SLR - July 2022 - Simon Ball, DPM
Reference: Caolo KC, Eble SK, Rider C, Elliott AJ, Demetracopoulos CA, Deland JT, Drakos MC, Ellis SJ. Clinical Outcomes and Complications With Open vs Minimally Invasive Achilles Tendon Repair. Foot Ankle Orthop. 2021 Nov 29;6(4):24730114211060063.Level of Evidence: Level III, Retrospective cohort study.
Scientific Literature Review
Reviewed By: Simon Ball, DPM
Residency Program: MetroWest Medical Center - Framingham, MA
Podiatric Relevance: There is a growing consensus that non-operative treatment of Achilles rupture has similar outcomes and complications as open repair, yet may lead to increased re-rupture. No consensus exists between traditional open techniques or the minimally invasive approach (MIS). Some studies showed that MIS may have fewer complications, and lower risk of infection. Various outcomes scores such as AOFAS, and ATRS have been used in assessment of Achilles tendon repair. However, no studies exist using PROMIS, which is a computer adaptive test with precision and validated for use in assessment of Achilles tendon repair and is recommended by AOFAS. Therefore, the authors hypothesized that both techniques would show improved PROMIS scores and equally effective with less complications.
Methods: N = 326 diagnosed with acute Achilles tendon rupture from 2016-2019, from a single center with nine (9) fellowship-trained orthopedic surgeons. Eight (8) patients were excluded for no treatment, and 133 were lost to follow up. Seven surgeons used MIS, and two surgeons used traditional open and decisions made based on competency. Information was collected pre-operatively, and at 1 and 2 years post-operatively. The PROMIS parameters included physical function, pain inference, pain intensity, global health, and depression. Furthermore, mechanism of rupture, percentage of injury from sports, and time from injury to surgery, and complications was reported. MIS involved a 4 cm incision with percutaneous sutures, with open repair using a >5 centimeter incision with krackow or bunnell, both using the same post-operative protocol.
Results: One hundred eighteen (118) Achilles ruptures underwent MIS, and 67 received the open repair. No significant difference in the pre-operative or post-operative PROMIS scores in all studies. No significant difference between MIS and open for average follow-up (1.6 years versus 1.5 years), average time from injury (7.4 days versus 7.9 days), percentage injury from sport (85.6 percent versus 91.0 percent), average age (37.6 years vs 39.1 years), BMI (26.7 versus 25.7), gender (82.2 percent male versus 77.6 percent male), most common mechanism (P = 0.45), and complication rates (19.5 percent vs 16.4 percent). Procedure duration for MIS was 43.2 minutes versus 47.1 minutes for open. Four re-ruptures in the MIS (3.3 percent) versus 1 in the open (1.5 percent), three deep infections in the MIS group (2.5 percent), and none with the open repair.
Conclusions: The authors concluded that there is no distinction between MIS and open repair in patient-reported outcomes and complication rates. However, they found that procedure duration was longer in the open repair which may be due to the larger incision. They also highlighted the increased cost of MIS owing to the commercially available minimally invasive devices. Overall, this is a sizable cohort of patients, however many were lost to follow up, but percentages were comparable to other studies. They compared studies of non-operative treatment with open, yet did not include a cohort of non-operative patients. This study was very valuable showing improvements in both categories, however, there was selection bias because the surgeons chose treatment based on their competences. Further randomized studies comparing open vs MIS are needed to justify the use of MIS over open techniques.