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THE DIAGNOSIS AND TREATMENT OF ACUTE ACHILLES TENDON RUPTURE
GUIDELINE AND EVIDENCE REPORT
CONFIDENTIAL DRAFT
Disclaimer 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49
This Clinical Practice Guideline was developed by an AAOS physician volunteer Work Group based on a systematic review of the current scientific and clinical information and accepted approaches to treatment and/or diagnosis. This Clinical Practice Guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s clinical circumstances. Disclosure Requirement In accordance with AAOS policy, all individuals whose names appear as authors or contributors to Clinical Practice Guideline filed a disclosure statement as part of the submission process. All panel members provided full disclosure of potential conflicts of interest prior to voting on the recommendations contained within this Clinical Practice Guidelines. Funding Source This Clinical Practice Guideline was funded exclusively by the American Academy of Orthopaedic Surgeons who received no funding from outside commercial sources to support the development of this document. FDA Clearance Some drugs or medical devices referenced or described in this Clinical Practice Guideline may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice. Copyright All rights reserved. No part of this Clinical Practice Guideline may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the AAOS. Published 2009 by the American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018 First Edition Copyright 2007 by the American Academy of Orthopaedic Surgeons
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Summary of Recommendations 50 51 52 53 54 55 56 57 58 59 60 61 62 63
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The following is a summary of the recommendations in the AAOS’ clinical practice guideline, The Diagnosis and Treatment of Acute Achilles Tendon Rupture. The scope of this guideline is specifically limited to acute Achilles tendon rupture. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician and other healthcare practitioners.
1. In the absence of the reliable evidence, it is the opinion of this work group that a detailed history and physical exam be performed. The physical examination should include two or more of the following tests to establish the diagnosis of acute Achilles tendon rupture:
o Clinical Thompson test (Simmonds squeeze test) o Decreased ankle plantar flexion strength o Presence of a palpable gap (defect, loss of contour) o Increased passive ankle dorsiflexion with gentle manipulation
Strength of Recommendation – Consensus* 2. We are unable to recommend for or against the routine use of magnetic resonance
imaging (MRI), ultrasound (ultrasonography), and radiograph (roentgengrams, x-rays) to confirm the diagnosis of acute Achilles tendon rupture.
Strength of Recommendation – Inconclusive
3. Non-operative treatment is an option for all patients with acute Achilles tendon rupture.
Strength of Recommendation: Weak
4. For patients treated non-operatively, we are unable to recommend for or against the use of immediate functional bracing for patients with acute Achilles tendon rupture
Strength of Recommendation: Inconclusive
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5. Operative treatment is an option in patients with acute Achilles tendon rupture. 89
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Strength of Recommendation: Weak
6. In the absence of reliable evidence, it is the opinion of the work group that although operative treatment is an option, it should be approached more cautiously in patients with diabetes, neuropathy, immunocompromised states, age above 65, tobacco use, sedentary lifestyle, obesity (BMI >30), peripheral vascular disease or local/systemic dermatologic disorders.
Strength of Recommendation: Consensus
7. For patients who will be treated operatively for an acute Achilles tendon rupture, we are unable to recommend for or against preoperative immobilization or restricted weight-bearing.
Strength of Recommendation: Inconclusive
8. We suggest that patients with an acute Achilles tendon rupture who are treated operatively undergo a minimally invasive technique rather than an open technique.
Strength of Recommendation: Moderate
9. We cannot recommend for or against the use of allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts in all acute Achilles tendon ruptures that are treated operatively.
Strength of Recommendation: Inconclusive
10. We cannot recommend for or against the use of antithrombotic treatment for patients with acute Achilles tendon ruptures.
Strength of Recommendation: Inconclusive
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
12. We suggest the use of a protective device that allows mobilization by 2- 4 weeks post operatively.
Strength of Recommendation: Moderate
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13. 13 We are unable to recommend for or against post-operative physiotherapy for patients with acute Achilles tendon rupture
Strength of Recommendation: Inconclusive
14. In all patients with acute Achilles tendon rupture, irrespective of treatment type,
we are unable to recommend a specific time at which patients can return to activities of daily living.
Strength of Recommendation: Inconclusive 15. In patients who participate in sports it is an option to return them to sports within
3-6 months after operative treatment for acute Achilles tendon rupture.
Strength of Recommendation: Weak
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
* While we strongly encourage reviewers to read the full guideline, please refer to the sections titled “Judging the Quality of Evidence” and “Defining the Strength of the Recommendations Table 1” for a detailed description of the link between the evidence supporting the Strength of a Recommendation and the language of the guideline.
Work Group153 154 Blinded for review
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Peer Review 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189
Participation in the AAOS peer review process does not constitute an endorsement of this guideline by the participating organization or the individuals listed below nor does it is any way imply the reviewer supports this document. The following organizations participated in peer review of this clinical practice guideline and gave explicit consent to be listed as a peer review organization of this document: American Academy of Family Practitioners American Podiatric Medical Association American Orthopaedic Society for Sports Medicine American College of Foot and Ankle Surgeons American Academy of Physical Medicine and Rehabilitation American Physical Therapy Association Individuals who participated in the peer review of this document and gave their explicit consent to be listed as reviewers of this document are: Avrill Roy Berkman, MD Christopher R. Carcia, MD Michael Heggeness, MD Harvey Insler, MD John Kirkpatrick, MD Michael S. Lee, DPM, FACFA Angus McBryde Jr., MD Ariz R. Mehta, MD Lawrence Oloff, DPM Steven Raikin, MD Charles Reitman, MD John Richmond, MD Kevin Shea, MD Naomi Sheilds, MD Nelson F. Soohoo, MD Glenn Weinraub, DPM, FACFAS
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Table of Contents 190
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SUMMARY OF RECOMMENDATIONS ..............................................................III
WORK GROUP .................................................................................................. VI
PEER REVIEW.................................................................................................. VII
TABLE OF CONTENTS ................................................................................... VIII
LIST OF TABLES.............................................................................................. XII
I. INTRODUCTION ...........................................................................................1
Overview ....................................................................................................................................................... 1
Goals and Rationale ..................................................................................................................................... 1
Intended Users .............................................................................................................................................. 1
Patient Population ........................................................................................................................................ 2
Incidence ....................................................................................................................................................... 2
Burden of Disease ......................................................................................................................................... 2
Etiology.......................................................................................................................................................... 2
Risk Factors .................................................................................................................................................. 2
Emotional and Physical Impact of Achilles Tendon Rupture .................................................................. 2
Potential Benefits, Harms, and Contraindications .................................................................................... 2
II. METHODS.....................................................................................................3
Formulating Preliminary Recommendations............................................................................................. 3
Study Inclusion Criteria............................................................................................................................... 4
Outcomes Considered .................................................................................................................................. 4
Literature Searches ...................................................................................................................................... 5
Data Extraction............................................................................................................................................. 6
Judging the Quality of Evidence ................................................................................................................. 6
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Defining the Strength of the Recommendations ........................................................................................ 7
Consensus Development............................................................................................................................... 8
Statistical Methods ....................................................................................................................................... 9
Peer Review................................................................................................................................................... 9
Public Commentary.................................................................................................................................... 10
The AAOS Guideline Approval Process................................................................................................... 10
Revision Plans ............................................................................................................................................. 10
Guideline Dissemination Plans .................................................................................................................. 10
III. RECOMMENDATIONS AND SUPPORTING EVIDENCE .......................12
Recommendation 1 ..................................................................................................................................... 13 Summary of Evidence.............................................................................................................................. 13 Excluded Articles..................................................................................................................................... 14 Study Quality ........................................................................................................................................... 15 Study Results ........................................................................................................................................... 16
Recommendation 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.............................................................................................................................. 43 Excluded Articles..................................................................................................................................... 49 Study Quality ........................................................................................................................................... 53
Recommendation 6 ..................................................................................................................................... 57
Recommendation 7 ..................................................................................................................................... 58
Recommendation 8 ..................................................................................................................................... 59 Percutaneous vs Open Repair .................................................................................................................. 60 Limited Open vs Open Repair ................................................................................................................. 60 Summary of Evidence.............................................................................................................................. 60
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Excluded Articles..................................................................................................................................... 63 Study Quality ........................................................................................................................................... 65 Study Results ........................................................................................................................................... 68
Recommendation 9 ..................................................................................................................................... 71 Autograft Tissue vs Open Repair............................................................................................................. 71 Augmentation with Synthetic Tissue vs Open Repair ............................................................................. 71 Summary of Evidence.............................................................................................................................. 72 Excluded Articles..................................................................................................................................... 74 Study Quality ........................................................................................................................................... 77 Study Results ........................................................................................................................................... 81
Recommendation 10 ................................................................................................................................... 85 Excluded Studies ..................................................................................................................................... 85
Recommendation 11 ................................................................................................................................... 86 Summary of Evidence.............................................................................................................................. 88 Summary of Complications ..................................................................................................................... 91 Excluded Articles..................................................................................................................................... 92 Study Quality ........................................................................................................................................... 93 Study Results ........................................................................................................................................... 98
Recommendation 12 ................................................................................................................................. 102 Summary of Evidence............................................................................................................................ 103 Summary of Complications ................................................................................................................... 109 Excluded Articles................................................................................................................................... 111 Study Quality ......................................................................................................................................... 112 Study Results ......................................................................................................................................... 117
Recommendation 13 ................................................................................................................................. 122 Summary of Evidence............................................................................................................................ 122 Excluded articles.................................................................................................................................... 123
Recommendation 14 ................................................................................................................................. 124 Summary of Evidence............................................................................................................................ 124 Excluded Articles................................................................................................................................... 131 Study Quality ......................................................................................................................................... 133
Recommendation 15 ................................................................................................................................. 136 Summary of Evidence............................................................................................................................ 137 Excluded Articles................................................................................................................................... 139 Study Quality ......................................................................................................................................... 141
Recommendation 16 ................................................................................................................................. 146 Summary of Evidence............................................................................................................................ 146 Excluded Articles................................................................................................................................... 148 Study Quality ......................................................................................................................................... 148
Future Research ....................................................................................................................................... 151
IV. APPENDIXES .............................................................................................152
Appendix I................................................................................................................................................. 153 Work Group........................................................................................................................................... 153
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Appendix II ............................................................................................................................................... 154 AAOS Bodies That Approved This Clinical Practice Guideline ........................................................... 154 Documentation of Approval .................................................................................................................. 155
Appendix III.............................................................................................................................................. 156 Literature Searches for Primary Studies ................................................................................................ 156
Appendix IV.............................................................................................................................................. 158 Study Attrition Flowchart ...................................................................................................................... 158
Appendix V ............................................................................................................................................... 159 Data Extraction Elements ...................................................................................................................... 159
Appendix VI.............................................................................................................................................. 160 Judging the Quality of Diagnostic Studies............................................................................................. 160 Judging the Quality of Treatment Studies ............................................................................................. 161
Appendix VII ............................................................................................................................................ 163 Form for Assigning Strength of Recommendation (Interventions) ....................................................... 163
Appendix VIII........................................................................................................................................... 165 Voting by the Nominal Group Technique ............................................................................................. 165
Appendix IX.............................................................................................................................................. 166 Structured Peer Review Form................................................................................................................ 166
Appendix X ............................................................................................................................................... 169 Peer Review Panel ................................................................................................................................. 169 Public Commentary ............................................................................................................................... 169
Appendix XI.............................................................................................................................................. 171 Description of Symbols Used in Tables................................................................................................. 171
Appendix XII ............................................................................................................................................ 172 Conflict of Interest................................................................................................................................. 172
Appendix XIII........................................................................................................................................... 173 References ............................................................................................................................................. 173 Excluded articles after full text review .................................................................................................. 178
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List of Tables 324 325
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Table 1 Defining the Strength of the Recommendation ..................................................... 8 Table 2 AAOS Guideline Language ................................................................................... 8 Table 3. Excluded Articles................................................................................................ 14 Table 4. Study Quality ...................................................................................................... 15 Table 5. Sensitivity and specificity of Palpation, Calf Squeeze and Matles tests ............ 16 Table 6. Excluded Articles................................................................................................ 18 Table 7. Study Quality ...................................................................................................... 19 Table 8. Sensitivity and Specificity .................................................................................. 20 Table 9. Operative vs. Cast – Function............................................................................. 22 Table 10. Operative vs. Cast – Pain.................................................................................. 22 Table 11. Operative vs. Cast – Return to Work................................................................ 22 Table 12. Operative vs. Cast - Return to Sport ................................................................ 23 Table 13. Operative vs. Cast - Rerupture.......................................................................... 23 Table 14. Operative vs. Cast - Satisfaction....................................................................... 24 Table 15. Operative vs. Cast – Complications.................................................................. 24 Table 16. Systematic Review Summary ........................................................................... 25 Table 17. Excluded Articles.............................................................................................. 26 Table 18. Study Quality .................................................................................................... 27 Table 19. Open vs. Cast - Function................................................................................... 28 Table 20. Cast vs. Open Repair - Pain .............................................................................. 28 Table 21. Operative vs. Cast - Return to Work................................................................. 30 Table 22. Operative vs. Cast - Return to Sport ................................................................. 31 Table 23. Operative vs. Cast - Rerupture.......................................................................... 31 Table 24 Cast vs. Open - Complications .......................................................................... 32 Table 25. Cast + Functional Brace vs. Cast - Rerupture................................................... 35 Table 26. Summary of Results - Case Series.................................................................... 35 Table 27. Summary of Systematic Reviews ..................................................................... 35 Table 28. Functional Bracing – Satisfaction (VAS) ......................................................... 35 Table 29. Functional Bracing - Satisfaction (%) .............................................................. 36 Table 30. Functional Bracing - Pain ................................................................................. 36 Table 31. Functional Bracing - Function .......................................................................... 36 Table 32. Functional Bracing - Strength........................................................................... 37 Table 33. Functional Bracing - Return to Work and Sports ............................................. 37 Table 34. Functional Bracing - Return to Work and Sports (days) .................................. 37 Table 35. Functional Bracing - Complications ................................................................. 38 Table 36. Functional Bracing - Rerupture ........................................................................ 38 Table 37. Functional Bracing - Excluded Studies ............................................................ 38 Table 38. Study Quality - Randomized Control Trials ..................................................... 39 Table 39. Study Quality - Non-Randomized Comparative Study .................................... 39 Table 40. Study Quality - Case Series .............................................................................. 40 Table 41. Open Repair – All Outcomes............................................................................ 43 Table 42. Open Repair - Return to work........................................................................... 43 Table 43. Open Repair - Activities of daily living............................................................ 44
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Table 44. Open Repair- Mean time until return to athletic activity.................................. 44 Table 45. Open Repair- Percent of patients able to return to activities of daily living .... 45 Table 46. Open Repair- Percent of patients able to return to work .................................. 45 Table 47. Open Repair- Percent of patients able to return to sports ................................. 45 Table 48: Open Repair- Percent of patients with pain..................................................... 46 Table 49. Open Repair- Percent of patients able to complete functional activities.......... 46 Table 50. Open Repair- Percent of patients with excellent satisfaction ........................... 46 Table 51. Minimally Invasive Repair- All outcomes....................................................... 47 Table 52. Minimally Invasive Repair- Percent of Patients able to return to activity........ 47 Table 53. Minimally Invasive Repair - Percent of patients able to return to sports ......... 48 Table 54. Minimally Invasive Repair - Satisfaction ......................................................... 48 Table 55. Minimally Invasive Repair - Mean time until return to activity....................... 48 Table 56. Minimally Invasive Repair-Percent of patients able to return to sports ........... 48 Table 57. Minimally Invasive Repair-Percent of patients able to return to work............. 49 Table 58. Excluded Articles.............................................................................................. 49 Table 59. Study Quality .................................................................................................... 53 Table 60. Percutaneous vs. Open - Global Outcomes ...................................................... 60 Table 61. Percutaneous and Limited Open vs. Open - Return to Activities and Function61 Table 62. Percutaneous vs. Open - Satisfaction............................................................... 61 Table 63. Percutaneous Repair and Limited Open Repair vs. Open - Complications...... 61 Table 64. Percutaneous and Limited Open vs. Open – Rerupture.................................... 62 Table 65. Excluded Studies - All Operative Techniques.................................................. 63 Table 66. Study Quality - RCTs ....................................................................................... 65 Table 67. Quality of Studies - Comparative Studies......................................................... 66 Table 68. Percutaneous vs. Open - Global Outcomes ..................................................... 68 Table 69. Percutaneous vs. Open - Return to Activities ................................................... 68 Table 70. Percutaneous vs. Open - Satisfaction................................................................ 68 Table 71. Percutaneous vs. Open - Complications ........................................................... 68 Table 72. Minimally Invasive vs. Open - Function .......................................................... 69 Table 73. Minimally Invasive vs. Open - Complications ................................................. 69 Table 74. Minimally Invasive vs. Open - Symptoms ....................................................... 70 Table 75. Minimally Invasive vs. Open - Return to Sport................................................ 70 Table 76. Minimally Invasive vs. Open - Complications ................................................. 70 Table 77. Autograft vs. Open - Pain and Stiffness ........................................................... 72 Table 78. Autograft vs. Open - Satisfaction ..................................................................... 72 Table 79. Autograft - Return to Activities and Sports ..................................................... 72 Table 80. Autograft vs. Open - Footwear Restrictions ..................................................... 73 Table 81. Autograft vs. Open - Hospitalization and Immobilization ............................... 73 Table 82. Autograft vs. Open - Complications................................................................. 73 Table 83. Excluded Studies - Allograft............................................................................. 74 Table 84. Excluded Studies - Autograft............................................................................ 74 Table 85. Excluded Studies - Synthetic Tissue................................................................. 75 Table 86- Biologic Adjuncts............................................................................................. 76 Table 87. Study Quality – Autograft RCTs ...................................................................... 77 Table 88. Study Quality - Autograft Comparative Studies.............................................. 78 Table 89. Study Quality - Synthetic Tissue Case Series.................................................. 80
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Table 90 Autograft vs. Open Pain and Stiffness............................................................... 81 Table 91. Autograft vs. Open - Satisfaction ..................................................................... 81 Table 92. Autograft vs. Open - Return to Sports .............................................................. 82 Table 93. Autograft vs. Open - Return to Activities......................................................... 82 Table 94. Autograft vs. Open - Footwear Restrictions ..................................................... 82 Table 95. Autograft vs. Open - Hospitalization vs. Immobilization................................. 83 Table 96. Autograft vs. Open - Complications................................................................. 83 Table 97. Synthetic Tissue - Results................................................................................. 84 Table 98. Antithrombotic Treatment - Excluded Studies ................................................. 85 Table 99: Description of treatment groups ...................................................................... 87 Table 100 Time until return to activity ............................................................................. 88 Table 101 Pain .................................................................................................................. 88 Table 102 Function ........................................................................................................... 89 Table 103 EuroQoL, Rand-36........................................................................................... 90 Table 104 Patient Subjective Results................................................................................ 90 Table 105 Reruptures........................................................................................................ 90 Table 106 Reported Complications .................................................................................. 91 Table 107 Systematic Reviews ......................................................................................... 91 Table 108 Article Inclusion List- Early weight-bearing vs. non-weight bearing ............. 92 Table 109. Quality- Weight-bearing vs. non-weight bearing ........................................... 93 Table 110 Study Data: Weight Bearing vs. Non-Weight Bearing.................................... 98 Table 111. Description of Treatment Groups ................................................................. 103 Table 112. Time to Return to Activity............................................................................ 103 Table 113. Pain .............................................................................................................. 105 Table 114. Function ........................................................................................................ 105 Table 115. EuroQoL, E5D, Ankle Performance Score................................................... 106 Table 116. Patient opinion of results .............................................................................. 107 Table 117. Footwear restrictions..................................................................................... 108 Table 118. Re-rupture ..................................................................................................... 108 Table 119. Early Motion vs. Cast - Complications......................................................... 109 Table 120. Systematic Reviews ...................................................................................... 109 Table 121. Mobilization vs. Immobilization Included Articles...................................... 111 Table 122. Mobilization vs. Immobilization Quality...................................................... 112 Table 123. Mobilization vs. Immobilization Study Data................................................ 117 Table 124. Post Operative Physiotherapy Regiments.................................................... 122 Table 125. Excluded Articles.......................................................................................... 123 Table 126. Non-Operative treatment - Percent of patients able to return to work.......... 124 Table 127. Non-Operative Treatment -Percent of patients able to return to ADL ......... 125 Table 128. Operative Treatment - Percent of patients returning to ADL ....................... 125 Table 129. Operative Treatment - Percent of patients able to return to work ................ 126 Table 130. Non-Operative Treatment - Mean time until return to work ........................ 128 Table 131. Non-Operative Treatment - Mean time until return to walking.................... 128 Table 132. Operative Treatment - Mean time to return to ADL..................................... 129 Table 133. Operative Treatment - Mean time until return to work ................................ 130 Table 134. Excluded Articles.......................................................................................... 131 Table 135. Patient return to activities of daily living...................................................... 133
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Table 136. Operative Treatment - Return to Recreational Activity................................ 137 Table 137. Operative Treatment - Return to sports ........................................................ 137 Table 138. Operative Treatment - Mean time to return to athletic activity .................... 139 Table 139. Excluded Articles.......................................................................................... 139 Table 140. Return to sports............................................................................................. 141 Table 141. Non-Operative Treatment - Percent of patients returning to athletic activity......................................................................................................................................... 146 Table 142. Non-Operative Treatment - Mean time until patients return to athletic activity......................................................................................................................................... 147 Table 143. Excluded studies ........................................................................................... 148 Table 144. Study Quality ................................................................................................ 148
I. INTRODUCTION 472
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OVERVIEW This clinical practice guideline is based on a systematic review of published studies on the treatment of acute Achilles tendon rupture in adults. Adults were defined as older than 19 years of age for this guideline. Acute Achilles tendon ruptures are defined as those treated within the first six weeks of injury. In addition to providing practice recommendations, this guideline also highlights gaps in the literature and areas that require future research.
This guideline is intended to be used by all appropriately trained surgeons and all qualified physicians diagnosing and treating Achilles tendon ruptures. It is also intended to serve as an information resource for decision makers and developers of practice guidelines and recommendations.
GOALS AND RATIONALE The purpose of this clinical practice guideline is to help improve treatment based on the current best evidence. Current evidence-based practice (EBP) standards demand that physicians use the best available evidence in their clinical decision making. To assist in this, this clinical practice guideline consists of a systematic review of the available literature regarding the treatment of Achilles tendon ruptures. The systematic review detailed herein was conducted between December 2008 and June 2009 and demonstrates where there is good evidence, where evidence is lacking, and what topics future research must target in order to improve the treatment of patients with acute Achilles tendon ruptures. AAOS staff and the physician work group systematically reviewed the available literature and subsequently wrote the following recommendations based on a rigorous, standardized process.
Musculoskeletal care is provided in many different settings by many different providers. We created this guideline as an educational tool to guide qualified physicians through a series of treatment decisions in an effort to improve the quality and efficiency of care. This guideline should not be construed as including all proper methods of care or excluding methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment must be made in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution.
INTENDED USERS This guideline is intended to be used by orthopaedic surgeons and all qualified physicians managing patients with acute Achilles tendon rupture. Typically, orthopaedic surgeons will have completed medical training, a qualified residency in orthopaedic surgery, and some may have completed additional sub-specialty training. It is also intended to serve as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. Diagnosis and treatment for patients with acute Achilles tendon rupture are based on the assumption that decisions are predicated on patient and physician mutual communication including discussion of available treatments and procedures applicable to the individual patient. Once the patient has been informed of
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available therapies and has discussed these options with his/her physician, an informed decision can be made. Clinician input based on experience with both conservative management and surgical skills increases the probability of identifying patients who will benefit from specific treatment options.
PATIENT POPULATION This document addresses the diagnosis and treatment of acute Achilles tendon rupture in adults (defined as patients 19 years of age and older).
INCIDENCE The incidence of Achilles tendon ruptures has been estimated to range from an annual average of 5.5 ruptures to 9.9 ruptures per 100,000 people in North America (Edmonton, Canada).1 Studies of European communities report comparable values ranging from 6 to 18 ruptures per 100,000 people.1-4
BURDEN OF DISEASE Those afflicted with an acute Achilles tendon rupture face a healing period that requires time away from work and limited athletic activity. Time away from work may impact the patient financially and limiting activity may impact the patient’s health.5
ETIOLOGY Most acute Achilles tendon ruptures are traumatic in origin. Some studies have shown that ruptured Achilles tendons have occult degeneration.3
RISK FACTORS Most ruptures of the Achilles tendons occur during sports activities, are more common in males in the third or fourth decade of life, and occur more frequently on the left side.1
EMOTIONAL AND PHYSICAL IMPACT OF ACHILLES TENDON RUPTURE Acute Achilles tendon rupture often results in sudden pain in the affected leg, the inability to bear weight and noticeable weakness of the affected ankle.3 The injury often results in the patient’s inability to walk or perform their regular activities of daily living. Patients face possible deformity if the tendon does not heal correctly and a substantial recovery period. Possible complications associated with Achilles tendon rupture include rerupture and, in cases of surgical repair, infection. POTENTIAL BENEFITS, HARMS, AND CONTRAINDICATIONS 545 The aim of treatment is pain relief and improvement or maintenance of the patient’s functional status. Long term results were often not available and complications varied by study (frequently they were not reported) in the literature available for this guideline. Most treatments are associated with some known risks, especially invasive and operative treatments. In addition, contraindications vary widely based on the treatment administered. Therefore, discussion of available treatments and procedures applicable to the individual patient rely on mutual communication between the patient and physician, weighing the potential risks and benefits for that patient.
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II. METHODS 554
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Each recommendation in this clinical practice guideline is based on a systematic review of the relevant medical literature. We developed systematic reviews for this guideline because these reviews employ specific processes designed to minimize bias in the selection, summary, and analysis of this literature.6, 7 In referring to bias, we explicitly mean both the biases that can arise from financial conflicts of interest and biases that can arise from intellectual conflicts if interest.
This section of the present document describes how we conducted our systematic reviews and how the guideline was developed. Accordingly, in this section we describe our strategies for finding relevant literature, our criteria for selecting articles to include in this guideline, how we extracted data, how we appraised and graded the evidence, our methods of statistical analysis, and the review and approval steps this guideline went through. Elsewhere in this document, we provide extensive documentation so that interested readers can assure themselves that we attempted to combat bias wherever possible.
This guideline and the underlying systematic reviews were prepared by an AAOS physician work group with the assistance of the AAOS Clinical Practice Guidelines Unit in the Department of Research and Scientific Affairs at the AAOS (Appendix I). The work group met on December 13, 2008 to establish the guideline’s scope. The work group met again on July 31 and August 1, 2009 to write and vote on the final recommendations and rationales for each recommendation. The resulting draft guidelines were then peer-reviewed, subsequently sent for public commentary, and then sequentially approved by the AAOS Evidence Based Practice Committee, AAOS Guidelines and Technology Oversight Committee, AAOS Council on Research, Quality Assessment, and Technology, and the AAOS Board of Directors (see Appendix II for a description of the AAOS bodies involved in the approval process)
FORMULATING PRELIMINARY RECOMMENDATIONS The work group began work on this guideline by constructing a set of preliminary recommendations. These recommendations specify [what] should be done in [whom], [when], [where], and [how often or how long]. They function as questions for the systematic review that underpins each preliminary recommendation, and they do not function as final recommendations or conclusions. Preliminary recommendations do not need to be true.
Once established, these a priori preliminary recommendations cannot be modified until the final work group meeting. The a priori and inviolate nature of the preliminary recommendations combats bias by preventing a “change in course” if a systematic review yields results that are not to someone’s liking. The results of each systematic review are presented and discussed at the final work group meeting. At this time the preliminary recommendations are modified in response to the evidence in the systematic review. All of the systematic reviews conducted for a given guideline are presented in it and, in general, all preliminary recommendations are modified.
AAOS Guideline Unit v0.3 10.12.09 3
STUDY INCLUSION CRITERIA 595
601 602 603
604 605
606
607
608 609 610
611 612
613
614 615
616
617 618
619 620
621 622 623 624 625 626
627 628 629 630 631
We developed a priori article inclusion criteria for our review. These criteria are our 596 “rules of evidence” and articles that do not meet them are, for the purposes of this 597 guideline, not evidence. 598
To be included in our systematic reviews (and hence, in this guideline) an article had to 599 be a report of a study that: 600
• Evaluated a treatment for acute Achilles tendon rupture. Acute Achilles tendon rupture is defined as a rupture treated within zero to six weeks post injury.
• Was a full report of a clinical study and was published in the peer reviewed literature
• Was an English language article published after 1965
• Was not a cadaveric, animal, in vitro, or biomechanical study
• Was not a retrospective case series, medical records review, meeting abstract, unpublished study report, case report, historical article, editorial, letter, or commentary
• Was the most recent report of a study or the report with the largest number of enrolled patients in a study with multiple publications
• Enrolled ≥ 10 patients in each of its study groups
• Enrolled a patient population comprised of at least 80% of patients with acute Achilles tendon rupture
• Reported quantified results
• Must have followed 50% or more of its patients on at least one outcome; if less than 80% follow up the outcome was down graded.
• Study must use validated outcome measures
When considering studies for inclusion, we included only the best available evidence. Accordingly, we first included Level I evidence. In the absence of two or more studies of this Level, we sequentially searched for and included Level II through Level IV evidence, and did not proceed to a lower level if there were two or more studies of a higher level. For example, if there were two Level II studies that addressed a recommendation, we did not include Level III or IV studies.
OUTCOMES CONSIDERED Clinical studies often report many different outcomes. We included only patient-oriented outcomes when they were available. As the term implies, patient-oriented outcomes are outcomes that matter to the patient. “They tell clinicians, directly and without the need for extrapolation, that a diagnostic, therapeutic, or preventive procedure helps patients
AAOS Guideline Unit v0.3 10.12.09 4
live longer or live better.”8 Examples of patient-oriented outcomes include pain and quality of life.
632 633
634 635 636 637
638 639 640 641 642 643 644 645 646
647 648 649 650 651
652 653 654 655
656 657 658 659 660
661 662 663 664 665
666 667 668
We included surrogate outcomes only when patient-oriented outcomes were not available. Surrogate outcomes are laboratory or other measurements that are used as substitutes for how a patient feels, functions, or survives.9 Radiographic results are an example of a surrogate outcome.
We only included data for an outcome if ≥ 50% of the patients were followed for that outcome. For example, some studies report short-term outcomes data on nearly all enrolled patients, and report longer-term data on less than half of the enrolled patients. In such cases, we did not include the longer-term data. Additionally, we downgraded the Level of Evidence by one in instances where 50% to ≤80% of patients were followed. For example, if an otherwise perfect randomized controlled trial reported data on all enrolled patients one week after patients received a treatment but reported data on only 60% of patients one year later, we considered data from the later follow-up time as Level II evidence.
We only included data for outcomes reporting the average length of time to return to an activity if >80 % of the patients were included in the calculation. For example, some studies report the mean time for return to work as 6 weeks but are only including data for patients who have actually returned to work and are ignoring patients who are unable to return. An outcome such as this would not be included.
LITERATURE SEARCHES We attempted to make our searches for articles comprehensive. Using comprehensive literature searches ensures that the evidence we considered for this guideline is not biased for (or against) any particular point of view.
We searched for articles published from January 1966 to June 2009. Strategies for searching electronic databases were constructed by a Medical Librarian and reviewed by the work group. The search strategies we used are provided in Appendix III. We searched six electronic databases; PubMed, EMBASE, CINAHL, The Cochrane Library, The National Guidelines Clearinghouse and TRIP database.
All searches of electronic databases were supplemented with manual screening of bibliographies of all retrieved publications. We also searched the bibliographies of recent systematic reviews and other review articles for potentially relevant citations. Finally, a list of potentially relevant studies not identified by our searches was provided by the work group members. Fifty-six studies met the inclusion criteria and were included.
A study attrition diagram (provided in Appendix IV) documents, for each recommendation, the number of articles we identified, where we identified these articles, the number of articles we included, and the number of articles we excluded.
