Multiple comparisons of the efficacy and safety for six treatments in Acute Achilles Tendon Rupture patients: A systematic review and network meta-analysis

Highlights

• Minimally Invasive Repair can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications and good prognosis.

• Accelerated Functional Rehabilitation is superior to Traditional Standard Rehabilitation without increasing the risk of re-rupture under strict rehabilitation management.

• Minimally Invasive Repair & Accelerated Functional Rehabilitation is the best therapeutic regime for Acute Achilles Tendon Rupture and more RCTs focused on AATR are needed.

Abstract

Background

The choice of the best therapeutic regimen for Acute Achilles Tendon Rupture (AATR) remains controversial. Our study aims to evaluate the efficacy and safety of therapeutic regimens in AATR patients using a network meta-analysis of data from clinical randomized controlled trials.

Material/methods

The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA).

Results

38 randomized controlled trials involving 2480 participants were included. The studies were published between 1981 and 2019. A total of 6 therapeutic regimens –open repair (OR), minimally invasive repair (MIR) and nonoperative treatment (non) combined with traditional standard rehabilitation (TSR) and accelerated functional rehabilitation (AFR) - were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the re-rupture rate, the therapeutic regimens were ranked as follows: OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR. In terms of the wound-related complication, the therapeutic regimens were ranked as follows: MIR&AFR, nonoperative treatment &AFR, MIR&TSR, nonoperative treatment &TSR, OR&AFR and OR&TSR. In terms of the sural nerve injury, the therapeutic regimens were ranked as follows: non, OR and MIR. In terms of the deep venous thrombosis, the therapeutic regimens were ranked as follows: MIR&AFR, OR&AFR, nonoperative treatment &AFR, OR&TSR, MIR&TSR and nonoperative treatment &TSR. In terms of the returning back to sport, the therapeutic regimens were ranked as follows: MIR&TSR, OR&AFR, OR&TSR, nonoperative treatment &AFR, nonoperative treatment &TSR and MIR&AFR.

Conclusions

MIR can repair the ruptured Achilles tendon and narrow the tendon gap with low risk of complications. AFR is superior to TSR without increasing the risk of rerupture. MIR&AFR is the best therapeutic regime for AATR. More RCTs focused on AATR are needed to further indicate this conclusion.

Introduction

The Achilles tendon (AT), the thickest and strongest tendon in the human body, plays a vital role in activities ranging from walking to athletics [1]. The incidence of Achilles tendon ruptures varies between 7 and 40 per 100,000 people depending on the target population and has been reported to be increasing [[2], [3], [4]]. Achilles tendon rupture is most common in young to the middle-aged active population who playing sport occasionally with a male-to-female ratio of 1.7:1 to 30:1. Acute Achilles Tendon Rupture (AATR) has a major impact on the quality of life of affected patients and the social economy [5,6].

The optimal management of AATR is controversial in recent studies [[7], [8], [9]]. Treatment includes open repair (OR), minimally invasive repair (MIR), and nonoperative treatment [10]. OR requires about 10 cm of vertical posteromedial incision and substantially reduces the risk of re-rupture. However, postoperative complications, including wound necrosis, infection, and adhesions, have been a tricky problem for surgeons. MIR, including Ma and Griffith's technique [11], Dresden technique [12], Tenolig [13] and Achillon [14], reduces incision length and minimizes the exposure of the Achilles tendon, thus reducing complications compared with OR [10,15]. Meanwhile, MIR has an acceptable re-rupture rate. Finally, nonoperative treatment is a well-accepted treatment modality in some regions with an 8.8–9.7% re-rupture rate [16,17].

Postoperative rehabilitation plays a significant role in management of AATR [[18], [19], [20]]. Postoperative rehabilitation can be divided into two rehabilitation regimens, including traditional standard rehabilitation(TSR) and accelerated functional rehabilitation(AFR). Traditional standard rehabilitation regimens include traditional cast immobilization for least 4 weeks then carry out functional exercise and weight-bearing. Accelerated functional rehabilitation regimens include controlled early functional exercise, controlled early weight-bearing or a combination of the two.

In recent years, studies have compared different combinations of various treatments and postoperative rehabilitation regimens for AATR using traditional meta-analysis [2,5,[21], [22], [23], [24], [25], [26], [27], [28], [29]]. Compared with traditional meta-analysis, network meta-analysis can be used to compare more than 3 interventions, even without direct comparisons [30,31].

Therefore, we carried out a network meta-analysis to rank OR&AFR, OR&TSR, MIR&AFR, MIR&TSR, nonoperative treatment &AFR and nonoperative treatment &TSR(Table1). Our study focused on evaluating the re-rupture rate, wound-related complication (Wound/skin infection, Scar/skin adhesion), sural nerve injury, deep venous thrombosis (DVT) and the number of patients returning to sport of the above therapeutic regimes in adults separately and update the included literatures [32] by using a network meta-analysis of the data from clinical randomized controlled trials.