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
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)
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.
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)
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. 2001 I 9 6 448 Soroceanu et al. 2012 I 9 5 447 Jones et al. 2012 I 9 2 216 Van der Eng et al. 2013 I 7 7 624 Operative vs. Non-Operative Treatment (with Early Functional Rehabilitation) Soroceanu et al. 2012 I 9 5 379 Jones et al. 2012 I 9 5 402 Van der Eng et al. 2013 I 7 7 624 Conservative Rehabilitation vs. Early Functional Rehabilitation (with Operative Treatment) Khan et al. 2005 I 6 5 273 Suchak et al. 2006 I 10 6 315 Huang et al. 2014 (EWB) I 8 6 279 Huang et al. 2014 (EM) I 8 3 131 McCormack et al. 2015 I 9 10 570 Open vs. Percutaneous Repair (with Conservative Rehabilitation) Khan et al. 2005 I 6 2 94 McMahon et al. 2010 I 9 6 277 Khan et al. 2010 I 9 4 174 Jones et al. 2012 I 9 4 174
Results Operative vs Non-Operative Treatment (with Conservative Rehabilitation) Outcome Operative (%) Non-Operative (%) P-value Re-Rupture Soroceanu et al. 2012 N/A N/A < 0.01 Jones et al. 2012 5.0% 10.4% n.s Bhandari et al. 2001 3.1% 13.0% < 0.01 Van der Eng et al. 2013 6.5% 10.0% 0.35 Wound Infection Bhandari et al. 2001 4.7% 0.0% n.s Return to Function Bhandari et al. 2001 68.2% 63.3% n.s Minor Complications Van der Eng et al. 2013 4.6% 0.0% n.s Major Complications Van der Eng et al. 2013 5.6% 3.6% n.s Total Complaints Bhandari et al. 2001 19.1% 25.1% n.s n.s; not significant
Results Operative vs Non-Operative Treatment (with Early Functional Rehabilitation) Outcome Operative (%) Non-Operative (%) P-value Re-Rupture Soroceanu et al. 2012 N/R N/R n.s Jones et al. 2012 5.0% 8.0% n.s Van der Eng et al. 2013 3.8% 11.9% n.s Minor Complications Van der Eng et al. 2013 15.4% 8.5% n.s Major Complications Van der Eng et al. 2013 5.5% 2.8% n.s n.s; not significant, N/R; rate not reported
Results Conservative Rehabilitation vs Early Functional Rehabilitation (with Operative Treatment) Outcome Conservative (%) Early Functional (%) P-value Re-Rupture Khan et al. 2005 5.0% 2.3% n.s Suchak et al. 2006 2.6% 3.9% n.s Huang et al. 2014 (EWB) 3.0% 2.1% n.s Huang et al. 2014 (EM) N/R N/R n.s Return to Sport Huang et al. 2014 (EWB) N/R N/R 0.04 Huang et al. 2014 (EM) N/R N/R n.s McCormack et al. 2015 81.2% 78.8% n.s Wound Complications Suchak et al. 2006 2.6% 3.9% n.s Minor Complications Huang et al. 2014 (EWB) N/R N/R 0.03 Huang et al. 2014 (EM) N/R N/R n.s Major Complications Huang et al. 2014 (EWB) N/R N/R n.s Huang et al. 2014 (EM) N/R N/R n.s McCormack et al. 2015 4.3% 6.7% n.s Total Complications (Other than Re-Rupture) Khan et al. 2005 35.7% 19.6% 0.04 n.s; not significant, N/R; rate not reported
Results Open vs. Percutaneous Repair (All with Conservative Rehabilitation) Outcome Open (%) Percutaneous (%) P-value Re-Rupture Khan et al. 2005 4.3% 2.1% n.s McMahon et al. 2010 2.2% 1.4% n.s Khan et al. 2010 2.3% 1.1% n.s Jones et al. 2012 N/R N/R n.s Wound Infection Khan et al. 2005 9.6% 0.0% 0.02 Khan et al. 2010 18.2% 0.0% 0.01 McMahon et al. 2010 16.7% 0.0% < 0.01 Jones et al. 2012 18.2% 0.0% 0.01 Other Complications Khan et al. 2005 26.1% 8.3% 0.04 n.s; not significant, N/R; rate not reported
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.
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