A clinical comparison of two different surgical techniques in the treatment of acute Achilles tendon ruptures: Limited-open approach vs. percutaneous approach

Abstract

Background: Surgical treatment is the commonly preferred method for treating acute Achilles tendon ruptures (AATRs) due to advantages such as less re-rupture rates, better functional results, and an early return to physical activities. The main aim of our study is to compare two common minimally invasive surgical methods, the limited open and the percutaneous approaches, regarding clinical outcomes.

Methods: A total of 53 patients (19 females and 34 males) who were treated with limited open (Group 1: 30 patients) and percutaneous (Group 2: 23 patients) approaches for AATRs were retrospectively evaluated between March 2019 and May 2020 in a level 1 trauma center. The evaluation included complications (soft tissue and skin problems, re-rupture, and sural nerve injury rates), the operation time, the duration of return to daily activities, The Achilles Tendon Total Rupture Score (ATRS), and the American Ortho-pedic Foot and Ankle Society (AOFAS) scores of the patients at the first and 6th months of follow-up. Patients' activity levels were compared with the Tegner Activity Scale (TAS).

Results: The mean age of all patients in this cohort was 45.1±14.1. The mean postoperative follow-up period for group 1 was 36.9±8.81 weeks, whereas, for group 2, it was 35.4±8.73 weeks (P=0.24). The mean age (P=0.47), gender distribution (P=0.41), and body mass index (P=0.29) were similar for both groups. The mean operation time (group 1: 47.1±5.4 vs. group 2: 44.4±6.1, P=0.06) and the duration of return to daily activities (group 1: 49.2±7.4 vs. group 2: 48.5±9.7, P=0.38) were also similar. There was no statistical difference between groups regarding functional results at first (ATRS: group 1: 79.9±3.2 vs. group 2: 79.5±3.9, [P=0.35], and AOFAS: group 1: 80.9±3.1 vs. group 2: 82.1±3.2, [P=0.10]) and 6th months (ATRS: group 1: 85.0±3.8 vs. group 2: 83.7±4.4, [P=0.13], and AO-FAS: group 1: 86.6±3.6 vs. group 2: 86.7±4.2, [P=0.46]). There were no statistically significant differences between groups regarding preoperative and last follow-up TAS scores (P= 0.94 and P=0.46, respectively). We observed no postoperative complications in group 1. There were three complications (13.1%) in group 2. One patient (4.4%) had a re-rupture, and two patients (8.7%) had sural nerve injuries.

Conclusion: Although both groups had similar functional results, the limited open approach yielded better clinical outcomes according to the complication results than the percutaneous approach.

Figure 1

The Flow chart of the patients in the study group.

Figure 2

Percutaneous (a) and limited open (b) Achilles repair techniques.

Figure 3

Figure 1. Limited-open repair of the Achilles tendon. (a) a mini-incision over the gap formation. (b) The interval between the superficial fascia of the leg and the paratenon is developed. (c) The suture, which is passed through the tendon with the help of a needle or cannula, is pulled to the incision line with the help of a clamp. (d) Distal and proximal sutures are knotted over the tendon, and the paratenon is repaired. (*: Saphenous vein, :Sural nerve).

Figure 4

Percutaneous repair of the Achilles tendon. (a) The medial and lateral edges of the proximal and the distal parts of the tendon are determined, and sutures are passed through the determined points of the tendon with the help of a needle or cannula. (b) Two stab incisions (medial and lateral) are made at the rupture site and the sutures are pulled from the determined points to the incision lines with the help of a mini hook. (c) Sutures are pulled out from the stab incisions and are knotted over the tendon. (d) The skin is closed. (*: Saphenous vein, :Sural nerve)