You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Management of Acute Achilles Tendon Ruptures in the United Kingdom
Abstract 1:
Purpose . To survey the management of acute Achilles tendon ruptures in the United Kingdom . Methods . A question naire with 4 different Achilles tendon rupture scenarios affecting patients of different ages and activity levels was sent to orthopaedic consultants specialised in sports trauma , foot and ankle surgery . Their treatment methods including surgical techniques , immobilisation and rehabilitation regimens were surveyed . Results . The response rate was 22 % ( 51/231 ) . Among the 51 respondents , 25 had managed less than 6 such patients in the preceding year . 26 ( 51 % ) used  clinical examination ( e.g. calf squeeze test )  to make the diagnosis , 16 ( 31 % ) used  ultrasonography  , and 4 ( 8 % ) used  magnetic resonance imaging . Surgical management  was preferred for younger and more functionally dem and ing individuals .  Open repairs  were used more often than  percutaneous repairs  ( 72 vs 19 % ) . Across the 4 scenarios , the mean time to return to full activity was 17 ( range , 12–32 ) weeks for conservative to 19 ( range , 10–40 ) weeks for surgical management . Conclusion . Variation in opinion among respondents was wide . R and omised controlled trials are needed to assess optimal treatment


Title 2:
[Repair of acute Achilles tendon rupture. Comparative study of two surgical techniques].
Abstract 2:
BACKGROUND The treatment of Achilles tendon rupture has been controversial , and attempts are made to attenuate the complications arising from invasive procedures with minimally invasive techniques . This paper is a comparison between the results of Lynn 's traditional open technique and those of minimally invasive surgery assisted with the Achillon instrument guide . MATERIAL AND METHODS A prospect i ve , r and omized study was carried out in fifty-six patients with acute rupture of the Achilles tendon . Twenty-eight of them underwent surgery with Lynn 's technique and 28 underwent minimally-invasive surgery assisted with a mechanical guide .  Patients were assessed at postoperative weeks 4 , 6 , 8 , 10 and 16 . They were examined for pain , muscle strength , presence or absence of Thomas sign , Merkel scale , ranges of motion , degree of amyotrophy , time to healing , degree of functional recovery , and complications . Data analysis was done with central trend measurements and nonparametric analyses . RESULTS The following were reported for Lynn 's technique ( LT ) and the minimally invasive approach ( MI ) : Mobility in extension : ( LT ) 40.3 + /- 0.59 degrees vs. ( MI ) 50.0 + /- 0.42 ( p < 0.01 ) ; flexion : ( LT ) 13.9 + /- 0.12 degrees vs. ( MI ) 18.2 + /- 18.2 degrees ( p < 0.01 ) ; amyotrophy : ( LT ) 2.9 + /- 0.09 cm vs. ( MI ) 1.5 + /- 0.13 ( p < 0.01 ) ; time to healing : ( LT ) 9.0 + /- 0.13 vs. ( MI ) 6.1 + /- 0.09 weeks ( p = 0.01 ) ; return to work : ( LT ) 9 weeks vs. ( MI ) 6 weeks . Postoperative complications were 19 for LT and 1 for MI . CONCLUSIONS The MI approach had statistically significant advantages over Lynn 's technique , which we attribute to a lesser tissue and neurovascular trauma


Title 3:
AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews.
Abstract 3:
OBJECTIVE Our purpose was to measure the agreement , reliability , construct validity , and feasibility of a measurement tool to assess  systematic review s ( AMSTAR ) . STUDY DESIGN AND SETTING We r and omly selected 30 systematic review s from a data base . Each was assessed by two review ers using : ( 1 ) the enhanced quality assessment question naire ( Overview of Quality Assessment Question naire [ OQAQ ] ) ; ( 2 ) Sacks ' instrument ; and ( 3 ) our newly developed measurement tool ( AMSTAR ) . We report on reliability ( interobserver kappas of the 11 AMSTAR items ) , intraclass correlation coefficients ( ICCs ) of the sum scores , construct validity ( ICCs of the sum scores of AMSTAR compared with those of other instruments ) , and completion times . RESULTS The interrater agreement of the individual items of AMSTAR was substantial with a mean kappa of 0.70 ( 95 % confidence interval [ CI ] : 0.57 , 0.83 ) ( range : 0.38 - 1.0 ) . Kappas recorded for the other instruments were 0.63 ( 95 % CI : 0.38 , 0.78 ) for enhanced OQAQ and 0.40 ( 95 % CI : 0.29 , 0.50 ) for the Sacks ' instrument . The ICC of the total score for AMSTAR was 0.84 ( 95 % CI : 0.65 , 0.92 ) compared with 0.91 ( 95 % CI : 0.82 , 0.96 ) for OQAQ and 0.86 ( 95 % CI : 0.71 , 0.94 ) for the Sacks ' instrument . AMSTAR proved easy to apply , each review taking about 15 minutes to complete . CONCLUSIONS AMSTAR has good agreement , reliability , construct validity , and feasibility . These findings need confirmation by a broader range of assessors and a more diverse range of review


