Surgical management of chronic ruptures of the Achilles tendon remains unclear

20 Pages·2013·0.31 MB·English

PublishedOnlineJuly4,2013
Surgical management of chronic ruptures
of the Achilles tendon remains unclear: a
systematic review of the management options§
MohammedHadi†,JonathanYoung†,LisaCooper†,MatthewCosta†,
andNicolaMaffulli‡*
D
o
† ‡ w
UniversityHospitalCoventryandWarwick,Coventry,UK,and QueenMaryUniversityofLondon, n
lo
London,UK a
d
e
d
fro
m
h
ttp
Background:ChronicrupturesoftheAchillestendoncausemarkedfunctional s://a
impairment.Giventhedifferentrepairtechniquesused,thereisaneedfora c
a
d
systematicreviewoftheliteraturetoinvestigatewhethertheseprocedureare e
m
comparablewithoneanotherwhenperformedbyexperiencedsurgeons. ic.o
u
p
Sourcesofdata:AsystematicliteraturesearchusingtheMedline(Pubmed), .c
o
EMBASEandCINHALdatabases. m
/b
m
Areasofagreement:Providedtherearenocontraindications,surgeryisregarded b
/a
thebestmanagementoption. rtic
le
Areasofcontroversy:Mostreportsarecaseserieswithsmallsamplesizesusing -a
b
s
non-validatedmeasures. tra
c
Growingpoints:Long-termresultsofsurgicalrepairproceduresarenowavailable. t/1
0
8
/1
Areastimelyfordevelopingresearch:Thecurrentliteraturedoesnotallow /9
clinicianstodefinitivelydeterminetheoptimalmanagementmodalityforchronic 5/3
4
ruptureoftheAchillestendon.Thereisaneedforrandomizedcontrolledtrials 58
8
whichusevalidatedfunctionaloutcomemeasures. 7 b
y
g
Keywords:Achillestendon/chronicrupture/systematicreview/management ue
s
t o
n
*Correspondenceaddress. Accepted:May3,2013 0
7
QueenMaryUniversityof A
p
E-mLaoiln:dno.mn,aLffounldli@onq,mUuKl.. ril 2
0
ac.uk 19
§Thisworkwasperformed
attheUniversityHospital
Coventry&Warwick,and
QueenMaryUniversityof
LondonBartsandThe
LondonSchoolof
MedicineandDentistry
InstituteofHealth
SciencesEducation.
BritishMedicalBulletin2013;108:95–114 &TheAuthor2013.PublishedbyOxfordUniversityPress.Allrightsreserved.
DOI:10.1093/bmb/ldt019 Forpermissions,pleasee-mail:[email protected]
M.Hadietal.
Introduction
ChronicrupturesoftheAchillestendoncausemarkedfootandanklefunc-
tional impairment.1 The management of acute ruptures is debated;2,3
chronicrupturesarenormallymanagedoperativelyunlesstherearecontra-
indicationstosurgery.4–6
Thetendonendsmaybethinandatrophicand,whensurgicalaugmen-
tation is required, tendon grafts, a turndown flap, a transfer of local D
o
tendons and synthetic materials have all been used for reconstruction, w
n
withnoevidencethatoneisclearlysuperiortoanother.7Giventhepreva- lo
a
d
lence of this injury,8 there is a need to ascertain whether the manysurgi- e
d
calproceduresdescribed,oftenwithsmallsamplesizesandnon-validated fro
m
outcomesmeasures,arecomparable. h
We performed a systematic review on the surgical management of ttps
chronicrupturesoftheAchillestendonusingfunctionaloutcomemeasures ://a
c
a
astheprimaryoutcomemeasure.Complicationrates,includingre-rupture d
e
m
rate,were secondaryoutcome measures.A tendonrupturewasconsidered ic
chronicifpresentedlaterthan4weeksaftertheindexinjury.4,9–17 .ou
p
.c
o
m
/b
Methods m
b
/a
rtic
Searchstrategy le
-a
b
An electronic literature search limited to human studies was performed stra
using the Ovid Medline (Pubmed), EMBASE and CINHAL Databases in ct/1
November 2012. Keywords and MeSH terms used are described in the 08
/1
flowchart (Fig. 1). We also manually searched the bibliographies of rele- /9
5
vant publications. All journal references were independently reviewed by /3
4
twoauthors(M.H.andJ.Y.).Amultistageassessment18wasusedtoiden- 58
8
tify articles. Where there was disagreement between the authorsthis was 7 b
y
settledbyconsensusbetweenallauthorsofthereview. g
u
e
s
t o
n
0
Inclusionandexclusioncriteria 7
A
p
Weincludedthefollowing: ril 2
0
1
(i) All studies, both descriptive and comparative, detailing the results of man- 9
agementofchronicrupturesoftheAchillestendon.
(ii) All studies describing the results of managing all skeletally mature adults
overtheageof18years.
(iii) All studies published in English, Spanish and Italian given the linguistic
capabilitiesoftheresearchteam.
96 BritishMedicalBulletin2013;108
ChronictearsoftheAchillestendon
D
o
w
n
lo
a
d
e
d
fro
m
h
ttp
s
://a
c
a
d
e
m
ic
.o
u
p
.c
o
m
/b
m
b
/a
rtic
le
-a
b
s
tra
c
t/1
0
8
/1
/9
5
/3
4
5
Fig.1 Flowchartdescribingtheprocessofidentifyingeligiblestudies. 8
8
7
b
y
g
u
Studieswereexcludedifthey es
t o
n
(i) includedlessthanfourpatients; 0
7
(ii) werereviews,expertopinion,lettersorcasereports. A
p
ril 2
0
Outcomemeasures 1
9
We considered all validated and non-validated functional outcome mea-
suresofthegastroc-soleus–Achillestendoncomplexreportedinthelitera-
ture as the primary outcome measure. Complications rates including
re-rupture rates, post-operative DVT, neurovascular injuries and superfi-
cialordeepinfectionsweresecondaryoutcomemeasures.
BritishMedicalBulletin2013;108 97
M.Hadietal.
Riskofbiasandqualityassessment
Eachstudywasgradedaccordingtothelevelofevidenceitprovided,and
reviewedqualitativelyforselection, performance,attrition, detectionand
reportingbiasesusingtheAHRQdesign-specificcriteria.19
Dataextraction
D
For each considered publication, two authors (M.H. and J.Y.) extracted o
w
and tabulated the data independently. Data included the author(s) nlo
a
details,dateofpublication,studydesign,levelofevidence,outcomemea- d
e
sures,resultsandauthor’sconclusions. d fro
m
h
Results ttps
://a
c
a
Of the 637 manuscripts identified and screened by our search strategy, de
m
34 eligible publications with a grand total of 484 individuals were ic
.o
included in the review. Figure 1 is a flowchart describing the process of u
p
identifyingeligiblestudies.Allstudieswerecaseseriesandusedoperative .co
m
management.Table1detailsthefindingsforeachoftheincludedstudies. /b
m
We did not identify any published randomized controlled trials (RCTs) b
/a
orformalsystematicreviews.Qualityassessmentofstudiesincludingrisk rtic
ofbiasisoutlinedinTable2. le-a
b
Elevensurgical techniques were reportedinthe literature.The twomain s
techniques described were peroneous brevis tendon (PB) transfer (six trac
studies/n=120) and flexor hallucis longus (FHL) tendon transfer (seven t/10
8
studies/n=105). Overall, the outcome measure most commonly used was /1
/9
the American Orthopaedic Foot and Ankle Society Scale score (AOFAS), 5/3
which is not validated for Achilles tendon rupture. Five studies20–23 used 45
8
8
thevalidatedoutcomemeasureAchillestendonrupturescore(ATRS). 7
b
A re-rupture was reported twice following surgical repair. Other y g
u
complications reported included infection 37 (7.6%), wound problems e
s
including scar hypersensitivity 23 (4.7%), Sural nerve injury 9 (1.8%), t o
n
deep vein thrombosis 6 (1.2%) and post-operative pain and tendonopa- 0
7
A
thies6(1.2%). p
Given the inconsistencies in the reporting outcomes, a meta-analysis ril 2
0
wasnotdeemedappropriate.Thedetailsoftheinterventionsandgeneral- 19
izabilityaredescribedforeachofthetechniquesbelow.
Managementoptions
ThemanagementofchronicrupturesoftheAchillestendonistechnically
demanding. Repair may be difficult given the retraction of the tendon
ends,5whichoftenrequiredebridementtohealthytissue.Therepairmay
98 BritishMedicalBulletin2013;108
B
ritish Table1 Theincludedstudies’repairmethodsandoutcomes
M
ed Author Repairmethod Outcomemeasures D
ical ow
Bulletin2013;10 APCBaaebnnrrtakeeohtlelvaiimaechnta9danl.d62 VPTer-iYrpcptueltenandbeiunonouduslserflerepapapairir AFMSCutavronelefdcrncatigfiiigrotecenhud:AmArOefngeFkAraleieSnnsSecccedoo:rironeinp3ogefprSa9ayt9tseit(edennmsotisdp(eMreda-eottcphresiacaosseraednsd)caSlpfecicrkcu1m98f8e)renceinallpatients NRNNeooo-nntrueempetnutrieoned NC11ooswumnorepaullnincdaetdrivoeehndissacemnacgee nloaded from
8 Deiparine26 AlsopossibleV-Yadvancement 50%(n=8):excellent(nopainonwalking,normalrangeofanklemotion) 1stiffanklewithsevereheelpain h
37.5%(n=6):good(pain-freerangeofmotionbutnotedtohave ttp
s
i1n2t.e5r%mi(tnte=n2t)t:efnaidrepranteiessnotnwthhoehwaoduwnodusnitdeddeuhriinscgepnrcoeloanndgewdawsaablklientgo) ://ac
a
performheelraisesandsingleleghops d
e
69%(n=11):decreased(average0.9cm)calfcircumference m
31%(n=5)normalcalfcircumference ic
Eliasetal.56 V-Ylengtheningandflexorhallucislongus AOFAS94.1(pre-op58.4) None 1wounddehiscencedowntothe .ou
tendongrafttransferviaoneincision 73%wereabletoperformasingle-legheelraise Achillestendon p.c
Allpatientsratedtheiroutcomesatisfactionaseitherverygood(10)orgood o
m
(5),(questionnaireandratingnotavailable) /b
Isokineticdynometryshowed:lossofplantarflexion7.7Nmtorqueat60°per m
b
secondand3.5Nmat120°persecond /a
ElShewyetal.28 Tguarstnrdoocw-sonlefluaspcso(mtwpoleixn)tratendinousflapsfrom RAeOtFuArnStsocoprereo-ifn9ju8r.y91le(vperleo-ofpac4t2iv.2it7y)w(Pit<hi0n.0a0p1e)riodof6–9months None 32dsueplaeyrefidciwaloinufnedcthioeanling rticle
Holzscoresstatisticallysignificantimprovementinallcriteria. -a
Ibrahimetal.55 PeroneusPBgraftandartificial‘LARS’ligament AOFAS:85.86,92%>72points.(pre-op48.64) None 2casesofskinnecrosis bs
Tegnerscore1.9(pre-op2.7) (1requiredrotationalflapplastics tra
c
Allpatientshadlossofcalfcircumferenceandplantarflexionstrength andotherhealedwitha t/1
Allabletoreturntoworkat8weeksReturntosportingactivitiesmean22 hypertrophicscar) 0
8
weeks /1
Ibrahimetal.46 Ligamentadvancedreinforcementsystem Averagetimetoreturntofullactivitywas18.3weeks None 1superficialinfection /9
5
(LARS)ligament AOFAS85.86(pre-op48.64) /3
4
Tegnerscores1.73(pre-op2.58) 5
Jacoband Directrepair,usingmodifiedtriplemini-Becker Asigunthifiocrasnotwdneocruetacsoeminecmalefacsiurcruem(bfaesreedncoenoonbtjhecetaivfefefcutnecdtiloengandsubjective None 1superficialwoundinfection Chro887 b
Paterson51 technique pAastcioenretosaft0iswfaactsidoens)cribedasexcellent,1–2good,3–4fairand5–7poor. 2deepwoundinfection nicty gu
ee
Limp:70%excellent,30%fair as
Pain:50%excellent,50%good rsot on
SNautmisfbaecrtioofnh:e1a0l%riseexsc:e(lnleunmt,b5e0r%nogtopordo,v3id0e%d)fa3ire,x2c0e%llenpto,o4rgood,2fair,1poor fthe 07 A
Averagelossofcalfstrength45% Ap
JSeenftnoinng4sand Polyestertape C‘APavoelwfrdaegira’emmceaetlafesrwu:raseisgmtinneifignct5sa.n5fo8tr%d7if/1fe6r:ennocesiignncifialcfadnitadmifefteerrencevs.uninjuredside. None 13fsuurptehrefircsiaulrgweoruyndinfections chillestril 2019
Tegneractivity:significantdecreaseinactivity(notclearwhenscoreswere 1Suralnervepalsy en
d
9 recorded) o
9 n
Continued
1 M
0
0 Table1 Continued .H
a
d
iD
eo
Author Repairmethod Outcomemeasures tw
an
l.lo
Function Re-rupture Complications ad
e
Kosaka39 Mwiothdiefinedd-tpoe-reonndesuustburreinvgis/ptreadnusfnecruclaotmedbifnaesdcia 6C5yb–1re1x0%str)eanngdth98te.0st5:±ga9i.n02o%f8i7n.0p5la±n1ta4r.8fl3e%xioinndstorresniflgetxhio(rnanstgreen8g5t%h–(r1a2n0g%e). None None d fro
m
flap/V-Ylengthening AOFAS:86.9±7.27 h
ROMtest:3patients(15%)wereunabletoperformmorethan10°ofankle ttp
dorsiflexion s
Subjectivequestionnaireresultsinverselycorrelatedwithagebutnot ://a
c
provided a
d
Kosanovichand Percutaneousrepair Leppilahtiscore(average83.3):11excellent,2good,5fair 1tendon Overall23%complicationrate e
m
Brilej61 Merkelscore:11excellent,6good,1fair non-union 1DVT ic
21Completehealing(95%),2(9%)5°increaseddorsiflexion 2suralnervepalsies .o
u
Allwereabletostandontiptoes 1complexregionalpainsyndrome p
28%mild-ormoderatepainwithnolimitationsondailyactivities;61%stand 2patientshadproblemswith .c
o
ontoes≥20s footwear m
Healraise13times(18onthenon-rupturedsite;P<0.05) /bm
Thedifferenceinworkperformancewas29%onaverage(P<0.05) b
NNooddiiffffeerreenncceeiinnicsaolmfceirtcruicmpfoewreenrce /artic
Lapidus31 MedialAchillestendonislandflapwitha Nolimitationtoactivityofdailylife None None le-a
modifiedKesslersuturetothedistaltendon Patientsatisfactionquestionnairegoodorexcellent(4gradescalenot b
s
provided) tra
Leeetal.49 ‘GraftJacket’ AOFAS:86.22pre-op(46.33)(P<0.001) None 1DVT c
Allcouldsingleheelraiseat6weeks 3superficialwoundinfections t/1
0
Averagereturn-to-activitytimewas15.2weeks 8
/1
VASpainscore:0.89 /9
MDaalhala4j2anand FHLtendongraft A33OpFAatSiemnetsagnroafde8d8(tphreeir-ooput6c9o)m(Pe<a0s.‘0v0e1ry)satisfactory’and3as‘satisfactory’. None 5superficialwoundinfections 5/34
5
Questionnairenotprovided 8
Maffulli20 Minimallyinvasivetechniqueusingaperoneus ATRSof92.5,(P<0.05) None 5superficialwoundinfections 87
PBgraft Anthropometricmeasurementssignificantlydecreaseincalfcircumflex:39.2 2hypertrophicscars by
vs.40.9cm g
u
Functionalassessment:significantlydecreaseincalfstrength:231.2Nvs.275.3 e
B s
ritishM Maffulli21 PeroneusPBtransfer ANBoTyRdSeonfs8c9o.r5e±:412e.x2ceploleinnttsresults,9goodresultsand3fairresults.Nonehada None 11stuenpderefincoiaplawthoyundinfection t on 07
edicalBu pL1o3ow3o.re2rrNepsecuoaltmktpoarrqeudewthitahn2t7h8e.1c±on1t5r3a.-1laNte;rPa=lu0n.0in4v),oblvuetdthliempba(tmieenatns,d2id41n.o7t± 2w1hrouyuppntedurrseenosfitciovnittyrao-flasuterrgaiclasilde April 2
lletin2 pacetricveitiiveesthisdecreaseinstrengthasinterferingwiththeirdailyorleisure 1cotnetnrdae-lnatoepraatlhsyidoefthe 019
01 Themaximumcalfcircumferenceremainedsignificantlydecreased
3
;1
0
8
B
ritish Maffulli22 Freegracilistendongraft ABoTyRdSesncosrceor9e0:.12±ex5c.e8l.lent,11goodand2fairresults None 13tseunpdeerfincoiaplawthoyundinfection
M
e Lowermeanpeaktorquethanthecontra-laterallimb(223.4±66.2N 2hypersensitivityofsurgical
dical pcoemrcpeiavreeddtwhiisthde2c9r6e.a5s±e6in4.s5trNe;nPgt=h0a.0s3h2a)m.Hpoewrienvgetrh,eniorndeaiolyftohrelepisautireents w1hoyupnedrtrophicscar Dow
Bulletin2013;10 MLeaafdfbuelltitaenrd6 Freegracilistransfer BaT1ch5ot/eyi2vd1mietgianeoxscio.rmdituermerisauc(al1tl,f9o9cpi5re)curamtefderleimncbelreesmssatirnoendgstihgannifincoann-tolypdeeractreedased None 5112coshrtnuueytnppprdetaeure-rlfirsnaeectonieoapsrflaiatcwtliohvsoenyidutoserncfaad-trlhianetfeercatliosindse nloaded from
8 Maxcalfcircumference:significantdecreasedinoperatedlegatpresentation h
andlatestfollow-up ttp
s
Allthepatientsreturnedtowork(typeofwork(officevs.manual)not ://a
described) c
a
Mannetal.12 FDLtendongraft Manncriteria:4excellent,2good,1fair None 2woundcomplicationsrequiring d
adjuvantprocedures:rotationflap em
Splitskingraft ic
Miskulinetal.38 PeroneusPBgraftwithplantaris Manncriteria(1991):allpatientsgood/excellentresults Notmentioned Notmentioned .ou
Nominalimprovementinplantarflexiontorque.notstatisticallysignificant p.c
Decreaseinplantarflexionbetweentheinjuredanduninjuredsides,not om
statisticallysignificant /b
Mulieretal.30 Gastrocnemius Group1:gastrocnemiusturndownflap 1patient(Group1) Delayedwoundhealing:7 m
turndownflapwithorwithoutFHLtransfer Leppilahtiscore:fair(62,range48–78) (Group1:3cases,Group2:4cases) b/a
40%patientsdeclinedindailyandsports-activities Deepinfection1 rtic
Group2:gastrocnemiusturndownflapwithFHLtransfer (Group1) le
Leppilahtiscore:goodresults(77,range67–89) 2DVT -a
b
33%patientsdeclinedindailyandsportsactivities (Group1:1,Group2:1) s
Nilsson-Helander Directrepairandfreegastrocnemius ATRSscoreof83 1re-rupture 3superficialwoundinfections tra
c
etal.59 aponeuroticflap Aftersurgery,therewasasignificantdecreaseinphysicalactivityandstrength followingadeep 2DVT t/1
Percentageofpatientsclassifiedashavingacceptablefunction(LSI≥80% infection 2alteredsensationoversural 08
comparedwithhealthyside) nerve /1
Ozakietal.13 Marlexmesh Plantarflexpower:94.8%ofnormalside None Minimalforeignbodyreaction /95
Calfwidth:96.9%ofnormalside /3
4
Heelheight:87.9%ofnormalside 5
Pintoreetal.24 PeroneusPBgraftwithplantaris CTeanlfddoinamweidtethr::S1i1g9n%ificoafnntodremcraelassideeincalfcircumferenceontheoperatedleg, None 2superficialinfections Chro887 b
Boydencriteria(1995):15/21excellentresults,peaktorquesignificantlylower 3scarsensitivity nicy g
inchronicrupture 1hypertrophicscar teue
Porteretal.50 Primaryrepair(endtoend) PSilganntifiacraflnetxdioenc:renaosesiginneifivcearsnitodnisftfreernengcthei(nchprloannitcarruflpetuxiroengproouwpe)r None 11pDaVtTienthadpainonactivity arsost on
Rush14 Turndownflaps(Gasctroc-soleousaponeurosis HCaelefld-tioa-mfleotoerrd:nisotasnigcne:ifi2cpaanttiedniftfsedreencrceeaisnedcahlfeseizl-eto-floordistance Notmentioned 1Swollenheel fthe 07 A
tube) Calfwidth:3patientsdecreasedcalfwidth 1woundslowtoheal Ap
Sarzaeem23 FSreemei-tendinosustendongrafttransfer CAAaTOlRfFSAc:iSr8c:9u9±m24±fe(5rpe(rnpecr-eeo-,popp3la27n±0te6±r)5,fl)P,e=Pxi0=o.n00:.00n10o1significantdifferencebetween None 21ssyumpeprtfiocmiaaltiincfDecVtTion chillestril 2019
e
operatedandhealthside n
1 d
0 VASresultsnotprovided o
1 n
Continued
1 M
0
2 .H
a
d
iD
Table1 Continued etow
an
l.lo
a
Author Repairmethod Outcomemeasures d
e
d
Function Re-rupture Complications fro
m
Takaoetal.29 Turndownflaps(gastrocnemiusfascialflaps) AOFAS:significantpost-opimprovementonoperatedlimbfrom72.6±5.3 None Notmentioned h
pre-operativelyto98.1±2.5post-operatively(P<0.0001) ttp
s
(sbigenttifiecraAnOt)FASscoreswithacceleratedrehabregime,notstatistically ://a
c
Isokineticdynamometryshowedimprovementofplantarflexionstrengthat ad
theankleinallpatients,butthiswasnotstatisticallysignificant em
Tay58 Twoturndownflapsandflexorhallucistendon AOFASmeanof94.2(nopre-op) None 1suralnervedamage ic
graftaugmentation MeanVASPainScorewas0.8 2heelnumbness. .o
u
Highscores(75–96)inall8domainsoftheSF-36questionnaire 1weaknessofbigtoeplantar p
Authorssatisfactionquestions flexion(notenodesis) .co
Usetal.54 V-Ygastrocnemiusrecession,excisionofscar Patientswereabletostandontiptoeandreturntotheirpreviousactivity None 1superficialinfection m/b
tissue,end-to-endanastomosisand levels m
gastrocnemiusaponeuroticflap Isokinetictesting:peaktorquedeficienciesinplantarflexionrangefrom∼2.5 b/a
Wapneretal.15 FHLtendongraft Mtoa2n2n%criteria:3excellent,3good,1fair None Notmentioned rticle
Plantarflexion:29.5%decreaseinplantarflexionpowerofnormalside -a
Sixofthepatientsreturnedto‘athletics’ bs
Wegrzyn57 Modifiedflexorhallucistendongraftwith Theaverageintervaltoworkrecoverywas5monthsandtosportswas10 None 1anklereflexsympathetic tra
c
augmentusingdirectrepair months.Allpatientsreturnedtoasportsactivityatalowerlevelcompared dystrophy t/1
withpre-injurylevel 0
8
AOFAS:98(pre-op64) /1
Isokinetictestingat30°/sand120°/srevealedanaveragedecreaseof28±11% /9
and36±4%,respectively,intheplantarflexionpeaktorque 5/3
Allhaddecreasedpowerattheinterphalangealjointbutthisdidnotappear 45
functional 88
Yasudaetal.57 Interpositionscartissue AOFAS:98.3(pre-op88.2)(P=0.027) None 1delayedwoundhealing 7 b
Allcouldsinglelegraise y
Nosignificantdifferenceincalfdiameter gu
B Nosignificantdifferenceinplantarflexionordorsiflexionangle es
ritishM Yeomanetal.41 Shortflexorhallucislongustendontransfer A(pOreF-AoSp::a5t13.4m)(ornatnhgse7296.8–8(r7a)nge64–94);at6months91.9(range77–100) None 11sDuVpTerficialinfection t on 0
edicalBulle M1((rp0aernoeag-unoetpSo1Fef0-r331a6.t19isvr–cee1o:s1ru86em7.a2.4et))d3(prmarneo-gninethj7us5r1y.40a–3c1.t20iv9(ir.ta5yn).ge74.1–115.4);at6months111.8 7 April 201
tin 9
2 ATRS,Achillestendonrupturescore;AOFAS,AmericanOrthopaedicFootandAnkleCriteria;VAS,VisualAnalogueScale;LSI,lowerlimbsymmetryindex.
