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Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR.

Methods

Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance.

Results

There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3–5%) versus conservative treatment (3.9–13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5–10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation.

Conclusion

This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR.

Level of evidence

IV.

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Data availability

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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Authors and Affiliations

  1. NYU Langone Health, NYU Langone Orthopedic Hospital, 171 Delancey Street, New York, NY, 10002, USA

    Dexter Seow, Wasif Islam, Grace W. Randall, Mohammad T. Azam, Matthew L. Duenes & John G. Kennedy

  2. National University Health System, Singapore, Singapore

    Dexter Seow, James Hui & Christopher J. Pearce

  3. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Dexter Seow, James Hui & Christopher J. Pearce

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  1. Dexter Seow
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  2. Wasif Islam
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  3. Grace W. Randall
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All authors contributed to the data collection, data analysis and writing of the manuscript.

Corresponding author

Correspondence to John G. Kennedy.

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Conflict of interest

Two of the authors declare conflicts of interest (C.J.P. and J.G.K.). C.J.P. is on the ESSKA-AFAS editorial board: Knee Surgery, Sports Traumatology, Arthroscopy. J.G.K. received support from the Ohnell Family Foundation and Mr. and Mrs. Michael J. Levitt. J.G.K. is a consultant for Arteriocyte Industries (Isto Biologics) and Arthrex®. J.G.K. receives research funding from Winston Fisher. The remaining authors declare no conflicts of interest.

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Seow, D., Islam, W., Randall, G.W. et al. Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses. Knee Surg Sports Traumatol Arthrosc 31, 3528–3540 (2023). https://doi.org/10.1007/s00167-023-07411-1

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