited

Recreational but not Daily Activities

53 Weight

Bearing vs. Non Weight

II ● ● x ● ●

Maffulli, et al.

2003 (a)

Discharged from Physiotherapy

(months) 53


bearing

II ● ● x ● ●

v1.0 12.04.09 106


All

grou

ps h

ave

sim

ilar c

hara

cter

istic

s at e

ntry

All

grou

ps h

ave

sim

ilar o

utco

me

perf

orm

ance

at e

ntry

All

grou

ps c

oncu

rren

tly

treat

ed

Follo

w U

p - 8

0% o

r mor

e

Sam

e ce

nter

for e

xper

imen

tal a

nd c

ontro

l gro

up d

ata


Maffulli, et al.

2003 (a)

Physiotherapy sessions (visits) 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)

Footwear restrictions- None, mild (most shoes

tolerated)

53

Weight Bearing vs. Non Weight

Bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)

Footwear restrictions-

Moderate (unable to tolerate

fashionable shoes, with or without

insert)

53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)


surgery 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (a)

Patient opinion of results- Excellent 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b) Pain- None 53


Bearing

II ● ● x ● ●

v1.0 12.04.09 107


All

grou

ps h

ave

sim

ilar c

hara

cter

istic

s at e

ntry

All

grou

ps h

ave

sim

ilar o

utco

me

perf

orm

ance

at e

ntry

All

grou

ps c

oncu

rren

tly

treat

ed

Follo

w U

p - 8

0% o

r mor

e

Sam

e ce

nter

for e

xper

imen

tal a

nd c

ontro

l gro

up d

ata


Maffulli, et al.

2003 (b)



Bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b) Pain- Moderate 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b) Return to Sports 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b)



bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b)



bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b) Return to Work 51


bearing

II ● ● x ● ●

Maffulli, et al.

2003(b) Changed Jobs 51


bearing

II ● ● x ● ●

v1.0 12.04.09 108


All

grou

ps h

ave

sim

ilar c

hara

cter

istic

s at e

ntry

All

grou

ps h

ave

sim

ilar o

utco

me

perf

orm

ance

at e

ntry

All

grou

ps c

oncu

rren

tly

treat

ed

Follo

w U

p - 8

0% o

r mor

e

Sam

e ce

nter

for e

xper

imen

tal a

nd c

ontro

l gro

up d

ata


Maffulli, et al.

2003 (b)

Experience Problems at work

due to injury 51


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b)

Full weight bearing (wks) 56‡‡


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b)

Activity Limitation - None 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003(b)


Recreational but not Daily Activities

53 Weight

Bearing vs. Non Weight

II ● ● x ● ●

Maffulli, et al.

2003 (b)


(months) 56‡‡


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b)

Physiotherapy sessions (visits) 56‡‡


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b)

Footwear restrictions- None, mild (most shoes

tolerated)

53

Weight Bearing vs. Non Weight

Bearing

II ● ● x ● ●

v1.0 12.04.09 109


All

grou

ps h

ave

sim

ilar c

hara

cter

istic

s at e

ntry

All

grou

ps h

ave

sim

ilar o

utco

me

perf

orm

ance

at e

ntry

All

grou

ps c

oncu

rren

tly

treat

ed

Follo

w U

p - 8

0% o

r mor

e

Sam

e ce

nter

for e

xper

imen

tal a

nd c

ontro

l gro

up d

ata


Maffulli, et al.

2003 (b)

Footwear restrictions-

Moderate (unable to tolerate

fashionable shoes, with or without

insert)

53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b)


surgery 53


bearing

II ● ● x ● ●

Maffulli, et al.

2003 (b)

Patient opinion of results- Excellent 53


bearing

II ● ● x ● ●

v1.0 12.04.09 110

STUDY RESULTS Table 120 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% p=0.68

Maffulli, et al 2003(a)

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



(months) II 12

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

Maffulli, et al 2003(a) Pain- None II 12

months 53 88% 89% p= 0.96 ‡


Pain- Mild, Occasional II 12

months 53 8% 7% p=0.97‡

Maffulli, et al 2003(a) Pain- Moderate II 12

months 53 4% 4% p=0.98 ‡


Activity Limitation - None II 12

months 53 92% 93% p=0.97‡


Activity Limitation - Limited Recreational

but not Daily Activities

II 12 months 53 8% 7% p=0.97

v1.0 12.04.09 111



Maffulli, et al 2003(a) Return to Sports II 12

months 38 89% 89% p=0.99 ‡


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% p=0.57‡


Footwear restrictions-Moderate (unable to tolerate fashionable

shoes, with or without insert)