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DATA EXTRACTION 669 670 671 672 673 674
675 676 677 678
679 680 681 682 683
684 685 686 687
688 689 690 691 692 693 694 695
696 697 698 699 700 701 702 703 704 705
706 707 708 709
Data elements extracted from studies were defined in consultation with the physician work group. Two analysts completed data extraction independently for all studies. The evidence tables were audited by the work group. Disagreements about the accuracy of extracted data were resolved by consensus. The elements extracted are provided in Appendix V.
The use of extracted data in our systematic reviews is another of our methods to combat bias. It ensures that our results are based on the numerical results reported in published articles and not on the authors’ conclusions in the “Discussion Sections” of their articles. Such author conclusions can be influenced by bias.
JUDGING THE QUALITY OF EVIDENCE Determining the quality of the included evidence is vitally important when preparing any evidence-based work product. Doing so conveys the amount of confidence one can have in any study’s results. One has more confidence in high quality evidence than in low quality evidence.
We assessed the quality of the evidence for each outcome at each time point reported in a study. We did not simply assess the overall quality of a study. Our approach follows the recommendations of the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) working group10 as well as others.11
We evaluated quality on a per outcome basis rather than a per study basis because quality is not necessarily the same for all outcomes and all follow-up times reported in a study. For example, a study might report results immediately after patients received a given treatment and after some period of time has passed. Often, nearly all enrolled patients contribute data at early follow-up times but, at much later follow-up times, only a few patients may contribute data. One has more confidence in the earlier data than in the later data. The fact that we would assign a higher quality score to the earlier results reflects this difference in confidence.
We assessed the quality of treatment studies using a two step process. First, we assigned a Level of Evidence to all results reported in a study based solely on that study’s design. Accordingly, all data presented in randomized controlled trials were initially categorized as Level I evidence, all results presented in non-randomized controlled trials and other prospective comparative studies were initially categorized as Level II, all results presented in retrospective comparative and case-control studies were initially categorized as Level III, and all results presented in case-series reports were initially categorized as Level IV. We next assessed each outcome at each reported time point using a quality questionnaire and, when quality standards were not met, downgraded the Level of evidence (for this outcome at this time point) by one level (Appendix VI).
In studies investigating a diagnostic test, we used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) instrument to identify potential bias and assess variability and the quality of reporting in studies reporting the effectiveness of diagnostic techniques. We utilized a two step process to assess the quality of diagnostic studies. All
AAOS Guideline Unit v0.3 10.12.09 6
studies enrolling a prospective cohort of patients are initially categorized as Level I studies. Any study that did not enroll the appropriate spectrum of patients (e.g. case-control studies) was initially categorized as a Level IV study. A study that we determined contained methodological flaws (i.e. QUADAS question answered ‘no’) that introduce bias were downgraded in a cumulative manner for each known bias (
710 711 712 713 714 715 716 717 718 719
720 721 722 723 724 725 726
727 728 729 730 731 732 733 734
735 736 737 738 739 740 741 742 743
744 745 746 747 748 749 750 751
Appendix VI). For example, a study that is determined by the QUADAS instrument to have two biases is downgraded to Level III and a study that is determined to have four or more biases is downgraded to a Level V study. Those studies that do not sufficiently report their methods for a potential bias are downgraded to Level II since we are unable to determine if the bias did or did not bias the results of the study.
Assigning a Level of Evidence on the basis of study design plus other quality characteristics ties the Levels of Evidence we report more closely to quality than Levels of Evidence based only on study design. Because we tie quality to Levels of Evidence, we are able to characterize the confidence one can have in their results. Accordingly, we characterize the confidence one can have in Level I evidence as high, the confidence one can have in Level II and III evidence as moderate, and the confidence one can have in Level IV and V evidence as low.
DEFINING THE STRENGTH OF THE RECOMMENDATIONS Judging the quality of evidence is only a stepping stone towards arriving at the strength of the guideline recommendation. Unlike Levels of Evidence (which apply only to a given result at a given follow-up time in a given study) strength of the recommendation takes into account the quality, quantity, and applicability of the available evidence. Strength of the recommendation also takes into account the trade-off between the benefits and harms of a treatment or diagnostic procedure, and the magnitude of a treatment’s effect.
The strength of a recommendation expresses the degree of confidence one can have in a recommendation. As such, the strength expresses how possible it is that a recommendation will be overturned by future evidence. It is very difficult for future evidence to overturn a recommendation that is based on many high quality randomized controlled trials that show a large effect. It is much more likely that future evidence will overturn recommendations derived from a few small case series. Consequently, recommendations based on the former kind of evidence are rated as “strong” and recommendations based on the latter kind of evidence are given strength of recommendation of “weak”.
To develop the strength of a recommendation, AAOS staff first assigned a preliminary strength rating for each recommendation that took only the quality and quantity of the available evidence into account (see Table 1). Work group members then modified the preliminary strength rating using the ‘Form for Assigning Grade of Recommendation (Interventions)’ shown in Appendix VII. This form is based on recommendations of the GRADE Working group10 and requires the work group to consider the harms, benefits, and critical outcomes associated with a treatment. It also requires the work group to evaluate the applicability of the evidence. The final strength of the recommendation is
AAOS Guideline Unit v0.3 10.12.09 7
assigned by the physician work group, which modifies the preliminary strength rating on the basis of these considerations.
752 753
754 Table 1 Defining the Strength of the Recommendation
Strength Overall
Quality of Evidence
Description of Evidence
Strong Good Quality Evidence
Level I evidence from more than one study with consistent findings for recommending for or against the intervention or diagnostic.
Moderate Fair Quality Evidence
Level II or III evidence from more than one study with consistent findings, or Level I evidence from a single study for recommending for or against the intervention or diagnostic.
Weak Poor Quality Evidence
Level IV or V evidence from more than one study with consistent findings, or Level II or III evidence from a single study for recommending for against the intervention or diagnostic.
Inconclusive No Evidence or Conflicting
Evidence
The evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention or diagnostic.
Consensus There is no supporting evidence. In the absence of reliable evidence, the work group is making a recommendation based on their clinical opinion considering the known harms and benefits associated with the treatment.
No Evidence
755 756 757 758
759
Each recommendation was written using language that accounts for the final strength of the recommendation. This language, and the corresponding strength of recommendation, is shown in Table 2.
Table 2 AAOS Guideline Language Strength of
Recommendation Guideline Language
We recommend Strong
We suggest Moderate
Is an option Weak
We are unable to recommend for or against Inconclusive In the absence of reliable evidence, it is the
opinion of this work group Consensus
760 761 762 763 764 765 766
CONSENSUS DEVELOPMENT The recommendations and their strength were voted on using a structured voting technique known as the nominal group technique.12 We present details of this technique in Appendix VIII. Voting on guideline recommendations was conducted using a secret ballot and work group members were blinded to the responses of other members. If disagreement between work group members was significant, there was further discussion
AAOS Guideline Unit v0.3 10.12.09 8
767 768 769 770
771 772 773 774 775 776 777 778 779
780 781 782 783 784 785 786 787
788 789
790 791
792 793 794 795 796
797 798 799 800
801 802 803 804 805
to see whether the disagreement(s) could be resolved. Up to three rounds of voting were held to attempt to resolve disagreements. If disagreements were not resolved following three voting rounds, no recommendation was adopted. Lack of agreement is a reason that the strength for some recommendations is labeled “Inconclusive.”
STATISTICAL METHODS When possible, we report the results of the statistical analyses conducted by the authors of the included studies. In some circumstances, statistical testing was not conducted; however, the authors reported sufficient quantitative data, including measures of dispersion or patient level data for statistical testing. In these circumstances we used the statistical program STATA (StatCorp LP, College Station, Texas) to conduct our own analysis to interpret the results of a study. P-values < 0.05 were considered statistically significant. Any statistical analysis conducted by the AAOS authors is denoted in the tables.
STATA was also used to determine 95% confidence intervals, using the method of Wilson, when authors of the included studies reported counts or proportions. The program was also used to determine the magnitude of the treatment effect. For data reported as means (and associated measures of dispersion) we calculated a standardized mean difference by the method of Hedges and Olkin.13 For proportions, we calculated the odds ratio as a measure of treatment effect. When no events occur (“zero event”) in a proportion, the variance of the arcsine difference was used to determine statistical significance (p < 0.05).14
We used the program TechDig 2.0 (Ronald B. Jones, Mundelein, Illinois) to estimate means and variances from studies presenting data only in graphical form.
When published studies only reported the median, range, and size of the trial, we estimated their means and variances according to a published method.15
PEER REVIEW The draft of the guideline and evidence report were peer reviewed by outside specialty organizations that were nominated by the physician work group prior to the development of the guideline. Peer review was accomplished using a structured peer review form (Appendix IX).
In addition, the physician members of the AAOS Guidelines and Technology Oversight Committee, the Evidence Based Practice Committee and the Chairpersons of the AAOS Occupational Health and Workers’ Compensation Committee and the Medical Liability Committee were given the opportunity to provide peer review of the draft document.
We forwarded the draft guideline to a total of 38 peer reviewers and 17 returned reviews. The disposition of all non-editorial peer review comments was documented and the guideline was modified in response to peer review. The peer reviews and the responses to them accompanied this guideline through the process of public commentary and the subsequent approval process. Peer reviewing organizations and peer reviewing
AAOS Guideline Unit v0.3 10.12.09 9
individuals are listed in this document if they explicitly agree to allow us to publish this information (
806 807
808 809 810 811 812 813 814 815 816
817 818 819 820 821 822 823
Appendix X).
Peer review of an AAOS guideline does not imply endorsement. This is clearly stated on the structured review form sent to all peer reviewers and is also posted within the guideline. Endorsement cannot be solicited during the peer review process because the documents may still undergo substantial change as a result of both the peer review and public commentary processes. In addition, no guideline can be endorsed by specialty societies outside of the Academy until the AAOS Board of Directors has approved it. Organizations that provide members who participate on the work group or peer review of a draft guideline will be solicited for endorsement once the document has completed the full review and approval processes.
PUBLIC COMMENTARY After modifying the draft in response to peer review, the guideline was submitted for a thirty day period of “Public Commentary.” Commentators consist of members of the AAOS Board of Directors (BOD), members of the Council on Research, Quality Assessment, and Technology (CORQAT), members of the Board of Councilors (BOC), and members of the Board of Specialty Societies (BOS). Based on these bodies, up to 185 commentators had the opportunity to provide input into the development of this guideline. Of these, XX returned public comments. 824
825 826 827 828 829 830 831 832
833 834 835 836 837 838
839 840 841 842
THE AAOS GUIDELINE APPROVAL PROCESS In response to the non-editorial comments submitted during the period of public commentary, the draft was again modified by the AAOS Clinical Practice Guidelines Unit and physician work group members. The AAOS Guidelines and Technology Oversight Committee, the AAOS Evidence-based Practice Committee, the AAOS Council on Research, Quality Assessment, and Technology, and the AAOS Board of Directors approved the final guideline draft. Descriptions of these bodies are provided in Appendix II
REVISION PLANS This guideline represents a cross-sectional view of current treatment and/or diagnosis and may become outdated as new evidence becomes available. This guideline will be revised in accordance with this new evidence, changing practice, rapidly emerging treatment options, and new technology. This guideline will be updated or withdrawn in five years in accordance with the standards of the National Guideline Clearinghouse.
GUIDELINE DISSEMINATION PLANS The primary purpose of the present document is to provide interested readers with full documentation about not only our recommendations, but also about how we arrived at those recommendations. This document is also posted on the AAOS website at http://www.aaos.org/research/guidelines/guide.asp. 843
844 845 846
Shorter versions of the guideline are available in other venues. Publication of most guidelines is announced by an Academy press release, articles authored by the work group and published in the Journal of the American Academy of Orthopaedic Surgeons,
AAOS Guideline Unit v0.3 10.12.09 10
and articles published in AAOS Now. Most guidelines are also distributed at the AAOS Annual Meeting in various venues such as on Academy Row and at Committee Scientific Exhibits.
847 848 849
854 855 856
Selected guidelines are disseminated by webinar, an Online Module for the Orthopeadic 850 Knowledge Online website, Radio Media Tours, Media Briefings, and by distributing 851 them at relevant Continuing Medical Education (CME) courses and at the AAOS 852 Resource Center. 853
Other dissemination efforts outside the AAOS include submitting the guideline to the National Guideline Clearinghouse and distributing the guideline at other medical specialty societies’ meetings.
AAOS Guideline Unit v0.3 10.12.09 11
III. RECOMMENDATIONS AND SUPPORTING EVIDENCE 857
AAOS Guideline Unit v0.3 10.12.09 12
858
863 864 865 866 867 868 869 870 871 872 873 874 875
876 877 878 879 880
881
882 883
884 885 886 887 888 889 890 891 892 893
894 895 896 897 898
RECOMMENDATION 1 859 In the absence of the reliable evidence, it is the opinion of this work group that a detailed 860 history and physical exam be performed. The physical examination should include two 861 or more of the following tests to establish the diagnosis of acute Achilles tendon rupture: 862
o Clinical Thompson test (Simmonds squeeze test) o Decreased ankle plantar flexion strength o Presence of a palpable gap (defect, loss of contour) o Increased passive ankle dorsiflexion with gentle manipulation
Strength of Recommendation - Consensus Rationale: A systematic review of the literature did not identify adequate evidence for or against the use of specific history and physical examination findings to confirm the diagnosis of acute Achilles tendon rupture. There was only one level V study16 identified that did not provide adequate data in support of any individual or combination of the physical tests.
The prompt and accurate diagnosis of acute Achilles tendon rupture is essential to providing patients with timely, effective, and appropriate care. A history and physical examination adds no cost or risk to patients. The work group therefore agreed that an opinion-based recommendation is warranted.
Supporting Evidence:
One Level V prospective study that enrolled patients with unilateral complete Achilles tendon tears was included.16
SUMMARY OF EVIDENCE The study16 used visual inspection at surgery as the gold standard for the diagnosis in patients who had open repair. The study author also used clinical exam, ultrasound and MRI as the reference standard for diagnosis when deciphering if patients had an Achilles tendon tear and to confirm the extent of the tear in patients treated non-operatively. Healthcare providers were not routinely blinded to the results of any given test. All patients received a physical examination; palpation (presence of a gap) and the calf squeeze test (Thompson/Simmonds squeeze test) were performed by the author in all patients. The author performed the Matles test (increased passive ankle dorsiflexion) on 107 of 174 patients.
The study author reported sensitivities and specificities for the tests based on the 133 patients treated with open repair and the 28 patients treated who did not have an Achilles tendon rupture. The author reported these test results individually. He did not consider if incremental value exists for any combination of the given physical tests when the tests are all performed during the physical examination.
AAOS Guideline Unit v0.3 10.12.09 13
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899 900
EXCLUDED ARTICLES Table 3. Excluded Articles
Author Title Exclusion Reason
Copeland SA; Rupture of the Achilles tendon: a new clinical test Not relevant
Matles AL Rupture of the tendo achilles: another diagnostic sign Commentary
STUDY QUALITY 901 902 Table 4. Study Quality
● = Yes ○ = No X = Not Reported n/a = not applicable
Author N
Spec
trum
bia
s avo
ided
Sele
ctio
n cr
iteria
des
crib
ed
App
ropr
iate
refe
renc
e st
anda
rd
Dis
ease
pro
gres
sion
bia
s avo
ided
Parti
al v
erifi
catio
n bi
as a
void
ed
Diff
eren
tial v
erifi
catio
n bi
as a
void
ed
Inco
rpor
atio
n bi
as a
void
ed
Inde
x te
st e
xecu
tion
desc
ribed
Ref
eren
ce st
anda
rd e
xecu
tion
desc
ribed
Test
revi
ew b
ias a
void
ed
Dia
gnos
tic re
view
bia
s avo
ided
Clin
ical
revi
ew b
ias a
void
ed
Uni
nter
rupt
able
/Inte
rmed
iate
test
re
sult(
s) re
porte
d
Reference Standard Index Test
With
draw
als e
xpla
ined
Maffulli 161 Palpation
Open Repair,Ultrasound or MRI or Clinical tests
X ○ ● ● ● ○ ● ● ● ● ○ ● ● ●
Maffulli 161
Calf Squeeze Test (Thompson test/Simmonds squeeze test)
Open Repair, Ultrasound or MRI or Clinical tests
X ○ ● ● ● ○ ● ● ● ● ○ ● ● ●
Maffulli 105
Matles Test (increased passive ankle dorsiflexion)
Open Repair, Ultrasound or MRI or Clinical tests
X ○ ● ● ● ○ ● ● ● ● ○ ● ● ○
AAOS Guideline Unit v0.3 10.12.09 15
903
904 905
STUDY RESULTS Table 5. Sensitivity and specificity of Palpation, Calf Squeeze and Matles tests
Author N Test Sensitivity‡ (95% CI)
Specificity‡ (95% CI)
Maffulli 161 Palpation (presence of a gap)
0.73 (0.65, 0.80)
0.89 (0.72, 0.98)
Maffulli 161 Calf Squeeze Test (Thompson test /
Simmonds squeeze test)
0.96 (0.91, 0.99)
0.93 (0.76, 0.99)
Maffulli 105 Matles Test (increased passive ankle dorsiflexion)
0.88 (0.79, 0.95)
0.86 (0.67, 0.96)
906 ‡ AAOS Calculation
AAOS Guideline Unit v0.3 10.12.09 16
907 908 909 910 911 912 913 914 915 916 917 918 919 920 921 922 923 924 925
926 927 928 929 930 931
932 933 934 935 936 937
938
RECOMMENDATION 2 We are unable to recommend for or against the routine use of magnetic resonance imaging (MRI), ultrasound (ultrasonography), and radiograph (roentgengrams, x-rays) to confirm the diagnosis of acute Achilles tendon rupture.
Strength of Recommendation – Inconclusive Rationale:
A systematic review of the literature failed to identify adequate evidence to make a recommendation for or against the routine use of MRI, ultrasound, or radiographs to confirm the diagnosis of acute Achilles tendon rupture. There were no studies that address MRI or radiographs as confirmatory tests and there were only two level V studies16, 17 that addressed ultrasound. These two studies contain unreliable data and cannot be combined to provide adequate evidence.
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.
AAOS Guideline Unit v0.3 10.12.09 17
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939 940 941 942 943 944 945
946 947
SUMMARY OF EVIDENCE Two Level V prospective studies that enrolled patients with complete Achilles tendon tears were found.16, 17 The studies used visual inspection at surgery as the gold standard for the diagnosis. One study had patients that underwent the Thompson test and then surgery. Patients in the second study underwent the Thompson test and Ultrasound and then surgery. The authors of the studies reported sensitivities and specificities or provided enough information for these parameters to be determined.
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
MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic
individuals
Does not investigate the diagnostic test
Hartgerink, et al. 2001
Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26
cases with surgical correlation
Retrospective Chart Review
Hollenberg, et al. 2000
Sonographic appearance of nonoperatively treated Achilles tendon ruptures
Does not investigate the diagnostic test
Kabbani, et al. 1993
Magnetic resonance imaging of tendon pathology about the foot and ankle. Part I. Achilles tendon Commentary
Kalebo, et al. 1992
Diagnostic value of ultrasonography in partial ruptures of the Achilles tendon
Chronic/neglected Achilles tendon rupture
Kayser, et al. 2005
Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound
imaging Partial Rupture
Kuwada, 2008 Surgical correlation of preoperative MRI findings of
trauma to tendons and ligaments of the foot and ankle
Less than 10 patients per group
Lehtinen, et al. 1994
Sonography of Achilles tendon correlated to operative findings
Chronic/neglected Achilles tendon rupture
Marshall, et al. 2002
Contrast-enhanced magic-angle MR imaging of the Achilles tendon
Less than 10 patients per group
Mathieson, et al. 1988
Sonography of the Achilles tendon and adjacent bursae
Less than 10 patients per group
Paavola, et al. 1998
Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. A
comparison between pre-operative ultrasonography and surgical findings
Retrospective Chart Review
948 949 950
STUDY QUALITY 951 952 953
Table 7. Study Quality
● = Yes ○ = No X = Not Reported n/a = not applicable
Author N
Uni
nter
rupt
able
/Inte
rmed
iate
test
resu
lt(s)
re
porte
d
Spec
trum
bia
s avo
ided
Sele
ctio
n cr
iteria
des
crib
ed
App
ropr
iate
refe
renc
e st
anda
rd
Dis
ease
pro
gres
sion
bia
s avo
ided
Parti
al v
erifi
catio
n bi
as a
void
ed
Diff
eren
tial v
erifi
catio
n bi
as a
void
ed
Inco
rpor
atio
n bi
as a
void
ed
Inde
x te
st e
xecu
tion
desc
ribed
Ref
eren
ce st
anda
rd e
xecu
tion
desc
ribed
Test
revi
ew b
ias a
void
ed
Dia
gnos
tic re
view
bia
s avo
ided
Clin
ical
revi
ew b
ias
avoi
ded
Reference Standard Index Test
With
draw
als
expl
aine
d
Maffulli 161
Calf Squeeze Test (Thompson test/Simmonds squeeze test)
Open Repair X ○ ● ● ● ○ ● ● ● ● ○ ● ● ●
Margetic 88
Calf Squeeze Test (Thompson test/Simmonds squeeze test) plus Ultrasound
Surgery X ○ ● ● ● ○ ● ● ● ○ ○ ● ● ○
AAOS Guideline Unit v0.3 10.12.09 19
STUDY RESULTS 954 955 Table 8. Sensitivity and Specificity
Author N Test Sensitivity (95% CI)
Specificity (95% CI)
Maffulli 161 Calf Squeeze Test (Thompson test /
Simmonds squeeze test)
0.96 (0.91, 0.99)
0.93 (0.76, 0.99)
Margetic et. al. 88
Calf Squeeze Test (Thompson test /
Simmonds squeeze test) plus ultrasound
0.91 (0.83, 0.96)
1.00 (0.16, 1.00)
AAOS Guideline Unit v0.3 10.12.09 20
956 957 958 959 960 961 962 963 964 965 966 967
968 969 970 971 972 973
974 975 976 977
978 979 980
981 982 983
984
985 986 987 988
989 990 991 992 993 994 995
RECOMMENDATION 3 Non-operative treatment is an option for patients with acute Achilles tendon rupture. Strength of Recommendation: Weak Rationale: A systematic review of non-operative treatment compared to operative treatment of acute Achilles tendon ruptures identified four level II studies including all operative techniques.18-21 Three studies included standard open treatment and one included a minimally invasive technique. Increased complications were noted in the open operative group.
When the outcomes of open and minimally invasive techniques were considered separately, the preliminary strength of recommendation was moderate. The group agreed that it was important to evaluate both functional outcomes and complications comparing non-operative and all operative treatment groups. When these heterogeneous groups were separated into non-operative and operative (including minimally invasive) treatments, the strength of recommendation was downgraded to weak.
The functional outcomes were favorable in the operative group in 1 of 2 level II studies and the return to activity and sport in 1 of 3 level II studies. Only 1 of 4 studies demonstrated improvement in the rerupture rate in the operative group. The remainder of the studies demonstrated no difference between the groups.
Higher complication rates, primarily due to impaired wound healing in the operative group, demonstrate the importance of awareness of surgical risk factors in the decision making of operative versus non-operative treatment (see Recommendation 6).
With acceptable functional results and lower complication rates than operative treatment, non-operative treatment of acute Achilles tendon ruptures is an option in all patients, especially those with increased surgical risk factors.
Supporting Evidence:
To address this recommendation, we analyzed studies that made two different comparisons. Three level II studies compared patients treated non-operatively (with casting) to patients treated with open repair and one level II study compared casting to minimally invasive open repair.18-21
Two studies examined functional outcomes and both found non-significant results (Table 9). Based on AAOS calculations, one of these studies did have significant results at two, three, and six months measured by the Musculoskeletal Functional Assessment Index (MFAI) in which patients with operative treatment had better functional ability than those treated non-operatively; our results differ from the authors because a higher powered statistical test was used. Two studies reported no significant difference in the number of patients with pain (see Table 10).
AAOS Guideline Unit v0.3 10.12.09 21
Three studies reported patients treated non-operatively did not significantly differ in the amount of time to return to work (see
996 997 998 999
1000 1001 1002 1003 1004 1005 1006 1007
Table 11). Three studies examined return to sports and one reported significant results in favor of patients treated with operative repair (see Table 12). One study reported significantly less reruptures in patients treated operatively (see Table 13).The occurrence of extreme residual tendon lengthening, DVT, and “major” complications were not significantly different between patients treated operatively or non-operatively. Minor complications reported in the included studies were related to the surgical intervention and therefore occurred less in patients treated non-operatively (see Table 15). SUMMARY OF EVIDENCE Table 9. Operative vs. Cast – Function
Duration (Months) Author Comparison Outcome LOE N 2
weeks 2 3 6 12
Twaddle Open vs. Cast MFAI* II 42 ○ ●Op ●Op ●Op ○
Cetti Open vs. Cast Function II 111 ○
1008 1009 1010 1011 1012 1013
*Musculoskeletal Functional Assessment Index ●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 10. Operative vs. Cast – Pain
Duration (Months) Author Comparison Outcome LOE N 2 3 12
Möller Open vs. Cast % w/ Pain* III 85 ○
Metz Minimally Invasive vs. Cast Pain (VAS) II 83 ○ ○ ○
1014 1015 1016 1017 1018 1019
*Level III evidence due to less than 80% of patients at follow-up ●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 11. Operative vs. Cast – Return to Work
Duration (Months)
Author Comparison Outcome LOE N 12 24
Cetti Open vs. Cast Sick Leave II 111 ○
AAOS Guideline Unit v0.3 10.12.09 22
Duration (Months)
Author Comparison Outcome LOE N 12 24
Möller Open vs. Cast Sick Leave II 112 ○
Metz Minimally
Invasive vs. Cast
Return to Work II 78 ○
1020 1021 1022 1023 1024
●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 12. Operative vs. Cast - Return to Sport
Duration (Months) Author Comparison Outcome LOE N 12 24
Cetti Open vs. Cast Return to Sport II 111 ●Op
Möller Open vs. Cast Return to Sport II 112 ○
Metz Minimally
Invasive vs. Cast
Return to Sport (%) II 69 ○
1025 1026 1027 1028 1029
●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance Table 13. Operative vs. Cast - Rerupture
Duration (Months) Author Outcome LOE N
12
Twaddle Rerupture II 42 ○
Cetti Rerupture II 111 ○
Möller Rerupture II 112 ●Op
Metz Rerupture II 83 ○
1030 1031 1032 1033
●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance
AAOS Guideline Unit v0.3 10.12.09 23
Table 14. Operative vs. Cast - Satisfaction 1034
Duration (Months) Author Comparison Outcome LOE N 2 3 6 12 24
Möller Open Repair vs. Cast Satisfaction* (VAS) III 85 ●Op ●Op ●Op ●Op
Metz Minimally Invasive vs. Cast
Satisfaction (VAS) II 83 ○ ○ ○
1035 1036 1037 1038 1039
1040
*Level III evidence due to less than 80% of patients at follow-up ●Op: Statistically Significant in Favor of Operative Repair ●Non-Op: Favors Non-Operative treatment with Cast ○ No statistical significance
Table 15. Operative vs. Cast – Complications
Duration (Months) Author Adverse event/
Complication LOE N 12
Cetti Major Complications - (not including rerupture) II 111 ○
Metz Total Complications II 83 ○
Möller Extreme Residual Tendon Lengthening II 112 ○
Möller DVT II 112 ○
Cetti Total - Minor Complications* II 111 ●Non-Op
Metz Partial Sensibility II 83 ●Non-Op
Cetti Disturbances of Sensibility II 111 ○
Möller Disturbance of Sensitivity II 112 ○
Metz Scar Adhesions II 83 ●Non-Op
Möller Scar Adhesions II 112 ●Non-Op
Cetti Suture granuloma II 111 ○
Möller Superficial infection II 112 ○
1041 1042 1043 1044
*As defined by the author: “Differences between major/minor complications is that major complications give functional discomfort.” Minor Complications include: Scar adhesions, superficial infection, disturbances of sensibility, suture granuloma, delayed wound healing. ●Op: Statistically Significant in Favor of Operative Repair
AAOS Guideline Unit v0.3 10.12.09 24
1045 1046 1047 1048
1049
●Non-Op: Statistically Significant in Favor of Non-Operative treatment with Cast ○ No statistical significance Summary of Systematic Reviews
Table 16. Systematic Review Summary
Author Conclusion Bhandari, M et al. 2002
"Deep venous thrombosis is more common after nonoperative treatment of Achilles tendon ruptures" (p. 195)."…The current group of randomized trials suggests a benefit to surgical repair of acute Achilles tendon ruptures in younger, active patients" (p. 199).
Bhandari, M et al. 2002
"Pooled analysis of studies did not reveal any difference in the risk of minor complaints or return to normal function between surgical repair and conservatively treated groups" (p. 190).
Bhandari, M et al. 2002
"Surgical treatment significantly reduces the risk of Achilles tendon re-ruptures, but increases the risk of infection, when compared with conservative therapy" (p. 190).
Bhandari, M et al. 2002
"In conclusion, open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of re-rupture compared with nonoperative treatment but has the drawback of a significantly higher risk of other complications, including wound infection" (p.2209).
Khan, RJK, et al. 2005
"Although operative treatment provides a reduced re-rupture rate over nonoperative treatment, the rate of moderate and mild complications in operative treatment is 20 times greater" (p. 211).
Lo, IKY, et al. 1997
"Presently, we favor non-operative treatment in patients with poor healing potential (i.e., smokers, diabetics, and patients with peripheral vascular disease)" (p. 211).
Lo, IKY, et al. 1997
"For healthy active individuals, we offer both forms of treatment, providing the patients with the estimates of treatment success and complication rates" (p. 211).
Lo, IKY, et al. 1997
"Surgical treatment is preferable to non-surgical treatment, produces better functional outcomes, and therefore appears to be the treatment of choice" (p. 156).
Lynch, RM 2004
"The incidence of re-rupture following non-surgical treatment is significantly higher than for surgical treatment" (p. 156).
Lynch, RM 2004
"The number of patients that need to be treated surgically to prevent one re-rupture if these patients were treated non-surgically is 5 (3-13, 95% confidence intervals)" (p.156).
Lynch, RM 2004
Lynch, RM 2004 "The incidence of minor complications following surgical treatment is large, but these do not appear to affect functional outcome" (p. 156).
AAOS Guideline Unit v0.3 10.12.09 25
Author Conclusion "Non-surgical treatment should be reserved for patients who refuse or who are unfit for operative repair" (p. 156). Lynch, RM 2004
1050 1051 1052
EXCLUDED ARTICLES Table 17. Excluded Articles
Author Title Exclusion Reason Doral, et al.
2009 Percutaneous suturing of the ruptured
Achilles tendon with endoscopic control Not best available evidence - not
comparative Neumayer,
et al. 2009
A new conservative-dynamic treatment for the acute ruptured Achilles tendon
Not best available evidence - not comparative
Ebinesan, et al.
2008
Conservative, open or percutaneous repair for acute rupture of the Achilles tendon
Not best available evidence - retrospective comparative
Lorkowski, et al. 2007
Evaluation of long term therapy outcomes for Achilles tendon ruptures
Combines operative and non-operative patients
Kotnis, et al. 2006
Dynamic ultrasound as a selection tool for reducing Achilles tendon re-ruptures Not best available evidence
van, et al. 2004
Results of surgical versus non-surgical treatment of Achilles tendon rupture Not best available evidence
Weber, et al. 2003
Non-operative treatment of acute rupture of the Achilles tendon. results of a new
protocol and comparison with operative treatment
Not best available evidence - retrospective comparative
Follak, et al. 2002
The utility of gait analysis in the rehabilitation of patients after surgical treatment of Achilles tendon rupture
Not best available evidence - not comparative
Moller, et al. 2002
Calf muscle function after Achilles tendon rupture. A prospective, randomised study
comparing surgical and non-surgical treatment
Duplicate - Data reported in prior study
Rumian, et al.
