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Operative versus Nonoperative Management of Acute Achilles Tendon Rupture

Expected-Value Decision Analysis

Mininder S. Kocher, MD, MPH^,,, Julius Bishop, Ryan Marshall, Karen K. Briggs, MBA and Richard J. Hawkins, MD

Steadman-Hawkins Sports Medicine Foundation, Vail, Colorado
Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts

Presented at the 68th annual meeting of the American Academy of Orthopaedic Surgeons, San Francisco, California, March 2001.

Address correspondence and reprint requests to Mininder S. Kocher, MD, MPH, Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115

Background: The optimal management strategy for acute Achilles tendon rupture is controversial.

Purpose: To determine the optimal management by using expected-value decision analysis.

Study Design: Cross-sectional study.

Methods: Outcome probabilities were determined from a systematic literature review, and patient-derived utility values were obtained from a visual analog scale questionnaire. A decision tree was constructed, and fold-back analysis was used to determine optimal treatment. Sensitivity analyses were used to determine the effect of varying outcome probabilities and utilities on decision-making.

Results: Outcome probabilities (expressed as operative; nonoperative) were as follows: well (0.762; 0.846), rerupture (0.022; 0.121), major complication (0.030; 0.025), moderate complication (0.075; 0.003), and mild complication (0.111; 0.005). Outcome utility values were well operative (7.9), well nonoperative (7.0), rerupture (2.6), major complication (1.0), moderate complication (3.5), and mild complication (4.7). Fold-back analysis revealed operative treatment as the optimal management strategy (6.89 versus 6.30). Threshold values were determined for the probability of a moderate complication from operative treatment (0.21) and the utility of rerupture (6.8).

Conclusions: Operative management was the optimal strategy, given the outcome probabilities and patient utilities we studied. Nonoperative management was favored by increasing rates of operative complications; operative, by decreasing utility of rerupture. We advocate a model of doctor-patient shared decision-making in which both outcome probabilities and patient preferences are considered.

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