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Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture

Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery

Grassi, Alberto MD1,2; Amendola, Annunziato MD3; Samuelsson, Kristian MD4; Svantesson, Eleonor MD4; Romagnoli, Matteo MD2; Bondi, Alice MD2; Mosca, Massimiliano MD2; Zaffagnini, Stefano Prof1,2

doi: 10.2106/JBJS.17.01364
Systematic Reviews
Supplementary Content

Background: There is no consensus on the optimal technique for repairing an acute Achilles tendon rupture. The purpose of this meta-analysis was to compare the complications, subjective outcomes, and functional results between minimally invasive surgery and open repair of an Achilles tendon rupture.

Methods: A systematic literature search of MEDLINE/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EBSCOhost, and was performed. Eligible studies were randomized controlled trials (RCTs) comparing minimally invasive surgery and open repair of acute Achilles tendon ruptures. A meta-analysis was performed, while bias and the quality of the evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. The meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.

Results: Eight studies, with 182 patients treated with minimally invasive surgery and 176 treated with open repair, were included. The meta-analysis showed a significantly decreased risk ratio (RR) of 0.21 (95% confidence interval [CI] = 0.10 to 0.40, p = 0.00001) for overall complications and 0.15 (95% CI = 0.05 to 0.46, p = 0.0009) for wound infection after minimally invasive surgery. Patients treated with minimally invasive surgery were more likely to report good or excellent subjective results (RR = 1.18, 95% CI = 1.04 to 1.33, p = 0.009). No differences between groups were found with respect to reruptures, sural nerve injury, return to preinjury activity level, time to return to work, or ankle range of motion. The overall quality of evidence was generally low because of a substantial risk of bias, heterogeneity, indirectness of outcome reporting, and evaluation of a limited number of patients.

Conclusions: There was a significantly decreased risk of postoperative complications, especially wound infection, when acute Achilles tendon rupture was treated with minimally invasive surgery compared with open surgery. Patients treated with minimally invasive surgery were significantly more likely to report a good or excellent subjective outcome. Current evidence is associated with high heterogeneity and a considerable risk of bias.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

1Dipartimento di Scienze Biomediche e Neuromotorie (DIBINEM), University of Bologna, Bologna, Italy

2II Clinica Ortopedica e Traumatologica (A.G., M.R., M.M., and S.Z.) and Dipartimento Rizzoli Sicilia (A.B.), IRCCS Rizzoli Orthopaedic Institute, Bologna, Italy

3Michael W. Krzyzewski Human Performance Laboratory, Department of Orthopaedic Surgery, Duke University, Durham, North Carolina

4Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

E-mail address for A. Grassi:

Copyright © 2018 by The Journal of Bone and Joint Surgery, Incorporated
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