- Email: [email protected]
Twelve-month outcomes following surgical repair of the Achilles tendon
G Model JINJ 6809 No. of Pages 5
Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Twelve-month outcomes following surgical repair of the Achilles tendon G. Fox, Medical Studenta , B.J. Gabbe, Professora , M. Richardson, Associate Professorb , A. Oppy, Orthopaedic Surgeonc , R. Page, Professord,e, E.R. Edwards, Associate Professora,f , R. Hau, Associate Professora,g , C.L. Ekegren, Research Fellowa,* a
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia Epworth Hospital, Richmond, Australia c Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Australia d Department of Orthopaedics, University Hospital Geelong, Geelong, Australia e School of Medicine, Deakin University, Geelong, Australia f Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Australia g Northern Hospital, Epping, Australia b
A R T I C L E I N F O
Keywords: Achilles tendon Injury Surgery Outcomes Extended Glasgow Outcome Scale Return to work Quality of life
A B S T R A C T
Introduction: Incidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient’s health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon. Methods: Two hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers. Results: At 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D-3L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period. Conclusions: Overall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management. ã 2016 Elsevier Ltd. All rights reserved.
Introduction Achilles tendon rupture (ATR) is one of the most common sportrelated injuries, causing sudden and severe disability [1]. Debate
* Corresponding author at: Monash University, Alfred Centre, 99 Commercial Rd., Melbourne, VIC 3004, Australia. E-mail address: [email protected] (C.L. Ekegren).
regarding surgical versus conservative repair for the initial management of ATR is well documented [2,3], and surgical repair remains a common approach [4,5]. It is widely established that this injury occurs most commonly in men aged 30–50 years, and incidence appears to have increased across all age groups over recent decades [1,6]. Given the increasing incidence and the potential severe disability conferred by this injury, there is
http://dx.doi.org/10.1016/j.injury.2016.07.013 0020-1383/ã 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: G. Fox, et al., Twelve-month outcomes following surgical repair of the Achilles tendon, Injury (2016), http:// dx.doi.org/10.1016/j.injury.2016.07.013
G Model JINJ 6809 No. of Pages 5
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G. Fox et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
reasonable drive to investigate outcomes among surgical patients, using standardised measures. Major long-term functional deficits have been found to persist following acute ATR, though large variations in recovery patterns have been observed between studies [7,8]. Commonly reported clinical measures following ATR include rates of re-rupture, as well as calf circumference, pain and post-operative complications [9,10]. However, there is a distinct lack of research investigating the practical consequences of reported clinical measures, and how these clinical measures relate to function. Where functional outcomes, such as heel raise tests, the Ankle Hind Foot Score and the Achilles Tendon Total Rupture Score (ATRS) have been reported they have been used inconsistently, making it difficult to compare findings between studies [11]. Furthermore, the use of injury or region specific measures, as opposed to generic patientcentred outcome measures limits the capacity to compare ATR patient outcomes to those of other injury types. Several studies have reported time to return to work (RTW) following ATR in an effort to evaluate treatment outcomes and investigate the practical implications of ATR recovery [8,9,12]. However, most studies have been restricted to smaller cohorts of less than 80 patients. Therefore, to clarify patient outcomes, studies of larger cohorts are required. The aims of this study were to: i) report the frequency of surgical Achilles tendon repairs within an orthopaedic trauma registry over a five-year period; and ii) report patients’ RTW status, health status, and functional outcomes at 12 months post-surgical repair of the Achilles tendon.
Methods Setting The Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) is a monitoring system for orthopaedic trauma in Victoria, Australia. The registry records data relating to orthopaedic injuries, treatments and outcomes based on admission to four hospitals in Victoria, Australia: one metropolitan trauma centre, one regional trauma centre, and the two adult major (level one) trauma centres. All patients aged 16 years and above with an emergency admission >24 h for a new orthopaedic injury are included on the registry. Patients with a fracture related to metastatic disease are excluded. The opt-out rate for the registry is less than 2%, with approximately 5800 patients registered per year. The complete VOTOR methodology has previously been described [13], and a brief outline is provided here. All patients registered by VOTOR are routinely followed-up at six and 12 months post-injury. Patients are contacted by trained telephone interviewers for collection of a range of outcomes relating to their physical function, pain, RTW status and health status. A patient’s next of kin is contacted for follow-up telephone interviews in circumstances where contact with the patient is not possible, e.g., language other than English, cognitive impairment, etc. Ethical approval for the registry has been granted by the institutional ethics committees of each participating hospital, and the Monash University Human Research Ethics Committee. To determine the coverage and representativeness of VOTOR data extracted for this study, population-level data on all Achilles tendon surgical repair cases were obtained from the Victorian Admitted Episodes Dataset (VAED). The VAED records admissions to all public and private acute hospitals, including day procedure
