Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures – a systematic review

Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures – a systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures – a systematic review Niklas Nilsson, Immanuel Stensöta, Katarina Nilsson Helander, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2613525/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Dec, 2023 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 8 You are reading this latest preprint version Abstract Introduction : A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to summarize the outcomes of chronic ATR treated using either a gastrocnemius aponeurosis flap or semitendinosus tendon graft. Methods : A systematic search was conducted in three databases (PubMed, Scopus and Cochrane), for studies describing outcomes after surgical treatment of chronic ATR using gastrocnemius aponeurosis flaps or semitendinosus tendon grafts with more than 10 patients included. The studies were assessed for quality and risk of bias using the Methodological Items used to assess risk of bias in Non-Randomized studies (MINORS). Results : Out of the 818 studies identified with the initial search, a total of 36 studies with 763 individual patients were included in this systematic review. Gastrocnemius aponeurosis flap was used in 21 and semitendinosus tendon graft was used in 13 of the studies. The mean (SD) postoperative Achilles tendon Total Rupture Score (ATRS) for patients treated with a gastrocnemius aponeurosis flap was 83 (14) points and the mean (SD) American Orthopaedic Foot and Ankle Score (AOFAS) was 96 (1.7) points compared with ATRS 88 (6.9) points and AOFAS 92 (5.6) points for patients treated with a semitendinosus tendon graft. The included studies generally had low-quality according to MINORS, with a median of 8 (range 2-13) for all studies. Conclusion: Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts give acceptable results with minimal complications and are valid methods for treating chronic ATR. The main difference is more wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries in patients treated with a semitendinosus grafts. The current literature on the subject is of mainly low quality and the absence of a patient-related outcome measure validated for chronic ATR makes comparisons between studies difficult. Level of Evidence : Level IV. Chronic Achilles tendon rupture Semitendinosus tendon graft Gastrocnemius aponeurosis flap Surgical repair Systematic review MINORS Figures Figure 1 Introduction Medical history and clinical examinations are considered to be sufficient in establishing the diagnosis of an acute Achilles tendon rupture [ 33 , 41 ]. However, occasionally treatment is delayed due to late presentation or misdiagnosis [ 8 , 41 ]. A delay of treatment leads to larger tendon-end diastasis with interposed scar tissue [ 9 ]. Achilles tendon ruptures that have had a delay in treatment by more than 4 weeks, are termed chronic and surgical intervention is required to recover lower leg function [ 1 , 7 , 14 , 27 , 29 ]. The traditional surgical intervention for chronic Achilles tendon ruptures involves considerably larger incisions than acute repairs leading to an increased risk of complications, such as infections and inadequate wound-healing [ 40 ]. Patients with chronic Achilles tendon ruptures report different symptoms compared with those of acute ruptures. Long-term pain and recurrent swelling are more frequent in patients with chronic ruptures [ 27 ]. In addition, altered gait with a weakness at push-off, a poor balance, and a reduced capability of performing heel-rises are commonly reported [ 16 , 41 ]. The literature includes various surgical techniques for the management of chronic Achilles tendon ruptures: V-Y plasty, tendon transfers, gastrocnemius aponeurosis/fascia flaps, direct repair and synthetic grafts, [ 1 , 8 , 14 , 26 , 27 , 29 , 34 , 45 , 63 , 65 ]. The choice of surgical procedure depends on the location of the rupture, the size of tendon-end diastasis, individual factors such as patient activity level and age, together with the preference and experience of the surgeon. In 2013 Hadi et al. [ 19 ] performed a systematic review on surgical techniques. They identified 11 different surgical techniques in 34 individual publications: (1) peroneus brevis tendon transfer, (2) flexor hallucis longus tendon transfer, (3) V-Y tendinous flap, (4) gastrocnemius turndown flaps, (5) flexor digitorum longus tendon transfer, (6) free gracilis tendon transfer, (7) free semitendinosus tendon graft transfer, (8) synthetic materials, (9) direct repair, (10) dual techniques, and (11) interposed tissue. The most common outcome measures used were the AOFAS and the ATRS scores. All the reported techniques presented satisfying results. However, it was difficult to do direct comparisons due to a limited number of patients, an absence of control groups, heterogenic groups of patients in the included studies, and different outcome measures. Even though many surgical techniques are described in the literature, no single technique has been shown to be superior to another. The aim of this systematic review was to analyse the current clinical evidence of two established techniques to treat chronic Achilles tendon ruptures: gastrocnemius aponeurosis flaps and semitendinosus tendon grafts. Method And Materials Search query The systematic search was performed on 2021-07-02, with an updated search on 2022-09-22, in three established databases: PubMed, Scopus and Cochrane Library using the search queries outlined in Table 1 . The initial search query included all studies presenting the outcome of chronic Achilles tendon ruptures treated surgically. In the final stage, studies presenting outcomes of gastrocnemius aponeurosis flaps or semitendinosus tendon grafts were isolated and analysed. The inclusion criteria were all studies, descriptive and comparative, presenting results on the management of chronic Achilles tendon ruptures in adults (> 18 years) using gastrocnemius aponeurosis flap or semitendinosus tendon graft. The exclusion criteria were (1) case-reports and case series with less than 10 patients, (2) reviews, (3) studies written in non-English languages and (4) expert opinions. The systematic review was registered in PROSPERO (CRD42022294130). Table 1 Search query, Boolean operators and search results in the databases PubMed, Scopus, and Cochrane. PubMed Search string Limits Number of records #1 (Achilles Tendon[mh] OR “Achilles tendon” [tiab] OR “Achilles tendons ”[tiab] OR “Calcaneal Tendon”[tiab] OR “Calcaneal Tendons”[tiab] OR “Tendo calcaneus”[tiab]) 12 515 #2 (chronic*[tiab] OR neglect*[tiab] OR miss*[tiab] OR delay*[tiab]) 2 204 598 #3 #1 AND #2 1 750 #4 (Rupture[mh] OR rupture[tiab] OR ruptures[tiab] OR tear*[tiab]) 192 888 #5 (Treatment Outcome[mh] OR treatment[tiab] OR therapy[tiab] OR outcome*[tiab] OR “clinical efficacy” [tiab] OR “clinical effectiveness” [tiab] OR complication*[tiab] OR re-rupture*[tiab] OR rerupture*[tiab]) 8 235 689 #6 #3 AND #4 AND #5 526 Scopus Search string Limits Number of records #1 TITLE-ABS-KEY ("Achilles tendon" OR "Achilles tendons" OR "Calcaneal Tendon" OR "Calcaneal Tendons" OR "Tendo calcaneus") 16 771 #2 TITLE-ABS-KEY (chronic* OR neglect* OR miss* OR delay*) 4 433 517 #3 #1 AND #2 2 439 #4 TITLE-ABS-KEY (rupture OR ruptures OR tear*) 387 825 #5 TITLE-ABS-KEY (treatment OR therapy OR outcome* OR “clinical efficacy” OR “clinical effectiveness” OR complication* OR re-rupture* OR rerupture*) 14 409 980 #6 #3 AND #4 AND #5 803 #7 #3 AND #4 AND #5 Limit to: Article, Review 762 Cochrane Search string Limits Number of records #1 ("Achilles tendon" OR "Achilles tendons" OR "Calcaneal Tendon" OR "Calcaneal Tendons" OR "Tendo calcaneus"):ti,ab,kw 1004 #2 (chronic* OR neglect* OR miss* OR delay*):ti,ab,kw 232 193 #3 #1 AND #2 206 #4 (Rupture OR ruptures OR tear*):ti,ab,kw 13 308 #5 (Treatment OR therapy OR outcome* OR “clinical efficacy” OR “clinical effectiveness” OR complication* OR re-rupture* OR rerupture*):ti,ab,kw 1 344 590 #6 #3 AND #4 AND #5 31 #7 #3 AND #4 AND #5 Limit to: Trials 30 Study selection The search was conducted by the authors and the initial search resulted in 1,340 studies, after removing duplicates, 818 studies remained. All studies were uploaded to the website Rayyan® for abstract review. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) was used to structure the filtering of studies (Fig. 1) [ 51 ]. Two authors (NN and IS) independently reviewed the abstracts of the included studies. Disagreement between the authors were settled through discussion. A total of 182 studies remained after the initial abstract review. These were all later successfully imported as full-text versions. For the full-text review, the studies were divided equally between the six authors and checked by a minimum of two authors. After the full-text filtering, 86 studies remained. Out of these, 36 individual studies used gastrocnemius aponeurosis flaps or semitendinosus tendon grafts to treat chronic Achilles tendon ruptures and were included in the review. Quality assessment To assess the methodological quality and risk of bias for the included studies the validated Methodological Index for Non-Randomized Studies (MINORS). MINORS is a quality assessment tool for systematic reviews first described by Slim et. al [ 59 ]. It is widely used and has a strong external validity. The studies included in this systematic review were all non-randomized and non-comparative studies. MINORS consists of twelve questions, where the last four questions are additional criteria in case of comparative studies. Each question can be scored from 0–2. A score of 0 meaning it is not reported in the study, a score of 1 meaning it is reported but inadequate, and a score of 2 meaning it is reported and adequate [ 59 ]. Result extraction Three reviewers extracted the data using a structured extraction protocol. The extracted data was surgical technique, number of patients, mean age, duration of follow-up, outcome measures, presented results. The results analysed were patient-reported outcomes, functional outcome measures and complication rates. Any disagreement was settled through discussion. Moreover, if any author were among the authors of the original study analysed, they did not perform any result extraction or quality assessment of that study. Results Study selection All the included studies were case series (Level IV) that either used a gastrocnemius aponeurosis flap or semitendinosus tendon graft to treat chronic Achilles tendon ruptures. A semitendinosus tendon graft was used in 13 studies and a gastrocnemius aponeurosis flap in 21 studies. There were two studies that used both surgical techniques. In the study by Bai et al. [ 4 ] 11 patients were treated with a gastrocnemius aponeurosis flap and 15 were treated with a semitendinosus tendon graft. The study by Gedam et al. [ 15 ] used both augmentation techniques in all patients and was therefore not part of the analysis. The extracted data from the studies is presented in Table 4 . The grand total number of patients included were 763. The study by Bąkowski et al. [ 5 ] included eight additional cadavers which were excluded from this systematic review. Quality assessment The included studies MINORS-scores are shown in Table 2 . The maximum points are 16 for non-randomized studies. The included studies generally had low quality according to MINORS, with a median of 8 out of 16 (range 2–13) for all studies. Table 2 The points of each study according to the MINORS-score. The maximum score is 16. Criteria 1. A clearly stated aim 2. Inclusion of consecutive patients 3. Prospective collection of data 4. Endpoints appropriate to the aim of the study 5. Unbiased assessment of the study endpoint 6. Follow up period appropriate to the aim of the study 7. Loss to follow up less than 5% 8. Prospective calculation of study size Finalized MINORS score Jain et al 2020 1 2 0 2 0 2 2 0 9/16 Elgohary et al 2016 1 1 1 1 0 2 2 0 8/16 Koh et al 2019 2 0 0 2 0 2 0 0 6/16 Massoud 2017 1 0 2 0 0 2 2 0 7/16 Kaul et al 2020 2 1 0 1 0 2 2 0 8/16 Guclu et al 2016 1 2 0 1 0 1 0 0 5/16 Sadek et al 2015 2 0 2 2 1 2 2 0 11/16 Seker et al 2016 2 2 0 2 0 1 0 0 7/16 Khiami et al 2013 2 2 0 1 1 2 0 0 8/16 Pavan Kumar et al 2013 2 2 0 1 0 2 2 0 9/16 Ozan et al 2017 2 0 0 1 0 2 2 0 7/16 Lins et al 2013 1 1 1 2 0 2 2 0 9/16 El Shazly et al 2014 2 1 2 2 0 2 0 1 10/16 Bąkowski et al 2020 1 0 0 1 0 2 2 2 8/16 Maffulli et al 2014 2 2 2 2 0 2 2 0 12/16 Song et al 2018 2 1 0 2 0 2 2 0 9/16 Dumbre et al 2014 1 1 1 2 0 2 2 0 9/16 Maffulli et al 2018 1 1 2 2 0 2 2 0 10/16 Bansal et al 2021 2 1 2 2 0 1 2 0 10/16 Gedam et al 2016 1 0 0 2 0 1 0 0 4/16 Li et al 2021 1 0 0 2 0 2 2 0 7/16 Bai et al 2019 1 1 0 2 0 2 0 0 6/16 Maffuli et al 2013 2 1 2 2 1 2 2 0 12/16 Nilsson Helander et al 2008 2 2 1 2 2 2 2 0 13/16 El Shewy et al 2009 0 2 1 1 0 2 2 0 8/16 Sarzaeem et al 2012 1 2 2 2 0 2 2 0 11/16 