Comparison of open, percutaneous, or mini-open repair in the treatment of Achilles tendon ruptures: a systematic review and meta-analysis based on comparison studies

Background: The Achilles tendon rupture is a common injury of the lower extremity, inducing pain and physical impairment. Surgical treatment methods include open, percutaneous, and mini-open repair techniques. This study aims to compare the outcomes of these three techniques. Methods: PubMed, Google Scholar, and EMBASE were searched until November 2023. Randomized controlled trials (RCT) and retrospective comparative studies (RCS) comparing either open versus percutaneous repair, open versus mini-open repair, or percutaneous vs. mini-open repair of the Achilles tendon rupture were included with at least one of the following outcomes: American Orthopedic Foot & Ankle Society (AOFAS) score, Achilles Tendon Total Rupture Score (ATRS) score, re-ruptures, sural nerve injuries, infections, wound dehiscence, deep vein thrombosis (DVT), and average operating time. Meta-analysis was mostly processed by RevMan 5. A P value of <= 0.05 was considered statistically significant. Risk of bias was assessed with RevMan 5 and the Newcastle-Ottawa scale. Results: Twenty-six studies, including 1,898 patients, were included. The percutaneous group had significantly more sural nerve injuries [risk ratio (RR) =0.28; 95% confidence interval (CI): 0.14 to 0.57; P<0.001], fewer infections (RR =2.99; 95% CI: 1.37 to 6.49; P=0.006), higher AOFAS score [standardized mean difference (SMD) =-0.32; 95% CI: -0.61 to -0.03; P=0.03], higher ATRS (SMD =-0.24; 95% CI: -0.47 to -0.02; P=0.03), and a shorter average operating period (SMD =2.29; 95% CI: 1.63 to 2.96; P<0.001) than the open repair group. The mini-open group had a significantly higher AOFAS score (SMD =-0.58; 95% CI: -1.06 to -0.09; P=0.02), higher ATRS (SMD =-0.65; 95% CI: -1.05 to -0.26; P=0.001), longer average operating time (SMD =-0.95; 95% CI: -1.46 to -0.45; P<0.001), and lower rates of re-ruptures and sural nerve injuries than the percutaneous group. The open group had significantly more infections than the mini-open group (RR =2.99; 95% CI: 1.07 to 8.37; P=0.04). Conclusions: The mini-open repair technique demonstrated superior function scores and lower complication rates than percutaneous repair and open repair. It should be the first choice when treating Achilles tendon ruptures, with percutaneous repair being a reliable alternative.