SLR - March 2013 - Patel
Reference: Alaxandra Soroceanu, MD, CM, MPH, Feroze Sidhwa, MD, MPH, Shahram Aarabi, MD, MPH, Annette Kaufman, MPH, PhD, and Mark Glazebrook, MD, PhD. J Bone Joint Surg Am. 2012 Dec 5;94-A(23):2136-43.
Scientific Literature Review
Reviewed by: Nilesh Patel, DPM
Residency Program: St. Vincent Hospital, Worcester, MA
Podiatric Relevance:
Acute Achilles tendon ruptures are a common injury seen in the lower extremity. Whether to surgically repair or conservatively treat the acute ruptured tendon has been analyzed in many articles. A reduction in the re-rupture rate by surgical repair has been generally accepted in North America. However, more current trials using functional bracing with early range of motion have tested this belief. This meta-analysis compared surgical treatment vs. conservative treatment with regard to: re-rupture rate, overall rate of complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the re-rupture rate.
Methods:
Two independent reviewers conducted a literature search, data extraction and quality assessment. Egger and Begg tests were performed to assess publication bias. I2 test was used to assess heterogeneity with fixed or random-effect models. Results were pooled groups of: risk ratios, risk differences, and weighted or standardized mean differences. The cause of heterogeneity was identified using meta-regression and subgroup analysis was used to analyze the effects of early range of motion.
Results:
A total of 10 studies met the inclusion criteria. This article suggests that surgical treatment and nonsurgical treatment of acute Achilles tendon rupture were equivalent with regard to re-rupture rate when the nonsurgical treatment protocol included early range of motion (risk difference -1.7 percent, p=0.45). However, if such functional rehabilitation was not employed, surgical repair reduced the re-rupture risk by 8.8 percent (p=0.001 in favor of surgery). The risk for other complications for surgically treated patients was 3.9 times that of nonsurgical patients, which resulted in an absolute risk increase of 15.8 percent (p=0.016 in favor of nonoperative management) for complications other then re-rupture. Patients undergoing surgical treatment were able to return to work about 19 days sooner (p=0.0014), on average than patients that underwent nonsurgical treatment, though the sample pool was small. Calf circumference (p=0.357), strength (p=0.806), or functional outcome (p=0.226) yielded no significant difference.
Conclusions:
According to the results of this meta-analysis, non-surgical treatment represents a reasonable treatment choice at centers that use functional rehabilitation with early range of motion since surgical repair did not decrease the rate of re-rupture and was associated with higher complication rate. Surgical repair can be considered at centers that do not employ early range of motion, or who are poor candidates. Even with the increase risk in overall post-complications, the re-rupture rates did decrease. The increased risk of having a complication other than a re-rupture in the surgical group (risk difference, 15.5 percent) appears to be more important than the increased risk of having a re-rupture (risk difference, 8.8 percent) in the nonsurgical group. It should be noted that the risk difference percentage is opinionated by each surgeon.