Takao et al 2003 0 2 0 1 0 2 2 0 7/16 Muliera et al 2003 1 0 0 1 0 2 2 0 6/16 Lin et al 2019 1 2 0 2 0 2 2 0 9/16 Werken et al 1983 0 0 1 0 0 0 1 0 2/16 Gunaratne et al 2021 1 2 0 1 0 2 0 0 6/16 Nilsson et al 2022 2 1 0 2 0 2 2 0 9/16 Nordenholm, Nilsson et al 2022 2 1 0 2 0 2 2 0 9/16 Nordenholm, Senorski et al 2022 2 1 2 2 1 2 2 0 12/16 Raju et al 2022 1 2 0 1 0 2 2 0 8/16 Tsukada et al 2022 1 2 0 2 0 2 0 0 7/16 Result extraction A summary of the results of each individual study is shown in Table 4 . The patients treated with gastrocnemius aponeurosis flap had a mean age of 44.5 years and were followed-up for a mean time period of 40 months. The patients treated with semitendinosus tendon grafts had a mean age and follow-up time of 44 years and 28 months, respectively. The outcome measures used in the studies were patient-reported outcome measures (ATRS [ 46 ], VAS [ 20 ], VISA-A [ 55 ], FADI [ 58 ], Tegner scale [ 60 ], and SF-36 [ 25 ]) mixed scores (AOFAS [ 61 ], Leppilahti [ 28 , 61 ], Hooker [ 49 ], Arner-Lindholm [ 3 ], Rupp-score [ 23 ] and Holz-scale [ 12 ]) and clinical tests (calf circumference [ 61 ], range of motion (ROM), muscle strength/isokinetic testing/heel-rise tests, ultrasonography and Manual Muscle Testing (MMT) [ 10 ]). The most used outcome measure was AOFAS with a total of 19 unique studies. Some outcome measures were only used once: including the Holz scale, Tegner scale, FADI, Hooker, MMT, Arner-Lindholm, Rupp-score and SF-36. The mean (SD; n) postoperative ATRS was 83 (14; 6 studies) and the mean (SD; n) AOFAS was 96 (1.7; 12 studies) for patients treated with a gastrocnemius aponeurosis flap. In comparison, the mean (SD; n) ATRS and AOFAS for semitendinosus tendon grafts were similar with scores of ATRS 88 (6.9; 7 studies) and AOFAS 92 (5.6; 9 studies). However, patients treated with semitendinosus tendon grafts had lower mean (SD; n) preoperative values with ATRS 38 (11.3; 6 studies) vs. 50 (11.1; 3 studies) and AOFAS 51 (13.3; 7 studies) vs. 62 (9.0; 10 studies). A comparison of the complications between gastrocnemius aponeurosis flaps and semitendinosus tendon grafts can be found in Table 3 . The most common complication found was superficial wound infection with a total of 27 patients (3.4%), 22 (4.6%) of which were treated with gastrocnemius aponeurosis flaps and 5 (1.5%) with semitendinosus tendon grafts. In general, patients treated with gastrocnemius aponeurosis flap had more complications than patients treated with semitendinosus tendon grafts, mainly due to wound healing problems. However, patients treated with semitendinosus graft were more prone to sural nerve injury due to a smaller surgical incision. Only one re-rupture occurred in the total group of 763 patients. That patient was treated with a gastrocnemius flap. Table 3 Overview of the complications for semitendinosus tendon grafts (ST-grafts) and gastrocnemius flaps (G-flaps) Overview of the complications Complications ST-grafts n (%) G-flaps n (%) Total n (%) Wound infection 5 (1.7) 22 (4.6) 27 (3.5) Delayed wound healing 2 (0.7) 16 (3.3) 18 (2.4) Deep Vein Thrombosis 1 (0.3) 6 (1.3) 7 (0.9) Wound dehiscence 1 (0.3) 6 (1.3) 7 (0.9) Deep infection - 5 (1.0) 5 (0.7) Persistent pain from the operation wound 5 (1.7) - 5 (0.7) Hypertrophic scar - 3 (0.6) 3 (0.4) Weakness from the donor site 2 (0.7) - 2 (0.3) Sural Nerve injury 4 (1.3) - 4 (0.5) Re-rupture - 1 (0.2) 1 (0.1) Persistent pain from the donor site 1 (0.3) - 1 (0.1) Stitch abscess - 1 (0.2) 1 (0.1) Sural nerve hypoesthesia - 1 (0.2) 1 (0.1) Aseptic superficial skin necrosis - 1 (0.2) 1 (0.1) Septic partial tendon necrosis - 1 (0.2) 1 (0.1) Table 4 The included studies, number of patients, age, follow-up time, outcome measures, results and complications. First author and publication year [reference] Repair method Number of patients Mean patient age Follow-up time Outcome measure Outcome results Complications (quantity) Jain et al 2020 [ 21 ] FHL + G-flap 15 43.5 years 19.07 months (13–24) AOFAS, ATRS AOFAS score: 98.4 SD 2.03 (94–100), preop: 72.07 SD 8.29 (62–83). ATRS score: 98 SD 1.85 (94–100), preop: 61.73 SD 8.16 (52–70). No re-ruptures. Serous discharge and delayed wound healing (2), wound infection (1). Elgohary et al 2016 [ 13 ] FHL + G-flap 19 47 years 29 months (13–52) AOFAS AOFAS score: at 6 months 88.4 (72–96), at 12 months and at last follow-up 94 (76–100), preop: 65 (52–72). Mean time for return to work was 90 days (42–120), and to sport activity (4 patients) it was 147.5 days (90–210). All patients had calf muscle hypotrophy with a mean difference of 0.6 cm in calf circumference (0.3–1.8). All patients were able to perform a single leg heel-rise at the last follow-up. No re-ruptures. Deep infection (1). Skin sloughing, needing a skin graft (1). Hypertrophic scar (1). Superficial infection (3). Koh et al 2019 [ 25 ] FHL + G-flap 49 60 years At least 12 months AOFAS, VAS, SF-36 AOFAS score: at 3 months 76 (SD 22), at 6 months 83 (SD 18), at 12 months 95 (SD 10), preop: 52 (SD 19). VAS score: at 12 months 0, preop: 5. SF-36: Physical function, physical limitation, bodily pain, and social function improved significantly after surgery, physical component score also improved significantly at 12 months. No re-ruptures. Stitch abscess (1). Wound dehiscence (1) Massoud 2017 [ 42 ] G-flap 15 25 years 5 years (3–8) Calf circumference, Range of motion Calf circumference was equal to the uninjured side in 12 patients. Three patients had calf muscle hypotrophy, which averaged 1.3 cm in difference to the healthy side (range 1–2). Active ankle motion range was equal to the contralateral in 14 patients. No re-ruptures. Superficial wound infection (3). Deep infection (1). Kaul et al 2020 [ 22 ] G-flap 16 Not reported At least 12 months LEPPILAHTI Leppilahti score: 12 months postop: 75% (12) had excellent result, 19% (3) had good result, and 6% (1) had fair result. No re-ruptures. Superficial surgical site infections (2). Delayed wound healing (1). Guclu et al 2016 [ 17 ] G-flap 17 33 years 16 years (13–18) AOFAS AOFAS score: 95 (SD 3), preop: 64 (SD 4). Mean calf circumference difference: 3.4 cm (1–6). Mean 30 degrees plantar flexion and 120 degrees plantar flexion peak torques: 89 and 45 Nm. Mean deficiency in 30 degrees and 120 degrees: 16% and 17%. No re-ruptures. Superficial wound infection (2). Sadek et al 2015 [ 56 ] G-flap 18 40.7 years 21.8 months AOFAS, calf circumference, Range of motion AOFAS score: at 3 months 86.8 (82–99), at 6 months 94.6 (89–100), at 12 months 94.9 (89–100). Preop: 62.2 (40–85). ROM (plantar flexion): mean 43 degrees, healthy side was 45.8. Preop: 25.2. ROM (dorsiflexion): 19.4. Preop 21.2, healthy side 22.3. Calf hypotrophy: 3.3 (1–6) cm. No re-ruptures. Delayed wound-healing (2). Superficial wound infection (1). Seker et al 2016 [ 58 ] G-flap 21 32.1 years 145.3 months AOFAS, Range of motion, calf circumference, heel-raise, VAS, FADI. Peak torque AOFAS score: 98.5 (90–100). FADI score: 98.9 (96.2–100). VAS score: 0. Calf circumference: 36.2 (30–40) compared with 37.2 (32–41) in healthy side. Ankle dorsiflexion: 18 (10–20) degrees compared with healthy side 19 (15–20) degrees. Plantar flexion: 30 (20–40) for both sides. Mean time for return to daily activities: 11.1 (8–16) weeks. Single heel rise was attainable after a mean of 14.1 (9–20) months after surgery. The mean plantar flexion peak torque for 30 and 120 degrees were 82 (70–142) and 42 (39–69) compared with the healthy side of 96 (70–145) and 43 (40–75). Median peak force deficiency was 6 (0–21) % at 30 degrees and 4.8 (0-12.5) % at 120 degrees. Mean dorsiflexion peak torque for 30 degrees: 51 (45–60) Nm compared with 55 (44–67) Nm on the healthy side. And the same bilaterally for 120 degrees with 39 (35–54) on the operative side and (31–55) on the healthy side. No re-ruptures. Superficial soft tissue infection (1). Khiami et al 2013 [ 24 ] G-flap 23 52.1 years 24.5 months (12–43) AOFAS AOFAS score: 96.1 SD 6.8 (range, 79–100). Preop: 63.6 SD 11.5. The group without abnormal MRI signal had a mean AOFAS score of 98.3 SD 3.9, and those with abnormality 92.5 SD 10.5. Twelve patients resumed leisure sports at their previous level by a mean ± SD (range) 9.4 SD 2 months (7–12); three competitive sportsmen resumed sport at their previous level by a mean 7.6 months. MRI performed at 1 year showed increased tendon volume without abnormality in 57% (8/14) of cases; 43% (6/14) showed abnormal images. No re-ruptures. Partially regressive sural nerve hypoesthesia (1). Aseptic superficial skin necrosis (1). Septic partial tendon necrosis (1). Pavan Kumar et al 2013 [ 52 ] G-flap 78 No mean, between 38–66 years 12 months LEPPILAHTI, ultrasonography LEPPILAHTI: 62 patients had excellent results (90-100p), 8 had good results (75-89p), 4 had fair results (60-74p), 2 had poor results (< 60p) and 2 were lost to follow up after 1 year. Nearly all patients resumed work at 6 months post-op and had normal walking, and stair climbing as well as normal dorsiflexion. No re-ruptures. Scar hypertrophy (2). Deep infection (1), superficial infection (2). Delayed wound healing (3). Ozan et al 2017 [ 49 ] G-flap 15 35.2 years 19.6 months Range of motion, Hooker, Heel-rise Mean calf hypotrophy was 1.2 cm (0-2.5). No patient had any limitations to daily living and the active and passive ankle ROM was "good". Mean time to work was 38 months. The mean time for patients to return to daily activity was 3.2 months (range, 2–5 months). All patients were able to perform singe-leg heel rises. Hooker scores were excellent for 11 patients and satisfactory for 4 patients. No re-ruptures. No infection, no complications reported. Lins et al 2013 [ 32 ] ST-graft 13 42.2 years 12 months AOFAS, Gait-pattern, Range of motion, Calf circumference AOFAS score: at 6 months postop: 68.5 (SD 18.7), at 12 months postop: 85.2 (SD 18.7). The control group walked faster. Their stance phase was also shorter than patients affected by rupture. The calf circumference at 6 months was 257 compared with 24.5 at 12 months. The ROM-values were lower for the injured ankle at both 6 and 12 months. No re-ruptures. No infections. Weakness at the donor site (1). El Shazly et al 2014 [ 11 ] ST-graft 15 37.7 years 24 months AOFAS, Isokinetic testing AOFAS score: at 24 months postop: 90.8. Preop: 32.6. Isokinetic testing showed a non-significant deficit (< 10%) of the plantar flexors on the injured side. No infections. Temporary sural nerve injury (1). Bąkowski et al 2020 [ 5 ] ST-graft 18 53 years 15.3 months (12–24) ATRS, VAS, QOL questions, calf circumference ATRS improved significantly (no data). Lower calf circumference (no data). VAS pain 1.0. VAS satisfaction 9.0. Median EQ-5D 80.0. Heel-rise endurance 10.5 vs 7.0. Isokinetic flexor peak torque better on non-injured side, 91.3 vs 111. Single hop showed no statistical difference between injured and uninjured side. No re-ruptures. Moderate donor site pain and weakness (1). Maffulli et al 2014 [ 35 ] ST-graft 26 46 years 31.4 months ATRS, calf circumference, isometric strength, heel-rises ATRS score: Postop latest follow-up: 86 (78–95). Preop: 42 (29–55). Calf circumference: 37.9 cm on the injured side vs 42.8 on the healthy side. Isometric 357 J on injured side vs 408 on healthy side. All patients could perform 10 heel-rises. No re-ruptures. No infections nor nerve injuries. Persistent pain over the distal operating wound (1). Song et al 2018 [ 60 ] ST-graft 36 36 years 53 months AOFAS, ATRS, VISA-A, Tegner. AOFAS score: Postop at latest follow-up 100 (86–100). Preop: 50 (5–75). VISA-A: Postop at latest follow-up: 94 (52–100). Preop: 23 (5–59). ATRS score: Postop at latest follow-up: 99 (84–100). Preop: 22.5 (6–67). Tegner score: Postop at latest follow-up: 4 (3–9). Preop: 1 (0–3). No re-ruptures. No infections or nerve injuries. Pain related to the operation wound (4). Dumbre et al 2014 [ 10 ] ST-graft 35 47 years 30.7 months (20–42) Weight bearing MMT Weight-bearing MMT postop at latest follow-up: 4/5. Preop: 2/5. Non-weight-bearing MMT postop at latest follow-up: 5/5. No re-ruptures. No complications reported. Maffulli et al 2018 [ 38 ] ST-graft 21 44.8 years 35.4 months ATRS, calf circumference, plantar flexion strength ATRS score: Postop at latest follow-up: 89.4 SD 3.2. Preop: 50.4 SD 7.5. Calf circumference postop: 38.7 cm SD 3.6 cm on the injured side, compared with 39.3 cm SD 3.4 cm on the healthy side. Plantar flexion strength: 424.3 N SD 42.9 N on the injured side, compared with 488.0 N SD 44.8 N on the healthy side. No re-ruptures reported. No complications reported. Bansal et al 2021 [ 6 ] ST-graft 10 45.1 years 12 months AOFAS AOFAS score: Postop at latest follow-up: 80.4. Preop: 40.8. All except one patient were able to walk on tiptoes. No re-ruptures. Superficial wound infection (1). Gedam et al 2016 [ 15 ] ST-graft + G-flap 14 45.6 years 30 months (12–78) AOFAS, ATRS AOFAS score: Postop at latest follow-up: 96.9 (90–100). Preop: 64.5 (35–79). ATRS score: Postop at latest follow-up: 91.4 (83–97). Preop: 49.4 (30–70). No re-ruptures. No complications reported. Li et al 2020 [ 30 ] ST-graft 26 44.2 years 15 months (12–18) AOFAS, Plantar flexion strength, VISA-A scale, VAS AOFAS score: Postop at latest follow-up: 91.3 SD 6.5. Preop: 44.9 SD 2.1. VISA-A: Postop at latest follow-up: 84.1 SD 3.9. Preop: 49.1 SD 3.2. VAS: Postop at latest follow-up 1.08 SD 0.3. Preop: 5.97 SD 0.7. Plantar flexion strength: Postop at latest follow-up: 133.7 N SD 17.5 N in injured side, compared with 141.5N SD 11.8 N in healthy side. All 26 was able to perform single leg heel-rises. No re-ruptures. No complications reported. Bai et al 2019 [ 4 ] ST-graft + G-flap Total: 26, G-flaps: 11, ST-grafts: 15 36.7 years 12 months AOFAS, Leppilahti score. ST-grafts: AOFAS score: Postop at latest follow-up: 93.5 SD 2.5. No preop measurement. Leppilahti score: Postop at latest follow-up: 95.1 SD 3.1. No preop measurement. Gastrocnemius-flaps: AOFAS score: Postop at latest follow-up: 92.6 SD 3.0. No preop measurement. Leppilahti score: Postop at latest follow-up: 94.7 SD 3.1. No preop measurement. No re-ruptures. Nerve injury (1 in ST-graft group). Infection (2 in G-flap group), DVT (2 in the Gastrocnemius-flap group). Maffulli et al 2013 [ 37 ] ST-graft 26 42 years 8.2 years (7–10) ATRS, calf circumference, isometric strength ATRS at latest follow-up was 88. Lower isometric strength in injured side vs healthy side. Calf circumference 39.7 (SD 7.1) cm on the injured side vs 41.5 (SD 6.6) cm on the healthy side. No re-ruptures. Superficial wound infection (2). Wound adhesion (1). Nilsson Helander et al 2008 [ 45 ] G-flap 28 46 years 29 months (12–117) ATRS, questionnaire for symptoms, physical activity, and satisfaction ATRS score: Postop at latest follow-up: 83 (24–100). 