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Table 1 Cohort description

From: Treatment of acute Achilles tendon rupture – a multicentre, non-inferiority analysis

Cohorts Included (n) Inclusions Exclusions Surgical treatment Non-surgical treatment Rehabilitation
Nilsson-Helander et al. [8]
(n = 97)
88 Clinically verified ATR which was treated within 72 h. Diabetes mellitus, previous ATR, other lower leg injuries, immunosuppressive therapy and neurovascular diseases. Seventy-nine patients were treated surgically using the modified Kessler suture technique 8 and 1–0 PDS. The paratenon was carefully repaired and the skin closed with interrupted nylon sutures. Post-operatively, the patients were placed in a below-the-knee cast with the foot in the 30° equinus position. Fourteen patients were treated immediately after randomisation, with a below-the-knee cast with the foot in the equinus position. All the patients in both groups were treated with a below-the-knee cast with the foot in the equinus position for 2 weeks, followed by an adjustable angle brace by a physiotherapist for the next 6 weeks. Weightbearing as tolerated was allowed after 6 to 8 weeks.
Olsson et al. [9]
(n = 100)
87 Clinically verified closed mid-tendon substance rupture treated within 96 h. Previous ATR, other lower leg injuries, neuromuscular diseases, diabetes mellitus, peripheral vascular disease, immunosuppressive treatment and inability to attend follow-up. Forty-two patients were operated on using the modified Kessler technique. The tendon was repaired end to end using core suturing with two strong semi-absorbable sutures. No cast was used and the ankle was post-operatively immobilised in a pneumatic walker brace including three heel pads that produce a plantarflexion angle of approximately 22°. Forty-five patients were treated immediately after randomisation, using the same brace as in the surgical group, including the three heel pads. Patients were allowed full weightbearing, which was encouraged from the first post-operative day for both groups. Early active rehabilitation started 2 weeks post-operatively and included both range of motion and strength training following a standardised protocol. The surgical group was mobilized in the brace for 6 weeks and the non-surgical group for 8 weeks.
Aufwerber et al. [12] (n = 150) 103 Clinically verified ATR which was treated within one week. Ongoing anticoagulation treatment, known kidney failure, heart failure with pitting oedema, thrombophlebitis, thromboembolic event during the previous 3 months, known malignancy, haemophilia, pregnancy, other surgery during the previous month, inability to follow instructions and planned follow-up at another hospital. One hundred and three patients were operated on surgically using the modified Kessler suture technique with two 1–0 polydioxanone (PDS II) sutures. The paratenon and fascia cruris were then sutured separately using 3–0 Vicryl (Ethicon). After surgery the patients were prospectively randomised into two groups, a full-weight-bearing and non-weight-bearing rehabilitation regime. Full-weight-bearing group: after surgery, a walker orthosis with an adjustable angle of motion was used for the next 6 weeks. Functional mobilisation with one-hour daily motion exercise was initiated directly post-operatively.
Non-weight-bearing group: received a conventional non-weight-bearing below-knee plaster cast with the ankle in a 30° equinus position. At 2 weeks post-operatively, the cast was replaced by a removable walker orthosis with three heel wedges for the remaining 4 weeks of immobilisation. Every consecutive week, a heel wedge was removed.
At 6 weeks, all patients discontinued immobilization.
Domeij-Arverud et al. [11]
(n = 26)
25 Clinically verified ATR which was treated within 72 h. Same as Aufwerber et al. [12] Twenty-five patients were operated surgically using the same techniques as Valkering et al. [13]
All patients received a below-knee plaster cast with the ankle in 30° equinus and were non-weight-bearing with crutches during the first 2 weeks.
After surgery the patients were prospectively randomised into two groups, both groups non-weight-bearing, but the intervention group received adjuvant foot intermittent pneumatic compression.
All patients received a below-knee plaster cast with the ankle in 30° equinus in the outpatient clinic shortly after the completion of surgery, and were non-weight-bearing with crutches during the first 2 weeks.
The intervention group received intermittent pneumatic compression applied to the foot under the plaster cast, which was discontinued at 2 weeks post-operatively.
At the 2-week visit all patients received a lower leg orthosis and were instructed to start full weight-bearing. The orthotic treatment was discontinued at 6 weeks post-operatively.
Domeij-Arverud et al. [10]
(n = 150)
119 Clinically verified ATR which was treated within 96 h. Same as Aufwerber et al. [12] One hundred and nineteen patients were operated surgically using the same techniques as Valkering et al. [13]
After surgery the patients were prospectively randomised into two groups both groups non-weight-bearing, but the intervention group received adjuvant calf intermittent pneumatic compression.
Control group: The patients received a below-knee plaster cast applied in the outpatient clinic shortly after the completion of surgery, with the ankle plantar-flexed to provide 30° of equinus. Patients were non-weight-bearing during the first 2 post-operative weeks and were given crutches.
Intervention group: The intervention group received intermittent pneumatic compression applied to the calf beneath a walker orthosis. At 2 weeks post-operatively the intervention was discontinued.
At the 2-week visit all patients received a lower leg orthosis and were instructed to start full weight-bearing. The orthotic treatment was discontinued at 6 weeks post-operatively.
  1. Clinically verified Achilles tendon rupture (ATR): presenting with symptoms including sudden increase in pain around the Achilles, weakness and poor balance and limited walking distance [14] and a palpable gap in the tendon and a positive Thompson test [15]
  2. PDS – polydioxanone