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2. medicine
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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 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
o
o
o
Clinical Thompson test (Simmonds squeeze test)
Decreased ankle plantar flexion strength
Presence of a palpable gap (defect, loss of contour)
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.
iii
2. We are unable to recommend for or against the routine use of magnetic resonance
imaging (MRI), ultrasound (ultrasonography), and radiograph (roentgengrams, xrays) 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
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.
iv
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
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.
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
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.
v
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
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.
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
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.
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
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.
vi
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
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.
vii
14. In all patients with acute Achilles tendon rupture, irrespective of treatment type,
we are unable to recommend a specific time at which patients can return to
activities of daily living.
Strength of Recommendation: Inconclusive
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.
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
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.
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.
viii
* 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.
ix
Work Group
Christopher P Chiodo MD, Chair
Brigham Orthopedic Associates
75 Francis Street
Boston MA 02115
Guidelines and Technology Oversight
Chair:
William C. Watters, III, MD
6624 Fannin #2600
Houston, TX 77030
Mark Glazebrook MD, Vice-Chair
Queen Elizabeth Health Sciences Center
Halifax Infirmary Suite 4867
1796 Summer Street
Halifax NS B3H 3A7 Canada
Guidelines and Technology Oversight ViceChair:
Michael J. Goldberg, MD
Department of Orthopaedics
Seattle Children’s Hospital
4800 Sand Point Way NE
Seattle, WA 98105
Eric Michael Bluman MD PhD
Madigan Army Medical Center
ATTN: MCHJ-SOP (Ortho Clinic)
9040 A Reid Street
Tacoma WA 98431-1100
Evidence Based Practice Committee Chair:
Michael Keith, MD
2500 Metro Health Drive
Cleveland, OH 44109-1900
Bruce E Cohen MD
1783 Sterling Road
Charlotte NC 28209
AAOS Staff:
Robert H. Haralson III, MD, MBA
AAOS Medical Director
6300 N River Road
Rosemont, IL 60018
John E Femino MD
Department of Orthopedics
University of Iowa Hospital and Clinics
JPP 01022
200 Hawkins Drive
Iowa City IA 52242
Charles M. Turkelson, PhD
Director of Research and Scientific Affairs
Eric Giza MD
UC Davis Dept of Orthopaedics
Ambulatory Care Services Bldg
4860 Y St #3800
Sacramento, CA 95817
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
x
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
xi
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
xii
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 2 ......................................................................................................................................17
Summary of Evidence ...............................................................................................................................18
Excluded Articles......................................................................................................................................18
Study Quality ............................................................................................................................................19
Study Results ............................................................................................................................................20
Recommendation 3 ......................................................................................................................................21
Summary of Evidence ...............................................................................................................................22
Excluded Articles......................................................................................................................................26
Study Quality ............................................................................................................................................27
Study Results ............................................................................................................................................28
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
xiii
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
Recommendation 15 ..................................................................................................................................150
Summary of Evidence .............................................................................................................................151
Excluded Articles....................................................................................................................................153
Study Quality ..........................................................................................................................................155
Recommendation 16 ..................................................................................................................................160
Summary of Evidence .............................................................................................................................160
Excluded Articles....................................................................................................................................163
Study Quality ..........................................................................................................................................163
Future Research ........................................................................................................................................166
Appendix I ..................................................................................................................................................168
Work Group ............................................................................................................................................168
Appendix II ................................................................................................................................................169
xiv
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
xv
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
xvi
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
xvii
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
xviii
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
xix
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. casecontrol 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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Table 1 Strength of Recommendation Descriptions
Statement
Rating
Strong
Moderate
Limited
Inconclusive
Description of Evidence Strength
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.
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.
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 wellconducted studies show little clear advantage to one approach
versus another.
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.
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.
Implication for Practice
Practitioners should follow a Strong
recommendation unless a clear and compelling
rationale for an alternative approach is present.
Practitioners should generally follow a
Moderate recommendation but remain alert to
new information and be sensitive to patient
preferences.
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.
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.
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.
A Consensus recommendation means that expert opinion
supports the guideline recommendation even though there is
no available empirical evidence that meets the inclusion
criteria.
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.
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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
Strength of
Recommendation
Guideline Language
We recommend
Strong
We suggest
Moderate
Is an option
Limited
We are unable to recommend for or against
In the absence of reliable evidence, it is the
opinion of this work group
Inconclusive
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.
12
v1.0 12.04.09
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
13
v1.0 12.04.09
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
14
v1.0 12.04.09
Selection criteria described
Appropriate reference standard
Disease progression bias avoided
Partial verification bias avoided
Differential verification bias avoided
Incorporation bias avoided
Index test execution described
Reference standard execution
described
Test review bias avoided
Diagnostic review bias avoided
Clinical review bias avoided
Uninterruptable/Intermediate test
result(s) reported
Withdrawals explained
Index Test
Reference
Standard
Spectrum bias avoided
STUDY QUALITY
Table 4. Study Quality
Palpation
Open
Repair,Ultrasound
or MRI or
Clinical tests
X
○
●
●
●
○
●
●
●
●
○
●
●
●
Open Repair,
Ultrasound or
MRI or Clinical
tests
X
○
●
●
●
○
●
●
●
●
○
●
●
●
Open Repair,
Ultrasound or
MRI or Clinical
tests
X
○
●
●
●
○
●
●
●
●
○
●
●
○
● = Yes ○ = No X = Not Reported
n/a = not applicable
Author
N
Maffulli 161
Calf Squeeze
Test
Maffulli 161
(Thompson
test/Simmonds
squeeze test)
Matles Test
(increased
Maffulli 105
passive ankle
dorsiflexion)
15
v1.0 12.04.09
STUDY RESULTS
Table 5. Sensitivity and specificity of Palpation, Calf Squeeze and Matles tests
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)
Author
N
‡ AAOS Calculation
16
v1.0 12.04.09
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.
Supporting 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.
17
v1.0 12.04.09
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.
EXCLUDED ARTICLES
Table 6. Excluded Articles
Author
Title
Exclusion Reason
Fornage, 1986
Achilles tendon: US examination
Less than 10 patients
per group
Haims, et al.
2000
Hartgerink,
et al. 2001
Hollenberg, et
al. 2000
Kabbani, et al.
1993
Kalebo, et al.
1992
Kayser, et al.
2005
Kuwada, 2008
Lehtinen, et
al. 1994
Marshall, et
al. 2002
Mathieson, et
al. 1988
Paavola, et al.
1998
MR imaging of the Achilles tendon: overlap of
findings in symptomatic and asymptomatic
individuals
Full- versus partial-thickness Achilles tendon tears:
sonographic accuracy and characterization in 26
cases with surgical correlation
Sonographic appearance of nonoperatively treated
Achilles tendon ruptures
Magnetic resonance imaging of tendon pathology
about the foot and ankle. Part I. Achilles tendon
Diagnostic value of ultrasonography in partial
ruptures of the Achilles tendon
Partial rupture of the proximal Achilles tendon: a
differential diagnostic problem in ultrasound
imaging
Surgical correlation of preoperative MRI findings of
trauma to tendons and ligaments of the foot and
ankle
Sonography of Achilles tendon correlated to
operative findings
Contrast-enhanced magic-angle MR imaging of the
Achilles tendon
Sonography of the Achilles tendon and adjacent
bursae
Ultrasonography in the differential diagnosis of
Achilles tendon injuries and related disorders. A
comparison between pre-operative ultrasonography
and surgical findings
18
Does not investigate
the diagnostic test
Retrospective Chart
Review
Does not investigate
the diagnostic test
Commentary
Chronic/neglected
Achilles tendon rupture
Partial Rupture
Less than 10 patients
per group
Chronic/neglected
Achilles tendon rupture
Less than 10 patients
per group
Less than 10 patients
per group
Retrospective Chart
Review
v1.0 12.04.09
Author
N
Withdrawals explained
Calf Squeeze
Test
Maffulli 161 (Thompson
test/Simmonds
squeeze test)
Calf Squeeze
Test
(Thompson
Margetic 88 test/Simmonds
squeeze test)
plus
Ultrasound
Uninterruptable/Intermediate test result(s)
reported
Index Test
Clinical review bias avoided
● = Yes ○ = No X = Not Reported
n/a = not applicable
Reference
Standard
Open
Repair
X
○
●
●
●
○
●
●
●
●
○
●
●
●
Surgery
X
○
●
●
●
○
●
●
●
○
○
●
●
○
19
v1.0 12.04.09
Diagnostic review bias avoided
Test review bias avoided
Reference standard execution
described
Index test execution described
Incorporation bias avoided
Differential verification bias avoided
Partial verification bias avoided
Disease progression bias avoided
Appropriate reference standard
Selection criteria described
Spectrum bias avoided
STUDY QUALITY
Table 7. Study Quality
STUDY RESULTS
Table 8. Sensitivity and Specificity
Author
N
Maffulli 161
Margetic
et. al.
88
Test
Calf Squeeze Test
(Thompson test /
Simmonds squeeze test)
Calf Squeeze Test
(Thompson test /
Simmonds squeeze test)
plus ultrasound
Sensitivity
(95% CI)
Specificity
(95% CI)
0.96
(0.91, 0.99)
0.93
(0.76, 0.99)
0.91
(0.83, 0.96)
1.00
(0.16, 1.00)
20
v1.0 12.04.09
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.
Supporting Evidence:
To address this recommendation, we analyzed studies that made two different
comparisons. Three level II studies compared patients treated non-operatively (with
21
v1.0 12.04.09
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
Duration (Months)
Author
Comparison
Twaddle Open vs. Cast
Cetti
Open vs. Cast
Outcome LOE
N
2
weeks
2
○
●Op
MFAI‡
II
42
Function
II
111
3
6
12
●Op ●Op
○
○
‡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
Möller
Open vs. Cast
% w/ Pain‡
III
85
Minimally Invasive vs. Cast Pain (VAS)
II
83
Metz
Duration (Months)
2
3
12
○
○
○
○
‡Level III evidence due to less than 80% of patients at follow-up
●Op: Statistically Significant in Favor of Operative Repair
22
v1.0 12.04.09
●Non-Op: Favors Non-Operative treatment with Cast
○ No statistical significance
Table 11. Operative vs. Cast – Return to Work
Author
Comparison
Outcome
LOE
Duration
(Months)
N
12
Cetti
Open vs. Cast
Sick Leave
II
111
Möller
Open vs. Cast
Sick Leave
II
112
24
○
○
Minimally
Invasive vs.
Return to Work
II
78
Cast
●Op: Statistically Significant in Favor of Operative Repair
●Non-Op: Favors Non-Operative treatment with Cast
○ No statistical significance
○
Metz
Table 12. Operative vs. Cast - Return to Sport
Author
Comparison
Outcome
LOE
Duration
(Months)
N
12
Cetti
Open vs. Cast
Möller
Open vs. Cast
Return to
Sport
Return to
Sport
II
111
II
112
24
●Op
Minimally
Return to
Invasive vs.
II
69
Sport (%)
Cast
●Op: Statistically Significant in Favor of Operative Repair
●Non-Op: Favors Non-Operative treatment with Cast
○ No statistical significance
Metz
○
○
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
23
v1.0 12.04.09
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
Duration (Months)
N
2
Möller
Open Repair vs. Cast
Satisfaction‡
(VAS)
III
85
Minimally Invasive
Satisfaction
II
83
vs. Cast
(VAS)
‡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
Metz
3
●Op
○
6
12
24
●Op ●Op ●Op
○
○
Table 15. Operative vs. Cast – Complications
Duration
(Months)
Adverse event/
Complication
LOE
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
Author
N
12
24
v1.0 12.04.09
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
Bhandari, M et al.
2002
Bhandari, M et al.
2002
Bhandari, M et al.
2002
Bhandari, M et al.
2002
Khan, RJK, et al.
2005
Lo, IKY, et al. 1997
Lo, IKY, et al. 1997
Lo, IKY, et al. 1997
Lynch, RM 2004
Conclusion
"Deep venous thrombosis is more common after
nonoperative treatment of Achilles tendon ruptures" (p. 195).
"…The current group of randomized trials suggests a benefit
to surgical repair of acute Achilles tendon ruptures in
younger, active patients" (p. 199).
"Pooled analysis of studies did not reveal any difference in
the risk of minor complaints or return to normal function
between surgical repair and conservatively treated groups"
(p. 190).
"Surgical treatment significantly reduces the risk of Achilles
tendon re-ruptures, but increases the risk of infection, when
compared with conservative therapy" (p. 190).
"In conclusion, open operative treatment of acute Achilles
tendon ruptures significantly reduces the risk of re-rupture
compared with nonoperative treatment but has the drawback
of a significantly higher risk of other complications,
including wound infection" (p.2209).
"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).
"Presently, we favor non-operative treatment in patients with
poor healing potential (i.e., smokers, diabetics, and patients
with peripheral vascular disease)" (p. 211).
"For healthy active individuals, we offer both forms of
treatment, providing the patients with the estimates of
treatment success and complication rates" (p. 211).
"Surgical treatment is preferable to non-surgical treatment,
produces better functional outcomes, and therefore appears
to be the treatment of choice" (p. 156).
25
v1.0 12.04.09
Author
Lynch, RM 2004
Lynch, RM 2004
Lynch, RM 2004
Lynch, RM 2004
Conclusion
"The incidence of re-rupture following non-surgical
treatment is significantly higher than for surgical treatment"
(p. 156).
"The number of patients that need to be treated surgically to
prevent one re-rupture if these patients were treated nonsurgically is 5 (3-13, 95% confidence intervals)" (p.156).
"The incidence of minor complications following surgical
treatment is large, but these do not appear to affect
functional outcome" (p. 156).
"Non-surgical treatment should be reserved for patients who
refuse or who are unfit for operative repair" (p. 156).
EXCLUDED ARTICLES
Table 17. Excluded Articles
Author
Title
Exclusion Reason
Doral, et al.
2009
Neumayer,
et al.
2009
Ebinesan, et
al.
2008
Lorkowski,
et al.
2007
Kotnis, et al.
2006
van, et al.
2004
Percutaneous suturing of the ruptured
Achilles tendon with endoscopic control
Not best available evidence - not
comparative
A new conservative-dynamic treatment for
the acute ruptured Achilles tendon
Not best available evidence - not
comparative
Conservative, open or percutaneous repair
for acute rupture of the Achilles tendon
Not best available evidence retrospective comparative
Evaluation of long term therapy outcomes
for Achilles tendon ruptures
Combines operative and nonoperative patients
Weber, et al.
2003
Follak, et al.
2002
Moller, et al.
2002
Rumian, et
al.
2001
Horstmann,
et al.
Dynamic ultrasound as a selection tool for
reducing Achilles tendon re-ruptures
Results of surgical versus non-surgical
treatment of Achilles tendon rupture
Non-operative treatment of acute rupture of
the Achilles tendon. results of a new
protocol and comparison with operative
treatment
The utility of gait analysis in the
rehabilitation of patients after surgical
treatment of Achilles tendon rupture
Calf muscle function after Achilles tendon
rupture. A prospective, randomised study
comparing surgical and non-surgical
treatment
Not best available evidence
Not best available evidence
Not best available evidence retrospective comparative
Not best available evidence - not
comparative
Duplicate - Data reported in prior
study
Surgical repair of the Achilles tendon. The
lateral approach
Not best available evidence - not
comparative
Isokinetic strength and strength endurance of
the lower limb musculature ten years after
Not best available evidence - not
comparative
26
v1.0 12.04.09
Author
Title
2000
Achilles tendon repair
Rowley, et
al.
1982
Rupture of the Achilles tendon treated by a
simple operative procedure
Inglis, et al.
1976
Nistor, et al.
1981
Jacobs, et al.
1978
Exclusion Reason
Ruptures of the tendo achillis. An objective
assessment of surgical and non-surgical
treatment
Surgical and non-surgical treatment of
Achilles Tendon rupture. A prospective
randomized study
No patient oriented outcome
Less than 10 patients per group
A new conservative-dynamic treatment for
the acute ruptured Achilles tendon
Not best available evidence
Combines acute and
neglected/chronic Achilles
tendon tear patients
Stochastic Randomization
Allocation Concealment
Patients Blinded
Those rating outcome Blinded
Follow Up - 80% or more
All groups have similar
outcome performance at entry
STUDY QUALITY
Table 18. Study Quality
Level II
●
●
○
●
●
×
Level II
●
●
○
●
●
×
Level II
●
●
○
●
●
●
Level II
●
●
○
●
●
●
Level II
●
●
○
●
●
●
Level II
●
●
○
●
●
●
Level III
●
●
○
●
○
●
Level II
×
×
○
●
●
●
Level II
Level II
×
×
×
×
○
○
●
●
●
●
●
●
● = Yes ○ = No
× = Not Reported
Author
Outcome
N
Twaddle
MFAI
42
Twaddle
Re-rupture
42
Moller
Re-rupture
112
Moller
Return to work
Quality of Life
(VAS)
Treatment
Results (VAS)
112
Moller
Moller
Moller
Pain
Cetti
Return to Work
Cetti
Return to Sports
Cetti
Hospitalization
112
112
85
111
111
111
Treatment(s)
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
27
Level of
Evidence
v1.0 12.04.09
Stochastic Randomization
Allocation Concealment
Patients Blinded
Those rating outcome Blinded
Follow Up - 80% or more
All groups have similar
outcome performance at entry
Level II
○
○
×
×
●
×
Level II
●
●
○
●
●
●
Level II
●
●
○
●
●
●
Level II
●
●
○
●
●
×
Level II
●
●
○
●
●
×
● = Yes ○ = No
× = Not Reported
Author
Outcome
N
Metz
Re-rupture
83
Metz
Return to work
83
Metz
Return to sport
83
Metz
Pain- VAS
Satisfaction VAS
83
Metz
83
Level of
Evidence
Treatment(s)
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
Operative vs.
Cast
STUDY RESULTS
Table 19. Open vs. Cast - Function
Durati
on
Open
Repair
mean (SD)
%
mean (SD)
%
42.4 (2.7)‡
43 (2.7)‡
p = 0.48‡
23.7 (2.6)‡
27.6 (3.4)‡
p = 0.002‡
15.2 (2.1)‡
17 (2.6)‡
p = 0.02‡
7.8 (2.1)‡
10.4 (2.2)‡
p = 0.004‡
3.4 (1.7)‡
4.2 (1.7)‡
p = 0.14‡
Cast
Author
Comparison
Outcome
LOE
N
Twaddle
Open vs. Cast
MFAI
II
42
Twaddle
Open vs. Cast
MFAI
II
42
Twaddle
Open vs. Cast
MFAI
II
42
Twaddle
Open vs. Cast
MFAI
II
42
Twaddle
Open vs. Cast
MFAI
II
42
II
111
12
months
5.4%
3.6%
NS
II
111
12
months
12.5%
18.2%
NS
II
111
12
months
8.9%
9.1%
NS
Cetti
Open vs. Cast
Cetti
Open vs. Cast
Cetti
Open vs. Cast
Function Abnormal
Gait
Function –
Abnormal
Run
Function Abnormal
Toe Stand
28
2
weeks
2
months
3
months
6
months
12
months
v1.0 12.04.09
Results
‡ AAOS Calculation
NS: No statistical significance; authors do not report p-value.
Table 20. Cast vs. Open Repair - Pain
Author
Möller
Möller
Möller
Comparison
Outcome
Open vs.
Cast
Open vs.
Cast
Pain None
Pain Moderate
Pain During
Walking
Open vs.
Cast
Minimally
Invasive
vs. Cast
Minimally
Metz
Invasive
vs. Cast
Minimally
Metz
Invasive
vs. Cast
‡ AAOS Calculation
Metz
Duration
Open
Repair
mean
(SD)
%
Minimally
Invasive
Cast
mean (SD)
%
mean (SD)
%
92%
n/a
88%
p = .69‡
6%
n/a
3%
p = .55‡
LOE
N
III
85
III
85
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‡
12
months
12
months
NS: No statistical significance; authors do not report p-value.
n/a: not applicable
29
v1.0 12.04.09
Results
Table 21. Operative vs. Cast - Return to Work
Author
Comparison
Outcome
LOE
N
Open
Repair
Minimally
Invasive
Cast
mean (SD)
mean (SD)
mean (SD)
43.4
(15.05)
n/a
56 (25.2)
NS
54.9 (47.9)
n/a
73.4 (56.5)
p=
0.06
Results
Duration
12
months
24
months
Cetti
Open vs. Cast
Return to Work (days)
II
111
Möller
Open vs. Cast
Sick Leave (days)
II
111
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
‡ AAOS Calculation
NS: No statistical significance; authors do not report p-value.
n/a: not applicable
30
v1.0 12.04.09
Table 22. Operative vs. Cast - Return to Sport
Author Comparison
Cetti
Open vs.
