Association of Surgical Timing With Complications and Patient-Reported Outcomes After Achilles Tendon Repair

Abstract

Background:

Achilles tendon ruptures pose a challenging recovery for patients, and complications after surgical repair are often associated with poor patient outcomes. The optimal timing for surgery remains a topic of debate and has not been extensively studied.

Purpose:

To determine whether the time from Achilles rupture injury to surgical repair is associated with postoperative complication rates and long-term patient-reported outcomes (PROs).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients undergoing surgical treatment for an Achilles rupture between 2016 and 2022 were retrospectively reviewed. Patients were stratified based on time-to-surgery (acute: 0-6 days, subacute: 7-13 days, delayed: 14-41 days, and chronic: 42+ days) and operative technique (open vs percutaneous). Surgical complications were assessed using clinical notes, while PROs—including Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF, PROMIS Pain Interference (PI), and Foot and Ankle Single Assessment Numeric Evaluation (FA SANE)—were collected via a digital survey. A minimum clinical follow-up of 3 months was required for inclusion in the complication analysis, and a minimum survey follow-up of 6 months was required for inclusion in the PRO analysis.

Results:

Complications were assessed in 350 patients: 116 acute (33%), 131 subacute (37%), 78 delayed (22%), and 25 chronic (7%). A total of 64 complications occurred in 56 patients (16%): 14 minor wound complications (4%), 8 major wound complications (2.3%), 13 reruptures (3.7%), 15 deep vein thromboses (4.3%), 3 sural nerve injuries (0.9%), and 9 cases of neuropathic pain (2.6%). There was no clinically meaningful difference in complication rates among the time-to-surgery cohorts. PROs were available for 146 patients (42%), with a mean follow-up of 23.8 ± 15.6 months and a similar distribution of time to surgery (33% acute, 44% subacute, 17% delayed, and 6% chronic). The mean postoperative PROMIS PF scores were highest in the acute group and decreased in later time-to-surgery groups (P = .016). No significant differences were found between groups with respect to PROMIS PI or FA SANE scores.

Conclusion:

The timing of surgical intervention after an Achilles tendon rupture did not significantly affect the overall postoperative complication rate. However, patients treated within the first week reported higher PF scores at the follow-up.

Achilles tendon ruptures are relatively common injuries that are on the rise in incidence globally.^12,24,33 While the mean return to play (RTP) rate after rupture is reported to be 80% across the orthopaedic literature, regaining full function is often difficult, and RTP rates vary highly depending on the definition applied. ³⁸ It has been shown that many patients continue to demonstrate persistent functional deficits at 7 years after injury.^6,26 There is ongoing debate regarding the appropriate treatment of acute Achilles tendon ruptures. Multiple systematic reviews, meta-analyses, and randomized controlled trials have compared nonoperative versus operative treatment for acute Achilles tendon rupture with heterogeneous findings.^9,10,19 While it is generally accepted that operative treatment has a lower risk of tendon rerupture coupled with a higher overall complication rate,^9,10,19 the debate is complicated by a multitude of treatment methods and techniques available for both nonsurgical and surgical intervention and postoperative rehabilitation.

When operative management is selected, several key factors significantly impact patient care and recovery. Operative treatment can introduce complications such as surgical site infection, wound complications, tendon adhesions, sural nerve injury, and other sensory disturbances. ²⁰ Open and percutaneous surgical treatment have both been well studied and compared in recent literature. While studies comparing open versus percutaneous approaches have reported that percutaneous surgeries require less surgical time, have lower deep infection rates, and similar rerupture rates and functional outcomes compared with open repairs, they have also demonstrated a substantially increased risk of sural nerve injury. ³⁶ In recent years, however, the importance of time from injury to surgery has emerged as a critical factor requiring further consideration when evaluating the outcomes of surgical repair.

Preliminary studies have demonstrated that the time from injury to surgery may play a role in clinical and functional outcomes, although available literature is sparse. Svedman et al ³⁵ found that patients treated within the first 48 hours had improved outcomes based on the Achilles Tendon Total Rupture Score (ATRS) and lower adverse event rates than patients treated >72 hours after injury. ³⁵ However, in a smaller cohort of 65 patients treated using open repair, Park et al ²⁹ did not find a difference in isokinetic muscle strength of the operative leg or patient-reported outcomes (PROs) (ATRS, Tegner scoring system, and visual analog scale) between patients treated within 48 hours compared with patients treated >48 hours after injury. For patients treated >1 week after injury, less information is available because of the relative infrequency of these procedures. Early studies have reported that functional outcomes and PROs are comparable in acute and delayed repairs,^2,4,8,18,23 although the population in these studies have been limited to a sample size of ≤21 patients. ¹⁵

An improved understanding of any potential association between time to surgery and patient outcomes may help providers optimize surgical care for patients. This study aimed to determine whether the time from Achilles rupture to surgical repair is associated with differences in complication rates or postoperative PROs. Based on the previous literature, we hypothesized that patients who received treatment a shorter time after their injury would report improved outcomes and lower complication rates after repair compared with those who received delayed surgical treatment.

