A Comparison of Minimally Invasive Achilles Repair Techniques on Functional Outcome and Failure Rates

Abstract

Category: Sports; Ankle Introduction/Purpose: The incidence of Achilles tendon ruptures (ATR) is 21.5 per 100,000 people, making it the most common tendon rupture of the lower extremity. Repair methods consist of the traditional open, indirect repair with suture anchors (Midsubstance SpeedBridge, MSB), or jig-assisted technique (Percutaneous Achilles Repair System, PARS) with MSB; the latter two being minimally invasive. Early mobilization is crucial for restoration of tendon strength and function. The available literature shows minimally invasive techniques allow early weight-bearing but lacks the direct comparison of the techniques on clinical recovery duration and patient outcomes. The purpose of the study was to compare safety (i.e., risk of re-rupture) and efficiency (i.e., days to medical clearance) between the traditional open, MSB, and PARS with MSB techniques for ATR repair. Methods: This retrospective study used the CPT code 27650 and yielded 103 patients that underwent a primary ATR between 2017 to 2021 that were managed by three fellowship-trained orthopedic surgeons. After excluding chronic tendinopathy, revisions, patients lost to follow up or non-compliance, 41 acutely injured patients remained. Patients were followed until medical clearance or they reached Maximal Medical Improvement (MMI). The chart review included complications (e.g., infection, healing issues, nerve issues, re-rupture), referral to physical therapy (PT), days non-weight bearing (NWB), physical exam findings, and patient compliance with recommendations. Continuous variables were examined using one-way ANOVAs, one-way ANCOVAs, Independent-Samples Median Tests, or Kruskall-Wallis H Tests for age, body mass index (BMI), recovery duration, days NWB, and days until PT referral. Chi-square tests or Fisher's Exact tests were performed to compare proportions for sex, and complications. Bonferroni adjustments were performed for post hoc testing. Results: 41 patients (39.7 +- 24 years old; 38 males; 7 females) and BMI of 30.3 +- 6.1 kg/m2 underwent an ATR repair. There were no significant differences between groups for re-rupture rates (none reported), complications (P = 0.245), age (P = 0.497), or BMI (P = 0.908). There were significant differences in recovery duration (P = 0.004) and days NWB (P = 0.001). After controlling for days NWB, recovery duration was significantly different between groups [F(2,41) = 6.098, P = 0.005; partial h2 = 0234]. Recovery duration for PARS (119.2 +- 44.0 days) was significantly quicker than both open (169.4 +- 41.6 days; P = 0.019) and MSB (167.2 +- 31.2 days; P = 0.009), but no differences between open and MSB (P = 1.00). Conclusion: The PARS with MSB method had a much shorter recovery duration with clearance occurring 50 days faster than other techniques. It is possible the PARS with MSB technique allowed for earlier mobilization which contributed to an accelerated recovery. Non-weight bearing days and early initiation of PT could be a factor in recovery duration and warrants further exploration. Future prospective research with a more homogenous patient population with a focus on early rehabilitation will provide greater insight.