Diagnosis and Treatment of Acute Achilles Tendon Rupture : JAAOS - Journal of the American Academy of Orthopaedic Surgeons

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AAOS Clinical Practice Guideline Summary

Diagnosis and Treatment of Acute Achilles Tendon Rupture

Chiodo, Christopher P. MD; Glazebrook, Mark MD; Bluman, Eric Michael MD, PhD; Cohen, Bruce E. MD; Femino, John E. MD; Giza, Eric MD; Watters, William C. III MD; Goldberg, Michael J. MD; Keith, Michael MD; Haralson, Robert H. III MD, MBA; Turkelson, Charles M. PhD; Wies, Janet L. MPH; Raymond, Laura MA; Anderson, Sara MPH; Boyer, Kevin; Sluka, Patrick MPH

Author Information
American Academy of Orthopaedic Surgeon 18(8):p 503-510, August 2010.
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Abstract

Overview and Rationale

This clinical practice guideline was approved by the American Academy of Orthopaedic Surgeons (AAOS) on December 4, 2009. It is based on a systematic review of published studies on the diagnosis and treatment of Achilles tendon rupture in adults.

The guideline provides practice recommendations and highlights gaps in the literature and areas that require future research. The purpose of this clinical practice guideline is to help improve treatment based on the current best evidence. Current evidence-based practice standards demand that physicians use the best available evidence in their clinical decisionmaking. To assist in this, this clinical practice guideline consists of a series of systematic reviews of the available literature regarding the diagnosis and treatment of Achilles tendon ruptures. These systematic reviews were conducted between January 1966 and June 2009; they show where good evidence exists, where evidence is lacking, and which topics future research must target to improve the treatment of patients with rupture of the Achilles tendon. AAOS staff and the Diagnosis and Treatment of Acute Achilles Tendon Rupture Guideline and Evidence Report 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 that are 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.

Potential Harms and Contraindications

Most treatments are associated with some known risks, especially invasive and surgical treatments. In addition, contraindications vary widely based on the treatment administered. Therefore, discussion of available treatments and procedures applicable to the individual patient rely on mutual communication between the patient and physician.

Methods

The methods used to develop this clinical practice guideline were designed to combat bias, enhance transparency, and promote reproducibility. Their purpose is to allow interested readers the ability to inspect all of the information the work group used to reach all of its decisions and to verify that these decisions are in accord with the best available evidence. The draft was subject to peer review and public commentary. It was approved by the AAOS Evidence-Based Practice Committee; Guidelines and Technology Oversight Committee; Council on Research, Quality Assessment, and Technology; and the Board of Directors. The methods used to prepare this guideline are detailed in the full clinical practice guideline, available at http://www.aaos.org/research/guidelines/atrguideline.pdf.

Recommendations

Each guideline recommendation was constructed using the following language, taking into account the recommendation grade and level of evidence:

We recommend: Recommendation grade, Strong. Level of evidence: Level I evidence from more than one study with consistent findings for recommending for or against the intervention or diagnostic.

We suggest: Recommendation grade, Moderate. Level of evidence: Level II or III evidence from more than one study with consistent findings, or Level I evidence from a single study for recommending for or against the intervention or diagnostic.

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

We are unable to recommend for or against: Recommendation grade, Inconclusive. Level of evidence: There is insufficient or conflicting evidence not allowing a recommendation for or against intervention.

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

Recommendation 1

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

• Clinical Thompson test (ie, Simmonds squeeze test)

• Decreased ankle plantar flexion strength

• Presence of a palpable gap (defect, loss of contour)

• Increased passive ankle dorsiflexion with gentle manipulation

This recommendation is graded Consensus. It is addressed by one level V study.1 The study authors used visual inspection at surgery as the benchmark for the diagnosis in patients who had undergone open repair. The study authors also used clinical examination, ultrasonography and MRI as the reference standard for diagnosis when deciphering whether patients had an Achilles tendon tear and to confirm the extent of the tear in patients treated nonsurgically. Health care providers were not routinely blinded to the results of any given test. All patients received a physical examination. Palpation (to establish the presence of a gap) and the calf squeeze test (ie, Thompson/Simmonds squeeze test) were performed by the authors in all patients. The authors performed the Matles test (ie, increased passive ankle dorsiflexion) on 107 of 174 patients.