Cast
Cetti
Open vs.
Cast
Möller
Open vs.
Cast
Cetti
Open vs.
Cast
Cetti
Open vs.
Cast
Möller
Open vs.
Cast
Outcome
N
II
111
12
months
79%
n/a
64%
p=
.21‡
II
111
12
months
57%
n/a
29%
p =.005
II
112
12
months
54%
n/a
54%
NS
II
111
12
months
21%
n/a
35%
NS
II
111
12
months
14%
n/a
22%
NS
II
112
12
months
16%
n/a
14%
p=
.620‡
II
69
12
months
n/a
67%
81%
p=
0.16
Return to
SportsTotal
Return to
Sport Same
Level
Return to
Sport Same
Level
Return to
Sport Diminished
Return to
Sport Stopped
Return to
Sport Stopped
Minimally
Invasive
vs. Cast
‡ AAOS Calculation
Metz
Open Minimally
Cast
Duration Repair Invasive
Results
%
%
%
LOE
Return to
Sport
NS: No statistical significance; authors do not report p-value.
n/a: not applicable
Table 23. Operative vs. Cast - Rerupture
Author
Complication
LOE
N
Cetti
Rerupture
II
111
Möller
Rerupture
II
112
Twaddle
Rerupture
II
42
Metz
Rerupture
II
83
Cetti
Second
Rerupture
II
111
Duration
12
months
12
months
6 months
12
months
12
months
Open
Repair
Minimally
Invasive
Cast
%
%
%
5.4%
n/a
12.7%
p = .167‡
1.7%
n/a
20.8%
p = < .001
10.0%
n/a
4.5%
p = .49‡
n/a
7.1%
12.2%
p = 0.44‡
0.0%
n/a
1.8%
p = .154‡
Results
‡ AAOS Calculation
n/a: not applicable
31
v1.0 12.04.09
Table 24 Cast vs. Open - Complications
Author
Metz
Cetti
Metz
Complications
Total
Complications
Major
Complications
(not including
rerupture)
Total
Complications
Other Than
Rerupture
LOE
N
%
28.6%
48.8%
p = 0.06
II
111
12
months
9.0%
n/a
16.3%
NS
II
83
12
months
n/a
21.4%
36.6%
p = 0.13
n/a
7.1%
2.4%
p = 0.30‡
3.6%
n/a
0%
p = 0.05
n/a
0
0.0%
NS
1.8%
n/a
0%
p = 0.158‡
12.5%
n/a
1.8%
p = 0.017‡
1.7%
n/a
0%
p = 0.16‡
n/a
9.5%
0.0%
p = 0.01‡
n/a
0.0%
2.4%
p = 0.15‡
0.0%
n/a
1.9%
p = 0.14‡
0.0%
n/a
0%
NS
Cetti
Deep Infection
II
111
II
83
II
111
II
111
II
112
Möller
%
n/a
83
Cetti
%
12
months
II
Cetti
Results
83
Sural Nerve Injury
Deep Wound
Infection
Delayed Wound
Healing
Disturbances of
Sensibility
Disturbance of
Sensitivity
Cast
II
Metz
Metz
Duration
Open Minimally
Repair Invasive
12
months
12
months
12
months
12
months
12
months
24
months
12
months
12
months
24
months
12
months
Metz
Partial Sensibility
II
83
Metz
DVT - lower leg
II
83
Möller
DVT
II
112
II
112
II
111
12
months
0.0%
n/a
1.8%
p = 0.15‡
II
112
24
months
0.0%
n/a
1.9%
p = 0.14‡
II
111
26.8%
n/a
5.4%
p = 0.004
II
83
n/a
4.8%
31.7%
p = .001‡
10.7%
n/a
3.6%
p = 0.136‡
n/a
7.1%
0.0%
p = 0.01‡
Cetti
Cetti
Möller
Cetti
Metz
Necrosis of the
Skin
Extreme Residual
Tendon
Lengthening
Extreme Residual
Tendon
Lengthening
Total - Minor
Complications
Skin Related
Complications
Cetti
Scar Adhesions
II
111
Metz
Scar Adhesions
II
83
12
months
12
months
12
months
12
months
32
v1.0 12.04.09
Author
Complications
LOE
N
Möller
Scar Adhesions
II
112
Cetti
Suture Granuloma
II
111
II
112
Superficial
Infection
‡ AAOS Calculation
Möller
Duration
24
months
12
months
24
months
Open Minimally
Repair Invasive
Cast
Results
%
%
%
13.6%
n/a
0%
p = <.001‡
1.8%
n/a
0%
p = 0.158‡
1.7%
n/a
0%
p = 0.16‡
NS: No statistical significance; authors do not report p-value.
n/a: not applicable
33
v1.0 12.04.09
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.
Supporting Evidence:
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 rerupture 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).
34
v1.0 12.04.09
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
Cast +
orthosis
(%)
Results
Author
Outcome
LOE
N
Duration
Cast
(%)
Saleh, et
al. 1992
Rerupture
II
31
12
months
6%
7%
p=.96‡
Ingvar, et
al. 2005
Rerupture
‡ AAOS calculation
IV
194
4 years
7%
10%
p=.51‡
Table 26. Summary of Results - Case Series
Author
Wallace
Outcome
Pain - none
LOE
IV
N
140
Duration
2.9 years
Results
(%)
78%
Wallace
Stiffness –
none
IV
140
2.9 years
55%
Wallace
Weakness –
none
IV
140
2.9 years
56%
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
Lynch, RM 2004
Conclusion
"Early functional mobilisation is more acceptable to
patients than plaster cast immobilisation and results in
improved functional outcomes" (p. 156).
35
v1.0 12.04.09
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
(%)
Wallace,
et al. 2004
Satisfaction – very
satisfied
IV
140
2.9 years
83%
IV
140
2.9 years
15%
IV
140
2.9 years
1%
IV
140
2.9 years
1%
Wallace,
et al. 2004
Wallace,
et al. 2004
Wallace,
et al. 2004
Satisfaction –
satisfied with
minor reservations
Satisfaction –
satisfied with
major reservations
Satisfaction –
dissatisfied
Table 30. Functional Bracing - Pain
Author
Outcome
LOE
N
Duration
Results
(%)
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
Author
Outcome
LOE
N
Duration
Results
(%)
Wallace,
et al. 2004
Stiffness – none
IV
140
2.9 years
55%
36
v1.0 12.04.09
Wallace,
et al. 2004
Stiffness – mild
IV
140
2.9 years
41%
Wallace,
et al. 2004
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
Author
Outcome
LOE
N
Duration
Results
(%)
Wallace,
et al. 2004
Weakness – none
IV
140
2.9 years
56%
Wallace,
et al. 2004
Weakness - mild
IV
140
2.9 years
33%
Wallace,
et al. 2004
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
Author
Outcome
McComis,
et al. 1997
Return to Full
Preinjury Level of
Employment
Return to Sports same or better
level
Return to Sports diminished or
none
Return to Sports same level
McComis,
et al. 1997
Return to Sports diminished
Wallace,
et al. 2004
Wallace,
et al. 2004
Wallace,
et al. 2004
LOE
N
Duration
Results
(%)
IV
122
2.9 years
98%
IV
101
2.9 years
37%
IV
101
2.9 years
63%
V
15
26 weeks
67%
V
15
26 weeks
33%
Table 34. Functional Bracing - Return to Work and Sports (days)
Author
Outcome
LOE
N
37
Results
(mean)
v1.0 12.04.09
Wallace,
et al. 2004
Time to Return to
Work
IV
122
McComis,
et al. 1997
Time to Return to
Work
V
15
Wallace,
et al. 2004
Time to Return to
Sports
IV
101
7 days
(max: 52 days)
4 days
(max: 3 weeks)
8 weeks
(range 2 weeks
- 6 months)
Table 35. Functional Bracing - Complications
N
Duration
(%)
Cast +
orthosis
(%)
IV
57
12
months
n/a
2%
n/a
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
Cast
Author
Outcome
Neumayer,
et al. 2009
Pulmonary
embolism
Wallace,
et al. 2004
Wallace,
et al. 2004
LOE
Results
n/a: not applicable
Table 36. Functional Bracing - Rerupture
Author
Outcome
LOE
N
Duration
Cast
(%)
Cast +
orthosis
(%)
Results
Neumayer,
et al. 2009
Complete
rerupture
IV
57
12 months
n/a
9%
n/a
Wallace, et
al. 2004
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
Edna TH;
Fruensgaard S, et
al.
Title
Non-operative treatment of Achilles tendon ruptures
Conservative treatment for acute rupture of the Achilles
tendon
38
Exclusion Reason
case series cast only
casting only
v1.0 12.04.09
Author
Title
Long-term results after functional non-operative
treatment of Achilles tendon rupture
Hufner TM, et al.
Exclusion Reason
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
Lea RB; Smith L;
Closed treatment of Achilles tendon rupture
Non-surgical treatment of tendo achillis rupture
case series cast only
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
The treatment of total ruptures of the Achilles tendon
by plaster immobilisation
Dynamised cast management of Achilles tendon
ruptures
Persson A, et al.
Roberts CP, et al
cast only case series
retrospective case series
Outcome
N
Treatment(s)
Level of
Evidence
Allocation Concealment
Patients Blinded
Author
Stochastic Randomization
Those rating outcome Blinded
Follow Up - 80% or more
All groups have similar
outcome performance at entry
STUDY QUALITY
Table 38. Study Quality - Randomized Control Trials
Saleh, et
al. 1992
Rerupture
31
Cast vs. Cast +
Orthosis
Level II
×
×
○
○
●
●
● = Yes ○ = No
× = Not Reported
● = Yes ○ = No
× = Not Reported
Completion
rate - less
than 20%
difference
All groups
between
concurrently
groups
groups
All
treated
All groups
same
receive
evaluated
treatment
groups
Allusing
outcome
samehave
approximately
measures
equal followFollow Up up times
center
Same
80% or more
for
experimental
Similar
and control
performance
group data
on outcome
Patient at
baseline
characteristics
comparable at
baseline
Table 39. Study Quality - Non-Randomized Comparative Study
39
v1.0 12.04.09
Author
Ingvar,
et al.
2005
Outcome
N
Treatment(s)
Level of
Evidence
Re-rupture
194
Cast vs. Cast
+ Orthosis
Level IV
×
○
●
●
●
×
●
●
×
Consecutive enrollment
of patients
Follow Up - 80% or more
All patients evaluated using
same outcome measures
Outcome
N
Treatment(s)
Level of
Evidence
All patients receive same treatment
All patients have approximately equal
follow-up times
Table 40. Study Quality - Case Series
Satisfaction (VAS)
46
Cast + Orthosis
Level IV
●
●
●
●
●
Satisfaction
140
Cast + Orthosis
Level IV
●
●
●
●
●
Pain
140
Cast + Orthosis
Level IV
●
●
●
●
●
Stiffness
140
Cast + Orthosis
Level IV
●
●
●
●
●
140
Cast + Orthosis
Level IV
●
●
●
●
●
Wallace, et al.
2004
Weakness
Return to Full
Preinjury Level of
Employment
122
Cast + Orthosis
Level IV
●
●
●
●
●
Wallace, et al.
2004
Return to Sports same or better level
101
Cast + Orthosis
Level IV
●
●
●
●
●
Wallace, et al.
2004
McComis, et al.
1997
McComis, et al.
1997
Return to Sports diminished or none
Return to Sports same level
Return to Sports diminished
101
Cast + Orthosis
Level IV
●
●
●
●
●
15
Cast + Orthosis
Level V
●
○
●
●
●
15
Cast + Orthosis
Level V
●
○
●
●
●
● = Yes ○ = No
× = Not Reported
Author
Neumayer, et al.
2009
Wallace, et al.
2004
Wallace, et al.
2004
Wallace, et al.
2004
Wallace, et al.
2004
40
v1.0 12.04.09
Consecutive enrollment
of patients
Follow Up - 80% or more
All patients evaluated using
same outcome measures
N
Treatment(s)
Level of
Evidence
All patients receive same treatment
All patients have approximately equal
follow-up times
122
Cast + Orthosis
Level IV
●
●
●
●
●
15
Cast + Orthosis
Level V
●
○
●
●
●
140
Cast + Orthosis
Level IV
●
●
●
●
●
57
Cast + Orthosis
Level IV
●
●
●
●
●
140
Cast + Orthosis
Level IV
●
●
●
●
●
Partial rerupture
57
Cast + Orthosis
Level IV
●
●
●
●
●
Partial rerupture
Pulmonary
embolism
140
Cast + Orthosis
Level IV
●
●
●
●
●
57
Cast + Orthosis
Level IV
●
●
●
●
●
DVT
Temporary Drop
foot
140
Cast + Orthosis
Level IV
●
●
●
●
●
140
Cast + Orthosis
Level IV
●
●
●
●
●
● = Yes ○ = No
× = Not Reported
Author
Outcome
Wallace, et al.
2004
McComis, et al.
1997
Wallace, et al.
2004
Neumayer, et al.
2009
Wallace, et al.
2004
Neumayer, et al.
2009
Wallace, et al.
2004
Neumayer, et al.
2009
Wallace, et al.
2004
Wallace, et al.
2004
Time to Return to
Work
Time to Return to
Work
Time to Return to
Sports
Complete rerupture
Complete rerupture
41
v1.0 12.04.09
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,
32
that 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 nonoperative 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.
Supporting Evidence:
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.
42
v1.0 12.04.09
Please see Recommendation 7 for results of operative treatment comparisons.
43
v1.0 12.04.09
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
44
v1.0 12.04.09
Table 43. Open Repair - Activities of daily living
Author
Bhattacharyya, et al.
2009
Bhattacharyya, et al.
2009
LOE
N
IV
53
IV
53
Uchiyama, et al. 2007
IV
84
Uchiyama, et al. 2007
IV
84
Outcome
Return to Normal Stair Climbing
(weeks)
Return to Normal Walking
(weeks)
Return to same level of sports
(months) (high level athletes)
Return to jogging (weeks)
Mean time
Mean
(SD)/(range)
19 (3.5)‡
17 (3)‡
5 (17-26 weeks)
12.3 (range 821)
‡AAOS Calculation
Table 44. Open Repair- Mean time until return to athletic activity
Author
LOE
N
Uchiyama, et al. 2007
IV
84
Uchiyama, et al. 2007
IV
84
Outcome
Return to same level of sports
(months) (high level athletes)
Return to jogging (weeks)
45
Mean time
Mean (range)
5 (17-26 weeks)
12.3 (8-21)
v1.0 12.04.09
Table 45. Open Repair- Percent of patients able to return to activities of daily living
Follow% of
up
Patients
2
Lim, et al. 2001
IV
33
Return to ADL
6%
months
3
Lim, et al. 2001
IV
33
Return to ADL
85%
months
6
Lim, et al. 2001
IV
33
Return to ADL
100%
months
Return to final functional
3
Lim, et al. 2001
IV
33
36%
activity‡
months
Return to final functional
6
Lim, et al. 2001
IV
33
64%
activity‡
months
‡ Final functional activity defined as “patient is unhindered in all his or her activities apart from
active sports”
Author
LOE
N
Outcome
Table 46. Open Repair- Percent of patients able to return to work
Author
LOE
N
Outcome
Followup
% 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
Author
LOE
N
Outcome
Followup
% 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
Cetti, et al. 1993
IV
52
Return to sports - same level
Lim, et al. 2001
IV
33
Lim, et al. 2001
IV
33
Moller, et al. 2001
IV
47
Return to active sporting/outdoor
activities
Return to active sporting/outdoor
activities
Return to sports - stopped
46
12
months
12
months
3
months
6
months
12
months
54%
62%
9%
48%
16%
v1.0 12.04.09
Author
LOE
N
Outcome
Cetti, et al. 1993
IV
52
Return to sports - stopped
Cetti, et al. 1993
IV
52
Return to sports - diminished
level
Followup
12
months
12
months
% of
Patients
15%
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
Cetti, et al. 1993
IV
56
Cetti, et al. 1993
IV
56
Cetti, et al. 1993
IV
56
Cetti, et al. 1993
IV
Cetti, et al. 1993
Outcome
Function-Abnormal ankle
movement
Function-Abnormal ankle
movement
Follow-up % of Patients
4 months
52%
12 months
18%
Function-Abnormal gait
4 months
27%
56
Function-Abnormal gait
12 months
5%
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
Lim, et al. 2001
LOE N
IV
33
Outcome
Satisfaction - Excellent
47
Follow-up % of Patients
6 months
42%
v1.0 12.04.09
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
ES Ng, et al.
2007
Lim, et al.
2001
Lim, et al.
2001
Lim, et al.
2001
Lim, et al.
2001
Lim, et al.
2001
Chillemi, et
al. 2002
LOE
N
Treatment
Outcome
Follow-up
% of
Patients
IV
25
percutaneous
Return to activity same level
65.5
months
96%
IV
33
percutaneous
Return to ADL
2 months
6%
IV
33
percutaneous
Return to ADL
3 months
76%
IV
33
percutaneous
Return to ADL
6 months
100%
IV
33
percutaneous
3 months
27%
IV
33
percutaneous
6 months
73%
IV
38
percutaneous
6 months
100%
Return to final
functional activity
Return to final
functional activity
Able to walk
without limitation
48
v1.0 12.04.09
Table 53. Minimally Invasive Repair - Percent of patients able to return to sports
Author
LOE
N
Treatment
Lim, et al.
2001
IV
33
percutaneous
Lim, et al.
2001
IV
33
percutaneous
Chillemi, et
al. 2002
IV
14
percutaneous
Outcome
Return to active
sporting/outdoor
activities
Return to active
sporting/outdoor
activities
Return to sports
activity (frequent
participant 2-3
times per week)
Follow-up
% of
Patients
3 months
0%
6 months
67%
nr
57%
nr: not reported
Table 54. Minimally Invasive Repair - Satisfaction
Author
LOE
Lim, et al.
2001
IV
Treatment
N
Outcome
Follow-up
%
percutaneous
33
Satisfaction Excellent
6 months
52%
Table 55. Minimally Invasive Repair - Mean time until return to activity
Author
LOE
Metz, et al.
IV
2008
Bhattacharyya,
IV
et al. 2009
Bhattacharyya,
IV
et al. 2009
Treatment
N
Outcome
Mean Time (Days)
Mean (SD)
minimally-invasive
40
Return to work
59 (82)
minimally-invasive
53
12.5 (3)‡
minimally-invasive
53
Return to Normal
Walking (weeks)
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
Metz, et al.
IV
2008
Metz, et al.
IV
2008
Metz, et al.
IV
2008
Metz, et al.
IV
2008
nr: not reported
Treatment
N
Outcome
Follow-up
% of
Patients
minimally-invasive
36
Return to sports
12 months
67%
minimally-invasive
36
Change sports
12 months
11%
minimally-invasive
36
Stop sports
12 months
22%
minimally-invasive
40
Return to work
nr
98%
49
v1.0 12.04.09
Table 57. Minimally Invasive Repair-Percent of patients able to return to work
Author
LOE
Metz, et al.
