Operative versus nonoperative management of acute Achilles tendon rupture: expected-value decision analysis.
BACKGROUND
The optimal management strategy for acute Achilles tendon rupture is controversial.


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


METHODS
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.
Kocher
Mininder S
MS
Steadman-Hawkins Sports Medicine Foundation, Vail, Colorado, USA.
Bishop
Julius
J
Marshall
Ryan
R
Briggs
Karen K
KK
Hawkins
Richard J
RJ
D000125:Achilles Tendon / Q000293:injuries* / Q000601:surgery*; D003430:Cross-Sectional Studies; D003661:Decision Support Techniques; D003663:Decision Trees; D006801:Humans; D012421:Rupture