The authors 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 authors reported these test results individually. They did not consider whether incremental value exists for any combination of the given physical tests when the tests are all performed during the physical examination.

Recommendation 2

We are unable to recommend for or against the routine use of MRI, ultrasonography, and radiography to confirm the diagnosis of acute Achilles tendon rupture.

This recommendation is graded Inconclusive.

No studies addressed MRI or radiography as confirmatory tests, and only two level V prospective studies1,2 addressed ultrasonography. These two studies contain unreliable data and cannot be combined to provide adequate evidence. The studies enrolled patients with complete Achilles tendon tear1,2 and used visual inspection at surgery as the benchmark for the diagnosis. In one study, patients underwent the Thompson test, followed by surgery.1 In the second study, patients underwent the Thompson test and ultrasonography, followed by surgery.2 The authors of the studies reported sensitivities and specificities or provided enough information for these parameters to be determined.

Recommendation 3

Nonsurgical treatment is an option for patients with acute Achilles tendon rupture.

This recommendation is graded Weak.

It is addressed by four level II studies, including all surgical techniques.3–6 To address this recommendation, we analyzed studies that made two different comparisons. Three level II studies compared patients treated nonsurgically (with casting) with patients treated with open repair.3–5 One level II study compared casting with minimally invasive open repair.6

Two studies examined functional outcomes, and both found nonsignificant results.3,4 Based on AAOS calculations, the study by Twaddle and Poon3 did have significant results at 2, 3, and 6 months, measured by the Musculoskeletal Function Assessment instrument, in which patients with surgical treatment had better functional ability than did those treated nonsurgically. Our results differ from those of the authors because a higher powered statistical test was used. Two studies reported no significant difference in the number of patients with pain.5,6

Three studies reported that patients treated nonsurgically did not significantly differ in the amount of time to return to work.4–6 Three studies examined return to sports;4–6 the study by Cetti et al4 reported significant results in favor of patients treated with surgical repair. The study by Möller et al5 reported significantly fewer reruptures in patients treated surgically. The occurrence of extreme residual tendon lengthening, deep vein thrombosis (DVT), and “major” complications were not significantly different between patients treated surgically and those treated nonsurgically. Minor complications reported in the included studies were related to the surgical intervention and therefore occurred less in patients treated nonsurgically.

Recommendation 4

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

This recommendation is graded Inconclusive.

It is addressed by one level II and one level IV study for rerupture rates and by two level IV studies and one level V study for functional outcome. We analyzed one level II and one level IV study that compared patients treated with cast plus a functional brace versus patients treated with a cast only.7,8 In both comparative studies, rerupture rates did not significantly differ between patients treated with cast plus orthosis versus cast.

In the three studies that reported results for patients treated with functional bracing, 78% 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 to 9 years.9–11 The average time to return to work was 7 days (range, 21 to 52 days). One study reported that 2% of patients had a pulmonary embolism;9 another study reported that 1% of patients had DVT and “temporary dropfoot.”11

Recommendation 5

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

This recommendation is graded Weak.

It is addressed by a systematic review of the literature, including eight studies that addressed the efficacy of open repair4,5,12–17 and six studies that addressed the efficacy of minimally invasive techniques.6,12,14,16,18,19 All are level IV studies. The 14 studies demonstrate a wide variety of patient-oriented outcome measures and duration to follow-up to evaluate patients receiving surgical treatment of Achilles tendon rupture. The inconsistency of these outcome measures makes comparisons between studies difficult. Because the body of evidence is weak, it does not allow for additional statistical analysis.

Recommendation 6

In the absence of reliable evidence, it is the opinion of the work group that, although surgical treatment is an option, it should be approached more cautiously in patients with diabetes or neuropathy, those in immunocompromised states or aged >65 years, those who use tobacco or have a sedentary lifestyle, those who are obese (body mass index >30), and those with peripheral vascular disease, or local/systemic dermatologic disorders.

This recommendation is graded Consensus.

We were unable to find any published studies that addressed the effects of co-morbid conditions on the success of surgical 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 nonsurgical treatment should occur before performing surgical repair of Achilles tendon ruptures in patients with conditions that may impair wound healing. These patients may be at increased risk for wound problems and infection, with subsequent detrimental effect on outcome.

Recommendation 7

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

This recommendation is graded Inconclusive.

