Achilles Tendon Repair- A Systematic Review of Overlapping Meta-Analysis

Transcription

1 Achilles Tendon Repair- A Systematic Review of Overlapping Meta-Analysis Eoghan T. Hurley 1,2, Youichi Yasui 1,3, Arianna L. Gianakos 1, Dexter Seow 1,2, Joseph Kromka 1,5, Yoshiharu Shimozono 1, Robin Megill 1, John G. Kennedy 1 1 Hospital for Special Surgery, New York, NY 2 Royal College of Surgeons in Ireland, Dublin, Ireland 3 Teikyo University School of Medicine, Department of Orthopaedic Surgery, Tokyo, Japan 4 Jersey City Medical Center, Department of Orthopaedic Surgery, Jersey City, NJ 5 University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

2 Disclosure John G. Kennedy MD, FRCS (Orth): Consultant Arteriocyte, Inc. Research Support Ohnell Family Founda6on Mr. & Mrs. Michael J. Levi= Arteriocyte, Inc. Board Member European Society of Sports Traumatology, Knee Surgery, and Arthroscopy (ESSKA) Interna6onal Society for Car6lage Repair of the Ankle (ISCRA)

3 Background Acute Achilles tendon ruptures (ATR) are a common sportsrelated injury with an incidence of between 8-37 per 100,000 per year. While there are several meta-analyses published on the optimal treatment of ATR based on randomized control trials, the reported outcomes conflict between each meta-analysis due to different methodologies. The aim of this study is to systematically review the clinical results represented in meta-analyses in the current literature on acute ATR.

4 Methods Cochrane Library, EMBASE, MEDLINE were screened using the PRISMA guidelines used to identify meta-analyses on Achilles tendon repair Level of evidence (LOE), and methodological quality of evidence (MQOE) using the AMSTAR score, were evaluated The following variables were collected for each study Re-rupture rate, wound infections, return to sport, and total complications Each meta-analysis was categorized into one of the following subgroupings: 1) Operative vs Non-Operative Treatment (with Conservative Rehabilitation) 2) Operative vs Non-Operative Treatment (with Functional Rehabilitation) 3) Conservative Rehabilitation vs Functional Rehabilitation (with Operative Treatment) 4) Open vs. Percutaneous Repair (with Conservative Rehabilitation)

5 Results Included Study Characteristics Study LOE MQOE No. of Included Studies No. of Patients Operative vs. Non-Operative Treatment (with Conservative Functional Rehabilitation) Bhandari et al I Soroceanu et al I Jones et al I Van der Eng et al I Operative vs. Non-Operative Treatment (with Early Functional Rehabilitation) Soroceanu et al I Jones et al I Van der Eng et al I Conservative Rehabilitation vs. Early Functional Rehabilitation (with Operative Treatment) Khan et al I Suchak et al I Huang et al (EWB) I Huang et al (EM) I McCormack et al I Open vs. Percutaneous Repair (with Conservative Rehabilitation) Khan et al I McMahon et al I Khan et al I Jones et al I

6 Results Operative vs Non-Operative Treatment (with Conservative Rehabilitation) Outcome Operative (%) Non-Operative (%) P-value Re-Rupture Soroceanu et al N/A N/A < 0.01 Jones et al % 10.4% n.s Bhandari et al % 13.0% < 0.01 Van der Eng et al % 10.0% 0.35 Wound Infection Bhandari et al % 0.0% n.s Return to Function Bhandari et al % 63.3% n.s Minor Complications Van der Eng et al % 0.0% n.s Major Complications Van der Eng et al % 3.6% n.s Total Complaints Bhandari et al % 25.1% n.s n.s; not significant

7 Results Operative vs Non-Operative Treatment (with Early Functional Rehabilitation) Outcome Operative (%) Non-Operative (%) P-value Re-Rupture Soroceanu et al N/R N/R n.s Jones et al % 8.0% n.s Van der Eng et al % 11.9% n.s Minor Complications Van der Eng et al % 8.5% n.s Major Complications Van der Eng et al % 2.8% n.s n.s; not significant, N/R; rate not reported

8 Results Conservative Rehabilitation vs Early Functional Rehabilitation (with Operative Treatment) Outcome Conservative (%) Early Functional (%) P-value Re-Rupture Khan et al % 2.3% n.s Suchak et al % 3.9% n.s Huang et al (EWB) 3.0% 2.1% n.s Huang et al (EM) N/R N/R n.s Return to Sport Huang et al (EWB) N/R N/R 0.04 Huang et al (EM) N/R N/R n.s McCormack et al % 78.8% n.s Wound Complications Suchak et al % 3.9% n.s Minor Complications Huang et al (EWB) N/R N/R 0.03 Huang et al (EM) N/R N/R n.s Major Complications Huang et al (EWB) N/R N/R n.s Huang et al (EM) N/R N/R n.s McCormack et al % 6.7% n.s Total Complications (Other than Re-Rupture) Khan et al % 19.6% 0.04 n.s; not significant, N/R; rate not reported

9 Results Open vs. Percutaneous Repair (All with Conservative Rehabilitation) Outcome Open (%) Percutaneous (%) P-value Re-Rupture Khan et al % 2.1% n.s McMahon et al % 1.4% n.s Khan et al % 1.1% n.s Jones et al N/R N/R n.s Wound Infection Khan et al % 0.0% 0.02 Khan et al % 0.0% 0.01 McMahon et al % 0.0% < 0.01 Jones et al % 0.0% 0.01 Other Complications Khan et al % 8.3% 0.04 n.s; not significant, N/R; rate not reported

10 Discussion & Conclusion Overall there exists a large volume of high quality meta-analyses on Achilles tendon repair. There currently persists conflicting information on whether early functional rehabilitation reduces the difference between operative and non-operative treatment. Operative treatment has been shown to have a higher rate of wound complications, although the rates of deep wound infections remains to be determined. Percutaneous repair resulted in similar re-rupture rates when compared to open surgery but for the rates of other complications including wound infections, this was diminished. Further meta-analyses which compare all cohorts are needed to ascertain best evidence.

11 References 1. Bhandari M, Guyatt GH, Siddiqui F, et al. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res. 2002;(400): Huang J, Wang C, Ma, X, Wang X, Zhang C, Chen L. Rehabilitation Regimen After Surgical Treatment of Acute Achilles Tendon Ruptures: A Systematic Review With Meta-analysis. Am J Sports Med. 2015;43: Jones MP, Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon rupture: key findings from a recent Cochrane review. J Bone Joint Surg Am. 2012;94(12):e Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010;(9): CD Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treat- ment of acute achilles tendon ruptures. A metaanalysis of rando- mized, controlled trials. J Bone Joint Surg Am. 2005;87: McCormack R, Bovard J. Early functional rehabilitation or cast immobilisation for the postoperative management of acute Achilles tendon rupture? A meta-analysis of randomised controlled trials. Br J Sports Med. 2015;49: McMahon SE, Smith TO, Hing CB. A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot Ankle Surg. 2011;17: Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94: Suchak AA, Spooner C, Reid DC, Jomha NM. Postoperative Rehabilitation Protocols for Achilles Tendon Ruptures A Meta-analysis. Clin Orthop Relat Res. 2006;445: van der Eng DM, Schepers T, Goslings JC, Schep NW. Rerupture rate after early weightbearing in operative versus conservative treatment of Achilles tendon ruptures: a meta-analysis. J Foot Ankle Surg. 2013;52:

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