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Review
. 2012 Dec 5;94(23):2136-43.
doi: 10.2106/JBJS.K.00917.

Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials

Alexandra Soroceanu  1 , Feroze Sidhwa, Shahram Aarabi, Annette Kaufman, Mark Glazebrook
Affiliations
Review

Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials

Alexandra Soroceanu et al. J Bone Joint Surg Am. .

Abstract

Background: Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate.

Methods: A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion.

Results: Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226).

Conclusions: The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients.

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Figures

Fig. 1
Fig. 1
Literature search strategy and results. RCT = randomized controlled trial.
Fig. 2
Fig. 2
Pooled results for the rerupture rate; results favoring operative intervention are plotted on the left. The risk difference between the two groups was 0.055, or 5.5%, in favor of surgery (p = 0.002). RD = risk difference, and CI = confidence interval.
Fig. 3
Fig. 3
Pooled results for the subgroup analysis of the rerupture rate; results favoring operative intervention are plotted on the left. The upper portion of the figure shows a significant difference in the trials that did not use early range of motion, whereas the lower portion shows that there was no significant difference in the trials that used early range of motion. RD = risk difference, and CI = confidence interval.
Fig. 4
Fig. 4
Pooled results for the rate of complications other than rerupture; results favoring operative intervention are plotted on the left. The risk difference was 15.8% in favor of nonsurgical treatment. RD = risk difference, and CI = confidence interval.
Fig. 5
Fig. 5
Pooled results for range of motion; results favoring operative intervention are plotted on the right. WMD = weighted mean difference, and CI = confidence interval.
Fig. 6
Fig. 6
Pooled results for strength; results favoring operative intervention are plotted on the right. SMD = standardized mean difference, and CI = confidence interval.
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References

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