How Do Surgeon Repairs Achilles Tendon Rupture

Introduction

Achilles tendon (AT), a combination of the tendinous portion of gastrocnemius and soleus muscles to form the strongest tendon in the homo body, is frequently injured mainly in the immature to center age agile population of guild, with the average age ranging from 37 to 44 years (i, 2). Increasing incidence of Achilles tendon rupture (ATR) is all the same reported in several studies due to the increasing older active population in social club and male person patients are more than common than female patients even though a college rupture force is required in the male (2–iv).

The etiology of ATR is rarely discussed while several risk factors are accounted for, such as steroid injection, rheumatoid arthritis, intake of fluoroquinolones, and long-term dialysis (5, 6). For the sake of its specificity in ambulation and activity, advisable management of ATR is essential.

Surgical repair and conservative treatment are 2 major management strategies widely adopted in ATR patients, but the consensus of the optimal treatment strategy is nevertheless debated. Several previous systemic reviews reported that like results occurred in surgical or non-surgical handling with the measurement of clinical score and patient satisfaction (seven, 8). In onetime studies comparing surgical and non-surgical processes, re-rupture rate was the predominant event measure out to assess the treatment success, while information technology is relatively low with the electric current handling protocols (nine–11). Collectively, fully restored function to the former level and self-satisfaction from patients should exist taken into consideration as an boosted assessment.

Although two previous meta-analyses compared the surgical and non-surgical handling in ATR, neither of them considered the abovementioned restored function to the former level or self-satisfaction. Moreover, the situation of inadequate inclusion of studies focusing on related topic occurred in both studies. Consequently, we aimed at thoroughly reviewing the ATR topic with additional assessments and performed a about comprehensive meta-analysis of randomized controlled trials (RCTs).

Methods

Protocol

This meta-analysis was conducted and performed nether the teaching of Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) checklists (12–14).

Searching Query and Eligibility Criteria

We thoroughly searched online public databases, namely, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, until 1st July 2022 with the keywords of Achilles tendon and surgery with their corresponding MeSH terms. Nosotros retrieved all studies comparing surgical vs. conservative handling in ATR patients for farther review. Duplicate studies were excluded, and 2 authors independently completed the initial championship and abstract screening. Merely RCTs that reported on the comparing of surgical vs. bourgeois treatment of ATR were included in this meta-analysis.

Later initial title and abstract screening, two independent authors reviewed all retrieved articles with full text. Nosotros excluded reviews, messages, editorial comments, briefing abstract, give-and-take, notes, viewpoint, no published full text, and case reports. Delayed treatment for more than 4 weeks was excluded and the same for treatment of re-rupture of ATR. At that place was no weight bearing or functional rehabilitation protocol restriction. The eligibility criteria were patients with ATR, surgical handling (open or minimally invasive surgery) vs. conservative treatment (cast immobilization or functional bracing), age >16 years old, treatment initiated within 4 weeks of injury, reporting of re-rupture, complications, functional outcomes, and patients' satisfaction on corresponding treatment and outcomes. Whatever disagreement on study inclusion was resolved by consensus or routine coming together of all authors listed in this meta-analysis. Detailed information about the eligibility criteria is shown in Tabular array one.

Table 1. Eligibility criteria applied in this meta-analysis.

Data Extraction

Two authors independently extracted both baseline demographics with all outcomes data, and disagreements were resolved past discussion in a routine coming together to preclude the occurrence of examination-qualified pooling (xv). All baseline demographics data were extracted from included studies and intersection was obtained for providing more detailed information every bit far every bit possible. Author names, country, age, gender, time betwixt injury and treatment, surgical technique, and follow-up were essential elements to extract. The same strategy was administered in issue information extraction in guild to make the virtually comprehensive pooled assay.

Primary and Secondary Result

Regarding raised concerns almost contempo studies (ix–eleven), unlike from the previous meta-analysis, render to sport (the same level as pre-treatment) and re-rupture rate were adopted as primary outcomes. Secondary outcomes consisted of complication rate (divers every bit complication occurred after treatment except for re-rupture), deep vein thrombosis, adhesion of scar to the underlying tendon, sural nerve injury, superficial infection, deep infection, menstruation of absence from work, functional scores of Achilles Tendon Rupture Score (ATRS) (16), and mean of dorsiflexion and plantarflexion. In addition, in scenario of returning to sport, patients who recover to the same level every bit pre-handling was pooled, which might describe the efficacy of treatment distinctly. Combined results were pooled in studies that reported open as well as minimally invasive surgery.