2001
Surgical repair of the Achilles tendon. The lateral approach
Not best available evidence - not comparative
Horstmann, et al. 2000
Isokinetic strength and strength endurance of the lower limb musculature ten years after
Achilles tendon repair
Not best available evidence - not comparative
Rowley, et al.
1982
Rupture of the Achilles tendon treated by a simple operative procedure No patient oriented outcome
Inglis, et al. 1976
Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical
treatment Less than 10 patients per group
Nistor, et al. 1981
Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective
randomized study Not best available evidence
AAOS Guideline Unit v0.3 10.12.09 26
Author Title Exclusion Reason
Jacobs, et al. 1978
Combines acute and neglected/chronic Achilles
tendon tear patients
A new conservative-dynamic treatment for the acute ruptured Achilles tendon
1053 1054 1055
STUDY QUALITY Table 18. Study Quality
● = Yes ○ = No × = Not Reported
Author
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
Follo
w U
p - 8
0% o
r m
ore
Outcome N Level of EvidenceTreatment(s)
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at e
ntry
Twaddle MFAI 42 Operative vs.
Cast Level II ● ● ○ ● ● ×
Twaddle Re-rupture 42 Operative vs.
Cast Level II ● ● ○ ● ● ×
Moller Re-rupture 112 Operative vs.
Cast Level II ● ● ○ ● ● ●
Moller Return to work 112 Operative vs.
Cast Level II ● ● ○ ● ● ●
Moller Quality of Life
(VAS) 112 Operative vs.
Cast Level II ● ● ○ ● ● ●
Moller Treatment
Results (VAS) 112 Operative vs.
Cast Level II ● ● ○ ● ● ●
Moller Pain 85 Operative vs.
Cast Level III ● ● ○ ● ○ ●
Cetti Return to Work 111 Operative vs.
Cast Level II × × ○ ● ● ●
Cetti Return to Sports 111 Operative vs.
Cast Level II × × ○ ● ● ●
Cetti Hospitalization 111 Operative vs.
Cast Level II × × ○ ● ● ●
Metz Re-rupture 83 Operative vs.
Cast Level II ○ ○ × × ● ×
Metz Return to work 83 Operative vs.
Cast Level II ● ● ○ ● ● ●
Metz Return to sport 83 Operative vs.
Cast Level II ● ● ○ ● ● ●
Metz Pain- VAS 83 Operative vs.
Cast Level II ● ● ○ ● ● ×
Metz Satisfaction -
VAS 83 Operative vs.
Cast Level II ● ● ○ ● ● ×
AAOS Guideline Unit v0.3 10.12.09 27
1056 1057 1058
STUDY RESULTS Table 19. Open vs. Cast - Function
Open Repair Cast
Author Comparison Outcome LOE N Durati
on mean (SD)
% mean (SD)
%
Results
Twaddle Open vs. Cast MFAI* II 42 2 weeks 42.4 (2.7)‡ 43 (2.7)‡ p = 0.48‡
Twaddle Open vs. Cast MFAI* II 42 2 months 23.7 (2.6)‡ 27.6 (3.4)‡ p = 0.002‡
Twaddle Open vs. Cast MFAI* II 42 3 months 15.2 (2.1)‡ 17 (2.6)‡ p = 0.02‡
Twaddle Open vs. Cast MFAI* II 42 6 months 7.8 (2.1)‡ 10.4 (2.2)‡ p = 0.004‡
Twaddle Open vs. Cast MFAI* II 42 12 months 3.4 (1.7)‡ 4.2 (1.7)‡ p = 0.14‡
Cetti Open vs. Cast Function - Abnormal
Gait II 111 12
months 5.4% 3.6% NS
Cetti Open vs. Cast Function – Abnormal
Run II 111 12
months 12.5% 18.2% NS
Cetti Open vs. Cast Function - Abnormal Toe Stand
II 111 12 months 8.9% 9.1% NS
1059 1060 1061 1062 1063
‡ AAOS Calculation NS: No statistical significance; authors do not report p-value. Table 20. Cast vs. Open Repair - Pain
Open Repair
Minimally Invasive Cast
Author Comparison Outcome LOE N Duration mean (SD) %
mean (SD) %
mean (SD) %
Results
Möller Open vs. Cast
Pain - None III 85 12
months 92% n/a 88% p = .69‡
Möller Open vs. Cast
Pain - Moderate III 85 12
months 6% n/a 3% p = .55‡
Möller Open vs. Cast
Pain - During
Walking III 85 12
months 2% n/a 9% p = .129‡
Metz Minimally Invasive vs. Cast
Pain (VAS)‡ II 83 2 months n/a 1.80
(1.40)‡ 1.56
(1.25)‡ p =
0.20‡
AAOS Guideline Unit v0.3 10.12.09 28
AAOS Guideline Unit v0.3 10.12.09 29
Open Repair
Minimally Invasive Cast
Author Comparison Outcome LOE N Duration mean (SD) %
mean (SD) %
Results mean (SD)
%
Metz Minimally Invasive vs. Cast
Pain (VAS)‡ II 83 3 months n/a 1.53
(1.71)‡ 1.80
(1.40)‡ p = 0.78‡
Metz Minimally Invasive vs. Cast
Pain (VAS)‡ II 83 12
months n/a 0.40 (0.93)‡ 0.78(1.40)‡ p =
0.92‡
‡ AAOS Calculation 1064 1065 1066 1067 1068
NS: No statistical significance; authors do not report p-value. n/a: not applicable
Table 21. Operative vs. Cast - Return to Work 1069
Open Repair
Minimally Invasive Cast
Author Comparison Outcome LOE N Duration mean (SD) mean (SD) mean (SD)
Results
Cetti Open vs. Cast Return to Work (days) II 111 12 months
43.4 (15.05) n/a 56 (25.2) NS
Möller Open vs. Cast Sick Leave (days) II 111 24 months 54.9 (47.9) n/a 73.4 (56.5) p =
0.06
Möller Open vs. Cast Return to heavy work (days) II 24 24
months 102.2 (52.7) n/a 108.1(34.7) NS
Möller Open vs. Cast Return to light work (days) II 54 24 months 35.7 (38) n/a 67.2 (65.9) p =
0.03
Möller Open vs. Cast Return to Work – Sedentary (days) II 34 24
months 30.8 (36.5) n/a 33.2 (54.7) NS
Metz Minimally Invasive vs. Cast Return to Work (days) II 78 12
months n/a 59 (82) p < 0.05 108 (115)
1070 1071 1072 1073 1074
‡ AAOS Calculation NS: No statistical significance; authors do not report p-value. n/a: not applicable
AAOS Guideline Unit v0.3 10.12.09 30
Table 22. Operative vs. Cast - Return to Sport 1075
Minimally Invasive Author Comparison Outcome LOE N Duration
Open Repair
%
Cast%
% Results
Cetti Open vs. Cast
Return to Sports- Total
II 111 12 months 79% n/a 64% p =
.21‡
Cetti Open vs. Cast
Return to Sport - Same Level
II 111 12 months 57% n/a 29% p =.005
Möller Open vs. Cast
Return to Sport - Same Level
II 112 12 months 54% n/a 54% NS
Cetti Open vs. Cast
Return to Sport -
DiminishedII 111 12
months 21% n/a 35% NS
Cetti Open vs. Cast
Return to Sport -
Stopped II 111 12
months 14% n/a 22% NS
Möller Open vs. Cast
Return to Sport -
Stopped II 112 12
months 16% n/a 14% p = .620‡
Metz Minimally Invasive vs. Cast
Return to Sport II 69 12
months n/a 67% 81% p = 0.16
1076 1077 1078 1079 1080
‡ AAOS Calculation NS: No statistical significance; authors do not report p-value. n/a: not applicable Table 23. Operative vs. Cast - Rerupture
Open Repair
Minimally Invasive Cast Author Complication LOE N Duration
% % % Results
Cetti Rerupture II 111 12 months 5.4% n/a 12.7% p = .167‡
Möller Rerupture II 112 12 months 1.7% n/a 20.8% p = < .001
Twaddle Rerupture II 42 6 months 10.0% n/a 4.5% p = .49‡
Metz Rerupture II 83 12 months n/a 7.1% 12.2% p = 0.44‡
Cetti Second Rerupture II 111 12
months 0.0% n/a 1.8% p = .154‡
1081 1082 1083
‡ AAOS Calculation n/a: not applicable
AAOS Guideline Unit v0.3 10.12.09 31
Table 24 Cast vs. Open - Complications 1084
Open Repair
Minimally Invasive Cast
Author Complications LOE N Duration% % %
Results
Metz Total Complications II 83 12
months n/a 28.6% 48.8% p = 0.06
Cetti
Major Complications (not including
rerupture)
II 111 12 months 9.0% n/a 16.3% NS
Metz
Total Complications
Other Than Rerupture
II 83 12 months n/a 21.4% 36.6% p = 0.13
Metz Sural Nerve Injury II 83 12 months n/a 7.1% 2.4% p = 0.30‡
Cetti Deep Infection II 111 12 months 3.6% n/a 0% p = 0.05
Metz Deep Wound Infection II 83 12
months n/a 0 0.0% NS
Cetti Delayed Wound Healing II 111 12
months 1.8% n/a 0% p = 0.158‡
Cetti Disturbances of Sensibility II 111 12
months 12.5% n/a 1.8% p = 0.017‡
Möller Disturbance of Sensitivity II 112 24
months 1.7% n/a 0% p = 0.16‡
Metz Partial Sensibility II 83 12 months n/a 9.5% 0.0% p = 0.01‡
Metz DVT - lower leg II 83 12 months n/a 0.0% 2.4% p = 0.15‡
Möller DVT II 112 24 months 0.0% n/a 1.9% p = 0.14‡
Cetti Necrosis of the Skin II 112 12
months 0.0% n/a 0% NS
Cetti Extreme Residual
Tendon Lengthening
II 111 12 months 0.0% n/a 1.8% p = 0.15‡
Möller Extreme Residual
Tendon Lengthening
II 112 24 months 0.0% n/a 1.9% p = 0.14‡
Cetti Total - Minor Complications II 111 12
months 26.8% n/a 5.4% p = 0.004
Metz Skin Related Complications II 83 12
months n/a 4.8% 31.7% p = .001‡
Cetti Scar Adhesions II 111 12 months 10.7% n/a 3.6% p = 0.136‡
Metz Scar Adhesions II 83 12 months n/a 7.1% 0.0% p = 0.01‡
AAOS Guideline Unit v0.3 10.12.09 32
Open Repair
Minimally Invasive Cast
Author Complications LOE N Duration% %
Results %
Möller Scar Adhesions II 112 24 months 13.6% n/a 0% p = <.001‡
Cetti Suture Granuloma II 111 12 months 1.8% n/a 0% p = 0.158‡
Möller Superficial Infection II 112 24
months 1.7% n/a 0% p = 0.16‡
1085 1086 1087 1088 1089 1090
‡ AAOS Calculation NS: No statistical significance; authors do not report p-value. n/a: not applicable
AAOS Guideline Unit v0.3 10.12.09 33
RECOMMENDATION 4 1091 1092 1093
1094
1095 1096 1097 1098 1099 1100
1101 1102
1103 1104 1105 1106
1107
1108 1109 1110 1111 1112 1113
1114 1115 1116
1117 1118 1119 1120
1121 1122 1123 1124 1125 1126 1127
For patients treated non-operatively, we are unable to recommend for or against the use of immediate functional bracing for patients with acute Achilles tendon rupture.
Strength of Recommendation: Inconclusive
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 re-rupture rates.
Seventy-eight percent of patients treated with a functional brace had no pain, 55% reported no stiffness, 56% had no weakness, 98% of patients returned to full level of employment and 37% returned to the same level of sports at 2.9 years. The average time to return to work was 7 days (range 21 – 52) (see Table 26).
One study reported 2% of patients had a pulmonary embolism and another study reported 1% of patients with a DVT and “temporary drop foot”(see Table 35).
AAOS Guideline Unit v0.3 10.12.09 34
SUMMARY OF EVIDENCE 1128 1129 1130
Table 25. Cast + Functional Brace vs. Cast - Rerupture
Cast Author Outcome LOE N Duration
Cast + orthosis
(%) (%) Results
Saleh, et al. 1992 Rerupture II 31
12 months 6% 7% p=.96‡
Ingvar, et al. 2005 Rerupture IV 194 4 years 7% 10% p=.51‡
‡ AAOS calculation 1131 1132 Table 26. Summary of Results - Case Series
Results Author Outcome LOE N Duration (%) Wallace Pain - none IV 140 2.9 years 78%
Wallace Stiffness –
none IV 140 2.9 years 55%
Wallace Weakness –
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%
1133
1134 Table 27. Summary of Systematic Reviews
Author Conclusion "Early functional mobilisation is more acceptable to patients than plaster cast immobilisation and results in improved functional outcomes" (p. 156).
Lynch, RM 2004
1135
1136
Table 28. Functional Bracing – Satisfaction (VAS)
Author Outcome LOE N Duration Results (mean ± SD)
Neumayer, et al. 2009
Satisfaction (VAS) IV 46 5 years 8.1 ± 2
1137
AAOS Guideline Unit v0.3 10.12.09 35
Table 29. Functional Bracing - Satisfaction (%) 1138
Author Outcome LOE N Duration Results (%)
Wallace, et al. 2004
Satisfaction – very satisfied IV 140 2.9 years 83%
Wallace, et al. 2004
Satisfaction –satisfied with
minor reservations IV 140 2.9 years 15%
Wallace, et al. 2004
Satisfaction –satisfied with
major reservations IV 140 2.9 years 1%
Wallace, et al. 2004
Satisfaction –dissatisfied IV 140 2.9 years 1%
1139 1140
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%
1141 1142
Table 31. Functional Bracing - Function
Author Outcome LOE N Duration Results (%)
Wallace, et al. 2004 Stiffness – none IV 140 2.9 years 55%
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%
1143
AAOS Guideline Unit v0.3 10.12.09 36
Table 32. Functional Bracing - Strength 1144
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%
1145 1146
Table 33. Functional Bracing - Return to Work and Sports
Author Outcome LOE N Duration Results (%)
Wallace, et al. 2004
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%
Wallace, et al. 2004
Return to Sports - diminished or
none IV 101 2.9 years 63%
McComis, et al. 1997
Return to Sports - same level V 15 26 weeks 67%
McComis, et al. 1997
Return to Sports - diminished V 15 26 weeks 33%
1147 1148
Table 34. Functional Bracing - Return to Work and Sports (days)
Author Outcome LOE N Results (mean)
Wallace, et al. 2004
Time to Return to Work IV 122 7 days
(max: 52 days) McComis, et al. 1997
Time to Return to Work V 15 4 days
(max: 3 weeks)
Wallace, et al. 2004
Time to Return to Sports IV 101
8 weeks (range 2 weeks
- 6 months) 1149
AAOS Guideline Unit v0.3 10.12.09 37
Table 35. Functional Bracing - Complications 1150
Cast
Author Outcome LOE N Duration
Cast + orthosis
(%) (%)
Results
Neumayer, et al. 2009
Pulmonary embolism IV 57
12 months n/a 2% n/a
Wallace, et al. 2004 DVT IV 140
2.9 years (0.4-8.2) n/a 1% n/a
Wallace, et al. 2004
Temporary Drop foot IV 140
2.9 years (0.4-8.2) n/a 1% n/a
1151 1152 1153
n/a: not applicable Table 36. Functional Bracing - Rerupture
Author Outcome LOE N Duration Cast (%)
Cast + orthosis
(%) Results
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
1154 1155 1156 1157
n/a: not applicable EXCLUDED ARTICLES Table 37. Functional Bracing - Excluded Studies
Author Title Exclusion Reason Edna TH; Non-operative treatment of Achilles tendon ruptures case series cast only
Fruensgaard S, et al.
Conservative treatment for acute rupture of the Achilles tendon casting only
Hufner TM, et al. Long-term results after functional non-operative treatment of Achilles tendon rupture cast only case series
Inglis AE, et al. Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment Less than 10 patients per arm
Josey RA, et al. Immediate, full weight bearing cast treatment of acute Achilles tendon ruptures: a long-term follow-up study cast only case series
Keller J, et al Closed treatment of Achilles tendon rupture case series cast only
AAOS Guideline Unit v0.3 10.12.09 38
Author Title Exclusion Reason Lea RB; Smith L; Non-surgical treatment of tendo achillis rupture casting only
Lildholdt T, et al Conservative treatment to Achilles tendon rupture. A follow-up study of 14 cases cast only case series
Nistor L; Conservative treatment of fresh subcutaneous rupture of the Achilles tendon casting only case series
Pendleton H, et al. Residual functional problems after non-operative treatment of Achilles tendon rupture cast only case series
Persson A, et al. The treatment of total ruptures of the Achilles tendon by plaster immobilisation cast only case series
Roberts CP, et al Dynamised cast management of Achilles tendon ruptures retrospective case series
1158 1159 1160
STUDY QUALITY Table 38. Study Quality - Randomized Control Trials
● = Yes ○ = No × = Not Reported
Author Outcome N
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Thos
e ra
ting
outc
ome
Blin
ded
Follo
w U
p - 8
0% o
r mor
e
Level of Evidence Treatment(s) A
ll gr
oups
hav
e si
mila
r ou
tcom
e pe
rfor
man
ce a
t ent
ry
Saleh, et al. 1992 Rerupture 31 Cast vs. Cast +
Orthosis Level II × × ○ ○ ● ●
1161 1162 Table 39. Study Quality - Non-Randomized Comparative Study
● = Yes ○ = No × = Not Reported
Author Outcome N
Com
plet
ion
rate
- le
ss th
an 2
0%
diff
eren
ce b
etw
een
grou
ps
All
grou
ps c
oncu
rren
tly
tre
ated
All
grou
ps re
ceiv
e sa
me
treat
men
t
All
grou
ps e
valu
ated
usi
ng
sam
e ou
tcom
e m
easu
res
All
grou
ps h
ave
appr
oxim
atel
y eq
ual
follo
w-u
p tim
es
Follo
w U
p - 8
0% o
r mor
e
Sam
e ce
nter
for e
xper
imen
tal a
nd
cont
rol g
roup
dat
a Si
mila
r per
form
ance
on
outc
ome
at
base
line
Treatment(s) Level of Evidence Pa
tient
cha
ract
eris
tics c
ompa
rabl
e at
ba
selin
e
Ingvar, et al. 2005 Re-rupture 194
Cast vs. Cast + Orthosis Level IV × ○ ● ● × ● ● ● ×
AAOS Guideline Unit v0.3 10.12.09 39
Table 40. Study Quality - Case Series 1163
● = Yes ○ = No × = Not Reported
Author Outcome N Treatment(s) Level of Evidence
Con
secu
tive
enro
llmen
t
of
pat
ient
s
Follo
w U
p - 8
0% o
r mor
e
All
patie
nts e
valu
ated
usi
ng
sa
me
outc
ome
mea
sure
s
All
patie
nts r
ecei
ve sa
me
treat
men
t
All
patie
nts h
ave
appr
oxim
atel
y eq
ual
follo
w-u
p tim
es
Neumayer, et al. 2009 Satisfaction (VAS) 46 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. 2004 Satisfaction 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. 2004 Pain 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. 2004 Stiffness 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. 2004 Weakness 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. 2004
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
Return to Sports - diminished or none 101 Cast + Orthosis Level IV ● ● ● ● ●
McComis, et al. 1997
Return to Sports - same level 15 Cast + Orthosis Level V ● ○ ● ● ●
McComis, et al. 1997
Return to Sports - diminished 15 Cast + Orthosis Level V ● ○ ● ● ●
Wallace, et al. 2004
Time to Return to Work 122 Cast + Orthosis Level IV ● ● ● ● ●
McComis, et al. 1997
Time to Return to Work 15 Cast + Orthosis Level V ● ○ ● ● ●
Wallace, et al. 2004
Time to Return to Sports 140 Cast + Orthosis Level IV ● ● ● ● ●
Neumayer, et al. 2009
Complete re-rupture 57 Cast + Orthosis Level IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 40
● = Yes ○ = No × = Not Reported
Author Outcome N Treatment(s) Level of Evidence
Con
secu
tive
enro
llmen
t
of
pat
ient
s
Follo
w U
p - 8
0% o
r mor
e
All
patie
nts e
valu
ated
usi
ng
sa
me
outc
ome
mea
sure
s
All
patie
nts h
ave
appr
oxim
atel
y eq
ual
follo
w-u
p tim
es
All
patie
nts r
ecei
ve sa
me
treat
men
t
Wallace, et al. 2004
Complete re-rupture 140 Cast + Orthosis Level IV ● ● ● ● ●
Neumayer, et al. 2009 Partial rerupture 57 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. 2004 Partial rerupture 140 Cast + Orthosis Level IV ● ● ● ● ●
Neumayer, et al. 2009
Pulmonary embolism 57 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. 2004 DVT 140 Cast + Orthosis Level IV ● ● ● ● ●
Wallace, et al. 2004
Temporary Drop foot 140 Cast + Orthosis Level IV ● ● ● ● ●
1164
AAOS Guideline Unit v0.3 10.12.09 41
RECOMMENDATION 5 1165 1166 1167 1168 1169 1170 1171 1172 1173 1174 1175 1176 1177 1178 1179
1180 1181 1182 1183 1184
1185 1186
1187
1188 1189 1190 1191 1192 1193 1194 1195 1196 1197
1198
Operative treatment is an option in patients with acute Achilles tendon rupture. AAOS Strength of Recommendation: Weak Rationale: To answer this recommendation, we reviewed studies addressing the efficacy of operative treatment. A systematic review of the literature included seven studies20, 19, 27, 28, 29, 30,31 that addressed the efficacy of open repair and five studies32, 29, 33, 21, 27 addressing the efficacy of minimally invasive techniques. This systematic review addressed only the efficacy of operative treatment and therefore did not consider the comparisons made in the studies. Please refer to Recommendation 3 and its rationale for a comparison of non-operative and operative treatment of acute Achilles tendon ruptures. In addition, relevant comparative information about operative techniques can be found in Recommendation 8 and its rationale.
A systematic review of the literature included seven studies20, 19, 27, 28, 29, 30,31 that addressed the efficacy of open repair and five studies32, 29, 33, 21, 27 addressing the efficacy of minimally invasive techniques. By six months the return to activity ranged from 73% to 100% after operative treatment (see Table 42 through Table 57). After twelve months, 92% of patients reported they had no pain (see Table 48).
All studies relevant to this Recommendation were Level IV (see Table 59) because this is non comparative data.
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 seven studies20, 19, 27, 28, 29, 30,31 that address efficacy of open repair and five studies 32, 29, 33, 21, 27 that address minimally invasive techniques. Table 42 through Table 57 demonstrate the wide variety of patient-oriented outcome measures and duration to follow-up used to evaluate patients receiving operative treatment for Achilles tendon rupture. The inconsistency of these outcome measures makes comparisons between studies difficult. Because the body of evidence is weak, it does not allow for additional statistical analysis.
Please see Recommendation 7 for results of operative treatment comparisons.
AAOS Guideline Unit v0.3 10.12.09 42
SUMMARY OF EVIDENCE 1199 1200 Table 41. Open Repair – All Outcomes
Result (Efficacy) Outcome
Time until Return to Work ?
Time until Return to Stair Climbing ?
Time until Return to Walking ?
Time until Return to Sports ?
Return to work (%) ?
Return to ADL (%) ?
Return to Final Functional Activities (%) ?
Pain (%) ?
Function- Abnormal ankle movement (%) ?
Abnormal Run (%) ?
Abnormal toe stand (%) ?
Satisfaction (%) ? 1201
1202 Table 42. Open Repair - Return to work
Author LOE N Outcome Mean time Mean (SD)
Moller, et al. 2001 IV 59 Return to work (days) 54.9 (nr)
Cetti, et al. 1993 IV 56 Return to work (weeks) 6.2 (SD 2.15)
Moller, et al. 2001 IV 59 Return to heavy work (days) 102.2 (nr)
Moller, et al. 2001 IV 59 Return to sedentary work (days) 30.8 (nr)
Moller, et al. 2001 IV 59 Return to light, mobile work (days) 35.7 (nr)
1203 nr: not reported
AAOS Guideline Unit v0.3 10.12.09 43
Table 43. Open Repair - Activities of daily living 1204
Author LOE N Outcome
Mean time Mean
(SD)/(range) Bhattacharyya, et al.
2009 IV 53 Return to Normal Stair Climbing (weeks) 19 (3.5)‡
Bhattacharyya, et al. 2009 IV 53 Return to Normal Walking
(weeks) 17 (3)‡
Uchiyama, et al. 2007 IV 84 Return to same level of sports (months) (high level athletes) 5 (17-26 weeks)
Uchiyama, et al. 2007 IV 84 12.3 (range 8-21) Return to jogging (weeks)
1205
1206
1207
‡AAOS Calculation
Table 44. Open Repair- Mean time until return to athletic activity
Author LOE N Outcome Mean time
Mean (range)
Uchiyama, et al. 2007 IV 84 Return to same level of sports (months) (high level athletes) 5 (17-26 weeks)
Uchiyama, et al. 2007 IV 84 Return to jogging (weeks) 12.3 (8-21)
AAOS Guideline Unit v0.3 10.12.09 44
1208
1209 Table 45. Open Repair- Percent of patients able to return to activities of daily living
Author LOE N Outcome Follow-up
% of Patients
Lim, et al. 2001 IV 33 Return to ADL 2 months 6%
Lim, et al. 2001 IV 33 Return to ADL 3 months 85%
Lim, et al. 2001 IV 33 Return to ADL 6 months 100%
Lim, et al. 2001 IV 33 Return to final functional activity*
3 months 36%
Lim, et al. 2001 IV 33 Return to final functional activity*
6 months 64%
1210 1211 1212
1213
* Final functional activity defined as “patient is unhindered in all his or her activities apart from active sports”
Table 46. Open Repair- Percent of patients able to return to work
Author LOE N Outcome Follow-up
% of Patients
Moller, et al. 2001 IV 59 Return to work (days) nr 100%
Moller, et al. 2001 IV 59 Return to sedentary work (days) nr 22%
Moller, et al. 2001 IV 59 Return to light, mobile work (days) nr 54%
Moller, et al. 2001 IV 59 Return to heavy work (days) nr 24%
1214 1215
1216
Nr: not reported
Table 47. Open Repair- Percent of patients able to return to sports
Author LOE N Outcome Follow-up
% of Patients
Coutts, et al 2002 IV 22 Return to pre-injury sporting level nr 91%
Moller, et al. 2001 IV 47 Return to sports - same level 12 months 54%
Cetti, et al. 1993 IV 52 Return to sports - same level 12 months 62%
Lim, et al. 2001 IV 33 Return to active sporting/outdoor activities
3 months 9%
Lim, et al. 2001 IV 33 Return to active sporting/outdoor activities
6 months 48%
Moller, et al. 2001 IV 47 Return to sports - stopped 12 months 16%
AAOS Guideline Unit v0.3 10.12.09 45
Follow-up Author LOE N Outcome % of
Patients
Cetti, et al. 1993 IV 52 Return to sports - stopped 12 months 15%
Cetti, et al. 1993 IV 52 Return to sports - diminished level
12 months 23%
1217
1218 Table 48: Open Repair- Percent of patients with pain
Author LOE N Outcome Follow-up % of PatientsAktas, et al. 2007 IV 30 Pain - Mild w/ maximal exertion 6 months 14%
Aktas, et al. 2007 IV 30 Pain - Absent 6 months 86%
Moller, et al. 2001 IV 52 Pain-during walking 12 months 2%
Moller, et al. 2001 IV 52 Pain-moderate 12 months 6%
Moller, et al. 2001 IV 52 Pain-none 12 months 92%
1219
1220 Table 49. Open Repair- Percent of patients able to complete functional activities
Author LOE N Outcome Follow-up % of Patients
Cetti, et al. 1993 IV 56 Function-Abnormal ankle movement 4 months 52%
Cetti, et al. 1993 IV 56 Function-Abnormal ankle movement 12 months 18%
Cetti, et al. 1993 IV 56 Function-Abnormal gait 4 months 27%
Cetti, et al. 1993 IV 56 Function-Abnormal gait 12 months 5%
Cetti, et al. 1993 IV 56 Function-Abnormal run 4 months 52%
Cetti, et al. 1993 IV 56 Function-Abnormal run 12 months 13%
Cetti, et al. 1993 IV 56 Function-Abnormal toe stand 4 months 21%
Cetti, et al. 1993 IV 56 Function-Abnormal toe stand 12 months 9%
1221
1222 Table 50. Open Repair- Percent of patients with excellent satisfaction
Author LOE N Outcome Follow-up % of Patients
Lim, et al. 2001 IV 33 Satisfaction - Excellent 6 months 42%
1223
AAOS Guideline Unit v0.3 10.12.09 46
Table 51. Minimally Invasive Repair- All outcomes 1224 Result
(Efficacy) Outcome
Return to Work (%) ?
Return to Stair Climbing (%) ?
Return to Walking (%) ?
Return to Sports (%) ?
Return to work (%) ?
Return to ADL (%) ?
Return to Final Functional Activities (%) ?
Satisfaction (%) ?
Function- Abnormal ankle movement (%) ?
Return to same level of activity (%) ?
Able to walk without limitations (%) ?
Return to sports (%) ? 1225
1226 Table 52. Minimally Invasive Repair- Percent of Patients able to return to activity
Author LOE N Treatment Outcome Follow-up % of Patients
ES Ng, et al. 2007 IV 25 percutaneous Return to activity -
same level 65.5
months 96%
Lim, et al. 2001 IV 33 percutaneous Return to ADL 2 months 6%
Lim, et al. 2001 IV 33 percutaneous Return to ADL 3 months 76%
Lim, et al. 2001 IV 33 percutaneous Return to ADL 6 months 100%
Lim, et al. 2001 IV 33 percutaneous Return to final
functional activity 3 months 27%
Lim, et al. 2001 IV 33 percutaneous Return to final
functional activity 6 months 73%
Chillemi, et al. 2002 IV 38 percutaneous Able to walk
without limitation 6 months 100%
1227 1228
1229
1230
AAOS Guideline Unit v0.3 10.12.09 47
Table 53. Minimally Invasive Repair - Percent of patients able to return to sports 1231
Author LOE N Treatment Outcome Follow-up % of Patients
Lim, et al. 2001 IV 33 percutaneous
Return to active sporting/outdoor
activities 3 months 0%
Lim, et al. 2001 IV 33 percutaneous
Return to active sporting/outdoor
activities 6 months 67%
Chillemi, et al. 2002 IV 14 percutaneous
Return to sports activity (frequent
participant 2-3 times per week)
nr 57%
1232 1233
1234
nr: not reported
Table 54. Minimally Invasive Repair - Satisfaction
Author LOE Treatment N Outcome Follow-up %
Lim, et al. 2001
IV percutaneous 33 Satisfaction - Excellent 6 months 52%
1235 1236 1237
Table 55. Minimally Invasive Repair - Mean time until return to activity
Author LOE Treatment N Outcome Mean Time (Days)Mean (SD)
Metz, et al. 2008 IV minimally-invasive 40 Return to work 59 (82)
Bhattacharyya, et al. 2009 IV minimally-invasive 53 Return to Normal
Walking (weeks) 12.5 (3)‡
Bhattacharyya, et al. 2009 IV minimally-invasive 53
Return to Normal Stair Climbing
(weeks) 14 (3)‡
1238 1239 1240
‡= AAOS Calculation
Table 56. Minimally Invasive Repair-Percent of patients able to return to sports
Author LOE Treatment N Outcome Follow-up % of
Patients Metz, et al.
2008 IV minimally-invasive 36 Return to sports 12 months 67%
Metz, et al. 2008
IV minimally-invasive 36 Change sports 12 months 11%
Metz, et al. 2008
IV minimally-invasive 36 Stop sports 12 months 22%
Metz, et al. 2008
IV minimally-invasive 40 Return to work nr 98%
1241 nr: not reported
AAOS Guideline Unit v0.3 10.12.09 48
Table 57. Minimally Invasive Repair-Percent of patients able to return to work 1242
Author LOE Treatment N Outcome Follow-up % of
Patients Metz, et al.
2008 IV minimally-invasive 40 Return to work nr 98%
1243 1244 1245 1246
nr: not reported EXCLUDED ARTICLES Table 58. Excluded Articles
Author Title Exclusion Reason
Leppilahti J;Forsman K;Puranen J;Orava S;
Outcome and prognostic factors of Achilles rupture repair using a new scoring method
Not best available evidence
Chiodo CP;Wilson MG;
Current concepts review: acute ruptures of the Achilles tendon
Not best available evidence
Weber M;Niemann M;Lanz R;Muller T;
Nonoperative treatment of acute rupture of the Achilles tendon: results of a new protocol and
comparison with operative treatment Retrospective
Maffulli N;Tallon C;Wong J;Lim
KP;Bleakney R;
Early weightbearing and ankle mobilization after open repair of acute midsubstance tears of the Achilles
tendon Not Relevant
Halasi T;Tallay A;Berkes I;
Percutaneous Achilles tendon repair with and without endoscopic control Retrospective
Costa ML;Shepstone L;Darrah C;Marshall
T;Donell ST;
Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study
Not best available evidence
Maffulli N;Tallon C;Wong J;Peng LK;Bleakney R;
No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon
Duplicate - Data reported in prior
study van der Linden-van der
Zwaag HM;Nelissen RG;Sintenie JB;
Results of surgical versus non-surgical treatment of Achilles tendon rupture
Not best available evidence
Steele GJ;Harter RA;Ting AJ;
Comparison of functional ability following percutaneous and open surgical repairs of acutely
ruptured Achilles tendons
No patient- oriented outcome
Cretnik A;Kosanovic M;Smrkolj V;
Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study
Not best available evidence
Goren D;Ayalon M;Nyska M;
Isokinetic strength and endurance after percutaneous and open surgical repair of Achilles tendon ruptures
No patient -oriented outcome
Wagnon R;Akayi M; The Webb-Bannister percutaneous technique for acute
Achilles' tendon ruptures: a functional and MRI assessment
Not best available evidence
AAOS Guideline Unit v0.3 10.12.09 49
Author Title Exclusion Reason
Mortensen HM;Skov O;Jensen PE;
Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective,
randomized clinical and radiographic study
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
Schonberger TJ;Janzing HM;Morrenhof JW;de Visser AC;Muitjens P;
Operative treatment of acute Achilles tendon rupture: Open end-to-end-reconstruction versus reconstruction
with Mitek-anchors
Retrospective case series
Metz R;Verleisdonk EJ;van der Heijden
GJ;Clevers GJ;Hammacher
ER;Verhofstad MH;van der WC;
Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate
full weightbearing--a randomized controlled trial Not Relevant
Suchak AA;Bostick GP;Beaupre
LA;Durand DC;Jomha NM;
The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the
Achilles tendon
All patients do not receive same
treatment
Blankstein A;Israeli A;Dudkiewicz
I;Chechik A;Ganel A;
Percutaneous Achilles tendon repair combined with real-time sonography
No patient oriented outcome
Maffulli N;Longo UG;Ronga M;Khanna
A;Denaro V;
Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly
Not best available evidence
Twaddle BC;Poon P; Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study
No relevant outcomes
Fujikawa A;Kyoto Y;Kawaguchi M;Naoi
Y;Ukegawa Y;
Achilles tendon after percutaneous surgical repair: serial MRI observation of uncomplicated healing
No patient oriented outcome
AAOS Guideline Unit v0.3 10.12.09 50
Author Title Exclusion Reason
Costa ML;MacMillan K;Halliday D;Chester
R;Shepstone L;Robinson AH;Donell
ST;
Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis Not Relevant
Carter TR;Fowler PJ;Blokker C;
Functional postoperative treatment of Achilles tendon repair Retrospective
Perez TA; Traumatic rupture of the Achilles Tendon.
Reconstruction by transplant and graft using the lateral peroneus brevis
Insufficient Quantitative
Data
Martinelli B; Percutaneous repair of the Achilles tendon in athletes Not best available evidence
Gorschewsky O;Pitzl M;Putz A;Klakow
A;Neumann W; Percutaneous repair of acute Achilles tendon rupture
Insufficient Quantitative
Data Mullaney MJ;McHugh MP;Tyler TF;Nicholas
SJ;Lee SJ;
Weakness in end-range plantar flexion after Achilles tendon repair
No patient oriented outcome
Rumian AP;Molloy S;Solan M;Newman
KJ;Elliott D;
Surgical repair of the Achilles tendon: The lateral approach
Not best available evidence
Ebinesan AD;Sarai BS;Walley GD;Maffulli
N;
Conservative, open or percutaneous repair for acute rupture of the Achilles tendon
Retrospective comparative
Chan SK;Chung SC;Ho YF; Minimally invasive repair of ruptured Achilles tendon Retrospective
Lildholdt T;Munch-Jorgensen T;
Conservative treatment to Achilles tendon rupture. A follow-up study of 14 cases
No description of surgery
Nistor L; Surgical and non-surgical treatment of Achilles Tendon rupture. A prospective randomized study
Not best available evidence
Haggmark T;Liedberg H;Eriksson
E;Wredmark T;
Calf muscle atrophy and muscle function after non-operative vs operative treatment of Achilles tendon
ruptures
No patient oriented outcome
Kangas J;Pajala A;Siira P;Hamalainen
M;Leppilahti J;
Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles
rupture repair: a prospective, randomized, clinical study
Not Relevant
Synder M;Zwierzchowski H;
Post-operative results in fresh injuries the Achilles tendon
Insufficient Quantitative
Data
AAOS Guideline Unit v0.3 10.12.09 51
Author Title Exclusion Reason
Therbo M;Petersen MM;Nielsen PK;Lund
B;
Loss of bone mineral of the hip and proximal tibia following rupture of the Achilles tendon
No patient oriented outcome
Solveborn SA;Moberg A;
Immediate free ankle motion after surgical repair of acute Achilles tendon ruptures
Surgeons did not follow same
technique
Kakiuchi M; A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair
Not best available evidence
Buchgraber A;Passler HH;
Percutaneous repair of Achilles tendon rupture. Immobilization versus functional postoperative
treatment No baseline data
Speck M;Klaue K; Early full weightbearing and functional treatment after surgical repair of acute Achilles tendon rupture No baseline data
Aoki M;Ogiwara N;Ohta T;Nabeta Y;
Early active motion and weightbearing after cross-stitch Achilles tendon repair
Insufficient Data
Dargel J;Ninck J;Koebke J;Appell
HJ;Pennig D;Hillekamp J;
Influence of knee flexion on plantarflexion moments after open or percutaneous Achilles tendon repair
Retrospective comparative
Follak N;Ganzer D;Merk H;
The utility of gait analysis in the rehabilitation of patients after surgical treatment of Achilles tendon
rupture
No relevant patient oriented
outcomes Horstmann T;Lukas C;Mayer F;Winter
E;Ambacher T;Heitkamp
H;Dickhuth H;
Isokinetic strength and strength endurance of the lower limb musculature ten years after Achilles tendon repair
All patients did not receive
exact surgery
Kerkhoffs GM;Struijs PA;Raaymakers EL;Marti RK;
Functional treatment after surgical repair of acute Achilles tendon rupture: wrap vs walking cast Not Relevant
Soldatis JJ;Goodfellow DB;Wilber JH; End-to-end operative repair of Achilles tendon rupture Retrospective
Cetti R; Ruptured Achilles tendon--preliminary results of a new treatment No baseline data
Cetti R;Henriksen LO;Jacobsen KS;
A new treatment of ruptured Achilles tendons. A prospective randomized study Not Relevant
AAOS Guideline Unit v0.3 10.12.09 52
STUDY QUALITY 1247 1248 Table 59. Study Quality
● = Yes ○ = No × = Not Reported
Author Outcome Measure N
Sam
e T
reat
men
ts
LoE
Con
secu
tive
Enr
ollm
ent
Follo
w u
p <8
0%
Sam
e O
utco
mes
Treatment
Equ
al F
ollo
w u
p T
ime
Aktas, et al. 2007 Pain - Mild w/ maximal exertion*
30 Open Repair IV ● ● ● ● ●
Aktas, et al. 2007 Pain - Absent* 30 Open Repair IV ● ● ● ● ●
Bhattacharyya, et al. 2009
Return to Normal Walking (weeks) 53 Open Repair IV ● ● ● ● ●
Bhattacharyya, et al. 2009
Return to Normal Stair Climbing (weeks)
53 Open Repair IV ● ● ● ● ●
Bhattacharyya, et al. 2009
Return to Normal Walking (weeks) 53 Minimally
Invasive Repair IV ● ● ● ● ●
Bhattacharyya, et al. 2009
Return to Normal Stair Climbing (weeks)
53 Minimally Invasive Repair IV ● ● ● ● ●
Cetti, et al. 1993 Return to work (weeks) 56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Return to sports - diminished level 56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Return to sports - same level 56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Return to sports - stopped 56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal ankle movement
56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal ankle movement
56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal gait 56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal gait 56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal run 56 Open Repair IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 53
● = Yes ○ = No × = Not Reported
Author Outcome Measure N Treatment LoE
Con
secu
tive
Enr
ollm
ent
Follo
w u
p <8
0%
Sam
e O
utco
mes
Equ
al F
ollo
w u
p Sa
me
Tre
atm
ents
Tim
e
Cetti, et al. 1993 Function-Abnormal run 56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal toe stand
56 Open Repair IV ● ● ● ● ●
Cetti, et al. 1993 Function-Abnormal toe stand
56 Open Repair IV ● ● ● ● ●
Chillemi, et al. 2002
Able to walk without limitation 38 Percutaneous
Repair IV ● ● ● ● ●
Chillemi, et al. 2002
Return to sports activity (frequent participant 2-3 times per week)
14 Percutaneous Repair IV ● ● ● ● ●
Coutts, et al 2002 Return to pre-injury sporting level
22 Open Repair IV ○ ● ● ● ●
ES Ng, et al. 2007
Return to activity - same level 25 Percutaneous
Repair IV ● ● ● ● ●
Gigante, et al. 2008
SF-12 - Physical Component Score 19 Percutaneous
Repair IV ● ● ● ● ●
Gigante, et al. 2008
SF-12 - Mental Component Score 19 Percutaneous
Repair IV ● ● ● ● ●
Lim, et al. 2001 Return to active sporting/outdoor activities
33 Open Repair IV ● ● ● ● ●
Lim, et al. 2001 Return to active sporting/outdoor activities
33 Percutaneous Repair IV ● ● ● ● ●
Lim, et al. 2001 Return to ADL 33 Open Repair
IV ● ● ● ● ●
Lim, et al. 2001 Return to final functional activity
33 Open Repair
IV ● ● ● ● ●
Lim, et al. 2001 Satisfaction - Excellent 33
Open Repair IV ● ● ● ● ●
Lim, et al. 2001 Return to final functional activity
33 Percutaneous Repair IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 54
● = Yes ○ = No × = Not Reported
Author Outcome Measure N Treatment LoE
Con
secu
tive
Enr
ollm
ent
Follo
w u
p <8
0%
Sam
e O
utco
mes
Equ
al F
ollo
w u
p Sa
me
Tre
atm
ents
Tim
e
Lim, et al. 2001 Return to active sporting/outdoor activities
33 Percutaneous Repair IV ● ● ● ● ●
Lim, et al. 2001 Return to active sporting/outdoor activities
33 Percutaneous Repair IV ● ● ● ● ●
Lim, et al. 2001 Satisfaction - Excellent 33 Percutaneous
Repair IV ● ● ● ● ●
Metz, et al. 2008 Return to work 40 Minimally Invasive Repair IV ● ● ● ● ●
Metz, et al. 2008 Return to sports 40 Minimally Invasive Repair IV ● ● ● ● ●
Metz, et al. 2008 Change sports 40 Minimally Invasive Repair IV ● ● ● ● ●
Metz, et al. 2008 Stop sports 40 Minimally Invasive Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to sedentary work (days)
59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to light, mobile work (days)
59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to work (days) 59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to heavy work (days) 59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to sports - same level 59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to sports - stopped 59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to sedentary work (days)
59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to light, mobile work (days)
59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to work (days) 59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001
Return to heavy work (days) 59 Open Repair IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 55
● = Yes ○ = No × = Not Reported
Author Outcome Measure N Treatment LoE
Con
secu
tive
Enr
ollm
ent
Follo
w u
p <8
0%
Sam
e O
utco
mes
Equ
al F
ollo
w u
p Sa
me
Tre
atm
ents
Tim
e
Moller, et al. 2001
Pain-during walking 59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001 Pain-moderate 59 Open Repair IV ● ● ● ● ●
Moller, et al. 2001 Pain-none 59 Open Repair IV ● ● ● ● ●
Uchiyama, et al. 2007
Return to jogging (weeks) 84 Open Repair IV ○ ● ● ● ●
Uchiyama, et al. 2007
Return to same level of sports (months) (high level athletes)
84 Open Repair IV ○ ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 56
RECOMMENDATION 6 1249 1250 1251 1252 1253 1254
1255 1256 1257
1258 1259 1260 1261 1262
1263 1264 1265 1266
1267
1268
1269
1270
1271
1272
1273
1274
1275
1276
1277
1278
In the absence of reliable evidence, it is the opinion of the work group that although operative treatment is an option , it should be approached more cautiously in patients with diabetes, neuropathy, immunocompromised states, age above 65, tobacco use, sedentary lifestyle, obesity (BMI >30), peripheral vascular disease or local/systemic dermatologic disorders.
AAOS Grade of Recommendation: Consensus Rationale:
Rupture of the Achilles tendon occurs not only in healthy active individuals, but also in those with substantial medical histories. We were unable to find any published studies that addressed the effects of co-morbid conditions on the success of operative repair. Therefore, this recommendation is based on expert opinion, and is consistent with current clinical practice.
The consensus of the work group is that consideration of non-operative treatment should occur before performing operative repair of Achilles tendon ruptures in those individuals with conditions that may impair wound healing. These individuals may be at increased risk for wound problems and infection with subsequent detrimental effect on outcome.
Supporting Evidence:
We did not identify any studies to address this recommendation.
AAOS Guideline Unit v0.3 10.12.09 57
RECOMMENDATION 7 1279 1280 1281 1282 1283
1284
1285 1286 1287 1288 1289 1290 1291 1292
1293
For patients who will be treated operatively for an acute Achilles tendon rupture, we are unable to recommend for or against preoperative immobilization or restricted weight-bearing.
AAOS Strength of Recommendation: Inconclusive
Rationale: We were unable to find any published studies that addressed the effects of preoperative immobilization or restricted weight-bearing on the success of operative repair of acute rupture of this tendon. Supporting Evidence:
We did not identify any studies to address this recommendation.
AAOS Guideline Unit v0.3 10.12.09 58
RECOMMENDATION 8 1294 1295 1296 1297 1298 1299 1300
1301
We suggest that patients with an acute Achilles tendon rupture who are treated operatively undergo a minimally invasive technique rather than an open technique. AAOS Grade of Recommendation: Moderate Rationale:
We defined the following operative repairs:
1302 1303 1304
Open – procedure utilizing an extended incision for exposure allowing visualization of the rupture and tendon to allow direct placement of sutures for the repair.
1305 1306
Limited-Open – procedure utilizing a small incision for exposure allowing direct visualization of the ruptured ends.
1307 1308 1309
1310 1311 1312 1313
1314 1315 1316
1317 1318 1319 1320 1321
1322 1323 1324 1325 1326 1327
1328 1329 1330
1331
Percutaneous – procedure without direct exposure of the tendon rupture site. Both the limited-open and percutaneous techniques are considered “minimally invasive.”
A systematic review identified two level II comparative trials investigating percutaneous repair and three level II comparative trials studying limited-open repairs.27, 29, 32, 34, 35 In these studies, there was no significant difference in return to activities, rerupture or satisfaction between open and minimally invasive techniques.
Three studies show that complications are less likely using minimally invasive techniques.27, 32, 35 One study comparing percutaneous to open repairs demonstrated better SF-12 global outcomes in the percutaneous group.34
The literature reviewed refers primarily to non insertional ruptures in which there is sufficient distal tendon for repair. It is acknowledged that a small subset of ACTR consist of purely insertional injuries, often with a segment of bone attached. The latter group is beyond the scope of this GL. However, the reader should be aware of the fact that the repair techniques reviewed may not be compatible with these distal ruptures.
Consideration should also be given to the location of the tear when performing a repair in a percutaneous or limited-open fashion. Tears located at the proximal or distal ends of the tendon may compromise the ability to successfully complete a limited open repair. The orthopaedic surgeon performing the repair may need to extend the incision, converting it to an open technique if unable to obtain good suture fixation with a limited-open or percutaneous technique.
We suggest the use of minimally invasive techniques for acute Achilles tendon repair because of the lower incidence of complications with these techniques compared to open repair.
AAOS Guideline Unit v0.3 10.12.09 59
Supporting Evidence: 1332
1333 1334 1335
1336 1337 1338 1339 1340
1341 1342 1343 1344 1345 1346
s repair had significantly fewer superficial infections (see Table 63). Wound 1347 puckering occurred significantly more in patients treated with percutaneous repair (see 1348
1349
1350 in 1351
1352
1353 1354
epair (see 1355
in the number of reruptures 1356 d with limited open repair had 1357
signif tly fewer com tions than ts tr ate n repair (see Table 63). 1358 SUMMARY OF EVIDENCE 1359 T Perc en - Gl al O omes1360
Duration
We examined studies that made two different comparisons. Two level II studies compared percutaneous repair to open repair.29, 34 One level II study and two level III studies compared limited open to open repair.32 27, 35
PERCUTANEOUS VS OPEN REPAIR Patients treated with percutaneous repair scored significantly higher on the SF-12 physical and mental component scores (see Table 60). There was no significant difference in the amount of patients who returned to functional activities, activities of daily living, (see
Table 61) or patient satisfaction (see Table 62). The amount of reruptures did not significantly differ between treatment groups (see Table 64) One study reported no significant difference in the number of sural nerve injuries (Table 63). Patients treated with percutaneous repair had significantly less wound breakdown/delay of healing as well as less scar adhesions (see Table 63). No significant difference in the amount of deep infections was reported. Patients treated with percutaneou
Table 63).
LIMITED OPEN VS OPEN REPAIR Patients treated with limited open repair returned to normal walking and stair climbingsignificantly less time than patients treated with standard open repair (see
Table 61). A significantly larger percentage of patients treated with limited open repair returned to sports and activities and had fewer symptoms compared to patients treated with open r
Table 61). Two studies reported no significant differencebetween treatment groups (see Table 64). Patients treate
ican plica patien e d with ope
able 60. utaneous vs. Op ob utc
Author Outcome LOE N 24 months
Gigante Component Score II 39 ● P SF-12 - Physical
Gigante SF-12 - MeComponent S
ntal core II 39 ● P
● P: Statistically Significant in Favor of Percutaneous Repair 1361 Op: Statistically Significant in Favor of Open Repair 1362
○ No statistical significance 1363 1364
●
AAOS Guideline Unit v0.3 10.12.09 60
1365
Table 61. Percutaneous and Limited Open vs. Open - Return to Activities and 1366 Function 1367
D ationOutcome ur (months) Author LOE N 6 12 63.5 Treatment
%
Lim
Percutaneous vs.
D II 66 ○
Open
Return to Activities of
aily Living
Lim
Percutaneous vs. Open
Retu nal
○
rned to FiFunctional
Activity II 66
Bhattacharyya Limited Open vs.
Open Return to Normal
Walking III 53
● L
Bhattacharyya Ret al
Sta g ● Limited Open vs.
Open urn to Normir Climbin III 53 L
ES Ng Limited Open vs.
Open Return to Activity II 68 ○
Kakiuchi Limited Open vs.
Open Return to Sports III 22
● L
KakLimited Open vs.
iuchi Open Symptoms III 22 ●L * Final Functional Activity: “When patient was unhindered in all his or her activities apart from 1368
1369 epair 1370
in Favor of Limited Open Repair 1371 Op: Statistically Significant in Favor of Open Repair 1372
1373 1374 Tab ercutane en - S t 1375
Outcome Duration
sports.” ● P: Statistically Significant in Favor of Percutaneous R● L: Statistically Significant ●○ No statistical significance
le 62. P ous vs. Op atisfac ion
Author LOE N ths% 6 mon
Lim Satisfaction II 66 ○ ● P: Statistically Significant in Favor of Percutaneous Repair 1376
Op: Statistically Significant in Favor of Open Repair 1377 1378
1379 Tab rcutan d Li O Repa ations 1380
uration months)
●○ No statistical significance
le 63. Pe eous Repair an mited pen ir vs. O - Compen plic
D (Author Complications LOE N 12 63.5 6
Lim
Sural Nerve Problems II 66 ○
Lim Deep Infection II 66 ○
AAOS Guideline Unit v0.3 10.12.09 61
Duration (months) Author Complications LOE N 12 6 63.5
Lim Adhesions II 66 ●P
Lim Superficial Infection II 66 ●P
Lim Keloid Formation II 66 ○
Lim Wound Puckering II
66 ● Op Delayed Wound
Healing Bhattacharyya III 53
● L
Bhattacharyya Severe Wound Infection and Dehiscence
III 53
● L
Bhattacharyya Minor Surgical Site Infection III 53
● L
Ng Wound Breakdown II 68 ● L
Ng Sural Nerve Injury II 68 ○
Ng Scar Adhesion II 68 ● L
Ng Superficial Infection II 68 ○
Ng Hypertrophic Scar II 68 ○ ● P: Statistically Significant in Favor of Percutaneous Repair 1381
1382 1383 1384 1385 1386
● L: Statistically Significant in Favor of Limited Open Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance Table 64. Percutaneous and Limited Open vs. Open – Rerupture
Duration (months) Author Outcome LOE N
6 63.5 65.5 Lim Rerupture II 66 ○ Ng Rerupture II 68 ○
Kakiuchi Rerupture III 22 ○ 1387 1388 1389 1390
1391
● P: Statistically Significant in Favor of Percutaneous Repair ● L: Statistically Significant in Favor of Limited Open Repair ● Op: Statistically Significant in Favor of Open Repair ○ No statistical significance
AAOS Guideline Unit v0.3 10.12.09 62
1392 1393 1394
EXCLUDED ARTICLES Table 65. Excluded Studies - All Operative Techniques
Author Title Exclusion Reason
Cretnik A, et al Percutaneous versus open repair of the ruptured Achilles tendon. a comparative study
Not best available evidence
Wagnon R, et al The Webb-Bannister percutaneous technique for acute
Achilles' tendon ruptures. a functional and MRI assessment
Not best available evidence
Atkas S, et al Open Versus Minimal Invasive Repair with Achillon Device
Not best available evidence
Assal M, et al Limited open repair of Achilles tendon ruptures. a technique with a new instrument and findings of a
prospective multicenter study
Not best available evidence - not comparative
Halasi T, et al Percutaneous Achilles tendon repair with and without endoscopic control
Not best available evidence - not comparative
Cretnik A, et al Percutaneous suturing of the ruptured Achilles tendon under local anesthesia
Not best available evidence - not comparative
Coutts A, et al Clinical and functional results of open operative repair for Achilles tendon rupture in a non-specialist surgical unit
Not best available evidence - not comparative
Calder JD, et al Independent evaluation of a recently described Achilles tendon repair technique
Not best available evidence - not comparative
Uchiyama E, et al A modified operation for Achilles tendon ruptures Not best available
evidence - not comparative
Maes R, et al; Is percutaneous repair of the Achilles tendon a safe technique? A study of 124 cases
Not best available evidence - not comparative
Amlang MH, et al The percutaneous suture of the Achilles tendon with the Dresden instrument
Not best available evidence - not comparative
Tang KL, et al Arthroscopically assisted percutaneous repair of fresh closed Achilles tendon rupture by Kessler's suture
Not best available evidence - not comparative
Fortis AP, et al Repair of Achilles tendon rupture under endoscopic control
Not best available evidence - not comparative
Schonberger TJ, et al
Operative treatment of acute Achilles tendon rupture. Open end-to-end-reconstruction versus reconstruction with
Mitek-anchors Retrospective case series
Hohendorff B, et al Long-term results after operatively treated Achilles tendon rupture. fibrin glue versus suture suture technique
AAOS Guideline Unit v0.3 10.12.09 63
Author Title Exclusion Reason
Kuwada GT; Critical analysis of tendo Achillis repair using Achilles tendon rupture classification system and repair
Not best available evidence - not comparative
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 real-time sonography
Not best available evidence - not comparative
Majewski M, et al Avoiding sural nerve injuries during percutaneous Achilles tendon repair
Not best available evidence - not comparative
Jung HG, et al Outcome of Achilles tendon ruptures treated by a limited open technique
Not best available evidence - not comparative
Scarfi G, et al Percutaneous repair of Achilles tendon Not best available
evidence - not comparative
Crnica S, et al Follow-up results of Achilles tendon rupture treatment by the method of modified percutaneous suture
Not best available evidence - not comparative
Perez TA; Traumatic rupture of the Achilles Tendon. Reconstruction by transplant and graft using the lateral peroneus brevis
Not best available evidence - not comparative
Ma GW;Griffith TG;
Percutaneous repair of acute closed ruptured Achilles tendon. a new technique
Not best available evidence - not comparative
Boyden EM, et al; Late versus early repair of Achilles tendon rupture. Clinical and biomechanical evaluation
Not best available evidence - not comparative
Soldatis JJ, et al End-to-end operative repair of Achilles tendon rupture Not best available
evidence - not comparative
Martinelli B; Percutaneous repair of the Achilles tendon in athletes Not best available
evidence - not comparative
Mellor SJ;Patterson MH; Tendo Achillis rupture; surgical repair is a safe option
Not best available evidence - not comparative
Bruggeman NB, et al
Wound complications after open Achilles tendon repair. an analysis of risk factors
Not best available evidence - not comparative
Webb JM;Bannister GC; Percutaneous repair of the ruptured tendo Achillis
Not best available evidence - not comparative
Gillespie HS;George EA;
Results of surgical repair of spontaneous rupture of the Achilles tendon
Not best available evidence - not comparative
AAOS Guideline Unit v0.3 10.12.09 64
Author Title Exclusion Reason
Jessing P;Hansen E; Surgical treatment of 102 tendo achillis ruptures-- suture or tenontoplasty?
Not best available evidence - not comparative
Kiviluoto O, et al Surgical repair of subcutaneous rupture of the Achilles tendon
Not best available evidence - not comparative
Haggmark T, et al Calf muscle atrophy and muscle function after non-operative vs. operative treatment of Achilles tendon
ruptures
Not best available evidence - not comparative
Bomler J;Sturup J; Achilles tendon rupture. An 8-year follow up Not best available
evidence - not comparative
Hogsaa B, et al Surgical treatment of Achilles tendon ruptures Not best available
evidence - not comparative
FitzGibbons RE, et al Percutaneous Achilles tendon repair
Not best available evidence - not comparative
Chillemi C, et al Percutaneous repair of Achilles tendon rupture. Ultrasonographical and isokinetic evaluation
Not best available evidence - not comparative
Gorschewsky O, et al
Not best available evidence - not comparative
Percutaneous repair of acute Achilles tendon rupture
1395 1396 1397
STUDY QUALITY Table 66. Study Quality - RCTs
● = Yes ○ = No × = Not Reported
Author Outcome N
Follo
w U
p - 8
0% o
r m
ore
Stoc
hast
ic
Ran
dom
izat
ion
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
Level of EvidenceTreatment(s)
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entr
y
Gigante, et al. 2008
SF-12. Physical
Component 39
Open Repair vs.
Percutaneous Repair
Level II ● × × ● ● ×
Gigante, et al. 2008
SF-12. Mental Component 39
Open Repair vs.
Percutaneous Repair
Level II ● × × ● ● ×
Lim, et al.
2001 Complications 66
Open Repair vs.
Percutaneous Level II ○ ● ● × ● ×
AAOS Guideline Unit v0.3 10.12.09 65
● = Yes ○ = No × = Not Reported
Author Outcome N Treatment(s) Level of Evidence
Stoc
hast
ic
Ran
dom
izat
ion
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entr
y
Follo
w U
p - 8
0% o
r m
ore
Repair
Lim, et al.
2001
Duration of Immobilization 66
Open Repair vs.
Percutaneous Repair
Level II ○ ● ● × ● ×
Lim, et al.
2001
Return to activities of daily living
66
Open Repair vs.
Percutaneous Repair
Level II ○ ● ● × ● ×
Lim, et al.
2001
Return to functional
activity 66
Open Repair vs.
Percutaneous Repair
Level II ○ ● ● × ● ×
1398
1399 Table 67. Quality of Studies - Comparative Studies
● = Yes ○ = No × = Not Reported
Author Outcome N Treatment(s) Level of Evidence A
ll gr
oups
hav
e si
mila
r ch
arac
teris
tics a
t ent
ry
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entry
All
grou
ps c
oncu
rren
tly
tre
ated
Follo
w U
p - 8
0% o
r mor
e
Sam
e ce
nter
for
expe
rimen
tal a
nd c
ontro
l gr
oup
data
Kakiuchi, et al. 1995
Return to Sports 22
Percutaneous and Minimally
Invasive vs. Open Repair
Level III × × ● ○ ●
Kakiuchi, et al. 1995
Symptoms - None 22
Percutaneous and Minimally
Invasive vs. Open Repair
Level III × × ● ○ ●
Kakiuchi, et al. 1995
Symptoms - Stiffness 22
Percutaneous and Minimally
Invasive vs. Open Repair
Level III × × ● ○ ●
AAOS Guideline Unit v0.3 10.12.09 66
● = Yes ○ = No × = Not Reported
Author Outcome N Treatment(s) Level of Evidence A
ll gr
oups
hav
e si
mila
r ch
arac
teris
tics a
t ent
ry
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entry
All
grou
ps c
oncu
rren
tly
tre
ated
Sam
e ce
nter
for
expe
rimen
tal a
nd c
ontro
l gr
oup
data
Follo
w U
p - 8
0% o
r mor
e
Kakiuchi, et al. 1995
Symptoms - Discomfort 22
Percutaneous and Minimally
Invasive vs. Open Repair
Level III × × ● ○ ●
Kakiuchi, et al. 1995
Symptoms - Pain 22
Percutaneous and Minimally
Invasive vs. Open Repair
Level III × × ● ○ ●
Kakiuchi, et al. 1995 Re-rupture 22
Percutaneous and Minimally
Invasive vs. Open Repair
Level III × × ● ○ ●
Ng, et al. 2006 Return to Activity -
Same Level 68
Percutaneous vs. Open Repair
Level II ● × ● ● ●
Ng, et al. 2006 Complications 68 Percutaneous
vs. Open Repair
Level II ● × ● ● ●
Bhattacharyya, et al. 2009
Return to Normal Walking
53 Minimally
Invasive vs. Open Repair
Level III ○ × ● ● ●
Bhattacharyya, et al. 2009
Return to Normal Stair
Climbing 53
Minimally Invasive vs. Open Repair
Level III ○ × ● ● ●
Bhattacharyya, et al. 2009
Severe Wound
Infection and Dehiscence
53 Minimally
Invasive vs. Open Repair
Level III ○ × ● ● ●
Bhattacharyya, et al. 2009
Minor Surgical Site
Infection 53
Minimally Invasive vs. Open Repair
Level III ○ × ● ● ●
Bhattacharyya, et al. 2009
Delayed Wound Healing
53 Minimally
Invasive vs. Open Repair
Level III ○ × ● ● ●
AAOS Guideline Unit v0.3 10.12.09 67
STUDY RESULTS 1400 1401 Table 68. Percutaneous vs. Open - Global Outcomes
Percutaneous Open Author Outcome LOE N Duration
mean (SD) mean (SD) Results
SF-12 - Physical Component Score II 39 24 months 52.6 (2.31) 50.7 (2.57) p = 0.02‡ Gigante, et al.
