Cochrane in CORR ®: Surgical Interventions for Treating Acute Achilles Tendon Ruptures (Review)

Importance of the Topic In recent decades, the increasing interest in competitive and recreational sport participation among aging adults has been accompanied by a rise in sports-related injuries [2, 5]. Rupture of the Achilles tendon is one of the most common such injuries, typically afflicting men in their fourth and fifth decades of life [2, 4]. It is estimated that the incidence of these injuries is 18 per 100,000 in some regions, a considerable rise from the two per 100,000 estimates in the 1980 s [2-4]. Despite the rising incidence, as well as the lengthy disability and rehabilitation associated with Achilles tendon ruptures, the ideal method of managing such injuries remains a matter of debate [5]. As per the clinical practice guidelines approved by the American Academy of Orthopaedic Surgeons, both surgical and nonsurgical treatment of acute Achilles tendon ruptures are acceptable options. However, the grade of recommendation remains weak for both treatment options, as there is a paucity of high-quality evidence and inconsistency in results to make strong recommendations either way [1]. Accordingly, a rigorous systematic review and meta-analysis of available high-quality evidence was warranted. Upon Closer Inspection Khan and Smith [3] performed a robust meta-analysis comparing several aspects in the management of acute Achilles tendon ruptures. Rerupture rates, complication rates (infections, adhesions, nerve injury) and long-term function, appropriately formed the primary outcomes in this review for which definitive conclusions were sought. However, the capacity of a systematic review to draw unequivocal conclusions hinges directly on the quality of studies that comprise it. Among the 12 randomized controlled trials included in this review, only five (42%) had adequate allocation concealment, four (33%) did not report the method of randomization, and no studies reported the use of blinded outcome assessors. Additionally, there was considerable variation amongst the trials in their postsurgical and nonsurgical rehabilitation protocols. Pooled treatment effects are difficult to interpret in such circumstances, as outcomes are influenced by both the intervention and rehabilitation. Because of the limited number of studies, pooled estimates could not be calculated across all comparisons being investigated. A compelling analysis was that of open surgical repair to nonsurgical management, in which the pooled estimates demonstrated lower rerupture rates (5% versus 12%, risk ratio [RR], 0.41), but higher rates of infection (RR 4.89), adhesions (RR, 11.73), and nerve injury (RR, 7.44) associated with surgical repair. However, this analysis consisted of six small trials with a small number of events in each trial. Take-Home Message Open surgical repair for the management of acute Achilles tendon ruptures appears favorable to nonsurgical management with respect to decreasing the risk of tendon rerupture, but has a higher risk of associated wound and nerve complications. Both surgical and nonsurgical management of such patients remain valid treatment options, as neither has proven superior in all patient important outcomes. However, additional trials that had been identified by the authors at the time of this review, but were not available for inclusion, have since been published. For instance, Willits et al. [6] performed a multicenter randomized trial of 144 patients that were randomized to either open surgical repair with accelerated rehabilitation or to accelerated rehabilitation alone. This trial found no significant difference in rerupture rates between the surgical and nonsurgical treatment arms at three months followup. These findings have been further corroborated by a recent meta-analysis of ten randomized trials comparing surgical intervention to nonsurgical treatment. A stratified analysis demonstrated no significant difference in rerupture rates if a functional rehabilitation protocol with early range of motion was instituted in the nonsurgical group (adjusted relative risk [ARR], 1.7%), whereas surgery significantly reduced rerupture when compare to prolonged immobilization (ARR, 8.8%) [5]. As such, the decision to proceed with surgical versus nonsurgical treatment in the management of acute Achilles tendon ruptures remains a matter of ongoing debate. Given the available evidence, treatment decisions should largely be made based on the available rehabilitation protocol and the preferences of a well-informed patient [5].

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