Endoscopic Assistance in Minimally Invasive Repair of Acute Achilles Ruptures: A Prospective Observational Study...

Background: The optimal management of acute Achilles tendon (AT) ruptures remains debated. Historically, surgical treatment has been preferred over conservative management because of a lower risk of rerupture. In recent decades, minimally invasive (MIS) and percutaneous techniques have been introduced to reduce the complications associated with the traditional open surgery. Comparable clinical outcomes have been demonstrated, with a lower rate of general complications but a higher risk of sural nerve palsy. Endoscopic assistance has been finally proposed to improve intraoperative visualization and potentially decrease this risk, although its actual potential benefit remains uncertain. Methods: A prospective observational study including a total of 94 patients who underwent surgical treatment for acute subcutaneous AT rupture was conducted. 60 of the patients were male and 34 were female, with a mean age at the time of surgery of 42.5 [18-78] years. The patients were then divided into three groups according to the surgical procedure performed: endoscopic-assisted MIS technique (A, n = 30), Ma-Griffith minimally invasive technique (M-G/MISI) (B, n = 34) and traditional open surgery (C, n = 32). Same post-operative protocol. The mean follow-up was 32 months (24-60 months). Patients were evaluated by time taken to return to driving (RTD), to their usual work activities (RTW), and, in active patients, to sports activities (RTS) at a level comparable to that prior to the injury was recorded. Clinical outcomes were evaluated with Achilles tendon Total Rupture Score (ATRS) and Ankle Hindfoot American Orthopaedic Foot and Ankle Society (AH-AOFAS) scores. Results: Significant differences among groups were found for RTD (p = 0.001), RTW (p < 0.001), and ATRS (p < 0.001), while RTS (p = 0.46) and AOFAS (p = 0.41) did not differ significantly. Post hoc analyses showed that the M-G/MISI group achieved faster return to driving and work and higher ATRS compared with the open group (all p < 0.05). No significant differences were detected between M-G/MISI and endoscopic-assisted techniques. Conclusions: All three techniques achieved good functional outcomes and low complication rates. Endoscopic assistance allowed visualization of suture passage and confirmation of gap reduction, but no superiority was observed in clinical outcomes or sural nerve safety. The M-G/MISI approach was associated with faster return to activity and higher ATRS compared with open repair.