16 patients were satisfied with the final outcome. No re-ruptures. Deep infection (1), wound closure complication (2), DVT (2). El Shewy et al 2009 [ 12 ] G-flap 11 34.3 years 7.45 years (6–9) AOFAS, Holz scale, Range of motion, calf circumference Holz scale: preop 10 poor, 1 fair. Postop 11 good. AOFAS: Preop 42.27 (39–46). Postop 98.9 (88–100). Ankle ROM (mean + SD): plantar flexion preop 20.5 SD 2.70. Postop 49.6 SD 1.5. Dorsiflexion preop 11.4 SD 3.23. Postop 17.7 SD 2.6. Calf (cm): Circumference (mean + SD)) Preop 31.6 SD 0.9. Postop 34.4 SD 0.89. Wasting (mean + SD) Preop 1.6 SD 0.4. Postop 0.7 SD 0.2. No re-ruptures. Small wound gaping (3), superficial wound infection (2). Sarzaeem et al 2012 [ 57 ] ST-graft 11 30 years 25 Months AOFAS, ATRS, Range of motion, Calf circumference ATRS: Preop: 32 SD 6 (24–39). Postop: 89 SD 4 (82–95). AOFAS: Preop: 70 SD 5 (61–78). Postop: 92 SD 5 (83–97). Circumference: Injured side: 36 SD 3 (30–42) cm. Healthy side: 38 SD 4 (33–45) cm ROM: Plantar flexion: Injured side: 36 SD 8 (22–50) degrees. Healthy side: 39 SD 6 (30–50) degrees. Dorsiflexion: Injured side: 13 SD 4 (5–20) degrees. Healthy side: 17 SD 4 (10–25) degrees. No re-ruptures. Superficial infection (2), DVT (1). Takao et al 2003 [ 62 ] G-flap 10 51 years 75.1 months (26–192) Calf circumference, Range of motion AOFAS - Preop: 72.6 SD 5.3 (68–82). Postop: 98.1 SD 2.5 (94–100). Cybex − 30 degrees, preop: Torque effect ranged from 8–68% at the low setting and from 19–33% at the high setting. Postop, the torque ranged from − 9–17% at the low setting and from − 13–23% at high setting. Not reported. Mulier et al 2003 [ 43 ] G-flap with and without FHL 19 37 years 18 months Leppilahti score, stiffness, muscle weakness, Range of motion, isokinetic calf muscle strength, CYBEX Leppilahti: Postop Gastrocnemius -flap: Fair, 62 (48–78). Postop Gastrocnemius-flap + FHL: Good, 77 (67–89). Cybex: G-flap: 23% (5–45) decrease in power and strength. Gastrocnemius -flap + FHL: 14% (5–35) decrease in power and strength. ROM: Gastrocnemius -flap: dorsiflexion 9 degrees (-5-20), plantar flexion 33 degrees (20–45). Gastrocnemius -flap + FLL: dorsiflexion 13 degrees (-5-25), plantar flexion 36 (20–45). Re-rupture (1). Deep infection (1 in g-flap only), DVT (1 in each group, 2 total), delayed wound healing (3 in g-flap, 4 in Gastrocnemius-flap + FHL). Lin et al 2019 [ 31 ] G-flap 20 38.5 years 32.8 months (12–68) AOFAS, ATRS ATRS: Preop: 39.6 SD 14.2 (20–72). Postop: 94.1 SD 4.9 (86–100). AOFAS: Preop: 59.3 SD 12.3 (40–75). Postop: 96.6 SD 3.8 (90–100). No re-ruptures. Superficial infection (1). Werken et al 1983 [ 64 ] G-flap 10 51 years At least 2 years Calf circumference Calf Circumference difference between the healthy and injured sided was 1-3.5 cm. No re-ruptures. Wound infection (2). Gunaratne et al. 2021 [ 18 ] G-flap 13 56 years 12 months ATRS Mean ATRS postop 72 Not reported. Nilsson et al. 2022 [ 44 ] ST-graft 22 60 years 12 months ATRS. ATRA. Heel-rise height. Heel-rise reps. Calf circumference. Ultrasonography. Concentric power. Heel-rise work. ATRS 76 (45–99). 89% were able to perform a single-leg heel-rise on the injured side. Tendon length 2.8 cm longer on the injured side compared with the non-injured and calf circumference 1.5 cm lower. ATRA was 60 (15) vs 49.5 (6) on the non-injured side. The same numbers for heel-rise height were 5.5 (5.75) vs 9.0 (2.75) and for heel-rise reps 11 (18) vs 26 (14). No re-ruptures. 2 superficial wound infections and 1 sural nerve injury. Nordenholm, Nilsson et al. 2022 [ 47 ] G-flap 22 61 years 12 months ATRS. PAS. FAOS. Heel-rise height. Heel-rise reps. Calf circumference. Ultrasonography. CMJ. Heel-rise work. Hopping ratio. ATRA. Dorsiflexion range. Mean (SD) ATRS 62 (26) and mean (SD) PAS 3.5 (1.1). The patients performed less well in the heel-rise test on the injured side compared with the healthy side with a median (IQR) of 20 (10) vs 24 (12) in heel-rise repetitions (p = 0.004), 8 (7) vs 10 (8) cm in heel-rise height (p < 0.001), 872 (1740) vs 1590 (2145) joule in total heel-rise work (p = 0.001) and 0.37 vs 0.48 in hopping ratio (p = 0.005). Patients with chronic Achilles tendon rupture exhibited an elongation of the injured Achilles tendon with median (IQR) ATRA of 55° (3) compared with 50° (9) (p < 0.001) and a median of 22.4 (2.9) cm compared with 20.5 (2.0) cm measured by ultrasound (p = 0.06). Calf circumference was smaller on the injured side with a median (IQR) of 37 (4) compared with 38 (4) cm (p = 001). No re-ruptures. 1 superficial wound infection. Nordenholm, Senorski et al. 2022 [ 48 ] G-flap 23 61 years 12 months Gait-analysis Significantly reduced step width (0.01 m (p = 0.014)), increased speed (− 0.12 m/s (p = 0.013)), stride length (− 0.12 m (p = 0.002)), ankle moment (− 0.64 Nm/kg (p < 0.001)) ankle power (− 1.38 W/kg (p < 0.001)) and knee power (− 0.36 W/kg (p = 0.003)) compared with the preoperative status. Not reported. Raju et al. 2022 [ 54 ] G-flap 12 47 years 34 months Calf diameter. Dorsiflexion. Heel-rises. VAS. Rupp-score. Calf-diameter increased 2.2 cm. Dorsiflexion increased 10 degrees. Rupp-score with 5 excellent and 7 good. No re-ruptures or complications. Tsukada et al. 2022 [ 66 ] ST-graft 10 52 years 35 months AOFAS. ATRS. VAS. Months until the patient could perform 20 single-leg heel-rises. AOFAS increased significantly from 64.2 SD 5.6 (range 58–72) points preoperatively to 95.0 SD 5.3 (range 90–100) points at the final follow-up (P < 0.001), as did mean ATRS, from 29.8 SD 4.4 (range 22–35) points to 86.2 SD 7.7 (range 70–94), respectively (P < 0.001). Mean time between surgery and ability to perform 20 continuous double-leg heel rises of the operated foot was 13.5 SD 3.4 (range 10–18) weeks. Re-ruptures not reported. 1 sural nerve injury. Discussion The most important finding of this systematic review was that both gastrocnemius aponeurosis flap and semitendinosus graft reconstructions were found to be effective in treating chronic Achilles tendon ruptures with similar favourable patient-reported outcome scores and performances in functional tests. Only one re-rupture was reported (0.12%) in the patient group treated with a gastrocnemius aponeurosis flap and no patient in the group treated with a semitendinosus graft. However, studies of higher quality are needed to fully determine the optimal way of treating chronic Achilles tendon ruptures. All the included studies were case series without matched control groups. Additionally, the articles used a variety of different outcome measures, which limited the comparisons between studies. Lastly, even though the gastrocnemius aponeurosis flaps, and semitendinosus tendon grafts are presented as distinctive groups, both groups were heterogenic with different interpretations of the techniques. In prior systematic reviews by Apinun et al. [ 2 ] and Hadi et al. [ 19 ], similar results have been shown with good functional patient-reported outcomes, and low re-rupture rates. The review performed by Hadi et al. identified 35 individual studies in 2013 whereas this systematic review identified a total of 86 individual publications on the same subject in 2022. The heterogenicity of outcome measures and surgical techniques, and the retrospective nature of limited cohort sizes remain. This meant that quantitative meta-analysis was deemed inappropriate. Studies including fewer than 10 patients were excluded from this systematic review. Most of these studies were case reports with one to two patients using no outcomes measures. Therefore, the exclusion of case reports did not result in any substantial data loss. The result of the included studies indicate that patients treated with a gastrocnemius flap are more prone to complications than patients treated with semitendinosus tendon graft. Due to the heterogenicity, no significant difference could be determined, however. Depending on the surgical technique a different pattern of complications occurred. Semitendinosus tendon grafts uses an autologous transplantation with risk of complications related to the hamstring donor site or sural nerve injury due to the location and the smaller size of the surgical incisions. Gastrocnemius flaps uses a turn-down flap or a free-flap from the aponeurosis with larger surgical wounds leading to an increased risk of infections and wound healing problems. [ 41 ] The MINORS assessment generally resulted in a low-quality with scores with a median of 8 out of 16. Moreover, the studies included in this review frequently used AOFAS as their main patient-reported outcome. It is known that this outcome measure is not validated for Achilles tendon ruptures. Instead, a patient-reported outcome such as ATRS could be used. This patient-reported outcome measure is also not validated for chronic Achilles tendon ruptures, but it is validated for acute Achilles tendon ruptures. In the future, research of chronic Achilles tendon ruptures would benefit from a patient-reported outcome measure that is validated for chronic ruptures, as that would allow for a clearer comparison between operating methods and outcome. The exclusions based on the number of patients and the language of the studies might have affected the results of this review. This review excluded all non-English studies and all studies with less than 10 patients. The exclusion criteria removed 108 studies due to language and 47 studies due to a small cohort size. The exclusion of studies in non-English language facilitated data extraction by avoiding outcome heterogeneity between studies, thus improving quality. The number of articles excluded based on sample size were large in number but were usually singular case reports without any outcome measures. Similarly, varying outcomes measures may have made comparisons between studies even harder. Following this systematic review, the authors recommendation is to individualise the treatment of chronic Achilles tendon ruptures depending on factors such as functional demands, comorbidities, tendon gap size, and the general experience of the orthopaedic surgeon treating the patient. The use of a gastrocnemius aponeurosis flap in tendon ruptures with a gap that is less than 5 centimetres (cm) is regarded as efficient. [ 12 , 45 ] In tendon ruptures with larger defects (> 5 cm) a semitendinosus tendon graft will bridge the defect. [ 36 , 57 ] Other alternatives include flexor hallucis longus graft [ 50 , 53 ] and peroneus tendon graft. [ 39 ] However, tendon elongation continues to be a problem despite established rehabilitation techniques. [ 36 , 57 ] Conclusion In conclusion, surgical reconstruction with both semitendinosus tendon grafts, and gastrocnemius aponeurosis flaps are considered effective in treating chronic Achilles tendon ruptures with good patient-reported outcomes and few re-ruptures. The complication profiles are different between the two techniques with more postoperative infections and wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries and donor site weakness in patients treated with a semitendinosus graft. There is a continued need for more prospective randomized controlled trials and a need for an established outcome measure for chronic Achilles tendon ruptures to fully evaluate the effectiveness of different reconstructive techniques in the treatment of chronic Achilles tendon ruptures. Declarations Ethics approval and consent to participate: Not applicable. Consent of publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: No external funding was received. Authors' contributions: All authors took part in the development of the study design. NN and IS reviewed the abstracts in Rayyan®. All authors performed the full-text filtering, result extraction and quality assessment. All authors read and approved the final manuscript. Acknowledgements: Not applicable. References Abraham E, & Pankovich, A. M. . Neglected rupture of the Achilles tendon. Treatment by VY tendinous flap. J Bone Joint Surg Am.1975;57(2):253-5. Apinun J, Jenvorapoj S, Arirachakaran A, Kongtharvonskul J. Clinical outcomes of chronic Achilles tendon rupture treated with flexor hallucis longus grafting and flexor hallucis longus grafting plus additional augmentation: A meta-analysis. 