Crook Bryan S, Varshneya Kunal, Meyer Lucy E, Anastasio Albert, Cullen Mark M, Lau Brian C
Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.
Stanford University School of Medicine, Stanford, California, USA.
Orthop J Sports Med. 2023 Feb 27;11(2):23259671231152904. doi: 10.1177/23259671231152904. eCollection 2023 Feb.
No consensus exists regarding the superiority of operative versus nonoperative management for Achilles tendon ruptures, as multiple randomized controlled trials conducted since the advent of early mobilization protocols have found outcomes for these 2 interventions to be more similar than were previously held.
To use a large national database to (1) compare reoperation and complication rates between operative and nonoperative treatment of acute Achilles tendon ruptures and (2) evaluate trends in treatment and cost over time.
Cohort study; Level of evidence, 3.
The MarketScan Commercial Claims and Encounters database was used to identify an unmatched cohort of 31,515 patients who sustained primary Achilles tendon ruptures between 2007 and 2015. Patients were stratified into operative and nonoperative treatment groups, and a propensity score-a matching algorithm-was used to establish a matched cohort of 17,996 patients (n = 8993 per treatment group). Reoperation rates, complications, and aggregate treatment costs were compared between groups with an alpha level of .05. A number needed to harm (NNH) was calculated from the absolute risk difference in complications between cohorts.
The operative cohort experienced a significantly larger total number of complications within 30 days of injury (1026 vs 917; = .0088). The absolute increase in cumulative risk was 1.2% with operative treatment, which resulted in an NNH of 83. Neither 1-year (1.1% [operative] vs 1.3% [nonoperative]; = .1201) nor 2-year reoperation rates (1.9% [operative] vs 2% [nonoperative]; = .2810) were significantly different. Operative care was more expensive than nonoperative care at 9 months and 2 years after injury; however, there was no difference in cost between treatments at 5 years. Before matching, the rate of surgical repair for Achilles tendon rupture remained stable, from 69.7% to 71.7% between 2007 and 2015, indicating little change in practice in the United States.
Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. Operative management was associated with an increased risk of complications and higher initial costs, which dissipated over time. Between 2007 and 2015 the proportion of Achilles tendon ruptures managed operatively remained similar despite increasing evidence that nonoperative management of Achilles tendon rupture may provide equivalent outcomes.
对于跟腱断裂的手术治疗与非手术治疗哪种更具优势，目前尚无共识，因为自早期活动方案出现以来进行的多项随机对照试验发现，这两种干预措施的结果比以前认为的更为相似。
利用一个大型国家数据库来（1）比较急性跟腱断裂手术治疗与非手术治疗的再次手术率和并发症发生率，以及（2）评估治疗和成本随时间的变化趋势。
队列研究；证据等级，3级。
使用MarketScan商业索赔和病历数据库，确定了2007年至2015年间31515例原发性跟腱断裂患者组成的非匹配队列。将患者分为手术治疗组和非手术治疗组，并使用倾向评分（一种匹配算法）建立了一个由17996例患者组成的匹配队列（每个治疗组n = 8993例）。比较两组之间的再次手术率、并发症和总治疗成本，α水平设定为0.05。根据队列之间并发症的绝对风险差异计算伤害所需人数（NNH）。
手术队列在受伤后30天内发生的并发症总数明显更多（1026例对917例；P = 0.0088）。手术治疗的累积风险绝对增加了1.2%，导致NNH为83。1年（手术组为1.1%对非手术组为1.3%；P = 0.1201）和2年的再次手术率（手术组为1.9%对非手术组为2%；P = 0.2810）均无显著差异。受伤后9个月和2年时，手术治疗比非手术治疗更昂贵；然而，5年时两种治疗的成本没有差异。在匹配之前，2007年至2015年间跟腱断裂的手术修复率保持稳定，从69.7%到71.7%，表明美国的实际做法变化不大。
结果表明，跟腱断裂手术治疗与非手术治疗的再次手术率没有差异。手术治疗与并发症风险增加和更高的初始成本相关，但随着时间推移这些差异会逐渐消失。2007年至2015年间，尽管越来越多的证据表明跟腱断裂的非手术治疗可能提供相同的结果，但接受手术治疗的跟腱断裂比例仍然相似。