Assessment of Heterogeneity

We analyzed statistical heterogeneity betwixt studies past means of I ^two-test and, the criteria were I ² > fifty% for existence of heterogeneity and I ² > seventy% for high heterogeneity (17).

Risk of Bias Cess

Two authors independently assessed the risk of bias from each written report under the educational activity of Cochrane Gamble of Bias Tool, and the same was done for protocols of included studies (18). During the entire assessment procedure, selection bias, performance bias, attrition bias, and reporting bias were analyzed, and publication bias was evaluated as well as visualization via Egger's-test (19). Collectively, risk of bias summary graph and funnel plot would be used to review bias existence better.

Statistical Analysis

All procedures involved in this meta-assay were performed nether Revman (Version v.three). Both continuous and dichotomous variables were presented in this study. Continuous variables were presented as hateful with standard departure and other forms of information presentation would be converted using the instruction described in the Cochrane Handbook for Systematic Reviews of Interventions and several methods reported in previous studies (xx–24). Dichotomous variables were presented every bit events and the full number of events. The Mantel–Haenszel model was used to analyze the pooled outcomes with the presentation of the gamble ratio (RR) and 95% confidence interval (CI). A fixed model would be adopted when I ⁱⁱ <50% while the random effect model was employed once I ² > fifty%. We administered overall the issue Z-test to determine the significance level for pooled effects. For the stratified analysis, a test for subgroup differences was used to make up one's mind the meaning level. Nosotros ready the significance level every bit a P-value lower than 0.05.

Results

Literature Search

All literature screening processes were performed with Endnote X8. After literature searching, a total of five,974 citations from PubMed, half dozen,587 citations from Embase, 23 citations from Cochrane, and 18 citations from Clinicaltrial.gov were obtained. We excluded 6,897 duplicate citations past using Endnote duplicate citations finding function. After initial title and abstract screening, five,593 citations were excluded and disagreement would exist resolved past the routine meeting of the research group. During full text screening, a total of 97 citations not compliant with the criteria were excluded and 13 citations of studies were included in this meta-analysis eventually (11, 25–36). The PRISMA flowchart of this meta-assay is displayed in Figure 1.

Effigy 1. PRISMA flowchart of this meta-analysis.

Baseline Characteristics

A total of 1,164 patients were included in this report, with 603 patients in the surgical group and 561 patients in the non-surgical group. The mean age of enrolled patients was around 40 years old, ranging from 18 to 63 years onetime, which conformed to the regular ATR population. Overall, male and female patients consisted of 84 and 16% of the population included in the study. For the time period between injury and treatment, 2 days was the shortest period reported by Twaddle et al. (29) while 21 days was the longest period reported past Nistor et al. (25). In addition, each included studies' surgical techniques were extracted for better interpretation of baseline characteristics, and cease-to-end Bunnell blazon was the virtually adopted technique for ATR repair. Last simply not least, dissimilar follow-upwardly periods could be a significant factor affecting the results and so that it was recorded. One and two years were the widely accepted follow-up menses amidst the included RCTs. The detailed information of baseline characteristics of each RCTs is shown in Table 2.

Table 2. Baseline characteristics of included studies.

Hazard of Bias Assessment

Two independent authors strictly assessed the risk of bias across studies under the pedagogy of Cochrane Collaboration Tool and the visualization of results is displayed in Supplementary Figure 1 (17). Run a risk of bias was relatively low owing to the characteristics of RCTs. However, an assessment of unclear take a chance occurred in several studies. Regarding selection bias nearly random sequence generation, Moller et al. (27) and Keating et al. (33) did not clearly land the situation and unclear risk was assessed in Nistor et al. (25), Fischer et al. (36), and Cetti et al. (26). When it comes to blinding of participants and personnel in performance bias, unclear take chances occurred in Nistor et al. and Cetti et al., while high gamble was assessed in Fischer et al. Inadequate blinding of cess was non clearly declared in Nistor et al. and Fischer et al. then that unclear hazard was obtained.

Publication bias was assessed by administrating Revman software and Egger's test was adopted. Each result mensurate was assessed individually and visualization of results is shown in Supplementary Figures 2A–L. Inspection of symmetry was obtained, indicating no publication bias amid each outcome measure.