Methods

Study Participants

Institutional review board approval was obtained before conducting the study. We retrospectively reviewed patients treated for an Achilles rupture between October 2016 and March 2022 at a single institution with multiple sites. Patients were initially identified through a search of Current Procedural Terminology codes and subsequently manually reviewed. The exclusion criteria encompassed patients <18 years at the time of surgery, those treated for chronic tendinosis or other complex nonrupture procedures, and those with a clinical follow-up duration of <3 months (±14 days) after their repair (Figure 1).

Figure 1.

Study screening criteria for the included patients.

Clinical Outcomes

A retrospective review of surgical information and clinical variables was conducted for all eligible patients, including a review of injury and treatment dates, surgical technique (open or percutaneous), and whether complications were described during follow-up visits. Complications were categorized as minor (wounds and/or infections that resolved with outpatient care), major (wounds and/or infections requiring operative intervention), rerupture, deep vein thrombosis (DVT), sural nerve injury, neuropathic pain, and other complications. The date of rerupture, when applicable, was recorded. Patients were stratified based on time-to-surgery (acute = 0-6 days, subacute = 7-13 days, delayed = 14-41 days, and chronic = 42+ days) and operative technique (open vs percutaneous).

Surgical Technique

Because of the multisurgeon nature of our group and this study, a heterogeneous combination of surgical techniques was employed in both the open and percutaneous groups. Surgeries performed by both foot and ankle fellowship-trained surgeons and trauma fellowship-trained surgeons (K.J.H. and J.A.M.) were included for analysis. The most commonly used techniques for open repairs were the modified Krackow and Kessler techniques. For percutaneous repairs, the Percutaneous Achilles Repair System (PARS) (Arthrex) was predominantly utilized, including both PARS-to-PARS repairs (utilizing sutures placed percutaneously into the substance of the tendon both proximally and distally) and PARS-to-calcaneus repairs (utilizing polyetheretherketone anchors placed percutaneously into the bone distally). The PARS device was also used in a select number of cases where a larger open incision was made to assist in the repair, and these patients were included in the open group.

Patient-Reported Outcomes

At the time of our study, all patients were invited to complete a follow-up research survey that included several PROs. Included in the study were several PROs that are routinely collected as part of the standard of care. A consent form was digitally obtained from all respondents before they completed the follow-up survey. For patients who did not complete the study, we reviewed our internal PROs database for any available outcomes that had been previously collected as part of the standard of care. If patients had completed the survey and had outcomes available in our database, their most recent score was used. The included PROs were the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) CAT (PF) Version 2.0, PROMIS Pain Interference (PROMIS PI) CAT Version 1.1, and Foot and Ankle Single Assessment Numeric Evaluation (FA SANE). The PROMIS PF assesses a patient’s self-reported capability rather than their actual physical performance—including upper extremity function, lower extremity function, and activities of daily living such as running errands.^16,30 The PROMIS PI assesses the consequences of self-reported pain on relevant aspects of a patient’s life to quantify pain interference. ¹ The FA SANE is a single-item PRO asking the patient “How would you rate your [extremity] today as a percentage of normal (0% to 100% scale, with 100% being normal)?” ⁵ Previous validation studies have demonstrated that the PROMIS PF strongly correlates with traditional Achilles outcome measures, such as ATRS, while also avoiding floor and ceiling effects. ²⁷ Those who did not complete at least 1 questionnaire, and those with a PRO follow-up of <6 months (± 14 days) were excluded from the PRO analysis. Patients excluded from the PRO analysis were still included in the clinical complications analysis if they had appropriate follow-up.

Statistical Analysis

Statistical analyses were performed using the R statistical package Version 4.1.0 (R Foundation). ³¹ Survey responses were tabulated and reported as frequencies and proportions. All continuous variables were checked for normal distribution using the Shapiro-Wilk test. For consistency, the mean and standard deviation were reported for continuous variables regardless of distribution. The median was also reported for select variables with non-normal distributions. For all comparisons of ≥3 groups, differences between groups were assessed using a 1-way analysis of variance if the sample was normally distributed. The Kruskal-Wallis test was used for non-normally distributed variables. If a statistical difference was found, a post hoc Tukey test (parametric) or a Dunn test with Holm correction (nonparametric) was conducted to identify the specific groups that exhibited differences. For comparisons between only 2 groups, such as open versus percutaneous repairs, an unpaired t test was used for normally distributed data, and a Mann-Whitney U test was utilized for non-normally distributed data. Large group categorical variables, such as demographic characteristics, were analyzed using a chi-square test of independence. Categorical variable tests with a small sample size, such as complications, were assessed using the Fisher exact test because of the small sample size. In all analyses, P < .05 was considered statistically significant.

Results

Patient Characteristics

A total of 608 patients who underwent Achilles tendon rupture repair during the study period were identified. A total of 46 ineligible patients were excluded (see Figure 1), and the remaining 562 charts were reviewed. Among these, 350 charts were included in the final clinical analysis, while 212 were excluded because of the insufficient clinical follow-up to assess complications (<3 months of follow-up). A total of 146 patients either completed our follow-up survey or had PROs already available and were included in our analysis of PROs. The mean age of patients in the complications cohort (n = 350) and the PRO cohort (n = 146) was 41 ± 12.4 (Table 1) and 42.5 ± 12.6 (Supplemental Table S1), respectively. The majority of injuries occurred during a sport (74.6%, Table 1). Of sport-related ruptures, injuries during basketball (25%) and soccer (17%) were the most common (A full breakdown of injuries by sport is available in the supplementary information Supplemental Table S4).