2008 SF-12- Mental Component Score II 39 24 months 52.2 (1.91) 50.4 (2.75) p = 0.02‡
1402 1403 1404
‡ AAOS calculation Table 69. Percutaneous vs. Open - Return to Activities
Author Outcome LOE N Duration Percutaneous (%)
Open (%) Results
Lim, et al. 2001 Return to
Activities of Daily Living
II 66 6 months 100% 100% NS
Lim, et al. 2001 Returned to Final
Functional Activity
II 66 6 months 100% 100% NS
NS: not significant; authors do not report p-value
Table 70. Percutaneous vs. Open - Satisfaction 1405
Author Outcome LOE N Duration Percutaneous (%)
Open (%) Results
Lim, et al. 2001 Satisfaction - Excellent II 66 6 months 52% 42% NS
NS: not significant; authors do not report p-value 1406
1407
1408
Table 71. Percutaneous vs. Open - Complications
Author Complications LOE N Duration Percutaneous(%)
Open (%) Results
Lim, et al 2001 Re-rupture II 66 6 months 3% 6% p = .55‡
Lim, et al. 2001
Sural Nerve Problems II 66 6 months 3% 0% p = .15‡
Lim, et al. 2001 Infections II 66 6 months 0% 21% p <
.001‡ Lim, et al.
2001 Keloid
Formation II 66 6 months 0% 3% p = .15‡
Lim, et al. 2001 Adhesions II 66 6 months 0% 6% p = .043
AAOS Guideline Unit v0.3 10.12.09 68
Author Complications LOE N Duration Percutaneous(%)
Open (%) Results
Lim, et al. 2001
Wound Puckering II 66 6 months 9% 0% p =
.013‡ ‡ AAOS calculation
Table 72. Minimally Invasive vs. Open - Function 1409
Author Outcome LOE N Duration Minimally
Invasive mean (SD)
Open Repair
mean (SD) Results
Return to Normal Walking (weeks) III 53 12 months 12.5 (3)‡ 17 (3)‡ p ≤ .001‡
Bhattacharyya, et al. 2009 Return to Normal
Stair Climbing (weeks)
III 53 12 months 14 (3)‡ 19 (3.5)‡ p ≤ .001‡
Ng, et al 2006 Return to
Activity - Same Level
II 68 65.5 months 96% 88% p = 0.244
‡ AAOS calculation
Table 73. Minimally Invasive vs. Open - Complications 1410
Author Complications LOE N Duration
Minimally Invasive Open
Repair (%)
Open (%) Results
Bhattacharyya, et al. 2009
Delayed Wound Healing III 53 12 months 0% 10% p <.001‡
Bhattacharyya, et al. 2009
Severe Wound Infection and Dehiscence
III 53 12 months 0% 10% p =.034‡
Bhattacharyya, et al. 2009
Minor Surgical Site Infection III 53 12 months 0% 25% p = .001‡
Ng, et al. 2006 Re-rupture II 68 65.5
months 0% 2% p = .223‡
Ng, et al. 2006
Sural Nerve Injury II 68 65.5
months 0% 2% p = .22‡
Ng, et al. 2006
Superficial Infection II 68 65.5
months 8% 5% p = .58‡
Ng, et al. 2006
Hypertrophic Scar II 68 65.5
months 4% 19% p = .052‡
Ng, et al. 2006 Scar Adhesion II 68 65.5
months 0% 9% p = .014‡
Ng, et al. 2006
Wound Breakdown/delay II 68 65.5
months 0% 12% p = .005‡
1411 ‡ AAOS calculation
AAOS Guideline Unit v0.3 10.12.09 69
Table 74. Minimally Invasive vs. Open - Symptoms 1412
Author Outcome LOE N Duration Minimally Invasive (%)
Open (%) Results
Kakiuchi, et al. 1995 Symptoms - Pain III 22 63.5
months 0% 20% p = .05‡
Kakiuchi, et al. 1995 Symptoms- None III 22 63.5
months 83% 40% p <.001‡
Kakiuchi, et al. 1995
Symptoms - Stiffness III 22 63.5
months 17% 30% p =.78‡
Kakiuchi, et al. 1995
Symptoms - Discomfort III 22 63.5
months 0% 10% p = .17‡
‡ AAOS calculation
Table 75. Minimally Invasive vs. Open - Return to Sport 1413
Author Outcome LOE N Duration
Minimally Invasive (%)
Open (%) Results
Return to Sport - Same or
increased level III 22 63.5
months 75% 10% p < .001‡
Return to Sport - Decreased III 22 63.5
months 8% 40% p = .17‡ Kakiuchi, et al. 1995
Return to Sport - No participation for other reasons
III 22 63.5 months 17% 50% p = .27‡
1414 1415 1416
‡ AAOS calculation
Table 76. Minimally Invasive vs. Open - Complications
Minimally Invasive (%) Open
Author Complications LOE N Duration % %
Results
Kakiuchi, et al. 1995 Rerupture III 22 63.5
months 0% 0% NS
1417 NS: not significant; authors do not report p-value
AAOS Guideline Unit v0.3 10.12.09 70
RECOMMENDATION 9 1418 1419 1420
1421
1422
1423 1424 1425
1426 1427
1428 1429 1430 1431
1432
1433 1434 1435 1436 1437
1438 1439 1440 1441
1442 1443 1444 1445 1446 1447 1448 1449
1450 1451 1452 1453 1454
We cannot recommend for or against the use of allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts in acute Achilles tendon ruptures that are treated operatively.
Strength of Recommendation: Inconclusive
Rationale
A systematic review failed to identify adequate evidence to make a recommendation for or against the use of allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts in acute Achilles tendon ruptures that are treated operatively.
No studies addressed adjunctive augmentation with allograft, xenograft, or biologic adjuncts.
Three level II studies36-38 compared open repair alone and autograft augmentation. One level IV study39 compared patients treated with synthetic tissue augmentation to open repair alone. All four of these studies failed to demonstrate significant improvement in outcomes or complications.
Supporting Evidence:
No studies were identified that address adjunctive augmentation with allograft (see Table 83), xenograft, or biologic adjuncts (see Table 86). We examined three level II studies that compared patients given adjunctive augmentation with autograft tissue vs. open repair.36-38 One Level IV study that compared patients given adjunctive augmentation with synthetic tissue vs. open repair.39
AUTOGRAFT TISSUE VS OPEN REPAIR Three studies reported that patients given adjunctive augmentation did not significantly differ in pain, stiffness, satisfaction, return to daily activities, return to sport, or footwear restrictions (see Table 77 - Table 80).
One study reported one patient given adjunct augmentation had a pulmonary embolism; no significant difference was found between treatment groups (see Table 82). In two studies, DVT rates did not significantly differ in patients given augmentation with autograft tissue vs. open repair. Two studies reported patients with deep infection. One study found patients treated with open repair had significantly less deep infections and the other study reported no significant difference. No significant differences were found in patients given augmentation with superficial infections, dysesthesia, Keloid, and dehiscence (see Table 82).
AUGMENTATION WITH SYNTHETIC TISSUE VS OPEN REPAIR We analyzed one non-comparative study that analyzed patients treated with synthetic tissue (polypropylene braid). All patients reported excellent results and all patients returned to previous activity (see Table 97). There were no reruptures and no healing impairment (see Table 97). One patient underwent a PB removal procedure 1 year after
AAOS Guideline Unit v0.3 10.12.09 71
surgery because of the distal heat-sealed end of the PB device stuck out of the tendon, causing an impingement on the shoe (see
1455 1456
1457 1458
Table 97).
SUMMARY OF EVIDENCE Table 77. Autograft vs. Open - Pain and Stiffness
Duration (months) Author LOE N Outcome 6 12 42
Pajala II 59 Pain ○
Aktas II 30 Pain ○
Taglialavoro II 46 Pain ○
Pajala II 59 Stiffness ○
1459 1460 1461 1462
1463
●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance
Table 78. Autograft vs. Open - Satisfaction Duration (months) Author LOE N Outcome 12 42
Taglialavoro II 46 Satisfaction ○
Pajala II 59 Satisfaction ○
1464 1465 1466 1467
●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 79. Autograft - Return to Activities and Sports
Duration (months)
Author LOE N Outcome 6 42
Taglialavoro II 46 Recovery of Daily
Activities (days) ○
Taglialavoro II 46
Return to Sports – Complaints during normal
activity ○
Aktas, et al II 30 Return to Sports – Same
Level / Pre-injury ○
Taglialavoro II 46 Return to Sports ○ 1468 1469 1470
●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance
AAOS Guideline Unit v0.3 10.12.09 72
1471 1472 Table 80. Autograft vs. Open - Footwear Restrictions
Duration (months) Author LOE N Outcome
12 42
Pajala II 59 Footwear Restrictions ○
Taglialavoro II 46 Conflict with shoes ○
1473 1474 1475 1476 1477
●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 81. Autograft vs. Open - Hospitalization and Immobilization
Author Outcome (Days) LOE N Duration
42 months
Taglialavoro Hospitalization II 46 ●Op
Taglialavoro Immobilization II 46 ●Op
1478 1479 1480 1481 1482
●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance Table 82. Autograft vs. Open - Complications
Duration (months) Author LOE N Outcome 6 12 42
Taglialavoro II 46 PE ○ Taglialavoro II 46 DVT ○
Pajala II 60 DVT ○ Aktas II 30 Deep Infection ○ Pajala II 60 Deep Infection ●Op
Pajala II 60 Superficial Infection ○
Pajala II 60 Re-rupture ○
Aktas II 30 Re-rupture ○ Taglialavoro II 46 Dysesthesia ○ Taglialavoro II 46 Cheloid ○ Taglialavoro II 46 Dehiscence ○
1483 1484 1485 1486
●Op: Statistically Significant in Favor of Open Operative Repair ●A: Statistically Significant in Favor of Open Repair with Adjunctive Augmentation ○ No statistical significance
AAOS Guideline Unit v0.3 10.12.09 73
EXCLUDED ARTICLES 1487 1488 Table 83. 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
1489 1490 Table 84. 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 Results of surgical treatment of rupture of the Achilles
tendon with use of the plantaris tendon Not best available
evidence
Elias, et al. 2007
Reconstruction for missed or neglected Achilles tendon rupture with V-Y lengthening and flexor hallucis longus
tendon transfer through one incision
Neglected/chronic Achilles tear patients
Garabito, et al. 2005
Augmented repair of acute Achilles tendon ruptures using gastrocnemius-soleus fascia
Not best available evidence
Hahn, et al. 2008
Treatment of chronic Achilles tendinopathy and ruptures with flexor hallucis tendon transfer: clinical outcome and
MRI findings
Less than 10 patients per group
Jessing, et al. 1975
Surgical treatment of 102 tendo achillis ruptures-- suture or tenontoplasty?
Not best available evidence
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% follow-up
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
AAOS Guideline Unit v0.3 10.12.09 74
Author Title Exclusion Reason
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
1491 1492 Table 85. Excluded Studies - Synthetic Tissue
Author Title Exclusion Reason Fernandez-Fairen, et
al. 1997
Augmented repair of Achilles tendon ruptures Retrospective case series
Hohendorff, et al. 2008
Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture Suture Technique
Parsons, et al. 1984
Achilles tendon repair with an absorbable polymer-carbon fiber composite
Combines acute and neglected/chronic
Achilles tendon tear patients
Parsons, et al. 1989
Patients had prior surgical or
conservative treatment
Long-term follow-up of Achilles tendon repair with an absorbable polymer carbon fiber composite
1493
AAOS Guideline Unit v0.3 10.12.09 75
Table 86- Biologic Adjuncts 1494
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
1495
AAOS Guideline Unit v0.3 10.12.09 76
1496 1497 1498
STUDY QUALITY Table 87. Study Quality – Autograft RCTs
● = Yes ○ = No × = Not Reported
Author
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
Follo
w U
p - 8
0% o
r m
ore
Outcome N Level of EvidenceTreatment(s) A
ll gr
oups
hav
e si
mila
r ou
tcom
e pe
rfor
man
ce a
t ent
ry
Pajala, et al.
2009 Stiffness 60 Open vs. Autograft
Augmentation Level II ● ● ● ○ ● ×
Pajala, et al.
2009
Footwear Restrictions 60 Open vs. Autograft
Augmentation Level II ● ● ● ○ ● ×
Pajala, et al.
2009 Pain 60 Open vs. Autograft
Augmentation Level II ● ● ● ○ ● ×
Pajala, et al.
2009 Satisfaction 60 Open vs. Autograft
Augmentation Level II ● ● ● ○ ● ×
Pajala, et al.
2009 Re-rupture 60 Open vs. Autograft
Augmentation Level II ● ● ● ○ ● ×
Pajala, et al.
2009 Deep Infection 60 Open vs. Autograft
Augmentation Level II ● ● ● ○ ● ×
Pajala, et al.
2009 DVT 60 Open vs. Autograft
Augmentation Level II ● ● ● ○ ● ×
Pajala, et al.
2009
Superficial Infection 60 Open vs. Autograft
Augmentation Level II ● ● ● ○ ● ×
Aktas, et al.
2007 Return to sport 30 Open vs. Autograft
Augmentation Level II × × ● ○ ● ×
Aktas, et al.
2007 Pain 30 Open vs. Autograft
Augmentation Level II ○ ● ● ○ ● ×
AAOS Guideline Unit v0.3 10.12.09 77
● = Yes ○ = No × = Not Reported
Author Outcome N Treatment(s) Level of Evidence
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at e
ntry
Follo
w U
p - 8
0% o
r m
ore
Aktas, et al.
2007 Deep Infection 30 Open vs. Autograft
Augmentation Level II ○ ● ● ○ ● ×
Aktas, et al.
2007 Re-rupture 30 Open vs. Autograft
Augmentation Level II ○ ● ● ○ ● ×
1499 1500
1501
Table 88. Study Quality - Autograft Comparative Studies
● = Yes ○ = No × = Not Reported
Author
Outcome N Level of Evidence A
ll gr
oups
hav
e si
mila
r cha
ract
eris
tics
at e
ntry
A
ll gr
oups
hav
e si
mila
r out
com
e pe
rfor
man
ce a
t ent
ry
All
grou
ps c
oncu
rren
tly
treat
ed
Follo
w U
p - 8
0% o
r mor
e
Treatment(s) Sam
e ce
nter
for e
xper
imen
tal a
nd
cont
rol g
roup
dat
a
Taglialavoro, et al 2004 Pain 46 Open vs. Autograft
Augmentation Level II ● ● ● ● ●
Taglialavoro, et al 2004
Recovery of Daily Activities 46 Open vs. Autograft
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 ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 78
● = Yes ○ = No × = Not Reported
Author Outcome N Treatment(s) Level of Evidence A
ll gr
oups
hav
e si
mila
r cha
ract
eris
tics
at e
ntry
A
ll gr
oups
hav
e si
mila
r out
com
e pe
rfor
man
ce a
t ent
ry
All
grou
ps c
oncu
rren
tly
treat
ed
Sam
e ce
nter
for e
xper
imen
tal a
nd
cont
rol g
roup
dat
a
Follo
w U
p - 8
0% o
r mor
e
Taglialavoro, et al 2004 Immobilization 46 Open vs. Autograft
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 Cheloid 46 Open vs. Autograft
Augmentation Level II ● ● ● ● ●
Taglialavoro, et al 2004 Dehiscence 46 Open vs. Autograft
Augmentation Level II ● ● ● ● ●
1502
AAOS Guideline Unit v0.3 10.12.09 79
Table 89. Study Quality - Synthetic Tissue Case Series 1503
● = Yes ○ = No × = Not Reported
Author
Con
secu
tive
enro
llmen
t
of
pat
ient
s
Follo
w U
p - 8
0% o
r mor
e
All
patie
nts e
valu
ated
usi
ng
sam
e ou
tcom
e m
easu
res
All
patie
nts r
ecei
ve sa
me
treat
men
t
Level of EvidenceOutcome N Treatment(s)
All
patie
nts h
ave
appr
oxim
atel
y eq
ual f
ollo
w-u
p tim
es
Giannini et al, 1994 Return to Sports 15 Synthetic Adjunctive
Augmentation Level IV ● ● ● ● ●
Giannini et al, 1994
Return to Previous Activity
15 Synthetic Adjunctive Augmentation Level IV ● ● ● ● ●
Giannini et al, 1994
Subjective Results-
Excellent 15 Synthetic Adjunctive
Augmentation Level IV ● ● ● ● ●
Giannini et al, 1994
Full weight-bearing (weeks) 15 Synthetic Adjunctive
Augmentation Level IV ● ● ● ● ●
Giannini et al, 1994 Re-rupture 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 ● ● ● ● ●
1504
AAOS Guideline Unit v0.3 10.12.09 80
STUDY RESULTS 1505 1506 Table 90 Autograft vs. Open Pain and Stiffness
Adjunctive Augmentation Open Author Outcome LOE N Duration
% % Results
Pajala, et al. 2009 No Pain vs. Pain II 59 12
months 79% (4%) 90% (0%) p = 0.35
Aktas, et al. 2007 Pain - Absent* II 30 6 months 94% 86% NS
Aktas, et al. 2007
Pain - Mild w/ maximal exertion* II 30 6 months 6% 14% NS
Taglialavoro, et al 2004 Pain - Absentª II 46 42
months 83% 73% NS
Taglialavoro, et al 2004
Pain - During Intense Trainingª II 46 42
months 17% 18% NS
Taglialavoro, et al 2004
Pain - During Moderate Trainingª II 46 42
months 0% 5% NS
Taglialavoro, et al 2004 Pain - Continuousª II 46 42
months 0% 5% NS
Pajala, et al. 2009 No stiffness vs. stiffness II 59 12
months 46% (36% 72% (16%) p = .10
*American Orthopaedic Foot and Ankle Score NS: not significant; authors do not report p-value
Table 91. Autograft vs. Open - Satisfaction 1507
Author Outcome LOE N Duration Adjunctive
Augmentation (%)
Open (%) Results
Pajala, et al. 2009
Very satisfied vs. all other satisfaction levels II 59 12
months 71% (11%) 71% (19%) p = 0.55
Taglialavoro, et al 2004 Satisfaction - Very Goodª II 46 42
months 46% 46% p = .98‡
Taglialavoro, et al 2004 Satisfaction - Goodª II 46 42
months 42% 46% p = .8‡
Taglialavoro, et al 2004 Satisfaction - Fairª II 46 42
months 13% 0% p = .01‡
Taglialavoro, et al 2004 Satisfaction - Poorª II 46 42
months 0% 9% p = .04‡
ª Modified McCormis Score ‡ AAOS Calculation
1508
AAOS Guideline Unit v0.3 10.12.09 81
1509 1510 Table 92. Autograft vs. Open - Return to Sports
Author Outcome LOE N Duration Adjunctive
Augmentation (%)
Open (%) Results
Aktas, et al. 2007
Return to Sports - Same Level / Pre-injury II 30 6 months 85% 89% p = .620‡
Taglialavoro, et al 2004
Return to Sports - Complete II 46 42
months 38% 32% NS
Taglialavoro, et al 2004
Return to Sports - Low Loss II 46 42
months 50% 55% NS
Taglialavoro, et al 2004
Return to Sports - Decreased II 46 42
months 8% 9% NS
Taglialavoro, et al 2004
Return to Sports - Not Recovered II 46 42
months 4% 0% NS
Taglialavoro, et al 2004
Return to Sports - Complaints during
normal activity II 46 42
months 0% 5% NS
1511 1512 1513 1514
‡ AAOS Calculation NS: not significant; authors do not report p-value Table 93. Autograft vs. Open - Return to Activities
Author Outcome LOE N Duration
Adjunctive Augmentation
mean (SD)
Open mean(SD) Results
Taglialavoro, et al 2004
Recovery of Daily Activities(days) II 46 42
months 128 (39) 106 (66) p = .17‡
1515 1516 1517 1518
‡ AAOS Calculation Table 94. Autograft vs. Open - Footwear Restrictions
Author Outcome LOE N Duration Adjunctive
Augmentation (%)
Open (%) Results
Pajala, et al. 2009
No footwear restrictions vs. footwear restrictions II 60 12
months 79% (4%) 90% (0%) p = 0.35
Taglialavoro, et al 2004 Shoe conflict II 46 42
months 38% 23% NS
1519 1520 1521
1522
1523
‡ AAOS Calculation NS: not significant; authors do not report p-value
AAOS Guideline Unit v0.3 10.12.09 82
Table 95. Autograft vs. Open - Hospitalization vs. Immobilization 1524
Author Outcome LOE N Duration Adjunctive
Augmentation mean (SD)
Open mean(SD) Results
Taglialavoro, et al 2004 Hospitalization (days) II 46 42
months 8.2 (2.3) 5.0 (1.9) p <.001‡
Taglialavoro, et al 2004 Immobilization (days) II 46 42
months 63.9 (15.8) 49.5 (10.6) p <.001‡
‡ AAOS Calculation 1525
1526 Table 96. Autograft vs. Open - Complications
Adjunctive Augmentation
Open Repair
Author Complication LOE N Duration % % Results
Taglialavoro, et al 2004 PE II 46 42 months 4% 0% NS
Taglialavoro, et al 2004 DVT II 46 42 months 4% 14% NS
Pajala, et al. 2009 DVT II 60 3 weeks 4% 0% NS
Pajala, et al. 2009 Deep Infection II 60 12 months 7% 0% p = .04‡
Aktas et al. 2007 Deep Infection II 30 6 months 6% 0% NS
Pajala, et al. 2009
Superficial Infection II 60 12 months 4% 13% NS
Pajala, et al. 2009 Re-rupture* II 60 12 months 11% 9% NS
Aktas et al. 2007 Re-rupture II 30 6 months 0% 0% NS
Taglialavoro, et al 2004 Dysesthesia II 46 42 months 13% 14% NS
Taglialavoro, et al 2004 Cheloid II 46 42 months 8% 5% NS
Taglialavoro, et al 2004 Dehiscence II 46 42 months 13% 9% NS
* Three of the patients with reruptures had obvious new injury during recovery period. One re-rupture occurred at ten weeks when patient was cycling up a steep hill. Two re-ruptures occurred at twelve weeks with minimum trauma; these patients were in the Open repair group and recalled having sustained a slight injury during the first three weeks. ‡ AAOS calculation NS: Non-Significant; Authors did not report p-value
1527
AAOS Guideline Unit v0.3 10.12.09 83
Table 97. Synthetic Tissue - Results 1528
Adjunctive AugmentationAuthor Outcome LOE N Duration mean (SD) %
Giannini et al, 1994 Subjective Results- Excellent IV 15 18
months 100%
Giannini et al, 1994 Return to Previous Activity IV 15 18
months 100%
Giannini et al, 1994 Re-rupture IV 15 18
months 0%
Giannini et al, 1994 Healing Impairment IV 15 18
months 0%
1529 1530
AAOS Guideline Unit v0.3 10.12.09 84
RECOMMENDATION 10 1531 1532 1533 1534
1535 1536 1537 1538
1539 1540 1541
We cannot recommend for or against the use of antithrombotic treatment for patients with acute Achilles tendon ruptures. Strength of Recommendation: Inconclusive
Rationale: A systematic review was conducted to determine if prophylaxis for thromboembolic events is warranted for patients with acute Achilles tendon rupture. No studies were identified that address this issue.
EXCLUDED STUDIES Table 98. Antithrombotic Treatment - Excluded Studies
Author Title Exclusion Reason
Nilsson-Helander, et al. 2009
High Incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study
Not Relevant; Does not answer the
recommendation. Lapidus, et al.
2007 Prolonged thromboprophylaxis with dalteparin after surgical treatment
of Achilles tendon rupture: a randomized, placebo-controlled study Less than 50%
follow up
Lassen, et al. 2002
Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization
Less than 80% Achilles tendon tear
patients
AAOS Guideline Unit v0.3 10.12.09 85
RECOMMENDATION 11 1542 1543 1544
1545
1546 1547 1548 1549 1550 1551 1552 1553 1554 1555 1556 1557 1558 1559 1560 1561 1562 1563 1564 1565 1566 1567 1568 1569 1570 1571 1572 1573 1574 1575 1576 1577 1578
1579 1580
1581 1582
We suggest early (≤ 2 weeks) post-operative protected weight bearing for patients with acute Achilles tendon rupture who have been treated operatively.
Strength of Recommendation: Moderate
Rationale: A systematic review identified three Level II studies40, 5, 41that compared early postoperative weight bearing to non-weight bearing following surgical repair of the Achilles tendon. All studies randomized the patients into two groups with either six weeks of non-weight bearing in a cast or early weight bearing with a modified splint device. One study40 permitted immediate toe-touch weight bearing starting the day of surgery in a cast. The second study5 allowed the weight bearing group to begin immediate rehabilitation on the first post-operative day in a modified splint. The patients in the third study41 began weight bearing two weeks after surgery. By two weeks, all investigators used a splint device that limited dorsiflexion to prevent compromise of the repair. After four weeks, Maffulli et al.40 allowed the non-weight bearing group to begin full weight bearing in a cast, while the other two studies5, 41 kept the non-weight bearing group on crutches for six weeks. One study5, found a significantly higher re-rupture rate in the early postoperative weight bearing group (2 of 23 patients) compared to non-weight bearing group (0 of 25 patients). Both patients had documented non-compliance with the use of their postoperative splint and fell during the first four weeks after surgery. Two studies40, 5 found that the weight bearing group had statistical improvement in the time to return to activities including work, sports, and normal walking. Suchak et al.41 found significantly better scores in physical functioning and reported fewer limitations of daily living six weeks after the operation. By 12 months, all three studies found that there was no significant difference between the two groups in outcomes such as pain and function. Although the ultimate level of function achieved after operative repair of an Achilles rupture is similar regardless of the post-operative weight bearing protocol, early post-operative weight bearing allows the patient to achieve a quicker return to activities during the first six months than those patients treated with traditional postoperative casting. Treatment decisions should be made in light of all circumstances presented by the patient. Mutual communication between patient and physician should include a discussion of the importance of patient compliance when a program is prescribed for the use of early weight bearing. Patient compliance to protocol is important to prevent re-rupture.
Supporting Evidence:
Three Level II studies 40, 5, 41 compare early postoperative weight-bearing to non-weight bearing following surgical repair of the Achilles tendon. The post-operative regimes in
AAOS Guideline Unit v0.3 10.12.09 86
1583 1584
1585 1586 1587 1588 1589 1590 1591 1592 1593 1594 1595 1596 1597 1598 1599
1600 1601 1602
1603
1604
the three studies are detailed in Table 99. For results of early weight-bearing versus non-weight bearing see Table 100 though Table 106.
Of thirty-two outcome measures comparing early weight-bearing to non-weight bearing, thirteen were statistically significant in favor of early weight bearing, while zero were in favor of non-weight bearing. Seven of the fifteen results in favor of early weight bearing measured time until returning to activity (return to sports, return to normal walking, return to stair climbing, return to work, return to full weight bearing, number of physical therapy visits, and time until release from physical therapy) (see Table 100). A second study5 that measured time until return to work did not find a statistically significant difference between groups. At one and a half months, the early weight-bearing group reported statistically significantly fewer limitations and scored statistically significantly higher on the physical function, social function, vitality, and emotion components of the Rand-36 scale. One study reported that statistically significantly more patients returned to sports at 12 months. However, two other studies reported no statistically significant difference in return to sports at six or twelve months. There was no statistically significant difference in pain, satisfaction, return to work, limitations, or footwear restrictions at twelve months (see Table 101 through Table 104).
One study5, reported significantly more re-ruptures in the early weight-bearing group. Of the two patients with re-ruptures, one patient did not follow the written rehabilitation protocol and the second patient suffered a fall on ice and forcibly dorsiflexed his ankle.
There were no statistically significant differences between groups in complications.
Table 99: Description of treatment groups Author Post operative Instructions
Maffulli, et al.
Early weight-bearing group: Bear weight on the tip toes of the operated leg as tolerated but keep leg elevated for the first two weeks. Begin weight-bearing as tolerated. Non-weight-bearing group: No weight bearing and keep leg elevated for first two weeks. Increase weight bearing at 4 weeks.
Costa, et al. Early weight-bearing group: Immediate weight-bearing and mobilization using carbon fibre orthosis with 1.5 cm heal raises. Non-weight-bearing group: Traditional plaster cast.
Suchak, et al.
Early weight-bearing group: Two weeks of non-weight-bearing followed by weight-bearing. Non-weight-bearing group: 6 weeks of non-weight bearing using auxiliary crutches.
1605
AAOS Guideline Unit v0.3 10.12.09 87
SUMMARY OF EVIDENCE 1606 1607 Table 100 Time until return to activity
Author Outcome LoE N Time to Return to Activity
Maffulli, et al 2003 Return to Sports (months) II 53 ●wb
Costa, et al 2006 Return to Normal Walking (weeks) II 48** ●wb
Costa, et al 2006 Return to Normal Stair Climbing (weeks) II 48** ●wb
Costa, et al 2006 Return to Work (weeks) II 48** ○
Maffulli, et al 2003 Return to Work (weeks) II 53 ●wb
Maffulli, et al 2003 Full weight-Bearing (wks) II 53 ●wb
Maffulli, et al 2003 Physiotherapy sessions (visits) II 53 ●wb
Maffulli, et al 2003 Discharged from Physiotherapy (months) II 53 ●wb
1608 1609 1610 1611 1612 1613 1614
Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks Table 101 Pain
Result (months)
Author Outcome LoE N 1.5 2 3 6 12
Maffulli, et al 2003 Pain- None II 53 ○*
Maffulli, et al 2003 Pain- Mild, Occasional II 53 ○*
Maffulli, et al 2003 Pain- Moderate II 53 ○*
1615 1616 1617 1618 1619
Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks
AAOS Guideline Unit v0.3 10.12.09 88
1620
1621 Table 102 Function
Author Outcome Result (months)
Suchak, et al 2008
No Limitations or Limitations only in recreation LoE N 1.5 6 12
Maffulli, et al 2003 No Limitations II 110 ●wb
Maffulli, et al 2003
Activity Limitation - Limited Recreational but not Daily Activities II 53 ○
Suchak, et al 2008 Return to at least partial sports II 53 ○*
Maffulli, et al 2003 Return to Sports II 110 ○*
Costa, et al 2006 Return to Sports II 38 ○*
Maffulli, et al 2003 Return to Work II 48** ●wb
Maffulli, et al 2003 Changed Jobs II 49 ○*
Maffulli, et al 2003
Experience Problems at work due to injury II 49 ○*
Maffulli, et al 2003
Footwear restrictions- None, mild (most shoes tolerated) II 49 ○*
Maffulli, et al 2003
Footwear restrictions- Moderate (unable to tolerate fashionable shoes,
with or without insert) II 53 ○*
Wb= weight bearing 1622 1623 1624 1625
**= Open cast group converted to orthosis at 3 weeks 1626
○= no statistically significant difference ●= statistically significant difference * AAOS calculations
AAOS Guideline Unit v0.3 10.12.09 89
Table 103 EuroQoL, Rand-36 1627
Results (Months) Author Outcome LoE N
1.5 2 6 12 Costa, et al
2006 EuroQoL - Health
Score II 48** ○ ○ ○
Costa, et al 2006 EuroQoL - E5D II 48** ○ ○ ○
Suchak, et al 2008
Rand-36 Physical Functioning II 110 ●wb
Suchak, et al 2008
Rand-36 Social Functioning II 110 ●wb
Suchak, et al 2008 Rand-36 Vitality II 110 ●wb
Suchak, et al 2008
Rand-36 Role-Emotional II 110 ●wb
1628 1629 1630 1631 1632 1633 1634
Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks Table 104 Patient Subjective Results
Results (Months)
Author Outcome LoE N 12 months
Maffulli, et al 2003
Patient opinion of results- Excellent
II 53 ○*
Maffulli, et al 2003
Percent satisfied with results of surgery
II 53 ○*
1635 1636 1637 1638 1639 1640
1641
Wb= weight bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks
Table 105 Reruptures
Author LoE Duration N Weight Bearing
Non-Weight Bearing
Statistically Significant Difference
Costa, et al 2006
II 1 year 48** 8.69% 0% ●* nwb
1642 1643 1644
**= Open cast group converted to orthosis at 3 weeks; ●* nwb= statistically significant difference in favor of non-weight-bearing
AAOS Guideline Unit v0.3 10.12.09 90
SUMMARY OF COMPLICATIONS 1645 1646 Table 106 Reported Complications
Author Complication LoE Duration N Weight Bearing
Non-Weight Bearing
Statistically Significant Difference
Suchak, et al 2008 DVT II 6
months 110 0% 2% ○*
Suchak, et al 2008 Necrosis of the skin II 6
months 110 0% 2% ○*
Suchak, et al 2008
Sural nerve dysesthesias, superficial
infections, delayed wound healing, scar
adhesions.
