Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study

Abstract

Introduction

Despite the presence of various different surgical procedures, the preferable technique for repair of acute Achilles tendon ruptures is unknown and, therefore, object of discussions. The purpose of this meta-analysis was to compare clinical outcomes and complication-rates between the minimally invasive and the standard open repair of acute Achilles tendon ruptures.

Materials and methods

This meta-analysis was performed according to the PRISMA guidelines. In September 2019 the main databases were accessed. All clinical trials of evidence level I to III comparing minimally invasive vs. open surgery of Achilles tendon rupture were included in the present study. Only articles reporting quantitative data under the outcomes of interest were included. Missing data under the outcomes of interest warranted the exclusion from the present work. For the statistical analysis we referred to the Review Manager Software Version 5.3. (The Nordic Cochrane Centre, Copenhagen). Continuous data were analysed through the inverse variance method. For the effect estimate the mean difference was used. Dichotomous data were analysed through the Mante–Haenszel method via odd ratio effect measure. The confidence interval was set at 95% in all the comparisons. Values of P < 0.05 were considered statistically significant.

Results

A total of 25 articles were included for meta-analysis. The funnel plot revealed poor data dispersion, attesting to this study a low risk of publication bias. The quality of the methodological assessment was moderate. Data from 2223 (1055 open, 1168 minimally invasive) surgical procedures were extracted. The mean follow-up was of 24.29 ± 22.4 months. The open group reported a lower value of post-operative palpable knot at last follow-up and a lower rate of sural nerve palsy. In the minimally-invasive group a shorter surgery duration and a lower rate of post-operative wound necrosis and reduced risk of wound scarring and adhesions has been evidenced. The minimally-invasive cohort detected the lowest values of superficial and deep infections. In both groups no significant difference was shown in re-rupture rate.

Conclusions

Compared to the minimally-invasive Achilles tendon reconstruction, the open procedure evidenced a lower rate of sural nerve palsy and postoperative palpable knot, whereas in the minimally-invasive reconstruction group quicker surgery duration, a lower rate of post-operative wound necrosis, superficial and deep infections and less scar tissue adhesions could be observed. No relevant discrepancies were detected among the two techniques in terms of post-operative re-rupture.

This is a preview of subscription content, access via your institution.

Fig. 1.
Fig. 2
Fig. 3

References

  1. 1.

    Yang X, Meng H, Quan Q, Peng J, Lu S, Wang A (2018) Management of acute Achilles tendon ruptures: a review. Bone Jt Res 7(10):561–569. https://doi.org/10.1302/2046-3758.710.BJR-2018-0004.R2

    CAS  Article  Google Scholar 

  2. 2.

    Wilkins R, Bisson LJ (2012) Operative versus nonoperative management of acute Achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. Am J Sports Med 40(9):2154–2160. https://doi.org/10.1177/0363546512453293

    Article  PubMed  Google Scholar 

  3. 3.

    Ma GW, Griffith TG (1977) Percutaneous repair of acute closed ruptured achilles tendon: a new technique. Clin Orthop Relat Res 128:247–255

    Google Scholar 

  4. 4.

    Daghino W, Enrietti E, Sprio AE, di Prun NB, Berta GN, Masse A (2016) Subcutaneous Achilles tendon rupture: a comparison between open technique and mini-invasive tenorrhaphy with Achillon((R)) suture system. Injury 47(11):2591–2595. https://doi.org/10.1016/j.injury.2016.09.009

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P (2002) Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. J Bone Jt Surg Am 84(2):161–170

    Article  Google Scholar 

  6. 6.

    Kakiuchi M (1995) A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair. J Bone Jt Surg Br 77(1):60–63

    CAS  Article  Google Scholar 

  7. 7.

    Gigante A, Moschini A, Verdenelli A, Del Torto M, Ulisse S, de Palma L (2008) Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study. Knee Surg Sports Traumatol Arthrosc 16(2):204–209. https://doi.org/10.1007/s00167-007-0448-z

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Hsu AR, Jones CP, Cohen BE, Davis WH, Ellington JK, Anderson RB (2015) Clinical outcomes and complications of percutaneous achilles repair system versus open technique for acute achilles tendon ruptures. Foot Ankl Int 36(11):1279–1286. https://doi.org/10.1177/1071100715589632

    Article  Google Scholar 

  9. 9.

