Minimally Invasive Repair
Open, limited open and percutaneous techniques are options for treating patients with acute Achilles tendon rupture.
LIMITED RECOMMENDATION Rationale
We defined the following operative repairs:
Open – procedure utilizing an extended incision for exposure allowing visualization of the rupture and tendon to allow direct placement of sutures for the repair.
Limited-Open – procedure utilizing a small incision for exposure allowing direct visualization of the ruptured ends.
Percutaneous – procedure without direct exposure of the tendon rupture site.
A systematic review identified three level II comparative trials29, 33, 35 investigating percutaneous repair and one level II and two level III comparative trials studying limited-open repairs.27, 36, 31 In both these comparisons, there was no significant difference in reruptures between open and minimally invasive techniques.
Two studies 29, 33 that compared percutaneous to open repairs found no statistically significant difference in return to activity. Two studies27, 36 comparing limited open to open repair found that patients treated with a limited open technique returned to activity sooner than those treated with an open repair.
There is no statistically significant difference in satisfaction in patients treated with percutaneous or open repairs.29 Patients treated with limited open repair techniques have statistically significantly fewer symptoms than those treated with open technique but no statistically significant differences in pain.
One study33 showed a statistically significant difference in the short term in favor of the percutaneous group for wound breakdown/delayed healing. Two studies29, 33 showed statistically significantly less scar adhesion in the percutaneous repair group compared with the open repair. Similarly, patients treated with limited open groups had statistically significantly fewer minor surgical site infections leading to delayed wound healing and in one study fewer severe wound infections.27
Beyond short term wound complications, there is no identified added benefit when comparing long term adverse events between open repair and minimally invasive repair. While in some studies33, 31 there were an increased number of superficial infections in the open repair group, there was no statistically significant difference between groups for deep infections31. One study29 reported a statistically significant difference in superficial infections between the open group and percutaneous groups, however, the authors29 did not administer IV antibiotics to the open control group. Based on these considerations, we downgraded this body of evidence to limited.
The literature reviewed refers primarily to non insertional ruptures in which there is sufficient distal tendon for repair. It is acknowledged that a small subset of ACTR consist of purely insertional injuries, often with a segment of bone attached. The latter group is beyond the scope of this GL. However, the reader should be aware of the fact that the repair techniques reviewed may not be compatible with these distal ruptures.
Consideration should also be given to the location of the tear when performing a repair in a percutaneous or limited-open fashion. Tears located at the proximal or distal ends of the tendon may compromise the ability to successfully complete a limited open repair. The orthopaedic surgeon performing the repair may need to extend the incision, converting it to an open technique if unable to obtain good suture fixation with a limited-open or percutaneous technique.
Open – procedure utilizing an extended incision for exposure allowing visualization of the rupture and tendon to allow direct placement of sutures for the repair.
Limited-Open – procedure utilizing a small incision for exposure allowing direct visualization of the ruptured ends.
Percutaneous – procedure without direct exposure of the tendon rupture site.
A systematic review identified three level II comparative trials29, 33, 35 investigating percutaneous repair and one level II and two level III comparative trials studying limited-open repairs.27, 36, 31 In both these comparisons, there was no significant difference in reruptures between open and minimally invasive techniques.
Two studies 29, 33 that compared percutaneous to open repairs found no statistically significant difference in return to activity. Two studies27, 36 comparing limited open to open repair found that patients treated with a limited open technique returned to activity sooner than those treated with an open repair.
There is no statistically significant difference in satisfaction in patients treated with percutaneous or open repairs.29 Patients treated with limited open repair techniques have statistically significantly fewer symptoms than those treated with open technique but no statistically significant differences in pain.
One study33 showed a statistically significant difference in the short term in favor of the percutaneous group for wound breakdown/delayed healing. Two studies29, 33 showed statistically significantly less scar adhesion in the percutaneous repair group compared with the open repair. Similarly, patients treated with limited open groups had statistically significantly fewer minor surgical site infections leading to delayed wound healing and in one study fewer severe wound infections.27
Beyond short term wound complications, there is no identified added benefit when comparing long term adverse events between open repair and minimally invasive repair. While in some studies33, 31 there were an increased number of superficial infections in the open repair group, there was no statistically significant difference between groups for deep infections31. One study29 reported a statistically significant difference in superficial infections between the open group and percutaneous groups, however, the authors29 did not administer IV antibiotics to the open control group. Based on these considerations, we downgraded this body of evidence to limited.
The literature reviewed refers primarily to non insertional ruptures in which there is sufficient distal tendon for repair. It is acknowledged that a small subset of ACTR consist of purely insertional injuries, often with a segment of bone attached. The latter group is beyond the scope of this GL. However, the reader should be aware of the fact that the repair techniques reviewed may not be compatible with these distal ruptures.
Consideration should also be given to the location of the tear when performing a repair in a percutaneous or limited-open fashion. Tears located at the proximal or distal ends of the tendon may compromise the ability to successfully complete a limited open repair. The orthopaedic surgeon performing the repair may need to extend the incision, converting it to an open technique if unable to obtain good suture fixation with a limited-open or percutaneous technique.