II 6 months 110 15% 16% ○*
Maffulli, et al 2003 Superficial Infection II 12
months 53 7.69% 7.40% ○*
Maffulli, et al 2003
Hypersensitivity of surgical wounds II 10-12
wks 53 15.38% 18.51% ○*
Maffulli, et al 2003 Hypertrophic Scar II 10-12
weeks 53 3.84% 0% ○*
Costa, et al 2006
Minor wound complications II Nr 48** 26% 21% ○*
Costa, et al 2006
Percsistent paraethesiae II Nr 48** 0% 4.3% ○*
1647 1648 1649 1650 1651 1652 1653 1654
Wb= weight bearing Nwb= non-weight-bearing ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks
Table 107 Systematic Reviews Author Conclusion
"Postoperative splinting in a cast followed by a functional brace rather than a cast alone reduces the overall complication rate" (p. 2209).
Khan, RJK, et al. 2005
"Early functional mobilisation is more acceptable to patients than plaster cast immobilisation and results in improved functional outcomes" (p. 156).
Lynch, RM 2004
Suchak, AA et al. 2006 "An early functional rehabilitation protocol for Achilles tendon ruptures improves patient satisfaction with reduction in minor complications and no increase in rerupture rate or infection rate" (p. 220).
AAOS Guideline Unit v0.3 10.12.09 91
EXCLUDED ARTICLES 1655 1656 Table 108 Article Inclusion List- Early weight-bearing vs. non-weight bearing
Author Title Exclusion Reason Maffulli, et
al. 2003
No adverse effect of early weight bearing following open repair of acute tears of the Achilles tendon Data reported previously
Costa, et al. 2003
Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study
Less than 10 patients per group
Wagnon, et al.
2005
The Webb-Bannister percutaneous technique for acute Achilles' tendon ruptures: a functional and MRI
assessment
No patient-oriented outcome
Aoki, et al. 1998
Early active motion and weight-bearing after cross-stitch Achilles tendon repair
Not best available evidence - not comparative
Speck, et al. 1998
Early full weight-bearing and functional treatment after surgical repair of acute Achilles tendon rupture
Not best available evidence - not comparative
Solveborn, et al. 1994
Not best available evidence - not comparative
Immediate free ankle motion after surgical repair of acute Achilles tendon ruptures
1657
AAOS Guideline Unit v0.3 10.12.09 92
STUDY QUALITY 1658 1659 Table 109. Quality- Weight-bearing vs. non-weight bearing
● = Yes ○ = No × = Not Reported n/a = not applicable
Author
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
ent
r
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
Follo
w U
p - 8
0% o
r m
ore
y
Outcome N Treatment(s) LoE
Costa, et al.
2006 Return to Sports 43
Weight-bearing vs. Non-
weight-bearing II ● ● × × ● ●
Costa, et al.
2006
Return to Sport (weeks)** 43
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 ● ● × × ● ×
Suchak, et al. 2008
RAND-36: Physical Function 109
Weight bearing vs. Non-weight
bearing II ● ● × × ● ×
AAOS Guideline Unit v0.3 10.12.09 93
● = Yes ○ = No × = Not Reported n/a = not applicable
Author Outcome N Treatment(s) LoE
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
ent
r
Follo
w U
p - 8
0% o
r m
ore
y
Suchak, et al. 2008
RAND-36: Mental health 109
Weight bearing vs. Non-weight
bearing II ● ● × × ● ×
Suchak, et al. 2008
Complications 110Weight 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: Role-physical 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 109Weight bearing vs. Non-weight
bearing II ● ● × × ● ×
Suchak, et al. 2008
RAND-36: Role-emotional 109
Weight bearing vs. Non-weight
bearing II ● ● × × ● ×
AAOS Guideline Unit v0.3 10.12.09 94
● = Yes ○ = No × = Not Reported n/a = not applicable
Author Outcome N Treatment(s) LoE
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
ent
r
Follo
w U
p - 8
0% o
r m
ore
y
Maffulli, et al. 2003
Pain- None 53
Weight Bearing vs. Non-Weight
Bearing
II ○ ○ ○ ● ● ×
Maffulli, et al. 2003
Pain- Mild, Occasional 53
Weight Bearing vs. Non-Weight
Bearing
II ○ ○ ○ ● ● ×
Maffulli, et al. 2003
Pain- Moderate 53
Weight Bearing vs. Non-weight-bearing
II ○ ○ × × ● ×
Maffulli, et al. 2003
Return to Sports 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ×
Maffulli, et al. 2003
Return to Sports (months) 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Return to Work (weeks) 53
Weight Bearing vs. Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Return to Work 53
Weight Bearing vs. Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Changed Jobs 53
Weight Bearing vs. Non-weight-bearing
II ○ ○ × × ● ●
AAOS Guideline Unit v0.3 10.12.09 95
● = Yes ○ = No × = Not Reported n/a = not applicable
Author Outcome N Treatment(s) LoE
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
ent
r
Follo
w U
p - 8
0% o
r m
ore
y
Maffulli, et al. 2003
Experience Problems at work
due to injury 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Full weight-Bearing (wks) 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Activity Limitation - None 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Activity Limitation - Limited
Recreational but not Daily Activities
53 Weight
Bearing vs. Non Weight
II ○ ○ × × ● ●
Maffulli, et al. 2003
Discharged from Physiotherapy
(months) 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Physiotherapy sessions (visits) 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Footwear restrictions- None, mild (most shoes
tolerated)
53
Weight Bearing vs. Non Weight
Bearing
II ○ ○ × × ● ●
AAOS Guideline Unit v0.3 10.12.09 96
● = Yes ○ = No × = Not Reported n/a = not applicable
Author Outcome N Treatment(s) LoE
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
ent
r
Follo
w U
p - 8
0% o
r m
ore
y
Maffulli, et al. 2003
Footwear restrictions-
Moderate (unable to tolerate
fashionable shoes, with or without
insert)
53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Percent satisfied with results of
surgery 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Patient opinion of results- Excellent 53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
1660
AAOS Guideline Unit v0.3 10.12.09 97
1661 1662 1663
STUDY RESULTS Table 110 Study Data: Weight Bearing vs. Non-Weight Bearing
Author Outcome LoE Duration N Weight Bearing
Non-Weight Bearing Result
Suchak, et al 2008
Rand-36 Physical Functioning II 6 week 110 61.4 (SD
29.4) 47.6 (SD
34.4) p = 0.03
Suchak, et al 2008
Rand-36 Social Functioning II 6 week 110 72.7 (SD
28.5) 60.7 (SD
26.8) p = 0.03
Suchak, et al 2008 Rand-36 Vitality II 6 week 110 69.4 (SD
23.7) 60.6 (SD
21.1) p = 0.04
Suchak, et al 2008
Rand-36 Role-Emotional II 6 week 110 84.6 (SD
32.0) 67.3 (SD
43.1) p = 0.02
Suchak, et al 2008
No Limitations or Limitations only in
recreation II 6 week 110 43% 9% p = <.001
Suchak, et al 2008
Return to at least partial sports II 6 months 110 67% 63%
OR 1.08 (95% CI .46, 2.54)
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% OR .95
(95% CI .12, 7.92)*
Maffulli, et al 2003 Pain- Mild, Occasional II 12
months 53 8% 7% OR 1.04 (95% CI
.07, 15.43)*
Maffulli, et al 2003 Pain- Moderate II 12
months 53 4% 4%
OR 1.04 (95% CI
.01, 84.73) *
Maffulli, et al 2003
Activity Limitation - None II 12
months 53 92% 93%
OR .96 (95% CI .0647975
14.24349*
AAOS Guideline Unit v0.3 10.12.09 98
Author Outcome LoE Duration N Weight Bearing
Non-Weight Bearing Result
Maffulli, et al 2003
Activity Limitation - Limited Recreational
but not Daily ActivitiesII 12
months 53 8% 7%
OR 1.041667 (95% CI
.07, 15.43)
Maffulli, et al 2003 Return to Sports II 12
months 38 89% 89% OR 1 (95%
CI .35, 2.78)*
Maffulli, et al 2003
Return to Sports (months) II 12
months 53 5.1 (SD 2.8) 6 (SD 3) p= 0.04
Maffulli, et al 2003
Footwear restrictions-None, mild (most shoes
tolerated) II 12
months 53 96% 93%
OR 1.08(95%
CI .46 2.50)
Maffulli, et al 2003
Footwear restrictions-Moderate (unable to tolerate fashionable
shoes, with or without insert)
II 12 months 53 4% 7%
OR .48 (95% CI .01, 9.92)
Maffulli, et al 2003
Percent satisfied with results of surgery II 12
months 53 88% 85% 1.04 (95%
CI .44, 2.47)*
Maffulli, et al 2003 Excellent II 12
months 53 88% 81% OR 1.08 (95% CI
.45, 2.59)*
Maffulli, et al 2003 Return to Work (weeks) II 12
months 53 9.2 (SD 2.5) 13.2 (SD 3) p= 0.05
Maffulli, et al 2003 Return to Work II 12
months 49 100% 100% 1
Maffulli, et al 2003 Changed Jobs II 12
months 49 1 2 OR .5
(95% CI .01, 10.31)
Maffulli, et al 2003
Experience Problems at work due to injury II 12
months 49 2 4 .5 (95% CI .04, 4.15)
Costa, et al 2006 Return to Sports II 1 year 48** 83% 68% p= 0.04
Costa, et al 2006
Return to Normal Walking (weeks) II 1 year 48** 12.5 (CI
10-18) 18 (CI 18-22) p= 0.03
Costa, et al 2006
Return to Normal Stair Climbing (weeks) II 1 year 48** 13 (CI 10-
18) 22 (CI 18-22) p= 0.02
AAOS Guideline Unit v0.3 10.12.09 99
Author Outcome LoE Duration N Weight Bearing
Non-Weight Bearing Result
Costa, et al 2006 Return to Work (weeks) II 1 year 48** 8 (CI 2-13) 4(CI 1-13) p= 0.59
Costa, et al 2006
EuroQoL - Health Score II 2 months 48** 75 (IQR
70-85) 75 (IQR 65-
80) p= 0.85
Costa, et al 2006
EuroQoL - Health Score II 6 months 48** 85 (IQR
80-90) 81 (IQR 75-
95) p= 0.96
Costa, et al 2006
EuroQoL - Health Score** II 1 year 48** 84 (IQR
75-95) 90 (IQR 85-
95) p= 0.14
Costa, et al 2006 EuroQoL - E5D II 2 months 48** 0.69 (IQR
0.6-0.9) 0.69 (IQR 0.6-0.7) p= 0.45
Costa, et al 2006 EuroQoL - E5D II 6 months 48** 0.8 (IQR
0.7-1.0) 0.8 (IQR 0.8-
1.0) p= 0.96
Costa, et al 2006 EuroQoL - E5D II 1 year 48** 1 (IQR
0.9-1.0) 1(IQR 0.8-
1.0) p= 0.15
Costa, et al 2006 Re-rupture II 1 year 48** 8.69% 0 p= 0.03*
Suchak, et al 2008 DVT II 6 months 110 0 2% p= 0.14*
Suchak, et al 2008 Necrosis of the skin II 6 months 110 0 2% p= 0.14*
Suchak, et al 2008
Sural nerve dysesthesias, superficial
infections, delayed wound healing, scar
adhesions.
II 6 months 110 15% 16% p= 0.89*
Maffulli, et al 2003 Superficial Infection II 12
months 53 7.69% 7.40% p= 0.97*
Costa, et al 2006 Minor wound
complications II Nr 48** 26% 21% p=0.17*
Costa, et al 2006 Persistent paraethesiae II Nr 48** 0% 4.3% p= 0.60*
Maffulli, et al 2003
Hypersensitivity of surgical wounds II 10-12
wks 53 15.38% 18.51% p= 0.76*
AAOS Guideline Unit v0.3 10.12.09 100
Author Outcome LoE Duration N Weight Bearing
Non-Weight Bearing Result
Maffulli, et al 2003 Hypertrophic Scar II 10-12
weeks 53 3.84% 0% p= 0.15*
1664 1665
*= AAOS calculations **= Open cast group converted to orthosis at 3 weeks
AAOS Guideline Unit v0.3 10.12.09 101
RECOMMENDATION 12 1666 1667 1668 1669 1670
1671 1672 1673 1674 1675 1676 1677 1678 1679 1680 1681 1682 1683 1684 1685 1686 1687 1688 1689 1690 1691 1692 1693 1694 1695 1696 1697
1698
1699 1700 1701 1702
1703 1704 1705 1706 1707 1708
We suggest the use of a protective device that allows mobilization by 2- 4 weeks post operatively. Strength of Recommendation: Moderate
Rationale: A systematic review identified five Level II 40, 42-44 studies comparing postoperative immobilization to postoperative mobilization following surgical repair of the Achilles tendon. All five studies randomized the patients into two groups with either six weeks in a cast or early motion with a modified splint device. For all studies, patients in the mobilization group had a splint or modified cast device that limited dorsiflexion to protect the repair. All five studies40, 5, 42-44 found that the weight bearing group had statistical improvement in the mean time to return to activities such as work and normal walking. One43 of three studies found a significantly higher rate in return to sport activities at twelve months, while two40, 39 found no difference. One study 5 found a significantly higher re-rupture rate in the postoperative mobilization group (2 of 23 patients) compared to the immobilization group (0 of 25 patients). Both patients had documented non-compliance with the use of their postoperative splint and fell during the first 4 weeks after surgery. By 12 to 18 months, all five studies40, 5, 42-44 found that there was no significant difference between the two groups in outcomes such as pain and function. Although the ultimate level of function achieved after operative repair of an Achilles rupture is similar regardless of the postoperative immobilization protocol, early postoperative mobilization allows the patient to achieve a quicker return to activities during the first six months than those patients treated with immobilization. However, treatment decisions should be made in light of all circumstances presented by the patient. Mutual communication between patient and physician should include a discussion of the importance of patient compliance when a program is prescribed for early mobilization. Patient compliance to protocol is important to aid in protection of the incision during the early post-operative period and is also important to prevent wound healing complications.
Supporting Evidence
Five Level II studies40, 5, 42-44 compare postoperative immobilization to postoperative mobilization. The post operative mobilization and immobilization regimes are detailed in Table 111. Please see Table 112 through Table 119 for results of mobilization versus immobilization.
Of the forty outcomes reported, sixteen were statistically significant in favor of early motion. Nine of the sixteen statistically significant results measured time until return to activity, sports, walking, stair climbing, work, weight bearing, discharge from physiotherapy, number of physiotherapy sessions, and sick leave (see Table 112). However, another study that reported time until return to sport and work did statistically significantly differ between groups (see Table 112). Patients in the early motion group
AAOS Guideline Unit v0.3 10.12.09 102
1709 1710 1711 1712 1713 1714 1715 1716 1717
1718 1719 1720
1721 1722 1723
1724
reported statistically significantly less pain at one month but no statistically significant difference in pain at three, six, or twelve months (see Table 113). One of seven outcome measures found a statistically significant difference in the percent of patients able to return to sports in favor of the motion group. Statistically significantly more patients were able to stand on their toes and walk as far as they could before surgery in the early motion group at three and six months. Patients in the early motion group were more satisfied with their cast at one year. There was no statistically significant difference between groups in regard to: patient opinion of results, footwear restrictions, EuroQoL, E5D, or Ankle Performance Score (see Table 114).
Costa, et al5, reported significantly more re-ruptures in the early weight-bearing group. Of the two patients with re-ruptures, one patient did not follow the written rehabilitation protocol and the second patients suffered a fall on ice and forcibly dorsiflexed his ankle.
Abnormal sensibility was significantly more prevalent in the immobilized group than in the motion group. There were no other statistically significant differences between groups in complications.
Table 111. Description of Treatment Groups Author Post operative Instructions
Costa, et al. Mobilization group: Immediate weight-bearing and mobilization using carbon fibre orthosis with 1.5 cm heal raises. Immobilization group: Traditional plaster cast.
Mortensen, et al. Mobilization group: Below the knee dorsal plaster splint followed by walker brace. Immobilization group: Below the knee plaster cast
Cetti, et al. Mobilization group. Mobile cast Immobilization group. Rigid below the knee cast
Kangas, et al Mobilization group. Below the knee dorsal cast for 6 weeks, this allowed for free plantar flexion. Immobilization group. Below the knee plaster cast
Maffulli, et al.
Early weight-bearing group: Bear weight on the tip toes of the operated leg as tolerated but keep leg elevated for the first two weeks. Begin weight-bearing as tolerated. Non-weight-bearing group: No weight bearing and keep leg elevated for first two weeks. Increase weight bearing at 4 weeks.
1725
1726 1727
SUMMARY OF EVIDENCE Table 112. Time to Return to Activity
Author Outcome LoE Comparison N Time to return
Maffulli, et al 2003
Return to Sports
(months) II
Early Motion vs.
Immobilization53 ●em
AAOS Guideline Unit v0.3 10.12.09 103
Author Outcome LoE Comparison N Time to return
Costa, et al 2005
Time in weeks taken to return to
sport
II Early Motion
vs. Cast
48** ○
Cetti, et al. 1994
Return to same level of
sports activities
II Early Motion
vs. Cast
60 ●em
Costa, et al 2005
Time in weeks until
return to stair climbing
II Early Motion
vs. Cast
48** ●em
Costa, et al 2005
Time in weeks taken to return to
walking
II Early Motion
vs. Cast
48** ●em
Costa, et al 2005
Time in weeks taken to return to
work.
II Early Motion
vs. Cast
48** ○
Cetti, et al. 1994
Mean Sick leave (days) II
Early Motion vs.
Cast 60 ●em
Maffulli, et al 2003
Return to Work (weeks) II
Early Motion Vs.
Immobilization53 ●em
Maffulli, et al 2003
Full weight-Bearing (wks) II
Early Motion Vs.
Immobilization53 ●em
Maffulli, et al 2003
Physiotherapy sessions (visits)
II Early Motion
Vs. Immobilization
53 ●em
Maffulli, et al 2003
Discharged from
Physiotherapy (months)
II Early Motion
Vs. Immobilization
53 ●em
1728 1729 1730 1731 1732 1733
em= early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks
AAOS Guideline Unit v0.3 10.12.09 104
Table 113. Pain 1734 Duration (Months) Author Outcome LoE Comparison N
1 3 6 12
Kangas, et al 2002 Vas Pain II
Early Motion vs.
Cast 50 ●em ○ ○
Maffulli, et al 2003 Pain- None II
Early Motion vs.
Immobilization 53
○
Maffulli, et al 2003
Pain- Mild, Occasional II
Early Motion Vs.
Immobilization 53
○
Maffulli, et al 2003 Pain- Moderate II
Early Motion Vs.
Immobilization 53
○
1735 1736 1737 1738 1739 1740 1741 1742
em= early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks
Table 114. Function
Duration (Months) Author Outcome LoE Comparison N
3 6 12 18
Costa, et al 2005
Return to sports II
Early Motion vs.
Cast
48** ○
Mortensen, et al 1999
Return to sports II
Early Motion vs.
Cast 61 ○
Maffulli, et al 2003
Return to Sports II Early Motion vs.
Immobilization 38 ○
Cetti, et al. 1994
Return sports
activities II
Early Motion vs.
Cast 60 ●e
m
Mortensen, et al 1999
Reached pre-injury
level II
Early Motion vs.
Cast 61 ○
Cetti, et al. 1994
Return to lesser level of sports activities
II Early Motion
vs. Cast
60 ○
AAOS Guideline Unit v0.3 10.12.09 105
Duration (Months) Author Outcome LoE Comparison
3 6 N
12 18
Cetti, et al. 1994
Stopped sports
activities II
Early Motion vs.
Cast 60 ○
Maffulli, et al 2003
No Limitations II
Early Motion Vs.
Immobilization 53 ○
Maffulli, et al 2003
Activity Limitation - Limited
Recreational but not
Daily Activities
II Early Motion
Vs. Immobilization
53 ○
Mortensen, et al 1999
Able to walk as far
before surgery
II Early Motion
vs. Cast
71 ●em
Cetti, et al. 1994
Able to stand on
toes II
Early Motion vs.
Cast 60 ●em ●em ○
Mortensen, et al 1999
Sick Leave (days) II
Early Motion vs.
Cast ●em
Maffulli, et al 2003
Return to Work II 49 ○
Maffulli, et al 2003
Changed Jobs II 49 ○
1743 1744 1745 1746 1747 1748 1749
em= early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks Table 115. EuroQoL, E5D, Ankle Performance Score
Duration (Months)
Author Outcome LoE Comparison N 3.5 4 12 15
Costa, et al 2006
EuroQoL - Health
Score** II
Early Motion
vs. Cast
48** ○ ○ ○
AAOS Guideline Unit v0.3 10.12.09 106
Costa, et al 2006
E5D (Dimension of Health
Score)
II
Early Motion
vs. Cast
48** ○ ○ ○
Kangas, et al 2002
Ankle Performance
Score - Excellent
II
Early Motion
vs. Cast
50 ○
1750 1751 1752 1753 1754 1755 1756
1757
em= early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks
Table 116. Patient opinion of results
Author Outcome LoE 3 m 6 m 12m 16m
Cetti, et al. 1994
Patient opinion of cast-
excellent II
●em
Mortensen, et al. 1999
Subjective Result-
Excellent II ○
Cetti, et al. 1994 Complaints II ●em ○ ●em
Maffulli, et al 2003
Patient opinion of results- Excellent
II ○
Maffulli, et al 2003
Percent satisfied with results of
surgery II ○
1758 1759 1760 1761 1762 1763 1764
em= early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks
AAOS Guideline Unit v0.3 10.12.09 107
AAOS Guideline Unit v0.3 10.12.09 108
1765 Table 117. Footwear restrictions
Duration (Months)
Author Outcome LoE Comparison N 12 16 Kangas,
et al 2002
Footwear Restrictions II
Early Motion vs.
Cast 50 ○
Maffulli, et al 2003
Footwear restrictions- None, mild (most shoes tolerated)
II Early Motion
vs. Cast
53 ○
Maffulli, et al 2003
Footwear restrictions- Moderate (unable to
tolerate fashionable
shoes, with or without insert)
II Early Motion
vs. Cast
53 ○
em= early motion 1766 1767 1768 1769 1770 1771 1772
○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks Table 118. Re-rupture
Author LoE Duration N Early Motion
Immobilization
Statistically Significant Difference
Cetti, et al. 1994
Re-rupture II 3% 7% ○
Costa, et al 2006 II 1 year 48
** 8.69% 0% ●* nwb
em= early motion 1773 1774 1775 1776 1777 1778 1779
○= no statistically significant difference ●= statistically significant difference * AAOS calculations **= Open cast group converted to orthosis at 3 weeks
SUMMARY OF COMPLICATIONS 1780 1781 Table 119. Early Motion vs. Cast - Complications
Author Complication LoE N Early Motion
Rigid Cast Group
Statistically Significant Difference
Cetti, et al. 1994 Infection II 60 0% 3% ○
Cetti, et al. 1994 Scar Adhesion II 60 3% 13% ○
Cetti, et al. 1994 Suture Granuloma II 60 3% 0% ○
Cetti, et al. 1994
Abnormal Sensibility II 60 3% 17% ●em
Cetti, et al. 1994 Keloid Scar II 60 10% 23% ○
Cetti, et al. 1994 Re-rupture II 60 3% 7% ○
Mortensen Deep Infection II 61 3% 0% ○
Mortensen Failed Repair II 61 3% 7% ○
Costa, et al 2006
Minor Wound Complications II 60 23% 20% ○
Maffulli, et al 2003
Superficial Infection II 53 7.69% 7.40% ○
Maffulli, et al 2003
Hypersensitivity of surgical wounds II 53 15.38% 18.51% ○
Maffulli, et al 2003 Hypertrophic Scar II 53 3.84% 0% ○
1782 1783 1784 1785 1786 1787
1788
em= early motion nem= not early motion ○= no statistically significant difference ●= statistically significant difference * AAOS calculated
Table 120. Systematic Reviews
Author Conclusion "Postoperative splinting in a cast followed by a functional brace rather than a cast alone reduces the overall complication rate" (p. 2209).
Khan, RJK, et al. 2005
Lynch, RM 2004 "Early functional mobilisation is more acceptable to patients than plaster cast immobilisation and results in improved functional outcomes" (p. 156).
AAOS Guideline Unit v0.3 10.12.09 109
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).
AAOS Guideline Unit v0.3 10.12.09 110
EXCLUDED ARTICLES 1789 1790 Table 121. Mobilization vs. Immobilization Included Articles
Author Title Exclusion Reason
Sorrenti SJ; Achilles tendon rupture: effect of early mobilization in rehabilitation after surgical repair Not relevant
Buchgraber A;Passler HH;
Percutaneous repair of Achilles tendon rupture. Immobilization versus functional postoperative
treatment
Not best available evidence
Kerkhoffs GM;Struijs PA;Raaymakers EL;Marti RK;
Functional treatment after surgical repair of acute Achilles tendon rupture: wrap vs. walking
cast Not relevant
Kauranen K;Kangas J;Leppilahti J;
Recovering motor performance of the foot after Achilles rupture repair: a randomized clinical
study about early functional treatment vs. early immobilization of Achilles tendon in tension
No patient oriented outcome
Maffulli N;Tallon C;Wong J;Lim
KP;Bleakney R;
Early weight-bearing and ankle mobilization after open repair of acute midsubstance tears of
the Achilles tendon Not relevant
Kangas J;Pajala A;Ohtonen
P;Leppilahti J;
Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative
regimens
Duplicate - Data reported in prior
study Majewski M;Schaeren S;Kohlhaas U;Ochsner
PE;
Postoperative rehabilitation after percutaneous Achilles tendon repair: Early functional therapy
versus cast immobilization
Not best available evidence
Solveborn SA;Moberg A;
Not best available evidence - not comparative
Immediate free ankle motion after surgical repair of acute Achilles tendon ruptures
1791
AAOS Guideline Unit v0.3 10.12.09 111
STUDY QUALITY 1792 1793 Table 122. Mobilization vs. Immobilization Quality
● = Yes ○ = No × = Not Reported n/a = not applicable
Author
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
Follo
w U
p - 8
0% o
r m
ore
Outcome N Treatment(s) LoE
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entr
y
Costa, et al.
2006 Sport 43
Mobilization vs.
ImmobilizationII ● ● × × ● ×
Costa, et al.
2006 Walking 43
Mobilization vs.
ImmobilizationII ● ● × × ● ×
Costa, et al.
2006
Stair Climbing 43
Mobilization vs.
ImmobilizationII ● ● × × ● ×
Costa, et al.
2006 Work 43
Mobilization vs.
ImmobilizationII ● ● × × ● ×
Kangas, et al.
2003
VAS Pain 50
Mobilization vs.
ImmobilizationII × ● ○ ○ ● ●
Kangas, et al.
2003
VAS Pain 50
Mobilization vs.
ImmobilizationII × ● ○ ○ ● ●
Kangas, et al.
2003
VAS Pain 50
Mobilization vs.
ImmobilizationII × ● ○ ○ ● ●
Kangas, et al.
2003
VAS Pain 50
Mobilization vs.
ImmobilizationII × ● ○ ○ ● ●
Kangas, et al.
2003
VAS Pain 50
Mobilization vs.
ImmobilizationII × ● ○ ○ ● ●
1794
AAOS Guideline Unit v0.3 10.12.09 112
1795
● = Yes ○ = No × = Not Reported n/a = not applicable
Author
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
Follo
w U
p - 8
0% o
r m
ore
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entr
y
Outcome N Treatment(s) LoE
Kangas, et al.
2003 Stiffness 50
Mobilization vs.
ImmobilizationII × ● ○ ○ ● ●
Kangas, et al.
2003
subjective calf muscle weakness
50 Mobilization
vs. Immobilization
II × ● ○ ○ ● ●
Kangas, et al.
2003
footwear restrictions 50
Mobilization vs.
ImmobilizationII × ● ○ ○ ● ●
Kangas, et al.
2003
Ankle performance
score 50
Mobilization vs.
ImmobilizationII × ● ○ ○ ● ●
Mortensen, et al. 1999
Sick Leave 61 Mobilization
vs. Immobilization
II ● ○ ○ ○ ○ ●
Mortensen, et al. 1999
Subjective assessment 61
Mobilization vs.
ImmobilizationII ● ○ ○ ○ ○ ●
Mortensen, et al. 1999
Sports Activity 61
Mobilization vs.
ImmobilizationII ● ○ ○ ○ ○ ●
Mortensen, et al. 1999
Pain 61 Mobilization
vs. Immobilization
II ● ○ ○ ○ ○ ●
1796
AAOS Guideline Unit v0.3 10.12.09 113
1797
● = Yes ○ = No × = Not Reported n/a = not applicable
Author
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
Follo
w U
p - 8
0% o
r m
ore
Outcome N Treatment(s) LoE
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entr
y
Mortensen, et al. 1999
Stiffness 61
Mobilization vs.
Immobilization
II ● ○ ○ ○ ○ ●
Mortensen, et al. 1999
Able to walk as far as pre surgery
-61
Mobilization vs.
Immobilization
II ● ○ ○ ○ ○ ●
Cetti, et al.
1994
Resumption of sports activity 111
Mobilization vs.
Immobilization
II × × × × × ○
Cetti, et al.
1993 Return to sport 111
Mobilization vs.
Immobilization
II × × ○ ● ● ●
Cetti, et al.
1993 Return to work 111
Mobilization vs.
Immobilization
II × × ○ ● ● ●
Cetti, et al.
1993 Re-rupture 111
Mobilization vs.
Immobilization
II × × ○ ● ● ●
Maffulli, et al. 2003
Pain- None 53
Mobilization vs.
Immobilization
II ○ ○ ○ ● ● ×
Maffulli, et al. 2003
Pain- Mild, Occasional 53
Mobilization vs.
Immobilization II ○ ○ ○ ● ● ×
Maffulli, et al. 2003
Pain- Moderate 53 Mobilization
vs. Immobilization
II ○ ○ × × ● ×
Maffulli, et al. 2003
Return to Sports 53
Mobilization vs.
Immobilization II ○ ○ × × ● ×
AAOS Guideline Unit v0.3 10.12.09 114
● = Yes ○ = No × = Not Reported n/a = not applicable
Author Outcome N Treatment(s) LoE
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entr
y
Follo
w U
p - 8
0% o
r m
ore
Maffulli, et al. 2003
Return to Sports (months) 53
Mobilization vs.
Immobilization II ○ ○ × × ● ●
Maffulli, et al. 2003
Return to Work (weeks) 53
Mobilization vs.
Immobilization
II ○ ○ × × ● ●
Maffulli, et al. 2003
Return to Work 53 Mobilization
vs. Immobilization
II ○ ○ × × ● ●
Maffulli, et al. 2003
Changed Jobs 53 Mobilization
vs. Immobilization
II ○ ○ × × ● ●
Maffulli, et al. 2003
Experience Problems at work due to
injury
53 Mobilization
vs. Immobilization
II ○ ○ × × ● ●
Maffulli, et al. 2003
Full weight-Bearing (wks) 53
Mobilization vs.
Immobilization II ○ ○ × × ● ●
Maffulli, et al. 2003
Activity Limitation -
None 53
Mobilization vs.
Immobilization II ○ ○ × × ● ●
Maffulli, et al. 2003
Activity Limitation -
Limited Recreational but not Daily
Activities
53 Mobilization
vs. Immobilization
II ○ ○ × × ● ●
Maffulli, et al. 2003
Discharged from
Physiotherapy (months)
53 Mobilization
vs. Immobilization
II ○ ○ × × ● ●
Maffulli, et al. 2003
Physiotherapy sessions (visits) 53
Mobilization vs.