II 12 months 53 4% 7% p=0.57‡


Percent satisfied with results of surgery II 12

months 53 88% 85% p=0.51‡

Maffulli, et al 2003(a) Excellent II 12

months 53 88% 81% p=0.47‡


Return to Work (weeks) II 12

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

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

months 49 100% 100% 1

Maffulli, et al 2003(a) Changed Jobs II 12

months 49 1 2 p=0.51‡


Experience Problems at work due to injury II 12

months 49 2 4 .p=0.41‡


Full weight bearing (wks) II 6 weeks 53‡‡

‡ 2.5 (SD

0.4) 5.7 (SD 2.2) P=0.013


Physiotherapy sessions (visits) II 12

months 53‡‡

‡ 8.3 (SD

4.1) 14.6 (SD 5.3) p = 0.008

Maffulli, et al 2003(b)


(months) II 12

months 53‡ 2.7 (SD 1.1) 4.7 (SD 2) <.08

Maffulli, et al 2003(b) Pain- None II 12

months 53 92% 86% P=0.46‡

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

v1.0 12.04.09 112



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


(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(a) 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‡

v1.0 12.04.09 113



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(a) Hypertrophic Scar II 10-12

weeks 53 3.84% 0% p= 0.15‡


Pain- Mild, Occasional II 12

months 53 8% 8% p=0.93

Maffulli, et al 2003 (b) Pain- Moderate II 12

months 53 0% 7% p=0.95


Activity Limitation - None II 12

months 53 0.96 89% p=0.37


Activity Limitation - Limited Recreational

but not Daily Activities

II 12 months 53 4% 11% p=0.91

Maffulli, et al 2003 (b) Return to Sports II 12

months 53‡ 89% 89% p=0.93


Time until Return to Sports (months) II 12

months 53‡‡

‡ 5.2 (SD 3) 6.1 (SD 2.8) p=0.45


Footwear restrictions-None, mild (most shoes tolerated)

II 12 months 53 96% 96% p=0.33


Footwear restrictions-Moderate (unable to tolerate fashionable


II 12 months 53 4% 4% p=0.97


Percent satisfied with results of surgery II 12

months 53 84% 89% p=0.37

Maffulli, et al 2003 (b) Excellent II 12

months 53 84% 89% p=0.37

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

months 51 100% 100% 1

Maffulli, et al 2003 (b) Changed Jobs II 12

months 49 1 2 p=0.61

v1.0 12.04.09 114




Experience Problems at work due to injury II 12

months 49 20% 11% p=0.91


Hypersensitivity of the surgical wound II 6 weeks 53 12% 4% p=0.97

Maffulli, et al 2003 (b) Hypertrophic scar II 6 weeks 53 4% 4% p=0.97

‡= AAOS calculations

v1.0 12.04.09 115

RECOMMENDATION 12 We suggest the use of a protective device that allows mobilization by 2- 4 weeks post operatively. AAOS Strength of Recommendation: Moderate

Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. A Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but the strength of the supporting evidence is not as strong. Implications: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences. Rationale: A systematic review identified five Level II 40, 43-45 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, 43-45 found that the weight bearing group had statistical improvement in the mean time to return to activities such as work and normal walking. One44 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, 43-45 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, 43-45 compare postoperative immobilization to postoperative mobilization. The post operative mobilization and immobilization regimes are detailed in

v1.0 12.04.09 116

Table 121. Please see Table 122 through Table 129 for results of mobilization versus immobilization.

Of the forty outcomes reported, seventeen were statistically significant in favor of early motion. Nine of the seventeen 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 122). However, another study that reported time until return to sport and work did statistically significantly differ between groups (see Table 122). Patients in the early motion group reported statistically significantly less pain at one month but no statistically significant difference in pain at three, six, or twelve months (see Table 123). 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 124).

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 121. 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. (a) Mobilization group: Removable splint and mobilization at 2 weeks. Immobilization group: Below the knee plaster cast.

