SLR - May 2022 - Katie J. Backstrand, DPM
Reference: Li Y, Jiang Q, Chen H, Xin H, He Q, Ruan D. Comparison of Mini-Open Repair System and Percutaneous Repair for Acute Achilles Tendon Rupture. BMC Musculoskelet Disord. 2021 Oct 30;22(1):914.Level of Evidence: Level III
Scientific Literature Review
Reviewed By: Katie J. Backstrand, DPM
Residency Program: Northwest Medical Center – Margate, FL
Podiatric Relevance: As the most common tendon rupture in the body, acute rupture of the Achilles tendon poses challenge to foot and ankle surgeons. A gold standard for treatment has yet to be established, and the argument of open vs. minimally invasive techniques has been widely debated. Many surgeons have converted to a percutaneous technique; however, sural nerve injury remains the most common complication following percutaneous surgery, with a prevalence as high as 6.8 percent. More recently, different minimally invasive operative approaches have been developed such as a mini-open repair in order to reduce incision complications and nerve damage. The goal of this study is to present a new mini-open Achilles repair system using a modified Ma-Griffith technique and compare it to the percutaneous repair. This technique is based on the Bunnell suture method and requires less knots as compared to other percutaneous techniques.
Methods: A level III retrospective control-matched study was performed comparing 34 patients with acute Achilles rupture treated with mini-open repair and 34 patients treated with percutaneous anastomosis (control group). The study took place via Navy General Hospital database between 2016 and 2018. Patients with acute, closed Achilles tendon rupture, coupled with a positive Thompson test, presence of a palpable dell, and complete rupture on ultrasonography were part of the inclusion criteria. In contrast, exclusion criteria consisted of incomplete ruptures, open injuries, a repair time of >two weeks and incomplete clinical data. In this study, percutaneous Achilles tendon repair was performed with the Ma-Griffith technique. The mini-open repair group was performed with the following process: (1) Establishment of the 2-3 centimeter surgical incision at the level of the tendon rupture with 5 millimeter incisions on either side on the proximal ends of the tendon, (2) Establishment of the proximal suture channel with tapered sleeves in order to avoid sural nerve injury, (3) Suturing of the ruptured Achilles tendon proximally and distally, (4) Anastomosis of the ruptured Achilles tendon.
Results: All patients in both groups were available for follow up. The mini-open repair group demonstrated higher AOFAS scores and Achilles tendon Total Rupture Score (ATRS) than the control group. No cases of sural nerve injury were reported in the mini-open repair group, whereas five cases of sural nerve injury were reported in the percutaneous repair group (p=0.027). However, no statistical differences were found in ankle range of motion or rate of wound necrosis or infection between the two groups. This study’s mini-open repair system was a variant of the Bunnell suture method, while simplifying the complex steps to other percutaneous repairs and limiting the number of knots along the tendon.
Conclusions: Clinical data from this study reveals satisfactory functional outcomes can be obtained from both percutaneous and mini-open methods. However, the new mini-open repair system is able to prevent the risk of sural nerve injury through direct visual control of the repair and is less technically challenging compared to the percutaneous method. AOFAS Ankle-Hindfoot Score and ATRS were higher than the control group, but this was not found to be statistically significant. Therefore, the mini-open repair may represent as a superior surgical option over its percutaneous counterpart.