    Amlang MH, Christiani P, Heinz P, Zwipp H (2006) The percutaneous suture of the Achilles tendon with the Dresden instrument. Oper Orthop Traumatol 18(4):287–299. https://doi.org/10.1007/s00064-006-1178-y

    Article  PubMed  Google Scholar 

  10. 10.

    Li Q, Wang C, Huo Y, Jia Z, Wang X (2016) Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review of overlapping meta-analyses. J Orthop Surg Res 11(1):65. https://doi.org/10.1186/s13018-016-0401-2

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Yang B, Liu Y, Kan S, Zhang D, Xu H, Liu F, Ning G, Feng S (2017) Outcomes and complications of percutaneous versus open repair of acute Achilles tendon rupture: a meta-analysis. Int J Surg 40:178–186. https://doi.org/10.1016/j.ijsu.2017.03.021

    Article  PubMed  Google Scholar 

  12. 12.

    Grassi A, Amendola A, Samuelsson K, Svantesson E, Romagnoli M, Bondi A, Mosca M, Zaffagnini S (2018) Minimally invasive versus open repair for acute Achilles tendon rupture: meta-analysis showing reduced complications, with similar outcomes, after minimally invasive surgery. J Bone Jt Surg Am 100(22):1969–1981. https://doi.org/10.2106/JBJS.17.01364

    Article  Google Scholar 

  13. 13.

    Rozis M, Benetos IS, Karampinas P, Polyzois V, Vlamis J, Pneumaticos SG (2018) Outcome of percutaneous fixation of acute achilles tendon ruptures. Foot Ankl Int 39(6):689–693. https://doi.org/10.1177/1071100718757971

    Article  Google Scholar 

  14. 14.

    Makulavicius A, Mazarevicius G, Klinga M, Urmanavicius M, Masionis P, Oliva XM, Uvarovas V, Porvaneckas N (2019) Outcomes of open "crown" type v. percutaneous Bunnell type repair of acute Achilles tendon ruptures. Randomized control study. Foot Ankl Surg. https://doi.org/10.1016/j.fas.2019.07.011

    Article  Google Scholar 

  15. 15.

    Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, Heng M, van der Meijden O, Groenwold RHH, Houwert RM (2019) Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ 364:k5120. https://doi.org/10.1136/bmj.k5120

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Anglemyer A, Horvath HT, Bero L (2014) Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials. Cochrane Database Syst Rev 4:000034. https://doi.org/10.1002/14651858.MR000034.pub2

    Article  Google Scholar 

  17. 17.

    Concato J, Shah N, Horwitz RI (2000) Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med 342(25):1887–1892. https://doi.org/10.1056/NEJM200006223422507

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Arditi C, Burnand B, Peytremann-Bridevaux I (2016) Adding non-randomised studies to a Cochrane review brings complementary information for healthcare stakeholders: an augmented systematic review and meta-analysis. BMC Health Serv Res 16(1):598. https://doi.org/10.1186/s12913-016-1816-5

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Frieden TR (2017) Evidence for health decision making—beyond randomized. Controll Trials N Engl J Med 377(5):465–475. https://doi.org/10.1056/NEJMra1614394

    Article  Google Scholar 

  20. 20.

    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Howick JCI, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H, Goddard O, Hodgkinson M (2011) The 2011 oxford levels of evidence. Oxford centre for evidence-based medicine available at https://www.cebm.net/index.aspx?o=5653

  22. 22.

    Majewski M, Rickert M, Steinbruck K (2000) Achilles tendon rupture. A prospective study assessing various treatment possibilities. Orthopade 29(7):670–676

    CAS  PubMed  Google Scholar 

  23. 23.

    Lim J, Dalal R, Waseem M (2001) Percutaneous vs open repair of the ruptured Achilles tendon—prospective randomized controlled study. Foot Ankl Int 22(7):559–568. https://doi.org/10.1177/107110070102200705

    CAS  Article  Google Scholar 

  24. 24.

    Rebeccato A, Santini S, Salmaso G, Nogarin L (2001) Repair of the achilles tendon rupture: a functional comparison of three surgical techniques. J Foot Ankl Surg 40(4):188–194

    CAS  Article  Google Scholar 

  25. 25.

    Riedl S, Sandberger L, Nitschmann K, Meeder PJ (2002) Suture of fresh Achilles tendon rupture. Comparison of open with percutaneous suture technique. Chirurg 73(6):607–614

    CAS  Article  Google Scholar 

  26. 26.

