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)

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

Related Posts:

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., & Ji, F. (2015). Surgical Versus Conservative Intervention for Acute Achilles Tendon Rupture Medicine, 94 (45) DOI: 10.1097/MD.0000000000001951