SUMMARY OF EVIDENCE Table 122. Time to Return to Activity

v1.0 12.04.09 117

Author Outcome LoE Comparison N Time to return

Maffulli, et al

2003(a)

Return to Sports

(months) II

Early Motion vs.

Immobilization 53 ●em

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

Maffulli, et al

2003(a)

Return to Work (weeks) II

Early Motion Vs.


Maffulli, et al

2003(a)

Full weight bearing (wks) II

Early Motion Vs.


Maffulli, et al 2003

Physiotherapy sessions (visits)

II Early Motion

Vs. Immobilization

53 ●em


Discharged from

Physiotherapy (months)

II Early Motion

Vs. Immobilization

53 ●em

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

v1.0 12.04.09 118

Table 123. Pain

Author Outcome LoE Comparison N Duration (Months)

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

○


Table 124. Function


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 ○

Cetti, et al. 1994

Stopped sports

activities II

Early Motion vs.

Cast 60 ○

v1.0 12.04.09 119


3 6 12 18


No Limitations II

Early Motion Vs.

Immobilization 53 ○



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 ○

em= early motion ○= no statistically significant difference ●= statistically significant difference ‡ AAOS calculations ‡‡= Open cast group converted to orthosis at 3 weeks Table 125. 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

II Early

Motion vs.

48‡‡ ○ ○ ○

v1.0 12.04.09 120

Score) Cast

Kangas, et al 2002

Ankle Performance

Score - Excellent

II

Early Motion

vs. Cast

50 ○


Table 126. 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 ●em

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



II ○



surgery II ○


v1.0 12.04.09 121

Table 127. 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 ○= no statistically significant difference ●= statistically significant difference ‡ AAOS calculations ‡‡= Open cast group converted to orthosis at 3 weeks Table 128. Rerupture

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


v1.0 12.04.09 122

SUMMARY OF COMPLICATIONS Table 129. 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% ○

em= early motion nem= not early motion ○= no statistically significant difference ●= statistically significant difference ‡ AAOS calculated

v1.0 12.04.09 123

Table 130. Systematic Reviews

Author Conclusion

Khan, RJK, et al. 2005

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


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).

v1.0 12.04.09 124

EXCLUDED ARTICLES Table 131. 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;



v1.0 12.04.09 125

STUDY QUALITY Table 132. Mobilization vs. Immobilization Quality


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.

Immobilization II ● ● × × ● ×

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.

Immobilization II × ● ○ ○ ● ●

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.


v1.0 12.04.09 126


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.

Immobilization II ● ○ ○ ○ ○ ●


Sports Activity 61

Mobilization vs.

Immobilization II ● ○ ○ ○ ○ ●


Pain 61 Mobilization

vs. Immobilization

II ● ○ ○ ○ ○ ●

v1.0 12.04.09 127


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 ○ ○ ○ ● ● ×



Mobilization vs.

Immobilization II ○ ○ ○ ● ● ×


Pain- Moderate 53 Mobilization

vs. Immobilization

II ○ ○ × × ● ×


Return to Sports 53

Mobilization vs.

Immobilization II ○ ○ × × ● ×

v1.0 12.04.09 128


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




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 ○ ○ × × ● ●

v1.0 12.04.09 129


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



Footwear restrictions- Moderate (unable to


shoes)

53 Mobilization

vs. Immobilization

II ○ ○ × × ● ●


Percent satisfied with

results of surgery

53


bearing

II ○ ○ × × ● ●



53


bearing

II ○ ○ × × ● ●

v1.0 12.04.09 130

STUDY RESULTS Table 133. Mobilization vs. Immobilization Study Data

Author

Outcome

LoE

Duration

N

Results 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% p=0.06‡


Returned to sports II 16 months 61 73% 76% OR =1

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

v1.0 12.04.09 131

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

2003 Vas Pain II 3 weeks 50 .83 ± 1.2 .82 ±

1.3 p= 0.797

Kangas, et al

2003 Vas Pain II 6 weeks 50 .65 ± 1.4 .60 ±

.09 p= 0.9

Kangas, et al

2003 No Stiffness II 60 weeks 50 44% 68% p>0.08

Kangas, et al

2003 Mild Stiffness II 60 weeks 50 56% 32% p>0.08

Kangas, et al

2003

No footwear restrictions II 60 weeks 50 68% 92% p>0.08

Kangas, et al

2003

Ankle Performance

Score - Excellent II 60 weeks 50 88% 92% p>0.08

Kangas, et al

2003 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‡

Cetti, et al. 1994 Scar Adhesion II Not Reported 60 3.3 13.3 0.141‡

v1.0 12.04.09 132

Results Author Outcome LoE Duration N Early Motion Cast Results 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



