Achilles tendon rupture is a common and potentially disabling injury, largely influencing young male adults who participate in sports, such as racket games, soccer, and basketball.1,2 The incidence of Achilles tendon rupture is up to 18 per 100,000 per year and is still increasing.2 In general, interventions for acute Achilles tendon rupture could be classified as surgical and conservative.3,4 In recent years, significant progress has been observed for the treatment of acute Achilles tendon rupture. However, the optimal intervention for acute Achilles tendon rupture is still uncertain.5–17
Multiple randomized clinical trials (RCTs) comparing surgical with conservative treatment have been reported for acute Achilles tendon ruptures, but their findings are conflicting regarding which procedure is better.5–17 In light of this, many meta-analyses of RCTs, representing the highest level of evidence, have been published to compare these 2 procedures for treating acute Achilles tendon rupture. However, these overlapping meta-analyses also showed discordant findings.18–26 Some articles suggested that surgical intervention for acute Achilles tendon rupture was associated with a significant increase with respect to the incidence of rerupture when comparing with conservative treatment;19 the others found no significant difference between surgical and conservative intervention.21 These inconsistent findings have resulted in uncertainty for decision makers with respect to the intervention of acute Achilles tendon rupture.
In recent years, systematic reviews of overlapping meta-analyses have been reported in many medical fields.27–30 These studies help to select the highest-quality level of evidence for decision making by evaluating the overlapping meta-analyses with the discordant findings on certain topic.27–30 However, to our knowledge, there is no systematic review of overlapping meta-analyses investigating the relative effects between surgical and conservative intervention for acute Achilles tendon rupture. The objective of the present study was to perform a systematic review of overlapping meta-analyses regarding surgical versus conservative treatment of acute Achilles tendon rupture, to assist decision makers in selection among conflicting meta-analyses, and to offer intervention recommendations by the best available evidence.
MATERIALS AND METHODS
This study was approved by the Research Ethics Committee of Changhai Hospital of Second Military Medical University, and conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.31 The design of this study was based on previous similar publications.27-30
On July 20, 2015, the databases of PubMed, EMBASE, and Cochrane Library were systematically retrieved. The keywords were used, including achilles, tendoachilles, calcaneal, calcanean, calcaneus, rupture, ruptures, ruptured, lesion, lesions, tear, tears, systematic review, and meta-analysis. The search was independently conducted by 2 authors, with the restriction of English language. The references of the included studies were also checked to find possible meta-analyses on this topic. The titles and abstracts were first reviewed, and the full texts were acquired if the information was not enough. Disagreements were settled by discussion, and a third author was consulted when necessary.
The inclusion criteria of this systematic review were: comparing surgical with conservative intervention for acute Achilles tendon rupture; meta-analysis only comprising RCTs; at least 1 outcome, such as rerupture rate and functional outcome. The narrative review, meetings abstract, correspondence, meta-analysis comprising non-RCTs, and systematic review without meta-analysis conducted were excluded.
The following data were independently extracted by 2 authors from the included meta-analyses: first author, year of publications, databases for search, primary study design, the number of RCTs included, heterogeneity or subgroup analysis of primary study, and meta-analysis results. When disagreements between the 2 authors could not be resolved by discussion, a third author was consulted.
The meta-analysis quality was evaluated by the Oxford Levels of Evidence32 and the Assessment of Multiple Systematic Reviews (AMSTAR) instrument.33 AMSTAR has been proven as a methodological assessment tool with good reliability, validity, and responsibility.34,35 It is widely used to evaluate the quality of systematic reviews.27–30 Meta-analyses quality was independently evaluated by 2 authors. Disagreements between authors were settled by discussion, and a third author was consulted if necessary.
Application of Jadad Decision Algorithm
The Jadad decision algorithm was conducted to investigate the source of inconsistency among systematic reviews, comprising differences in clinical question, inclusion and exclusion criteria, data extraction, quality assessment, data pooling, and statistical analysis.36 It has been widely conducted to offer treatment recommendations among meta-analyses with discordant conclusions.27–30,36 This algorithm was independently applied by 3 authors, who reached a consensus regarding which meta-analysis offered the best available evidence.
A flowchart of the study selection is depicted in Figure 1. A total of 521 titles were found from the literature source. Nine meta-analyses met the inclusion criteria.18–26 The characteristics of these included meta-analyses are listed in Table 1. These studies were published between 2002 and 2013. The primary studies of included meta-analyses were published between 1981 and 2011, and the number of primary trials ranged from 4 to 10 (Table 2).
Three of the included meta-analyses only included English literature,18,19,21 and the others had no language restriction.20,22–26 The databases of Medline were searched in all included meta-analyses, whether PubMed, Cochrane Library, Embase, OVID, and BIOSIS were included in search strategy was inconsistent among the studies. Search methodology used in the included meta-analyses is shown in Table 3.
All meta-analyses included RCTs or quasi-RCT, and were determined as Level-II evidence according to Oxford Levels of Evidence (Table 4). The results of AMSTAR scores for the included meta-analyses are listed in Table 5, ranging from 5 to 10 (median 7). Two Cochrane reviews with 10 scores of AMSTAR were the highest-quality studies.22,23
The I2 statistic value, as a measurement tool for investigating the interstudy variability, was used to evaluate the heterogeneity of study in each meta-analysis (Table 6).18–26 Only 1 study performed sensitivity analyses according to methodological quality (Table 4).19 A total of 3 meta-analyses did not conduct sensitivity or subgroup analysis (Table 6).18,25,26
Results of Jadad Decision Algorithm
Which meta-analysis offered the best available evidence among the 9 included meta-analyses was investigated following the Jadad decision algorithm.36 The meta-analysis result of the each study is depicted in Figure 2. Based on that the included studies investigated the same question, did not comprise the same trials, and the selection criteria were discordant, the Jadad decision algorithm indicated that the best available evidence should be chosen according to the publication status and the methodological quality of primary trials, language restrictions, and analysis of data on individual patients (Fig. 3). Hence, a high-quality study with more RCTs was selected.24 This study demonstrated that when conservative intervention included early range of motion protocol, it was equal to surgical treatment with respect to rerupture rate, range of motion, calf circumference, and functional outcomes, while it decreased the risk of other complications. If functional rehabilitation was not performed, conservative intervention shows a significant increase with respect to the incidence of rerupture.
Meta-analysis of RCTs, representing the highest level of evidence, helps clinicians, patients, and policy-makers to make decisions.37 Although many meta-analyses regarding the same topic have been conducted to assess some intervention methods, they have resulted in discordant conclusions.36 Such conflict findings complicate decision makers, who make choices among alternative interventions based on these best available evidence. Multiple meta-analyses have found that both conservative and surgical intervention could improve the preoperative clinical status, but the relative effects between these 2 procedures are still uncertain.18–26
Most of meta-analyses included in this systematic review comprehensively conducted the literature search within similar period, but they did not comprise the same primary trials, and not provide the same conclusions for the intervention of acute Achilles tendon rupture.18–26 The possible sources of inconsistence among meta-analyses have been analyzed and reported by Jadad et al,36 including the clinical question, study selection and inclusion, data extraction, assessment of study quality, assessment of the ability to combine studies, and statistical methods for data synthesis. Moreover, a decision algorithm was also designed to choose the high-quality level of evidence from currently discordant systematic reviews.36 This decision tool adopted in this study was widely used to find the best available evidence among overlapping systematic reviews.27–30
The meta-analysis by Soroceanu et al24 was selected in terms of the Jadad decision algorithm. This study demonstrated that surgical treatment was superior to conservative treatment with respect to rerupture rate, range of motion, and time to return to work. However, the improvement of range of motion in surgical group was not beyond clinically important difference. There was no difference between surgical and conservative intervention in strength, calf circumference, and functional outcome. The functional outcome was expressed with use of different scales in each RCT, including Functional Index for the Lower Leg and Ankle,11 the Musculoskeletal Functional Assessment Instrument,13 Leppilahti score.14,16 Conservative intervention was superior to surgical treatment regarding the rate of complications. However, when conservative intervention included functional rehabilitation, it was equal to surgical treatment with regard to the incidence of rerupture. Therefore, Soroceanu et al24 concluded that conservative intervention should be a reasonable choice at centers offering functional rehabilitation with early range of motion, because surgical intervention did not show a significant decrease in the incidence of rerupture while a higher incidence of other complications. Surgical intervention could be preferred at centers that do not perform early range of motion. It showed a higher risk of other complications, but it decreased the incidence of rerupture.
There are several limitations in the present study. First, the literature search was limited to articles published in English. Non-English literature could not be included in this systematic review despite multiple databases being searched. Second, to get the highest level of evidence, meta-analyses only comprising RCTs were included in this study. However, all the included studies were Level-II evidence. Therefore, this systematic review could not offer treatment recommendations based on Level-I evidence.
Based on the present systematic review of overlapping meta-analyses that compared surgical with conservative intervention for acute Achilles tendon rupture, the best available evidence indicated that conservative intervention for acute Achilles tendon rupture may be preferred at centers offering functional rehabilitation, because it shows similar rerupture rate when comparing with surgical treatment while low risk of other complications. However, surgical treatment should be considered at centers without functional rehabilitation because it could reduce the incidence of rerupture.
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