Chief Outcomes

Re-rupture Rate

All included thirteen studies reported the event of re-rupture charge per unit, and we divided it into re-rupture in accelerated functional rehabilitation and re-rupture not in accelerated functional rehabilitation as subgroup analysis. In the subgroup of re-rupture that occurred in accelerated functional rehabilitation, no meaning difference between surgical and conservative treatment could exist observed (three studies, 289 participants, Z = 1.04, P = 0.30, I ⁱⁱ = 0%, RR: 0.59, 95% CI: 0.22 to 1.59). In contrast, compared with the conservative grouping, significant reduction in re-rupture rate not in accelerated functional rehabilitation could be observed in the surgical treatment group (x studies, 850 participants, Z = 3.90, P < 0.0001, I ^two = 0%, RR: 0.34, 95% CI: 0.19 to 0.58). Collectively, the overall issue showed that surgical treatment was associated with significant reduction in re-rupture rate (13 studies, 1139 participants, Z = 3.97, P < 0.0001, I ⁱⁱ = 0%, RR: 0.38, 95% CI: 0.24 to 0.41). Detailed information about the re-rupture rate is shown in Figure 2A.

Figure 2. Forest plot of primary outcome measure out. (A) Forest plot of re-rupture rate. (B) Woods plot of return to sport (same level).

Render to Sport

There were eight studies that reported the result of return to sport amid patients receiving ATR repair. Cetti et al. (26) and Costa et al. (28) reported the favorable consequence of surgical handling in recovering ATR patients' sporting chapters compared with conservative management, while Manent et al. (35) reported the opposite result favoring conservative treatment. Collectively, the overall upshot indicated no significant difference between surgical and conservative handling in sport capacity recovery (eight studies, 567 participants, Z = 0.35, P = 0.73, I ^two = 75%, RR: 1.09, 95% CI: 0.67 to 1.77). Detailed information about returning to sport is shown in Figure 2B.

Secondary Outcomes

Complication Rate

We defined complication rate as complexity that occurred after ATR handling other than re-rupture, and it was reported in 12 of the included studies. The overall result indicated that the complication rate after handling in the conservative treatment grouping was significantly lower than that in surgical treatment grouping (12 studies, i,107 participants, Z = ii.56, P = 0.01, I ² = 69%, RR: ii.62, 95% CI: 1.25 to 5.46). Chief complications that occurred later on ATR handling were deep vein thrombosis, adhesion of scar to the underlying tendon, the sural nerve injury, and superficial and deep infection. Detailed information well-nigh the overall complexity rate is shown in Figure 3A.

Figure 3. Forest plot of secondary outcome measure out indicating complication. (A) Forest plot of complexity rate. (B) Forest plot of deep vein thrombosis. (C) Woods plot of adhesion to underlying tendon. (D) Woods plot of sural nervus injury. (Eastward) Forest plot of superficial infection. (F) Forest plot of deep infection.

Deep Vein Thrombosis

Deep vein thrombosis, a severe complexity that usually occurred after ATR handling attributable to plaster casting immobilization (28), was reported in eight of the included studies. The overall result showed that no significant evidence could exist obtained to distinguish better management strategy to avoid deep vein thrombosis (eight studies, 777 participants, Z = 1.12, P = 0.26, I ² = 0%, RR: 0.58, 95% CI: 0.22 to 1.51). Detailed information nigh deep vein thrombosis is displayed in Figure 3B.

Adhesion

Adhesion of scar to the underlying tendon was reported in three of the included studies, and it might lead to secondary surgery. The overall result revealed that the surgical process might increase the incidence of adhesion of scar to underlying tendons (3 studies, 294 participants, Z = 2.08, P = 0.04, I ² = 55%, RR: 8.77, 95% CI: 1.13 to 67.99). Detailed information about the adhesion of scar to the underlying tendon is displayed in Figure 3C.

Sural Nerve Injury

Disturbance in sensation of ATR patients later handling due to sural nerve injury was reported in six of the included studies. The overall results showed that a significantly increased incidence of sural nerve injury occurred in patients with surgical treatment than conservative management in ATR (half-dozen studies, 603 participants, Z = 3.71, P = 0.0002, I ² = 0%, RR:six.77, 95% CI: 2.47 to 18.56). Detailed data is shown in Figure 3D.

Infection

Wound infection was a common complexity of surgical handling in ATR repair, and it could be divided into superficial and deep infection. For superficial infection, compared with the surgical treatment grouping, conservative management showed significant evidence to prevent infection after treatment (seven studies, 659 participants, Z = 3.28, P = 0.001, I ² = 0%, RR: 7.34, 95% CI: two.23 to 24.17). Detailed information is shown in Effigy 3E.

In contrast, regarding deep infection, in that location was no pregnant deviation betwixt surgical treatment and conservative treatment group, even though no example of deep infection in the conservative grouping was reported (eight studies, 653 participants, Z = i.88, P = 0.06, I ² = 0%, RR: 3.85, 95% CI: 0.95 to 15.65). Detailed information near deep infection is shown in Figure 3F.