0
1
3
;1
0
8
B Table2 Riskofbiasandqualityassessmentofincludedstudies
ritish Author Selectionbias Attritionbias Detectionbias Performancebias Reporting
M
e bias
d D
icalBulletin Saddeneeldmseccrpotiabgioterinaedpnphtroiccsess Ti(nriamjunergyes:i)mnceean, Ssiazmeple Lfoolsltotwo-up F(moleloawn)-up Iansdseespseonrdent Design Le(Oevvixdefeolnordcfe) Osupregreaotning Post-oprehabilitationregime Omuetacsoumrees ownloade
2013;10 APabnrakohvaimcha9nd Y (4–52)weeks 4 None 12months Surgeon Retrospective 4 Notstated Nreognim-uen.ifVoarrmyinreghaambioliutanttioonftimein Other d from
8 cast h
Heellifts(some) ttp
CBaenrteetleliaentdal.62 ((YY))DDaattaabbaassee 1141wweeeekkss 2106 NNoonnee NFooltlopwro-uvpidaetd NSuortgsetoatned RReettrroossppeeccttiivvee 44 NSiontgsletated UUnniiffoorrmmrreehhaabbiilliittaattiioonnrreeggiimmee: AMOoFdAifiSed s://ac
Deiparine26 6weeksand3 surgeon Day1post-oprangeofmotion anklescore ad
months exercises.Weightbearingwithan em
ankle–footorthosis.(removedat6 ic
weeks).Theuseoffoldedsoft .o
u
materialasheelinsert p
Eliasetal.56 (Y)consecutive 17(1–57) 15 None 106weeks Y Retrospective 4 Notstated Uniformrehabilitationregime: AOFAS .co
weeks (52–235) Splintedfor2weeksin m/b
slightequinusnon-weightbearing m
At2weeksplacedintoAchilles b/a
thyinpdefforaocttwureedbgoeostasnwdiitnhsttrhurecteedto rticle
removeonewedgeevery2weeks -a
ElShewyetal.28 (Y)Consecutive 15weeks 11 None 6–9years Surgeon Retrospective 4 Notstated Unclearifuniformrehabilitation AOFAS bs
regime Holzscore tra
Ibrahimetal.55 Database 15weeks 13 3(23%) 45months Surgeon Retrospective 4 Single Uniformrehabilitationregime: AOFAS ct/1
Allmalepatients surgeon footinitiallykeptplantigradeina Tangerscore 0
8
plasterfor2weeksandstagedto /1
fullweightbearingat6weeks /9
5
Ibrahimetal.46 (Y)Consecutive 15weeks 14 None 36months Surgeon Retrospective 4 Single Uniformrehabilitationregime AOFAS /3
surgeon Tangerscore 45
JPaactoebrsoannd51 (Y)Database Notdefined 10 1(10%) 54months Y Retrospective 4 SSiunrggleeon Uniformrehabilitationregime Other Chro887 b
Jenningsand (Y)Database (16weeks– 16 None 36months Y Retrospective 4 Notstated Uniformacceleratedrehabilitation Tangerscore ny
Sefton4 13years) regime ict gu
Kosaka39 (Y)Consecutive (4–104) 20 None 164.05±5.07 Y Retrospective 4 Notstated Uniformrehabilitationregime AOFAS eaes
weeks months rst o
on
KBroilseajn61ovichand (Y)Database 7.1weeks 18 None 67months Y Retrospective 4 Ssuinrggleeon UuPpnatitfioeonrdmtosrrwseieflhreaexbiciolaintstaoetidvoeanrnardepgbeirmroioeudghotf Lsscceooprrpeei,aMhteirkel ftheA 07 Ap
Lapidus31 (Y)Consecutive (4–72)weeks 9 None 3.1years Y Retrospective 4 Ssuinrggleeon U4–n8ifworemekrsehabilitationregime Other chillestril 2019
