SLR - May 2023 - Jennifer M. So, DPM, PGY-2
Title: Outcomes and Complications of Open Versus Minimally invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled TrialsReference: Attia AK, Mahmoud K, d'Hooghe P, Bariteau J, Labib SA, Myerson MS. Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Sports Med. 2023;51(3):825-836. doi:10.1177/03635465211053619
Level of Evidence: 1
Reviewed By: Jennifer M. So, DPM, PGY-2
Residency Program: University of Florida College of Medicine - Jacksonville. Jacksonville, FL.
Podiatric Relevance: This article serves as the current largest meta-analysis of randomized controlled trials, exemplifying the current highest level of evidence to date. This study highlights the similarity in functional outcomes between open and minimally invasive surgical (MIS) Achilles tendon repair while identifying the key advantages and disadvantages of each.
Methods: The authors conducted a literature review and meta-analysis of open and MIS repair of acute achilles tendon ruptures. Their study had a total of 522 patients divided into two groups (260 open versus 262 MIS) from 10 randomized controlled trials. Their primary outcomes included functional outcomes, re-rupture rate, sural nerve injury, superficial and deep infections. Their secondary outcomes were skin complications, other complications, adhesions, ankle range of motion, and surgical time. Open repair techniques included the Krakow, Kessler, and Bunnel while MIS techniques were the Ma and Griffith, the Achillon, modified Bunnell, and Tenolig. Based on prior studies' limitations, the authors chose to exclude heterogeneous studies with a small number of patients. They evaluated each study’s risk of bias with the Newcastle-Ottawa scale.
Results: Similar outcomes between the open and MIS repair groups include the mean postoperative AOFAS score (94.8, 95.7), total complication rate (15.5%, 10.4%), mean re-rupture rate (2.5%, 1.5%), deep infection rate (1.4%, 0%), and skin necrosis, dehiscence, adhesion, and keloid scar rate. There was a statistically significant difference between the open and MIS repair in the following outcomes: mean sural nerve injury rate (0%, 3.4%), superficial infection rate (6.0%, 0.4%), surgical time (51.0 minutes, 29.7 minutes), ankle range of motion (34.3°, 40.0°), time to return to sport (163.3 days, 182.8 days).
Conclusions: Open and MIS Achilles tendon repair both pose their advantages and disadvantages. Open repair yielded no sural nerve injuries and a quicker return to sports while MIS repair had a lower surgical time, lower superficial infection rate, less ankle stiffness, greater plantarflexion, and a lower re-rupture rate. Interestingly, the mean re-rupture rate favored MIS, which is significantly lower than in the previous MIS literature. Also, MIS yielded a low 3.4% sural nerve injury rate, significantly lower than 60% from Ma and Griffitth’s original study. All sural nerve injuries were temporary and resolved within 1 year. Also, the 3 studies employing the MIS Achillon device yielded no sural injury. Further studies are required before considering MIS Achilles tendon repair as a gold standard. However, this study shows promise with the MIS Achilles tendon repair with proper patient selection.