We were unable to find any published studies that addressed the effects of presurgical immobilization or restricted weight bearing on the success of surgical repair of acute rupture of this tendon.

Recommendation 8

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

This recommendation is graded Weak.

It is addressed by three level II comparative trials investigating percutaneous repair14,18,20 and by one level II and two level III comparative trials studying limited open repairs.12,16,21

We defined the following surgical repairs:

• Open: a procedure using an extended incision for exposure, allowing visualization of the rupture and tendon to allow direct placement of sutures for the repair.

• Limited open: a procedure using a small incision for exposure, allowing direct visualization of the ruptured ends.

• Percutaneous: a procedure without direct exposure of the tendon rupture site.

Percutaneous Versus Open Repair

Two level II studies compared percutaneous repair to open repair.14,18 Patients treated with percutaneous repair scored significantly higher on the Medical Outcomes Study 12-Item Short Form physical and mental component scores.20 There was no significant difference in the number of patients who returned to functional activities, in activities of daily living,14,18 or in patient satisfaction.14 The amount of reruptures did not significantly differ between treatment groups.14,18

Two studies14,18 reported on complications. There was no significant difference in the number of sural nerve injuries, superficial infections with staphylococcus, hypertonic scars, or keloid formations. Patients treated with percutaneous repair had significantly less wound breakdown/delay of healing as well as fewer scar adhesions. No significant difference in the amount of deep infections was reported. Lim et al14 reported a statistically significant difference in superficial infection, whereas Ng et al18 did not report a difference. However, Lim et al,14 who did report more superficial infections in the open repair group, did not administer intravenous antibiotics. Wound puckering occurred significantly more in patients treated with percutaneous repair.14

Limited Open Versus Open Repair

Patients treated with limited open repair did not have less pain or score higher on the American Orthopaedic Foot and Ankle Society scale than did patients treated with open repair.16 Patients treated with limited open repair returned to normal walking,12 stair climbing,12 and sports21 in significantly less time than did patients treated with standard open repair. A significantly larger percentage of patients treated with limited open repair had fewer symptoms compared with patients treated with open repair.21

There was no significant difference in the number of reruptures between treatment groups.21 There was no statistically significant difference in DVT, large hematoma, stiffness of ankle, insertional tendinopathy, or deep infection between the open and limited repair groups.16 However, patients treated with limited open repair had significantly fewer severe wound infections,12 superficial infections,16 and minor surgical site infections12 than did patients treated with open repair.

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 surgically.

This recommendation is graded Inconclusive.

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 surgically. No studies addressed adjunctive augmentation with allograft, xenograft, or biologic adjuncts. Three level II studies compared open repair alone and autograft augmentation.17,22,23 One level IV study compared patients treated with synthetic tissue augmentation to open repair alone.24 All four of these studies failed to demonstrate significant improvement in outcomes or complications.

Recommendation 10

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

This recommendation is graded Inconclusive.

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

Recommendation 11

We suggest early (≥2 weeks) postoperative protected weight bearing (including limiting dorsiflexion) for patients with acute Achilles tendon rupture who have been treated surgically.

This recommendation is graded Moderate.

A systematic review identified four level II studies that compared early postoperative weight bearing with non-weight bearing following surgical repair of the Achilles tendon.25–28 All studies compared patients with either 6 weeks of non-weight bearing in a cast to early weight bearing. Two studies permitted immediate weight bearing starting the day of surgery in a cast,25,28 defined as toetouch weight bearing in one study.25 The third study allowed the weight-bearing group to begin immediate rehabilitation on the first postoperative day in a modified splint.26 The patients in the fourth study began weight bearing 2 weeks after surgery.27 By 2 weeks, three groups of investigators used a splint device that limited dorsiflexion to prevent compromise of the repair.25–27 After 4 weeks, Maffulli and colleagues25,28 allowed the non-weight-bearing group to begin full weight bearing in a cast, whereas the authors of the other two studies kept the non-weight-bearing group on crutches for 6 weeks.26,27

One study found a significantly higher rerupture rate in the early postoperative weight-bearing group (2 of 23 patients) compared with the non-weight-bearing group (0 of 25 patients).26 Both patients had documented noncompliance with the use of their postoperative splint, and both fell during the first 4 weeks after surgery.

