SLR - February 2018 - Mark Vaughn

Outcomes and Complications of Percutaneous Versus Open Repair of Acute Achilles Tendon Rupture: A Meta-Analysis

Reference: Yang B, Liu Y, Kan S, Zhang D, Xu H, Liu F, Ning G, Feng S. Outcomes and Complications of Percutaneous Versus Open Repair of Acute Achilles Tendon Rupture: A Meta-Analysis. Int J Surg. 2017 Apr;40:178–186. doi: 10.1016/j.ijsu.2017.03.021. Epub 2017 Mar 11.

Scientific Literature Review

Reviewed By: Mark Vaughn, DPM
Residency Program: UF Health Jacksonville, Jacksonville, FL

Podiatric Relevance: Acute Achilles tendon rupture (AATR) is the most common tendon rupture in the human body. Much debate exists in the literature in regards to whether conservative or operative treatment is superior. Conservative treatment offers disadvantages, including higher incidence of rerupture rate and elongation of the musculotendinous unit. Open repair has lower rate of rerupture but has been associated with major wound complications and increased operative time when compared to percutaneous repair. Percutaneous repair, which was first described in 1977 by Ma and Griffith, has been criticized due to high risk for sural nerve injury and higher rate of rerupture in comparison with open repair. Percutaneous repair leads to a lower incidence of postoperative wound complications and a much faster operative time. With much debate in literature, this meta-analysis was designed to assist in further evaluating the outcomes and complications of these two operative methods.

Methods: Multiple databases were searched, including PubMed, Web of Science, EMBASE and the Cochrane Library up to 2016. Two reviewers independently screened the studies for eligibility, evaluated the quality and extracted date from eligible studies with confirmation by cross-checking. The major results and conclusions were concluded, and the different complication rates and functional outcomes were compared. Meta-analysis was processed by Rev Man 5.3 software.

Results: A total of twelve studies met the inclusion criteria, which included five randomized controlled trials and seven retrospective cohort studies involving 815 patients. Sural nerve injury rate in the percutaneous group was significantly higher (RR = 3.52, 95 percent CI 1.45 to 8.57, P = 0.006). The occurrence rate of sural nerve injury was 5.5 percent with percutaneous treatment and 1.2 percent with open treatment. Open group had a much higher rate of deep infection (RR = 0.33, 95 percent CI 0.11 to 0.96, P = 0.04), and subgroup analysis of five RCTs showed no significant difference (RR = 0.42, 95 percent CI 0.09 to 2.10, P = 0.29). The occurrence of rate of deep infection was 0.6 percent with percutaneous and 3.6 percent with open. In regards to rerupture rate of open versus percutaneous, there was no significant difference, 2.7 percent compared to 3.1 percent, respectively. Percutaneous operation time was shorter (RR = -1.99, 95 percent CI -3.81 to -0.80, P = 0.001). The duration of surgery was 24–54.55 min in the percutaneous group compared with 45.9–68.8 min in the open group. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score showed statistically different in the two groups.

Conclusions: The authors’ meta-analysis of current evidence suggests that percutaneous repair is a superior surgical option to open repair for treating AATR. This conclusion is made due to the advantages of operation time, deep infection and AOFAS score. Limitations to this meta-analysis include small sample size, therefore, more multicenter and RCTs will need to be conducted to help further evaluate both surgical options for repair of AATR. 

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