Summary

This systematic review found that surgical treatment was significantly favored over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury.

Abstract

Background

Acute Achilles tendon rupture (AATR) is a common injury with an incidence rate of up to 31 per 100,000 per year. Multiple meta-analyses have been published on the treatment of AATR, with conflicting conclusions. The purpose of this study is to systematically review and evaluate the current meta-analyses for the treatment of 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 two-fold: 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 favor 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 favored 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 favored in terms of lower complication rates (7.5%-10.4%). When comparing rehabilitation protocols following open repair (4 studies), conservative treatment (9 studies), or combined (3 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 favored 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. However, further meta-analysis controlling for differences in rehabilitation protocols is necessary to make further conclusions.