Immobilization II ○ ○ × × ● ●
Maffulli, et al. 2003
Footwear restrictions- None, mild
53 Mobilization
vs. Immobilization
II ○ ○ × × ● ●
AAOS Guideline Unit v0.3 10.12.09 115
● = Yes ○ = No × = Not Reported n/a = not applicable
Author Outcome N Treatment(s) LoE
Stoc
hast
ic R
ando
miz
atio
n
Allo
catio
n C
once
alm
ent
Patie
nts B
linde
d
Tho
se r
atin
g ou
tcom
e B
linde
d
All
grou
ps h
ave
sim
ilar
outc
ome
perf
orm
ance
at
entr
y
Follo
w U
p - 8
0% o
r m
ore
Maffulli, et al. 2003
Footwear restrictions- Moderate (unable to
tolerate fashionable
shoes)
53 Mobilization
vs. Immobilization
II ○ ○ × × ● ●
Maffulli, et al. 2003
Percent satisfied with
results of surgery
53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
Maffulli, et al. 2003
Patient opinion of results- Excellent
53
Weight Bearing vs.
Non-weight-bearing
II ○ ○ × × ● ●
1798
AAOS Guideline Unit v0.3 10.12.09 116
STUDY RESULTS 1799 1800 Table 123. Mobilization vs. Immobilization Study Data
Results Author
Outcome
LoE
Duration
N Early Motion Cast Results
Cetti, et al. 1994
Return to same level of sports
activities II 1 year 60 80% 50% p=
0.0292
Cetti, et al. 1994
Return to lesser level of sports
activities II 1 year 60 7% 13% p= 0.616
Cetti, et al. 1994
Stopped sports activities II 1 year 60 3% 13% p= 0.141
Cetti, et al. 1994
Patient opinion of cast- excellent II 1 year 60 77% 20% p=
0.0005
Cetti, et al. 1994
Mean Sick leave (days) II NA 60 20.2
(Range 3-75)
53.4 (Range 1-182)
p= 0.0009
Cetti, et al. 1994
Able to stand on toes II 3 months 60 83% 53% p= 0.025
Cetti, et al. 1994
Able to stand on toes II 6 months 60 100% 77% p= 0.011
Cetti, et al. 1994
Able to stand on toes II 12
months 60 100% 97% p= 0.15*
Cetti, et al. 1994 Re-rupture II NA 60 3% 7% p= 0.55*
Cetti, et al. 1994 Complaints II 3 months 60 17.0 25.00 p= 0.047
Cetti, et al. 1994 Complaints II 6 months 60 10.00 14.00 p=
0.290* Cetti, et al.
1994 Complaints II 12 months 60 3.00 11.00 p= 0.03
Mortensen, et al 1999
Able to walk as far as they could
before surgery II 12 weeks 61 19% 40% p= 0.06
Mortensen, et al 1999
Subjective Result - excellent II 16
months 61 84% 63%
OR 3.01 (95 % CI
.785-12.76)*
Mortensen, et al 1999
Returned to sports II 16 months 61 73% 76% OR =1
1801 1802 1803
*= AAOS calculations **= Open cast group converted to orthosis at 3 weeks
AAOS Guideline Unit v0.3 10.12.09 117
1804 Results Author Outcome LoE Duration N Early Motion Cast Results Mortensen,
et al 1999
Reached pre-injury level II 16 months 61 57% 55% 1
Mortensen, et al 1999
Time until pre-injury level
reached (months)
II NA 61 6 (2.5-13)
9 (6-14) P <0.01
Kangas, et al
2002 Vas Pain II 1 week 50 2.17± 2.7 2.02 ±
1.7 p= 0.08
Kangas, et al
2002 Vas Pain II 3 weeks 50 .83 ± 1.2 .82 ±
1.3 p= 0.797
Kangas, et al
2002 Vas Pain II 6 weeks 50 .65 ± 1.4 .60 ±
.09 p= 0.9
Kangas, et al
2002 No Stiffness II 60 weeks 50 44% 68%
OR .369 (95% CI
0.09-1.34)*
Kangas, et al
2002 Mild Stiffness II 60 weeks 50 56% 32%
OR .369 (95% CI
0.09-1.34)*
Kangas, et al
2002
No footwear restrictions II 60 weeks 50 68% 92%
OR .369 (95% CI
0.09-1.34)*
Kangas, et al
2002
Ankle Performance
Score - Excellent II 60 weeks 50 88% 92%
OR 1 (95% CI
0.27-3.59)*
Kangas, et al
2002 Re-rupture II 5 months 50 4% 8% 1.000
Costa, et al 2006
Return to Normal
Walking** II Time
measurement 48 18 (95% CI 12-22)
18 (95% CI 18-
22)
p= 0.027
Costa, et al 2006
Return to Normal Stair Climbing**
II Time measurement 48 17 (95% CI 11-
18)
18 (95% CI 14-
22)
p= 0.023
Cetti, et al. 1994 Infection II Not Reported 60 0 3.3 p= 0.155*
AAOS Guideline Unit v0.3 10.12.09 118
Results Author Outcome LoE Duration N Early Motion Cast Results Cetti, et al.
1994 Scar Adhesion II Not Reported 60 3.3 13.3 0.141*
Cetti, et al. 1994
Suture Granuloma II Not Reported 60 3.3 0 0.155*
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%
OR .95 (95% CI
.12, 7.92)*
Maffulli, et al 2003
Pain- Mild, Occasional II 12 months 53 8% 7%
OR 1.04 (95% CI
.07, 15.43)*
Maffulli, et al 2003 Pain- Moderate II 12 months 53 4% 4%
OR 1.04 (95% CI
.01, 84.73) *
Maffulli, et al 2003
Activity Limitation -
None II 12 months 53 92% 93%
OR .96 (95% CI .0647975
14.24349*
Maffulli, et al 2003
Activity Limitation -
Limited Recreational but
not Daily Activities
II 12 months 53 8% 7%
OR 1.041667 (95% CI
.07, 15.43)
Maffulli, et al 2003 Return to Sports II 12 months 38 89% 89%
OR 1 (95% CI
.35, 2.78)* Maffulli, et
al 2003 Return to Sports
(months) II 12 months 53 5.1 (SD 2.8) 6 (SD 3) 0.04
Maffulli, et al 2003
Footwear restrictions-None, mild
II 12 months 53 96% 93%
OR 1.08(95%
CI .46 2.50)
AAOS Guideline Unit v0.3 10.12.09 119
Results Author Outcome LoE Duration N Early Motion Cast Results
Maffulli, et al 2003
Footwear restrictions-Moderate (unable to
tolerate fashionable
shoes, with or without insert)
II 12 months 53 4% 7% OR .48 (95% CI .01, 9.92)
Maffulli, et al 2003
Percent satisfied with results of
surgery II 12 months 53 88% 85%
1.04 (95% CI .44, 2.47)*
Maffulli, et al 2003 Excellent II 12 months 53 88% 81%
OR 1.08 (95% CI
.45, 2.59)*
Maffulli, et al 2003
Return to Work (weeks) II 12 months 53 9.2 (SD 2.5) 13.2
(SD 3) p= 0.05
Maffulli, et al 2003 Return to Work II 12 months 49 100% 100% 1
Maffulli, et al 2003 Changed Jobs II 12 months 49 1 2
OR .5 (95% CI
.01, 10.31)
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*
1805 1806 1807
*= AAOS calculations **= Open cast group converted to orthosis at 3 weeks
AAOS Guideline Unit v0.3 10.12.09 120
1808 Results
Author Outcome LoE Duration N Early Motion Cast ResultsCetti, et
al. 1994
Abnormal Sensibility II Not
Reported 60 3.3 16.7 p= 0.066*
Cetti, et al.
1994 Keloid Scar II Not
Reported 60 10 23.3 p= 0.157*
Mortensen Deep Infection II 6 weeks 3% 0% p=
0.154*
Mortensen Failed Repair II 6 weeks 3% 7% p= 0.52*
Costa Minor Wound Complications II Varying Tie 23% 20% p=
0.79* Kangas, et
al 2002
Re-rupture II 5 months 4% 8% p= 0.545*
Costa, et al
2005
Time in weeks taken to return to
work.
II Time measurement 48 22 26 p=
0.593*
Costa, et al 2006
EuroQoL - Health
Score** II 10 weeks 48 75 (IQR 70-85) 75 (IQR 65-80) p=
0.854
Costa, et al 2006
EuroQoL - Health
Score** II 6months 48 85 (IQR 80-90) 81 (IQR 75-95) p=
0.956
Costa, et al 2006
EuroQoL - Health
Score** II 12 months 48 84 (IQR 75-95) 90 (IQR 85-95) p= .138
Costa, et al 2006
E5D (Dimension of Health Score)
II 10 weeks 48 0.69 (IQR 0.6-0.9) 0.69 (IQR 0.6-0.7) p= 0.450
Costa, et al 2006
E5D (Dimension of Health Score)
II 6months 48 0.8 (IQR 0.7-1.0) 0.8 (IQR 0.8-1.0) p= 0.956
Costa, et al 2006
E5D (Dimension of Health Score)
II 12 months 48 1 (IQR 0.9-1.0) p= 0.146 1(IQR 0.8-1.0)
1809 1810 1811
*= AAOS calculations **= Open cast group converted to orthosis at 3 weeks
AAOS Guideline Unit v0.3 10.12.09 121
RECOMMENDATION 13 1812 1813 1814 1815 1816
1817
1818 1819 1820
1821 1822 1823 1824 1825 1826 1827
We are unable to recommend for or against post-operative physiotherapy for patients with acute Achilles tendon rupture. AAOS Strength of Recommendation: Inconclusive
Rationale:
A systematic review did not identify any studies that met the inclusion criteria. Supporting Evidence:
We searched for any studies addressing post operative physical therapy including supervised and unsupervised physical therapy. The only studies that we identified did not specifically study whether physical therapy was effective. Therefore, it is not possible to draw evidence-based conclusions for this recommendation. SUMMARY OF EVIDENCE Table 124. Post Operative Physiotherapy Regiments
Author LOE Treatment N Post Treatment PT Regimen
15Cast followed
by walking cast Majewski III Percutaneous
Repair Combination splint and shoe 88
Both groups received same PT at 8 weeks
Calder IV Mini-Open Repair 46 Functional
Brace "Active physiotherapy programme"
at 2 weeks
Troop IV Open Repair 13 Cast (5) Splint (8)
All had supervised PT. Authors do not report details of PT regimen.
Saw IV Open Repair 19Cast followed
by walking boot
All patients began supervised active ankle dorsiflexion at 1 week. Neutral
position of the ankle at 2 weeks. Active non-weight bearing exercises at 6 weeks. Normal walking allowed
at 8 weeks.
Moberg IV Operative Repair 17 Mobile plaster
cast
Immediate free ankle joint movement. Free weightbearing and
mobilization at 6 weeks.
II Open Repair 25Dorsal rigid splint at 6
weeks
Both groups performed "standard rehabilitation program;" Authors do not specify details of PT program Kangas
II Open Repair 25Both groups performed "standard
rehabilitation program;" Authors do not specify details of PT program
Plaster splint
1828
AAOS Guideline Unit v0.3 10.12.09 122
EXCLUDED ARTICLES 1829 1830 Table 125. Excluded Articles
Author Title Exclusion Reason
Majewski M, et al
Postoperative rehabilitation after percutaneous Achilles tendon repair: Early functional therapy versus cast
immobilization
Does not answer the recommendation
Calder JD, et al.
Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study
Does not answer the recommendation
Troop RL, et al. Early motion after repair of Achilles tendon ruptures Does not answer the
recommendation Saw Y, et
al. Early mobilization after operative repair of ruptured
Achilles tendon Does not answer the
recommendation
Moberg A, et al.
Surgically repaired Achilles tendon ruptures with postoperative mobile ankle cast: A 12-month follow-up study with an isokinetic and a dynamic muscle function
test
Does not answer the recommendation
Kangas J, et al.
Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens
Does not answer the recommendation
AAOS Guideline Unit v0.3 10.12.09 123
RECOMMENDATION 14 1831 1832 1833 1834 1835 1836
1837
1838 1839 1840 1841 1842
1843
1844 1845 1846 1847 1848 1849 1850 1851 1852 1853 1854
1855 1856
In patients with acute Achilles tendon rupture, irrespective of treatment type, we are unable to recommend a specific time at which patients can return to activities of daily living. Strength of Recommendation: Inconclusive
Rationale:
A systematic review identified 18 studies that reported on return to low impact activities. Our meta-analysis suggested the results of these studies were very different from each other and this is confirmed by examining their individual results (See supporting evidence below).
Supporting Evidence:
Eighteen studies5, 45, 46, 47, 48, 49, 20,41, 50, 30,21,51,52, 25,48, 19, 40 are included that report data on return to low impact activity. We have tabled the mean length of time to return to activity and the percent of patients able to return after either non-operative or operative treatments (see Table 126 through Table 133). We attempted meta-analysis for the following patient groups and outcomes: mean time for non-operative patients to return to work (I^2 95%), mean time for operative patients to return to work (I^2 >90%), and the percent of operative patients able to return to work at three months (I^2 at 3 months >75%). The results of these studies are so different from each other, as demonstrated by the high heterogeneity, that it is difficult to draw any conclusions about the time to return to recreational or athletic activity. There were too few studies included for each outcome to investigate the reasons for heterogeneity.
SUMMARY OF EVIDENCE Table 126. Non-Operative treatment - Percent of patients able to return to work
Author LOE Treatment N Outcome Duration (months)
% of Patients
Costa, et al. 2006 IV
immediate weight-bearing
mobilization 22 Return to work 12 59%
Costa, et al. 2006 IV plaster cast
immobilization 26 Return to work 12 65%
Hufner, et al. 2006 IV cast and boot 125 Return to work 0.6 45%
1857
AAOS Guideline Unit v0.3 10.12.09 124
Table 127. Non-Operative Treatment -Percent of patients able to return to ADL 1858
Author LOE Treatment N Outcome Duration (months)
% of Patients
Costa, et al. 2006 IV
immediate weight-bearing
mobilization 22 Return to normal
walking 12 73%
Costa, et al. 2006 IV plaster cast
immobilization 26 Return to normal walking 12 85%
1859
1860 Table 128. Operative Treatment - Percent of patients returning to ADL
Author LOE Treatment N Outcome Duration (months) %
Scarfi, et al. 2002 IV percutaneous repair 20 Return to ADL 2 100%
Tang, et al. 2007 IV arthroscopically assisted
percutaneous 20 Resume walking 3 100%
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%
1861
AAOS Guideline Unit v0.3 10.12.09 125
Table 129. Operative Treatment - Percent of patients able to return to work 1862
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%
Suchak, et al. 2008
IV open repair 103 Return to work 1.7 65%
Jung, et al. 2008 IV limited open 27 Return to work 2 100%
Hogsaa, et al. 1990
IV open repair 68 Return to work -
same employment (weeks)
> 3 15%
Suchak, et al. 2011
IV open repair 103 Return to work 3 82%
Moller, et al. 2001 IV end-to-end suture w/o
augmentation 14 Return to heavy work 3.5 100%
Kuskucu, et al. 2005
IV fibrin sealant 32 Return to daily work 6 97%
Hogsaa, et al. 1990
IV open repair 68 Return to work -
same employment (weeks)
< 6 18%
Suchak, et al. 2008
IV open repair 103 Return to work 6 97%
Lansdaal, et al. 2007
IV minimally-invasive 150 Return to work - same work 12 98%
AAOS Guideline Unit v0.3 10.12.09 126
Duration (months) Author LOE Treatment N Outcome %
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%
Maffulli, et al. 2003
IV open repair (non-weight-bearing) 26 Return to work -
same job 12 92%
Maffulli, et al. 2003
IV open repair (non-weight-bearing) 26 Return to work 12 100%
Maffulli, et al. 2003
IV open repair (weight-bearing) 23 Return to work -
same job 12 96%
Maffulli, et al. 2003
IV open repair (weight-bearing) 23 Return to work 12 100%
1863
AAOS Guideline Unit v0.3 10.12.09 127
Table 130. Non-Operative Treatment - Mean time until return to work 1864 Author LOE Treatment N Outcome Duration (weeks)
Metz, et al. 2008 IV functional brace 33 Return to work 15.4 (SD 16.42)
Costa, et al. 2006 IV immediate weight-
bearing mobilisation 22 Return to work 1 (95% CI 1-13)*
Costa, et al. 2006 IV immediate weight-
bearing mobilisation 22 Return to normal walking 18 (95% CI 12-22)*
Moller, et al. 2001 IV Below the knee plaster
cast 53 Return to work 10.48 (SD 8.07)
Wallace, et al. 2004 IV cast 122 Return to work 2.36 (SD 1.19)
Cetti, et al. 1993 IV below-knee plaster cast 55 Return to work 8 (SD 3.6)
Costa, et al. 2006 IV plaster cast
immobilisation 26 Return to work 10 (95% CI 2-22)*
Moller, et al. 2001 IV Below the knee plaster
cast 22 Return to light, mobile work 9.6 (SD 9.4)
Moller, et al. 2001 IV Below the knee plaster
cast 22 Return to sedentary work 4.7 (SD7.8)
Costa, et al. 2006 IV plaster cast
immobilisation 26 Return to normal walking 18 (95% CI 18-22)*
1865 1866
1867
* AAOS Calculation
Table 131. Non-Operative Treatment - Mean time until return to walking Author LOE Treatment N Outcome Duration (weeks)
Costa, et al. 2006 IV immediate weight-
bearing mobilisation 22 Return to normal walking 18 (95% CI 12-22)*
Costa, et al. 2006 IV plaster cast
immobilisation 26 Return to normal walking 18 (95% CI 18-22)*
AAOS Guideline Unit v0.3 10.12.09 128
Table 132. Operative Treatment - Mean time to return to ADL 1868 Author LOE Treatment N Outcome Duration (Weeks)
Costa, et al. 2006 IV
open end-to-end (immediate weight-
bearing mobilisation) 23 Return to normal
walking 12.5 (95% CI 10-
18)*
Costa, et al. 2006 IV open end-to-end (plaster
cast immobilisation) 25 Return to normal walking
18 (95% CI 18-22)*
Maffulli, et al. 2003 IV open repair (non-weight-
bearing) 27 Walk w/o crutches 5.5 (SD 2.2; range 4.6-8.1)
Maffulli, et al. 2003 IV open repair (weight-
bearing) 26 Walk w/o crutches 2.5 (SD 0.4; range 1.2-3.1)
Costa, et al. 2006 IV
open end-to-end (immediate weight-
bearing mobilisation) 23 Return to stair
climbing 13 (95% CI 10-
18)*
Costa, et al. 2006 IV open end-to-end (plaster
cast immobilisation) 25 Return to stair climbing
22 (95% CI 18-22)*
Calder, et al. 2006 IV percutaneous repair 25 Return to driving 4.14 (range .7-9)
1869 1870
* AAOS Calculation
AAOS Guideline Unit v0.3 10.12.09 129
1871
1872 Table 133. Operative Treatment - Mean time until return to work Author LOE Treatment N Outcome Duration (Weeks)
Moller, et al. 2001 IV end-to-end suture w/o
augmentation 14 Return to heavy work 14.6 (SD 7.5)
Coutts, et al. 2002 IV open repair 15 Return to work -
manual 11.1 (range 8-24)
Moller, et al. 2001 IV end-to-end suture w/o
augmentation 32 Return to light, mobile work 5.1 (SD 5.4)
Moller, et al. 2001 IV end-to-end suture w/o
augmentation 13 Return to sedentary work 4.4(SD 5.2)
Moller, et al. 2001 IV end-to-end suture w/o
augmentation 59 Return to work 7.8(SD 68.4)
Cetti, et al. 1993 IV end-to-end suture 56 Return to work 6.2 (SD 2.15)
Metz, et al. 2008 IV minimally-invasive 40 Return to work 8.4 (SD 11.71)
Lansdaal, et al. 2007 IV minimally-invasive 15
0 Return to work 4 (range .14-52.57)*
Calder, et al. 2005 IV
mini-open repair w/ early active
rehabilitation 46 Return to work 3.12 (range .57-11)
Costa, et al. 2006 IV
open end-to-end (immediate weight-
bearing mobilisation) 23 Return to work 8 (95% CI 2-13)*
Costa, et al. 2006 IV
open end-to-end (plaster cast
immobilisation) 25 Return to work 4 (95% CI 1-13)*
Calder, et al. 2006 IV percutaneous repair 25 Return to work 2.7 (range .85-11)
Majewski, et al. 2008 IV percutaneous w/ shoe 14 Return to work 5.2 (range .7-18.85)
Wagnon, et al. 2005 IV percutaneous repair
(Webb-Bannister) 22 Return to work (months) 1.07
Doral, et al. 2009 IV endoscopy assisted
percutaneous 62 Return to work 11.7 (range 10-13)
1873 1874
1875
* AAOS Calculation
AAOS Guideline Unit v0.3 10.12.09 130
EXCLUDED ARTICLES 1876 1877 Table 134. Excluded Articles
Author Title Reason for Exclusion Costa ML;Shepstone L;Darrah C;Marshall
T;Donell ST;
Immediate full-weight-bearing mobilisation for repaired Achilles
tendon ruptures: a pilot study
Less than 80% follow up
Goren D;Ayalon M;Nyska M;
Isokinetic strength and endurance after percutaneous and open surgical
repair of Achilles tendon ruptures
No patient oriented outcome
van der Linden-van der Zwaag HM;Nelissen
RG;Sintenie JB;
Results of surgical versus non-surgical treatment of Achilles tendon
rupture Not 80% follow
Kakiuchi M; A combined open and percutaneous
technique for repair of tendo Achilles. Comparison with open repair
Not 80% time follow up
Hufner TM;Brandes DB;Thermann H;Richter M;Knobloch K;Krettek
C;
Long-term results after functional nonoperative treatment of Achilles
tendon rupture
Not best available evidence
Roberts C;Rosenblum S;Uhl R;Fetto J;
Team physician #6. Surgical treatment of Achilles tendon rupture
Not best available evidence
Mortensen HM;Skov O;Jensen PE;
Early motion of the ankle after operative treatment of a rupture of the
Achilles tendon. A prospective, randomized clinical and radiographic
study
Not best available evidence
Maes R;Copin G;Averous C;
Is percutaneous repair of the Achilles tendon a safe technique? A study of
124 cases
Not best available evidence
Cretnik A;Kosanovic M;Smrkolj V;
Percutaneous versus open repair of the ruptured Achilles tendon: a
comparative study
Not best available evidence
Chiodo CP;Wilson MG; Current concepts review: acute ruptures of the Achilles tendon
Not best available evidence
Fernandez-Fairen M;Gimeno C;
Augmented repair of Achilles tendon ruptures
Not best available evidence
Wagnon R;Akayi M;
The Webb-Bannister percutaneous technique for acute Achilles' tendon
ruptures: a functional and MRI assessment
Not best available evidence
Martinelli B; Percutaneous repair of the Achilles tendon in athletes
Not best available evidence
Park HG;Moon DH;Yoon JM;
Limited open repair of ruptured Achilles tendons with Bunnel-type
sutures
Not best available evidence
Edna TH; Non-operative treatment of Achilles tendon ruptures
Not best available evidence
Jessing P;Hansen E; Surgical treatment of 102 tendo achillis ruptures-- suture or
Not best available evidence
AAOS Guideline Unit v0.3 10.12.09 131
Author Title Reason for Exclusion tenontoplasty?
Closed treatment of Achilles tendon rupture Keller J;Rasmussen TB; Not best available
evidence Majewski M;Rohrbach M;Czaja S;Ochsner P;
Avoiding sural nerve injuries during percutaneous Achilles tendon repair
Not best available evidence
Jennings AG;Sefton GK;Newman RJ;
Repair of acute rupture of the Achilles tendon: a new technique
using polyester tape without external splintage
Not best available evidence
Suchak AA;Bostick GP;Beaupre LA;Durand
DC;Jomha NM;
The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles
tendon
Does not report relevant outcomes
Pendleton H;Resch S;Stenstrom A;Astrom I;
Residual functional problems after non-operative treatment of Achilles
tendon rupture Retrospective
Weber M;Niemann M;Lanz R;Muller T;
Nonoperative treatment of acute rupture of the Achilles tendon: results
of a new protocol and comparison with operative treatment
Retrospective
AAOS Guideline Unit v0.3 10.12.09 132
STUDY QUALITY 1878 1879 1880
Table 135. Patient return to activities of daily living
●= yes ○= no x= not reported
Author Outcome Measure
Sam
e T
reat
men
t
N LoE
Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equ
al F
ollo
w u
p T
ime
Calder, et al. 2005 Return to previous sporting activities 46 IV ● ● ● ● x
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 ● ● ● ● ●
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 ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 133
●= yes ○= no x= not reported
Author Outcome Measure N LoE
Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equ
al F
ollo
w u
p T
ime
Sam
e T
reat
men
t
Jung, et al. 2008 Resume light exercise 27 IV x ● ● ● ●
Jung, et al. 2008 Return to previous sporting activities 27 IV x ● ● ● ●
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 ● ● ● ●
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 ● ● ● ● ●
Metz, et al. 2008 Return to sports 33 IV ● ● ● ● ● Metz, et al. 2008 Return to sports 36 IV ● ● ● ● ●
Moller, et al. 2001 Return to sports - same level 47 IV ● ● ● ● ●
Scarfi, et al. 2002 Return to sports activities 20 IV x ● ● ● ●
Solveborn, et al. 1994
Return to previous sports activity w/o any difficulty 16 IV ● ● ● ● ●
Solveborn, et al. 1994 Return to sports 16 IV ● ● ● ● ●
Taglialavoro, et al. 2004 Return to sports - complete 24 IV ● ● ● ● ●
Taglialavoro, et al. 2004 Return to sports - complete 22 IV ● ● ● ● ●
Tang, et al. 2007 Return to sports level 6 IV x ● ● ● ● Troop, et al. 1995 Resume jogging/running 13 IV ● ● ● ● ● Troop, et al. 1995 Resume jogging/running 13 IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 134
●= yes ○= no x= not reported
Author Outcome Measure N LoE
Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equ
al F
ollo
w u
p T
ime
Sam
e T
reat
men
t
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
AAOS Guideline Unit v0.3 10.12.09 135
RECOMMENDATION 15 1881 1882 1883 1884 1885
1886
1887 1888 1889 1890 1891
1892 1893
1894 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906
In patients who participate in sports it is an option to return them to sports within 3-6 months after operative treatment for acute Achilles tendon rupture. Strength of Recommendation: Weak
Rationale:
A systematic review identified 23 level IV studies providing data on return to sports after operative treatment. Two studies53, 50 reported return to jogging at three months. One study 46 reported return to sport at four months. Five studies54, 37,53, 50,55 reported that 83%-100% of patient returned to sports at six months. Ten studies19,56, 57, 52, 56, 54 , 40, 5, 21,
20 reported that 32-100% of patients returned to sports at 12 months or more.
Supporting Evidence:
Twenty-three21,5,20, 19, 49,39, 58,53,50,46,37,56, 57,38,25, 59,52,28,30,33, 54, 40studies are included that report data on return to athletic activity. We have tabled the percent of patients able to return to recreational and sports activities after operative treatments and the mean length of time to return to athletic activity (see Table 136 through Table 138 ). We attempted meta-analysis for the following patient groups and outcomes: percent operative patients able to return to activity at ≥ 12 months (I^2 >80%) (see Table 136 ) percent of operative patients able to return to sports at 6 and at 12 months (I ^2 >90%) (see Table 137), and mean time for operative patients to return to sports (I ^2 >95%) (see Table 138). The results of these studies are so different from each other, as demonstrated by the high heterogeneity, that it is difficult to draw any conclusions about the time to return to recreational or athletic activity. There were too few studies included for each outcome to investigate the reasons for heterogeneity. The remainder of outcomes and patient groups do not include enough studies to attempt meta-analysis.
AAOS Guideline Unit v0.3 10.12.09 136
SUMMARY OF EVIDENCE 1907 1908 Table 136. Operative Treatment - Return to Recreational Activity
Author LOE Treatment N Outcome Duration (months) % Hogsaa, et al.
