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AAOS issues guidelines for torn Achilles tendon treatment
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The American Academy of Orthopaedic Surgeons has approved and released an evidence-based clinical practice guideline for the diagnosis and treatment of acute Achilles tendon rupture, according to an academy press release.
“A recommendation of special interest to patients having surgery is that in most cases their ankle should be mobilized and some weight-bearing allowed post-operatively,” Christopher Chiodo, MD, stated in the release. “More than one high-quality study has demonstrated that such controlled early motion and weight-bearing is beneficial, especially with regard to return of function.”
He added, “As for orthopedic surgeons, the academy work group found no evidence to support the use of biological agents, autograft or synthetic tissue when surgically repairing Achilles tendon ruptures.”
Inconclusive findings
Inconclusive evidence-based research was identified for recommending for or against the following:
- the use of physical therapy following surgery;
- a specific time in which patients can return to the activities of daily living — irrespective of treatment type; or
- a specific time in which patients can return to athletic activity when treated without surgery.
Statistically, Achilles tendon rupture is more common in males in their 30s and 40s. Yet today, more people remain active as they age, so it is common to see this injury in all age groups, according to the press release.
Recommendations
This final guideline contains 16 recommendations, and includes that operative treatment for an Achilles tendon rupture should be approached more cautiously in the following individuals:
- patients over age 65;
- patients with sedentary lifestyles;
- obese individuals;
- those with immuno-compromised status;
- smokers; and
- patients with diabetes, neuropathy, and vascular (circulatory) disorders.
After a thorough analysis of the literature, the work group was unable to recommend for or against the routine use of the following tests to confirm a diagnosis of acute Achilles tendon rupture: ultrasound; radiographs (X-rays and similar tests); and MRI.
Operative treatment is an option for treating patients with Achilles tendon rupture, the academy noted. Some studies showed possible advantages to the minimally invasive repair of this tendon, specifically with regard to wound healing, but this needs to be validated by further research.
Some recent studies demonstrated acceptable outcomes based on function with non-operative management, using braces or casts.
Lack of data
According to Chiodo, these guidelines are the result of a robust review of the literature, which included screening and reading thousands of citations, abstracts and articles. Ultimately, they selected about 50 papers upon which to base their recommendations.
Chiodo said he was surprised by the lack of high quality prospective, randomly controlled clinical trials on many topics important to orthopedic surgeons.
“There is a definite need for large studies utilizing multi-center protocols and databases,” he stated in the release. “We also need to establish patient registries that include large volumes of cases, so we can follow these patients and sufficiently evaluate long-term outcome.
“It is also important to mention that decision-making does not end at the time of surgery,” he added. “Postoperative protocols are important as well.”
