SLR - October 2018 - Jason C. Spector

Augmented Versus Nonaugmented Repair of Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis

Reference: Zhang, Y. J., Zhang, C., Wang, Q., & Lin, X. J. (2018). Augmented Versus Nonaugmented Repair of Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis. The American journal of sports medicine, 46(7), 1767–1772.

Scientific Literature Review

Reviewed By: Jason C. Spector, DPM
Residency Program: Northwest Medical Center, Margate, FL

Podiatric Relevance: Acute Achilles Tendon ruptures are commonly treated with surgical intervention, especially in the young and active patient population. Surgical repair ensures a lower rerupture rate and facilitates a faster recovery of muscle strength. Current surgical repair techniques include simple end-to-end repair, suture with augmentation and percutaneous. Nonaugmented repairs feature a shorter incision with lower prevalence of wound complications while augmented repairs reportedly have increased tensile strength. Few studies have examined the clinical benefits between repairs, prompting a thorough systemic review and meta-analysis by the authors. They sought to determine whether augmented repair improved clinical satisfaction (versus nonaugmented repair) based on prospective, randomized controlled trials (RCTs). The results of this investigation may help surgeons determine whether or not to implement augmented surgical techniques in repair of acute Achilles Tendon ruptures.

Methods: This paper was a meta-analysis conducted study. A literature search on PubMed, Web of Science and EMBASE was performed on peer-reviewed articles to isolate all RCTs comparing augmented to nonaugmented acute Achilles tendon repair from January 1980 to August 2016. Articles were selected based on risk of bias, modified Coleman score and level of evidence. All included studies were level 1 with a modified Coleman score of greater than 80. Data collection included authors, number of patients, mean age, surgical procedure, subjective outcome satisfaction, rerupture rate, Leppilahti score, AOFAS score, ankle joint motion, calf muscle strength and minor surgical complications.

Results: There were 1,857 articles identified by the author’s literature search. After systematic filtering with specific inclusion and exclusion criteria, 69 RCTs remained. The authors then read the full text of each article and decided to analyze four articles. The included studies utilized single end-to-end suture technique for nonaugmented repair. Augmented repair was performed with a gastrocnemius fascial flap in three studies and plantaris tendon in one study. One hundred sixty-nine total patients were analyzed (83 augmented versus 86 nonaugmented repairs). The authors' results showed no increased satisfaction rate with augmented versus nonaugmented repair (93 percent and 90 percent, respectfully). No significant differentiation was found for rerupture rate (7.2 percent for augmented and 9.3 percent for nonaugmented), superficial and deep infections or other associated complications. In addition, mean loss of calf circumference, ankle joint range of motion and mean relative isometric deficit of plantarflexion strength were similar between augmented and nonaugmented repairs.

Conclusions: This paper marks the first meta-analysis study on RCTs comparing augmented and nonaugmented acute Achilles tendon rupture repairs. Augmented repair has been previously considered in order to lower the rerupture rate following tendon repair, providing stronger reconstruction and stability. The results of this paper do not suggest increased patient satisfaction after augmented repair. In particular, time to return to work and sport did not significantly differ between the two groups. The authors conclude that augmented repair of acute Achilles tendon rupture does not reduce rerupture rate or infection rate but increases incision length and prolongs operating time. The results of this study provide a foundation for surgeons to appropriately consider acute Achilles tendon repair with or without augmentation. 

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