(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% p= 0.96 ‡


Pain- Mild, Occasional II 12 months 53 8% 7% p=0.97‡

Maffulli, et al 2003 Pain- Moderate II 12 months 53 4% 4% p=0.98 ‡



None II 12 months 53 92% 93% p=0.97‡



Limited Recreational but

not Daily Activities

II 12 months 53 8% 7% p=0.97

Maffulli, et al 2003 Return to Sports II 12 months 38 89% 89% p=0.99 ‡


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% p=0.57‡


Footwear restrictions-Moderate (unable to



II 12 months 53 4% 7% p=0.57‡

v1.0 12.04.09 133

Results Author Outcome LoE Duration N Early Motion Cast Results Maffulli, et

al 2003


surgery II 12 months 53 88% 85% p=0.51‡

Maffulli, et al 2003 Excellent II 12 months 53 88% 81% p=0.47‡


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 p=0.51‡



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‡


v1.0 12.04.09 134

Results

Author Outcome LoE Duration N Early Motion Cast Results Cetti, 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) 1(IQR 0.8-1.0) p = 0.146


v1.0 12.04.09 135

RECOMMENDATION 13 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 134. Post Operative Physiotherapy Regiments

Author LOE Treatment N Post Treatment PT Regimen

Majewski III Percutaneous Repair

15 Cast followed

by walking cast Both groups received same PT at 8

weeks 88 Combination

splint and shoe

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 19 Cast 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.

v1.0 12.04.09 136

Author LOE Treatment N Post Treatment PT Regimen

Moberg IV Operative Repair 17 Mobile plaster

cast

Immediate free ankle joint movement. Free weightbearing and

mobilization at 6 weeks.

Kangas

II Open Repair 25 Dorsal rigid splint at 6

weeks

Both groups performed "standard rehabilitation program;" Authors do not specify details of PT program

II Open Repair 25 Plaster splint Both groups performed "standard

rehabilitation program;" Authors do not specify details of PT program



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


v1.0 12.04.09 137

RECOMMENDATION 14 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. AAOS Strength of Recommendation: Inconclusive

Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm. Implications: Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role. 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). Supporting Evidence: Eighteen studies5, 46, 47, 48, 49, 50, 20,41, 51, 30,21,52,53, 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 136 through Table 143). 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 136. 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. IV cast and boot 125 Return to work 0.6 45%

v1.0 12.04.09 138

2006

Table 137. Non-Operative Treatment -Percent of patients able to return to ADL


% of Patients


immediate weight bearing

mobilization 22 Return to normal

walking 12 73%


immobilization 26 Return to normal walking 12 85%

Table 138. 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%

v1.0 12.04.09 139

Table 139. Operative Treatment - Percent of patients able to return to work


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%

v1.0 12.04.09 140




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%

v1.0 12.04.09 141

Table 140. Non-Operative Treatment - Mean time until return to work 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) ‡


Table 141. 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) ‡

v1.0 12.04.09 142

Table 142. Operative Treatment - Mean time to return to ADL 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)


v1.0 12.04.09 143

Table 143. 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)


v1.0 12.04.09 144


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



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


v1.0 12.04.09 145

Author Title Reason for Exclusion

Jessing P;Hansen E; Surgical treatment of 102 tendo

achillis ruptures-- suture or tenontoplasty?


Keller J;Rasmussen TB; Closed treatment of Achilles tendon rupture





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

v1.0 12.04.09 146

STUDY QUALITY Table 145. Patient return to activities of daily living

●= yes ○= no x= not reported

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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


v1.0 12.04.09 147


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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 ● ● ● ● ●

v1.0 12.04.09 148


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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

v1.0 12.04.09 149

RECOMMENDATION 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. AAOS Strength of Recommendation: Limited

Description: Evidence from two or more “Low” strength studies with consistent findings, or evidence from a single “Moderate” quality study recommending for or against the intervention or diagnostic. A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another. Implications: Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

Rationale:

