Background: There is a lack of consensus regarding the best option
for the treatment of acute Achilles tendon rupture. Treatment can be broadly
classified as operative (open or percutaneous) or nonoperative (casting or
functional bracing). Postoperative splinting can be performed with a rigid
cast (proximal or distal to the knee) or a more mobile functional brace. The
aim of this meta-analysis was to identify and summarize the evidence from
randomized, controlled trials on the effectiveness of different interventions
for the treatment of acute Achilles tendon ruptures.
Methods: We searched multiple databases (including EMBASE, CINAHL,
and MEDLINE) as well as reference lists of articles and contacted authors.
Keywords included Achilles tendon, rupture, and tendon injuries. Three
reviewers extracted data and independently assessed trial quality with use of
a ten-item scale.
Results: Twelve trials involving 800 patients were included. There
was a variable level of methodological rigor and reporting of outcomes. Open
operative treatment was associated with a lower risk of rerupture compared
with nonoperative treatment (relative risk, 0.27; 95% confidence interval,
0.11 to 0.64). However, it was associated with a higher risk of other
complications, including infection, adhesions, and disturbed skin sensibility
(relative risk, 10.60; 95% confidence interval, 4.82 to 23.28). Percutaneous
repair was associated with a lower complication rate compared with open
operative repair (relative risk, 2.84; 95% confidence interval, 1.06 to 7.62).
Patients who had been managed with a functional brace postoperatively
(allowing for early mobilization) had a lower complication rate compared with
those who had been managed with a cast (relative risk, 1.88; 95% confidence
interval, 1.27 to 2.76). Because of the small number of patients involved, no
definitive conclusions could be made regarding different nonoperative
Conclusions: Open operative treatment of acute Achilles tendon
ruptures significantly reduces the risk of rerupture compared with
nonoperative treatment, but operative treatment is associated with a
significantly higher risk of other complications. Operative risks may be
reduced by performing surgery percutaneously. Postoperative splinting with use
of a functional brace reduces the overall complication rate.
Level of Evidence: Therapeutic Level I. See Instructions
to Authors for a complete description of levels of evidence.