e
n
1 Continued d
0 o
3 n
Table2 Continued
1 M
0
4 .H
a
Author Selectionbias Attritionbias Detectionbias Performancebias Reporting d
bias ieDo
Selectionprocess Timesince Sample Lostto Follow-up Independent Design Levelof Operating Post-oprehabilitationregime Outcome tawn
andpatient injury:mean, size follow-up (mean) assessor evidence surgeon measures l.lo
a
demographics (range) (Oxford) d
e
described d
Leeetal.49 (Y)Database (36weeks-5 9 None 20months Surgeon Retrospective 4 Single Uniformrehabilitationregime AOFAS from
years) author Well-paddedposteriorsplint h
placedinagentlegravityankle ttp
s
eEqaurliynufusnpcotsioitnioanlrehabilitation ://a
c
program ad
Mahajanand (Y)Database 15(12–24) 36 None 12months Surgeon Retrospective 4 Single Uniformrehabilitationregime AOFAS em
Dalal42 weeks surgeon ic
Maffuli20 (Y)Tertiary (8–36)weeks 38 6 5–8years Surgeon Retrospective 4 Single Uniformrehabilitationregime ATRSa .o
u
referrals surgeon p
Maffulli21 (Y)Tertiary (6–36)weeks 22 6 15.5years Y Long-term 4 Single Uniformrehabilitationregime ATRSa .co
m
referrals prospective surgeon Boyden /b
study score m
Maffulli22 (Y)Tertiary (8–36)weeks 21 6 10.9 Y Long-term 4 Single Uniformrehabilitationregime ATRSa b/a
referrals pstruodspyective surgeon sBcooryeden rticle
Maffulliand (Y)Database (8–36)weeks 21 None 24months Y Prospective 4 Single Uniformrehabilitationregime Boydenscore -a
Leadbetter6 surgeon bs
Mannetal.12 (Y)Database (12weeks–3 7 None 39months Surgeon Retrospective 4 notstated Uniformrehabilitationregime Manncriteria tra
c
Miskulinetal.38 N (y5e–a4r0s))weeks 5 None 12months Surgeon Retrospective 4 Single Uniformrehabilitationregime Manncriteria t/10
8
surgeon /1
Mulieretal.30 N 32(8weeks– 19(two None 18months Surgeon Retrospective 4 Two Uniformrehabilitationregime Leppilhahti /9
5
4years) groups) surgeons score /3
Nilsson-Helander (Y)Consecutive 12(4–29) 28 None Over29 Y Retrospective 4 Initially Uniformrehabilitationregime ATRSa 45
etal.59 weeks months single 88
surgeon 7 b
Ozakietal.13 Y (8–32)weeks 6 None 36months Surgeon Retrospective 4 Notstated Uniformrehabilitationregime Other y
Pintoreetal.24 (Y)consecutive (6–36)weeks 22 None 53months Y Prospective 4 Single Uniformrehabilitationregime Boydenscore gu
B chronic, comparative surgeon es
ritishM 27fresh ostbusdeyrvational t on 0
edicalBu PRoursthe1r4etal.50 (YY)Database 7(w1we2e–ek2es6k)s 115 NNoonnee 11.85––254.8myoenatrhss SSuurrggeeoonn RReettrroossppeeccttiivvee 44 NSsuionrtggsleetoanted NUonnif-ournmifroerhmabreilhitaabtiiolitnarteiognimreegime OOtthheerr 7 April 2
lle Continued 01
tin 9
2
0
1
3
;1
0
8