IV
2008
nr: not reported
Treatment
N
Outcome
Follow-up
% of
Patients
minimally-invasive
40
Return to work
nr
98%
Follow-up
% of
Patients
22 months
4.5%
Table 58. Minimally Invasive Repair-Pain
Author
Aktas, et
al.2009
LOE
IV
Treatment
N
minimally-invasive
23
Outcome
Percent of patient
with mild pain
during exertion
EXCLUDED ARTICLES
Table 59. Excluded Articles
Author
Title
Leppilahti J;Forsman
K;Puranen J;Orava S;
Outcome and prognostic factors of Achilles rupture
repair using a new scoring method
Chiodo CP;Wilson
MG;
Current concepts review: acute ruptures of the
Achilles tendon
Maffulli N;Tallon
C;Wong J;Lim
KP;Bleakney R;
Nonoperative treatment of acute rupture of the
Achilles tendon: results of a new protocol and
comparison with operative treatment
Early weightbearing and ankle mobilization after open
repair of acute midsubstance tears of the Achilles
tendon
Halasi T;Tallay
A;Berkes I;
Percutaneous Achilles tendon repair with and without
endoscopic control
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
van der Linden-van der
Zwaag HM;Nelissen
RG;Sintenie JB;
Results of surgical versus non-surgical treatment of
Achilles tendon rupture
Weber M;Niemann
M;Lanz R;Muller T;
50
Exclusion
Reason
Not best
available
evidence
Not best
available
evidence
Retrospective
Not Relevant
Retrospective
Not best
available
evidence
Not relevantlooks at effect
of weight
bearing
following
surgery
Not best
available
evidence
v1.0 12.04.09
Author
Title
Steele GJ;Harter
RA;Ting AJ;
Comparison of functional ability following
percutaneous and open surgical repairs of acutely
ruptured Achilles tendons
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
Wagnon R;Akayi M;
Mortensen HM;Skov
O;Jensen PE;
The Webb-Bannister percutaneous technique for acute
Achilles' tendon ruptures: a functional and MRI
assessment
Early motion of the ankle after operative treatment of
a rupture of the Achilles tendon. A prospective,
randomized clinical and radiographic study
Exclusion
Reason
No patientoriented
outcome
Not best
available
evidence
No patient oriented
outcome
Not best
available
evidence
Not best
available
evidence
Hufner TM;Brandes
DB;Thermann
H;Richter M;Knobloch
K;Krettek C;
Long-term results after functional nonoperative
treatment of Achilles tendon rupture
Not best
available
evidence
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
Not best
available
evidence
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
Operative treatment of acute Achilles tendon rupture:
Open end-to-end-reconstruction versus reconstruction
with Mitek-anchors
Retrospective
case series
Acute Achilles tendon rupture: minimally invasive
surgery versus nonoperative treatment with immediate
full weightbearing--a randomized controlled trial
Not Relevant
Schonberger TJ;Janzing
HM;Morrenhof JW;de
Visser AC;Muitjens P;
Metz R;Verleisdonk
EJ;van der Heijden
GJ;Clevers
GJ;Hammacher
ER;Verhofstad MH;van
der WC;
Suchak AA;Bostick
GP;Beaupre
LA;Durand DC;Jomha
NM;
The influence of early weight bearing compared with
All patients do
non-weight bearing after surgical repair of the Achilles not receive same
tendon
treatment
51
v1.0 12.04.09
Author
Blankstein A;Israeli
A;Dudkiewicz
I;Chechik A;Ganel A;
Maffulli N;Longo
UG;Ronga M;Khanna
A;Denaro V;
Title
Percutaneous Achilles tendon repair combined with
real-time sonography
Favorable Outcome of Percutaneous Repair of
Achilles Tendon Ruptures in the Elderly
Exclusion
Reason
No patient
oriented
outcome
Not best
available
evidence
Early motion for Achilles tendon ruptures: is surgery
important? A randomized, prospective study
No relevant
outcomes
Achilles tendon after percutaneous surgical repair:
serial MRI observation of uncomplicated healing
No patient
oriented
outcome
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
Martinelli B;
Percutaneous repair of the Achilles tendon in athletes
Twaddle BC;Poon P;
Fujikawa A;Kyoto
Y;Kawaguchi M;Naoi
Y;Ukegawa Y;
Costa ML;MacMillan
K;Halliday D;Chester
R;Shepstone
L;Robinson AH;Donell
ST;
Gorschewsky O;Pitzl
M;Putz A;Klakow
A;Neumann W;
Mullaney MJ;McHugh
MP;Tyler TF;Nicholas
SJ;Lee SJ;
Rumian AP;Molloy
S;Solan M;Newman
KJ;Elliott D;
Ebinesan AD;Sarai
BS;Walley GD;Maffulli
N;
Percutaneous repair of acute Achilles tendon rupture
Weakness in end-range plantar flexion after Achilles
tendon repair
Surgical repair of the Achilles tendon: The lateral
approach
Insufficient
Quantitative
Data
Not best
available
evidence
Insufficient
Quantitative
Data
No patient
oriented
outcome
Not best
available
evidence
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;MunchJorgensen T;
Conservative treatment to Achilles tendon rupture. A
follow-up study of 14 cases
No description
of surgery
52
v1.0 12.04.09
Author
Title
Nistor L;
Surgical and non-surgical treatment of Achilles
Tendon rupture. A prospective randomized study
Haggmark T;Liedberg
H;Eriksson
E;Wredmark T;
Kangas J;Pajala A;Siira
P;Hamalainen
M;Leppilahti J;
Calf muscle atrophy and muscle function after nonoperative vs operative treatment of Achilles tendon
ruptures
Early functional treatment versus early immobilization
in tension of the musculotendinous unit after Achilles
rupture repair: a prospective, randomized, clinical
study
Exclusion
Reason
Not best
available
evidence
No patient
oriented
outcome
Not Relevant
Insufficient
Quantitative
Data
No patient
oriented
outcome
Surgeons did
not follow same
technique
Not best
available
evidence
Synder
M;Zwierzchowski H;
Post-operative results in fresh injuries the Achilles
tendon
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
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 crossstitch 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
Isokinetic strength and strength endurance of the lower
limb musculature ten years after Achilles tendon repair
All patients did
not receive
exact surgery
Functional treatment after surgical repair of acute
Achilles tendon rupture: wrap vs walking cast
Not Relevant
Horstmann T;Lukas
C;Mayer F;Winter
E;Ambacher
T;Heitkamp
H;Dickhuth H;
Kerkhoffs GM;Struijs
PA;Raaymakers
EL;Marti RK;
53
v1.0 12.04.09
Author
Title
Exclusion
Reason
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
54
Not Relevant
v1.0 12.04.09
STUDY QUALITY
Table 60. Study Quality
Aktas, et al. 2007
Pain - Mild w/
maximal
exertion‡
Aktas, et al. 2007
Pain - Absent‡
Bhattacharyya, et
al. 2009
Return to Normal
Walking (weeks)
Return to Normal
Stair Climbing
(weeks)
Return to Normal
Walking (weeks)
Return to Normal
Stair Climbing
(weeks)
Return to work
(weeks)
Bhattacharyya, et
al. 2009
Bhattacharyya, et
al. 2009
Bhattacharyya, et
al. 2009
Cetti, et al. 1993
Treatment
LoE
Same Treatments
Equal Follow up
Time
Outcome
Measure
30
Open Repair
IV
●
●
●
●
●
30
Open Repair
IV
●
●
●
●
●
53
Open Repair
IV
●
●
●
●
●
53
Open Repair
IV
●
●
●
●
●
53
Minimally
Invasive Repair
IV
●
●
●
●
●
53
Minimally
Invasive Repair
IV
●
●
●
●
●
56
Open Repair
IV
●
●
●
●
●
N
Consecutive
Enrollment
Follow up <80%
Author
Same Outcomes
● = Yes ○ = No
× = Not Reported
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
●
●
●
●
●
56
Open Repair
IV
●
●
●
●
●
56
Open Repair
IV
●
●
●
●
●
56
Open Repair
IV
●
●
●
●
●
56
Open Repair
IV
●
●
●
●
●
Cetti, et al. 1993
Cetti, et al. 1993
Cetti, et al. 1993
Cetti, et al. 1993
Return to sports stopped
FunctionAbnormal ankle
movement
FunctionAbnormal ankle
movement
FunctionAbnormal gait
Cetti, et al. 1993
FunctionAbnormal gait
56
Open Repair
IV
●
●
●
●
●
Cetti, et al. 1993
FunctionAbnormal run
56
Open Repair
IV
●
●
●
●
●
55
v1.0 12.04.09
Cetti, et al. 1993
Cetti, et al. 1993
Chillemi, et al.
2002
Chillemi, et al.
2002
Coutts, et al 2002
ES Ng, et al. 2007
FunctionAbnormal run
FunctionAbnormal toe
stand
FunctionAbnormal toe
stand
Able to walk
without limitation
Return to sports
activity (frequent
participant 2-3
times per week)
Return to preinjury sporting
level
Return to activity
- same level
Gigante, et al.
2008
SF-12 - Physical
Component Score
Gigante, et al.
2008
SF-12 - Mental
Component Score
Return to active
sporting/outdoor
activities
Return to active
sporting/outdoor
activities
Lim, et al. 2001
Lim, et al. 2001
Lim, et al. 2001
Lim, et al. 2001
Lim, et al. 2001
Lim, et al. 2001
Return to ADL
Return to final
functional
activity
Satisfaction Excellent
Return to final
functional
activity
Treatment
LoE
Same Treatments
Equal Follow up
Time
Cetti, et al. 1993
Outcome
Measure
56
Open Repair
IV
●
●
●
●
●
56
Open Repair
IV
●
●
●
●
●
56
Open Repair
IV
●
●
●
●
●
38
Percutaneous
Repair
IV
●
●
●
●
●
14
Percutaneous
Repair
IV
●
●
●
●
●
22
Open Repair
IV
○
●
●
●
●
25
Percutaneous
Repair
IV
●
●
●
●
●
19
Percutaneous
Repair
IV
●
●
●
●
●
19
Percutaneous
Repair
IV
●
●
●
●
●
33
Open Repair
IV
●
●
●
●
●
33
Percutaneous
Repair
IV
●
●
●
●
●
IV
●
●
●
●
●
IV
●
●
●
●
●
IV
●
●
●
●
●
IV
●
●
●
●
●
N
33
Open Repair
Consecutive
Enrollment
Follow up <80%
Author
Same Outcomes
● = Yes ○ = No
× = Not Reported
Open Repair
33
33
33
Open Repair
Percutaneous
Repair
56
v1.0 12.04.09
Lim, et al. 2001
Lim, et al. 2001
Return to active
sporting/outdoor
activities
Return to active
sporting/outdoor
activities
Satisfaction Excellent
Treatment
LoE
Same Treatments
Equal Follow up
Time
Lim, et al. 2001
Outcome
Measure
33
Percutaneous
Repair
IV
●
●
●
●
●
33
Percutaneous
Repair
IV
●
●
●
●
●
IV
●
●
●
●
●
IV
●
●
●
●
●
IV
●
●
●
●
●
IV
●
●
●
●
●
IV
●
●
●
●
●
N
33
Metz, et al. 2008
Return to work
40
Metz, et al. 2008
Return to sports
40
Metz, et al. 2008
Change sports
40
Metz, et al. 2008
Stop sports
40
Return to
Moller, et al. 2001 sedentary work
(days)
Return to light,
Moller, et al. 2001 mobile work
(days)
Return to work
Moller, et al. 2001
(days)
Return to heavy
Moller, et al. 2001
work (days)
Return to sports Moller, et al. 2001
same level
Moller, et al. 2001
Moller, et al. 2001
Moller, et al. 2001
Moller, et al. 2001
Moller, et al. 2001
Return to sports stopped
Return to
sedentary work
(days)
Return to light,
mobile work
(days)
Return to work
(days)
Return to heavy
work (days)
Percutaneous
Repair
Minimally
Invasive Repair
Minimally
Invasive Repair
Minimally
Invasive Repair
Minimally
Invasive Repair
Consecutive
Enrollment
Follow up <80%
Author
Same Outcomes
● = Yes ○ = No
× = Not Reported
59
Open Repair
IV
●
●
●
●
●
59
Open Repair
IV
●
●
●
●
●
59
Open Repair
IV
●
●
●
●
●
59
Open Repair
IV
●
●
●
●
●
59
Open Repair
IV
●
●
●
●
●
59
Open Repair
IV
●
●
●
●
●
59
Open Repair
IV
●
●
●
●
●
59
Open Repair
IV
●
●
●
●
●
59
Open Repair
IV
●
●
●
●
●
Open Repair
IV
●
●
●
●
●
59
57
v1.0 12.04.09
Pain-during
walking
Moller, et al. 2001 Pain-moderate
Moller, et al. 2001 Pain-none
Uchiyama, et al.
Return to jogging
2007
(weeks)
Return to same
Uchiyama, et al.
level of sports
2007
(months) (high
level athletes)
Moller, et al. 2001
N
Treatment
LoE
Same Treatments
Equal Follow up
Time
Outcome
Measure
59
Open Repair
IV
●
●
●
●
●
59
59
Open Repair
Open Repair
IV
IV
●
●
●
●
●
●
●
●
●
●
84
Open Repair
IV
○
●
●
●
●
84
Open Repair
IV
○
●
●
●
●
Consecutive
Enrollment
Follow up <80%
Author
Same Outcomes
● = Yes ○ = No
× = Not Reported
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
●
●
●
●
●
58
v1.0 12.04.09
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.
Supporting Evidence:
We did not identify any studies to address this recommendation.
59
v1.0 12.04.09
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.
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:
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.
60
v1.0 12.04.09
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 limitedopen 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
61
v1.0 12.04.09
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 limitedopen or percutaneous technique.
Supporting Evidence:
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).
62
v1.0 12.04.09
SUMMARY OF EVIDENCE- PERCUTANEOUS VS. OPEN
Table 61. Percutaneous and Limited Open vs. Open - Global Outcomes
Author
Outcome
LOE
N
Duration
24 months
Gigante
SF-12 - Physical
Component Score
II
39
●P
SF-12 - Mental
II
39
●P
Component Score
● P: Statistically Significant in Favor of Percutaneous Repair
● Op: Statistically Significant in Favor of Open Repair
○ No statistical significance
Gigante
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
○
○
Returned to Final
II
66
○
Functional Activity‡
● 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.”
Lim
Table 63. Percutaneous vs. Open - Satisfaction
Outcome
Author
%
Duration
LOE
N
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
63
65.5
v1.0 12.04.09
Author
Adverse Event
LOE
N
Duration
(months)
6
65.5
Ng
Wound breakdown/
delay healing
II
68
●P
Ng
Sural Nerve Injury
II
68
○
Lim
II
66
○
II
66
○
Lim
Sural Nerve Problems
Deep Infection with
staphalococcus
Adhesions
II
66
●P
Ng
Scar Adhesion
II
68
●P
Ng
Superficial Infection
II
68
○
Lim
II
66
Ng
Superficial Infection
Superficial Infection
with staphalococcus
Hypertrophic Scar
II
68
Lim
Keloid Formation
II
66
Lim
Lim
●P
○
○
○
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
Author
Adverse Event
LOE
N
Duration
(months)
6
65.5
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,
64
v1.0 12.04.09
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
Outcome
Author
%
Duration
LOE
N
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
Author
Outcome
LOE
N
Duration
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
Outcome
Author
(weeks)
LOE
N
Duration
63.5
12
months
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
Kakiuchi
Outcome
(%)
Symptoms
LOE
N
III
22
Duration
63.5 months
● Mini
● Mini: Statistically Significant in Favor of Minimally Invasive Repair
65
v1.0 12.04.09
● Op: Statistically Significant in Favor of Open Repair
○ No statistical significance
Table 70. Limited Open Repair vs. Open - Complications
Author
Bhattacharyya
Bhattacharyya
Complication
Minor Surgical Site
Infection with
Delayed Wound
Healing
Severe Wound
Infection and
Dehiscence
LOE
N
Duration
6
12
Months
months
III
53
● Mini
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
66
v1.0 12.04.09
EXCLUDED ARTICLES
Table 72. Excluded Studies - All Operative Techniques
Author
Cretnik A, et al
Wagnon R, et al
Assal M, et al
Title
Percutaneous versus open repair of the ruptured Achilles
tendon. a comparative study
The Webb-Bannister percutaneous technique for acute
Achilles' tendon ruptures. a functional and MRI
assessment
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
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
Hohendorff B, et al
Kuwada GT;
Operative treatment of acute Achilles tendon rupture.
Open end-to-end-reconstruction versus reconstruction with
Mitek-anchors
Long-term results after operatively treated Achilles tendon
rupture. fibrin glue versus suture
Critical analysis of tendo Achillis repair using Achilles
tendon rupture classification system and repair
67
Exclusion Reason
Not best available
evidence
Not best available
evidence
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Retrospective case series
suture technique
Not best available
evidence - not
comparative
v1.0 12.04.09
Author
Title
Exclusion Reason
Lansdaal JR, et al
The results of 163 Achilles tendon ruptures treated by a
minimally invasive surgical technique and functional after
treatment
Not best available
evidence - not
comparative
Blankstein A, et al
Percutaneous Achilles tendon repair combined with realtime 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
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
Martinelli B;
Percutaneous repair of the Achilles tendon in athletes
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?
68
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
v1.0 12.04.09
Author
Title
Kiviluoto O, et al
Surgical repair of subcutaneous rupture of the Achilles
tendon
Haggmark T, et al
Calf muscle atrophy and muscle function after nonoperative vs. operative treatment of Achilles tendon
ruptures
Bomler J;Sturup J;
Achilles tendon rupture. An 8-year follow up
Hogsaa B, et al
Surgical treatment of Achilles tendon ruptures
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
Exclusion Reason
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Stochastic
Randomization
Allocation Concealment
Patients Blinded
Those rating outcome
Blinded
Follow Up - 80% or more
All groups have similar
outcome performance at
entry
STUDY QUALITY
Table 73. Study Quality - RCTs
Level II
●
×
×
●
●
×
Level II
●
×
×
●
●
×
Level II
○
●
●
×
●
×
Level II
○
●
●
×
●
×
● = Yes ○ = No
× = Not Reported
Author
Outcome
N
Gigante,
et al.
2008
SF-12.
Physical
Component
39
Gigante,
et al.
2008
SF-12. Mental
Component
39
Lim, et
al.
2001
Complications
66
Lim, et
al.
Duration of
Immobilization
66
Treatment(s)
Open Repair
vs.
Percutaneous
Repair
Open Repair
vs.
Percutaneous
Repair
Open Repair
vs.
Percutaneous
Repair
Open Repair
vs.
Level of
Evidence
69
v1.0 12.04.09
Stochastic
Randomization
Allocation Concealment
Patients Blinded
Those rating outcome
Blinded
Follow Up - 80% or more
All groups have similar
outcome performance at
entry
Level II
○
●
●
×
●
×
Level II
○
●
●
×
●
×
Level II
×
×
×
○
●
●
● = Yes ○ = No
× = Not Reported
Author
Outcome
N
2001
Lim, et
al.
2001
Return to
activities of
daily living
66
Lim, et
al.
2001
Return to
functional
activity
66
Aktas,
et al.
2009
AOFAS
40
Treatment(s)
Percutaneous
Repair
Open Repair
vs.
Percutaneous
Repair
Open Repair
vs.
Percutaneous
Repair
Minimally
Invasive vs.
Open
Level of
Evidence
70
v1.0 12.04.09
Level of
Evidence
All groups have similar
characteristics at entry
All groups have similar
outcome performance at
entry
All groups concurrently
treated
Follow Up - 80% or more
Same center for
experimental and control
group data
Table 74. Quality of Studies - Comparative Studies
Level III
×
×
●
○
●
Level III
×
×
●
○
●
Level III
×
×
●
○
●
Level III
×
×
●
○
●
Level III
×
×
●
○
●
Level III
×
×
●
○
●
Level II
●
×
●
●
●
Level II
●
×
●
●
●
Level III
○
×
●
●
●
Level III
○
×
●
●
●
Level III
○
×
●
●
●
● = Yes ○ = No
× = Not Reported
Author
Outcome
Kakiuchi, et
al. 1995
Return to
Sports
22
Kakiuchi, et
al. 1995
Symptoms None
22
Kakiuchi, et
al. 1995
Symptoms Stiffness
22
Kakiuchi, et
al. 1995
Symptoms Discomfort
22
Kakiuchi, et
al. 1995
Symptoms Pain
22
Kakiuchi, et
al. 1995
Re-rupture
22
Ng, et al. 2006
Return to
Activity Same Level
68
Ng, et al. 2006
Complications
68
Bhattacharyya,
et al. 2009
Bhattacharyya,
et al. 2009
Bhattacharyya,
et al. 2009
Return to
Normal
Walking
Return to
Normal Stair
Climbing
Severe
Wound
Infection and
N
53
53
53
Treatment(s)
Percutaneous
and Minimally
Invasive vs.
Open Repair
Percutaneous
and Minimally
Invasive vs.
Open Repair
Percutaneous
and Minimally
Invasive vs.
Open Repair
Percutaneous
and Minimally
Invasive vs.
Open Repair
Percutaneous
and Minimally
Invasive vs.
Open Repair
Percutaneous
and Minimally
Invasive vs.
Open Repair
Percutaneous
vs. Open
Repair
Percutaneous
vs. Open
Repair
Minimally
Invasive vs.
Open Repair
Minimally
Invasive vs.
Open Repair
Minimally
Invasive vs.
Open Repair
71
v1.0 12.04.09
Level of
Evidence
All groups have similar
characteristics at entry
All groups have similar
outcome performance at
entry
All groups concurrently
treated
Follow Up - 80% or more
Same center for
experimental and control
group data
Level III
○
×
●
●
●
Level III
○
×
●
●
●
● = Yes ○ = No
× = Not Reported
Author
Outcome
N
Treatment(s)
Dehiscence
Bhattacharyya,
et al. 2009
Bhattacharyya,
et al. 2009
Minor
Surgical Site
Infection
Delayed
Wound
Healing
53
53
Minimally
Invasive vs.
Open Repair
Minimally
Invasive vs.
Open Repair
72
v1.0 12.04.09
STUDY RESULTS
Table 75. Limited open vs. Open - Global Outcomes
Author
Outcome
Gigante, et al.
2008
LOE
SF-12 - Physical
Component Score
SF-12- Mental
Component Score
N
Duration
Minimally
Invasive
Open
mean (SD)
mean (SD)
Results
II
39
24 months
52.6 (2.31)
50.7 (2.57)
p = 0.02‡
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
Lim, et al. 2001
Lim, et al. 2001
Return to
Activities of Daily
Living
Returned to Final
Functional
Activity
LOE
N
Duration
Percutaneous
(%)
Open
(%)
Results
II
66
6 months
100%
100%
NS
II
66
6 months
100%
100%
NS
NS: not significant; authors do not report p-value
Table 77. Percutaneous vs. Open - Satisfaction
Author
Outcome
LOE
N
Duration
Percutaneous
(%)
Open
(%)
Results
Lim, et al. 2001
Satisfaction Excellent
II
66
6 months
52%
42%
NS
NS: not significant; authors do not report p-value
Table 78. Percutaneous vs. Open - Complications
Author
Lim, et al
2001
Lim, et al.
2001
Lim, et al.
2001
Lim, et al.
2001
N
Duration
Percutaneous
(%)
Open
(%)
Results
II
66
6 months
3%
6%
p = .55‡
II
66
6 months
3%
0%
p = .15‡
II
66
6 months
0%
3%
II
66
6 months
0%
3%
Complications LOE
Re-rupture
Sural Nerve
Problems
Deep infection
with wound
breakdown and
staphalococcus
infection
Superficial
Infection with
staphalococcus
infection
73
p = 0.155‡
p = 0.155‡
v1.0 12.04.09
Author
N
Duration
Percutaneous
(%)
Open
(%)
Results
II
66
6 months
0%
15%
p=0.001‡
II
66
6 months
0%
3%
p = .15‡
Adhesions
II
66
6 months
0%
6%
p = .043
Wound
Puckering
II
66
6 months
9%
0%
p = .013‡
Deep Infection
II
40
Post
operative
0%
5%
p=0.15‡
II
40
0%
15%
p=0.011‡
II
40
5%
0
p=0.15‡
II
40
0%
5%
p=0.15‡
II
40
0%
5%
p=0.15‡
II
40
0%
5%
p=0.15‡
Complications LOE
Lim, et al.
2001
Lim, et al.
2001
Lim, et al.
2001
Lim, et al.
2001
Aktas, et al.
2009
Superficial
Infection
Keloid
Formation
Aktas, et al.
Superficial
2009
Infection
Aktas, et al.
Insertional
2009
Tendinopathy
Aktas, et al. Stiffness of the
2009
ankle
Aktas, et al.
Large
2009
Hematoma
Aktas, et al.
DVT
2009
‡ AAOS calculation
Post
operative
Post
operative
Post
operative
Post
operative
Post
operative
Table 79. Minimally Invasive vs. Open- Pain
Author
Aktas, et al.
2009
Outcome
LOE
N
Duration
Percutaneous
(%)
Open
(%)
Results
Pain
II
46
22 months
4.5%
13%
P=0.3
Table 80. Minimally Invasive vs. Open- Global Outcomes
Author
Aktas, et al.
2009
Outcome
LOE
N
Duration
Percutaneous
(%)
Open
(%)
Results
Pain
II
46
22 months
4.5%
13%
P=0.3
Table 81. Minimally Invasive vs. Open - Function
Author
Outcome
Bhattacharyya,
et al. 2009
Return to Normal
Walking (weeks)
Return to Normal
Stair Climbing
(weeks)
LOE
N
Duration
Minimally
Invasive
mean (SD)
Open
Repair
mean (SD)
Results
III
53
12 months
12.5 (3)‡
17 (3)‡
p ≤ .001‡
III
53
12 months
14 (3)‡
19 (3.5)‡
p ≤ .001‡
74
v1.0 12.04.09
Author
Outcome
Return to
Activity - Same
Level
‡ AAOS calculation
Ng, et al 2006
LOE
N
Duration
Minimally
Invasive
mean (SD)
Open
Repair
mean (SD)
Results
II
68
65.5
months
96%
88%
p = 0.244
Open
(%)
Results
Table 82. Minimally Invasive vs. Open - Complications
Author
Bhattacharyya,
et al. 2009
Bhattacharyya,
et al. 2009
Complications
Minor Surgical
Site Infection
with Delayed
Wound Healing
Severe Wound
Infection and
Dehiscence
Ng, et al.
Re-rupture
2006
Ng, et al.
Sural Nerve
2006
Injury
Ng, et al.
Superficial
2006
Infection
Ng, et al.
Hypertrophic
2006
Scar
Ng, et al.
Scar Adhesion
2006
Ng, et al.
Wound
2006
Breakdown/delay
‡ AAOS calculation
LOE
N
Duration
Minimally
Invasive Open
Repair
(%)
III
53
12 months
0%
17%
III
53
12 months
0%
7%
p =.034‡
II
68
0%
2%
p = .223‡
II
68
0%
2%
p = .22‡
II
68
8%
5%
p = .58‡
II
68
4%
19%
p = .052‡
II
68
0%
9%
p = .014‡
II
68
0%
12%
p = .005‡
65.5
months
65.5
months
65.5
months
65.5
months
65.5
months
65.5
months
p <.001‡
Table 83. Minimally Invasive vs. Open - Symptoms
Author
Outcome
Kakiuchi, et al.
Symptoms - Pain
1995
Kakiuchi, et al.
Symptoms- None
1995
Kakiuchi, et al.
Symptoms 1995
Stiffness
Kakiuchi, et al.
Symptoms 1995
Discomfort
‡ AAOS calculation
LOE
N
III
22
III
22
III
22
III
22
Duration
63.5
months
63.5
months
63.5
months
63.5
months
75
Minimally
Invasive (%)
Open
(%)
Results
0%
20%
p = .05‡
83%
40%
p <.001‡
17%
30%
p =.78‡
0%
10%
p = .17‡
v1.0 12.04.09
Table 84. Minimally Invasive vs. Open - Return to Sport
Author
Outcome
Return to Sport Same or
increased level
Return to Sport Kakiuchi, et al.
Decreased
1995
Return to Sport No participation
for other reasons
‡ AAOS calculation
Open
(%)
Results
75%
10%
p < .001‡
63.5
months
8%
40%
p = .17‡
63.5
months
17%
50%
p = .27‡
Minimally
Invasive (%)
Open
%
%
0%
0%
LOE
N
Duration
III
22
63.5
months
III
22
III
22
Minimally
Invasive (%)
Table 85. Minimally Invasive vs. Open - Complications
Author
Complications
LOE
N
Duration
Kakiuchi, et al.
63.5
Rerupture
III
22
1995
months
NS: not significant; authors do not report p-value
76
Results
NS
v1.0 12.04.09
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.
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 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
77
v1.0 12.04.09
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
Pajala
II
59
Pain
Aktas
II
30
Pain
Taglialavoro
II
46
Pain
Pajala
II
59
Stiffness
Duration (months)
6
12
42
○
○
○
○
●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
Taglialavoro
II
46
Satisfaction
Pajala
II
59
Satisfaction
Duration
(months)
12
42
○
○
●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
Author
LOE
N
Taglialavoro
II
46
Outcome
Recovery of Daily
Activities (days)
78
Duration (months)
6
42
○
v1.0 12.04.09
Author
LOE
N
Taglialavoro
II
46
Aktas, et al
II
30
Duration (months)
6
42
Outcome
Return to Sports –
Complaints during normal
activity
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
Duration
(months)
12
42
Author
LOE
N
Outcome
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
Author
LOE
N
Outcome
Duration (months)
6
12
Taglialavoro
II
46
PE
42
○
Taglialavoro
II
46
DVT
○
Pajala
II
60
DVT
Aktas
II
30
Deep Infection
Pajala
II
60
Deep Infection
●Op
Pajala
II
60
Superficial
○
○
79
○
v1.0 12.04.09
Author
LOE
N
Outcome
Duration (months)
6
12
42
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
Author
Title
Exclusion Reason
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
Author
Title
Exclusion Reason
Bradley, et al.
1990
Percutaneous and open surgical repairs of Achilles tendon
ruptures. A comparative study
Not best available
evidence
Coull, et al.
2003
Flexor hallucis longus tendon transfer: evaluation of
postoperative morbidity
Not best available
evidence
Cretnik, et al.
2004
Incidence and outcome of rupture of the Achilles tendon
Not best available
evidence
Dekker, et al.
1977
Elias, et al.
2007
Garabito, et al.
2005
Hahn, et al.
2008
Jessing, et al.
1975
Results of surgical treatment of rupture of the Achilles
tendon with use of the plantaris tendon
Reconstruction for missed or neglected Achilles tendon
rupture with V-Y lengthening and flexor hallucis longus
tendon transfer through one incision
Augmented repair of acute Achilles tendon ruptures using
gastrocnemius-soleus fascia
Treatment of chronic Achilles tendinopathy and ruptures
with flexor hallucis tendon transfer: clinical outcome and
MRI findings
Surgical treatment of 102 tendo achillis ruptures-- suture or
tenontoplasty?
80
Not best available
evidence
Neglected/chronic
Achilles tear patients
Not best available
evidence
Less than 10 patients
per group
Not best available
evidence
v1.0 12.04.09
Author
Title
Exclusion Reason
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
Not best available
evidence
Lynn, et al.
1966
Repair of the torn Achilles tendon, using the plantaris tendon
as a reinforcing membrane
Less than 50% followup
Maffulli, et al.
2005
Free gracilis tendon graft in neglected tears of the Achilles
tendon
Neglected/chronic
Achilles tear patients
Roberts, et al.
1989
Team physician #6. Surgical treatment of Achilles tendon
rupture
Not best available
evidence
Schedl, et al.
1979
Achilles tendon repair with the plantaris tendon compared
with repair using polyglycol threads
Not best available
evidence
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
Fernandez-Fairen, et
al.
1997
Hohendorff, et al.
2008
Title
Exclusion Reason
Augmented repair of Achilles tendon ruptures
Retrospective case
series
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
Parsons, et al.
1989
Long-term follow-up of Achilles tendon repair with an
absorbable polymer carbon fiber composite
Combines acute and
neglected/chronic
Achilles tendon tear
patients
Patients had prior
surgical or
conservative treatment
Table 95- Biologic Adjuncts
Author
Title
Exclusion Reason
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
Less than 10 patients
per group
81
v1.0 12.04.09
Stochastic Randomization
Allocation Concealment
Patients Blinded
Follow Up - 80% or more
Outcome
N
Treatment(s)
Level of
Evidence
Those rating outcome Blinded
All groups have similar outcome
performance at entry
STUDY QUALITY
Table 96. Study Quality – Autograft RCTs
Stiffness
60
Open vs. Autograft
Augmentation
Level II
●
●
●
○
●
×
Footwear
Restrictions
60
Open vs. Autograft
Augmentation
Level II
●
●
●
○
●
×
Pain
60
Open vs. Autograft
Augmentation
Level II
●
●
●
○
●
×
Satisfaction
60
Open vs. Autograft
Augmentation
Level II
●
●
●
○
●
×
Re-rupture
60
Open vs. Autograft
Augmentation
Level II
●
●
●
○
●
×
Deep Infection
60
Open vs. Autograft
Augmentation
Level II
●
●
●
○
●
×
DVT
60
Open vs. Autograft
Augmentation
Level II
●
●
●
○
●
×
Superficial
Infection
60
Open vs. Autograft
Augmentation
Level II
●
●
●
○
●
×
Return to sport
30
Open vs. Autograft
Augmentation
Level II
×
×
●
○
●
×
Pain
30
Open vs. Autograft
Augmentation
Level II
○
●
●
○
●
×
● = Yes ○ = No
× = Not Reported
Author
Pajala, et
al.
2009
Pajala, et
al.
2009
Pajala, et
al.
2009
Pajala, et
al.
2009
Pajala, et
al.
2009
Pajala, et
al.
2009
Pajala, et
al.
2009
Pajala, et
al.
2009
Aktas, et
al.
2007
Aktas, et
al.
2007
82
v1.0 12.04.09
Stochastic Randomization
Allocation Concealment
Patients Blinded
Follow Up - 80% or more
N
Treatment(s)
Level of
Evidence
Those rating outcome Blinded
Outcome
All groups have similar outcome
performance at entry
Deep Infection
30
Open vs. Autograft
Augmentation
Level II
○
●
●
○
●
×
Re-rupture
30
Open vs. Autograft
Augmentation
Level II
○
●
●
○
●
×
● = Yes ○ = No
× = Not Reported
Author
Aktas, et
al.
2007
Aktas, et
al.
2007
Follow Up - 80% or more
Outcome
N
Treatment(s)
Level of
Evidence
All groups have similar outcome
performance at entry
All groups concurrently
treated
Author
All groups have similar characteristics
at entry
Same center for experimental and
control group data
Table 97. Study Quality - Autograft Comparative Studies
Taglialavoro,
et al 2004
Pain
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
Recovery of
Daily Activities
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
Return to Sports
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
Satisfaction
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
Hospitalization
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
● = Yes ○ = No
× = Not Reported
83
v1.0 12.04.09
N
Treatment(s)
Level of
Evidence
All groups have similar outcome
performance at entry
Follow Up - 80% or more
Outcome
All groups have similar characteristics
at entry
All groups concurrently
treated
Author
Same center for experimental and
control group data
Taglialavoro,
et al 2004
Immobilization
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
DVT
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
PE
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
Dysesthesia
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
Shoe conflict
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
Keloid
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
Taglialavoro,
et al 2004
Dehiscence
46
Open vs. Autograft
Augmentation
Level II
●
●
●
●
●
● = Yes ○ = No
× = Not Reported
84
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Consecutive enrollment
of patients
Follow Up - 80% or more
Author
Outcome
N
Treatment(s)
Level of
Evidence
All patients evaluated using
same outcome measures
All patients receive same treatment
All patients have approximately
equal follow-up times
Table 98. Study Quality - Synthetic Tissue Case Series
Giannini et
al, 1994
Return to Sports
15
Synthetic Adjunctive
Augmentation
Level IV
●
●
●
●
●
15
Synthetic Adjunctive
Augmentation
Level IV
●
●
●
●
●
15
Synthetic Adjunctive
Augmentation
Level IV
●
●
●
●
●
15
Synthetic Adjunctive
Augmentation
Level IV
●
●
●
●
●
● = Yes ○ = No
× = Not Reported
Giannini et
al, 1994
Giannini et
al, 1994
Giannini et
al, 1994
Return to
Previous
Activity
Subjective
ResultsExcellent
Full weight
bearing (weeks)
Giannini et
al, 1994
Rerupture
15
Synthetic Adjunctive
Augmentation
Level IV
●
●
●
●
●
Giannini et
al, 1994
Healing
Impairment
15
Synthetic Adjunctive
Augmentation
Level IV
●
●
●
●
●
Giannini et
al, 1994
Return to
Swimming
15
Synthetic Adjunctive
Augmentation
Level IV
●
●
●
●
●
85
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STUDY RESULTS
Table 99 Autograft vs. Open Pain and Stiffness
Author
Pajala, et al.
2009
Aktas, et al.
2007
Aktas, et al.
2007
Taglialavoro,
et al 2004
Taglialavoro,
et al 2004
Taglialavoro,
et al 2004
Taglialavoro,
et al 2004
Pajala, et al.
2009
Outcome
LOE
N
Duration
Adjunctive
Augmentation
%
Open
Results
%
No Pain vs. Pain
II
59
12
months
79% (4%)
90% (0%)
p = 0.35
Pain - Absent‡
II
30
6 months
94%
86%
NS
Pain - Mild w/ maximal
exertion‡
II
30
6 months
6%
14%
NS
Pain - Absentª
II
46
83%
73%
NS
II
46
17%
18%
NS
II
46
0%
5%
NS
Pain - Continuousª
II
46
0%
5%
NS
No stiffness vs. stiffness
II
59
12
months
46% (36%
72% (16%)
p = .10
Duration
Adjunctive
Augmentation
(%)
Open (%)
Results
71% (11%)
71% (19%)
p = 0.55
46%
46%
p = .98‡
42%
46%
p = .8‡
13%
0%
p = .01‡
0%
9%
p = .04‡
Pain - During Intense
Trainingª
Pain - During Moderate
Trainingª
42
months
42
months
42
months
42
months
‡American Orthopaedic Foot and Ankle Score
NS: not significant; authors do not report p-value
Table 100. Autograft vs. Open - Satisfaction
Author
Outcome
Pajala, et al. Very satisfied vs. all other
2009
satisfaction levels
Taglialavoro,
Satisfaction - Very Goodª
et al 2004
Taglialavoro,
Satisfaction - Goodª
et al 2004
Taglialavoro,
Satisfaction - Fairª
et al 2004
Taglialavoro,
Satisfaction - Poorª
et al 2004
ª Modified McComis Score
‡ AAOS Calculation
LOE
N
II
59
II
46
II
46
II
46
II
46
12
months
42
months
42
months
42
months
42
months
86
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Table 101. Autograft vs. Open - Return to Sports
Author
Outcome
Aktas, et al.
2007
Taglialavoro,
et al 2004
Taglialavoro,
et al 2004
Taglialavoro,
et al 2004
Taglialavoro,
et al 2004
Return to Sports - Same
Level / Pre-injury
Return to Sports Complete
Return to Sports - Low
Loss
Return to Sports Decreased
Return to Sports - Not
Recovered
Return to Sports Taglialavoro,
Complaints during
et al 2004
normal activity
‡ AAOS Calculation
LOE
N
Duration
Adjunctive
Augmentation
(%)
Open
(%)
Results
II
30
6 months
85%
89%
p = .620‡
II
46
38%
32%
NS
II
46
50%
55%
NS
II
46
8%
9%
NS
II
46
4%
0%
NS
II
46
0%
5%
NS
42
months
42
months
42
months
42
months
42
months
NS: not significant; authors do not report p-value
Table 102. Autograft vs. Open - Return to Activities
Author
Outcome
Taglialavoro,
Recovery of Daily
et al 2004
Activities(days)
‡ AAOS Calculation
LOE
N
II
46
Adjunctive
Open
Duration Augmentation
mean(SD)
mean (SD)
42
128 (39)
106 (66)
months
Results
p = .17‡
Table 103. Autograft vs. Open - Footwear Restrictions
Author
Outcome
LOE
N
Duration
Adjunctive
Augmentation
(%)
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
Open (%)
Results
‡ AAOS Calculation
NS: not significant; authors do not report p-value
87
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Table 104. Autograft vs. Open - Hospitalization vs. Immobilization
Author
Taglialavoro,
et al 2004
Taglialavoro,
et al 2004
Outcome
LOE
N
Duration
Hospitalization (days)
II
46
Immobilization (days)
II
46
42
months
42
months
Adjunctive
Augmentation
mean (SD)
Open
mean(SD)
Results
8.2 (2.3)
5.0 (1.9)
p <.001‡
63.9 (15.8)
49.5
(10.6)
p <.001‡
‡ AAOS Calculation
Table 105. Autograft vs. Open - Complications
Author
Taglialavoro,
et al 2004
Taglialavoro,
et al 2004
Pajala, et al.
2009
Complication
LOE
N
Duration
Adjunctive
Augmentation
Open
Repair
%
%
Results
PE
II
46
42 months
4%
0%
NS
DVT
II
46
42 months
4%
14%
NS
DVT
II
60
3 weeks
4%
0%
NS
Pajala, et al.
Deep Infection
II
60
12 months
7%
0%
p = .04‡
2009
Aktas et al.
