1 Introduction

Achilles tendon (AT) is one of the strongest tendons of the human body¹ and takes its name from Achilles, the famous warrior of the ancient Greek literature.

Rupture of this tendon occurs mainly during sports activities, more frequently in middle-aged men, especially recreational sportsmen who play sports occasionally.² The incidence of the tendon's rupture has increased over the last decades, a fact that is attributed to the increased sports participation among the population.^3–5

Management of AT rupture is a controversial issue. Surgical and conservative treatments are the current alternatives. Conservative treatment involves early equinus cast application for 6–8 weeks in order to approximate the edges of the ruptured tendon together to promote healing. Operative treatment involves open or percutaneous surgical technique in order to repair the ruptured tendon. Although there is an argument whether surgical or non-surgical treatment is the best option, operation appears to be more suitable for athletes due to the faster return to previous activities and the lower re-rupture rate.^6–8

Percutaneous suturing of the AT was first introduced by Ma and Griffith in 1977⁹ as an alternative for open repair, in order to avoid the procedure's complications. Since then, much progress has been made. Technological development brought modifications that improved the original technique,^10–14 such as ultrasonography or endoscopy-assisted and mini-open technique, leading to better and more satisfying results.

Although there is no consensus over the ideal surgical procedure for athletes, several studies suggest that percutaneous repair offers better cosmetic results, reduced costs and yet comparable functional outcome and complication rate when compared to open repair.^15–17

The purpose of this study is to present a review of the existing literature concerning the results of percutaneous repair of the AT rupture in athletic population with emphasis on the time and the level of return to sports activities.

2 Materials and methods

3 Results

Thirteen studies from 1990 to 2014 were assessed. The number of patients included in each study ranged from 12¹⁸ to 144,¹⁹ for a total of 670 repairs. Three studies^11,12,19 were endoscopy-assisted, one study²⁰ was ultrasonography-assisted, and in one study,²¹ combined mini-open and percutaneous technique was performed.

Follow-up period was 1 year or above in 11 out of 12 studies. One study²² reported 6 months minimum follow-up. Eighty-one patients were reported as professional level athletes at their pre-injury state. The sex ratio was clearly in favor of males (M/F: 558/100). The ratio was not clarified for 12 patients.¹⁸ Mean age was between 30 and 40 years in 10 out of 13, above 40 in two^22,23 and below 30 in one²¹ (Table 1).

4 Discussion

Epidemiological data of our study confirmed the prominence of male patients versus females with AT rupture.⁵ Mean age at the time of the injury was calculated as 36.9 years (Table 1).

The most frequent complication was sural nerve damage (3.3%). Infection of the operated area and delayed healing were less frequent (2.1%). DVT and adhesions were reported rarely (0.6%).

Re-rupture rate was extremely low (2.1%)(Table 2). Four studies reported re-ruptures: 6 (2 total, 4 partial) out of 144 patients,¹⁹ 5 (1 total, 4 partial) out of 132 patients,²⁶ 1 (total) out of 75 patients,²⁰ and 2 (total) out of 12 patients.¹⁸ The first three are on the top-4 studies concerning the sample size, and as a matter of fact, the number of the re-ruptures occurred is acceptable. The fourth study is the oldest included in our review and was conducted at a time that percutaneous technique was relatively new.^9,18 According to the above, re-rupture rate outcomes were satisfying.

Functional outcomes were pleasing. High average AOFAS, ATRS, Hannover scale, and VISA-A scale scores were recorded (Table 3).

Strength decrease of the operated limb was reported repeatedly. On the other hand, this decrease, recorded during the measurements, rarely affected patients’ single-leg tiptoe rising test.²⁶ Endurance reduction was reported too.^18,21 Limited or increased ROM was often observed; however, high average clinical outcome scores (AOFAS, ATRS, Hannover, VISA-A scale) revealed that ROM alterations rarely affected the limb's function. Significant calf circumference reduction was reported in three studies.^12,19,27 We are cautious over the outcomes regarding functional evaluation, because rehabilitation protocols were not taken into consideration in this review.

Ninety-one percent (91.4%, 273/299) of the people that participated in 9 studies resumed practicing sports (Table 4). On the other hand, 8.6% (26/299) of them, plus 23 athletes (out of 167 patients) reported in three studies, abandoned sports.^19,22,23 Even though the rates of patients that stopped sports activities is low, it could have been lower, as long as the majority of patients that quit sports did so due to mental block and not functional incapability.

In addition to the great percentage of patients who returned to sports, level of return to sports results were satisfying too. Eighty-four percent (84%, 145/173) of a group that included athletes and non-athletes and 78% (115/150) of a group that exclusively consisted of athletes achieved a same or higher level of return (Table 5). Furthermore, one study, which was actually the oldest one, reported 86% return to sports to the same or higher level.¹⁸ Although rehabilitation protocol was not taken into consideration, the results from above show that a great amount of patients not only resumed practicing sports but did it at their pre-injury level too.

Finally, the average time of return to sports after analyzing 9 studies was 18.1 weeks (8–48) (Table 6). As the range shows, there is a wide distribution regarding the time of return. Lack of rehabilitation protocol evaluation, inevitably, makes the interpretation of the results above inconclusive.

The present investigation has several limitations. Lack of direct contact with the authors of the articles, included in this study, inevitably affects scientific validity, which is biased by the quality of reporting. Also, linguistic capabilities of the research team were limited to English, possibly missing papers written in other languages. Level of evidence was mentioned only in three studies (Level 4). Consequently, the strength of the studies’ results included in our review may be questioned.

5 Conclusion

Percutaneous repair is an excellent choice for people practicing sports after AT rupture. In our study, we did not evaluate rehabilitation. Nevertheless, the combination of low re-rupture rate (Table 2) and high percentage of return to the same or higher sports level (Table 5) allows us to establish that athletic population should prefer percutaneous repair after AT rupture.

Conflicts of interest

The authors have none to declare.