SLR - January 2019 - Kelsey J. Millonig

Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery

Reference: Grassi A, Amendola A, Samuelsson K, Svantesson E, Romagnoli M, Bondi A, Mosca M, Zaffagnini S. Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery. J Bone Joint Surg Am. 2018 Nov 21;100(22):1969–1981.

Scientific Literature Review

Reviewed By: Kelsey J. Millonig, DPM, MPH
Residency Program: Franciscan Foot & Ankle Institute, Federal Way, WA

Podiatric Relevance: Despite numerous treatment modalities, the surgical approach to acute Achilles tendon ruptures (AATRs) is still widely debated. Surgical approaches, including minimally invasive and open surgical repair, have historically been compared regarding outcomes and complications. Prior literature has debated whether a minimally invasive approach may provide optimal outcomes with minimized risk for surgical complications, earlier healing and accelerated postoperative rehabilitation. However, minimally invasive techniques may be more demanding and a potential weaker construct. This meta-analysis aims to compare the complications, subjective patient outcomes and functional results between minimally invasive surgery and open repair of an Achilles tendon rupture.

Methods: A meta-analysis was completed of randomized controlled trials (RCTs) comparing minimally invasive surgery and open repair of AATRs. A literature search was completed in February 2017 with no criteria regarding surgical procedure, study sample size or duration of follow-up. The study was completed according to PRISMA guidelines with the Cochrane Database and GRADE used to determine bias and quality of evidence. Primary outcome measures included complications, subjective outcomes and functional results. Complications evaluated included reruptures, infections, wound complications, adhesions, keloid formation, sural nerve injury, residual pain, ankle stiffness and venous thromboembolism. Subjective outcomes were defined as patient satisfaction, return to preinjury activity and return to work. Functional results measured included AOFAS and ankle range of motion.

Results: Eight studies with publication dates between 1997 and 2014 were included in this study. A total of 182 patients treated minimally invasively and 176 treated with open repair were included in analysis. These RCTs included varied Ma and Griffith and Achillon system minimally invasive techniques. Minimally invasive surgery demonstrated a significant decrease in complications with risk ratio (RR) of 0.21 and decrease in wound infection 0.15 RR. Ankle stiffness was significantly less common after minimally invasive surgery. Subjective results demonstrated minimally invasive surgical patients were more likely to report good or excellent results. AOFAS scores were statistically significantly higher by 2.74 points in the open repair group; however, this did not appear to be clinically relevant. No statistical significance was found between rerupture rates, sural nerve injury, return to preinjury activity level, time to return to work and ankle range of motion. The quality of evidence was low due to high heterogeneity and significant selection and detection bias.

Conclusions: The authors concluded minimally invasive surgery for AATR in nonelderly healthy individuals offers similar functional outcomes and enhanced subjective outcomes with lower risk of surgical complications. There are significant limitations of this study, including the quality of evidence and differences in surgical technique and postoperative course within both surgical groups among RCTs included. Both minimally invasive and open repair techniques demonstrate options for AATR. However, it must be considered that specific surgical technique and postoperative course may change results significantly and with relatively new surgical techniques regarding minimally invasive AATR growing, additional research on specific techniques is necessary. 

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