Clinical practice guideline covers diagnosis and treatment

A rupture of the Achilles tendon is a catastrophic event that occurs when the forces placed on the Achilles tendon exceed its tensile limits. The annual incidence of Achilles tendon ruptures has been estimated to range from 5.5 to 9.9 ruptures per 100,000 people in North America.

Individuals who sustain an acute Achilles tendon rupture often experience sudden pain in the affected leg, an inability to bear weight, and weakness of the affected ankle. The subsequent healing period requires time away from work and limits athletic activity. Time away from work may have a financial impact on the patient, and limiting activity may affect the patient’s health. The aims of treatment are timely and accurate diagnosis, pain relief, restoration of functional status, and return to prerupture activities.

Once a timely and accurate diagnosis is made, the decision to use conservative or surgical treatment is next. Both of these treatment options include further options such as method and extent of immobilization or type of surgery.

Work group goal
The goal of the AAOS work group on the diagnosis and treatment of acute Achilles tendon ruptures is to provide assistance to healthcare professionals qualified to treat Achilles tendon ruptures. The clinical practice guidelines can provide guidance on how to select treatment options.

To develop the clinical practice guidelines, the work group first formulated a set of preliminary recommendations that specified what should be done in whom, when, where, and how often or for how long. These were intended to function as the questions for a systematic review by an AAOS staff research team.

Once all the relevant published articles were assembled and cat-egorized as to Level of Evidence (I to IV), the work group then developed a final recommendation with one of the following grades:

• Strong—good quality evidence
• Moderate—fair quality evidence
• Weak—poor quality evidence
• Inconclusive—insufficient or conflicting evidence
• Consensus—in the absence of reliable evidence, the work group makes a recommendation based on clinical opinion.

The work group recommended both nonsurgical and surgical treatment as options for all patients with an acute Achilles tendon rupture (Fig. 1). Both of these treatment modalities, however, were assigned a weak grade of support. The following two recommendations achieved a moderate grade of support:

• Early (within the first 2 weeks after surgery) protected weight bearing for patients with acute Achilles tendon rupture who have been treated surgically
• The use of a protective device that allows mobilization by 2–4 weeks after surgery

Despite a lack of reliable evidence to provide any support, the work group included a consensus recommendation on the need for a detailed history and physical examination to establish the diagnosis of an acute Achilles tendon rupture. The work group also provided a consensus recommendation that surgical treatment should be approached more cautiously in patients who are elderly, use tobacco, or have certain pre-existing medical conditions.

Future research
Clearly, despite the fact that an acute Achilles tendon rupture is a common, devastating injury, little consistent, high-quality literature can be found to provide strong evidence for various aspects of the diagnosis and treatment of this condition. The work group identified the following areas as focal points for developing high-quality, randomized, controlled trials.

• The need for the routine use of magnetic resonance imaging (MRI), ultrasound (ultrasonography), and radiography (roentgenograms, X-rays) to confirm the diagnosis of acute Achilles tendon rupture
• The need for presurgical immobilization or restricted weight bearing
• The need for allograft, autograft, xenograft, synthetic tissue, or biologic adjuncts in the treatment of acute Achilles tendon ruptures
• The need for antithrombotic treatment for patients with acute Achilles tendon ruptures
• The need for physiotherapy for patients with acute Achilles tendon ruptures

A summary of the recommendations can be found in Table 1.

The complete guideline is available online.

Mark A. Glazebrook, MD, served as the vice chair on the acute Achilles tendon rupture diagnosis and treatment clinical practice guideline work group. He reports the following disclosures: Biomimetic; DePuy; Linvatec; Arthrex; Smith & Nephew; Stryker; Wright Medical Technology.

Guideline development
The Clinical Practice Guideline for the Diagnosis and Treatment of Acute Achilles Tendon Ruptures, adopted by the AAOS Board of Directors at their December 2009 meeting, was developed by a volunteer work group that included Christopher P. Chiodo, MD, chair; Mark A. Glazebrook, MD, vice chair; Bruce E. Cohen, MD; Eric Giza, MD; John E. Femino, MD; William C. Watters III, MD, chair, Guidelines and Technology Oversight Committee (GTOC); Michael J. Goldberg, MD, GTOC vice chair, Michael W. Keith, MD, chair, Evidence-Based Practice Committee; Robert H. Haralson III, MD, MBA; Charles M. Turkelson, PhD, AAOS director of research and scientific affairs; Janet L. Wies, MPH, AAOS clinical practice guideline manager, and AAOS research analysts Kevin Boyer; Patrick Sluka, MPH; Laura Raymond, MA; Sara Anderson, MPH.

The American Orthopaedic Foot and Ankle Society has endorsed this clinical practice guideline, which was funded by the AAOS. The guideline is based on a systematic review of the current scientific and clinical information on accepted approaches to treatment and/or diagnosis. The entire process included a review panel of internal and external committees, public commentaries, and final approval by the AAOS Board of Directors.

The methods used to prepare the guideline were rigorous, employed to minimize bias and develop a set of reliable, transparent, and accurate clinical recommendations for treating acute Achilles tendon ruptures. These methods are detailed in the full guideline.