Surgical interventions for treating acute Achilles tendon ruptures

 

Abstract

Background

There is a lack of consensus on the best management of the acute Achilles tendon rupture. Treatment can be broadly classified into surgical (open or percutaneous) and non-surgical (cast immobilisation or functional bracing).

Objectives

To evaluate the relative effects of surgical versus non-surgical treatment, or different surgical interventions, for acute Achilles tendon ruptures in adults.

Search strategy

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 3), MEDLINE (1966 to 20th July 2009), EMBASE (1966 to 2009 week 29), CINAHL (1983 to July 2007) and reference lists of articles.

Selection criteria

All randomised and quasi-randomised trials comparing surgical versus non-surgical treatment or different surgical methods for acute Achilles tendon ruptures in adults.

Data collection and analysis

Two review authors independently selected potentially eligible trials; trials were then assessed for quality using a 10-item scale. Where possible, data were pooled.

Main results

Twelve trials involving 844 participants were included. One trial tested two comparisons.

Quality assessment revealed a poor level of methodological rigour in many studies, particularly with regard to concealment of allocation and the lack of assessor blinding.

Open surgical treatment compared with non-surgical treatment (6 trials, 536 participants) was associated with a statistically significant lower risk of rerupture (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.21 to 0.77), but a higher risk of other complications including infection (RR 4.89, 95% CI 1.09 to 21.91), adhesions and disturbed skin sensibility (numbness). Functional status including sporting activity was variably and often incompletely reported, including frequent use of non standardised outcome measures, and the results were inconclusive.

Open surgical repair compared with percutaneous repair (4 trials, 174 participants) was associated with a higher risk of infection (RR 9.32, 95% CI 1.77 to 49.16). These figures should be interpreted with caution because of the small numbers involved. Similarly, no definitive conclusions could be made regarding different tendon repair techniques (3 trials, 147 participants).

Authors' conclusions

Open surgical treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with non-surgical treatment, but produces significantly higher risks of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously.

 

Plain language summary

Surgical interventions for treating acute Achilles tendon ruptures

Rupture of the Achilles tendon is common and said to be increasing. It typically occurs in males in their 30s and 40s who play sport intermittently. People present with severe pain in the tendon, at the back of the ankle. Signs include a palpable gap at the rupture site, and marked weakness of ankle plantar-flexion (movement so toes point downwards). Options for management include non-surgical interventions (plaster of Paris, bracing or splinting) or surgical repair of the tendon. Following either method of treatment, the ankle may be immobilised for up to 12 weeks (in a cast, allowing no movement at the ankle and variable weight-bearing), or mobilised early (in a brace, allowing movement at the ankle and partial to full weight-bearing).

Twelve trials including 794 participants acute Achilles tendon rupture were included. The majority of participants were male, and the average ages of the study populations were between 36 to 41 years. Many of the trials had flawed methods that undermined the reliability of their results.

Open surgical treatment compared with non-surgical treatment (6 studies, 502 participants) was associated with a lower risk of rerupture, but a higher risk of other complications such as infection, adhesions and disturbed skin sensibility (numbness and tingling). There were insufficient and inconclusive data on function and sporting activities.

Percutaneous repair (involving stab incisions through which the repair suture is passed through without direct exposure of the tendon) compared with open repair (4 studies, 174 participants) was associated with a lower risk of infection. These figures should be interpreted with caution because of the small numbers involved. Similarly, no definitive conclusions could be made regarding different tendon repair techniques (3 studies, 141 participants).

 

Resumen

Antecedentes

Intervenciones quirúrgicas para el tratamiento de la rotura aguda del tendón de Aquiles

Existe una falta de consenso sobre el mejor tratamiento para la rotura aguda del tendón de Aquiles. El tratamiento puede clasificarse en términos generales en quirúrgico (abierto o percutáneo) y no quirúrgico (inmovilización con yeso o aplicación de una abrazadera funcional).

Objetivos

Evaluar los efectos relativos del tratamiento quirúrgico versus no quirúrgico, o las diferentes intervenciones quirúrgicas, para las roturas agudas del tendón de Aquiles en adultos.

Estrategia de búsqueda

Se hicieron búsquedas en el Registro Especializado de Ensayos Controlados del Grupo Cochrane de Lesiones Óseas, Articulares y Musculares (Cochrane Bone, Joint and Muscle Trauma Group) (julio 2009), Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) (Cochrane Library 2009, número 3), MEDLINE (1966 hasta el 20 julio 2009), EMBASE (1966 hasta 2009, semana 29), CINAHL (1983 hasta julio 2007) y en listas de referencias de artículos.

Criterios de selección

Todos los ensayos con asignación al azar y cuasialeatorios que comparan el tratamiento quirúrgico versus no quirúrgico o los diferentes métodos quirúrgicos para las roturas agudas del tendón de Aquiles en adultos.

Obtención y análisis de los datos

Dos autores de la revisión, de forma independiente, seleccionaron ensayos potencialmente elegibles; luego se evaluaron los ensayos en cuanto a la calidad mediante una escala de diez ítems. Cuando fue posible, se agruparon los datos.

Resultados principales

Se incluyeron 12 ensayos que incluyeron 844 participantes. Un ensayo evaluó dos comparaciones.

La evaluación de la calidad reveló un nivel deficiente del rigor metodológico en muchos estudios, en particular con respecto a la ocultación de la asignación y la ausencia de cegamiento del evaluador.

El tratamiento con cirugía abierta en comparación con el tratamiento no quirúrgico (6 ensayos, 536 participantes) se asoció con un riesgo menor estadísticamente significativo de nueva rotura (cociente de riesgos [CR] 0,41; intervalo de confianza [IC] del 95%: 0,21 a 0,77), aunque con un riesgo mayor de otras complicaciones incluida la infección (CR 4,89; IC del 95%: 1,09 a 21,91), las adherencias y la alteración de la sensibilidad de la piel (adormecimiento). El estado funcional incluida la actividad deportiva fue informado de forma variable y a menudo de un modo incompleto, incluido el uso frecuente de medidas de resultado no estandarizadas, y los resultados no fueron concluyentes.

La reparación con cirugía abierta comparada con la reparación percutánea (4 ensayos, 174 participantes) se asoció con un riesgo mayor de infección (CR 9,32; IC del 95%: 1,77 a 49,16). Estas cifras deben interpretarse con cautela debido al escaso número incluido. De igual manera, no pudieron establecerse conclusiones definitivas con respecto a las diferentes técnicas de reparación del tendón (3 ensayos, 147 participantes).

Conclusiones de los autores

El tratamiento con cirugía abierta de las roturas agudas del tendón de Aquiles reduce significativamente el riesgo de la nueva rotura en comparación con el tratamiento no quirúrgico, pero produce riesgos significativamente mayores de otras complicaciones, incluida la infección de la herida. Lo último citado puede reducirse al realizar la cirugía por vía percutánea.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano