Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 21, Issue 6, pp 1361–1368 | Cite as

Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair

  • M. R. Carmont
  • C. Heaver
  • A. Pradhan
  • O. Mei-Dan
  • K. Gravare Silbernagel



Recent meta-analyses have shown reduced re-rupture rates for the surgical management of Achilles ruptures. However, percutaneous repair has been demonstrated to lead to improved function and patient satisfaction but greater complications than open repair. In the current economic climate, it is reasonable to consider the financial cost of rupture management for both the patient and the provider. The cost-effectiveness of operative treatment of ruptures of the Achilles tendon was determined based upon theatre occupancy, clinic attendance and cast changes, operative complications and functional assessment score.


The cost-effectiveness of the surgical management of Achilles tendon ruptures between 2005 and 2011 in our unit was audited by comparing 49 patients receiving percutaneous repair to 35 patients whom had open repairs.


There was no significant difference in complications between the two surgical techniques: (Open vs. Percutaneous) overall rates 14.3 versus 10.4 %: infection; 2.7 versus 2.0 %, transient sural nerve damage: 5.6 versus 8.1 %, wound breakdown: 2.8 versus 0.0 %, re-rupture: 2.8 versus 2.0 %. Achilles Total Rupture Scores (ATRS) were comparable [Open 89 (65–100) at 49 months vs. Percutaneous 88.8 (33–100) at 12 months (n.s.)]. Theatre occupancy (P < 0.00) and hospital stay (P < 0.00) were significantly longer with open repair [43 min (26–70) and 2.9 days (0–4)] compared to percutaneous repair [15 min (12–43) and 1.2 days (0–2)]. Excluding the costs of running the operating theatre, we have estimated the costs of surgery for open repair to be £935 and percutaneous repair to be £574.


This study suggests that percutaneous repair of the Achilles tendon resulted in reduced costs and yet had comparable outcome and complications rates to open repair in surgical management of the Achilles tendon. Percutaneous repair should be considered as the primary method of cost-effective surgical management of Achilles tendon rupture.

Level of evidence

A retrospective cohort study, Level III.


Achilles Surgery Open Percutaneous Cost-effectiveness 


  1. 1.
    Aktas S, Kocaoglu B (2009) Open versus minimal invasive repair with the Achillon device. Foot Ankle Int 30(5):391–397PubMedCrossRefGoogle Scholar
  2. 2.
    Carmont MR, Maffulli N (2008) Modified percutaneous repair of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc 16:199–203PubMedCrossRefGoogle Scholar
  3. 3.
    Carmont MR, Silbernagel KG, Nilson-Helander K, Mei-Dan O, Karlsson J, Maffulli N (2012) Cross cultural adaptation of the Achilles tendon Total Rupture Score with reliability, validity and responsiveness evaluation. Knee Surg Sports Traumatol Arthrosc PMID:22847247Google Scholar
  4. 4.
    Chan AP, Chan YY, Fong DT, Wong PY, Lam HY, Lo CK, Yung PS, Fung KY, Chan KM (2011) Clinical and biomechanical outcome of minimal invasive and open repair of the Achilles tendon. Sports Med Arthrosc Rehabil Ther Technol 3(1):32Google Scholar
  5. 5.
    Cretnik A, Kosanovic M, Smrkoli V (2005) Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med 33:1369–1379PubMedCrossRefGoogle Scholar
  6. 6.
    Ebinesan AD, Sarai BS, Walley GD, Maffulli N (2008) Conservative, open or percutaneous repair for acute rupture of the Achilles tendon. Disabil Rehabil 30(20–22):1721–1725PubMedCrossRefGoogle Scholar
  7. 7.
    Gigante A, Moschini A, Verdenelli A, Del Torto M, Ulisse S, De Palma L (2008) Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomised prospective study. Knee Surg Sports Traumatol Arthrosc 16:204–209PubMedCrossRefGoogle Scholar
  8. 8.
    Goel PG, Chan D, Watson K, Mohtadi N (2009) Safety and hospital costs of Achilles tendon surgery: the serendipitous impact of a randomised controlled trial. Can J Surg 52(6):467–472PubMedGoogle Scholar
  9. 9.
    Goren D, Ayalon M, Nyska M (2005) Isokinetic strength and endurance after percutaneous and open surgical repair of the Achilles tendon ruptures. Foot Ankle Int 26(4):286–290PubMedGoogle Scholar
  10. 10.
    Haji A, Sahai A, Symes A, Vyas JK (2004) Percutaneous versus open tendon Achillis repair. Foot Ankle Int 25(4):215–218PubMedGoogle Scholar
  11. 11.
    Henriquez H, Munoz R, Carcuo G, Bastias C (2012) Is percutaneous repair better than open repair in acute Achilles ruptures? Clin Orthop Relat Res 470:998–1003PubMedCrossRefGoogle Scholar
  12. 12.
    Kearney RS, Costa M (2012) Current concepts in the rehabilitation of an acute rupture of the tendo Achillis. J Bone Jt Surg Br 94-B(1):28–31CrossRefGoogle Scholar
  13. 13.
    Keating JF, Will EM (2011) Operative versus non-operative management of the acute rupture of the tendo Achillis: a prospective randomised evaluation of functional outcome. J Bone Jt Surg Br 93(8):1071–1078Google Scholar
  14. 14.
    Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M (2005) Treatment of acute Achilles tendon rupture: a meta-analysis of randomized controlled trials. J Bone Jt Surg Am 87-A(10):2202–2210CrossRefGoogle Scholar
  15. 15.
    Khan RJ, Carey Smith RL (2010) Surgical interventions for treating Achilles tendon rupture. Cochrane Database Syst Rev 9:CD003674PubMedGoogle Scholar
  16. 16.
    Kotnis R, David S, Handley R, Willett K, Ostlere S (2006) Dynamic ultrasound as a selection tool for reducing Achilles tendon re-ruptures. Am J Sports Med 34(9):1395–1400PubMedCrossRefGoogle Scholar
  17. 17.
    Lapidus LJ, Rosfors S, Ponzer S, Levander C, Elvri A, Lärfors G, de Bri E (2007) Prolonged thromboprophylaxis with Dalteparin after surgical treatment of Achilles tendon rupture: a randomized prospective controlled study. J Orthop Trauma 21(1):52–57PubMedCrossRefGoogle Scholar
  18. 18.
    Lim J, Dalai R, Waseem M (2001) Percutaneous versus open repair of the ruptured Achilles tendon—a prospective randomized controlled study. Foot Ankle Int 22:559–568PubMedGoogle Scholar
  19. 19.
    Macquet AJ, Christensen RJ, Debenham M, Wyatt M, Panting AL (2011) Open repair of the acutely torn Achilles tendon under local anaesthetic. ANZ J Surg 81(9):619–623PubMedCrossRefGoogle Scholar
  20. 20.
    McMahon SE, Smith TO, Hing CB (2011) A meta-analysis of randomized controlled studies comparing conventional to mini-invasive approaches for repair of Achilles tendon rupture. Foot Ankle Surg 17(4):211–217PubMedCrossRefGoogle Scholar
  21. 21.
    Maffulli N (1998) The clinical diagnosis of subcutaneous tears of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med 26(2):266–270PubMedGoogle Scholar
  22. 22.
    Maffulli N, Waterston SW, Squair J, Reaper J, Douglas AS (1999) Changing incidence of Achilles tendon rupture in Scotland: a 15 year study. Clin J Sport Med 9(3):157–160PubMedCrossRefGoogle Scholar
  23. 23.
    Maffulli N, Longon UG, Ronga M, Khanna A, Denaro V (2010) Favorable outcome of percutaneous repair of Achilles tendon ruptures in the elderly. Clin Orthop Relat Res 468:1039–1046PubMedCrossRefGoogle Scholar
  24. 24.
    Maffulli N, Longo UG, Mafulli GD, Khanna A, Denaro V (2011) Achilles tendon ruptures in diabetic patients. Arch Orthop Trauma Surg 131(1):33–38PubMedCrossRefGoogle Scholar
  25. 25.
    Nilsson-Helander K, Thomee R, Silbernagel KG, Thomee P, Faxen E, Eriksson BI, Karlsson J (2007) The Achilles tendon Total Rupture Score (ATRS): development and validation. Am J Sports Med 35:421–426PubMedCrossRefGoogle Scholar
  26. 26.
    Nilsson-Helander K, Thurin A, Karlsson J, Eriksson BI (2009) High incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study. Knee Surg Sports Traumatol Arthrosc 17(10):1234–1238PubMedCrossRefGoogle Scholar
  27. 27.
    Nilsson-Helander K, Silbernagel KG, Thomee R, Faxen E, Olsson N, Eriksson BI, Karlsson J (2010) Acute Achilles tendon rupture: a randomized controlled study comparing surgical and non surgical treatments using validated outcome measure. Am J Sports Med 38:2186–2193PubMedCrossRefGoogle Scholar
  28. 28.
    Olsson N, Nilsson-Helander K, Karlsson J, Eriksson BI, Thomee R, Faxen E, Silbernagel KG (2011) Major functional deficits persist 2 years after acute Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 19(8):1385–1393PubMedCrossRefGoogle Scholar
  29. 29.
    Patel A, Ogawa B, Charlton T, Thordarson D (2012) Incidence of DVT and PE after Achilles tendon rupture. Clin Orthop Relat Res 470:270–274PubMedCrossRefGoogle Scholar
  30. 30.
    Rushton PR, Singh AK, Deshmukh RG (2012) A case of fresh rupture after open repair of a ruptured Achilles tendon. J Foot Ankle Surg 51(1):95–98PubMedCrossRefGoogle Scholar
  31. 31.
    Schroeder D, Lehmann M, Steinbrueck K (1997) Treatment of acute Achilles tendon ruptures: open vs. Percutaneous vs. conservative treatment: a prospective randomised study. Orthop Trans 21:1228Google Scholar
  32. 32.
    Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A (2010) Operative versus non-operative treatment of acute Achilles tendon ruptures: a multicenter randomized trail using accelerated functional rehabilitation. J Bone Jt Surg Am 92:767–775CrossRefGoogle Scholar
  33. 33.
    Wilkins R, Bisson LJ (2012) Operative vs. non-operative management of acute Achilles tendon rupture: a quantitative review of randomised controlled trials. Am J Sports Med 40(9):2154–2160PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • M. R. Carmont
    • 1
  • C. Heaver
    • 1
  • A. Pradhan
    • 1
  • O. Mei-Dan
    • 2
  • K. Gravare Silbernagel
    • 3
  1. 1.The Department of Orthopaedic SurgeryPrincess Royal HospitalTelford, ShropshireUK
  2. 2.The Department of Sports MedicineUniversity of Colorado HospitalsAuroraUSA
  3. 3.University of the SciencesPhiladelphiaUSA

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