New Meta-Analysis: Surgery vs. Conservative Treatment for Acute Achilles Tendon Rupture
Study Background
Acute Achilles tendon rupture is currently the most common form of Achilles tendon rupture, and its treatment can be divided into conservative and surgical treatment. The traditional view is that conservative treatment of acute Achilles tendon rupture has a higher re-rupture rate and fewer other complications; two meta-analyses of surgical vs. conservative treatment of acute Achilles tendon rupture have been published, and both studies have similar views, with similar long-term postoperative outcomes for conservative and surgical treatment of acute Achilles tendon rupture, differing only in re-rupture rates and complications such as infection.
More recent randomized controlled studies on acute Achilles tendon rupture have been published, and the data from the newly published article were reorganized and analyzed by Alexabdra et al. from the United States, and the results were published in 2012.12.5, issue 94 of JBJS USA.
Literature search strategy: “Achilles tendon” [MeSH or TW], “rupture or tear” [MeSH or TW], “random” [MeSH or TW], a total of 615 relevant literature, of which 596 did not meet the inclusion criteria and 19 remaining articles, 9 of which were excluded due to inconsistent topics or incomplete information, and the remaining 10 articles met the study inclusion criteria.
Study results.
Re-rupture rate: all 10 articles reported on the re-rupture rate for conservative and surgical treatment, and meta-analysis showed that the absolute risk difference between conservative and surgical treatment groups was 5.5%, with a smaller re-rupture rate in the surgical group (p=0.002), and differential analysis of between-group heterogeneity found that early rehabilitation exercises performed after surgery was a more significant heterogeneity factor, and a change in differential factor according to Adjustment of data analysis revealed that if early functional exercise was performed in the conservative treatment group, there was no significant difference in the rate of re-rupture between the surgical and conservative treatment groups (1.7%, p=0.45); whereas if early functional exercise was not performed in the conservative group, there was a significant difference in the rate of re-rupture between the surgical and conservative treatment groups, and the surgical group could significantly reduce the rate of re-rupture (8.8% reduction, p=0.01).
Other complications: 9 papers reported complications other than re-rupture, such as superficial or deep infection, skin or tendon necrosis, scar adhesions, peroneal nerve injury, ankle hypokinesis, Achilles tendon lengthening, deep vein thrombosis, pulmonary embolism, etc. Meta-analysis studies suggested that the above complications occurred less in the conservative treatment group (15.8% reduction, p=0.016).
Time to return to work after surgery: four papers reported the time to return to work after surgery. Analysis of the data showed that the time to return to work was faster in the surgical treatment group than in the conservative treatment group.
Ankle mobility: 3 publications reported the recovery of ankle mobility after surgery in the healthy and affected limbs, and the comparison did not reveal any significant difference between the groups.
Calf gastrocnemius diameter: 3 papers reported on the comparison of gastrocnemius diameter between the healthy and affected limbs after surgery, and data analysis did not reveal any significant differences between groups.
Achilles tendon strength: 6 papers reported the recovery of muscle strength, and the data analysis did not reveal any significant difference between groups.
Functional prognosis: 4 papers reported postoperative functional recovery, and data analysis did not reveal any significant differences between groups.
Analysis of results.
The results of the study suggested that if conservatively treated patients were treated with formal early rehabilitation functional exercise, there was no significant difference between the postoperative Achilles tendon rerupture rate and surgical treatment; whereas if patients did not receive early rehabilitation exercise, their rerupture rate was 8.8% higher than that of the surgical group; the complication rate was 15.8% higher in the surgical treatment group than in the conservative treatment group, while their postoperative return to work was 19.16 days faster than that of the conservative group, but The investigators concluded that this benefit cannot be used as a theoretical support point for surgery being better than conservative treatment, given the inconsistent literature criteria for providing postoperative return to work time, and more randomized studies at a later stage are needed to clarify; while there were no significant differences between groups in ankle motion, calf gastrocnemius diameter, Achilles tendon muscle strength, and functional prognosis.
Study conclusions.
Conservative treatment of Achilles tendon rupture needs to be considered first in all trauma treatment centers where standardized early functional exercise is available; if the trauma treatment center cannot provide effective early rehabilitation exercise measures, surgical treatment of patients with Achilles tendon rupture is recommended to avoid excessive re-rupture rate after conservative treatment.
This Meta-analysis differs from previous ones in that it raises the role of early postoperative rehabilitation exercises to a relatively high level in patients in the conservative treatment group, and concludes that standardized early functional rupture can achieve a similar chance of re-rupture as the surgical treatment group. The Clove Park orthopedic board currently has documented posts from physician comrades who have personally experienced conservative treatment of acute Achilles tendon ruptures. There is a very good discussion of conservative and surgical treatment in that post, and everyone is welcome to actively participate.
But in fact, until now, the treatment of acute Achilles tendon rupture by the majority of domestic orthopedic surgeons still stops at surgical treatment, and the conclusion of the newly published Meta-analysis of conservative vs. surgical treatment of acute Achilles tendon also concluded that surgical treatment is more advantageous in trauma centers that do not have a standardized rehabilitation strategy for early conservative treatment, but this should not be the basis for doctors’ decision to prefer surgical treatment, and doctors can only choose surgical treatment when they are Based on the familiarity with conservative treatment and postoperative rehabilitation fracture strategy, the physician only makes the choice of surgical or non-surgical strategy based on the actual condition needs of the patient is the best plan. At present, conservative treatment strategy is seldom mentioned, and the translator is very willing to believe that it is the current excessively poor medical environment in China that causes physicians to avoid conservative treatment, but it is not also the reason that the majority of orthopedic surgeons do not know enough about conservative treatment.
Despite the difficulties of the current medical dilemma, the road ahead is difficult and we hope that we will all work together.