Menstruation of Absence From Piece of work

ATR results in loss of motor ability too as absenteeism from patients' occupation and then that a dissimilar time period is an essential assessment alphabetize. The pooled result showed that neither surgical handling nor bourgeois direction had a shorter period of absenteeism from work (three studies, 330 participants, Z = 0.10, P = 0.92, I ² = 77%, RR: −0.22, 95% CI: −4.32 to iii.89). Detailed information is displayed in Figure 4A.

Figure 4. Forest plot of secondary issue measure indicating menses of absence from piece of work and ATRS. (A) Wood plot of period of absence from work. (B) Wood plot of functional score (ATRS).

ATRS Functional Score

ATRS functional score, with high reliability, validity, and sensitivity for quantifying functional outcome of patient receiving ATR treatment, is an indispensable index to determine the better treatment (16). According to pooled results, at that place was no significant departure between surgical and conservative treatment regarding ATRS cess (three studies, 207 participants, Z = one.86, P = 0.06, I ⁱⁱ = 0%, RR: 4.27, 95% CI: −0.24 to 8.77). Detailed data about the ATRS assessment is displayed in Effigy 4B.

Flexion

Range of motion is a reflection of articulation motor power, and dorsiflexion and plantarflexion are suitable indexes to the assessment. For mean dorsiflexion, the surgical handling grouping was like to the conservative treatment group (ii studies, 204 participants, Z = 0.32, P = 0.75, I ⁱⁱ = 51%, RR: 0.62, 95% CI: −three.23 to 4.46). Detailed information about dorsiflexion is shown in Effigy 5A.

Figure five. Forest plot of secondary issue measure indicating flexion. (A) Forest plot indicating hateful of dorsiflexion. (B) Forest plot indicating mean of plantarflexion.

Similarly, no pregnant difference could be observed regarding the pooled result of mean plantarflexion (iv studies, 349 participants, Z = 1.08, P = 0.28, I ² = 92%, RR: ii.43, 95% CI: −1.97 to 6.83). Detailed information virtually plantarflexion is shown in Figure 5B.

Discussion

Innovation

This is the most comprehensive meta-analysis of RCTs comparing outcomes subsequently receiving surgical treatment vs. bourgeois treatment of ATR. The overall results revealed that surgical treatment had a lower re-rupture rate, while no significant difference was found in the subgroup of accelerated functional rehabilitation with early range of motion, which might indicate that early involvement of rehabilitation was not beneficial to functional recovery. In add-on, for pooled results of render to sport, which is first treated as principal outcome, no significant difference could be obtained. In contrast, conservative treatment was associated with a lower complication charge per unit (other than re-rupture), which should be taken into consideration when deciding on treatment.

In comparing with the old meta-analysis of this topic performed by Deng et al. (37), v more studies are included in this meta-assay, which makes it the most comprehensive one. Deng et al. have taken re-rupture rate, deep vein thrombosis, return to sport, ankle range of move, and related score into consideration, while adhesion, sural nervus injury, menses of absence from piece of work, and infection are added in our study. Moreover, master outcomes and secondary outcomes are separated in this meta-analysis, which clearly provides dissimilar levels of evidence for clinical practise. Collectively, with more than included studies and additional pooled outcomes, concluded evidences are solid.

To the best of our noesis, treatment on ATR should be focused on optimal functional recovery accompanied past the least complication. Combined with the novel master effect of render to sport included in this study, similar functional recovery was observed between surgical and conservative treatment group, even though surgical treatment was recommended owing to a lower re-rupture rate co-ordinate to previous studies (38, 39). Moreover, bourgeois management accompanied with early weight begetting of the injured tendon was reported to stimulate collagen and healing procedure, leading to a similar re-rupture charge per unit every bit surgical treatment (x, forty–42). Collectively, a novel recommendation of more than just because re-rupture and conservative treatment with similar functional recovery as well equally a lesser complexity on ATR might exist considered if patients' condition were suitable.

Exploration of Complications

Till at present, the optimal treatment for ATR patients is mainly based on expert consensus and on the basis of judgment from the principal clinician. Surgical repair, with a lower re-rupture charge per unit, is favorable in nigh cases, while complications (20.4 vs. vii.0%) other than re-rupture are troublesome such every bit deep vein thrombosis, wound infection, and awareness disturbance (sural nervus injury).