Title 4:
Open versus minimal invasive repair with Achillon device.
Abstract 4:
BACKGROUND We prospect ively analyzed and compared the functional and clinical results of patients with st and ard open and minimally invasive repair with the Achillon suture system  at mid-term followup . MATERIAL S AND METHODS From February 2004 to May 2007 , 40 consecutive patients were operated for the treatment of acute Achilles tendon rupture with two different methods . None of the cases required adjunctive procedures like plantaris , flexor hallucis longus or gastrocnemius augmentation ( Lindholm , Bosworth ) to allow for acceptable end to end apposition . The patients were divided equally into two groups . In Group 1 , only Krakow end-to-end suturing technique and in Group 2 , Minimal invasive repair with Achillon suture system ( Integra Life Sciences Corporation , Plainsboro , NJ ) was used respectively . The average age of the patients was 40 years . Patients in study groups were followed up at mean of 22.4 ( range , 10 to 48 ) months after surgery . At the end of the followup time , functional outcome scores and complications were evaluated . RESULTS The AOFAS hindfoot clinical outcome scores were 98.7 in Group 1 , 96.8 in Group 2 . Although there was a numerical increase in AOFAS Scores in Group 1 , there was no significant difference . The surgical outcome concerning local tenderness , skin adhesions , scar and tendon thickness was better in Group 2 than in Group 1 with statistical significance . CONCLUSION Although functional outcomes of both treatment groups were the same , minimally invasive repair with the Achillon suture system provided safe , reliable and practical treatment with low risk of complications in the treatment of acute Achilles tendon ruptures


Title 5:
[Achilles tendon rupture. A prospective study assessing various treatment possibilities].
Abstract 5:
The object of this study was to compare treatment of ruptured Achilles tendon by operative " end to end " surgery , percutaneous repair , or conservative therapy clinical ly ; a subject of considerable controversy in the literature . These three methods were compared in 73 patients in a r and omized trial between 1994 and 1996 . After 2.5 years ( 11 - 41 months ) , the actual activities were assigned to the Hannover Achilles tendon score and the ability of doing work or sport activities was assessed . After this period , 59.3 % of the patients showed good and excellent results on the Achilles tendon score , with over 79 points ( open surgery 59.1 % , percutaneous 60 % , conservative treatment 58.3 % ) . None of the patients reached the maximum score of 100 points . During the isometric strength tests , the patients with percutaneous repair had a lower weakening of the treated leg ( 8.9 % ) compared to the open-operated ( 12.7 % ) and non-operated patients ( 17.8 % ) . Of the patients who had percutaneous surgery , 88 % rated their treatment as good or excellent ; those who had open surgery 77.3 % , and those with conservative treatment 75 % . The percutaneous group were able to resume work and sport much sooner than the other two groups . Bearing in mind the literature and these results , we have developed an algorithm for treating Achilles tendon rupture to assist decision making in daily routine . In this way , the use of percutaneous Achilles tendon repair can be carried out in most of cases


Title 6:
Percutaneous vs. Open Repair of the Ruptured Achilles Tendon—A Prospective Randomized Controlled Study
Abstract 6:
A prospect i ve r and omized controlled trial comparing open and percutaneous repair  of closed ruptured Achilles tendons was performed over a period of 30 months . Sixty-six patients from seven district general hospitals were entered into the study with 33 patients r and omized into each group . A modification of the technique described by Ma and Griffith was used in the percutaneous group and a Kessler suture supplemented with interrupted sutures was used in the open group . Patients were followed up for a minimum of six months . The mean age was 38.5 years ( 26 to 53 years ) . Forty patients were male and 26 female . After the rupturing event but prior to surgery , it was noted that seven patients had paresthesia in the territory of the sural nerve . The mean duration of immobilization was 12.4 weeks ( 10 to 14 ) . The complications in the open group included seven wound infections ( 21 % ) , two adhesions ( 6 % ) and two cases of re-rupture ( 6 % ) . In the percutaneous group there were three cases of wound puckering ( 9 % ) , one re-rupture ( 3 % ) and one case with persistent paresthesia in the sural nerve territory ( 3 % ) . The difference in infective wound complications between the two groups was statistically significant ( Fisher 's exact test P = 0.01 ) . Percutaneous repair is advocated on the basis of the low rate of complications and improved cosmetic appearance


Title 7:
Early Weightbearing and Ankle Mobilization after Open Repair of Acute Midsubstance Tears of the Achilles Tendon
Abstract 7:
Purpose To study the effects of early weightbearing and ankle mobilization after acute repair of ruptured Achilles tendon . Study Design Comparative longitudinal study . Methods Patients in group 1 were postoperatively immobilized with their ankle in gravity equinus , they were encouraged to bear weight on the operated limb as soon as possible to full weightbearing , and they received a single cast change at 2 weeks , with the ankle accommo date d in an anterior splint in a planti grade position , allowing the ankle to be plantar flexed fully but not dorsiflexed above neutral . Patients in group 2 were immobilized with their ankle in full equinus with a cast change at 2 weeks , when the ankle was immobilized in mid equinus , and at 4 weeks , when the ankle was immobilized in a planti grade position , and they were advised to bear weight . Results Patients in group 1 attended fewer outpatient visits , completely discarded their crutches at an average of 2.5 weeks , and more were satisfied with the results of surgery . At ultrasonography , the average thickness of the repaired tendon was 12.1 mm , with no difference in the thickness of the ruptured tendon regardless of postoperative management . There was no significant difference in isometric strength between the two groups . Conclusions Early weightbearing with the ankle planti grade is not detrimental to the outcome of repair after acute rupture of the Achilles tendon and shortens the time needed for rehabilitation . However , strength deficit and muscle atrophy are not prevented


Title 8:
Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study
Abstract 8:
There is no agreement on the ideal type of surgical management for Achilles tendon rupture . The present r and omized prospect i ve study was performed to compare outcome data of open and percutaneous repair in the treatment of Achilles tendon rupture . Forty consecutive patients with acute rupture of Achilles tendon were recruited . Patients were r and omized to receive open ( group A ) or percutaneous repair with Tenolig ® ( group B ) . All patients followed the same rehabilitation protocol except for slight differences in the duration of immobilization . Follow-up included objective evaluation ( at 4 and 12 months ) , subjective evaluation using the SF-12 ® question naire ( at 24 months ) , and bilateral ultrasound scanning and isokinetic testing ( at 12 months ) . The differences in the parameters evaluated clinical ly were not significant except for ankle circumference , which was significantly greater in group B. There were two minor complications in the open repair group and one case of failed repair in the percutaneous group . SF-12 ® question naire , ultrasound and isokinetic test data did not show significant differences between the groups . The present study demonstrates that the open and the percutaneous technique  are both safe and effective in repairing the ruptured Achilles tendon and that both afford the same degree of restoration of clinical , ultrasound and isokinetic patterns . Medium-term results were substantially comparable . Percutaneous repair is performed on a day-surgery basis , it reduces cutaneous complications and operation times , and enables faster recovery , enhancing overall patient compliance . To us , these characteristics make it preferable to open repair in managing subcutaneous ruptures of Achilles tendon in non-professional sports practicing adults


Title 9:
Introducing levels of evidence to the journal.
Abstract 9:
Orthopaedic surgeons have always based their clinical care on evidence . Surgeons use evidence to make decisions tailored to an individual patient 's needs and circumstances . The primary sources of evidence for clinicians are studies published in the medical and surgical literature , such as The Journal of Bone and Joint Surgery . In June 2000 , The Journal introduced the quarterly Evidence -Based Orthopaedics section 1 . This section introduces orthopaedic surgeons to recent r and omized trials relevant to the practice of orthopaedic surgery published in forty-two journals other than The Journal of Bone and Joint Surgery . Structured abstract s of these studies are
A high- quality meta- analysis with more RCTs was chosen , which suggested that there was no statistically significant difference between  MIS and OS regarding rerupture rate , tissue adhesion , sural nerve injury , deep infection , and deep vein thrombosis .
However , MIS could decrease superficial infection rate , and had a better patient satisfaction for good to excellent outcomes in comparison to OS .
Conclusions Based on the best available evidence , MIS may be superior to OS for treating acute Achilles tendon rupture .