Deep Infection
II
30
6 months
6%
0%
NS
2007
Pajala, et al.
Superficial
II
60
12 months
4%
13%
NS
2009
Infection
Pajala, et al.
Re-rupture‡
II
60
12 months
11%
9%
NS
2009
Aktas et al.
Re-rupture
II
30
6 months
0%
0%
NS
2007
Taglialavoro,
Dysesthesia
II
46
42 months
13%
14%
NS
et al 2004
Taglialavoro,
Keloid
II
46
42 months
8%
5%
NS
et al 2004
Taglialavoro,
Dehiscence
II
46
42 months
13%
9%
NS
et al 2004
‡ 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
88
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Table 106. Synthetic Tissue - Results
Author
Outcome
LOE
N
Duration
Adjunctive
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%
Rerupture
IV
15
Healing Impairment
IV
15
Giannini et al,
1994
Giannini et al,
1994
89
18
months
18
months
0%
0%
v1.0 12.04.09
RECOMMENDATION 10
We cannot recommend for or against the use of antithrombotic treatment for patients with
acute Achilles tendon ruptures.
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 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
Author
Title
Nilsson-Helander,
et al. 2009
High Incidence of deep venous thrombosis after Achilles tendon
rupture: a prospective study
Lapidus, et al.
2007
Prolonged thromboprophylaxis with dalteparin after surgical treatment
of Achilles tendon rupture: a randomized, placebo-controlled study
Lassen, et al.
2002
Exclusion Reason
Not Relevant; Does
not answer the
recommendation.
Less than 50%
follow up
Less than 80%
Use of the low-molecular-weight heparin reviparin to prevent deepAchilles tendon tear
vein thrombosis after leg injury requiring immobilization
patients
90
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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 postoperative 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.
91
v1.0 12.04.09
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.
Supporting Evidence:
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
Maffulli, et al.(a)
Maffulli, et al (b)
Costa, et al.
Post operative Instructions
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.
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.
Early weight bearing group: Immediate weight bearing and
mobilization using carbon fibre orthosis with 1.5 cm heal raises.
92
v1.0 12.04.09
Suchak, et al.
Non-weight bearing group: Traditional plaster cast.
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.
93
v1.0 12.04.09
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
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
○‡
94
1.5 2 3 6
12
v1.0 12.04.09
Result (months)
Author
Outcome
LoE
N
Maffulli, et al 2003 (b) Pain- Mild, Occasional
II
53
○‡
Maffulli, et al 2003 (b)
II
53
○‡
Pain- Moderate
1.5 2 3 6
12
Wb= weight bearing
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
95
v1.0 12.04.09
Table 111 Function
Author
Outcome
Result (months)
LoE
N
1.5
●wb
6
12
Suchak, et al
2008
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (b)
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (b)
Suchak, et al
2008 (a)
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (b)
No Limitations or Limitations only in
recreation
II
110
No Limitations
II
53
○‡
No Limitations
II
53
○
53
○‡
53
○‡
Costa, et al 2006
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (b)
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (b)
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (b)
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (b)
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (b)
Activity Limitation - Limited
Recreational but not Daily Activities
Activity Limitation - Limited
Recreational but not Daily Activities
II
II
○‡
Return to at least partial sports
II
38
Return to Sports
II
48
○‡
Return to Sports
II
53
○‡
Return to Sports
II
48‡‡
●wb
Return to Work
II
49
○‡
Return to Work
II
53
○‡
Changed Jobs
II
49
○‡
○‡
Changed Jobs
Experience Problems at work due to
injury
Experience Problems at work due to
injury
Footwear restrictions- None, mild
(most shoes tolerated)
Footwear restrictions- None, mild
(most shoes tolerated)
Footwear restrictions- Moderate
(unable to tolerate fashionable shoes,
with or without insert)
Footwear restrictions- Moderate
(unable to tolerate fashionable shoes,
with or without insert)
49
○‡
53
○‡
II
53
○‡
II
53
○‡
II
II
53
○‡
II
II
○‡
53
Wb= weight bearing
○= no statistically significant difference
●= statistically significant difference
96
v1.0 12.04.09
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
Table 112 EuroQoL, Rand-36
Author
Outcome
LoE
N
Costa, et al
EuroQoL - Health
II
48‡‡
2006
Score
Costa, et al
EuroQoL - E5D
II
48‡‡
2006
Suchak, et al
Rand-36 Physical
II
110
2008
Functioning
Suchak, et al
Rand-36 Social
II
110
2008
Functioning
Suchak, et al
Rand-36 Vitality
II
110
2008
Suchak, et al
Rand-36 RoleII
110
2008
Emotional
Wb= weight bearing
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
Results (Months)
1.5
2
6
12
○ ○
○
○ ○
○
●wb
●wb
●wb
●wb
Table 113 Patient Subjective Results
Author
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (a)
Maffulli, et al
2003 (a)
Outcome
Patient opinion
of resultsExcellent
Percent satisfied
with results of
surgery
Patient opinion
of resultsExcellent
Percent satisfied
with results of
surgery
LoE
N
Results
(Months)
12 months
II
53
○‡
II
53
○‡
II
53
○‡
II
53
○‡
Wb= weight bearing
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
97
v1.0 12.04.09
Table 114 Reruptures
Author
LoE
Duration
N
Weight
Bearing
Non-Weight
Bearing
Costa,
et al
II
1 year
48‡‡
8.69%
0%
2006
‡‡= Open cast group converted to orthosis at 3 weeks;
●‡ nwb= statistically significant difference in favor of non-weight bearing
98
Statistically
Significant Difference
●‡ nwb
v1.0 12.04.09
SUMMARY OF COMPLICATIONS
Table 115 Reported Complications
Author
Suchak,
et al
2008
Suchak,
et al
2008
Suchak,
et al
2008
NonStatistically
Weight Significant
Bearing Difference
Complication
LoE
Duration
N
Weight
Bearing
DVT
II
6 months
110
0%
2%
○‡
Necrosis of the
skin
II
6 months
110
0%
2%
○‡
Sural nerve
dysesthesias,
superficial
infections,
delayed wound
healing, scar
adhesions.
II
6 months
110
15%
16%
○‡
Maffulli,
Superficial
et al
II
12 months
53
7.69%
7.40%
○‡
Infection
2003 (a)
Maffulli, Hypersensitivity
et al
of surgical
II
10-12 wks
53
15.38% 18.51%
○‡
2003 (a)
wounds
Maffulli,
Hypertrophic
et al
II
10-12 weeks
53
3.84%
0%
○‡
Scar
2003 (a)
Costa, et
Minor wound
II
Nr
48‡‡
26%
21%
○‡
al 2006
complications
Costa, et
Persistent
II
Nr
48‡‡
0%
4.3%
○‡
al 2006
paraethesiae
Maffulli, Hypersensitivity
12%
4%
et al
of surgical
II
10-12 wks 53‡‡‡
○‡
2003 (b)
wounds
Maffulli,
Hypertrophic
4%
4%
et al
II
10-12 weeks 53‡‡‡
○‡
Scar
2003 (b)
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
99
v1.0 12.04.09
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).
Lynch, RM 2004
"Early functional mobilisation is more acceptable to patients than
plaster cast immobilisation and results in improved functional
outcomes" (p. 156).
Suchak, AA et al. 2006
"An early functional rehabilitation protocol for Achilles tendon
ruptures improves patient satisfaction with reduction in minor
complications and no increase in rerupture rate or infection rate"
(p. 220).
100
v1.0 12.04.09
EXCLUDED ARTICLES
Table 117 Article Inclusion List- Early weight bearing vs. non-weight bearing
Author
Title
Exclusion Reason
Costa, et al.
2003
Wagnon, et
al.
2005
Immediate full-weight bearing mobilisation for
repaired Achilles tendon ruptures: a pilot study
The Webb-Bannister percutaneous technique for
acute Achilles' tendon ruptures: a functional and MRI
assessment
Less than 10 patients per
group
Aoki, et al.
1998
Early active motion and weight bearing after crossstitch 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
Immediate free ankle motion after surgical repair of
acute Achilles tendon ruptures
101
No patient-oriented
outcome
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
Not best available
evidence - not
comparative
v1.0 12.04.09
Treatment(s)
LoE
Allocation Concealment
Patients Blinded
N
Stochastic Randomization
Those rating outcome Blinded
Follow Up - 80% or more
All groups have similar outcome performance
at baseline
STUDY QUALITY
Table 118. Quality- Weight bearing vs. non-weight bearing- RCT
II
●
●
×
×
●
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Outcome
Costa, et
al.
2006
Return to Sports
43
Weight bearing
vs. Non-weight
bearing
Costa, et
al.
2006
Return to Sport
(weeks) ‡‡
43
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
●
Costa, et
al.
2006
Return to Normal
Walking (weeks)
43
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
●
Costa, et
al.
2006
Return to Normal
Stair Climbing
(weeks)
43
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
●
Costa, et
al.
2006
Return to Work
(weeks)
43
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
●
Costa, et
al.
2006
EuroQoL - Health
Score‡‡
43
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
Costa, et
al.
2006
EuroQoL - E5D‡
43
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
102
v1.0 12.04.09
Outcome
N
Treatment(s)
LoE
Stochastic Randomization
Allocation Concealment
Patients Blinded
Author
Those rating outcome Blinded
Follow Up - 80% or more
All groups have similar outcome performance
at baseline
Suchak, et
al.
2008
RAND-36:
Physical Function
109
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
Suchak, et
al.
2008
RAND-36: Mental
health
109
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
Suchak, et
al.
2008
Complications
110
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
Suchak, et
al.
2008
RAND-36: Social
Functioning
109
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
Suchak, et
al.
2008
RAND-36: Rolephysical
109
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
Suchak, et
al.
2008
RAND-36: Bodily
pain
109
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
Suchak, et
al.
2008
RAND-36:
General health
109
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
Suchak, et
al.
2008
RAND-36:
Vitality
109
Weight bearing
vs. Non-weight
bearing
II
●
●
×
×
●
×
● = Yes ○ = No × = Not Reported
n/a = not applicable
103
v1.0 12.04.09
Suchak, et
al.
2008
RAND-36: Roleemotional
109
Weight bearing
vs. Non-weight
bearing
II
104
All groups have similar outcome performance
at baseline
LoE
Follow Up - 80% or more
Treatment(s)
Those rating outcome Blinded
N
Patients Blinded
Outcome
Allocation Concealment
Author
Stochastic Randomization
● = Yes ○ = No × = Not Reported
n/a = not applicable
●
●
×
×
●
×
v1.0 12.04.09
All groups have similar characteristics at entry
All groups have similar outcome performance at entry
All groups concurrently treated
Follow Up - 80% or more
Same center for experimental and control group data
Table 119. Quality- Weight bearing vs. non-weight bearing- Comparative
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Outcome
N
Maffulli,
et al.
2003 (a)
Pain- None
53
Maffulli,
et al.
2003 (a)
Pain- Mild,
Occasional
53
Maffulli,
et al.
2003 (a)
Pain- Moderate
53
Maffulli,
et al.
2003 (a)
Return to Sports
53
Maffulli,
et al.
2003 (a)
Return to Sports
(months)
53
Maffulli,
et al.
2003 (a)
Return to Work
(weeks)
53
Treatment(s)
Weight
Bearing vs.
Non-Weight
Bearing
Weight
Bearing vs.
Non-Weight
Bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
105
LoE
v1.0 12.04.09
All groups have similar characteristics at entry
All groups have similar outcome performance at entry
All groups concurrently treated
Follow Up - 80% or more
Same center for experimental and control group data
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
Weight
Bearing vs.
Non Weight
II
●
●
x
●
●
Weight
Bearing vs.
Non-weight
bearing
II
●
●
x
●
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Outcome
N
Maffulli,
et al.
2003 (a)
Return to Work
53
Maffulli,
et al.
2003(a)
Changed Jobs
53
Maffulli,
et al.
2003 (a)
Experience
Problems at work
due to injury
53
Maffulli,
et al.
2003 (a)
Full weight
bearing (wks)
53
Maffulli,
et al.
2003 (a)
Activity Limitation
- None
53
Maffulli,
et al.
2003(a)
Activity Limitation
- Limited
Recreational but
not Daily
Activities
53
Maffulli,
et al.
2003 (a)
Discharged from
Physiotherapy
(months)
53
Treatment(s)
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
106
LoE
v1.0 12.04.09
All groups have similar characteristics at entry
All groups have similar outcome performance at entry
All groups concurrently treated
Follow Up - 80% or more
Same center for experimental and control group data
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Outcome
Maffulli,
et al.
2003 (a)
Physiotherapy
sessions (visits)
Maffulli,
et al.
2003 (a)
Maffulli,
et al.
2003 (a)
Footwear
restrictions- None,
mild (most shoes
tolerated)
Footwear
restrictionsModerate (unable
to tolerate
fashionable shoes,
with or without
insert)
N
53
53
53
Maffulli,
et al.
2003 (a)
Percent satisfied
with results of
surgery
53
Maffulli,
et al.
2003 (a)
Patient opinion of
results- Excellent
53
Maffulli,
et al.
2003 (b)
Pain- None
53
Treatment(s)
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non Weight
Bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-Weight
Bearing
107
LoE
v1.0 12.04.09
All groups have similar characteristics at entry
All groups have similar outcome performance at entry
All groups concurrently treated
Follow Up - 80% or more
Same center for experimental and control group data
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Outcome
N
Maffulli,
et al.
2003 (b)
Pain- Mild,
Occasional
53
Maffulli,
et al.
2003 (b)
Pain- Moderate
53
Maffulli,
et al.
2003 (b)
Return to Sports
53
Maffulli,
et al.
2003 (b)
Return to Sports
(months)
53
Maffulli,
et al.
2003 (b)
Return to Work
(weeks)
51
Maffulli,
et al.
2003 (b)
Return to Work
51
Maffulli,
et al.
2003(b)
Changed Jobs
51
Treatment(s)
Weight
Bearing vs.
Non-Weight
Bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
108
LoE
v1.0 12.04.09
All groups have similar characteristics at entry
All groups have similar outcome performance at entry
All groups concurrently treated
Follow Up - 80% or more
Same center for experimental and control group data
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Outcome
N
Maffulli,
et al.
2003 (b)
Experience
Problems at work
due to injury
51
Maffulli,
et al.
2003 (b)
Full weight
bearing (wks)
56‡‡
Maffulli,
et al.
2003 (b)
Activity Limitation
- None
53
Maffulli,
et al.
2003(b)
Activity Limitation
- Limited
Recreational but
not Daily
Activities
53
Maffulli,
et al.
2003 (b)
Discharged from
Physiotherapy
(months)
56‡‡
Maffulli,
et al.
2003 (b)
Physiotherapy
sessions (visits)
56‡‡
Maffulli,
et al.
2003 (b)
Footwear
restrictions- None,
mild (most shoes
tolerated)
53
Treatment(s)
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non Weight
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non Weight
Bearing
109
LoE
v1.0 12.04.09
Treatment(s)
LoE
All groups have similar characteristics at entry
All groups have similar outcome performance at entry
All groups concurrently treated
Follow Up - 80% or more
N
Same center for experimental and control group data
53
Weight
Bearing vs.
Non-weight
bearing
II
●
●
x
●
●
II
●
●
x
●
●
II
●
●
x
●
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Outcome
Maffulli,
et al.
2003 (b)
Footwear
restrictionsModerate (unable
to tolerate
fashionable shoes,
with or without
insert)
Maffulli,
et al.
2003 (b)
Percent satisfied
with results of
surgery
53
Maffulli,
et al.
2003 (b)
Patient opinion of
results- Excellent
53
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
110
v1.0 12.04.09
STUDY RESULTS
Table 120 Study Data: Weight Bearing vs. Non-Weight Bearing
Weight Non-Weight
Bearing
Bearing
Result
110
61.4 (SD
29.4)
47.6 (SD
34.4)
p = 0.03
6 week
110
72.7 (SD
28.5)
60.7 (SD
26.8)
p = 0.03
II
6 week
110
69.4 (SD
23.7)
60.6 (SD
21.1)
p = 0.04
II
6 week
110
84.6 (SD
32.0)
67.3 (SD
43.1)
p = 0.02
No Limitations or
Suchak, et al
Limitations only in
2008
recreation
II
6 week
110
43%
9%
p = <.001
Suchak, et al
2008
II
6 months 110
67%
63%
p=0.68
Author
Outcome
Suchak, et al
2008
Rand-36 Physical
Functioning
II
6 week
Suchak, et al
2008
Rand-36 Social
Functioning
II
Suchak, et al
2008
Rand-36 Vitality
Suchak, et al
2008
Rand-36 RoleEmotional
Return to at least
partial sports
LoE Duration N
Maffulli, et al Full weight bearing
2003(a)
(wks)
II
12
months
53
2.5 (SD
0.4)
5.5 (SD 2.2) p = 0.021
Maffulli, et al
2003(a)
Physiotherapy
sessions (visits)
II
12
months
53
6.1 (SD
3.1)
13.6 (SD 4.8) p = 0.03
Maffulli, et al
2003(a)
Discharged from
Physiotherapy
(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 ‡
Maffulli, et al
2003(a)
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 ‡
Maffulli, et al Activity Limitation 2003(a)
None
II
12
months
53
92%
93%
p=0.97‡
Activity Limitation Maffulli, et al Limited Recreational
2003(a)
but not Daily
Activities
II
12
months
53
8%
7%
p=0.97
111
v1.0 12.04.09
LoE Duration N
Weight Non-Weight
Bearing
Bearing
Author
Outcome
Maffulli, et al
2003(a)
Return to Sports
II
12
months
38
89%
89%
p=0.99 ‡
Maffulli, et al
2003(a)
Return to Sports
(months)
II
12
months
53
5.1 (SD
2.8)
6 (SD 3)
p= 0.04
12
months
53
96%
93%
p=0.57‡
12
months
53
4%
7%
p=0.57‡
Footwear restrictionsNone, mild (most
II
shoes tolerated)
Footwear restrictionsModerate (unable to
Maffulli, et al
tolerate fashionable II
2003(a)
shoes, with or without
insert)
Maffulli, et al
2003(a)
Result
Maffulli, et al Percent satisfied with
2003(a)
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‡
Maffulli, et al
2003(a)
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‡
Maffulli, et al Experience Problems
2003(a)
at work due to injury
II
12
months
49
2
4
.p=0.41‡
Maffulli, et al Full weight bearing
2003 (b)
(wks)
II
6 weeks
53‡‡
‡
2.5 (SD
0.4)
5.7 (SD 2.2)
P=0.013
Maffulli, et al
2003 (b)
Physiotherapy
sessions (visits)
II
12
53‡‡
months
‡
8.3 (SD
4.1)
14.6 (SD 5.3) p = 0.008
Maffulli, et al
2003(b)
Discharged from
Physiotherapy
(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
112
v1.0 12.04.09
Weight Non-Weight
Bearing
Bearing
Result
48‡‡
12.5 (CI
18 (CI 18-22)
10-18)
p= 0.03
1 year
48‡‡
13 (CI 1022 (CI 18-22)
18)
p= 0.02
1 year
48‡‡ 8 (CI 2-13) 4(CI 1-13)
Author
Outcome
Costa, et al
2006
Return to Normal
Walking (weeks)
II
1 year
Costa, et al
2006
Return to Normal
Stair Climbing
(weeks)
II
Costa, et al
2006
Return to Work
(weeks)
II
Costa, et al
2006
EuroQoL - Health
Score
II
2 months 48‡‡
75 (IQR
70-85)
75 (IQR 6580)
p= 0.85
Costa, et al
2006
EuroQoL - Health
Score
II
6 months 48‡‡
85 (IQR
80-90)
81 (IQR 7595)
p= 0.96
Costa, et al
2006
EuroQoL - Health
Score‡‡
II
84 (IQR
75-95)
90 (IQR 8595)
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 0.8 (IQR 0.80.7-1.0)
1.0)
p= 0.96
Costa, et al
2006
EuroQoL - E5D
II
1 year
48‡‡
1 (IQR
0.9-1.0)
1(IQR 0.81.0)
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
Necrosis of the skin
2008
II
6 months 110
0
2%
p= 0.14‡
Sural nerve
dysesthesias,
Suchak, et al superficial infections,
2008
delayed wound
healing, scar
adhesions.
II
6 months 110
15%
16%
p= 0.89‡
Maffulli, et al
Superficial Infection
2003(a)
II
12
months
53
7.69%
7.40%
p= 0.97‡
II
Nr
48‡‡
26%
21%
p=0.17‡
Costa, et al
2006
Minor wound
complications
LoE Duration N
1 year
113
48‡‡
p= 0.59
v1.0 12.04.09
Author
Outcome
Costa, et al
2006
Persistent
paraethesiae
LoE Duration N
Weight Non-Weight
Bearing
Bearing
Result
II
Nr
48‡‡
0%
4.3%
p= 0.60‡
Maffulli, et al Hypersensitivity of
2003(a)
surgical wounds
II
10-12
wks
53
15.38%
18.51%
p= 0.76‡
Maffulli, et al
Hypertrophic Scar
2003(a)
II
10-12
weeks
53
3.84%
0%
p= 0.15‡
Maffulli, et al
2003 (b)
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
Maffulli, et al Activity Limitation 2003 (b)
None
II
12
months
53
0.96
89%
p=0.37
Activity Limitation Maffulli, et al Limited Recreational
2003 (b)
but not Daily
Activities
II
12
months
53
4%
11%
p=0.91
Maffulli, et al
2003 (b)
II
12
months
53‡
89%
89%
p=0.93
II
12
53‡‡
5.2 (SD 3) 6.1 (SD 2.8)
months
‡
p=0.45
12
months
53
96%
96%
p=0.33
12
months
53
4%
4%
p=0.97
Return to Sports
Maffulli, et al Time until Return to
2003 (b)
Sports (months)
Footwear restrictionsNone, mild (most
II
shoes tolerated)
Footwear restrictionsModerate (unable to
Maffulli, et al
tolerate fashionable II
2003 (b)
shoes, with or without
insert)
Maffulli, et al
2003 (b)
Maffulli, et al Percent satisfied with
2003 (b)
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
114
v1.0 12.04.09
Author
Outcome
LoE Duration N
Weight Non-Weight
Bearing
Bearing
Result
Maffulli, et al Experience Problems
2003 (b) at work due to injury
II
12
months
49
20%
11%
p=0.91
Maffulli, et al Hypersensitivity of
2003 (b)
the surgical wound
II
6 weeks
53
12%
4%
p=0.97
Maffulli, et al
Hypertrophic scar
2003 (b)
II
6 weeks
53
4%
4%
p=0.97
‡= AAOS calculations
115
v1.0 12.04.09
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
116
v1.0 12.04.09
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
Costa, et al.
Mortensen, et al.
Cetti, et al.
Kangas, et al
Maffulli, et al. (a)
Post operative Instructions
Mobilization group: Immediate weight bearing and mobilization
using carbon fibre orthosis with 1.5 cm heal raises.
Immobilization group: Traditional plaster cast.
Mobilization group: Below the knee dorsal plaster splint followed by
walker brace.
Immobilization group: Below the knee plaster cast
Mobilization group. Mobile cast
Immobilization group. Rigid below the knee cast
Mobilization group. Below the knee dorsal cast for 6 weeks, this
allowed for free plantar flexion.
Immobilization group. Below the knee plaster cast
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
117
v1.0 12.04.09
Author
Maffulli,
et al
2003(a)
Costa, et al
2005
Cetti, et al.
1994
Costa, et al
2005
Costa, et al
2005
Costa, et al
2005
Cetti, et al.
1994
Maffulli,
et al
2003(a)
Maffulli,
et al
2003(a)
Outcome
Return to
Sports
(months)
Time in
weeks taken
to return to
sport
Return to
same level of
sports
activities
Time in
weeks until
return to stair
climbing
Time in
weeks taken
to return to
walking
Time in
weeks taken
to return to
work.
LoE
II
Comparison
Early Motion
vs.
Immobilization
Time to
return
53
●em
II
Early Motion
vs.
Cast
48‡‡
○
II
Early Motion
vs.
Cast
60
●em
II
Early Motion
vs.
Cast
48‡‡
●em
II
Early Motion
vs.
Cast
48‡‡
●em
II
Early Motion
vs.
Cast
48‡‡
○
60
●em
53
●em
53
●em
53
●em
53
●em
Mean Sick
leave (days)
II
Return to
Work (weeks)
II
Full weight
bearing (wks)
II
Early Motion
vs.
Cast
Early Motion
Vs.
Immobilization
Early Motion
Vs.
Immobilization
Early Motion
Vs.
Immobilization
Physiotherapy
sessions
II
(visits)
Discharged
Early Motion
Maffulli,
from
II
Vs.
et al 2003 Physiotherapy
Immobilization
(months)
em= early motion
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
Maffulli,
et al 2003
N
118
v1.0 12.04.09
Table 123. Pain
Author
Outcome
LoE
Comparison
N
1
Kangas, et al
2002
Vas Pain
II
Maffulli, et al
2003
Pain- None
II
Maffulli, et al
2003
Pain- Mild,
Occasional
II
Maffulli, et al
2003
Pain- Moderate
II
Early Motion
vs.
Cast
●em
50
Early Motion
vs.
Immobilization
Early Motion
Vs.
Immobilization
Early Motion
Vs.
Immobilization
Duration
(Months)
3
6
○
12
○
53
○
53
○
53
○
em= early motion
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
Table 124. Function
Author
Outcome
LoE
Comparison
N
3
Costa, et al
2005
Return to
sports
II
Mortensen,
et al
1999
Return to
sports
II
Maffulli, et
al 2003
Return to
Sports
II
Cetti, et al.
1994
Mortensen,
et al
1999
Cetti, et al.
1994
Cetti, et al.
1994
Return
sports
activities
Reached
pre-injury
level
Return to
lesser level
of sports
activities
Stopped
sports
activities
II
II
Early Motion
vs.
Cast
Early Motion
vs.
Cast
Early Motion vs.
Immobilization
Early Motion
vs.
Cast
Early Motion
vs.
Cast
48
‡‡
Duration
(Months)
6
12
○
○
61
38
○
60
●e
m
○
61
II
Early Motion
vs.
Cast
60
○
II
Early Motion
vs.
Cast
60
○
119
18
v1.0 12.04.09
Author
Outcome
Duration
(Months)
6
12
LoE
Comparison
N
II
Early Motion
Vs.
Immobilization
53
○
II
Early Motion
Vs.
Immobilization
53
○
II
Early Motion
vs.
Cast
71
●em
60
●em
3
Maffulli, et
al 2003
Maffulli, et
al 2003
Mortensen,
et al
1999
Cetti, et al.
1994
No
Limitations
Activity
Limitation
- Limited
Recreation
al but not
Daily
Activities
Able to
walk as far
before
surgery
Able to
stand on
toes
II
Early Motion
vs.
Cast
Early Motion
vs.
Cast
●em
18
○
Mortensen,
et al
1999
Sick Leave
(days)
II
Maffulli, et
al 2003
Return to
Work
II
49
○
Maffulli, et
al 2003
Changed
Jobs
II
49
○
●em
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
Costa,
et al
2006
EuroQoL Health
Score‡‡
Costa,
et al
2006
E5D
(Dimension
of Health
LoE Comparison
N
3.5
Early
Motion
II
48‡‡ ○
vs.
Cast
Early
II
Motion
48‡‡ ○
vs.
120
4
12
○
○
○
○
15
v1.0 12.04.09
Score)
Cast
Ankle
Early
Performance
Motion
II
50
Score vs.
Excellent
Cast
em= early motion
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
Kangas,
et al
2002
○
Table 126. Patient opinion of results
Author
Cetti, et al.
1994
Mortensen,
et al. 1999
Cetti, et al.
1994
Outcome
Patient opinion
of castexcellent
Subjective
ResultExcellent
Complaints
LoE
3m
6m
12m
16m
II
●em
●em
II
II
●em
Patient opinion
of resultsII
Excellent
Percent satisfied
Maffulli, et
with results of
II
al 2003
surgery
em= early motion
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
Maffulli, et
al 2003
121
○
●em
○
○
v1.0 12.04.09
Table 127. Footwear restrictions
Duration
(Months)
Author
Kangas,
et al
2002
Outcome
LoE
Footwear
Restrictions
II
Comparison
Early Motion
vs.
Cast
Footwear
restrictionsEarly Motion
None, mild
II
vs.
(most shoes
Cast
tolerated)
Footwear
restrictionsModerate
Maffulli,
Early Motion
(unable to
et al
II
vs.
tolerate
2003
Cast
fashionable
shoes, with or
without insert)
em= early motion
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
Maffulli,
et al
2003
N
12
16
○
50
53
○
53
○
Table 128. Rerupture
Author
LoE
Duration
N
Early
Motion
Cetti, et al.
ReII
3%
1994
rupture
Costa, et al
48
II
1 year
8.69%
2006
‡‡
em= early motion
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
122
Immobilizatio
n
Statistically
Significant
Difference
7%
○
0%
●‡ nwb
v1.0 12.04.09
SUMMARY OF COMPLICATIONS
Table 129. Early Motion vs. Cast - Complications
Rigid Cast
Group
Statistically
Significant
Difference
Author
Complication
LoE
N
Early
Motion
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%
○
60
23%
20%
○
53
7.69%
7.40%
○
53
15.38%
18.51%
○
53
3.84%
0%
○
Costa, et al
Minor Wound
II
2006
Complications
Maffulli, et al
Superficial
II
2003
Infection
Maffulli, et al Hypersensitivity
II
2003
of surgical wounds
Maffulli, et al
Hypertrophic Scar
II
2003
em= early motion
nem= not early motion
○= no statistically significant difference
●= statistically significant difference
‡ AAOS calculated
123
v1.0 12.04.09
Table 130. Systematic Reviews
Author
Khan, RJK, et al.
2005
Lynch, RM 2004
Suchak, AA et al.
2006
Conclusion
"Postoperative splinting in a cast followed by a
functional brace rather than a cast alone reduces the
overall complication rate" (p. 2209).
"Early functional mobilisation is more acceptable to
patients than plaster cast immobilisation and results in
improved functional outcomes" (p. 156).
"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).
124
v1.0 12.04.09
EXCLUDED ARTICLES
Table 131. Mobilization vs. Immobilization Included Articles
Author
Title
Maffulli N;Tallon
C;Wong J;Lim
KP;Bleakney R;
Kangas J;Pajala
A;Ohtonen
P;Leppilahti J;
Majewski M;Schaeren
S;Kohlhaas U;Ochsner
PE;
Achilles tendon rupture: effect of early
mobilization in rehabilitation after surgical repair
Percutaneous repair of Achilles tendon rupture.
Immobilization versus functional postoperative
treatment
Functional treatment after surgical repair of
acute Achilles tendon rupture: wrap vs. walking
cast
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
Early weight bearing and ankle mobilization
after open repair of acute midsubstance tears of
the Achilles tendon
Achilles tendon elongation after rupture repair: a
randomized comparison of 2 postoperative
regimens
Postoperative rehabilitation after percutaneous
Achilles tendon repair: Early functional therapy
versus cast immobilization
Solveborn SA;Moberg
A;
Immediate free ankle motion after surgical repair
of acute Achilles tendon ruptures
Sorrenti SJ;
Buchgraber A;Passler
HH;
Kerkhoffs GM;Struijs
PA;Raaymakers
EL;Marti RK;
Kauranen K;Kangas
J;Leppilahti J;
125
Exclusion Reason
Not relevant
Not best available
evidence
Not relevant
No patient
oriented outcome
Not relevant
Duplicate - Data
reported in prior
study
Not best available
evidence
Not best available
evidence - not
comparative
v1.0 12.04.09
Stochastic Randomization
Allocation Concealment
Patients Blinded
Those rating outcome
Blinded
Follow Up - 80% or more
All groups have similar
outcome performance at
entry
STUDY QUALITY
Table 132. Mobilization vs. Immobilization Quality
II
●
●
×
×
●
×
II
●
●
×
×
●
×
II
●
●
×
×
●
×
II
●
●
×
×
●
×
II
×
●
○
○
●
●
II
×
●
○
○
●
●
II
×
●
○
○
●
●
II
×
●
○
○
●
●
II
×
●
○
○
●
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Costa, et
al.
2006
Costa, et
al.
2006
Costa, et
al.
2006
Costa, et
al.
2006
Kangas, et
al.
2003
Kangas, et
al.
2003
Kangas, et
al.
2003
Kangas, et
al.
2003
Kangas, et
al.
2003
Outcome
N
Sport
43
Walking
43
Stair
Climbing
43
Work
43
VAS
Pain
50
VAS
Pain
50
VAS
Pain
50
VAS
Pain
50
VAS
Pain
50
Treatment(s)
LoE
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
126
v1.0 12.04.09
Outcome
N
Stochastic Randomization
Allocation Concealment
Patients Blinded
Those rating outcome
Blinded
Follow Up - 80% or more
All groups have similar
outcome performance at
entry
Kangas, et
al.
2003
Stiffness
Mobilization
50
vs.
Immobilization
II
×
●
○
○
●
●
Kangas, et
al.
2003
subjective
calf muscle
weakness
50
Mobilization
vs.
Immobilization
II
×
●
○
○
●
●
footwear
restrictions
50
II
×
●
○
○
●
●
Ankle
performance
score
50
II
×
●
○
○
●
●
Sick Leave
61
II
●
○
○
○
○
●
Subjective
assessment
61
II
●
○
○
○
○
●
Sports
Activity
61
II
●
○
○
○
○
●
Pain
61
II
●
○
○
○
○
●
● = Yes ○ = No × = Not Reported
n/a = not applicable
Author
Kangas, et
al.
2003
Kangas, et
al.
2003
Mortensen,
et al.
1999
Mortensen,
et al.
1999
Mortensen,
et al.
1999
Mortensen,
et al.
1999
Treatment(s)
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
127
LoE
v1.0 12.04.09
N
Mortense
n, et al.
1999
Stiffness
61
Mortense
n, et al.
1999
Able to walk as
far as pre
surgery
61
Cetti, et
al.
1994
Resumption of
sports activity
111
Cetti, et
al.
1993
Return to sport
111
Cetti, et
al.
1993
Return to work
111
Cetti, et
al.
1993
Re-rupture
111
Maffulli,
et al.
2003
Pain- None
53
Pain- Mild,
Occasional
53
Pain- Moderate
53
Return to
Sports
53
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Treatment(s)
Mobilization
vs.
Immobilizatio
n
Mobilization
vs.
Immobilizatio
n
Mobilization
vs.
Immobilizatio
n
Mobilization
vs.
Immobilizatio
n
Mobilization
vs.
Immobilizatio
n
Mobilization
vs.
Immobilizatio
n
Mobilization
vs.
Immobilizatio
n
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
●
○
○
○
○
●
II
●
○
○
○
○
●
II
×
×
×
×
×
○
II
×
×
○
●
●
●
II
×
×
○
●
●
●
II
×
×
○
●
●
●
II
○
○
○
●
●
×
II
○
○
○
●
●
×
II
○
○
×
×
●
×
II
○
○
×
×
●
×
128
LoE
v1.0 12.04.09
All groups have similar
outcome performance at
entry
Patients Blinded
Outcome
Follow Up - 80% or more
Allocation Concealment
Author
Those rating outcome
Blinded
Stochastic Randomization
II
● = Yes ○ = No × = Not Reported
n/a = not applicable
N
Maffulli,
et al.
2003
Return to
Sports (months)
53
Maffulli,
et al.
2003
Return to Work
(weeks)
53
Return to Work
53
Changed Jobs
53
Experience
Problems at
work due to
injury
53
Full weight
bearing (wks)
53
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Activity
Limitation None
Activity
Limitation Limited
Recreational
but not Daily
Activities
Discharged
from
Physiotherapy
(months)
53
Treatment(s)
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilizatio
n
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
○
○
×
×
●
●
II
○
○
×
×
●
●
II
○
○
×
×
●
●
II
○
○
×
×
●
●
Mobilization
vs.
Immobilization
II
○
○
×
×
●
●
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
II
○
○
×
×
●
●
II
○
○
×
×
●
●
LoE
All groups have similar
outcome performance at
entry
Patients Blinded
Outcome
Follow Up - 80% or more
Allocation Concealment
Author
Those rating outcome
Blinded
Stochastic Randomization
II
● = Yes ○ = No × = Not Reported
n/a = not applicable
53
Mobilization
vs.
Immobilization
II
○
○
×
×
●
●
53
Mobilization
vs.
Immobilization
II
○
○
×
×
●
●
II
○
○
×
×
●
●
II
○
○
×
×
●
●
Physiotherapy
sessions (visits)
53
Footwear
restrictionsNone, mild
53
Mobilization
vs.
Immobilization
Mobilization
vs.
Immobilization
129
v1.0 12.04.09
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Footwear
restrictionsModerate
(unable to
tolerate
fashionable
shoes)
Percent
satisfied with
results of
surgery
Patient opinion
of resultsExcellent
N
Treatment(s)
53
Mobilization
vs.
Immobilization
○
○
×
×
●
●
53
53
Weight
Bearing vs.
Non-weight
bearing
Weight
Bearing vs.
Non-weight
bearing
II
○
○
×
×
●
●
II
○
○
×
×
●
●
130
LoE
v1.0 12.04.09
All groups have similar
outcome performance at
entry
Patients Blinded
Maffulli,
et al.
2003
Outcome
Follow Up - 80% or more
Allocation Concealment
Author
Those rating outcome
Blinded
Stochastic Randomization
II
● = Yes ○ = No × = Not Reported
n/a = not applicable
STUDY RESULTS
Table 133. Mobilization vs. Immobilization Study Data
Author
Cetti, et al.
1994
Cetti, et al.
1994
Outcome
Return to same
level of sports
activities
Return to lesser
level of sports
activities
Stopped sports
activities
Patient opinion of
cast- excellent
Cetti, et al.
1994
Mean Sick leave
(days)
Cetti, et al.
1994
Cetti, et al.
1994
Results
Early Motion
Cast
LoE
Duration
N
II
1 year
60
80%
50%
p=
0.0292
II
1 year
60
7%
13%
p= 0.616
II
1 year
60
3%
13%
p= 0.141
II
1 year
60
77%
20%
p=
0.0005
II
NA
60
20.2
(Range 3-75)
53.4
(Range
1-182)
p=
0.0009
60
83%
53%
p= 0.025
60
100%
77%
p= 0.011
60
100%
97%
p= 0.15‡
60
3%
7%
p= 0.55‡
60
17.0
25.00
p= 0.047
60
10.00
14.00
p=
0.290‡
60
3.00
11.00
p= 0.03
61
19%
40%
p= 0.06
61
84%
63%
p=0.06‡
61
73%
76%
OR =1
Cetti, et al.
Able to stand on
II
3 months
1994
toes
Cetti, et al.
Able to stand on
II
6 months
1994
toes
Cetti, et al.
Able to stand on
12
II
1994
toes
months
Cetti, et al.
Re-rupture
II
NA
1994
Cetti, et al.
Complaints
II
3 months
1994
Cetti, et al.
Complaints
II
6 months
1994
Cetti, et al.