A systematic review identified 23 level IV studies providing data on return to sports after operative treatment. Two studies54, 51 reported return to jogging at three months. One study 47 reported return to sport at four months. Five studies55, 32,54, 51,56 reported that 83%-100% of patient returned to sports at six months. Ten studies19,57, 58, 53, 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, 50,39, 59,54,51,47,32,57, 58,38,25, 60,53,28,30,34, 55, 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 146 through Table 148 ). We attempted meta-analysis for the following patient groups and outcomes: percent operative patients able to return to activity at ≥ 12 months (I2>80%) (see Table 146 ) percent of operative patients able to return to sports at 6 and at 12 months (I2>90%) (see Table 147), and mean time for operative patients to return to sports (I2>95%) (see Table 148). 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.

v1.0 12.04.09 150

SUMMARY OF EVIDENCE Table 146. 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%

Table 147. 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%

v1.0 12.04.09 151


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%

v1.0 12.04.09 152

Table 148. 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)



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




v1.0 12.04.09 153


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

v1.0 12.04.09 154

STUDY QUALITY Table 150. Return to sports


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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 ● ● ● ● ●

v1.0 12.04.09 155


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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 ● ● ● ● ●


v1.0 12.04.09 156


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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 ● ● ● ● ●



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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 ● ● ● ● ●

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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 ● ● ● ●

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RECOMMENDATION 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. AAOS 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 151 and Table 152). 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 151. 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 %

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Table 152. 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) ‡

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EXCLUDED ARTICLES Table 153. 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



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Metz, et al. 2008 Re-rupture 33 IV ● ● ● ● ●

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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 ● ● ● ●

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









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FUTURE RESEARCH 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 limited 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.

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IV. APPENDIXES

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APPENDIX I WORK GROUP Christopher P Chiodo MD, Chair Brigham Orthopedic Associates 75 Francis Street Boston MA 02115 Mark Glazebrook MD, Vice-Chair Queen Elizabeth Health Sciences Center Halifax Infirmary Suite 4867 1796 Summer Street Halifax NS B3H 3A7 Canada Eric Michael Bluman MD PhD Madigan Army Medical Center ATTN: MCHJ-SOP (Ortho Clinic) 9040 A Reid Street Tacoma WA 98431-1100 Bruce E Cohen MD 1783 Sterling Road Charlotte NC 28209 John E Femino MD Department of Orthopedics University of Iowa Hospital and Clinics JPP 01022 200 Hawkins Drive Iowa City IA 52242 Eric Giza MD UC Davis Dept of Orthopaedics Ambulatory Care Services Bldg 4860 Y St #3800 Sacramento, CA 95817

Guidelines and Technology Oversight Chair: William C. Watters, III, MD 6624 Fannin #2600 Houston, TX 77030 Guidelines and Technology Oversight Vice-Chair: Michael J. Goldberg, MD Department of Orthopaedics Seattle Children’s Hospital 4800 Sand Point Way NE Seattle, WA 98105 Evidence Based Practice Committee Chair: Michael Keith, MD 2500 Metro Health Drive Cleveland, OH 44109-1900 AAOS Staff: Robert H. Haralson III, MD, MBA AAOS Medical Director 6300 N River Road Rosemont, IL 60018 Charles M. Turkelson, PhD Director of Research and Scientific Affairs Janet L. Wies MPH AAOS Clinical Practice Guideline Mgr AAOS Research Analysts Laura Raymond MA - Lead Analyst Sara Anderson MPH Kevin Boyer BS Patrick Sluka MPH

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APPENDIX II TIME FROM RUPTURE TO TREATMENT Table 155. Time from injury to treatment Author Time from Injury to treatment


0-3 days, 45 patients 4-7 days, 14 patients 8-14 days, 7 patients 14-28 days, 10 patients

Moller, et al 2001

Attended hospital within 3 days Non-op group treated immediately Surgery performed within 2 days in 95% of cases

Metz, et al. 2008 Within 3 days of rupture

Cetti, et al 1993 Mean 0.6 days (range 0-7 days)

Twaddle, et al 2007

Presented within 10 days of injury Operated within 48 hours

Ingvar, et al. 2005

1 day after injury, 25 patients 2-7 days after injury, 10 patients 8-31 days after injury, 11 patients

Saleh, et al. 1992 Presented within 48 hours of injury

Neumayer, et al. 2009 Less than ten days

Wallace, et al. 2004 Mean 22 hours (range 1 hour, 17.5 days)

Bhattacharyya, et al 2008

7 days

Uchiyama, et al. 2007 Acute not defined

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Author Time from Injury to treatment

Lim, et al. 2001 Presented less than 7 days

Coutts, et al. 2002

Time to presentation: 24 hours, 13 patients 1-14 days, 7 patients 4-18 weeks, 5 patients Operated on within an average of 3 days (range 24 hours -10 days) from presentation

Aktas, et al 2007 1.5 days (range 2-56 hours)


Ng et al. 2006 within 7 days (85% treated within one day)

Chellemi, et al. 2002 Within 4 days

Gigante, et al. 2007 Acute not defined

Kakiuchi, et al 1995 Range 1-9 days

Giannini, et al 1994 6 days

Taglialavoro, et al 2004 Not Reported

Suchak, et al. 2008 Within 2 weeks of injury

Maffulli, et al. 2003 (a) 0-7 days

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Maffulli, et al. 2003 (b) 0-7 days

Costa, et al. 2005 0-7 days

Mortensen, et al. 1999 0-48 hours to presentation

Cetti, et al 1993 7-112 hours

Kangas, et al 2002 0-7 days

Scarfi, et al 2002 2 days (range 1-5 days)

Hogsaa, et al 1990

Less than 3 days, 96% of patients More than 3 days, 4% of patients

Doral, et al 2009 0-10 days

Troop, et al 1995 0-2 weeks

Kuskucu, et al 2005 Average 4 days (range, 3-8 days)

Solveborn, et al. 1994 Average 1.8 days (range, 0-5 days)

Lansdaal, et al. 2007 0-2 weeks

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Garbito, et al. 2004 Within 24 hours of injury

Gorschewsky, et al 2004

Average within 24 hours

Hufner, et al. 2006 Within one week

Tang, et al 2007 6 hours- 18 days

Jung, et al 2008

Mean 5.4 days ( range 1-23 days) 87% of patients were operated in less than 2 weeks

Wagnon, et al 2005 Less than 2 weeks to presentation


Margetic, et al 2007 Not Reported

McComis, et al. 1997 Not Reported

Fortis, et al. 2008 Not Reported

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APPENDIX III 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.

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DOCUMENTATION OF APPROVAL

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 December 2, 2009

AAOS Evidence Based Practice Committee December 2, 2009

AAOS Council on Research, Quality Assessment, December 2, 2009 and Technology

AAOS Board of Directors December 4, 2009

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APPENDIX IV LITERATURE SEARCHES FOR PRIMARY STUDIES The literature searches were performed using the following databases. The full search strategies are listed below:

• 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

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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

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APPENDIX V STUDY ATTRITION FLOWCHART

4247 citations identified by literature search

2481 abstracts screened for inclusion

1766 citations excluded

281 articles recalled for full text review

2200 abstracts excluded

235 articles excluded

46 articles included

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APPENDIX VI DATA EXTRACTION ELEMENTS The data elements below were extracted into electronic forms in Microsoft® Access and Microsoft® Excel. The extracted information includes: Study Characteristics (for all relevant outcomes in a study)

• 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

Patient Characteristics (for all treatment groups in a study)

• patient inclusion/exclusion criteria • co-interventions (if used) and co-morbidities (if present) • measures of disease severity • Complications

Results (for all relevant outcomes in a study)

• 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

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APPENDIX VII 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?

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JUDGING THE QUALITY OF TREATMENT STUDIES 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?

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?

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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?

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?

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APPENDIX VIII 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?


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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.

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APPENDIX IX 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:

Work group Size Number of Permissible

Dissenters

≤ 3 Not allowed, statistical significance cannot be

obtained

4-5 0

6-8 1

9 1 or 2

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.

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APPENDIX X 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. Reviewer Information: Name of Reviewer_________________________________________ Address_________________________________________________ City___________________ State_________________ Zip Code___________ Phone _____________________Fax ________________________ E-mail_______________________ Specialty Area/Discipline: _______________________________________ Work setting: _________________________________________________ Credentials: _________________________________________________ May we list you as a Peer Reviewer in the final Guidelines? Yes No Are you reviewing this guideline as Yes No a representative of a professional society? 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

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mailto:[email protected]

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COMMENTS 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.