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Achilles tendon ruptures--peroneus brevis transfer. Foot Ankle.1987;7(4):253-9. van der Werken C, Marti RK. Operative repair of ruptured achilles tendon and functional after-treatment--II. Delayed rupture. Neth J Surg.1983;35(2):65-8. Wapner KL, Hecht PJ, Mills RH, Jr. Reconstruction of neglected Achilles tendon injury. Orthop Clin North Am.1995;26(2):249-63. Yassin M, Gupta V, Martins A, Mahadevan D, Bhatia M. Patient reported outcomes and satisfaction following single incision Flexor Hallucis Longus (FHL) augmentation for chronic Achilles tendon pathologies. J Clin Orthop Trauma.2021;23:101650. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Dec, 2023 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Major revision 12 Sep, 2023 Reviews received at journal 31 Aug, 2023 Reviewers agreed at journal 28 Aug, 2023 Reviewers invited by journal 19 Mar, 2023 Editor assigned by journal 17 Mar, 2023 Editor invited by journal 02 Mar, 2023 Submission checks completed at journal 02 Mar, 2023 First submitted to journal 21 Feb, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2613525","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":180221399,"identity":"14d0b643-202e-44cb-8f2c-117dec32692d","order_by":0,"name":"Niklas Nilsson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABKklEQVRIie2QMUvDQBSAXzi4W66tY460/yFSiAhB/0pKwSm6dBIHC4XrUnF28l8cjhcCqUPANdDFmFXEUoQKGbwzWaRJwU3kvuHuPd77uPcOwGD4iyBsSX1jUuW0R27zZx102xWoFFTlfbZIkasV3PpMrUCt+G4WYrsqNHNEcCC3JVx0ESne1w9A3ew8ufwIT/oYUP6S7SrHMyyjGw4TjKjH7lKgLH07Ww3EWA2Gh8NwV3FjMpWdKYw4ohh1uNp6GXgrJlSq1nFalKgstUKKjVZABt6Eies9CpaxqioFXEcrB4+hZ61FvE8J4gG39WBqF25TtkjGjiWWas6WXZ6Sw/y19Ef387n6Me6f9sgsWn+KKx3kRYNSY/8MEP0+W9sbsLa/6TYYDIb/zhdr/lueVwOKFAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Gothenburg","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Niklas","middleName":"","lastName":"Nilsson","suffix":""},{"id":180221401,"identity":"9230b07e-6745-48af-bc92-3693dad39230","order_by":1,"name":"Immanuel Stensöta","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Immanuel","middleName":"","lastName":"Stensöta","suffix":""},{"id":180221403,"identity":"4a88460d-1af7-49e3-94dd-ecd5f5b48fc1","order_by":2,"name":"Katarina Nilsson Helander","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Katarina","middleName":"Nilsson","lastName":"Helander","suffix":""},{"id":180221405,"identity":"f806e286-58d6-4e35-b8b6-dc3d76f423f4","order_by":3,"name":"Annelie Brorsson","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Annelie","middleName":"","lastName":"Brorsson","suffix":""},{"id":180221407,"identity":"67793793-1fc7-494f-b3bf-d5384f137727","order_by":4,"name":"Michael R Carmont","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michael","middleName":"R","lastName":"Carmont","suffix":""},{"id":180221409,"identity":"46c6f805-0b7c-4cd1-bcd2-d711b39db10e","order_by":5,"name":"Sebastian Concaro","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Concaro","suffix":""}],"badges":[],"createdAt":"2023-02-21 19:29:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2613525/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2613525/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-023-07064-8","type":"published","date":"2023-12-08T15:01:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":33906640,"identity":"1f61af54-a55d-43a7-9005-4705fe9fc7a1","added_by":"auto","created_at":"2023-03-07 15:01:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":177418,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePRISMA-flowchart for the inclusion of studies, The PRISMA 2020 statement [51].\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-2613525/v1/c4c9a339bfc646957f326479.png"},{"id":47989298,"identity":"d5950593-9bea-4786-bbe5-b2c51b73d71a","added_by":"auto","created_at":"2023-12-11 15:08:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":871845,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2613525/v1/997dbe11-7eff-4f3f-b727-40bd969c6b8d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures – a systematic review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical history and clinical examinations are considered to be sufficient in establishing the diagnosis of an acute Achilles tendon rupture [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. However, occasionally treatment is delayed due to late presentation or misdiagnosis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. A delay of treatment leads to larger tendon-end diastasis with interposed scar tissue [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Achilles tendon ruptures that have had a delay in treatment by more than 4 weeks, are termed chronic and surgical intervention is required to recover lower leg function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The traditional surgical intervention for chronic Achilles tendon ruptures involves considerably larger incisions than acute repairs leading to an increased risk of complications, such as infections and inadequate wound-healing [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients with chronic Achilles tendon ruptures report different symptoms compared with those of acute ruptures. Long-term pain and recurrent swelling are more frequent in patients with chronic ruptures [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In addition, altered gait with a weakness at push-off, a poor balance, and a reduced capability of performing heel-rises are commonly reported [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature includes various surgical techniques for the management of chronic Achilles tendon ruptures: V-Y plasty, tendon transfers, gastrocnemius aponeurosis/fascia flaps, direct repair and synthetic grafts, [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. The choice of surgical procedure depends on the location of the rupture, the size of tendon-end diastasis, individual factors such as patient activity level and age, together with the preference and experience of the surgeon.\u003c/p\u003e \u003cp\u003eIn 2013 Hadi et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] performed a systematic review on surgical techniques. They identified 11 different surgical techniques in 34 individual publications: (1) peroneus brevis tendon transfer, (2) flexor hallucis longus tendon transfer, (3) V-Y tendinous flap, (4) gastrocnemius turndown flaps, (5) flexor digitorum longus tendon transfer, (6) free gracilis tendon transfer, (7) free semitendinosus tendon graft transfer, (8) synthetic materials, (9) direct repair, (10) dual techniques, and (11) interposed tissue. The most common outcome measures used were the AOFAS and the ATRS scores. All the reported techniques presented satisfying results. However, it was difficult to do direct comparisons due to a limited number of patients, an absence of control groups, heterogenic groups of patients in the included studies, and different outcome measures.\u003c/p\u003e \u003cp\u003eEven though many surgical techniques are described in the literature, no single technique has been shown to be superior to another. The aim of this systematic review was to analyse the current clinical evidence of two established techniques to treat chronic Achilles tendon ruptures: gastrocnemius aponeurosis flaps and semitendinosus tendon grafts.\u003c/p\u003e"},{"header":"Method And Materials","content":"\u003cp\u003eSearch query\u003c/p\u003e \u003cp\u003eThe systematic search was performed on 2021-07-02, with an updated search on 2022-09-22, in three established databases: PubMed, Scopus and Cochrane Library using the search queries outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The initial search query included all studies presenting the outcome of chronic Achilles tendon ruptures treated surgically. In the final stage, studies presenting outcomes of gastrocnemius aponeurosis flaps or semitendinosus tendon grafts were isolated and analysed. The inclusion criteria were all studies, descriptive and comparative, presenting results on the management of chronic Achilles tendon ruptures in adults (\u0026gt;\u0026thinsp;18 years) using gastrocnemius aponeurosis flap or semitendinosus tendon graft. The exclusion criteria were (1) case-reports and case series with less than 10 patients, (2) reviews, (3) studies written in non-English languages and (4) expert opinions. The systematic review was registered in PROSPERO (CRD42022294130).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSearch query, Boolean operators and search results in the databases PubMed, Scopus, and Cochrane.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePubMed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch string\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimits\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of records\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Achilles Tendon[mh] OR \u0026ldquo;Achilles tendon\u0026rdquo; [tiab] OR \u0026ldquo;Achilles tendons \u0026rdquo;[tiab] OR \u0026ldquo;Calcaneal Tendon\u0026rdquo;[tiab] OR \u0026ldquo;Calcaneal Tendons\u0026rdquo;[tiab] OR \u0026ldquo;Tendo calcaneus\u0026rdquo;[tiab])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(chronic*[tiab] OR neglect*[tiab] OR miss*[tiab] OR delay*[tiab])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026nbsp;204 598\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#1 AND #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026nbsp;750\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Rupture[mh] OR rupture[tiab] OR ruptures[tiab] OR tear*[tiab])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e192 888\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Treatment Outcome[mh] OR treatment[tiab] OR therapy[tiab] OR outcome*[tiab] OR \u0026ldquo;clinical efficacy\u0026rdquo; [tiab] OR \u0026ldquo;clinical effectiveness\u0026rdquo; [tiab] OR complication*[tiab] OR re-rupture*[tiab] OR rerupture*[tiab])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u0026nbsp;235 689\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#3 AND #4 AND #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e526\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScopus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch string\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimits\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of records\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTITLE-ABS-KEY (\"Achilles tendon\" OR \"Achilles tendons\" OR \"Calcaneal Tendon\" OR \"Calcaneal Tendons\" OR \"Tendo calcaneus\")\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 771\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTITLE-ABS-KEY (chronic* OR neglect* OR miss* OR delay*)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026nbsp;433 517\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#1 AND #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026nbsp;439\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTITLE-ABS-KEY (rupture OR ruptures OR tear*)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e387 825\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTITLE-ABS-KEY (treatment OR therapy OR outcome* OR \u0026ldquo;clinical efficacy\u0026rdquo; OR \u0026ldquo;clinical effectiveness\u0026rdquo; OR complication* OR re-rupture* OR rerupture*)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u0026nbsp;409 980\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#3 AND #4 AND #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e803\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#3 AND #4 AND #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimit to: \u003c/p\u003e \u003cp\u003eArticle, Review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCochrane\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch string\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimits\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber of records\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\"Achilles tendon\" OR \"Achilles tendons\" OR \"Calcaneal Tendon\" OR \"Calcaneal Tendons\" OR \"Tendo calcaneus\"):ti,ab,kw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(chronic* OR neglect* OR miss* OR delay*):ti,ab,kw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e232 193\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#1 AND #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Rupture OR ruptures OR tear*):ti,ab,kw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 308\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Treatment OR therapy OR outcome* OR \u0026ldquo;clinical efficacy\u0026rdquo; OR \u0026ldquo;clinical effectiveness\u0026rdquo; OR complication* OR re-rupture* OR rerupture*):ti,ab,kw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026nbsp;344 590\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#3 AND #4 AND #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e#3 AND #4 AND #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimit to: \u003c/p\u003e \u003cp\u003eTrials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eStudy selection\u003c/p\u003e \u003cp\u003eThe search was conducted by the authors and the initial search resulted in 1,340 studies, after removing duplicates, 818 studies remained. All studies were uploaded to the website Rayyan\u0026reg; for abstract review. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) was used to structure the filtering of studies (Fig.\u0026nbsp;1) [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Two authors (NN and IS) independently reviewed the abstracts of the included studies. Disagreement between the authors were settled through discussion. A total of 182 studies remained after the initial abstract review. These were all later successfully imported as full-text versions. For the full-text review, the studies were divided equally between the six authors and checked by a minimum of two authors.\u003c/p\u003e \u003cp\u003eAfter the full-text filtering, 86 studies remained. Out of these, 36 individual studies used gastrocnemius aponeurosis flaps or semitendinosus tendon grafts to treat chronic Achilles tendon ruptures and were included in the review.\u003c/p\u003e \u003cp\u003eQuality assessment\u003c/p\u003e \u003cp\u003eTo assess the methodological quality and risk of bias for the included studies the validated Methodological Index for Non-Randomized Studies (MINORS). MINORS is a quality assessment tool for systematic reviews first described by Slim et. al [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. It is widely used and has a strong external validity. The studies included in this systematic review were all non-randomized and non-comparative studies. MINORS consists of twelve questions, where the last four questions are additional criteria in case of comparative studies. Each question can be scored from 0\u0026ndash;2. A score of 0 meaning it is not reported in the study, a score of 1 meaning it is reported but inadequate, and a score of 2 meaning it is reported and adequate [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResult extraction\u003c/p\u003e \u003cp\u003eThree reviewers extracted the data using a structured extraction protocol. The extracted data was surgical technique, number of patients, mean age, duration of follow-up, outcome measures, presented results. The results analysed were patient-reported outcomes, functional outcome measures and complication rates. Any disagreement was settled through discussion. Moreover, if any author were among the authors of the original study analysed, they did not perform any result extraction or quality assessment of that study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eStudy selection\u003c/p\u003e\n\u003cp\u003eAll the included studies were case series (Level IV) that either used a gastrocnemius aponeurosis flap or semitendinosus tendon graft to treat chronic Achilles tendon ruptures. A semitendinosus tendon graft was used in 13 studies and a gastrocnemius aponeurosis flap in 21 studies. There were two studies that used both surgical techniques. In the study by Bai et al. [\u003cspan\u003e4\u003c/span\u003e] 11 patients were treated with a gastrocnemius aponeurosis flap and 15 were treated with a semitendinosus tendon graft. The study by Gedam et al. [\u003cspan\u003e15\u003c/span\u003e] used both augmentation techniques in all patients and was therefore not part of the analysis. The extracted data from the studies is presented in Table \u003cspan\u003e4\u003c/span\u003e. The grand total number of patients included were 763. The study by Bąkowski et al. [\u003cspan\u003e5\u003c/span\u003e] included eight additional cadavers which were excluded from this systematic review.\u003c/p\u003e\n\u003cp\u003eQuality assessment\u003c/p\u003e\n\u003cp\u003eThe included studies MINORS-scores are shown in Table \u003cspan\u003e2\u003c/span\u003e. The maximum points are 16 for non-randomized studies. The included studies generally had low quality according to MINORS, with a median of 8 out of 16 (range 2\u0026ndash;13) for all studies.\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe points of each study according to the MINORS-score. The maximum score is 16.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCriteria\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1.\u003c/p\u003e\n \u003cp\u003eA clearly stated aim\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2.\u003c/p\u003e\n \u003cp\u003eInclusion of consecutive patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e3.\u003c/p\u003e\n \u003cp\u003eProspective collection of data\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e4.\u003c/p\u003e\n \u003cp\u003eEndpoints appropriate to the aim of the study\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e5.\u003c/p\u003e\n \u003cp\u003eUnbiased assessment of the study endpoint\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e6.\u003c/p\u003e\n \u003cp\u003eFollow up period appropriate to the aim of the study\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e7.\u003c/p\u003e\n \u003cp\u003eLoss to follow up less than 5%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e8.\u003c/p\u003e\n \u003cp\u003eProspective calculation of study size\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFinalized MINORS score\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJain et al 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElgohary et al 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKoh et al 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMassoud 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKaul et al 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGuclu et al 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSadek et al 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeker et al 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKhiami et al 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePavan Kumar et al 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOzan et al 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLins et al 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEl Shazly et al 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBąkowski et al 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaffulli et al 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSong et al 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDumbre et al 2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaffulli et al 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBansal et al 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGedam et al 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLi et al 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBai et al 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaffuli et al 2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNilsson Helander et al 2008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEl Shewy et al 2009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSarzaeem et al 2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTakao et al 2003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuliera et al 2003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLin et al 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWerken et al 1983\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGunaratne et al 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNilsson et al 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNordenholm, Nilsson et al 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNordenholm, Senorski et al 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRaju et al 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTsukada et al 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResult extraction\u003c/p\u003e\n\u003cp\u003eA summary of the results of each individual study is shown in Table \u003cspan\u003e4\u003c/span\u003e. The patients treated with gastrocnemius aponeurosis flap had a mean age of 44.5 years and were followed-up for a mean time period of 40 months. The patients treated with semitendinosus tendon grafts had a mean age and follow-up time of 44 years and 28 months, respectively. The outcome measures used in the studies were patient-reported outcome measures (ATRS [\u003cspan\u003e46\u003c/span\u003e], VAS [\u003cspan\u003e20\u003c/span\u003e], VISA-A [\u003cspan\u003e55\u003c/span\u003e], FADI [\u003cspan\u003e58\u003c/span\u003e], Tegner scale [\u003cspan\u003e60\u003c/span\u003e], and SF-36 [\u003cspan\u003e25\u003c/span\u003e]) mixed scores (AOFAS [\u003cspan\u003e61\u003c/span\u003e], Leppilahti [\u003cspan\u003e28\u003c/span\u003e, \u003cspan\u003e61\u003c/span\u003e], Hooker [\u003cspan\u003e49\u003c/span\u003e], Arner-Lindholm [\u003cspan\u003e3\u003c/span\u003e], Rupp-score [\u003cspan\u003e23\u003c/span\u003e] and Holz-scale [\u003cspan\u003e12\u003c/span\u003e]) and clinical tests (calf circumference [\u003cspan\u003e61\u003c/span\u003e], range of motion (ROM), muscle strength/isokinetic testing/heel-rise tests, ultrasonography and Manual Muscle Testing (MMT) [\u003cspan\u003e10\u003c/span\u003e]). The most used outcome measure was AOFAS with a total of 19 unique studies. Some outcome measures were only used once: including the Holz scale, Tegner scale, FADI, Hooker, MMT, Arner-Lindholm, Rupp-score and SF-36.\u003c/p\u003e\n\u003cp\u003eThe mean (SD; n) postoperative ATRS was 83 (14; 6 studies) and the mean (SD; n) AOFAS was 96 (1.7; 12 studies) for patients treated with a gastrocnemius aponeurosis flap. In comparison, the mean (SD; n) ATRS and AOFAS for semitendinosus tendon grafts were similar with scores of ATRS 88 (6.9; 7 studies) and AOFAS 92 (5.6; 9 studies). However, patients treated with semitendinosus tendon grafts had lower mean (SD; n) preoperative values with ATRS 38 (11.3; 6 studies) vs. 50 (11.1; 3 studies) and AOFAS 51 (13.3; 7 studies) vs. 62 (9.0; 10 studies).\u003c/p\u003e\n\u003cp\u003eA comparison of the complications between gastrocnemius aponeurosis flaps and semitendinosus tendon grafts can be found in Table \u003cspan\u003e3\u003c/span\u003e. The most common complication found was superficial wound infection with a total of 27 patients (3.4%), 22 (4.6%) of which were treated with gastrocnemius aponeurosis flaps and 5 (1.5%) with semitendinosus tendon grafts. In general, patients treated with gastrocnemius aponeurosis flap had more complications than patients treated with semitendinosus tendon grafts, mainly due to wound healing problems. However, patients treated with semitendinosus graft were more prone to sural nerve injury due to a smaller surgical incision. Only one re-rupture occurred in the total group of 763 patients. That patient was treated with a gastrocnemius flap.\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eOverview of the complications for semitendinosus tendon grafts (ST-grafts) and gastrocnemius flaps (G-flaps)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eOverview of the complications\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eST-grafts n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eG-flaps n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDelayed wound healing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeep Vein Thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWound dehiscence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeep infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersistent pain from the operation wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertrophic scar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeakness from the donor site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSural Nerve injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRe-rupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersistent pain from the donor site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStitch abscess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSural nerve hypoesthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAseptic superficial skin necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeptic partial tendon necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003e\u003cem\u003eThe included studies, number of patients, age, follow-up time, outcome measures, results and complications.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFirst author and publication year [reference]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRepair method\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean patient age\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up time\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome measure\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcome results\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComplications (quantity)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJain et al 2020 [\u003cspan\u003e21\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFHL\u0026thinsp;+\u0026thinsp;G-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.07 months (13\u0026ndash;24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, ATRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: 98.4 SD 2.03 (94\u0026ndash;100), preop: 72.07 SD 8.29 (62\u0026ndash;83).\u003c/p\u003e\n \u003cp\u003eATRS score: 98 SD 1.85 (94\u0026ndash;100), preop: 61.73 SD 8.16 (52\u0026ndash;70).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Serous discharge and delayed wound healing (2), wound infection (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElgohary et al 2016 [\u003cspan\u003e13\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFHL\u0026thinsp;+\u0026thinsp;G-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 months (13\u0026ndash;52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: at 6 months 88.4 (72\u0026ndash;96), at 12 months and at last follow-up 94 (76\u0026ndash;100), preop: 65 (52\u0026ndash;72). Mean time for return to work was 90 days (42\u0026ndash;120), and to sport activity (4 patients) it was 147.5 days (90\u0026ndash;210). All patients had calf muscle hypotrophy with a mean difference of 0.6 cm in calf circumference (0.3\u0026ndash;1.8). All patients were able to perform a single leg heel-rise at the last follow-up.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Deep infection (1). Skin sloughing, needing a skin graft (1). Hypertrophic scar (1). Superficial infection (3).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKoh et al 2019 [\u003cspan\u003e25\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFHL\u0026thinsp;+\u0026thinsp;G-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAt least 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, VAS, SF-36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: at 3 months 76 (SD 22), at 6 months 83 (SD 18), at 12 months 95 (SD 10), preop: 52 (SD 19).\u003c/p\u003e\n \u003cp\u003eVAS score: at 12 months 0, preop: 5.\u003c/p\u003e\n \u003cp\u003eSF-36: Physical function, physical limitation, bodily pain, and social function improved significantly after surgery, physical component score also improved significantly at 12 months.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Stitch abscess (1). Wound dehiscence (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMassoud 2017 [\u003cspan\u003e42\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 years (3\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalf circumference, Range of motion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalf circumference was equal to the uninjured side in 12 patients. Three patients had calf muscle hypotrophy, which averaged 1.3 cm in difference to the healthy side (range 1\u0026ndash;2).\u003c/p\u003e\n \u003cp\u003eActive ankle motion range was equal to the contralateral in 14 patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Superficial wound infection (3). Deep infection (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKaul et al 2020 [\u003cspan\u003e22\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAt least 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLEPPILAHTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeppilahti score: 12 months postop: 75% (12) had excellent result, 19% (3) had good result, and 6% (1) had fair result.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Superficial surgical site infections (2). Delayed wound healing (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGuclu et al 2016 [\u003cspan\u003e17\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 years (13\u0026ndash;18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: 95 (SD 3), preop: 64 (SD 4). Mean calf circumference difference: 3.4 cm (1\u0026ndash;6). Mean 30 degrees plantar flexion and 120 degrees plantar flexion peak torques: 89 and 45 Nm. Mean deficiency in 30 degrees and 120 degrees: 16% and 17%.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Superficial wound infection (2).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSadek et al 2015 [\u003cspan\u003e56\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.7 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.8 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, calf circumference, Range of motion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: at 3 months 86.8 (82\u0026ndash;99), at 6 months 94.6 (89\u0026ndash;100), at 12 months 94.9 (89\u0026ndash;100). Preop: 62.2 (40\u0026ndash;85). ROM (plantar flexion): mean 43 degrees, healthy side was 45.8. Preop: 25.2.\u003c/p\u003e\n \u003cp\u003eROM (dorsiflexion): 19.4. Preop 21.2, healthy side 22.3.\u003c/p\u003e\n \u003cp\u003eCalf hypotrophy: 3.3 (1\u0026ndash;6) cm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Delayed wound-healing (2). Superficial wound infection (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeker et al 2016 [\u003cspan\u003e58\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.1 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e145.3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, Range of motion, calf circumference, heel-raise, VAS, FADI. Peak torque\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: 98.5 (90\u0026ndash;100). FADI score: 98.9 (96.2\u0026ndash;100). VAS score: 0. Calf circumference: 36.2 (30\u0026ndash;40) compared with 37.2 (32\u0026ndash;41) in healthy side. Ankle dorsiflexion: 18 (10\u0026ndash;20) degrees compared with healthy side 19 (15\u0026ndash;20) degrees. Plantar flexion: 30 (20\u0026ndash;40) for both sides. Mean time for return to daily activities: 11.1 (8\u0026ndash;16) weeks. Single heel rise was attainable after a mean of 14.1 (9\u0026ndash;20) months after surgery. The mean plantar flexion peak torque for 30 and 120 degrees were 82 (70\u0026ndash;142) and 42 (39\u0026ndash;69) compared with the healthy side of 96 (70\u0026ndash;145) and 43 (40\u0026ndash;75). Median peak force deficiency was 6 (0\u0026ndash;21) % at 30 degrees and 4.8 (0-12.5) % at 120 degrees. Mean dorsiflexion peak torque for 30 degrees: 51 (45\u0026ndash;60) Nm compared with 55 (44\u0026ndash;67) Nm on the healthy side. And the same bilaterally for 120 degrees with 39 (35\u0026ndash;54) on the operative side and (31\u0026ndash;55) on the healthy side.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Superficial soft tissue infection (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKhiami et al 2013 [\u003cspan\u003e24\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.1 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.5 months (12\u0026ndash;43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: 96.1 SD 6.8 (range, 79\u0026ndash;100). Preop: 63.6 SD 11.5. The group without abnormal MRI signal had a mean AOFAS score of 98.3 SD 3.9, and those with abnormality 92.5 SD 10.5. Twelve patients resumed leisure sports at their previous level by a mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range) 9.4 SD 2 months (7\u0026ndash;12); three competitive sportsmen resumed sport at their previous level by a mean 7.6 months. MRI performed at 1 year showed increased tendon volume without abnormality in 57% (8/14) of cases; 43% (6/14) showed abnormal images.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Partially regressive sural nerve hypoesthesia (1). Aseptic superficial skin necrosis (1). Septic partial tendon necrosis (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePavan Kumar et al 2013 [\u003cspan\u003e52\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo mean, between 38\u0026ndash;66 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLEPPILAHTI, ultrasonography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLEPPILAHTI: 62 patients had excellent results (90-100p), 8 had good results (75-89p), 4 had fair results (60-74p), 2 had poor results (\u0026lt;\u0026thinsp;60p) and 2 were lost to follow up after 1 year. Nearly all patients resumed work at 6 months post-op and had normal walking, and stair climbing as well as normal dorsiflexion.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Scar hypertrophy (2). Deep infection (1), superficial infection (2). Delayed wound healing (3).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOzan et al 2017 [\u003cspan\u003e49\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange of motion, Hooker, Heel-rise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean calf hypotrophy was 1.2 cm (0-2.5). No patient had any limitations to daily living and the active and passive ankle ROM was \u0026quot;good\u0026quot;. Mean time to work was 38 months. The mean time for patients to return to daily activity was 3.2 months (range, 2\u0026ndash;5 months). All patients were able to perform singe-leg heel rises. Hooker scores were excellent for 11 patients and satisfactory for 4 patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. No infection, no complications reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLins et al 2013 [\u003cspan\u003e32\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, Gait-pattern, Range of motion, Calf circumference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: at 6 months postop: 68.5 (SD 18.7), at 12 months postop: 85.2 (SD 18.7). The control group walked faster. Their stance phase was also shorter than patients affected by rupture. The calf circumference at 6 months was 257 compared with 24.5 at 12 months. The ROM-values were lower for the injured ankle at both 6 and 12 months.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. No infections. Weakness at the donor site (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEl Shazly et al 2014 [\u003cspan\u003e11\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.7 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, Isokinetic testing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: at 24 months postop: 90.8. Preop: 32.6. Isokinetic testing showed a non-significant deficit (\u0026lt;\u0026thinsp;10%) of the plantar flexors on the injured side.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo infections. Temporary sural nerve injury (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBąkowski et al 2020 [\u003cspan\u003e5\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.3 months (12\u0026ndash;24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS, VAS, QOL questions, calf circumference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS improved significantly (no data). Lower calf circumference (no data). VAS pain 1.0. VAS satisfaction 9.0. Median EQ-5D 80.0. Heel-rise endurance 10.5 vs 7.0. Isokinetic flexor peak torque better on non-injured side, 91.3 vs 111. Single hop showed no statistical difference between injured and uninjured side.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Moderate donor site pain and weakness (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaffulli et al 2014 [\u003cspan\u003e35\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS, calf circumference, isometric strength, heel-rises\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS score: Postop latest follow-up: 86 (78\u0026ndash;95). Preop: 42 (29\u0026ndash;55). Calf circumference: 37.9 cm on the injured side vs 42.8 on the healthy side. Isometric 357 J on injured side vs 408 on healthy side. All patients could perform 10 heel-rises.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. No infections nor nerve injuries. Persistent pain over the distal operating wound (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSong et al 2018 [\u003cspan\u003e60\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, ATRS, VISA-A, Tegner.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: Postop at latest follow-up 100 (86\u0026ndash;100). Preop: 50 (5\u0026ndash;75). VISA-A: Postop at latest follow-up: 94 (52\u0026ndash;100). Preop: 23 (5\u0026ndash;59). ATRS score: Postop at latest follow-up: 99 (84\u0026ndash;100). Preop: 22.5 (6\u0026ndash;67). Tegner score: Postop at latest follow-up: 4 (3\u0026ndash;9). Preop: 1 (0\u0026ndash;3).