12
Complaints
II
1994
months
Mortensen, Able to walk as far
et al
as they could
II
12 weeks
1999
before surgery
Mortensen,
Subjective Result 16
et al
II
excellent
months
1999
Mortensen,
16
et al
Returned to sports
II
months
1999
‡= AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
131
Results
v1.0 12.04.09
Results
Author
Outcome
LoE
Duration
N
Early Motion
Cast
Results
Mortensen,
et al
1999
Reached preinjury level
II
16 months
61
57%
55%
1
Mortensen,
et al
1999
Time until preinjury level
reached
(months)
II
NA
61
6
(2.5-13)
9
(6-14)
P <0.01
Vas Pain
II
1 week
50
2.17± 2.7
2.02 ±
1.7
p= 0.08
Vas Pain
II
3 weeks
50
.83 ± 1.2
.82 ±
1.3
p= 0.797
Vas Pain
II
6 weeks
50
.65 ± 1.4
.60 ±
.09
p= 0.9
No Stiffness
II
60 weeks
50
44%
68%
p>0.08
Mild Stiffness
II
60 weeks
50
56%
32%
p>0.08
No footwear
restrictions
II
60 weeks
50
68%
92%
p>0.08
Ankle
Performance
Score - Excellent
II
60 weeks
50
88%
92%
p>0.08
Re-rupture
II
5 months
50
4%
8%
1.000
48
18 (95% CI 1222)
Kangas, et
al
2002
Kangas, et
al
2003
Kangas, et
al
2003
Kangas, et
al
2003
Kangas, et
al
2003
Kangas, et
al
2003
Kangas, et
al
2003
Kangas, et
al
2003
18
(95%
CI 1822)
18
(95%
CI 1422)
Costa, et al
2006
Return to
Normal
Walking‡‡
II
Time
measurement
Costa, et al
2006
Return to
Normal Stair
Climbing‡‡
II
Time
measurement
48
17 (95% CI 1118)
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‡
132
p= 0.027
p= 0.023
v1.0 12.04.09
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‡
Maffulli, et
al 2003
Full weight
bearing (wks)
II
12 months
53
2.5 (SD 0.4)
5.5 (SD
2.2)
p= 0.021
Maffulli, et
al 2003
Physiotherapy
sessions (visits)
II
12 months
53
6.1 (SD 3.1)
13.6
(SD
4.8)
p= 0.03
Maffulli, et
al 2003
Discharged from
Physiotherapy
(months)
II
12 months
53
2.1 (SD 1.1)
4.6 (SD
2)
p<.0001
Maffulli, et
al 2003
Pain- None
II
12 months
53
88%
89%
p= 0.96 ‡
Maffulli, et
al 2003
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 ‡
II
12 months
53
92%
93%
p=0.97‡
II
12 months
53
8%
7%
p=0.97
Maffulli, et
al 2003
Maffulli, et
al 2003
Activity
Limitation None
Activity
Limitation Limited
Recreational but
not Daily
Activities
Maffulli, et
al 2003
Return to Sports
II
12 months
38
89%
89%
p=0.99 ‡
Maffulli, et
al 2003
Return to Sports
(months)
II
12 months
53
5.1 (SD 2.8)
6 (SD
3)
0.04
II
12 months
53
96%
93%
p=0.57‡
II
12 months
53
4%
7%
p=0.57‡
Maffulli, et
al 2003
Maffulli, et
al 2003
Footwear
restrictionsNone, mild
Footwear
restrictionsModerate
(unable to
tolerate
fashionable
shoes, with or
without insert)
133
v1.0 12.04.09
Results
Author
Outcome
Maffulli, et
al 2003
Percent satisfied
with results of
surgery
LoE
II
Maffulli, et
al 2003
Excellent
Maffulli, et
al 2003
Duration
N
Early Motion
Cast
Results
12 months
53
88%
85%
p=0.51‡
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‡
Maffulli, et
al 2003
Hypersensitivity
of surgical
wounds
II
10-12 wks
53
15.38%
18.51%
p= 0.76‡
Maffulli, et
al 2003
Hypertrophic
Scar
II
10-12 weeks
53
3.84%
0%
p= 0.15‡
‡= AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
134
v1.0 12.04.09
Author
Cetti, et
al.
1994
Cetti, et
al.
1994
Outcome
LoE
Duration
N
Abnormal
Sensibility
II
Not
Reported
60
Keloid Scar
II
Not
Reported
60
Mortensen
Deep
Infection
II
Mortensen
Failed Repair
Costa
Kangas, et
al
2002
Results
Early Motion
Cast
Results
3.3
16.7
p=
0.066‡
10
23.3
p=
0.157‡
6 weeks
3%
0%
II
6 weeks
3%
7%
Minor Wound
Complications
II
Varying Tie
23%
20%
Re-rupture
II
5 months
4%
8%
Time in
weeks taken
Time
II
48
22
26
to return to
measurement
work.
EuroQoL Costa, et
Health
II
10 weeks
48
75 (IQR 70-85)
75 (IQR 65-80)
al 2006
Score‡‡
EuroQoL Costa, et
Health
II
6months
48
85 (IQR 80-90)
81 (IQR 75-95)
al 2006
Score‡‡
EuroQoL Costa, et
Health
II
12 months
48
84 (IQR 75-95)
90 (IQR 85-95)
al 2006
Score‡‡
E5D
Costa, et
(Dimension of
II
10 weeks
48 0.69 (IQR 0.6-0.9) 0.69 (IQR 0.6-0.7)
al 2006
Health Score)
E5D
Costa, et
(Dimension of
II
6months
48 0.8 (IQR 0.7-1.0) 0.8 (IQR 0.8-1.0)
al 2006
Health Score)
E5D
Costa, et
(Dimension of
II
12 months
48
1 (IQR 0.9-1.0)
1(IQR 0.8-1.0)
al 2006
Health Score)
‡= AAOS calculations
‡‡= Open cast group converted to orthosis at 3 weeks
Costa, et
al
2005
135
v1.0 12.04.09
p=
0.154‡
p=
0.52‡
p=
0.79‡
p=
0.545‡
p=
0.593‡
p=
0.854
p=
0.956
p=
.138
p=
0.450
p=
0.956
p=
0.146
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
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 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
Majewski
LOE
Treatment
III
Percutaneous
Repair
N
15
88
Calder
IV
Mini-Open
Repair
46
Troop
IV
Open Repair
13
Saw
IV
Open Repair
19
Post
Treatment
Cast followed
by walking
cast
Combination
splint and shoe
Functional
Brace
Cast (5)
Splint (8)
Cast followed
by walking
boot
136
PT Regimen
Both groups received same PT at 8
weeks
"Active physiotherapy programme"
at 2 weeks
All had supervised PT. Authors do
not report details of PT regimen.
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
Author
Moberg
N
Post
Treatment
IV
Operative
Repair
17
Mobile plaster
cast
II
Open Repair
25
Dorsal rigid
splint at 6
weeks
II
Open Repair
25
Plaster splint
LOE
Treatment
Kangas
PT Regimen
Immediate free ankle joint
movement. Free weightbearing and
mobilization at 6 weeks.
Both groups performed "standard
rehabilitation program;" Authors do
not specify details of PT program
Both groups performed "standard
rehabilitation program;" Authors do
not specify details of PT program
EXCLUDED ARTICLES
Table 135. Excluded Articles
Author
Majewski
M, et al
Calder JD,
et al.
Troop RL,
et al.
Saw Y, et
al.
Moberg A,
et al.
Kangas J, et
al.
Title
Postoperative rehabilitation after percutaneous Achilles
tendon repair: Early functional therapy versus cast
immobilization
Early, active rehabilitation following mini-open repair of
Achilles tendon rupture: a prospective study
Early motion after repair of Achilles tendon ruptures
Early mobilization after operative repair of ruptured
Achilles tendon
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
Achilles tendon elongation after rupture repair: a
randomized comparison of 2 postoperative regimens
137
Exclusion Reason
Does not answer the
recommendation
Does not answer the
recommendation
Does not answer the
recommendation
Does not answer the
recommendation
Does not answer the
recommendation
Does not answer the
recommendation
v1.0 12.04.09
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
Costa, et al.
2006
IV
Costa, et al.
2006
Hufner, et al.
IV
IV
Treatment
immediate weight
bearing
mobilization
plaster cast
immobilization
cast and boot
N
Outcome
Duration
(months)
% of
Patients
22
Return to work
12
59%
26
Return to work
12
65%
125
Return to work
0.6
45%
138
v1.0 12.04.09
2006
Table 137. Non-Operative Treatment -Percent of patients able to return to ADL
Author
LOE
Costa, et al.
2006
IV
Costa, et al.
2006
IV
Treatment
immediate weight
bearing
mobilization
plaster cast
immobilization
N
Outcome
Duration
(months)
% of
Patients
22
Return to normal
walking
12
73%
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%
Costa, et
al. 2006
IV
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%
Costa, et
al. 2006
IV
open end-to-end
(immediate weight
bearing mobilisation)
23
Return to stair
climbing
12
96%
Costa, et
al. 2006
IV
open end-to-end (plaster
cast immobilisation)
25
Return to stair
climbing (months)
12
96%
139
v1.0 12.04.09
Table 139. Operative Treatment - Percent of patients able to return to work
Author
LOE
Treatment
N
Outcome
Duration
(months)
%
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%
Moller, et
al. 2001
IV
end-to-end suture w/o
augmentation
13
Return to sedentary
work
1
100%
Hogsaa,
et al.
1990
IV
open repair
68
Return to work same employment
(weeks)
<1
29%
IV
open repair
103
Return to work
1.7
65%
IV
limited open
27
Return to work
2
100%
IV
open repair
68
Return to work same employment
(weeks)
>3
15%
IV
open repair
103
Return to work
3
82%
IV
end-to-end suture w/o
augmentation
14
Return to heavy
work
3.5
100%
IV
fibrin sealant
32
Return to daily
work
6
97%
IV
open repair
68
Return to work same employment
(weeks)
<6
18%
IV
open repair
103
Return to work
6
97%
IV
minimally-invasive
150
Return to work same work
12
98%
Suchak,
et al.
2008
Jung, et
al. 2008
Hogsaa,
et al.
1990
Suchak,
et al.
2011
Moller, et
al. 2001
Kuskucu,
et al.
2005
Hogsaa,
et al.
1990
Suchak,
et al.
2008
Lansdaal,
et al.
2007
140
v1.0 12.04.09
Author
LOE
Treatment
N
Outcome
Duration
(months)
%
Costa, et
al. 2006
IV
open end-to-end
(immediate weight
bearing mobilisation)
23
Return to work
12
87%
Costa, et
al. 2006
IV
open end-to-end (plaster
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%
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
Maffulli,
et al.
2003
141
v1.0 12.04.09
Table 140. Non-Operative Treatment - Mean time until return to work
Author
LOE
Metz, et al.
IV
2008
Costa, et al.
IV
2006
Costa, et al.
IV
2006
Moller, et al.
IV
2001
Wallace, et al.
IV
2004
Cetti, et al.
IV
1993
Costa, et al.
IV
2006
Moller, et al.
IV
2001
Moller, et al.
IV
2001
Costa, et al.
IV
2006
‡ AAOS Calculation
Treatment
N
Outcome
Duration (weeks)
functional brace
33
Return to work
15.4 (SD 16.42)
22
Return to work
1 (95% CI 1-13) ‡
22
Return to normal
walking
18 (95% CI 12-22) ‡
53
Return to work
10.48 (SD 8.07)
cast
122
Return to work
2.36 (SD 1.19)
below-knee plaster cast
55
Return to work
8 (SD 3.6)
26
Return to work
10 (95% CI 2-22) ‡
immediate weight
bearing mobilisation
immediate weight
bearing mobilisation
Below the knee plaster
cast
plaster cast
immobilisation
Below the knee plaster
cast
Below the knee plaster
cast
plaster cast
immobilisation
22
22
26
Return to light,
mobile work
Return to sedentary
work
Return to normal
walking
9.6 (SD 9.4)
4.7 (SD7.8)
18 (95% CI 18-22) ‡
Table 141. Non-Operative Treatment - Mean time until return to walking
Author
Costa, et al.
2006
Costa, et al.
2006
LOE
IV
IV
Treatment
immediate weight
bearing mobilisation
plaster cast
immobilisation
142
N
22
26
Outcome
Return to normal
walking
Return to normal
walking
Duration (weeks)
18 (95% CI 12-22) ‡
18 (95% CI 18-22) ‡
v1.0 12.04.09
Table 142. Operative Treatment - Mean time to return to ADL
Author
LOE
Costa, et al.
2006
IV
Costa, et al.
2006
Maffulli, et
al. 2003
Maffulli, et
al. 2003
Costa, et al.
2006
IV
IV
IV
IV
Costa, et al.
IV
2006
Calder, et
IV
al. 2006
‡ AAOS Calculation
Treatment
open end-to-end
(immediate weight
bearing mobilisation)
open end-to-end (plaster
cast immobilisation)
open repair (non-weight
bearing)
open repair (weight
bearing)
open end-to-end
(immediate weight
bearing mobilisation)
open end-to-end (plaster
cast immobilisation)
percutaneous repair
143
N
Outcome
Duration (Weeks)
23
Return to normal
walking
12.5 (95% CI 1018) ‡
25
Return to normal
walking
27
Walk w/o crutches
26
Walk w/o crutches
18 (95% CI 18-22)
‡
5.5 (SD 2.2; range
4.6-8.1)
2.5 (SD 0.4; range
1.2-3.1)
23
Return to stair
climbing
13 (95% CI 10-18)
‡
25
Return to stair
climbing
22 (95% CI 18-22)
‡
25
Return to driving
4.14 (range .7-9)
v1.0 12.04.09
Table 143. Operative Treatment - Mean time until return to work
Author
Moller, et
al. 2001
Coutts, et
al. 2002
Moller, et
al. 2001
Moller, et
al. 2001
Moller, et
al. 2001
Cetti, et al.
1993
Metz, et al.
2008
Lansdaal,
et al. 2007
LOE
IV
IV
IV
IV
IV
Treatment
end-to-end suture w/o
augmentation
open repair
end-to-end suture w/o
augmentation
end-to-end suture w/o
augmentation
end-to-end suture w/o
augmentation
N
Outcome
Return to heavy
work
Return to work manual
Return to light,
mobile work
Return to sedentary
work
Duration (Weeks)
59
Return to work
7.8(SD 68.4)
14
15
32
13
14.6 (SD 7.5)
11.1 (range 8-24)
5.1 (SD 5.4)
4.4(SD 5.2)
IV
end-to-end suture
56
Return to work
6.2 (SD 2.15)
IV
minimally-invasive
40
Return to work
8.4 (SD 11.71)
IV
minimally-invasive
15
0
Return to work
4 (range .14-52.57)
‡
46
Return to work
3.12 (range .57-11)
23
Return to work
8 (95% CI 2-13) ‡
25
Return to work
4 (95% CI 1-13) ‡
percutaneous repair
25
Return to work
2.7 (range .85-11)
percutaneous w/ shoe
14
Return to work
5.2 (range .7-18.85)
22
Return to work
(months)
1.07
62
Return to work
11.7 (range 10-13)
Calder, et
al. 2005
IV
Costa, et al.
2006
IV
Costa, et al.
2006
IV
Calder, et
IV
al. 2006
Majewski,
IV
et al. 2008
Wagnon, et
IV
al. 2005
Doral, et al.
IV
2009
‡ AAOS Calculation
mini-open repair w/
early active
rehabilitation
open end-to-end
(immediate weight
bearing mobilisation)
open end-to-end
(plaster cast
immobilisation)
percutaneous repair
(Webb-Bannister)
endoscopy assisted
percutaneous
144
v1.0 12.04.09
EXCLUDED ARTICLES
Table 144. Excluded Articles
Author
Costa ML;Shepstone
L;Darrah C;Marshall
T;Donell ST;
Goren D;Ayalon
M;Nyska M;
van der Linden-van der
Zwaag HM;Nelissen
RG;Sintenie JB;
Kakiuchi M;
Hufner TM;Brandes
DB;Thermann H;Richter
M;Knobloch K;Krettek
C;
Roberts C;Rosenblum
S;Uhl R;Fetto J;
Mortensen HM;Skov
O;Jensen PE;
Maes R;Copin
G;Averous C;
Cretnik A;Kosanovic
M;Smrkolj V;
Chiodo CP;Wilson MG;
Fernandez-Fairen
M;Gimeno C;
Wagnon R;Akayi M;
Martinelli B;
Park HG;Moon
DH;Yoon JM;
Edna TH;
Title
Immediate full-weight bearing
mobilisation for repaired Achilles
tendon ruptures: a pilot study
Isokinetic strength and endurance
after percutaneous and open surgical
repair of Achilles tendon ruptures
Results of surgical versus nonsurgical treatment of Achilles tendon
rupture
A combined open and percutaneous
technique for repair of tendo Achilles.
Comparison with open repair
Long-term results after functional
nonoperative treatment of Achilles
tendon rupture
Reason for Exclusion
Less than 80% follow
up
No patient oriented
outcome
Not 80% follow
Not 80% time follow
up
Not best available
evidence
Team physician #6. Surgical
treatment of Achilles tendon rupture
Early motion of the ankle after
operative treatment of a rupture of the
Achilles tendon. A prospective,
randomized clinical and radiographic
study
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
Current concepts review: acute
ruptures of the Achilles tendon
Augmented repair of Achilles tendon
ruptures
The Webb-Bannister percutaneous
technique for acute Achilles' tendon
ruptures: a functional and MRI
assessment
Percutaneous repair of the Achilles
tendon in athletes
Limited open repair of ruptured
Achilles tendons with Bunnel-type
sutures
Not best available
evidence
Non-operative treatment of Achilles
tendon ruptures
Not best available
evidence
145
Not best available
evidence
Not best available
evidence
Not best available
evidence
Not best available
evidence
Not best available
evidence
Not best available
evidence
Not best available
evidence
Not best available
evidence
v1.0 12.04.09
Author
Jessing P;Hansen E;
Keller J;Rasmussen TB;
Majewski M;Rohrbach
M;Czaja S;Ochsner P;
Jennings AG;Sefton
GK;Newman RJ;
Suchak AA;Bostick
GP;Beaupre LA;Durand
DC;Jomha NM;
Pendleton H;Resch
S;Stenstrom A;Astrom I;
Weber M;Niemann
M;Lanz R;Muller T;
Title
Surgical treatment of 102 tendo
achillis ruptures-- suture or
tenontoplasty?
Closed treatment of Achilles tendon
rupture
Avoiding sural nerve injuries during
percutaneous Achilles tendon repair
Repair of acute rupture of the
Achilles tendon: a new technique
using polyester tape without external
splintage
The influence of early weight bearing
compared with non-weight bearing
after surgical repair of the Achilles
tendon
Residual functional problems after
non-operative treatment of Achilles
tendon rupture
Nonoperative treatment of acute
rupture of the Achilles tendon: results
of a new protocol and comparison
with operative treatment
146
Reason for Exclusion
Not best available
evidence
Not best available
evidence
Not best available
evidence
Not best available
evidence
Does not report
relevant outcomes
Retrospective
Retrospective
v1.0 12.04.09
Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up
Time
STUDY QUALITY
Table 145. Patient return to activities of daily living
Calder, et al. 2005
Return to previous sporting
activities
46
IV
●
●
●
●
x
Calder, et al. 2006
Return to previous sporting
activities
25
IV
●
●
●
●
x
Cetti, et al. 1993
Return to sports - same level
47
IV
●
●
●
●
●
Cetti, et al. 1993
Return to sports - same level
52
IV
●
●
●
●
●
Chillemi, et al.
2002
Return to sports - frequent‡‡
(months)
14
IV
●
●
●
●
●
Costa, et al. 2006
Costa, et al. 2006
Return to sports
Return to sports
23
25
IV
●
●
●
●
●
●
●
●
26
IV
x
x
x
●
●
●
●
22
IV
x
●
●
●
●
23
IV
●
●
●
●
22
IV
x
x
●
●
●
●
20
IV
x
●
●
●
●
●= yes ○= no x= not reported
Costa, et al. 2006
Costa, et al. 2006
Costa, et al. 2006
Coutts, et al. 2002
Coutts, et al. 2002
Return to stair climbing
(weeks)
Return to stair climbing
(weeks)
Return to sports (weeks)
Return to pre-injury level of
sporting participation
Return to sports
IV
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
●
●
●
●
Garabito, et al.
2004
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
Hogsaa, et al. 1990
Resumption of recreational
activities
63
IV
●
●
●
●
●
147
v1.0 12.04.09
Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up
Time
Jung, et al. 2008
Resume light exercise
27
IV
x
●
●
●
●
Jung, et al. 2008
Return to previous sporting
activities
27
IV
x
●
●
●
●
Kuskucu, et al.
2005
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
●
●
●
●
Activity limitations - none
27
IV
●
●
●
●
●
Activity limitations - none
26
IV
●
●
●
●
●
Return to sports
19
IV
●
●
●
●
●
Return to sports
19
IV
●
●
●
●
●
Return to sports
19
IV
●
●
●
●
●
Return to sports
19
IV
●
●
●
●
●
Return to sports
24
IV
●
●
●
●
●
Return to sports
Return to sports
33
36
IV
●
●
●
●
●
IV
●
●
●
●
●
Moller, et al. 2001
Return to sports - same level
47
IV
●
●
●
●
●
Scarfi, et al. 2002
Return to sports activities
20
IV
x
●
●
●
●
Solveborn, et al.
1994
Solveborn, et al.
1994
Taglialavoro, et al.
2004
Return to previous sports
activity w/o any difficulty
16
IV
●
●
●
●
●
Return to sports
16
IV
●
●
●
●
●
Return to sports - complete
24
IV
●
●
●
●
●
Return to sports - complete
22
IV
●
●
●
●
●
Return to sports level
Resume jogging/running
Resume jogging/running
6
13
IV
x
●
●
●
●
IV
IV
●
●
●
●
●
●
●
●
●
●
●= yes ○= no x= not reported
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2003
Maffulli, et al.
2009
Metz, et al. 2008
Metz, et al. 2008
Taglialavoro, et al.
2004
Tang, et al. 2007
Troop, et al. 1995
Troop, et al. 1995
148
13
v1.0 12.04.09
Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up
Time
Uchiyama, et al.
2007
Resume jogging (weeks)
84
IV
x
●
●
●
●
Uchiyama, et al.
2007
Return to sports for high-level
athletes - original game level
21
IV
x
●
●
●
●
Wallace, et al.
2004
Return to sports (weeks)
101
IV
●
●
●
●
x
●= yes ○= no x= not reported
149
v1.0 12.04.09
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.
Supporting Evidence:
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.
150
v1.0 12.04.09
SUMMARY OF EVIDENCE
Table 146. Operative Treatment - Return to Recreational Activity
Author
Hogsaa, et al.
1990
LOE
Treatment
N
IV
open repair
63
Hogsaa, et al.
1990
IV
open repair
63
Hogsaa, et al.
1990
IV
open repair
Maffulli, et al.
2003
IV
Maffulli, et al.
2003
Duration (months)
%
6-12
30%
Resumption of recreational
activities
3-6
33%
63
Resumption of recreational
activities
<3
10%
open repair (nonweight bearing)
27
Activity limitations - none
12
93%
IV
open repair
(weight bearing)
26
Activity limitations - none
12
92%
Hogsaa, et al.
1990
IV
open repair
63
Resumption of recreational
activities
> 12
51%
Giannini, et al.
1994
IV
15
Return to pre-injury level
of activity
18
100%
Fortis, et al.
2008
IV
20
Return to previous activity
levels
30
100%
adjunctive
augmentation
(synthetic graft)
endoscopically
assisted
percutaneous
Outcome
Resumption of recreational
activities
Table 147. Operative Treatment - Return to sports
Author
Troop, et al.
1995
LOE
IV
Treatment
end-to-end w/
early motion
N
Outcome
Duration
(months)
%
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
16
Return to sports - pre-injury
level of activity
6
85%
Tang, et al.
2007
IV
6
Return to sports level
6
83%
Jung, et al.
2008
IV
27
Return to previous sporting
activities
6
100%
adjunctive
augmentation
(autograft)
arthroscopically
assisted
percutaneous
limited open
151
v1.0 12.04.09
Author
LOE
Calder, et al.
2005
IV
Aktas, et al.
2008
IV
Calder, et al.
2006
Cetti, et al.
1993
Duration
(months)
%
Return to previous sporting
activities
6
100%
14
Return to sports - pre-injury
level of activity
6
89%
percutaneous
repair
25
Return to previous sporting
activities
6
100%
end-to-end suture
52
Return to sports - same level
12
62%
16
Return to previous sports
activity w/o any difficulty
12
81%
16
Return to sports
12
100%
47
Return to sports - same level
12
54%
36
Return to sports
12
67%
152
Return to sports - same level
12
64%
23
Return to sports
12
83%
25
Return to sports
12
68%
19
Return to sports
12
89%
19
Return to sports
12
89%
24
Return to sports - complete
42
38%
22
Return to sports - complete
42
32%
62
Return to previous sporting
activities
46
95%
54
Return to sports - pre-injury
level
96
43%
N
Outcome
46
open repair
IV
IV
Solveborn, et
al. 1994
IV
Solveborn, et
al. 1994
IV
Moller, et al.
2001
IV
Metz, et al.
2008
IV
Lansdaal, et al.
2007
IV
Costa, et al.
2006
IV
Costa, et al.
2006
IV
Maffulli, et al.
2003
IV
Maffulli, et al.
2003
IV
Taglialavoro,
et al. 2004
IV
Taglialavoro,
et al. 2004
IV
Doral, et al.
2009
IV
Garabito, et al.
2004
IV
Treatment
mini-open repair
w/ early active
rehabilitation
end-to-end suture
w/ below-knee
transport splint
cast
end-to-end suture
w/ below-knee
transport splint
cast
end-to-end suture
w/o augmentation
minimallyinvasive
minimallyinvasive
open end-to-end
(immediate
weight bearing
mobilisation)
open end-to-end
(plaster cast
immobilisation)
open repair (nonweight bearing)
open repair
(weight bearing)
adjunctive
augmentation
(autograft)
open repair
endoscopy
assisted
percutaneous
adjunctive
augmentation
(autograft)
152
v1.0 12.04.09
Table 148. Operative Treatment - Mean time to return to athletic activity
Author
Doral, et al.
2009
Troop, et al.
1995
Lansdaal, et
al. 2007
LOE
IV
IV
Treatment
N
endoscopy assisted
percutaneous
end-to-end w/ early
motion
62
13
Duration
(months)
Outcome
Rehabilitation
training
Resume
jogging/running
11.7 (SD 0.75)
3 (SD 0.75)
IV
minimally-invasive
152
Return to sports
7.1 (SD 3.8)
Costa, et al.
2006
IV
open end-to-end
(immediate weight
bearing
mobilisation)
23
Return to sports
(weeks)
11.14 (95% CI
5-17) ‡
Uchiyama, et
al. 2007
IV
open repair
84
Coutts, et al.
2002
IV
open repair
22
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)
19
Return to sports
6 (SD 3)
19
Return to sports
5.1 (SD 2.8)
Maffulli, et
al. 2003
Maffulli, et
al. 2003
Gorschewsky,
et al. 2004
Maffulli, et
al. 2009
Chillemi, et
al. 2002
IV
IV
open repair (nonweight bearing)
open repair (weight
bearing)
Resume jogging
(weeks)
Return to pre-injury
level of sporting
participation
3.5(SD .9)
40.8 (SD 25.2)
IV
percutaneous repair
66
Return to original
sport
5.46 (SD 1.5)
IV
percutaneous repair
24
Return to sports
88 (SD 14.5)
IV
percutaneous repair
14
Return to sports frequent‡ (months)
8 (SD 1.5)
EXCLUDED ARTICLES
Table 149. Excluded Articles
Author
Suchak AA;Bostick
GP;Beaupre LA;Durand
DC;Jomha NM;
Majewski M;Rohrbach
M;Czaja S;Ochsner P;
Title
Reason for
Exclusion
The influence of early weight bearing compared
No relevant
with non-weight bearing after surgical repair of the
outcomes
Achilles tendon
Avoiding sural nerve injuries during percutaneous Not best available
Achilles tendon repair
evidence
153
v1.0 12.04.09
Author
Title
Reason for
Exclusion
Time of return to
sports not
reported
The Webb-Bannister percutaneous technique for
acute Achilles' tendon ruptures: a functional and
MRI assessment
Isokinetic strength and endurance after
Goren D;Ayalon M;Nyska
No patientpercutaneous and open surgical repair of Achilles
M;
oriented outcome
tendon ruptures
Current concepts review: acute ruptures of the Not best available
Chiodo CP;Wilson MG;
Achilles tendon
evidence
Cretnik A;Kosanovic
Percutaneous versus open repair of the ruptured Not best available
M;Smrkolj V;
Achilles tendon: a comparative study
evidence
Repair of acute rupture of the Achilles tendon: a
Jennings AG;Sefton
Not best available
new technique using polyester tape without external
GK;Newman RJ;
evidence
splintage
van der Linden-van der
Results of surgical versus non-surgical treatment of Less than 80%
Zwaag HM;Nelissen
Achilles tendon rupture
follow up
RG;Sintenie JB;
Costa ML;Shepstone
Immediate full-weight bearing mobilisation for
Less than 80%
L;Darrah C;Marshall
repaired Achilles tendon ruptures: a pilot study
follow up
T;Donell ST;
Early motion of the ankle after operative treatment
Mortensen HM;Skov
Not best available
of a rupture of the Achilles tendon. A prospective,
O;Jensen PE;
evidence
randomized clinical and radiographic study
A combined open and percutaneous technique for
Less than 80%
Kakiuchi M;
repair of tendo Achillis. Comparison with open
follow up
repair
Roberts C;Rosenblum S;Uhl Team physician #6. Surgical treatment of Achilles Not best available
R;Fetto J;
tendon rupture
evidence
Not best available
Keller J;Rasmussen TB;
Closed treatment of Achilles tendon rupture
evidence
Percutaneous repair of the Achilles tendon in
Not best available
Martinelli B;
athletes
evidence
Fernandez-Fairen
Not best available
Augmented repair of Achilles tendon ruptures
M;Gimeno C;
evidence
Park HG;Moon DH;Yoon Limited open repair of ruptured Achilles tendons Not best available
JM;
with Bunnel-type sutures
evidence
Wagnon R;Akayi M;
154
v1.0 12.04.09
Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up Time
STUDY QUALITY
Table 150. Return to sports
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
●
●
●
●
●
Calder, et al. 2005
Return to previous sporting
activities
46
IV
●
●
●
●
x
Calder, et al. 2006
Return to previous sporting
activities
25
IV
●
●
●
●
x
Cetti, et al. 1993
Return to sports - same level
47
IV
●
●
●
●
●
Cetti, et al. 1993
Return to sports - same level
52
IV
●
●
●
●
●
Chillemi, et al.
2002
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 stair climbing
(weeks)
22
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
●
●
●
●
●
●= yes ○= no x= not reported
155
v1.0 12.04.09
Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up Time
Fortis, et al. 2008
Return to previous activity
levels
20
IV
x
●
●
●
●
Garabito, et al.
2004
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
●
●
●
●
●
Hogsaa, et al. 1990
Resumption of recreational
activities
63
IV
●
●
●
●
●
Hogsaa, et al. 1990
Resumption of recreational
activities
63
IV
●
●
●
●
●
Jung, et al. 2008
Resume light exercise
27
IV
x
●
●
●
●
Jung, et al. 2008
Return to previous sporting
activities
27
IV
x
●
●
●
●
Kuskucu, et al.
2005
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
●
●
●
●
Re-rupture
33
IV
●
●
●
●
●
Absence from work
33
IV
●
●
●
●
●
Return to sport
33
IV
●
●
●
●
●
Pain - VAS
33
IV
●
●
●
●
●
Pain - VAS
33
IV
●
●
●
●
●
●= yes ○= no x= not reported
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
156
v1.0 12.04.09
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up Time
Pain - VAS
33
IV
●
●
●
●
●
Satisfaction - VAS
33
IV
●
●
●
●
●
Satisfaction - VAS
33
IV
●
●
●
●
●
Satisfaction - VAS
33
IV
●
●
●
●
●
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 - same level
59
IV
●
●
●
●
●
Moller, et al. 2001
Return to sports - stopped
59
IV
●
●
●
●
●
Moller, et al. 2001
Return to sedentary work
(days)
59
IV
●
●
●
●
●
Moller, et al. 2001
Return to light, mobile work
(days)
59
IV
●
●
●
●
●
Scarfi, et al. 2002
Return to sports activities
20
IV
x
●
●
●
●
Solveborn, et al.
1994
Return to previous sports
activity w/o any difficulty
16
IV
●
●
●
●
●
Return to sports
16
IV
●
●
●
●
●
Return to sports - complete
24
IV
●
●
●
●
●
Return to sports - complete
22
IV
●
●
●
●
●
●= yes ○= no x= not reported
Author
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Solveborn, et al.
1994
Taglialavoro, et al.
2004
Taglialavoro, et al.
2004
157
v1.0 12.04.09
Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up Time
Uchiyama, et al.
2007
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 - same 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 ankle
movement
56
IV
●
●
●
●
●
Cetti, et al. 1993
Function-Abnormal gait
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 run
56
IV
●
●
●
●
●
Cetti, et al. 1993
Function-Abnormal toe stand
56
IV
●
●
●
●
●
Cetti, et al. 1993
Function-Abnormal toe stand
56
IV
●
●
●
●
●
Chillemi, et al.
2002
Able to walk without
limitation
Return to sports activity
(frequent participant 2-3 times
per week)
38
IV
●
●
●
●
●
14
IV
●
●
●
●
●
●= yes ○= no x= not reported
Chillemi, et al.
2002
158
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Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up Time
Coutts, et al 2002
Return to pre-injury sporting
level
22
IV
x
●
●
●
●
Maffulli, et al.
2003
Activity limitations - none
27
IV
●
●
●
●
●
Maffulli, et al.
2003
Activity limitations - none
26
IV
●
●
●
●
●
Maffulli, et al.
2003
Return to sports
19
IV
●
●
●
●
●
Maffulli, et al.
2003
Return to sports
19
IV
●
●
●
●
●
Maffulli, et al.
2003
Return to sports
19
IV
●
●
●
●
●
Maffulli, et al.
2003
Return to sports
19
IV
●
●
●
●
●
Maffulli, et al.
2009
Return to sports
24
IV
●
●
●
●
●
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
●
●
●
●
●= yes ○= no x= not reported
159
v1.0 12.04.09
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
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 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
Author
Metz, et al.
2008
Costa, et al.
2006
Costa, et al.
2006
Moller, et al.
2001
Cetti, et al.
1993
LOE
Treatment
N
Outcome
Duration
(months)
%
IV
functional brace
33
Return to sports
12
82%
12
56%
12
52%
12
54%
12
34 %
IV
IV
IV
IV
immediate weight
bearing mobilisation
plaster cast
immobilisation
below the knee
plaster cast
below-knee plaster
cast
18
21
38
47
160
Return to sports
(months)
Return to sports
(months)
Return to sports - same
level (months)
Return to sports-same
level
v1.0 12.04.09
161
v1.0 12.04.09
Table 152. Non-Operative Treatment - Mean time until patients return to athletic
activity
Author
Wallace, et al.
2004
LOE
IV
Costa, et al. 2006
IV
Costa, et al. 2006
IV
Treatment
Duration
(weeks)
N Outcome
cast
plaster cast
immobilisation
immediate weight
bearing
mobilisation
162
101
Return to sports (weeks)
10 (SD 4.9)
26
Return to stair climbing
(weeks)
18 (95% CI
14-22) ‡
22
Return to stair climbing
(weeks)
17 (95% CI
11-18) ‡
v1.0 12.04.09
EXCLUDED ARTICLES
Table 153. Excluded studies
Author
Reason for
Exclusion
Current concepts review: acute ruptures of the Not best available
Achilles tendon
evidence
Title
Chiodo CP;Wilson MG;
van der Linden-van der
Zwaag HM;Nelissen
RG;Sintenie JB;
Costa ML;Shepstone
L;Darrah C;Marshall
T;Donell ST;
Weber M;Niemann M;Lanz
R;Muller T;
Pendleton H;Resch
S;Stenstrom A;Astrom I;
Results of surgical versus non-surgical treatment
of Achilles tendon rupture
Less than 80%
follow up
Immediate full-weight bearing mobilisation for
repaired Achilles tendon ruptures: a pilot study
Less than 80%
follow up
Nonoperative treatment of acute rupture of the
Achilles tendon: results of a new protocol and
comparison with operative treatment
Residual functional problems after non-operative
treatment of Achilles tendon rupture
Retrospective
Retrospective
Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up Time
STUDY QUALITY
Table 154. Study Quality
Cetti, et al. 1993
Return to sports - same level
47
IV
●
●
●
●
●
Cetti, et al. 1993
Return to sports - same level
52
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 stair climbing
(weeks)
22
IV
x
●
●
●
●
Re-rupture
33
IV
●
●
●
●
●
●= yes ○= no x= not reported
Metz, et al. 2008
163
v1.0 12.04.09
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up Time
Absence from work
33
IV
●
●
●
●
●
Return to sport
33
IV
●
●
●
●
●
Pain - VAS
33
IV
●
●
●
●
●
Pain - VAS
33
IV
●
●
●
●
●
Pain - VAS
33
IV
●
●
●
●
●
Satisfaction - VAS
33
IV
●
●
●
●
●
Satisfaction - VAS
33
IV
●
●
●
●
●
Satisfaction - VAS
33
IV
●
●
●
●
●
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 - same level
59
IV
●
●
●
●
●
Moller, et al. 2001
Return to sports - stopped
59
IV
●
●
●
●
●
Moller, et al. 2001
Return to sedentary work
(days)
59
IV
●
●
●
●
●
Moller, et al. 2001
Return to light, mobile work
(days)
59
IV
●
●
●
●
●
Wallace, et al.
2004
Return to sports (weeks)
101
IV
x
●
●
●
●
●= yes ○= no x= not reported
Author
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
Metz, et al. 2008
164
v1.0 12.04.09
Author
Outcome Measure
N
LoE
Consecutive
Follow up 80
Same Outcomes
Same Treatment
Equal Follow up Time
Cetti, et al. 1993
Return to sports - same 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 ankle
movement
56
IV
●
●
●
●
●
Cetti, et al. 1993
Function-Abnormal gait
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 run
56
IV
●
●
●
●
●
Cetti, et al. 1993
Function-Abnormal toe stand
56
IV
●
●
●
●
●
Cetti, et al. 1993
Function-Abnormal toe stand
56
IV
●
●
●
●
●
●= yes ○= no x= not reported
165
v1.0 12.04.09
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 nonoperative 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.
166
v1.0 12.04.09
IV. APPENDIXES
167
v1.0 12.04.09
APPENDIX I
Guidelines and Technology Oversight
Chair:
William C. Watters, III, MD
6624 Fannin #2600
Houston, TX 77030
WORK GROUP
Christopher P Chiodo MD, Chair
Brigham Orthopedic Associates
75 Francis Street
Boston MA 02115
Guidelines and Technology Oversight ViceChair:
Michael J. Goldberg, MD
Department of Orthopaedics
Seattle Children’s Hospital
4800 Sand Point Way NE
Seattle, WA 98105
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
Evidence Based Practice Committee Chair:
Michael Keith, MD
2500 Metro Health Drive
Cleveland, OH 44109-1900
Bruce E Cohen MD
1783 Sterling Road
Charlotte NC 28209
AAOS Staff:
Robert H. Haralson III, MD, MBA
AAOS Medical Director
6300 N River Road
Rosemont, IL 60018
John E Femino MD
Department of Orthopedics
University of Iowa Hospital and Clinics
JPP 01022
200 Hawkins Drive
Iowa City IA 52242
Charles M. Turkelson, PhD
Director of Research and Scientific Affairs
Janet L. Wies MPH
AAOS Clinical Practice Guideline Mgr
Eric Giza MD
UC Davis Dept of Orthopaedics
Ambulatory Care Services Bldg
4860 Y St #3800
Sacramento, CA 95817
AAOS Research Analysts
Laura Raymond MA - Lead Analyst
Sara Anderson MPH
Kevin Boyer BS
Patrick Sluka MPH
168
v1.0 12.04.09
APPENDIX II
TIME FROM RUPTURE TO TREATMENT
Table 155. Time from injury to treatment
Author
Time from Injury to treatment
Maffulli, et al.
1998
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
169
v1.0 12.04.09
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)
Aktas, et al
2009
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
170
v1.0 12.04.09
Author
Time from Injury to treatment
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
171
v1.0 12.04.09
Author
Time from Injury to treatment
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
Aktas, et al
2009
1.5 days (range 2-56 hours)
Margetic, et al
2007
Not Reported
McComis, et al.
1997
Not Reported
Fortis, et al.
2008
Not Reported
172
v1.0 12.04.09
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,
and Technology
December 2, 2009
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 nonoperativ*[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 postoperative*[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
1766 citations excluded
2481 abstracts screened
for inclusion
2200 abstracts excluded
281 articles recalled for
full text review
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?
Was there more than 80% follow-up for all patients in the control group and the
experimental group on the outcome of interest?
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?
Was there more than 80% follow-up for all patients in the control group and the
experimental group on the outcome of interest?
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?
What is the resulting strength of recommendation?
STEP 4:
BALANCE BENEFITS AND HARMS
Are there trade-offs between benefits and harms that alter the strength of
recommendation obtained in STEP 3?
What is the resulting strength of recommendation?
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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?
What is the resulting strength of recommendation?
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:
Number of Permissible
Dissenters
Work group Size
≤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
U
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.
U
U
U
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
a representative of a professional society?
Yes
No
If yes, may we list your society as a reviewer
of this guideline?
Yes
No
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.
H
H
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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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:
U
U
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 evidencebased 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
OR
95% CI
○
● op
Description
Odds Ratio = The odds in Group B divided by the odds in Group A, where the odds is
the probability of the outcome occurring divided by the probability of the outcome not
occurring.
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.
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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