Three studies found that the weight-bearing group had statistical improvement in the time to return to activities, including work, sports, and normal walking.25,26,28 Suchak et al27 reported significantly better scores in physical functioning and reported fewer limitations of daily living 6 weeks after the operation. By 12 months, all four studies found no significant difference between the two groups in outcomes such as pain and function.

Although the ultimate level of function achieved after surgical repair of an Achilles rupture is similar regardless of the postoperative weight-bearing protocol, early postoperative weight bearing allows a quicker return to activities during the first 6 months compared with traditional postoperative casting. Treatment decisions should be made in light of all circumstances presented by the patient. Mutual communication between patient and physician should include a discussion of the importance of patient compliance when a program is prescribed for the use of early weight bearing. Patient compliance to protocol is important to prevent rerupture.

Recommendation 12

We suggest the use of a protective device that allows mobilization by 2 to 4 weeks postoperatively.

This recommendation is graded Moderate.

It is addressed by five level II studies.25,26,29–31 All five studies randomized the patients into two groups, with either 6 weeks in a cast or early motion with a modified splint device. In all studies, patients in the mobilization group had a splint or modified cast device that limited dorsiflexion to protect the repair.

All five studies found that the weight-bearing group had statistical improvement in the mean time to return to activities such as work and normal walking.25,26,29–31 One of three studies found a significantly higher rate in return to sport activities at 12 months,30 while two found no difference.25,26 One study found a significantly higher rerupture rate in the postoperative mobilization group (2 of 23 patients) compared with the immobilization group (0 of 25 patients).26 Both patients had documented noncompliance with the use of their postoperative splint and fell during the first 4 weeks after surgery. By 12 to 18 months, all five studies reported no significant difference between the two groups in outcomes such as pain and function.25,26,29–31

Recommendation 13

We are unable to recommend for or against postoperative physiotherapy for patients with acute Achilles tendon rupture.

This recommendation is graded Inconclusive.

A systematic review did not identify any studies that met the inclusion criteria. We searched for any studies that addressed postoperative physical therapy, including supervised and unsupervised physical therapy. The studies we identified did not specifically address whether physical therapy was effective. Therefore, it is not possible to draw evidence-based conclusions for this recommendation.

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.

This recommendation is graded Inconclusive.

It is addressed by 18 level IV studies7,11,12,17–27,32–35 that reported on return to low-impact activities. Our meta-analysis suggested that the results of these studies were very different from each other, as demonstrated by the high heterogeneity; thus, it is difficult to draw any conclusions about the time to return to recreational or athletic activity. This was confirmed by examining the individual results.

Recommendation 15

In patients who participate in sports it is an option to return them to sports within 3 to 6 months after surgical treatment of acute Achilles tendon rupture.

This recommendation is graded Weak.

It is addressed by 23 level IV studies that provided data on return to sports after surgical treatment.2,4,7,9–11,18,21,22,24–37 Two studies reported return to jogging at 3 months.22,28 One study reported return to sport at 4 months.18 Five studies reported that 83% to 100% of patient returned to sports at 6 months.2,22,27–29 Eleven studies reported that 32% to 100% of patients returned to sports at 12 months or more.7,11,24–30,32,33

Recommendation 16

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

This recommendation is graded Inconclusive.

A systematic review identified five level IV studies that provided data on return to sports after nonsurgical treatment.11,26,32–34 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 nonsurgical treatment. These studies did not provide adequate evidence to permit a recommendation be made for the specific time patients can return to athletic activity following nonsurgical treatment of Achilles tendon rupture.

Future Research

Although the current guideline is instructive in many ways, it also demonstrates a substantial need for future research. Wherever the strength of a specific Recommendation is weak or inconclusive, a need exists for well-designed studies and high-level evidence.

As such, the most obvious need is for further, high-level investigations into the fundamental question whether surgical management is superior to nonsurgical management of acute Achilles ruptures. Hundreds of studies are centered on this question, but too few are high-level randomized control trials.

Beyond this, several other areas of needed research exist. Does the clinician routinely need MRI or ultrasonography for the diagnosis of an Achilles rupture? Probably not. However, no high-level studies exist to help answer this question. For nonsurgical treatment, low-level evidence supports the use of immediate functional bracing, but again, further randomized trials are necessary. Postoperatively, 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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