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. No infections or nerve injuries. Pain related to the operation wound (4).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDumbre et al 2014 [\u003cspan\u003e10\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.7 months (20\u0026ndash;42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight bearing MMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight-bearing MMT postop at latest follow-up: 4/5. Preop: 2/5. Non-weight-bearing MMT postop at latest follow-up: 5/5.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. No complications reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaffulli et al 2018 [\u003cspan\u003e38\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.8 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS, calf circumference, plantar flexion strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS score: Postop at latest follow-up: 89.4 SD 3.2. Preop: 50.4 SD 7.5. Calf circumference postop: 38.7 cm SD 3.6 cm on the injured side, compared with 39.3 cm SD 3.4 cm on the healthy side. Plantar flexion strength: 424.3 N SD 42.9 N on the injured side, compared with 488.0 N SD 44.8 N on the healthy side.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures reported. No complications reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBansal et al 2021 [\u003cspan\u003e6\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.1 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: Postop at latest follow-up: 80.4. Preop: 40.8. All except one patient were able to walk on tiptoes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Superficial wound infection (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGedam et al 2016 [\u003cspan\u003e15\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u0026thinsp;+\u0026thinsp;G-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.6 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 months (12\u0026ndash;78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, ATRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: Postop at latest follow-up: 96.9 (90\u0026ndash;100). Preop: 64.5 (35\u0026ndash;79). ATRS score: Postop at latest follow-up: 91.4 (83\u0026ndash;97). Preop: 49.4 (30\u0026ndash;70).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. No complications reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLi et al 2020 [\u003cspan\u003e30\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 months (12\u0026ndash;18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, Plantar flexion strength, VISA-A scale, VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS score: Postop at latest follow-up: 91.3 SD 6.5. Preop: 44.9 SD 2.1. VISA-A: Postop at latest follow-up: 84.1 SD 3.9. Preop: 49.1 SD 3.2. VAS: Postop at latest follow-up 1.08 SD 0.3. Preop: 5.97 SD 0.7. Plantar flexion strength: Postop at latest follow-up: 133.7 N SD 17.5 N in injured side, compared with 141.5N SD 11.8 N in healthy side. All 26 was able to perform single leg heel-rises.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. No complications reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBai et al 2019 [\u003cspan\u003e4\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u0026thinsp;+\u0026thinsp;G-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal: 26,\u003c/p\u003e\n \u003cp\u003eG-flaps: 11,\u003c/p\u003e\n \u003cp\u003eST-grafts: 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.7 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, Leppilahti score.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-grafts: AOFAS score: Postop at latest follow-up: 93.5 SD 2.5. No preop measurement. Leppilahti score: Postop at latest follow-up: 95.1 SD 3.1. No preop measurement.\u003c/p\u003e\n \u003cp\u003eGastrocnemius-flaps: AOFAS score: Postop at latest follow-up: 92.6 SD 3.0. No preop measurement. Leppilahti score: Postop at latest follow-up: 94.7 SD 3.1. No preop measurement.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Nerve injury (1 in ST-graft group). Infection (2 in G-flap group), DVT (2 in the Gastrocnemius-flap group).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaffulli et al 2013 [\u003cspan\u003e37\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2 years (7\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS, calf circumference, isometric strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS at latest follow-up was 88. Lower isometric strength in injured side vs healthy side. Calf circumference 39.7 (SD 7.1) cm on the injured side vs 41.5 (SD 6.6) cm on the healthy side.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Superficial wound infection (2). Wound adhesion (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNilsson Helander et al 2008 [\u003cspan\u003e45\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 months (12\u0026ndash;117)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS, questionnaire for symptoms, physical activity, and satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS score: Postop at latest follow-up: 83 (24\u0026ndash;100). 16 patients were satisfied with the final outcome.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Deep infection (1), wound closure complication (2), DVT (2).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEl Shewy et al 2009 [\u003cspan\u003e12\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.45 years (6\u0026ndash;9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, Holz scale, Range of motion, calf circumference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHolz scale: preop 10 poor, 1 fair. Postop 11 good. AOFAS: Preop 42.27 (39\u0026ndash;46). Postop 98.9 (88\u0026ndash;100). Ankle ROM (mean\u0026thinsp;+\u0026thinsp;SD): plantar flexion preop 20.5 SD 2.70. Postop 49.6 SD 1.5. Dorsiflexion preop 11.4 SD 3.23. Postop 17.7 SD 2.6. Calf (cm): Circumference (mean\u0026thinsp;+\u0026thinsp;SD)) Preop 31.6 SD 0.9. Postop 34.4 SD 0.89. Wasting (mean\u0026thinsp;+\u0026thinsp;SD) Preop 1.6 SD 0.4. Postop 0.7 SD 0.2.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Small wound gaping (3), superficial wound infection (2).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSarzaeem et al 2012 [\u003cspan\u003e57\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 Months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, ATRS, Range of motion, Calf circumference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS: Preop: 32 SD 6 (24\u0026ndash;39). Postop: 89 SD 4 (82\u0026ndash;95).\u003c/p\u003e\n \u003cp\u003eAOFAS: Preop: 70 SD 5 (61\u0026ndash;78). Postop: 92 SD 5 (83\u0026ndash;97).\u003c/p\u003e\n \u003cp\u003eCircumference: Injured side: 36 SD 3 (30\u0026ndash;42) cm. Healthy side: 38 SD 4 (33\u0026ndash;45) cm\u003c/p\u003e\n \u003cp\u003eROM: Plantar flexion: Injured side: 36 SD 8 (22\u0026ndash;50) degrees. Healthy side: 39 SD 6 (30\u0026ndash;50) degrees. Dorsiflexion: Injured side: 13 SD 4 (5\u0026ndash;20) degrees. Healthy side: 17 SD 4 (10\u0026ndash;25) degrees.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Superficial infection (2), DVT (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTakao et al 2003 [\u003cspan\u003e62\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.1 months (26\u0026ndash;192)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalf circumference, Range of motion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS - Preop: 72.6 SD 5.3 (68\u0026ndash;82). Postop: 98.1 SD 2.5 (94\u0026ndash;100).\u003c/p\u003e\n \u003cp\u003eCybex \u0026minus;\u0026thinsp;30 degrees, preop: Torque effect ranged from 8\u0026ndash;68% at the low setting and from 19\u0026ndash;33% at the high setting. Postop, the torque ranged from \u0026minus;\u0026thinsp;9\u0026ndash;17% at the low setting and from \u0026minus;\u0026thinsp;13\u0026ndash;23% at high setting.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMulier et al 2003 [\u003cspan\u003e43\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap with and without FHL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeppilahti score, stiffness, muscle weakness, Range of motion, isokinetic calf muscle strength, CYBEX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeppilahti: Postop Gastrocnemius -flap: Fair, 62 (48\u0026ndash;78). Postop Gastrocnemius-flap\u0026thinsp;+\u0026thinsp;FHL: Good, 77 (67\u0026ndash;89).\u003c/p\u003e\n \u003cp\u003eCybex: G-flap: 23% (5\u0026ndash;45) decrease in power and strength. Gastrocnemius -flap\u0026thinsp;+\u0026thinsp;FHL: 14% (5\u0026ndash;35) decrease in power and strength.\u003c/p\u003e\n \u003cp\u003eROM: Gastrocnemius -flap: dorsiflexion 9 degrees (-5-20), plantar flexion 33 degrees (20\u0026ndash;45). Gastrocnemius -flap\u0026thinsp;+\u0026thinsp;FLL: dorsiflexion 13 degrees (-5-25), plantar flexion 36 (20\u0026ndash;45).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRe-rupture (1). Deep infection (1 in g-flap only), DVT (1 in each group, 2 total), delayed wound healing (3 in g-flap, 4 in Gastrocnemius-flap\u0026thinsp;+\u0026thinsp;FHL).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLin et al 2019 [\u003cspan\u003e31\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.8 months (12\u0026ndash;68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS, ATRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS: Preop: 39.6 SD 14.2 (20\u0026ndash;72). Postop: 94.1 SD 4.9 (86\u0026ndash;100).\u003c/p\u003e\n \u003cp\u003eAOFAS: Preop: 59.3 SD 12.3 (40\u0026ndash;75). Postop: 96.6 SD 3.8 (90\u0026ndash;100).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Superficial infection (1).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWerken et al 1983 [\u003cspan\u003e64\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAt least 2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalf circumference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalf Circumference difference between the healthy and injured sided was 1-3.5 cm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. Wound infection (2).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGunaratne et al. 2021 [\u003cspan\u003e18\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean ATRS postop 72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNilsson et al. 2022 [\u003cspan\u003e44\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS. ATRA. Heel-rise height. Heel-rise reps. Calf circumference. Ultrasonography. Concentric power. Heel-rise work.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS 76 (45\u0026ndash;99). 89% were able to perform a single-leg heel-rise on the injured side. Tendon length 2.8 cm longer on the injured side compared with the non-injured and calf circumference 1.5 cm lower. ATRA was 60 (15) vs 49.5 (6) on the non-injured side. The same numbers for heel-rise height were 5.5 (5.75) vs 9.0 (2.75) and for heel-rise reps 11 (18) vs 26 (14).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. 2 superficial wound infections and 1 sural nerve injury.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNordenholm, Nilsson et al. 2022 [\u003cspan\u003e47\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATRS. PAS. FAOS. Heel-rise height. Heel-rise reps. Calf circumference. Ultrasonography. CMJ. Heel-rise work. Hopping ratio. ATRA. Dorsiflexion range.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean (SD) ATRS 62 (26) and mean (SD) PAS 3.5 (1.1). The patients performed less well in the heel-rise test on the injured side compared with the healthy side with a median (IQR) of 20 (10) vs 24 (12) in heel-rise repetitions (p\u0026thinsp;=\u0026thinsp;0.004), 8 (7) vs 10 (8) cm in heel-rise height (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), 872 (1740) vs 1590 (2145) joule in total heel-rise work (p\u0026thinsp;=\u0026thinsp;0.001) and 0.37 vs 0.48 in hopping ratio (p\u0026thinsp;=\u0026thinsp;0.005). Patients with chronic Achilles tendon rupture exhibited an elongation of the injured Achilles tendon with median (IQR) ATRA of 55\u0026deg; (3) compared with 50\u0026deg; (9) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a median of 22.4 (2.9) cm compared with 20.5 (2.0) cm measured by ultrasound (p\u0026thinsp;=\u0026thinsp;0.06). Calf circumference was smaller on the injured side with a median (IQR) of 37 (4) compared with 38 (4) cm (p\u0026thinsp;=\u0026thinsp;001).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures. 1 superficial wound infection.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNordenholm, Senorski et al. 2022 [\u003cspan\u003e48\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGait-analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSignificantly reduced step width (0.01 m (p\u0026thinsp;=\u0026thinsp;0.014)), increased speed (\u0026minus;\u0026thinsp;0.12 m/s (p\u0026thinsp;=\u0026thinsp;0.013)), stride length (\u0026minus;\u0026thinsp;0.12 m (p\u0026thinsp;=\u0026thinsp;0.002)), ankle moment (\u0026minus;\u0026thinsp;0.64 Nm/kg (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)) ankle power (\u0026minus;\u0026thinsp;1.38 W/kg (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)) and knee power (\u0026minus;\u0026thinsp;0.36 W/kg (p\u0026thinsp;=\u0026thinsp;0.003)) compared with the preoperative status.