Treatment of Acute Achilles Tendon Ruptures: A Meta-Analysis of Randomized, Controlled Trials

• Published in: Journal of bone and joint surgery. American volume 2005-10, Vol.87 (10), p.2202-2210
• Main Authors: Khan, Riaz J.K, Fick, Dan, Keogh, Angus, Crawford, John, Brammar, Tim, Parker, Martyn
• Format: Article
• Language: English
• Subjects: Achilles Tendon - injuries; Acute Disease; Biological and medical sciences; Diseases of the osteoarticular system; Humans; Injuries of the limb. Injuries of the spine; Manipulation, Orthopedic; Medical sciences; Orthopedic Fixation Devices; Orthopedic Procedures; Orthopedic surgery; Randomized Controlled Trials as Topic; Rupture; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Tendon Injuries - therapy; Traumas. Diseases due to physical agents; Treatment Outcome
• ISSN: 0021-9355; 1535-1386
• DOI: 10.2106/JBJS.D.03049

BackgroundThere is a lack of consensus regarding the best option for the treatment of acute Achilles tendon rupture. Treatment can be broadly classified as operative (open or percutaneous) or nonoperative (casting or functional bracing). Postoperative splinting can be performed with a rigid cast (proximal or distal to the knee) or a more mobile functional brace. The aim of this meta-analysis was to identify and summarize the evidence from randomized, controlled trials on the effectiveness of different interventions for the treatment of acute Achilles tendon ruptures.MethodsWe searched multiple databases (including EMBASE, CINAHL, and MEDLINE) as well as reference lists of articles and contacted authors. Keywords included Achilles tendon, rupture, and tendon injuries. Three reviewers extracted data and independently assessed trial quality with use of a ten-item scale.ResultsTwelve trials involving 800 patients were included. There was a variable level of methodological rigor and reporting of outcomes. Open operative treatment was associated with a lower risk of rerupture compared with nonoperative treatment (relative risk, 0.27; 95% confidence interval, 0.11 to 0.64). However, it was associated with a higher risk of other complications, including infection, adhesions, and disturbed skin sensibility (relative risk, 10.60; 95% confidence interval, 4.82 to 23.28). Percutaneous repair was associated with a lower complication rate compared with open operative repair (relative risk, 2.84; 95% confidence interval, 1.06 to 7.62). Patients who had been managed with a functional brace postoperatively (allowing for early mobilization) had a lower complication rate compared with those who had been managed with a cast (relative risk, 1.88; 95% confidence interval, 1.27 to 2.76). Because of the small number of patients involved, no definitive conclusions could be made regarding different nonoperative treatment regimens.ConclusionsOpen operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with nonoperative treatment, but operative treatment is associated with a significantly higher risk of other complications. Operative risks may be reduced by performing surgery percutaneously. Postoperative splinting with use of a functional brace reduces the overall complication rate.Level of EvidenceTherapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.