SLR - November 2021 - Deep N. Shah

What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Reference: Meulenkamp, Brad, et al. “What Is the Best Evidence to Guide Management of Acute Achilles Tendon Ruptures? A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.” Clinical Orthopaedics & Related Research, Publish Ahead of Print, 2021, doi:10.1097/corr.0000000000001861.

Level of Evidence: Level I, therapeutic study

Scientific Literature Review

Reviewed By: Deep N. Shah, DPM, MBA
Residency Program: Crozer Keystone Health System – Chester, PA

Podiatric Relevance: Achilles tendon ruptures are debilitating conditions requiring intensive rehabilitation no matter the treatment. Despite the rising incidence, uncertainty exists regarding the best treatment for acute Achilles tendon ruptures. Numerous meta-analyses have been performed to establish the superiority of one treatment over another (i.e. operative vs. non-operative vs. functional rehabilitation). However, simultaneous comparison of the multiple treatment options using traditional study designs is problematic due to logistical constraints such as small sample sizes and limited treatment comparisons. Simultaneous comparison of head-to-head studies and not previously compared head-to-head evidence showed that risk of re-rupture after acute Achilles rupture is no different across contemporary treatments.  

Methods: Five databases and grey literature sources were searched from inception to September 30, 2019 comparing treatment of acute Achilles tendon ruptures using primary immobilization, functional rehabilitation, open surgical repair, or MIS repair. Nineteen RCTs (1316 patients) were included in the final analysis.  Inclusion criteria: two or more interventions for treatment of first-time, acute (less than four weeks since injury), with a minimum follow-up of six months. The mean number of patients per study treatment arm was 35 +/- 16, mean age was 41 +/- 5 years, mean sex composition was 80 percent males, and mean follow-up was 22 +/- 12 months. Exclusion criteria included preprint servers and foreign-language journals, specified databases, chronic ruptures, reruptures, preexisting Achilles tendinopathy, and studies greater than 20 percent or less than six-month loss to follow up. Interventions of interest included cast immobilization with delayed weight bearing for at least six weeks, bracing and/or splinting with ROM earlier than 6 weeks (functional rehabilitation), open surgical repair, and percutaneous or minimally open surgical repair (MIS). MIS treatment included all surgical modalities that did not completely open and reflect the paratenon, including limited transverse incisions, suture-shuttling techniques, and device-assisted techniques. The primary outcomes for quantitative synthesis were rerupture and post-treatment complications resulting in surgery. Secondary outcomes included functional outcome score, strength, and ROM. Both outcomes were evaluated at the longest reported follow-up.

Results: Greatest risk of rerupture was found in primary immobilization than open surgery. Also, minimally invasive surgery had fewest complications, and lowest risk than functional rehabilitation, open surgery, and primary immobilization. Risk of complications resulting in surgery was no different between primary immobilization and open surgery.

Conclusions: Risk of rerupture was not different between open surgical repair, MIS repair, and functional rehabilitation. Primary immobilization was associated with a greater risk of rerupture than open repair. There was a lower risk of complications resulting in surgery with MIS repair relative to both open surgery and functional rehabilitation, and they found no difference in risk between functional rehabilitation and open surgery. Additionally, MIS repair was associated with a lower risk of complications, while immobilization was associated with a greater risk of complication resulting in surgery than open surgical repair. Further exploration is needed to differentiate serious but infrequent complications (i.e., deep infection) between contemporary treatments. 

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