Incidence of deep vein thrombosis is reported from 0.3–50%, and it is a significant gene causing poor quality of life every bit well every bit the burden of social price (43–46). Immobilization such equally plaster casting has been a potential pathogenesis leading to deep vein thrombosis (47). Although pooled results of deep vein thrombosis did not reveal a significant deviation, it seemed to occur oftentimes in the conservative grouping (2.1%), which might be attributable to a long flow of plaster casting. Consequently, thromboprophylaxis is necessary after ATR treatment and intermittent pneumatic compression has been reported to exist highly effective in reducing deep vein thrombosis in ATR patients (43).

Wound infection, classified as superficial and deep infection, is one of the major complications in ATR patients receiving surgical repair. In our study, superficial (5.eight%) and deep infection (2.two%) were reported in the surgical handling group, which was deleterious and intractable with poor outcome (48). A recent meta-analysis has ended that a minimally invasive method could significantly reduce wound infection charge per unit compared with open surgery (49). Furthermore, negative pressure wound therapy has been reported to exist constructive for post-operative wound infection of ATR, which could be adopted (50).

Regarding sural nervus injury, leading to sensational disturbance later on treatment, the incidence in surgical treatment (seven.8%) was significantly higher than conservative treatment. Direct damage in open repair or lack of visualization in minimally invasive operative procedures has been the potential reason for causing injury and a modified medialization of percutaneous suture was reported with a lower incidence of sural nerve injury (51).

Exploration of Functional Consequence

Functional outcomes were defined equally period of absenteeism from work and ATRS score, and the pooled result revealed a similar outcome betwixt the surgical and bourgeois treatment group. Not surprisingly, like results were plant in pooled outcomes of mean dorsiflexion and plantarflexion. Collectively, in functional recovery, conservative treatment might take a similar prognosis to surgical repair.

Limitation and Implication for Time to come Research

Although a total of 13 RCTs are included in this meta-analysis, the recorded categories of complications are still limited, which results in disturbance of comprehensive assessment of each treatment strategy. Specifically, for deep vein thrombosis, more cases occurred in the conservative treatment grouping, only thromboprophylaxis is only reported in iv included studies (eleven, 27, 31, 33), which may confuse the result. Functional outcomes are similar in both groups according to our study's pooled outcome, but the number of studies reporting functional outcomes such as menstruation of absence from work, ATRS score, and dorsiflexion and plantarflexion are limited. Furthermore, different periods of follow-up, surgical techniques and conservative management strategy may lead to different outcomes.

Future research with a specific focus on comorbidities other than re-rupture is necessary, and it volition provide more clues for surgeons or physicians to brand an optimal determination. Regarding the summary of our results, a novel inspiration about adopting bourgeois direction as the major treatment plan with bottom complication and similar event has been generated. However, patients' expectations are also essential that the athletic population may prefer surgical treatment to expedite recovery and prolong their professional careers (52). Consequently, hereafter RCTs are needed to investigate if surgical and conservative treatment have similar outcomes and prognosis, especially in return-to-sport ability.

Determination

In this meta-analysis, surgical treatment was revealed to be significant in the reduction of re-rupture rate but associated with a college complexity rate. Conservative treatment was found to be capable of having similar functional outcomes with surgical treatment. Collectively, nosotros recommend bourgeois treatment if patients' status and expectations are suitable, but surgeon and doc discretion is too important in decision making.

Data Availability Statement

The original contributions generated in the study are included in the article/Supplementary Material, further inquiries tin be directed to the corresponding authors.

Author Contributions

GS and QT: conceptualization, literature researching, methodology, information analysis, and manuscript writing. JL and XZ: investigation. LC and HH: supervision, conceptualization, professional person suggestion, and revision. All authors have read and approved the manuscript.

Conflict of Interest

The authors declare that the enquiry was conducted in the absenteeism of whatever commercial or fiscal relationships that could be construed as a potential conflict of interest.

Acknowledgments

This manuscript has been released as a pre-print at Inquiry Square (53).

Supplementary Material

The Supplementary Cloth for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fsurg.2021.607743/total#supplementary-cloth

Supplementary Figure ane. Visualization of bias assessment. (A) Summary of gamble of bias. (B) Risk of bias graph.

Supplementary Figure 2. Funnel-plot indicating publication bias of each pooled effect. (A) Re-rupture rate; (B) Return-to-sport (Same level); (C) Complication rate; (D) Deep vein thrombosis; (E) Adhesion to underlying tendon; (F) Sural nervus injury; (G) Superficial infection; (H) Deep infection; (I) Menstruation absenteeism from work; (J) ATRS; (K) mean of dorsiflexion; (Fifty) mean of plantarflexion.

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Source: https://www.frontiersin.org/articles/10.3389/fsurg.2021.607743/full

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