    Haji A, Sahai A, Symes A, Vyas JK (2004) Percutaneous versus open tendo achillis repair. Foot Ankl Int 25(4):215–218. https://doi.org/10.1177/107110070402500404

    Article  Google Scholar 

  27. 27.

    Miller D, Waterston S, Reaper J, Barrass V, Maffulli N (2005) Conservative management, percutaneous or open repair of acute Achilles tendon rupture: a retrospective study. Scott Med J 50(4):160–165. https://doi.org/10.1177/003693300505000408

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Cretnik A, Kosanovic M, Smrkolj V (2005) Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med 33(9):1369–1379. https://doi.org/10.1177/0363546504271501

    Article  PubMed  Google Scholar 

  29. 29.

    Bhattacharyya M, Gerber B (2009) Mini-invasive surgical repair of the Achilles tendon–does it reduce post-operative morbidity? Int Orthop 33(1):151–156. https://doi.org/10.1007/s00264-008-0564-5

    Article  PubMed  Google Scholar 

  30. 30.

    Ebinesan AD, Sarai BS, Walley GD, Maffulli N (2008) Conservative, open or percutaneous repair for acute rupture of the Achilles tendon. Disabil Rehabil 30(20–22):1721–1725. https://doi.org/10.1080/09638280701786815

    Article  PubMed  Google Scholar 

  31. 31.

    Avina Valencia JA, Guillen Alcala MA (2009) Repair of acute Achilles tendon rupture. Comparative study of two surgical techniques. Acta Ortop Mex 23(3):125–129

    PubMed  Google Scholar 

  32. 32.

    Aktas S, Kocaoglu B (2009) Open versus minimal invasive repair with Achillon device. Foot Ankl Int 30(5):391–397. https://doi.org/10.3113/FAI.2009.0391

    Article  Google Scholar 

  33. 33.

    Chan AP, Chan YY, Fong DT, Wong PY, Lam HY, Lo CK, Yung PS, Fung KY, Chan KM (2011) Clinical and biomechanical outcome of minimal invasive and open repair of the Achilles tendon. Sports Med Arthrosc Rehabil Ther Technol 3(1):32. https://doi.org/10.1186/1758-2555-3-32

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Henriquez H, Munoz R, Carcuro G, Bastias C (2012) Is percutaneous repair better than open repair in acute Achilles tendon rupture? Clin Orthop Relat Res 470(4):998–1003. https://doi.org/10.1007/s11999-011-1830-1

    Article  PubMed  Google Scholar 

  35. 35.

    Grubor P, Grubor M (2012) Treatment of Achilles tendon rupture using different methods. Vojnosanit Pregl 69(8):663–668

    Article  Google Scholar 

  36. 36.

    Carmont MR, Heaver C, Pradhan A, Mei-Dan O, Gravare Silbernagel K (2013) Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair. Knee Surg Sports Traumatol Arthrosc 21(6):1361–1368. https://doi.org/10.1007/s00167-013-2423-1

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Karabinas PK, Benetos IS, Lampropoulou-Adamidou K, Romoudis P, Mavrogenis AF, Vlamis J (2014) Percutaneous versus open repair of acute Achilles tendon ruptures. Eur J Orthop Surg Traumatol 24(4):607–613. https://doi.org/10.1007/s00590-013-1350-7

    Article  PubMed  Google Scholar 

  38. 38.

    Kolodziej L, Bohatyrewicz A, Kromuszczynska J, Jezierski J, Biedron M (2013) Efficacy and complications of open and minimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study–preliminary report. Int Orthop 37(4):625–629. https://doi.org/10.1007/s00264-012-1737-9

    Article  PubMed  Google Scholar 

  39. 39.

    Jallageas R, Bordes J, Daviet JC, Mabit C, Coste C (2013) Evaluation of surgical treatment for ruptured Achilles tendon in 31 athletes. Orthop Traumatol Surg Res 99(5):577–584. https://doi.org/10.1016/j.otsr.2013.03.024

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Rosso C, Buckland DM, Polzer C, Sadoghi P, Schuh R, Weisskopf L, Vavken P, Valderrabano V (2015) Long-term biomechanical outcomes after Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 23(3):890–898. https://doi.org/10.1007/s00167-013-2726-2

    Article  PubMed  Google Scholar 

  41. 41.

    Obada B, Serban AO (2014) Achilles tendon ruptures: comparison between the clinical results of classical versus mini-invasive or percutaneous surgical treatment. ARS Med Tomitana 78(3):135–138

    Google Scholar 

  42. 42.