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APPENDIX XI 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 explicitly consented to be listed as a peer review organization in this appendix. The organizations that reviewed the document and gave written consent to publication are listed below:

American Academy of Family Practitioners American Academy of Physical Medicine and Rehabilitation American College of Foot and Ankle Surgeons American Orthopaedic Foot and Ankle Society American Orthopaedic Society for Sports Medicine American Physical Therapy Association American Podiatric Medical Association Individuals who participated in the peer review of this document and gave their explicit written 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

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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 commentary, these changes are also documented and forwarded to the AAOS bodies that approve the final guideline. The organizations that reviewed the document and consented to publication are listed below:

German Society for Foot and Ankle Surgery (GFFC) Public commentators who gave explicit written consent to be listed in this document include the following: Laura Gehrig, MD Kurt F. Konkel, MD John McGraw COL, USAR, MC David Thordarson, MD Mathew Walther, MD Kristy Weber, MD For this guideline, outside specialty societies could post the confidential draft of the guideline to their “member only” website. The only society that submitted a compiled response as a result of this posting was the American Orthopaedic Foot and Ankle Society. Responses garnered from this posting were compiled by the specialty society and submitted as one succinct public commentary by a member of the AOFAS evidence-based medicine committee. Please contact the AOFAS for these member names since we do not have explicit written consent to publish the names of these members.

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.

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APPENDIX XII DESCRIPTION OF SYMBOLS USED IN TABLES Symbol Description

OR 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.

95% CI 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.

○ An open circle in a Summary of Evidence Table indicates that the result is not statistically significant.

● op 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)

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APPENDIX XIII CONFLICT OF INTEREST

Eric Michael Bluman, MD (Tacoma, WA): 4 (DePuy, A Johnson & Johnson Company). Submitted on: 08/23/2008 and last confirmed as accurate on 10/09/2008.

Christopher P Chiodo, MD (Boston, MA): 1 (American Orthopaedic Foot and Ankle Society; Mass Ortho Association); 2 (Foot and Ankle International); 3 (Aircast(DJ); Arthrex, Inc); 4 (DePuy, A Johnson & Johnson Company); 5A (Smith & Nephew; Zimmer); 7 (DJ Orthopaedics; EBI; Carticept); 8 (Johnson & Johnson; Zimmer). Submitted on: 10/24/2008.

Bruce E Cohen, MD (Charlotte, NC): 2 (Foot and Ankle International; Techniques in Foot and Ankle Surgery); 3 (DJ Orthopaedics; Wright Medical Technology, Inc); 4 (Arthrex, Inc); 5A (Wright Medical Technology, Inc.; Smith & Nephew); 7 (DJ Orthopaedics; Wright Medical Technology, Inc.); 9 (Lippincott). Submitted on: 05/18/2008.

John E Femino, MD (Iowa City, IA): (n). Submitted on: 10/30/2008.

Eric Giza, MD (Sacramento, CA): 5A (Arthrex, Inc). Submitted on: 02/13/2008.

Mark Glazebrook, MD (Halifax,NS Canada): 2 (Foot and Ankle International); 5A (DePuy, A Johnson & Johnson Company; Linvatec); 7 (Arthrex, Inc; Biomimetic; DePuy, A Johnson & Johnson Company); 8 (Smith & Nephew; Stryker; Wright Medical Technology, Inc.). Submitted on: 11/04/2008.

William Charles Watters III, MD: 1 (North American Spine Society; Work Loss Data Institute); 2 (The Spine Journal); 5A (Stryker; Intrinsic Therapeutics; MeKessen Health Care Solutions). Submitted on: 10/09/2007 at 08:09 PM and last confirmed as accurate on 04/23/2008.

Disclosure Items: (n) = Respondent answered 'No' to all items indicating no conflicts. 1=Board member/owner/officer/committee appointments; 2= Medical/Orthopaedic Publications; 3= Royalties; 4= Speakers bureau/paid presentations;5A= Paid consultant; 5B= Unpaid consultant; 6= Research or institutional support from a publisher; 7= Research or institutional support from a company or supplier; 8= Stock or Stock Options; 9= Other financial/material support from a publisher; 10= Other financial/material support from a company or supplier.

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APPENDIX XIV REFERENCES

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the diagnosis and treatment of acute achilles tendon rupture

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