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRaju et al. 2022 [\u003cspan\u003e54\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eG-flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalf diameter. Dorsiflexion. Heel-rises. VAS. Rupp-score.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCalf-diameter increased 2.2 cm. Dorsiflexion increased 10 degrees. Rupp-score with 5 excellent and 7 good.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo re-ruptures or complications.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTsukada et al. 2022 [\u003cspan\u003e66\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eST-graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS. ATRS. VAS. Months until the patient could perform 20 single-leg heel-rises.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAOFAS increased significantly from 64.2 SD 5.6 (range 58\u0026ndash;72) points preoperatively to 95.0 SD 5.3 (range 90\u0026ndash;100) points at the final follow-up (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as did mean ATRS, from 29.8 SD 4.4 (range 22\u0026ndash;35) points to 86.2 SD 7.7 (range 70\u0026ndash;94), respectively (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Mean time between surgery and ability to perform 20 continuous double-leg heel rises of the operated foot was 13.5 SD 3.4 (range 10\u0026ndash;18) weeks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRe-ruptures not reported. 1 sural nerve injury.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important finding of this systematic review was that both gastrocnemius aponeurosis flap and semitendinosus graft reconstructions were found to be effective in treating chronic Achilles tendon ruptures with similar favourable patient-reported outcome scores and performances in functional tests. Only one re-rupture was reported (0.12%) in the patient group treated with a gastrocnemius aponeurosis flap and no patient in the group treated with a semitendinosus graft. However, studies of higher quality are needed to fully determine the optimal way of treating chronic Achilles tendon ruptures. All the included studies were case series without matched control groups. Additionally, the articles used a variety of different outcome measures, which limited the comparisons between studies. Lastly, even though the gastrocnemius aponeurosis flaps, and semitendinosus tendon grafts are presented as distinctive groups, both groups were heterogenic with different interpretations of the techniques.\u003c/p\u003e \u003cp\u003eIn prior systematic reviews by Apinun et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and Hadi et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], similar results have been shown with good functional patient-reported outcomes, and low re-rupture rates. The review performed by Hadi et al. identified 35 individual studies in 2013 whereas this systematic review identified a total of 86 individual publications on the same subject in 2022. The heterogenicity of outcome measures and surgical techniques, and the retrospective nature of limited cohort sizes remain. This meant that quantitative meta-analysis was deemed inappropriate. Studies including fewer than 10 patients were excluded from this systematic review. Most of these studies were case reports with one to two patients using no outcomes measures. Therefore, the exclusion of case reports did not result in any substantial data loss.\u003c/p\u003e \u003cp\u003eThe result of the included studies indicate that patients treated with a gastrocnemius flap are more prone to complications than patients treated with semitendinosus tendon graft. Due to the heterogenicity, no significant difference could be determined, however. Depending on the surgical technique a different pattern of complications occurred. Semitendinosus tendon grafts uses an autologous transplantation with risk of complications related to the hamstring donor site or sural nerve injury due to the location and the smaller size of the surgical incisions. Gastrocnemius flaps uses a turn-down flap or a free-flap from the aponeurosis with larger surgical wounds leading to an increased risk of infections and wound healing problems. [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe MINORS assessment generally resulted in a low-quality with scores with a median of 8 out of 16. Moreover, the studies included in this review frequently used AOFAS as their main patient-reported outcome. It is known that this outcome measure is not validated for Achilles tendon ruptures. Instead, a patient-reported outcome such as ATRS could be used. This patient-reported outcome measure is also not validated for chronic Achilles tendon ruptures, but it is validated for acute Achilles tendon ruptures. In the future, research of chronic Achilles tendon ruptures would benefit from a patient-reported outcome measure that is validated for chronic ruptures, as that would allow for a clearer comparison between operating methods and outcome.\u003c/p\u003e \u003cp\u003eThe exclusions based on the number of patients and the language of the studies might have affected the results of this review. This review excluded all non-English studies and all studies with less than 10 patients. The exclusion criteria removed 108 studies due to language and 47 studies due to a small cohort size. The exclusion of studies in non-English language facilitated data extraction by avoiding outcome heterogeneity between studies, thus improving quality. The number of articles excluded based on sample size were large in number but were usually singular case reports without any outcome measures. Similarly, varying outcomes measures may have made comparisons between studies even harder.\u003c/p\u003e \u003cp\u003eFollowing this systematic review, the authors recommendation is to individualise the treatment of chronic Achilles tendon ruptures depending on factors such as functional demands, comorbidities, tendon gap size, and the general experience of the orthopaedic surgeon treating the patient. The use of a gastrocnemius aponeurosis flap in tendon ruptures with a gap that is less than 5 centimetres (cm) is regarded as efficient. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] In tendon ruptures with larger defects (\u0026gt;\u0026thinsp;5 cm) a semitendinosus tendon graft will bridge the defect. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] Other alternatives include flexor hallucis longus graft [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] and peroneus tendon graft. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] However, tendon elongation continues to be a problem despite established rehabilitation techniques. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, surgical reconstruction with both semitendinosus tendon grafts, and gastrocnemius aponeurosis flaps are considered effective in treating chronic Achilles tendon ruptures with good patient-reported outcomes and few re-ruptures. The complication profiles are different between the two techniques with more postoperative infections and wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries and donor site weakness in patients treated with a semitendinosus graft. There is a continued need for more prospective randomized controlled trials and a need for an established outcome measure for chronic Achilles tendon ruptures to fully evaluate the effectiveness of different reconstructive techniques in the treatment of chronic Achilles tendon ruptures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent of publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo external funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e All authors took part in the development of the study design. NN and IS\u0026nbsp;reviewed the abstracts in Rayyan\u0026reg;. All authors performed the full-text filtering, result extraction and quality assessment. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbraham E, \u0026amp; Pankovich, A. M. . Neglected rupture of the Achilles tendon. Treatment by VY tendinous flap. J Bone Joint Surg Am.1975;57(2):253-5.\u003c/li\u003e\n\u003cli\u003eApinun J, Jenvorapoj S, Arirachakaran A, Kongtharvonskul J. Clinical outcomes of chronic Achilles tendon rupture treated with flexor hallucis longus grafting and flexor hallucis longus grafting plus additional augmentation: A meta-analysis. Foot Ankle Surg.2020;26(7):717-22.\u003c/li\u003e\n\u003cli\u003eArner O, Lindholm A. Subcutaneous rupture of the Achilles tendon; a study of 92 cases. 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J Clin Orthop Trauma.2021;23:101650.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic Achilles tendon rupture, Semitendinosus tendon graft, Gastrocnemius aponeurosis flap, Surgical repair, Systematic review, MINORS","lastPublishedDoi":"10.21203/rs.3.rs-2613525/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2613525/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: A chronic Achilles tendon rupture (ATR) is defined as an ATR that has been left untreated for more than four weeks following rupture. This systematic review aims to summarize the outcomes of chronic ATR treated using either a gastrocnemius aponeurosis flap or semitendinosus tendon graft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A systematic search was conducted in three databases (PubMed, Scopus and Cochrane), for studies describing outcomes after surgical treatment of chronic ATR using gastrocnemius aponeurosis flaps or semitendinosus tendon grafts with more than 10 patients included. The studies were assessed for quality and risk of bias using the Methodological Items used to assess risk of bias in Non-Randomized studies (MINORS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Out of the 818 studies identified with the initial search, a total of 36 studies with 763 individual patients were included in this systematic review. Gastrocnemius aponeurosis flap was used in 21 and semitendinosus tendon graft was used in 13 of the studies. The mean (SD) postoperative Achilles tendon Total Rupture Score (ATRS) for patients treated with a gastrocnemius aponeurosis flap was 83 (14) points and the mean (SD) American Orthopaedic Foot and Ankle Score (AOFAS) was 96 (1.7) points compared with ATRS 88 (6.9) points and AOFAS 92 (5.6) points for patients treated with a semitendinosus tendon graft. The included studies generally had low-quality according to MINORS, with a median of 8 (range 2-13) for all studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eBoth gastrocnemius aponeurosis flaps and semitendinosus tendon grafts give acceptable results with minimal complications and are valid methods for treating chronic ATR. The main difference is more wound healing complications in patients treated with a gastrocnemius aponeurosis flap and more sural nerve injuries in patients treated with a semitendinosus grafts. The current literature on the subject is of mainly low quality and the absence of a patient-related outcome measure validated for chronic ATR makes comparisons between studies difficult.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Evidence\u003c/strong\u003e: Level IV.\u003c/p\u003e","manuscriptTitle":"Both gastrocnemius aponeurosis flaps and semitendinosus tendon grafts are effective in the treatment of chronic Achilles tendon ruptures – a systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-07 15:01:17","doi":"10.21203/rs.3.rs-2613525/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-09-12T11:44:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-08-31T17:54:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309e4c55-4548-4a62-a272-6974c602ff76","date":"2023-08-28T10:21:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-03-19T23:38:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-03-17T07:43:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-03-02T10:45:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-03-02T10:38:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2023-02-21T19:16:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"67257220-c9dc-4a74-9568-c3c21216f624","owner":[],"postedDate":"March 7th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-12-11T15:05:56+00:00","versionOfRecord":{"articleIdentity":"rs-2613525","link":"https://doi.org/10.1186/s12891-023-07064-8","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2023-12-08 15:01:08","publishedOnDateReadable":"December 8th, 2023"},"versionCreatedAt":"2023-03-07 15:01:17","video":"","vorDoi":"10.1186/s12891-023-07064-8","vorDoiUrl":"https://doi.org/10.1186/s12891-023-07064-8","workflowStages":[]},"version":"v1","identity":"rs-2613525","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2613525","identity":"rs-2613525","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}