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Letter to the Editor

Dear Editor: I read with interest the detailed review of the management of Achilles tendon ruptures by Wong et al. (“Quantitative Review of Operative and Nonoperative Management of Achilles Tendon Ruptures,” July/August, 2002, pages 565–575). However, having reviewed the literature up to the year 2001, it is apparent that an important measure of treatment effect—the number needed to treat—has not been reported previously in the literature. Table 1 illustrates one measure of treatment effect—rerupture rates—for surgical compared with nonsurgical treatment for the three prospective randomized trials published in the English language literature. Möller et al. identified a significantly higher rerupture rate in a nonsurgical compared with the surgical group, 20.8% versus 1.7% (P 0.001, number needed to treat 5 [3–13, 95% confidence intervals]). However, in studies performed by Cetti et al. and Nistor, no significant differences in rerupture rates were demonstrated between surgical and nonsurgical treatment groups, 12.7% versus 5.4% and 8% versus 4.5%, respectively. Möller et al. also identified a significant difference in patients’ opinion of treatment methods and quality of life during treatment (P 0.0001); patients preferred surgical treatment with early functional mobilization. While there was no significant difference between both groups for length of time before return to work, patients with jobs requiring mobility returned to work sooner after surgical treatment (P 0.03). Cetti et al. also found that surgical treatment resulted in a better outcome and patient satisfaction than nonsurgical treatment. However, there was no significant difference in the mean length of time off work, major complications, or rerupture rate. At the 12-month follow-up, a greater proportion of patients in the surgical group had normal ankle movements, smaller reduction in calf circumference, and returned to sports at the same level of activity as in the nonsurgical group (P 0.005). Nonsurgical treatment resulted in significantly lower rates of minor complications (P 0.004). Nistor identified a significantly increased length of time off work after surgical repair, increased patient satisfaction after nonsurgical treatment, but no differences in level of activity or plantar flexion strength. Nonsurgical treatment produced as good a functional outcome as surgical treatment, with less risk of complications. It therefore appears that surgical treatment is superior to nonsurgical treatment in the prevention of rerupture in the management of acute complete Achilles tendon rupture. The number needed to treat surgically to prevent one rerupture if these patients were treated nonsurgically is 5 (3–13, 95% confidence intervals).