MIS Achilles Tendon Repair Superior to Open Repair

Minimally invasive surgery is a safe and reliable technique for Achilles Tendon Repair, researchers of a new study contend.

In the study, “Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials,” the researchers compared the outcomes between open repair and a minimally invasive technique.

Findings were published on December 15, 2021, in The American Journal of Sports Medicine.

An acute Achilles tendon rupture is one of the most common injuries in sports, affecting 18 per 100,000 athletes.

“Traditionally, open surgical repair has provided improved functional outcomes, reduced re-rupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair,” the researchers wrote.

During the systemic review and meta-analysis of randomized controlled trials, they focused on functional outcomes, re-ruptures, sural nerve injuries and infections as the primary outcomes. Secondary outcomes included skin complications, adhesions, other complications, ankle range of motion and surgical time.

Overall, 10 clinical trials with 522 patients were included. The open repair group include 260 patients while the minimally invasive group included 262 patients.

The mean postoperative American Orthopedic Foot and Ankle Society Score was 94.8 for open repair and 95.7 for minimally invasive surgery. There was no significant difference between the two scores (mean difference, –0.73 [95% CI, –1.70 to 0.25]; p = .14; I² = 0%).

The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for minimally invasive surgery. The mean re-rupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; p = .50; I² = 0%).

In the open repair group, there were no sural nerve injuries, however, there were in the minimally invasive surgery group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; p = .02; I² = 0%).

The overall superficial infection rate was higher for the open repair group as was the deep infection rate. No deep infections were reported in the minimally invasive surgery group.

There were however no significant differences between the two groups when it came to skin necrosis and dehiscence rate, adhesion rate or keloid scar rate.

The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; p < .001; I² = 15%).

“Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while minimally invasive surgery was associated with a greater risk of temporary sural nerve palsy. The re-rupture rate and functional outcomes were mostly equivalent,” the researchers wrote.

“We found minimally invasive surgery to be a safe and reliable technique. However, high-quality standardized random controlled trials are still needed before recommending minimally invasive surgery as the gold standard for managing Achilles tendon ruptures.”

Study authors include Ahmed Khalil Attia, M.D., of Penn State Health Milton S. Hershey Medical Center in Hershey, PA, Karim Mahmoud, M.D., of Emory University Hospital in Atlanta, Georgia, Pieter d’Hooghe, M.D. of Aspetar Orthopaedic and Sports Medicine Hospital in Doha, Qatar, Jason Barieteau, M.D., of Emory University Hospital in Atlanta, Georgia, Sameh A. Labib, M.D. of Emory University Hospital, and Mark S. Myerson, M.D., of the University of Colorado School of Medicine.