1990 IV open repair 63 Resumption of recreational activities 6-12 30%
Hogsaa, et al. 1990 IV open repair 63 Resumption of recreational
activities 3-6 33%
Hogsaa, et al. 1990 IV open repair 63 Resumption of recreational
activities < 3 10%
Maffulli, et al. 2003 IV open repair (non-
weight-bearing) 27 Activity limitations - none 12 93%
Maffulli, et al. 2003 IV open repair
(weight-bearing) 26 Activity limitations - none 12 92%
Hogsaa, et al. 1990 IV open repair 63 Resumption of recreational
activities > 12 51%
Giannini, et al. 1994 IV
adjunctive augmentation
(synthetic graft) 15 Return to pre-injury level
of activity 18 100%
Fortis, et al. 2008 IV
endoscopically assisted
percutaneous 20 Return to previous activity
levels 30 100%
1909
1910 Table 137. Operative Treatment - Return to sports
Author LOE Treatment N Outcome Duration (months) %
Troop, et al. 1995 IV end-to-end w/
early motion 13 Resume jogging/running 3 92%
Jung, et al. 2008 IV limited open 27 Resume light exercise 3 100%
Troop, et al. 1995 IV end-to-end w/
early motion 13 Resume jogging/running 3 92%
Scarfi, et al. 2002 IV percutaneous
repair 20 Return to sports activities 4 100%
Kuskucu, et al. 2005 IV fibrin sealant 32 Return to amateur sports
activity 6 97%
Aktas, et al. 2007 IV
adjunctive augmentation
(autograft) 16 Return to sports - pre-injury
level of activity 6 85%
Tang, et al. 2007 IV
arthroscopically assisted
percutaneous 6 Return to sports level 6 83%
Jung, et al. 2008 IV limited open 27 Return to previous sporting
activities 6 100%
AAOS Guideline Unit v0.3 10.12.09 137
Duration (months) Author LOE Treatment N Outcome %
Calder, et al. 2005 IV
mini-open repair w/ early active rehabilitation
46 Return to previous sporting activities 6 100%
Aktas, et al. 2008 IV open repair 14 Return to sports - pre-injury
level of activity 6 89%
Calder, et al. 2006 IV percutaneous
repair 25 Return to previous sporting activities 6 100%
Cetti, et al. 1993 IV end-to-end suture 52 Return to sports - same level 12 62%
Solveborn, et al. 1994 IV
end-to-end suture w/ below-knee transport splint
cast
16 Return to previous sports activity w/o any difficulty 12 81%
Solveborn, et al. 1994 IV
end-to-end suture w/ below-knee transport splint
cast
16 Return to sports 12 100%
Moller, et al. 2001 IV end-to-end suture
w/o augmentation 47 Return to sports - same level 12 54%
Metz, et al. 2008 IV minimally-
invasive 36 Return to sports 12 67%
Lansdaal, et al. 2007 IV minimally-
invasive 152 Return to sports - same level 12 64%
Costa, et al. 2006 IV
open end-to-end (immediate
weight-bearing mobilisation)
23 Return to sports 12 83%
Costa, et al. 2006 IV
open end-to-end (plaster cast
immobilisation) 25 Return to sports 12 68%
Maffulli, et al. 2003 IV open repair (non-
weight-bearing) 19 Return to sports 12 89%
Maffulli, et al. 2003 IV open repair
(weight-bearing) 19 Return to sports 12 89%
Taglialavoro, et al. 2004 IV
adjunctive augmentation
(autograft) 24 Return to sports - complete 42 38%
Taglialavoro, et al. 2004 IV open repair 22 Return to sports - complete 42 32%
Doral, et al. 2009 IV
endoscopy assisted
percutaneous 62 Return to previous sporting
activities 46 95%
Garabito, et al. 2004 IV
adjunctive augmentation
(autograft) 54 Return to sports - pre-injury
level 96 43%
AAOS Guideline Unit v0.3 10.12.09 138
1911
1912 Table 138. Operative Treatment - Mean time to return to athletic activity
Author LOE Treatment N Outcome Duration (months)
Doral, et al. 2009 IV endoscopy assisted
percutaneous 62 Rehabilitation training 11.7 (SD 0.75)
Troop, et al. 1995 IV end-to-end w/ early
motion 13 Resume jogging/running 3 (SD 0.75)
Lansdaal, et al. 2007 IV minimally-invasive 152 Return to sports 7.1 (SD 3.8)
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 Resume jogging
(weeks) 3.5(SD .9)
Coutts, et al. 2002 IV open repair 22
Return to pre-injury level of sporting
participation 40.8 (SD 25.2)
Coutts, et al. 2002 IV open repair 20 Return to sports 4.5 (SD 2.14)
Uchiyama, et al. 2007 IV open repair 21
Return to sports for high-level athletes - original game level
5 (SD .35)
Maffulli, et al. 2003 IV open repair (non-
weight-bearing) 19 Return to sports 6 (SD 3)
Maffulli, et al. 2003 IV open repair (weight-
bearing) 19 Return to sports 5.1 (SD 2.8)
Gorschewsky, et al. 2004 IV percutaneous repair 66 Return to original
sport 5.46 (SD 1.5)
Maffulli, et al. 2009 IV percutaneous repair 24 Return to sports 88 (SD 14.5)
Chillemi, et al. 2002 IV percutaneous repair 14 Return to sports -
frequent* (months) 8 (SD 1.5)
1913
1914 1915
EXCLUDED ARTICLES Table 139. Excluded Articles
Author Title Reason for Exclusion
Suchak AA;Bostick GP;Beaupre LA;Durand
DC;Jomha NM;
The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the
Achilles tendon
No relevant outcomes
Majewski M;Rohrbach M;Czaja S;Ochsner P;
Avoiding sural nerve injuries during percutaneous Achilles tendon repair
Not best available evidence
AAOS Guideline Unit v0.3 10.12.09 139
Author Title Reason for Exclusion
Wagnon R;Akayi M; The Webb-Bannister percutaneous technique for acute Achilles' tendon ruptures: a functional and
MRI assessment
Time of return to sports not reported
Goren D;Ayalon M;Nyska M;
Isokinetic strength and endurance after percutaneous and open surgical repair of Achilles
tendon ruptures
No patient-oriented outcome
Chiodo CP;Wilson MG; Current concepts review: acute ruptures of the Achilles tendon
Not best available evidence
Cretnik A;Kosanovic M;Smrkolj V;
Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study
Not best available evidence
Jennings AG;Sefton GK;Newman RJ;
Repair of acute rupture of the Achilles tendon: a new technique using polyester tape without external
splintage
Not best available evidence
van der Linden-van der Zwaag HM;Nelissen
RG;Sintenie JB;
Results of surgical versus non-surgical treatment of Achilles tendon rupture
Less than 80% follow up
Costa ML;Shepstone L;Darrah C;Marshall
T;Donell ST;
Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study
Less than 80% follow up
Mortensen HM;Skov O;Jensen PE;
Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective,
randomized clinical and radiographic study
Not best available evidence
Kakiuchi M; A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open
repair
Less than 80% follow up
Roberts C;Rosenblum S;Uhl R;Fetto J;
Team physician #6. Surgical treatment of Achilles tendon rupture
Not best available evidence
Keller J;Rasmussen TB; Closed treatment of Achilles tendon rupture Not best available evidence
Martinelli B; Percutaneous repair of the Achilles tendon in athletes
Not best available evidence
Fernandez-Fairen M;Gimeno C; Augmented repair of Achilles tendon ruptures Not best available
evidence Park HG;Moon DH;Yoon
JM; Limited open repair of ruptured Achilles tendons
with Bunnel-type sutures Not best available
evidence
AAOS Guideline Unit v0.3 10.12.09 140
STUDY QUALITY 1916 1917 Table 140. Return to sports
●= yes ○= no x= not reported
Author Outcome Measure
Sam
e T
reat
men
t
N LoE Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equ
al F
ollo
w u
p T
ime
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 ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 141
●= yes ○= no x= not reported
Author Outcome Measure N LoE Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equ
al F
ollo
w u
p T
ime
Sam
e T
reat
men
t
Fortis, et al. 2008 Return to previous activity levels 20 IV x ● ● ● ●
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 ● ● ● ●
Metz, et al. 2008 Re-rupture 33 IV ● ● ● ● ●
Metz, et al. 2008 Absence from work 33 IV ● ● ● ● ●
Metz, et al. 2008 Return to sport 33 IV ● ● ● ● ●
Metz, et al. 2008 Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Pain - VAS 33 IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 142
●= yes ○= no x= not reported
Author Outcome Measure N LoE Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equ
al F
ollo
w u
p T
ime
Sam
e T
reat
men
t
Metz, et al. 2008 Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Satisfaction - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Satisfaction - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Satisfaction - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Return to sedentary work
(days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to light, mobile work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to heavy work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to sports - 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 ● ● ● ● ●
Solveborn, et al. 1994 Return to sports 16 IV ● ● ● ● ●
Taglialavoro, et al. 2004 Return to sports - complete 24 IV ● ● ● ● ●
Taglialavoro, et al. 2004 Return to sports - complete 22 IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 143
●= yes ○= no x= not reported
Author Outcome Measure N LoE Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equ
al F
ollo
w u
p T
ime
Sam
e T
reat
men
t
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 38 IV ● ● ● ● ●
Chillemi, et al. 2002
Return to sports activity (frequent participant 2-3 times
per week) 14 IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 144
●= yes ○= no x= not reported
Author Outcome Measure N LoE Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equ
al F
ollo
w u
p T
ime
Sam
e T
reat
men
t
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 ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 145
RECOMMENDATION 16 1918 1919 1920 1921 1922
1923
1924 1925 1926 1927 1928 1929
1930 1931 1932 1933 1934 1935
1936 1937 1938
In patients with acute Achilles tendon rupture treated non-operatively, we are unable to recommend a specific time at which patients can return to athletic activity. Strength of Recommendation: Inconclusive
Rationale:
A systematic review identified 5 level IV studies21,5,20, 19,25 providing data on return to sports after non-operative treatment. These studies did not provide adequate evidence to make a recommendation for the specific time patients can return to athletic activity following non-operative treatment for Achilles tendon rupture. Supporting Evidence:
Five Level IV studies21,5,20, 19,25 that provided data on return to sports after non-operative treatment were identified. We have tabled the percent of patients and the mean length of time to return to athletic activity reported by the authors of these studies (see Table 141 and Table 142). The lack of studies, variation in treatments and variation in reported outcomes makes it difficult to draw any conclusions about the time to return to athletic activity following non-operative treatment.
SUMMARY OF EVIDENCE Table 141. Non-Operative Treatment - Percent of patients returning to athletic activity
Author LOE Treatment N Outcome Duration (months) %
Metz, et al. 2008 IV functional brace 33 Return to sports 12 82%
Costa, et al. 2006 IV immediate weight-
bearing mobilisation 18 Return to sports (months) 12 56%
Costa, et al. 2006 IV plaster cast
immobilisation 21 Return to sports (months) 12 52%
Moller, et al. 2001 IV below the knee
plaster cast 38 Return to sports - same level (months) 12 54%
Cetti, et al. 1993 IV below-knee plaster
cast 47 Return to sports-same level 12 34 %
1939
AAOS Guideline Unit v0.3 10.12.09 146
1940 1941 1942
Table 142. Non-Operative Treatment - Mean time until patients return to athletic activity
Author LOE Treatment N Outcome Duration (weeks)
Wallace, et al. 2004 IV cast 101 Return to sports (weeks) 10 (SD 4.9)
Costa, et al. 2006 IV plaster cast immobilisation 26 Return to stair climbing
(weeks) 18 (95% CI
14-22)*
Costa, et al. 2006 IV immediate weight-
bearing mobilisation
22 Return to stair climbing (weeks)
17 (95% CI 11-18)*
1943
AAOS Guideline Unit v0.3 10.12.09 147
1944 1945 1946
EXCLUDED ARTICLES Table 143. Excluded studies
Author Title Reason for Exclusion
Chiodo CP;Wilson MG; Current concepts review: acute ruptures of the Achilles tendon
Not best available evidence
van der Linden-van der Zwaag HM;Nelissen
RG;Sintenie JB;
Results of surgical versus non-surgical treatment of Achilles tendon rupture
Less than 80% follow up
Costa ML;Shepstone L;Darrah C;Marshall
T;Donell ST;
Immediate full-weight-bearing mobilisation for repaired Achilles tendon ruptures: a pilot study
Less than 80% follow up
Weber M;Niemann M;Lanz R;Muller T;
Nonoperative treatment of acute rupture of the Achilles tendon: results of a new protocol and
comparison with operative treatment Retrospective
Pendleton H;Resch S;Stenstrom A;Astrom I;
Residual functional problems after non-operative treatment of Achilles tendon rupture Retrospective
1947
1948 1949
STUDY QUALITY Table 144. Study Quality
●= yes ○= no x= not reported
Author Outcome Measure
Sam
e Tr
eatm
ent
N LoE
Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equa
l Fol
low
up
Tim
e Cetti, et al. 1993 Return to sports - same level 47 IV ● ● ● ● ●
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 ● ● ● ●
Metz, et al. 2008 Re-rupture 33 IV ● ● ● ● ●
AAOS Guideline Unit v0.3 10.12.09 148
●= yes ○= no x= not reported
Author Outcome Measure N LoE
Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equa
l Fol
low
up
Tim
e
Sam
e Tr
eatm
ent
Metz, et al. 2008 Absence from work 33 IV ● ● ● ● ●
Metz, et al. 2008 Return to sport 33 IV ● ● ● ● ●
Metz, et al. 2008 Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Pain - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Satisfaction - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Satisfaction - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Satisfaction - VAS 33 IV ● ● ● ● ●
Metz, et al. 2008 Return to sedentary work
(days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to light, mobile work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to heavy work (days) 59 IV ● ● ● ● ●
Moller, et al. 2001 Return to sports - 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 ● ● ● ●
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●= yes ○= no x= not reported
Author Outcome Measure N LoE
Con
secu
tive
Follo
w u
p 80
Sam
e O
utco
mes
Equa
l Fol
low
up
Tim
e
Sam
e Tr
eatm
ent
Cetti, et al. 1993 Return to sports - 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 ● ● ● ● ●
1950
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FUTURE RESEARCH 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967
While the current guideline is instructive in many ways, it also demonstrates a substantial need for future research. Wherever the strength of a specific Recommendation is weak or inconclusive, there exists a need for well-designed studies and high-level evidence. As such, the most obvious need is for further, high-level investigations into the fundamental question of whether or not surgical management is superior to non-operative management of acute Achilles ruptures. There are hundreds of studies that are centered on this question, but too few are high-level randomized control trials. Beyond this, there are several other areas of needed research. Does the clinician routinely need MRI or an ultrasound for the diagnosis of an Achilles rupture? Probably not. However, there are no high-level studies to help answer this question. For non-operative treatment, low-level evidence supports the use of immediate functional bracing, but again more randomized trials are necessary. Post-operatively, is DVT prophylaxis necessary? Does the patient really need physical therapy? These are very important questions that so far remain unanswered.
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IV. APPENDIXES 1968
AAOS Guideline Unit v0.3 10.12.09 152
APPENDIX I 1969 1970 1971
WORK GROUP Blinded for peer review
AAOS Guideline Unit v0.3 10.12.09 153
APPENDIX II 1972 1973 1974 1975 1976 1977 1978 1979
1980 1981 1982 1983 1984
1985 1986 1987 1988 1989 1990 1991 1992 1993
1994 1995 1996 1997 1998 1999 2000 2001 2002
2003 2004 2005
AAOS BODIES THAT APPROVED THIS CLINICAL PRACTICE GUIDELINE Guidelines and Technology Oversight Committee The AAOS Guidelines and Technology Oversight Committee (GTOC) consist of sixteen AAOS members. The overall purpose of this Committee is to oversee the development of the clinical practice guidelines, performance measures, health technology assessments and utilization guidelines.
Evidence Based Practice Committee The AAOS Evidence Based Practice Committee (EBPC) consists of ten AAOS members. This Committee provides review, planning and oversight for all activities related to quality improvement in orthopaedic practice, including, but not limited to evidence-based guidelines, performance measures, and outcomes.
Council on Research, Quality Assessment, and Technology To enhance the mission of the AAOS, the Council on Research, Quality Assessment, and Technology promotes the most ethically and scientifically sound basic, clinical, and translational research possible to ensure the future care for patients with musculoskeletal disorders. The Council also serves as the primary resource to educate its members, the public, and public policy makers regarding evidenced-based medical practice, orthopaedic devices and biologics, regulatory pathways and standards development, patient safety, occupational health, technology assessment, and other related areas of importance.
The Council is comprised of the chairs of the AAOS Biological Implants, Biomedical Engineering, Evidence Based Practice, Guidelines and Technology Oversight, Occupational Health and Workers’ Compensation, Patient Safety, Research Development, and US Bone and Joint Decade committees. Also on the Council are the AAOS second vice-president, representatives of the Diversity Advisory Board, the Women's Health Issues Advisory Board, the Board of Specialty Societies (BOS), the Board of Councilors (BOC), the Communications Cabinet, the Orthopaedic Research Society (ORS), the Orthopedic Research and Education Foundation (OREF), and three members at large.
Board of Directors The 17 member AAOS Board of Directors manages the affairs of the AAOS, sets policy, and determines and continually reassesses the Strategic Plan.
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DOCUMENTATION OF APPROVAL 2006 2007
2008
2009
2010
2011
2012
2013 2014
2015
AAOS Work Group Draft Completed August 18, 2009
Peer Review Completed September 18, 2009
Public Commentary Completed November 12, 2009
AAOS Guidelines and Technology Oversight Committee _________________
AAOS Evidence Based Practice Committee _________________
AAOS Council on Research, Quality Assessment, _________________ and Technology
AAOS Board of Directors _________________
AAOS Guideline Unit v0.3 10.12.09 155
APPENDIX III 2016
2020 2021 2022 2023 2024 2025 2026 2027 2028 2029
2030
2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052
2053
2054 2055 2056 2057
LITERATURE SEARCHES FOR PRIMARY STUDIES 2017 The literature searches were performed using the following databases. The full search 2018 strategies are listed below: 2019
• PubMed • EMBASE • CINAHL • The Cochrane Library • The National Guidelines Clearinghouse • TRIP Database - Guidelines
All literature searches were supplemented with manual screening of bibliographies in publications accepted for inclusion into the evidence base. In addition, the bibliographies of recent review articles were searched for potentially relevant citations.
PubMed was searched using the following strategy:
(("Achilles Tendon"[mh] OR Achilles[tw]) AND ((("Tendon Injuries"[mh] OR injuries[sh] OR injur*[tiab] OR ruptur*[tiab] OR re-ruptur*[tiab] OR tears[tiab] OR torn[tiab] OR tear[tiab]) AND (diagnosis[sh] OR diagnos*[tw] OR "Magnetic Resonance Imaging"[mh] OR MRI[tiab] OR Ultrasonography[mh] OR sonograph*[tiab] OR ultrasound[tiab] OR radiograph*[tiab] OR Radiography[mh] OR x-ray[tiab] OR imaging[tiab] OR gap[tiab] OR "Thompson test"[tw] OR therapy[sh] OR treated[tiab] OR treatment*[tiab] OR brace[tiab] OR bracing[tiab] OR cast[tiab] OR casting[tiab] OR casts[tw] OR "Casts, Surgical"[mh] OR immobiliz*[tiab] OR surgery[tiab] OR surgical*[tiab] OR operati*[tiab] OR repair*[tiab] OR reconstruct*[tiab] OR non-operativ*[tiab] OR nonoperativ*[tiab] OR "weight bearing"[tiab] OR "Recovery of Function"[mh] OR "Physical Therapy Modalities"[mh] OR physiotherapy[tiab] OR Anticoagulants[pa])) OR ((repair*[tiab] OR surgery[tiab] OR surgery[sh] OR surgical*[tiab] OR operati*[tiab] OR repair*[tiab] OR reconstruct*[tiab] OR post-operative*[tiab] OR postoperative*[tiab]) AND ("Physical Therapy Modalities"[mh] OR physiotherapy[tiab] OR brace[tiab] OR bracing[tiab] OR cast[tiab] OR casting[tiab] OR casts[tw] OR "Casts, Surgical"[mh] OR immobiliz*[tiab] OR low-impact[tiab] OR activity[tiab] OR activities[tiab] OR "weight bearing"[tiab] OR weight-bearing[tiab] OR "Recovery of Function"[mh])))) AND "1966"[PDat]:"2008"[PDat] AND “1”[EDat]:”2008/12/21”[EDAT] AND English[lang] AND (human[mh] OR in process[sb] OR publisher[sb]) NOT (comment[pt] OR editorial[pt] OR letter[pt] OR addresses[pt] OR news[pt] OR "newspaper article"[pt] OR “historical article”[pt] OR "case reports"[pt] OR "retrospective case study"[tw])
EMBASE was searched using the following strategy:
('Achilles tendon rupture'/de OR (('Achilles tendon'/de OR Achilles) AND ('tendon reconstruction'/de OR ((('tendon injury'/de OR injur* OR ruptur* OR reruptur* OR tears OR torn OR tear) AND (diagnos* OR 'nuclear magnetic resonance imaging'/exp OR mri OR 'ultrasound'/de OR ultrasound OR sonograph* OR radiograph* OR 'radiography'/de
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2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068
2069
2070 2071 2072
2073
2074
2075
2076
2077
2078
OR imaging OR gap OR 'thompson test' OR treated OR treatment* OR brace OR bracing OR cast OR casts OR 'plaster cast'/de OR 'walking aid'/de OR immobiliz* OR surgery OR surgical* OR operati* OR repair* OR reconstruct* OR nonoperativ* OR 'weight bearing'/de OR 'weight bearing' OR 'convalescence'/de OR 'physiotherapy'/exp OR physiotherapy OR 'anticoagulant agent'/exp)) OR ((repair* OR surgery OR surgical* OR operti* OR reconstruct* OR postoperative*) AND ('physiotherapy'/de OR physiotherapy OR brace OR bracing OR case OR casting OR casts OR 'plaster cast'/de OR 'walking aid'/de OR immobiliz* OR 'low impact' OR activity OR activities OR 'weight bearing'/de OR 'weight bearing' OR convalescence/de)))))) AND ([article]/lim OR [conference paper]/lim OR [review]/lim) AND [english]/lim AND [humans]/lim AND [embase]/lim NOT [22-12-2008]/sd
CINAHL was searched using the following strategy:
MM "Achilles Tendon" or Achilles and MM "tendon injuries" or ruptur* and ( PT “research” and LA English and PY 1966-2008 ) not (PT “editorial” or PT “letter” or PT “case study” or MM “case studies”)
The Cochrane Library was searched using the following strategy:
Achilles AND (injur* OR ruptur* OR re-ruptur* OR tears OR torn OR tear)
The National Guidelines Clearinghouse was searched using the following strategy:
Achilles tendon rupture
The TRIP Database - Guidelines was searched using the following strategy:
Achilles tendon rupture
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APPENDIX IV 2079 2080
2081
STUDY ATTRITION FLOWCHART
2481 abstracts screened for inclusion
1766 citations excluded
281 articles recalled for full text review
2200 abstracts excluded
237 articles excluded
44 articles included
4247 citations identified by literature search
AAOS Guideline Unit v0.3 10.12.09 158
APPENDIX V 2082 2083 2084 2085 2086
7
2089 2090 2091 2092 2093 2094
5
2097 2098 2099 2100
1
2103 2104 2105 2106 2107 2108 2109 2110
DATA EXTRACTION ELEMENTS The data elements below were extracted into electronic forms in Microsoft® Access and Microsoft® Excel. The extracted information includes: 208 Study Characteristics (for all relevant outcomes in a study) 2088
• methods of randomization and allocation • use of blinding (patient, caregiver, evaluator) • funding source/conflict of interest • duration of the study • number of subjects and follow-up percentage • experimental and control groups
209 Patient Characteristics (for all treatment groups in a study) 2096
• patient inclusion/exclusion criteria • co-interventions (if used) and co-morbidities (if present) • measures of disease severity • Complications
210 Results (for all relevant outcomes in a study) 2102
• outcome measure • is the outcome measure patient-oriented? validated? objective/subjective? • duration at which outcome measure was evaluated • statistic reported (for dichotomous results) • mean value and measure and value of dispersion (continuous results) • statistical test used, value of test statistic, and p-value • verification of calculations
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APPENDIX VI 2111 2112 2113 2114 2115 2116
2117 2118
2119
2120
2121 2122
2123 2124
2125
2126 2127
2128 2129
2130 2131
2132 2133
2134 2135
2136 2137
2138
2139
JUDGING THE QUALITY OF DIAGNOSTIC STUDIES The QUADAS tool is used to identify sources of bias, variability, and the quality of reporting in studies of diagnostic accuracy. Fourteen questions answered “yes”, “no”, or “unclear” contribute to the QUADAS tool. There is no score derived from the use of the QUADAS tool.
Was the spectrum of patient’s representative of the patients who will receive the test in practice?
Were selection criteria clearly described?
Is the reference standard likely to correctly classify the target condition?
Is the time period between ref. standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?
Did the whole sample or a random selection of the sample, receive verification using a reference standard of diagnosis?
Did patients receive the same reference standard regardless of the index test result?
Was the reference standard independent of the index test (i.e. the index test did not form part of the reference standard)?
Was the execution of the index test described in sufficient detail to permit replication of the test?
Was the execution of the reference standard described in sufficient detail to permit its replication?
Were the index test results interpreted without knowledge of the results of the reference standard?
Were the reference standard results interpreted without knowledge of the results of the index test?
Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?
Were uninterpretable/intermediate test results reported?
Were withdrawals from the study explained?
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JUDGING THE QUALITY OF TREATMENT STUDIES 2140 2141
2142
2143
2144
2145 2146
2147 2148
2149 2150
2151 2152
2153 2154
RANDOMIZED CONTROLLED TRIALS
Did the study employ stochastic randomization?
Was there concealment of allocation?
Were subjects blinded to the treatment they received?
Were those who assessed/rated the patient’s outcomes blinded to the group to which the patients were assigned?
Was there more than 80% follow-up for all patients in the control group and the experimental group on the outcome of interest?
Did patients in the different study groups have similar levels of performance on ALL of the outcome variables at the time they were assigned to groups?
For randomized crossover studies, was there evidence that the results obtained in the study’s two experimental groups (in period 1 and 2) did not differ?
For randomized crossover studies, was there evidence that the results of the two control groups (in period 1 and 2) did not differ?
2155
2156 2157
2158 2159
2160
2161 2162
2163 2164
2165 2166
2167 2168
2169
2170
PROSPECTIVE NON- RANDOMIZED CONTROLLED STUDIES
Were the characteristics of patients in the different study groups comparable at the beginning of the study?
Did patients in the different study groups have similar levels of performance on ALL of the outcome variables at baseline?
Were all of the study’s groups concurrently treated?
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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2171
2172
2173
2174
2175 2176
2177
2178 2179
2180 2181
2182 2183
2184 2185
RETROSPECTIVE COMPARATIVE STUDIES
Was there less than 20% difference in completion rates in the study’s groups?
Were all of the study’s groups concurrently treated?
Was the same treatment given to all patients enrolled in the experimental and
Were the same laboratory tests, clinical findings, psychological instruments, etc. used to measure the outcomes in all of the study’s groups?
Were the follow-up times in all of the study’s relevant groups approximately equal?
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?
2186
2187
2188
2189 2190
2191
2192
CASE SERIES
Was enrollment in the study consecutive?
Was there more than 80% follow-up for all patients on the outcome of interest?
Were the same laboratory tests, clinical findings, psychological instruments, etc. used to measure the outcomes in all patients?
Were the patients instructed/not given concomitant or adjuvant treatments?
Were the follow-up times for all patients approximately equal?
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APPENDIX VII 2193 2194 2195 2196 2197
2198 2199
2200
2201
2202
2203
2204
2205
2206 2207
2208 2209
2210
2211
2212 2213
2214
2215
2216
2217
2218 2219
2220
2221
FORM FOR ASSIGNING STRENGTH OF RECOMMENDATION (INTERVENTIONS) GUIDELINE RECOMMENDATION___________________________________
PRELIMINARY STRENGTH OF RECOMMENDATION:________________________________________
STEP 1: LIST BENEFITS AND HARMS
Please list the benefits (as demonstrated by the systematic review) of the intervention
Please list the harms (as demonstrated by the systematic review) of the intervention
Please list the benefits for which the systematic review is not definitive
Please list the harms for which the systematic review is not definitive
STEP 2: IDENTIFY CRITICAL OUTCOMES
Please circle the above outcomes that are critical for determining whether the intervention is beneficial and whether it is harmful
Are data about critical outcomes lacking to such a degree that you would lower the preliminary strength of the recommendation?
What is the resulting strength of recommendation?
STEP 3: EVALUATE APPLICABILITY OF THE EVIDENCE
Is the applicability of the evidence for any of the critical outcomes so low that substantially worse results are likely to be obtained in actual clinical practice?
Please list the critical outcomes backed by evidence of doubtful applicability:
Should the strength of recommendation be lowered because of low applicability?
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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2222
2223 2224
2225
2226 2227
STEP 5 CONSIDER STRENGTH OF EVIDENCE
Does the strength of the existing evidence alter the strength of recommendation obtained in STEP 4?
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 VIII 2228 2229 2230 2231 2232 2233 2234 2235 2236 2237 2238 2239 2240
VOTING BY THE NOMINAL GROUP TECHNIQUE Voting on guideline recommendations will be conducted using a modification of the nominal group technique (NGT), a method previously used in guideline development.12 Briefly each member of the guideline work group ranks his or her agreement with a guideline recommendation on a scale ranging from 1 to 9 (where 1 is “extremely inappropriate” and 9 is “extremely appropriate”). Consensus is obtained if the number of individuals who do not rate a measure as 7, 8, or 9 is statistically non-significant (as determined using the binomial distribution). Because the number of work group members who are allowed to dissent with the recommendation depends on statistical significance, the number of permissible dissenters varies with the size of the work group. The number of permissible dissenters for several work group sizes is given in the table below:
Number of Permissible Dissenters Work group Size
Not allowed, statistical significance cannot be
obtained ≤ 3
4-5 0
6-8 1
9 1 or 2
2241 2242 2243 2244 2245 2246 2247
2248
The NGT is conducted by first having members vote on a given recommendation without discussion. If the number of dissenters is “permissible”, the recommendation is adopted without further discussion. If the number of dissenters is not permissible, there is further discussion to see whether the disagreement(s) can be resolved. Three rounds of voting are held to attempt to resolve disagreements. If disagreements are not resolved after three voting rounds, no recommendation is adopted.
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APPENDIX IX 2249 2250 2251
STRUCTURED PEER REVIEW FORM Review of any AAOS confidential draft allows us to improve the overall guideline but does not imply endorsement by any given individual or any specialty society who participates in our review processes. The AAOS review process may result in changes to the documents; therefore, endorsement cannot be solicited until the AAOS Board of Directors officially approves the final guideline.
2252 2253 2254 2255 2256 2257 2258 2259 2260 2261 2262 2263 2264 2265 2266 2267 2268
Reviewer Information: Name of Reviewer_________________________________________ Address_________________________________________________ City___________________ State_________________ Zip Code___________ Phone _____________________Fax ________________________ E-mail_______________________ Specialty Area/Discipline: _______________________________________ Work setting: _________________________________________________ Credentials: _________________________________________________
2269 2270
May we list you as a Peer Reviewer in the final Guidelines? Yes No
2271 2272 2273
Are you reviewing this guideline as Yes No a representative of a professional society?
2274 2275 2276 2277 2278 2279 2280 2281 2282 2283 2284 2285 2286 2287 2288 2289 2290 2291 2292
If yes, may we list your society as a reviewer Yes No of this guideline? Reviewer Instructions Please read and review this Draft Clinical Practice Guideline and its associated Technical Report with particular focus on your area of expertise. Your responses are confidential and will be used only to assess the validity, clarity, and accuracy of the interpretation of the evidence. If applicable, please specify the draft page and line numbers in your comments. Please feel free to also comment on the overall structure and content of the guideline and Technical Report. If you need more space than is provided, please attach additional pages. Please complete and return this form electronically to wies@aaos.org or fax the form back to Jan Weis at (847) 823-9769. Thank you in advance for your time in completing this form and giving us your feedback. We value your input and greatly appreciate your efforts. Please send the completed form and comments by Month, Day, Year
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2293
COMMENTS 2294 2295 2296 2297 2298 2299 2300 2301 2302 2303 2304 2305 2306 2307 2308 2309 2310 2311 2312 2313 2314 2315 2316 2317
Please provide a brief explanation of both your positive and negative answers in the preceding section. If applicable, please specify the draft page and line numbers in your comments. Please feel free to also comment on the overall structure and content of the guideline and Technical Report
OVERALL ASSESSMENT Would you recommend these guidelines for use in practice? (check one) Strongly recommend _______ Recommend (with provisions or alterations) _______ Would not recommend _______ Unsure _______ COMMENTS: Please provide the reason(s) for your recommendation.
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APPENDIX X 2318 2319
2320 2321 2322 2323 2324 2325 2326 2327 2328 2329 2330 2331 2332
2333 2334 2335 2336 2337 2338
PEER REVIEW PANEL
Participation in the AAOS peer review process does not constitute an endorsement of this guideline by the participating organization. Peer review of the draft guideline is completed by an outside Peer Review Panel. Outside peer reviewers are solicited for each AAOS guideline and consist of experts in the guideline’s topic area. These experts represent professional societies other than AAOS and are nominated by the guideline Work group prior to beginning work on the guideline. For this guideline, eleven outside peer review organizations were invited to review the draft guideline and all supporting documentation. Seven societies participated in the review of this guideline draft and six explicitly consented to be listed as a peer review organization in this appendix. One organizations did not give explicit consent that the organization name could be listed in this publication. The organizations that reviewed the document and consented to publication are listed below:
Individuals who participated in the peer review of this document and gave their consent to be listed as reviewers of this document are: 2339
2340 2341 2342 2343 2344 2345 2346 2347 2348 2349 2350 2351 2352 2353
2354 2355 2356 2357 2358 2359 2360 2361
Again, participation in the AAOS guideline peer review process does not constitute an endorsement of the guideline by the participating organizations or the individuals listed above. PUBLIC COMMENTARY A period of public commentary follows the peer review of the draft guideline. If significant non-editorial changes are made to the document as a result of public
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2362 2363 2364 2365 2366 2367 2368 2369 2370 2371 2372 2373 2374
2375 2376 2377 2378 2379 2380
commentary, these changes are also documented and forwarded to the AAOS bodies that approve the final guideline. Public commentators who gave explicit consent to be listed in this document include the following:
Participation in the AAOS guideline public commentary review process does not constitute an endorsement of the guideline by the participating organizations or the individual listed nor does it is any way imply the reviewer supports this document.
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APPENDIX XI 2381 2382 DESCRIPTION OF SYMBOLS USED IN TABLES
Symbol Description Odds Ratio = The odds in Group B divided by the odds in Group A, where the odds is the probability of the outcome occurring divided by the probability of the outcome not occurring.
OR
95% Confidence Interval = A measure of uncertainty of the point estimate: if the trial were repeated an infinite number of times, then the 95% CI calculated for each trial would contain the true effect 95% of the time.
95% CI
An open circle in a Summary of Evidence Table indicates that the result is not statistically significant. ○
A filled-in circle in a Summary of Evidence Table indicates that the result is statistically significant in favor of the listed treatment (in this example, in favor of op = operative treatment)
● op
2383
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APPENDIX XII 2384 2385 2386
CONFLICT OF INTEREST Blinded for peer review
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APPENDIX XIII 2387 2388 2389 2390 2391
2392 2393 2394
2395 2396
2397 2398
2399 2400 2401
2402 2403
2404 2405
2406 2407
2408 2409
2410 2411
2412 2413
2414 2415 2416
2417 2418
2419 2420 2421
REFERENCES (1) Suchak AA, Bostick G, Reid D, Blitz S, Jomha N. The incidence of Achilles
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