centres, in the state of Victoria. Victoria has a population of 5.9 million; 25% of the Australian population [14]. Participants We included all patients registered by VOTOR with an Achilles tendon injury managed surgically from 1 July 2009 to 30 June 2014. Cases undergoing surgical repair of the Achilles tendon were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) injury diagnosis code for Injury of Achilles tendon, “S860” combined with any relevant procedure code (Repair of Achilles tendon, “49718-01”; Secondary (delayed) repair of Achilles tendon, “49724-00”; Reconstruction of Achilles tendon, “49724-01”; or Other repair of tendon of ankle, “4971800”). Cases undergoing surgical repair of the Achilles tendon were identified in the VAED dataset for the same age and date range using the same ICD and procedure codes. Transfers between hospitals and readmissions to the same hospital were excluded from the VAED dataset. Procedure The following data were extracted from the VOTOR registry for all eligible patients: year of injury, demographic details (age and gender), level of education, occupation, activity at the time of injury, pre-injury work status and pre-injury level of disability. Data extracted from the VAED for all eligible patients included year of hospital admission, age group and gender. For all VOTOR patients, we analysed outcomes recorded at 12 months, including function, RTW status and health status. Function was reported using the Extended Glasgow Outcome Scale (GOS-E) which categorises patients according to the following eight outcomes: 0 = Dead, 1 = Vegetative State, 2 = Lower Severe Disability, 3 = Upper Severe Disability, 4 = Lower Moderate Disability, 5 = Upper Moderate Disability, 6 = Lower Good Recovery, and 7 = Upper Good Recovery [13]. Return to work status at 12 months (yes/no) was recorded for patients who were working for income prior to their injury. Those who had returned to work were also asked whether they had returned to the same organisation, and if so, whether they had returned to the same role within that organisation. Health status was reported using the 3-level European Quality of Life-5 Dimensions (EQ-5D-3L) measure [15]. This is a standardised questionnaire that asks patients to describe their health status. The dimensions assessed are Mobility, Activity, Pain, Anxiety and Self-care, with three scoring levels per dimension: ‘No Problems’, ‘Some Problems’ and ‘Severe Problems’. Analysis Descriptive statistics were used to summarise the characteristics and outcomes of the sample. Chi-square analyses were used to compare the demographics of VOTOR and VAED patients. For the purpose of this analysis and to aid interpretation, we dichotomised GOS-E response categories into two outcome categories: ‘Fully Recovered’ (score of 7, corresponding to Upper Good Recovery) and ‘Not Fully Recovered’ (<7). The EQ-5D-3L responses were dichotomised into ‘No Problems’ and ‘Some Problems’. The EQ5D summary score was also calculated, providing a single score summarising all five domains. The EQ-5D summary score is normalised to population scores, ranging from 0.59 to 1, with scores <0 = health state worse than death, 0 = equivalent to death, and 1 = perfect health [15]. All analyses were performed using Stata Version 13 and significance was set at p < 0.05.
Please cite this article in press as: G. Fox, et al., Twelve-month outcomes following surgical repair of the Achilles tendon, Injury (2016), http:// dx.doi.org/10.1016/j.injury.2016.07.013
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Results Profile of participants From 1 July 2009–30 June 2014, there were 3184 surgical repairs of the Achilles tendon registered across Victoria (Table 1). Over the same period, there were 204 surgically managed Achilles tendon injury cases registered by VOTOR. This represented 6.4% of the total number of surgical Achilles tendon repairs state-wide. While the total number of surgical repairs of the Achilles tendon registered across Victoria over the study period remained stable, there was a 68% decrease in the incidence of surgical Achilles tendon repair at VOTOR hospitals over the same five-year period (Table 1). This decrease was particularly evident from 2011/12 to 2012/13. Compared to VAED patients, VOTOR patients were younger (p < 0.001) and more commonly male (p < 0.001) (Table 1). Of all included VOTOR patients, 81% were male (n = 166) (Table 1). The age of surgical patients ranged from 17 to 83 years, with a mean (SD) age of 36.8 (11) years. Seventy-five percent (n = 152) of patients were aged between 25 and 44 years. Of patients with a recorded activity at the time of injury (n = 167), 90%
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were participating in sports, leisure or active recreation when injured. Among the recorded places of injury (n = 129), athletics or sports areas were the most common (78%). Where occupation was known for patients (n = 171), 60% were managers, administrators and professionals, and where education level was known (n = 191), 46% were university educated (Table 1). 12. -month outcomes The rate of follow-up at 12 months was 92%. The median GOS-E score at 12 months was 6, corresponding to Lower Good Recovery (IQR: 5–7), and 42% (n = 87) reported having fully recovered (equivalent to 7; Upper Good Recovery) (Fig. 1, Table 2). Ninety-four percent (n = 184) of VOTOR patients reported working prior to their injury. Return to work status at 12 months was known for 95% of patients (n = 175). Of the patients followed up, 95% (n = 167) had returned to work by 12 months (Table 2). Of these, 86% (n = 144) returned to the same organisation, and 98% (n = 141) of people who returned to their pre-injury work place had returned to the same role within that organisation. The prevalence of problems on each of the EQ-5D-3L items at 12 months was 0.5%
Table 1 Profile of surgical Achilles tendon repair patients registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and the Victorian Admitted Episodes Dataset (VAED) July 2009–June 2014. Population Descriptor Financial year 2009–10 2010–11 2011–12 2012–13 2013–14 Gender Male Female Age 16–24 25–34 35–44 45–54 55–64 65+ Activity at time of injurya Sports, leisure and active recreation activity Working for income Other specified activity Place of injuryb Home Athletics or sports area Road/Street/Highway Trade, service, industrial or construction area Other specified place Education levelc University degree Advanced diploma Completed highschool Did not complete highschool Work prior Yes No No Preinjury disabilityd None Disability present Occupatione Managers, administrators and professionals Tradespersons, labourers, production and transport workers Clerical, service and sales workers Self-employed, not further specified a b c d e
VOTOR (n = 204) n (%)
VAED (n = 3184) n (%)
50 (24.5) 49 (24.0) 64 (31.4) 25 (12.3) 16 (7.8)
610 (19.2) 596 (18.7) 700 (22.0) 679 (21.3) 599 (18.8)
166 (81.4) 38 (18.6)
2311 (72.6) 873 (27.4)
18 (8.8) 82 (40.2) 70 (34.3) 18 (8.8) 9 (4.4) 7 (3.4)
183 (5.7) 676 (21.2) 998 (31.3) 629 (19.8) 408 (12.8) 290 (9.0)
150 (89.8) 6 (3.6) 11 (6.6) 11 (8.5) 101 (78.3) 4 (3.1) 5 (3.9) 8 (6.2) 87 50 25 29
(45.6) (26.2) (13.1) (15.2)
184 (93.9) 12 (6.1) 188 (95.9) 8 (4.1) 102 (59.7) 47 (27.5) 19 (11.1) 3 (1.8)
Data missing for n = 37 cases. Data missing for n = 75 cases. Data missing for n = 13 cases. Data missing for n = 8 cases. Data missing for n = 33 cases.
Please cite this article in press as: G. Fox, et al., Twelve-month outcomes following surgical repair of the Achilles tendon, Injury (2016), http:// dx.doi.org/10.1016/j.injury.2016.07.013
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GOS-E outcome categories
Upper good recovery Lower good recovery Upper moderate disability Lower moderate disability Upper severe disability Lower severe disability Dead or vegetative state 0
10
20
30
40
50
60
70
80
90
Number of patients Fig. 1. 12-month functional outcome following surgical Achilles tendon repair (GOS-E score) (n = 187). Functional outcomes at 12 months recorded using the Extended Glasgow Outcome Scale (GOS-E). The median functional outcome was 6, corresponding to Lower Good Recovery.
for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain (Table 2). 16% of patients reported problems with more than one domain. The mean EQ-5D summary score at 12 months post-injury was 0.90 (95% CI 0.87, 0.93). Discussion Rupture of the Achilles tendon constitutes a debilitating injury and, similar to the findings in this study, typically occurs among middle-aged men participating in sport-related activities [1]. This study was prompted by the notable lack of research investigating patient-reported functional outcomes and associated health status following surgical repair of the Achilles tendon. Using data from surgical patients registered by VOTOR, we aimed to clarify 12-month outcomes among surgical patients. We used standardised measures (the GOS-E and EQ-5D-3L) to report functional outcomes and health status, as well as RTW status at 12 months. We identified a decline in the incidence of surgical Achilles tendon repair at VOTOR hospitals over the five-year study period, relative to the number of surgically repaired Achilles tendons registered across Victoria over the same period. Almost one-quarter of patients reported problems with pain and discomfort 12 months after surgery, and a similar proportion of patients reported moderate functional disability, indicating problems in the areas of work, study, relationships and/or social and leisure activities. Bostick et al. [8] reported that whilst most patients returned to usual activities six months following surgical Table 2 12-month outcomes of surgical Achilles tendon repair patients (n = 204) registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Outcomes
VOTOR patients n (%)
Returned to worka Fully recovered (GOS-E)b Health-related quality of life (EQ-5D-3L) No problems with mobilityb No problems with usual activitiesb No problems with pain/discomfortc No problems with anxiety/depressiond No problems with self-careb
167 (95.4) 78 (41.7) 161 (86.1) 155 (82.9) 141 (76.2) 163 (87.6) 186 (99.5)
GOS-E, Extended Glasgow Outcome Scale; EQ-5D-3L, 3-level European Quality of Life 5 Dimension measure. a Data missing for n = 9 cases. b Data missing for n = 17 cases. c Data missing for n = 19 cases. d Data missing for n = 18 cases.
repair of ATR, a considerable proportion of their 73-patient cohort reported calf muscle endurance impairment 12 months following surgery, and this was thought to impact performance of daily activities and sport. These findings highlight the significant impact of ATR on global function in an otherwise healthy group of patients. One long-term follow-up study reported that the majority of ATR patients had not fully recovered two years following injury, regardless of surgical or non-surgical management, and only minor improvements were found to occur between the 12- and 24month evaluations [7]. This suggests that the focus ought to be on improvement within the first year of management to enhance long-term recovery. Variation in post-operative rehabilitation regimes may account for the variation in patient-reported outcomes across our cohort, given that previous studies have found aggressive post-repair rehabilitation to be critical for achieving favourable outcomes [9,16,17]. Within VOTOR, the incidence of surgical Achilles tendon repair decreased over the five-year study period, relative to the number of surgical repairs registered across Victoria over the same time. This may reflect changes in emergency department policy whereby these patients may be regarded as non-urgent and sent to a General Practitioner for further management, or to a hospital clinic where they may be booked as elective surgery and therefore would not enter the VOTOR database. Alternatively, this may reflect a change in practice at the VOTOR hospitals, whereby surgery may be becoming a less common approach for Achilles tendon repair. Surgical repair of ATR has previously been associated with favourable patient recoveries, including reduced rates of rerupture, relative to non-surgical repair [18]. However, the results of a recent systematic review and meta-analysis published in 2012 suggest that centres using functional rehabilitation programs should opt for non-surgical ATR repair [2]. Increased education within emergency departments regarding functional non-operative management for optimising patient outcomes, as recommended in recent studies, may have contributed to the observed decrease in incidence of surgical Achilles tendon repair [2,16,17]. One limitation of this study was the homogeneity of the cohort, which prevented identification of statistically significant associations between patient variables and outcomes through multivariate modelling. Studies with greater variation of patient demographics and injury details would be useful for the identification of predictors of outcome among patient subgroups, which may assist medical practitioners in determining optimal management plans for individual patients. However, the large
Please cite this article in press as: G. Fox, et al., Twelve-month outcomes following surgical repair of the Achilles tendon, Injury (2016), http:// dx.doi.org/10.1016/j.injury.2016.07.013
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cohort recruited across four large trauma hospitals allowed for a detailed description of this population, and reliable recording of 12-month outcomes. Although our sample was restricted to surgical patients within VOTOR hospitals, and therefore may not represent the general population, we believe that this is an accurate representation of outcomes among surgical patients. It is acknowledged that the absence of non-surgical Achilles tendon patients within VOTOR meant that we could not compare outcomes between surgical and non-surgical cohorts. Although we only analysed data describing 12-month outcomes, there is the potential to progress to 24-month VOTOR follow-up data for future studies. Future studies with longer follow-up durations would improve our understanding of ATR recovery patterns in the longterm. Conclusion The purpose of this study was to report the frequency of surgical Achilles tendon repairs within an orthopaedic trauma registry over a five-year period, and to investigate the 12-month outcomes among surgical patients, using data registered by VOTOR. We identified a 68% decrease in the number of surgically repaired Achilles tendons within the VOTOR registry over the five-year study period, while the number of surgical Achilles tendon repairs remained relatively stable at the state-level. The majority of patients had returned to work 12 months post-injury, but over half reported some degree of functional deficit at this time-point and almost one quarter reported problems with pain and discomfort. The results of this study highlight the deleterious impact of ATR recovery on function and health status among a considerable portion of patients at 12 months following surgical repair. Conflict of interest statement The authors of this manuscript certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Acknowledgements Melissa Hart, Sue McLellan, Adrian Buzgau, David Attwood and the Steering Committee of VOTOR are thanked for their assistance with this project. The Victorian Injury Surveillance Unit (VISU), Monash University is acknowledged for the provision and preliminary analysis of data from the Victorian Admitted Episodes Dataset (VAED). The Victorian Orthopaedic Trauma Outcomes
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Registry (VOTOR) is funded by the Transport Accident Commission via the Institute for Safety, Compensation and Recovery Research (ISCRR). Christina Ekegren is supported by a National Health and Medical Research Council of Australia Early Career Fellowship (GNT1106633). Belinda Gabbe was supported by a National Health and Medical Research Council of Australia Career Development Fellowship (GNT1048731). References [1] Brukner P, Kahn KCQ. Pain in the Achilles region. In: Pike Carolyn, editor. Clinical sports medicine. Australia: Nicole Meehan: McGraw-Hill; 2007. p. 590–612. [2] Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am 2012;94:2136–43. [3] Holm C, Kjaer M, Eliasson P. Achilles tendon rupture-treatment and complications: a systematic review. Scand J Med Sci Sports 2015;25:e1–10. [4] Arslan A, Cepni SK, Sahinkaya T, May C, Mutlu H, Parmaksizoglu AS. Functional outcomes of repair of Achilles tendon using a biological open surgical method. Acta Orthop Traumatol Turc 2014;48:563–9. [5] Strauss EJ, Ishak C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes. Injury 2007;38:832–8. [6] Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Leppilahti J. Epidemiology of Achilles tendon ruptures: increasing incidence over a 33-year period. Scand J Med Sci Sports 2015;25:e133–8. [7] Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Thomee R, Faxen E, et al. Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2011;19:1385–93. [8] Bostick GP, Jomha NM, Suchak AA, Beaupre LA. Factors associated with calf muscle endurance recovery 1year after achilles tendon rupture repair. J Orthop Sports Phys Ther 2010;40:345–51. [9] Jackson G, Sinclair VF, McLaughlin C, Barrie J. Outcomes of functional weightbearing rehabilitation of Achilles tendon ruptures. Orthopedics 2013;36: e1053–9. [10] Bergkvist D, Astrom I, Josefsson PO, Dahlberg LE. Acute Achilles tendon rupture: a questionnaire follow-up of 487 patients. J Bone Joint Surg Am 2012;94:1229–33. [11] Kearney RS, Achten J, Lamb SE, Plant C, Costa ML. A systematic review of patient-reported outcome measures used to assess Achilles tendon rupture management: what's being used and should we be using it? Br J Sports Med 2012;46:1102–9. [12] Rosso C, Vavken P, Polzer C, Buckland DM, Studler U, Weisskopf L, et al. Longterm outcomes of muscle volume and Achilles tendon length after Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2013;21:1369–77. [13] Gabbe BJ, Sutherland AM, Hart MJ, Cameron PA. Population-based capture of long-term functional and quality of life outcomes after major trauma: the experiences of the Victorian State Trauma Registry. J Trauma 2010;69:532–6. [14] 3101.0 – Australian Demographic Statistics, Jun 2015 http://www.abs.gov.au/ AUSSTATS/[email protected]/DetailsPage/3101.0Jun%202015?OpenDocument. [15] Polinder S, Haagsma J, Bonsel G, Essink-Bot M, Toet H, van Beeck E. The measurement of long-term health-related quality of life after injury: comparison of EQ-5D and the health utilities index. Inj Prev 2010;16:147–53. [16] Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, et al. Operative versus non-operative treatment of acute Achilles tendon ruptures: a multicentre randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 2010;92:2767–75. [17] Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med 2007;35:2033– 8. [18] Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute rupture of tendon Achillis: a prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 2001;83:843–8.
Please cite this article in press as: G. Fox, et al., Twelve-month outcomes following surgical repair of the Achilles tendon, Injury (2016), http:// dx.doi.org/10.1016/j.injury.2016.07.013
Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Twelve-month outcomes following surgical repair of the Achilles tendon G. Fox, Medical Studenta , B.J. Gabbe, Professora , M. Richardson, Associate Professorb , A. Oppy, Orthopaedic Surgeonc , R. Page, Professord,e, E.R. Edwards, Associate Professora,f , R. Hau, Associate Professora,g , C.L. Ekegren, Research Fellowa,* a
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia Epworth Hospital, Richmond, Australia c Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Australia d Department of Orthopaedics, University Hospital Geelong, Geelong, Australia e School of Medicine, Deakin University, Geelong, Australia f Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Australia g Northern Hospital, Epping, Australia b
A R T I C L E I N F O
Keywords: Achilles tendon Injury Surgery Outcomes Extended Glasgow Outcome Scale Return to work Quality of life
A B S T R A C T
Introduction: Incidence of Achilles tendon rupture (ATR) has increased over recent years, and debate regarding optimal management has been widely documented. Most papers have focused on surgical success, complications and short term region-specific outcomes. Inconsistent use of standardised outcome measures following surgical ATR repair has made it difficult to evaluate the impact of ATR on a patient’s health status post-surgery, and to compare this to other injury types. This study aimed to report the frequency of surgical repairs of the Achilles tendon over a five-year period within an orthopaedic trauma registry, and to investigate return to work (RTW) status, health status and functional outcomes at 12 months post-surgical repair of the Achilles tendon. Methods: Two hundred and four adults registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who underwent surgical repair of the Achilles tendon between July 2009 and June 2014 were included in this prospective cohort study. The Extended Glasgow Outcome Scale (GOS-E), 3-level European Quality of Life 5 Dimension measure (EQ-5D-3L), and RTW status 12 months following surgical ATR repair were collected through structured telephone interviews conducted by trained interviewers. Results: At 12 months, 92% of patients were successfully followed up. Of those working prior to injury, 95% had returned to work. 42% of patients reported a full recovery on the GOS-E scale. The prevalence of problems on the EQ-5D-3L at 12 months was 0.5% for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain. 16% of patients reported problems with more than one domain. The number of surgical repairs of the Achilles tendon within the VOTOR registry decreased by 68% over the five-year study period. Conclusions: Overall, patients recover well following surgical repair of the Achilles tendon. However, in this study, deficits in function persisted for over half of patients at 12 months post-injury. The decreased incidence of surgical Achilles tendon repair may reflect a change in practice at VOTOR hospitals whereby surgery may be becoming less favoured for initial ATR management. ã 2016 Elsevier Ltd. All rights reserved.
Introduction Achilles tendon rupture (ATR) is one of the most common sportrelated injuries, causing sudden and severe disability [1]. Debate
* Corresponding author at: Monash University, Alfred Centre, 99 Commercial Rd., Melbourne, VIC 3004, Australia. E-mail address: [email protected] (C.L. Ekegren).
regarding surgical versus conservative repair for the initial management of ATR is well documented [2,3], and surgical repair remains a common approach [4,5]. It is widely established that this injury occurs most commonly in men aged 30–50 years, and incidence appears to have increased across all age groups over recent decades [1,6]. Given the increasing incidence and the potential severe disability conferred by this injury, there is
http://dx.doi.org/10.1016/j.injury.2016.07.013 0020-1383/ã 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: G. Fox, et al., Twelve-month outcomes following surgical repair of the Achilles tendon, Injury (2016), http:// dx.doi.org/10.1016/j.injury.2016.07.013
G Model JINJ 6809 No. of Pages 5
2
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reasonable drive to investigate outcomes among surgical patients, using standardised measures. Major long-term functional deficits have been found to persist following acute ATR, though large variations in recovery patterns have been observed between studies [7,8]. Commonly reported clinical measures following ATR include rates of re-rupture, as well as calf circumference, pain and post-operative complications [9,10]. However, there is a distinct lack of research investigating the practical consequences of reported clinical measures, and how these clinical measures relate to function. Where functional outcomes, such as heel raise tests, the Ankle Hind Foot Score and the Achilles Tendon Total Rupture Score (ATRS) have been reported they have been used inconsistently, making it difficult to compare findings between studies [11]. Furthermore, the use of injury or region specific measures, as opposed to generic patientcentred outcome measures limits the capacity to compare ATR patient outcomes to those of other injury types. Several studies have reported time to return to work (RTW) following ATR in an effort to evaluate treatment outcomes and investigate the practical implications of ATR recovery [8,9,12]. However, most studies have been restricted to smaller cohorts of less than 80 patients. Therefore, to clarify patient outcomes, studies of larger cohorts are required. The aims of this study were to: i) report the frequency of surgical Achilles tendon repairs within an orthopaedic trauma registry over a five-year period; and ii) report patients’ RTW status, health status, and functional outcomes at 12 months post-surgical repair of the Achilles tendon.
Methods Setting The Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) is a monitoring system for orthopaedic trauma in Victoria, Australia. The registry records data relating to orthopaedic injuries, treatments and outcomes based on admission to four hospitals in Victoria, Australia: one metropolitan trauma centre, one regional trauma centre, and the two adult major (level one) trauma centres. All patients aged 16 years and above with an emergency admission >24 h for a new orthopaedic injury are included on the registry. Patients with a fracture related to metastatic disease are excluded. The opt-out rate for the registry is less than 2%, with approximately 5800 patients registered per year. The complete VOTOR methodology has previously been described [13], and a brief outline is provided here. All patients registered by VOTOR are routinely followed-up at six and 12 months post-injury. Patients are contacted by trained telephone interviewers for collection of a range of outcomes relating to their physical function, pain, RTW status and health status. A patient’s next of kin is contacted for follow-up telephone interviews in circumstances where contact with the patient is not possible, e.g., language other than English, cognitive impairment, etc. Ethical approval for the registry has been granted by the institutional ethics committees of each participating hospital, and the Monash University Human Research Ethics Committee. To determine the coverage and representativeness of VOTOR data extracted for this study, population-level data on all Achilles tendon surgical repair cases were obtained from the Victorian Admitted Episodes Dataset (VAED). The VAED records admissions to all public and private acute hospitals, including day procedure
centres, in the state of Victoria. Victoria has a population of 5.9 million; 25% of the Australian population [14]. Participants We included all patients registered by VOTOR with an Achilles tendon injury managed surgically from 1 July 2009 to 30 June 2014. Cases undergoing surgical repair of the Achilles tendon were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) injury diagnosis code for Injury of Achilles tendon, “S860” combined with any relevant procedure code (Repair of Achilles tendon, “49718-01”; Secondary (delayed) repair of Achilles tendon, “49724-00”; Reconstruction of Achilles tendon, “49724-01”; or Other repair of tendon of ankle, “4971800”). Cases undergoing surgical repair of the Achilles tendon were identified in the VAED dataset for the same age and date range using the same ICD and procedure codes. Transfers between hospitals and readmissions to the same hospital were excluded from the VAED dataset. Procedure The following data were extracted from the VOTOR registry for all eligible patients: year of injury, demographic details (age and gender), level of education, occupation, activity at the time of injury, pre-injury work status and pre-injury level of disability. Data extracted from the VAED for all eligible patients included year of hospital admission, age group and gender. For all VOTOR patients, we analysed outcomes recorded at 12 months, including function, RTW status and health status. Function was reported using the Extended Glasgow Outcome Scale (GOS-E) which categorises patients according to the following eight outcomes: 0 = Dead, 1 = Vegetative State, 2 = Lower Severe Disability, 3 = Upper Severe Disability, 4 = Lower Moderate Disability, 5 = Upper Moderate Disability, 6 = Lower Good Recovery, and 7 = Upper Good Recovery [13]. Return to work status at 12 months (yes/no) was recorded for patients who were working for income prior to their injury. Those who had returned to work were also asked whether they had returned to the same organisation, and if so, whether they had returned to the same role within that organisation. Health status was reported using the 3-level European Quality of Life-5 Dimensions (EQ-5D-3L) measure [15]. This is a standardised questionnaire that asks patients to describe their health status. The dimensions assessed are Mobility, Activity, Pain, Anxiety and Self-care, with three scoring levels per dimension: ‘No Problems’, ‘Some Problems’ and ‘Severe Problems’. Analysis Descriptive statistics were used to summarise the characteristics and outcomes of the sample. Chi-square analyses were used to compare the demographics of VOTOR and VAED patients. For the purpose of this analysis and to aid interpretation, we dichotomised GOS-E response categories into two outcome categories: ‘Fully Recovered’ (score of 7, corresponding to Upper Good Recovery) and ‘Not Fully Recovered’ (<7). The EQ-5D-3L responses were dichotomised into ‘No Problems’ and ‘Some Problems’. The EQ5D summary score was also calculated, providing a single score summarising all five domains. The EQ-5D summary score is normalised to population scores, ranging from 0.59 to 1, with scores <0 = health state worse than death, 0 = equivalent to death, and 1 = perfect health [15]. All analyses were performed using Stata Version 13 and significance was set at p < 0.05.
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Results Profile of participants From 1 July 2009–30 June 2014, there were 3184 surgical repairs of the Achilles tendon registered across Victoria (Table 1). Over the same period, there were 204 surgically managed Achilles tendon injury cases registered by VOTOR. This represented 6.4% of the total number of surgical Achilles tendon repairs state-wide. While the total number of surgical repairs of the Achilles tendon registered across Victoria over the study period remained stable, there was a 68% decrease in the incidence of surgical Achilles tendon repair at VOTOR hospitals over the same five-year period (Table 1). This decrease was particularly evident from 2011/12 to 2012/13. Compared to VAED patients, VOTOR patients were younger (p < 0.001) and more commonly male (p < 0.001) (Table 1). Of all included VOTOR patients, 81% were male (n = 166) (Table 1). The age of surgical patients ranged from 17 to 83 years, with a mean (SD) age of 36.8 (11) years. Seventy-five percent (n = 152) of patients were aged between 25 and 44 years. Of patients with a recorded activity at the time of injury (n = 167), 90%
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were participating in sports, leisure or active recreation when injured. Among the recorded places of injury (n = 129), athletics or sports areas were the most common (78%). Where occupation was known for patients (n = 171), 60% were managers, administrators and professionals, and where education level was known (n = 191), 46% were university educated (Table 1). 12. -month outcomes The rate of follow-up at 12 months was 92%. The median GOS-E score at 12 months was 6, corresponding to Lower Good Recovery (IQR: 5–7), and 42% (n = 87) reported having fully recovered (equivalent to 7; Upper Good Recovery) (Fig. 1, Table 2). Ninety-four percent (n = 184) of VOTOR patients reported working prior to their injury. Return to work status at 12 months was known for 95% of patients (n = 175). Of the patients followed up, 95% (n = 167) had returned to work by 12 months (Table 2). Of these, 86% (n = 144) returned to the same organisation, and 98% (n = 141) of people who returned to their pre-injury work place had returned to the same role within that organisation. The prevalence of problems on each of the EQ-5D-3L items at 12 months was 0.5%
Table 1 Profile of surgical Achilles tendon repair patients registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and the Victorian Admitted Episodes Dataset (VAED) July 2009–June 2014. Population Descriptor Financial year 2009–10 2010–11 2011–12 2012–13 2013–14 Gender Male Female Age 16–24 25–34 35–44 45–54 55–64 65+ Activity at time of injurya Sports, leisure and active recreation activity Working for income Other specified activity Place of injuryb Home Athletics or sports area Road/Street/Highway Trade, service, industrial or construction area Other specified place Education levelc University degree Advanced diploma Completed highschool Did not complete highschool Work prior Yes No No Preinjury disabilityd None Disability present Occupatione Managers, administrators and professionals Tradespersons, labourers, production and transport workers Clerical, service and sales workers Self-employed, not further specified a b c d e
VOTOR (n = 204) n (%)
VAED (n = 3184) n (%)
50 (24.5) 49 (24.0) 64 (31.4) 25 (12.3) 16 (7.8)
610 (19.2) 596 (18.7) 700 (22.0) 679 (21.3) 599 (18.8)
166 (81.4) 38 (18.6)
2311 (72.6) 873 (27.4)
18 (8.8) 82 (40.2) 70 (34.3) 18 (8.8) 9 (4.4) 7 (3.4)
183 (5.7) 676 (21.2) 998 (31.3) 629 (19.8) 408 (12.8) 290 (9.0)
150 (89.8) 6 (3.6) 11 (6.6) 11 (8.5) 101 (78.3) 4 (3.1) 5 (3.9) 8 (6.2) 87 50 25 29
(45.6) (26.2) (13.1) (15.2)
184 (93.9) 12 (6.1) 188 (95.9) 8 (4.1) 102 (59.7) 47 (27.5) 19 (11.1) 3 (1.8)
Data missing for n = 37 cases. Data missing for n = 75 cases. Data missing for n = 13 cases. Data missing for n = 8 cases. Data missing for n = 33 cases.
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GOS-E outcome categories
Upper good recovery Lower good recovery Upper moderate disability Lower moderate disability Upper severe disability Lower severe disability Dead or vegetative state 0
10
20
30
40
50
60
70
80
90
Number of patients Fig. 1. 12-month functional outcome following surgical Achilles tendon repair (GOS-E score) (n = 187). Functional outcomes at 12 months recorded using the Extended Glasgow Outcome Scale (GOS-E). The median functional outcome was 6, corresponding to Lower Good Recovery.
for self-care, 11% for anxiety, 13% for mobility, 16% for activity, and 22% for pain (Table 2). 16% of patients reported problems with more than one domain. The mean EQ-5D summary score at 12 months post-injury was 0.90 (95% CI 0.87, 0.93). Discussion Rupture of the Achilles tendon constitutes a debilitating injury and, similar to the findings in this study, typically occurs among middle-aged men participating in sport-related activities [1]. This study was prompted by the notable lack of research investigating patient-reported functional outcomes and associated health status following surgical repair of the Achilles tendon. Using data from surgical patients registered by VOTOR, we aimed to clarify 12-month outcomes among surgical patients. We used standardised measures (the GOS-E and EQ-5D-3L) to report functional outcomes and health status, as well as RTW status at 12 months. We identified a decline in the incidence of surgical Achilles tendon repair at VOTOR hospitals over the five-year study period, relative to the number of surgically repaired Achilles tendons registered across Victoria over the same period. Almost one-quarter of patients reported problems with pain and discomfort 12 months after surgery, and a similar proportion of patients reported moderate functional disability, indicating problems in the areas of work, study, relationships and/or social and leisure activities. Bostick et al. [8] reported that whilst most patients returned to usual activities six months following surgical Table 2 12-month outcomes of surgical Achilles tendon repair patients (n = 204) registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Outcomes
VOTOR patients n (%)
Returned to worka Fully recovered (GOS-E)b Health-related quality of life (EQ-5D-3L) No problems with mobilityb No problems with usual activitiesb No problems with pain/discomfortc No problems with anxiety/depressiond No problems with self-careb
167 (95.4) 78 (41.7) 161 (86.1) 155 (82.9) 141 (76.2) 163 (87.6) 186 (99.5)
GOS-E, Extended Glasgow Outcome Scale; EQ-5D-3L, 3-level European Quality of Life 5 Dimension measure. a Data missing for n = 9 cases. b Data missing for n = 17 cases. c Data missing for n = 19 cases. d Data missing for n = 18 cases.
repair of ATR, a considerable proportion of their 73-patient cohort reported calf muscle endurance impairment 12 months following surgery, and this was thought to impact performance of daily activities and sport. These findings highlight the significant impact of ATR on global function in an otherwise healthy group of patients. One long-term follow-up study reported that the majority of ATR patients had not fully recovered two years following injury, regardless of surgical or non-surgical management, and only minor improvements were found to occur between the 12- and 24month evaluations [7]. This suggests that the focus ought to be on improvement within the first year of management to enhance long-term recovery. Variation in post-operative rehabilitation regimes may account for the variation in patient-reported outcomes across our cohort, given that previous studies have found aggressive post-repair rehabilitation to be critical for achieving favourable outcomes [9,16,17]. Within VOTOR, the incidence of surgical Achilles tendon repair decreased over the five-year study period, relative to the number of surgical repairs registered across Victoria over the same time. This may reflect changes in emergency department policy whereby these patients may be regarded as non-urgent and sent to a General Practitioner for further management, or to a hospital clinic where they may be booked as elective surgery and therefore would not enter the VOTOR database. Alternatively, this may reflect a change in practice at the VOTOR hospitals, whereby surgery may be becoming a less common approach for Achilles tendon repair. Surgical repair of ATR has previously been associated with favourable patient recoveries, including reduced rates of rerupture, relative to non-surgical repair [18]. However, the results of a recent systematic review and meta-analysis published in 2012 suggest that centres using functional rehabilitation programs should opt for non-surgical ATR repair [2]. Increased education within emergency departments regarding functional non-operative management for optimising patient outcomes, as recommended in recent studies, may have contributed to the observed decrease in incidence of surgical Achilles tendon repair [2,16,17]. One limitation of this study was the homogeneity of the cohort, which prevented identification of statistically significant associations between patient variables and outcomes through multivariate modelling. Studies with greater variation of patient demographics and injury details would be useful for the identification of predictors of outcome among patient subgroups, which may assist medical practitioners in determining optimal management plans for individual patients. However, the large
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cohort recruited across four large trauma hospitals allowed for a detailed description of this population, and reliable recording of 12-month outcomes. Although our sample was restricted to surgical patients within VOTOR hospitals, and therefore may not represent the general population, we believe that this is an accurate representation of outcomes among surgical patients. It is acknowledged that the absence of non-surgical Achilles tendon patients within VOTOR meant that we could not compare outcomes between surgical and non-surgical cohorts. Although we only analysed data describing 12-month outcomes, there is the potential to progress to 24-month VOTOR follow-up data for future studies. Future studies with longer follow-up durations would improve our understanding of ATR recovery patterns in the longterm. Conclusion The purpose of this study was to report the frequency of surgical Achilles tendon repairs within an orthopaedic trauma registry over a five-year period, and to investigate the 12-month outcomes among surgical patients, using data registered by VOTOR. We identified a 68% decrease in the number of surgically repaired Achilles tendons within the VOTOR registry over the five-year study period, while the number of surgical Achilles tendon repairs remained relatively stable at the state-level. The majority of patients had returned to work 12 months post-injury, but over half reported some degree of functional deficit at this time-point and almost one quarter reported problems with pain and discomfort. The results of this study highlight the deleterious impact of ATR recovery on function and health status among a considerable portion of patients at 12 months following surgical repair. Conflict of interest statement The authors of this manuscript certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Acknowledgements Melissa Hart, Sue McLellan, Adrian Buzgau, David Attwood and the Steering Committee of VOTOR are thanked for their assistance with this project. The Victorian Injury Surveillance Unit (VISU), Monash University is acknowledged for the provision and preliminary analysis of data from the Victorian Admitted Episodes Dataset (VAED). The Victorian Orthopaedic Trauma Outcomes
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Registry (VOTOR) is funded by the Transport Accident Commission via the Institute for Safety, Compensation and Recovery Research (ISCRR). Christina Ekegren is supported by a National Health and Medical Research Council of Australia Early Career Fellowship (GNT1106633). Belinda Gabbe was supported by a National Health and Medical Research Council of Australia Career Development Fellowship (GNT1048731). References [1] Brukner P, Kahn KCQ. Pain in the Achilles region. In: Pike Carolyn, editor. Clinical sports medicine. Australia: Nicole Meehan: McGraw-Hill; 2007. p. 590–612. [2] Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am 2012;94:2136–43. [3] Holm C, Kjaer M, Eliasson P. Achilles tendon rupture-treatment and complications: a systematic review. Scand J Med Sci Sports 2015;25:e1–10. [4] Arslan A, Cepni SK, Sahinkaya T, May C, Mutlu H, Parmaksizoglu AS. Functional outcomes of repair of Achilles tendon using a biological open surgical method. Acta Orthop Traumatol Turc 2014;48:563–9. [5] Strauss EJ, Ishak C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes. Injury 2007;38:832–8. [6] Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Leppilahti J. Epidemiology of Achilles tendon ruptures: increasing incidence over a 33-year period. Scand J Med Sci Sports 2015;25:e133–8. [7] Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Thomee R, Faxen E, et al. Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 2011;19:1385–93. [8] Bostick GP, Jomha NM, Suchak AA, Beaupre LA. Factors associated with calf muscle endurance recovery 1year after achilles tendon rupture repair. J Orthop Sports Phys Ther 2010;40:345–51. [9] Jackson G, Sinclair VF, McLaughlin C, Barrie J. Outcomes of functional weightbearing rehabilitation of Achilles tendon ruptures. Orthopedics 2013;36: e1053–9. [10] Bergkvist D, Astrom I, Josefsson PO, Dahlberg LE. Acute Achilles tendon rupture: a questionnaire follow-up of 487 patients. J Bone Joint Surg Am 2012;94:1229–33. [11] Kearney RS, Achten J, Lamb SE, Plant C, Costa ML. A systematic review of patient-reported outcome measures used to assess Achilles tendon rupture management: what's being used and should we be using it? Br J Sports Med 2012;46:1102–9. [12] Rosso C, Vavken P, Polzer C, Buckland DM, Studler U, Weisskopf L, et al. Longterm outcomes of muscle volume and Achilles tendon length after Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2013;21:1369–77. [13] Gabbe BJ, Sutherland AM, Hart MJ, Cameron PA. Population-based capture of long-term functional and quality of life outcomes after major trauma: the experiences of the Victorian State Trauma Registry. J Trauma 2010;69:532–6. [14] 3101.0 – Australian Demographic Statistics, Jun 2015 http://www.abs.gov.au/ AUSSTATS/[email protected]/DetailsPage/3101.0Jun%202015?OpenDocument. [15] Polinder S, Haagsma J, Bonsel G, Essink-Bot M, Toet H, van Beeck E. The measurement of long-term health-related quality of life after injury: comparison of EQ-5D and the health utilities index. Inj Prev 2010;16:147–53. [16] Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, et al. Operative versus non-operative treatment of acute Achilles tendon ruptures: a multicentre randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 2010;92:2767–75. [17] Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med 2007;35:2033– 8. [18] Moller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute rupture of tendon Achillis: a prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br 2001;83:843–8.
Please cite this article in press as: G. Fox, et al., Twelve-month outcomes following surgical repair of the Achilles tendon, Injury (2016), http:// dx.doi.org/10.1016/j.injury.2016.07.013