Surgical versus conservative intervention for acute Achilles tendon rupture. A PRISMA-compliant systematic review of overlapping meta-analysis.
Zhang H, Tang H, He Q, Wei Q, Tong D, Wang C, Wu D, Wang G, Zhang X, Ding W, Li D, Ding C, Liu K, and Ji F. Medicine. 2015. 94(45).
Take Home Message: Conservative treatment with early range of motion is equivalent to surgical treatments of Achilles tendon ruptures.
Achilles tendon ruptures are devastating injuries, which are often seen in an athletic population. While many authors have conducted meta-analyses to compare surgical versus conservative treatment of Achilles tendon ruptures they often conflict with each other. It may be beneficial to conduct a systematic review of overlapping meta-analysis to help determine the optimal treatment strategy. Therefore, Zhang and colleagues completed a systematic review of meta-analyses to investigate the effects of surgical versus conservative interventions of acute Achilles tendon ruptures. Two authors independently identified 9 meta-analyses via a comprehensive literature search, in accordance with the PRISMA statement. All 9 meta-analyses included only randomized controlled trials. Two researchers then independently extracted the first author, publication year, databases for search, study design, number of included randomized controlled trials, and results. The meta-analyses were evaluated using the Oxford Levels of Evidence and the Assessment of Multiple Systematic Reviews (AMSTAR) tool. The evaluation was performed by 2 independent reviewers and a third reviewer was consulted if there was disagreement between the primary reviewers. Overall, the methodological quality of the 9 included meta-analyses ranged from 5 to 10 out of 10 possible points. The authors selected a high-quality meta-analysis with more randomized trials. Overall, the authors determined that conservative intervention coupled with an early range-of-motion protocol are equivalent to surgical treatments in terms of rerupture rate, range of motion, calf circumference, and functional outcomes. However, conservative treatment without functional rehabilitation increased the risk of reruptures compared with surgical treatment.
Overall, this study presents some interesting data, which supports the use of conservative intervention, particularly with early range-of-motion, for acute Achilles tendon ruptures. Even more interesting than the clinical implications however may be the study design itself. A systematic reviews of overlapping meta-analysis exhibits an extremely high level of scientific evidence. Studies such as this can lead to very practical and informative conclusions which can greatly impact clinical practice. However, it would have been interesting if the authors could combine the results of each meta-analysis or tried to reanalyze the original studies that were include in each meta-analysis. Despite this, we should consider conservative care with functional rehabilitation as a potential option for managing Achilles tendon ruptures.
Questions for Discussion: When discussing current trends seen in clinical literature with your sports medicine team, how much does level of evidence play into your clinical decision making? How confident do you feel in assessing various levels of evidence in scientific literature?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban