# Operative versus nonoperative management of acute Achilles tendon rupture: a systematic review and meta-analysis of clinical outcomes from randomized controlled trials

## TL;DR

This study compares surgical and non-surgical treatments for Achilles tendon ruptures, finding that surgery reduces re-ruptures but increases complications, while minimally invasive surgery offers the best balance.

## Contribution

A meta-analysis of 14 RCTs provides updated evidence on the comparative effectiveness of operative and nonoperative treatments for Achilles tendon ruptures.

## Key findings

- Minimally invasive surgery significantly lowers re-rupture rates compared to nonoperative treatment.
- Open surgery has higher complication rates than nonoperative treatment.
- Minimally invasive surgery allows for faster return to work compared to nonoperative treatment.

## Abstract

The objective of this study was to compare the differences in re-rupture rates, complications, and functional assessments of Achilles tendon ruptures (ATRs) treated operatively or nonoperatively to guide clinical treatment choices.

A literature search was performed in the PubMed, Cochrane Library, and Embase databases up to March 1, 2025, for randomized controlled trials (RCTs) involving patients with ATR receiving operative and nonoperative therapies. Primary outcomes included re-rupture rates, complications, and functional assessment. Meta-analysis of the extracted data was carried out using Review Manager 5.3 and Stata 17.0.

A total of 14 RCTs were included in the meta-analysis, comprising 1,628 participants. The meta-analysis results revealed a considerably lower re-rupture rate in both the minimally invasive (MI) group (risk ratio [RR], 0.28; 95% confidence interval [CI]: 0.11 to 0.74) and the open group (RR, 0.30; 95% CI: 0.19 to 0.50). For complications, subgroup analysis showed no significant difference between the MI and nonoperative groups (RR, 2.40; 95% CI: 0.52 to 10.98), whereas the open group had a higher complication rate (RR, 3.03; 95% CI: 1.75 to 5.26) than nonoperative groups. There was no significant difference in the functional assessment between operative and nonoperative groups. Regarding return to work, the MI group returned to work earlier compared to the nonoperative group.

Open operative treatment significantly reduces the rate of re-rupture compared to nonoperative treatment but is accompanied by a higher risk of complications. MI treatment offers both of these advantages, along with superiority in return to work.