Best Evidence to Guide Management of Acute Achilles Tendon Ruptures

Key points

Overview

This systematic review used network meta-analysis to compare four treatments for acute Achilles tendon rupture in a single analysis, including comparisons rarely made head to head in trials. The authors conclude that patients can be counselled that rerupture risk is likely no different across contemporary treatments, while MIS repair may carry a lower risk of complications resulting in surgery, a benefit to be balanced against the potential risks of MIS techniques.

Background

Achilles tendon ruptures are described as common and debilitating, typically in 30- to 40-year-old males, with little consensus on the best treatment. Complications largely unique to surgery, such as wound dehiscence and infection, occur in up to 10% to 15% of treated patients. Functional rehabilitation with early weightbearing and ankle mobilization has been used more widely, and surgical treatment has fallen by more than 50% over the past 20 years, a trend not seen in the United States.

Methods

Medline, Embase, CINAHL, PEDro and the Cochrane Central Register were searched up to September 30, 2019. Eligible trials compared two or more treatments for first-time acute ruptures (less than 4 weeks since injury) with at least 6 months of follow-up. Primary immobilization meant cast immobilization with delayed weightbearing for at least 6 weeks; functional rehabilitation required ankle range of motion before 6 weeks. From 630 citations, 19 trials published between 1981 and 2018 were included; mean age was 41 years, 80% of participants were male and mean follow-up was 22 months.

Rerupture

Compared with open repair, the odds of rerupture did not differ for MIS repair (OR 0.96) or functional rehabilitation (OR 2.18), and functional rehabilitation did not differ from MIS. Primary immobilization had greater odds of rerupture than open repair (OR 4.06, 95% credible interval 1.47 to 11.88). Open repair and MIS were ranked most favourably for this outcome.

Complications resulting in surgery

In 15 trials with 949 patients, MIS repair had lower odds of complications resulting in surgery than open repair (OR 0.22, 95% credible interval 0.04 to 0.93) and functional rehabilitation (OR 0.16), whereas functional rehabilitation and open repair did not differ. Immobilization carried a greater risk than any other treatment. The authors point to moderate-quality evidence for MIS versus open repair, with a number needed to treat of 40.

Limitations

Reruptures were counted in both outcomes, so treatments with more reruptures are overrepresented in the second endpoint. Minor complications and sural nerve injury (24% of complications after MIS) could not be analysed, and patient-reported outcomes and return to work or sport were not pooled because the evidence was heterogeneous.

Frequently asked questions

Does surgery lower the risk of rerupture compared with functional rehabilitation?

No difference in rerupture risk was found between open repair, MIS repair and functional rehabilitation; only primary immobilization had a higher risk than open repair.

Why might MIS repair be preferred?

It was associated with fewer complications resulting in surgery, but the authors stress weighing this against the drawbacks of MIS techniques, such as sural nerve injury.

Which outcomes could not be assessed?

Patient-reported function, return to work or sport, and minor complications were not analysed because of small samples, heterogeneity or inconsistent reporting.

Source

Meulenkamp B, Woolnough T, Cheng W, Shorr R, Stacey D, Richards M, Gupta A, Fergusson D, Graham ID. 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 and Related Research 2021;479(10):2119-2131. DOI: 10.1097/CORR.0000000000001861. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.