SLR - September 2019 - Maybelle C. Maningat
Reference: Wu Y, Mu Y, Yin L, Wang Z, Liu W, Wan H. Complications in the Management of Acute Achilles Tendon Rupture: A Systematic Review and Network Meta-analysis of 2060 Patients. Am J Sports Med. 2019 Jul; 47(9), 2251-2260.Scientific Literature Review
Reviewed By: Maybelle C. Maningat, DPM
Residency Program: Hoboken University Medical Center – Hoboken, NJ
Podiatric Relevance: The effectiveness of various treatment modalities and rehabilitation regimens of acute Achilles tendon ruptures (AATR) has been widely studied in recent years, with reports of effectiveness using different standards. Treatment modalities include open surgery (OS), minimally invasive surgery (MIS), and non-operative (NS). Rehabilitation regimens are classified as cast immobilization (EI) and accelerated rehabilitation (AR). However, there exists a variation in standard treatments which impedes the comparability of such studies in determining ideal combination of treatment and rehabilitation. This systematic review and network meta-analysis studies the treatment modalities and rehabilitation regimen for AATR, and compares the combination of treatment and rehabilitation with overall incidence of three major complications: deep vein thrombosis (DVT), deep infection, and re-rupture, to determine the best management.
Methods: A systematic review and network meta-analysis was completed according to PRISMA guidelines and evaluated randomized controlled trials (RCT) of AATR. This included a total of six different treatment and rehabilitation (T+R) methods. Three treatment modalities included were: non-surgery, minimally invasive surgery, and open surgery. Two rehabilitation regimens included were early immobilization and accelerated rehabilitation. A literature search from date of inception through February 2018 was performed; noting inclusion criteria specific for patient, interventions for control subjects, outcome measures, and study design. Cochrane “risk of bias” was used to determine study quality assessment. Primary outcome measures included re-rupture, deep infection, and DVT. Secondary outcomes included incidence of minor complications in different treatments, of which were mostly skin- and tendon-related. Ranking probabilities for all (T+R) methods were estimated, and presented as the percentage of the area under the curve, which were presented as SUCRA.
Results: Twenty-nine reports published between 1981 and 2017 were included in this study. Two thousand and sixty patients were included in the analysis, with network comparisons of the six different management methods and risk of major complications: A (NS+AR), B (MIS+AR), C (OS+AR), D (NS+EI), E (MIS+EI), F (OS+EI). The mean incidence of overall major complications from all management methods was 9.13 percent. Management B (MIS+AR) showed a significantly lower risk of major complications with relative risk (RR) of 0.22. For minor complications, significant heterogeneity was found. There was no statistically significant relationship between complication results and study size, year, male percentage, and follow-up.
Conclusions: All management combinations were ranked and discovered to be the safest way to treat AATR in terms of having the lowest risk of DVT, deep infection, and re-rupture. The authors suggest that the complication risks were as important as the effectiveness outcomes in evaluating the complete management method of AATR. Management B (MIS +AR) had the lowest complication risk, concluding that it was the best treatment modality. There are significant limitations of this study, as AR covers several rehabilitation protocols that differ significantly. Second, the quality of some included studies influenced the main results. Lastly, patients lost to follow-up may have developed complications without being reported. MIS+AR was found to be superior in the management modality in terms of fewer major complications. Notably NS+EI is significantly associated with the highest risk of complications.