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The objective of this systematic review and network meta\u2010analysis was to compare failure load and elongation after cyclic loading of Achilles tendon repair techniques at time\u2010zero.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>The databases PubMed, CENTRAL and Web of Science were searched for all published in\u2010vitro studies comparing Achilles tendon repair techniques, or augmentation with autografts\/biomaterials, and reports of failure load or elongation after cyclic loading. Only studies using human cadaveric Achilles tendons and matched pairs, or randomized specimen allocation, were selected for quantitative synthesis. A network meta\u2010analysis per primary outcome was performed. Results were summarized as P score rankings and their validity was assessed using statistical methods.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Sixteen studies, comprising 367 tendon repairs, were included. The following repair techniques were used (<jats:italic>n<\/jats:italic>\u2009=\u2009number of studies): Krackow (<jats:italic>n<\/jats:italic>\u2009=\u20098), Achillon (n\u2009=\u20094), double Krackow (<jats:italic>n<\/jats:italic>\u2009=\u20093), Bunnell (<jats:italic>n<\/jats:italic>\u2009=\u20093), Percutaneous Achilles Repair System (<jats:italic>n<\/jats:italic>\u2009=\u20093), Percutaneous Achilles Repair System Midsubstance (<jats:italic>n<\/jats:italic>\u2009=\u20092), Kessler (<jats:italic>n<\/jats:italic>\u2009=\u20093), double Kessler (<jats:italic>n<\/jats:italic>\u2009=\u20091), modified triple Kessler (<jats:italic>n<\/jats:italic>\u2009=\u20091), triple bundle (<jats:italic>n<\/jats:italic>\u2009=\u20091), a multifilament stainless steel cable\u2010crimp technique (<jats:italic>n<\/jats:italic>\u2009=\u20091) and a double loop knot stitch (<jats:italic>n<\/jats:italic>\u2009=\u20091). Five studies assessed augmentation with autografts\/biomaterials. Regarding the failure load, biomaterial augmented Krackow repairs occupied the first four positions in the ranking, followed by the multifilament stainless steel cable\u2010crimp and Percutaneous Achilles Repair System Midsubstance techniques. Concerning elongation after cyclic loading, the triple Kessler was ranked first, followed by the Achillon and Percutaneous Achilles Repair System Midsubstance techniques. A negligible correlation between ranks was found (<jats:italic>r<\/jats:italic><jats:sub>s<\/jats:sub>\u2009=\u20090.11; <jats:italic>p<\/jats:italic>\u2009=\u20090.75n.s.), meaning that a higher repair tensile strength is not necessarily related to improved performance in regard to avoidance of elongation.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>In the failure load network meta\u2010analysis, biomaterial augmented Krackow repairs ranked highest, but noticeable statistical heterogeneity was found. Regarding elongation with cyclic loading, the modified triple Kessler stitch showed the highest probability of ranking first.<\/jats:p><\/jats:sec><jats:sec><jats:title>Level of evidence<\/jats:title><jats:p>Level IV.<\/jats:p><\/jats:sec>","DOI":"10.1007\/s00167-021-06613-9","type":"journal-article","created":{"date-parts":[[2021,6,5]],"date-time":"2021-06-05T07:02:38Z","timestamp":1622876558000},"page":"1644-1657","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Modified triple Kessler with least risk of elongation among Achilles tendon repair techniques: a systematic review and network meta\u2010analysis of human cadaveric studies"],"prefix":"10.1002","volume":"31","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9234-7041","authenticated-orcid":false,"given":"Pedro","family":"Diniz","sequence":"first","affiliation":[{"name":"<!--<label>1<\/label>--> Department of Orthopaedic Surgery Hospital de Sant\u2019Ana Rua de Benguela 501 2775\u2010028 Parede Portugal"},{"name":"<!--<label>2<\/label>--> Department of Bioengineering, iBB \u2010 Institute for Bioengineering and Biosciences Instituto Superior T\u00e9cnico, Universidade de Lisboa, Av. 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