    Lonzaric D, Kruscic A, Dinevski D, Povalej Brzan P, Jesensek Papez B (2017) Primary surgical repair of acute Achilles tendon rupture: comparative results of three surgical techniques. Wien Klin Wochenschr 129(5–6):176–185. https://doi.org/10.1007/s00508-016-1158-7

    Article  PubMed  Google Scholar 

  43. 43.

    Araujo PJ, Moreno MV, de Souza GJ, Gomes MJ, Vieira TE, Jalil VS (2018) Comparison between the open and minimally invasive repair technique in acute Achilles tendon injuries. Sci J Foot Ankl 4(12):265–270. https://doi.org/10.30795/scijfootankle.2018.v12.789

    Article  Google Scholar 

  44. 44.

    Baumfeld D, Baumfeld T, Spiezia F, Nery C, Zambelli R, Maffulli N (2019) Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears. Foot Ankl Surg 25(4):503–506. https://doi.org/10.1016/j.fas.2018.03.003

    Article  Google Scholar 

  45. 45.

    Alcelik I, Diana G, Craig A, Loster N, Budgen A (2017) Minimally invasive versus open surgery for acute achilles tendon ruptures a systematic review and meta-analysis. Acta Orthop Belg 83(3):387–395

    PubMed  Google Scholar 

  46. 46.

    Lacoste S, Feron JM, Cherrier B (2014) Percutaneous Tenolig((R)) repair under intra-operative ultrasonography guidance in acute Achilles tendon rupture. Orthop Traumatol Surg Res 100(8):925–930. https://doi.org/10.1016/j.otsr.2014.09.018

    CAS  Article  PubMed  Google Scholar 

  47. 47.

    Aibinder WR, Patel A, Arnouk J, El-Gendi H, Korshunov Y, Mitgang J, Uribe J (2013) The rate of sural nerve violation using the Achillon device: a cadaveric study. Foot Ankl Int 34(6):870–875. https://doi.org/10.1177/1071100712473097

    Article  Google Scholar 

  48. 48.

    Liechti DJ, Moatshe G, Backus JD, Marchetti DC, Clanton TO (2018) A percutaneous knotless technique for acute achilles tendon ruptures. Arthrosc Tech 7(2):e171–e178. https://doi.org/10.1016/j.eats.2017.08.065

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Poynton AR, O'Rourke K (2001) An analysis of skin perfusion over the achilles tendon in varying degrees of plantarflexion. Foot Ankl Int 22(7):572–574. https://doi.org/10.1177/107110070102200707

    CAS  Article  Google Scholar 

  50. 50.

    Saxena A, Maffulli N, Nguyen A, Li A (2008) Wound complications from surgeries pertaining to the Achilles tendon: an analysis of 219 surgeries. J Am Podiatr Med Assoc 98(2):95–101

    Article  Google Scholar 

  51. 51.

    Marican MM, Fook-Chong SM, Rikhraj IS (2015) Incidence of postoperative wound infections after open tendo Achilles repairs. Singap Med J 56(10):549–554. https://doi.org/10.11622/smedj.2015150

    Article  Google Scholar 

  52. 52.

    Amlang MH, Zwipp H, Friedrich A, Peaden A, Bunk A, Rammelt S (2011) Ultrasonographic classification of Achilles tendon ruptures as a rationale for individual treatment selection. ISRN Orthop 2011:869703. https://doi.org/10.5402/2011/869703

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Yammine K, Assi C (2017) Efficacy of repair techniques of the Achilles tendon: a meta-analysis of human cadaveric biomechanical studies. Foot (Edinb) 30:13–20. https://doi.org/10.1016/j.foot.2016.09.006

    Article  Google Scholar 

  54. 54.

    Sadoghi P, Rosso C, Valderrabano V, Leithner A, Vavken P (2012) Initial Achilles tendon repair strength–synthesized biomechanical data from 196 cadaver repairs. Int Orthop 36(9):1947–1951. https://doi.org/10.1007/s00264-012-1533-6

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

No external source of funding was used.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Matthias Gatz.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study informed consent is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gatz, M., Driessen, A., Eschweiler, J. et al. Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study. Arch Orthop Trauma Surg 141, 383–401 (2021). https://doi.org/10.1007/s00402-020-03437-z

Download citation

Keywords

  • Achilles tendon rupture
  • Percutaneous
  • Minimal invasive
  • Open surgery
  • Complications