Table 1.

Patient Characteristics ^a

		Time from Achilles Rupture to Surgery
	Overall, N = 350	Acute, 0-6 Days, n = 116	Subacute, 7-13 Days, n = 131	Delayed, 14-41 Days, n = 78	Chronic 42+ Days, n = 25	P b
Age, years	41 ± 12.4	41.2 ± 12.1	39.1 ± 11.2	42 ± 13.7	46.4 ± 14.4	.107
BMI, kg/m2	27.6 ± 5.25	27.2 ± 5.65	27.1 ± 4.81	28.1 ± 4.05	30.2 ± 7.78	.020
Sex
Female	70 (20)	26 (22.4)	27 (20.6)	14 (17.9)	3 (12)	.646
Male	280 (80)	90 (77.6)	104 (79.4)	64 (82.1)	22 (88)
Laterality
Left	170 (48.6)	52 (44.8)	72 (55)	37 (47.4)	9 (36)	.220
Right	180 (51.4)	64 (55.2)	59 (45)	41 (52.6)	16 (64)
Injury mechanism
Not sports	89 (25.4)	26 (22.4)	32 (24.4)	20 (25.6)	11 (44)	.159
Sports	261 (74.6)	90 (77.6)	99 (75.6)	58 (74.4)	14 (56)
Technique
Open	166 (47.4)	37 (31.9)	65 (49.6)	45 (57.7)	19 (76)	<.001
Percutaneous	184 (52.6)	79 (68.1)	66 (50.4)	33 (42.3)	6 (24)

^aData are presented as mean ± SD or n (%). Bolded P values indicate statistically significant difference between groups (P < .05). BMI, body mass index.

^bGroups were compared using the Kruskal-Wallis test with the post hoc Dunn test (continuous variables) and the chi-square test (categorical variables).

Time From Achilles Rupture to Surgery

Among the 350 patients included for complications analysis, 116 patients were in the acute group (33%), 131 were in the subacute group (37%), 78 were in the delayed group (22%), and 25 were in the chronic group (7%). A similar distribution was observed between the groups for our PRO subanalysis cohort, although with a lower total population of 146 (Supplemental Table S1). In a subgroup analysis of the demographic data, we found a significant difference in body mass index (BMI) (P = .02) among the time-to-surgery groups (see Table 1). Evaluating the BMI, a post-hoc Tukey test revealed that the delayed group had a significantly higher mean BMI compared with the acute group. There was no significant difference between the time-to-surgery groups for age and BMI in the smaller PRO cohort (see Supplemental Table S1). There was also a significant difference between the techniques used in each subgroup, with more percutaneous approaches employed in the subacute and acute groups. In contrast, the delayed and chronic groups utilized more open techniques (P < .001) for both the total complications cohort and the PRO cohort.

Complications After Surgery

A total of 64 complications were recorded for 56 patients (16%, Table 2). Across all patients, 14 patients had a minor wound complication (4%), 8 had a major wound complication (2.3%), 13 had reruptures (3.7%), 15 had DVTs (4.3%), 3 had a sural nerve injury (0.9%), and 9 patients experienced neuropathic pain (2.6%). One patient had prominent sutures and weakness due to attenuation of the repair site (other, 0.3%). Among all complications, the only significant difference based on the time from injury to surgery was observed in the rate of reruptures. The subacute group had no reruptures, which was significantly lower than the rerupture rates in the acute, delayed, and chronic groups (P < .01). However, this finding may not be clinically meaningful, as 3 reruptures occurred in patients who underwent surgery on day 14 after injury, just 1 day beyond the subacute group cutoff. All reruptures, except 1, occurred within 3 months of the index surgery (mean, 47.2 ± 41.2 days; median, 40 days; range, 9-159 days). One patient developed tendinosis after their original repair and experienced a rerupture 159 days after the initial surgery. When limiting our time-to-surgery analysis to patients who received only a percutaneous (Supplemental Table S2) or open (Supplemental Table S3) repair, we observed the same results.

Table 2.

Complications after Achilles Rupture Repair ^a

	Acute, n = 116	Subacute, n = 131	Delayed, n = 78	Chronic, n = 25	P b
Total patients with complications	20 (17.2)	21 (16)	11 (14.1)	4 (16)	.96
DVT	4 (3.4)	7 (5.3)	4 (5.1)	0 (0)	.78
Major wound	2 (1.7)	3 (2.3)	2 (2.6)	1 (4)	.78
Minor wound	5 (4.3)	6 (4.6)	2 (2.6)	1 (4)	.91
Rerupture	7 (6)	0 (0)	4 (5.1)	2 (8)	<.01
Sural nerve injury	1 (0.9)	1 (0.8)	0 (0)	1 (4)	.35
Neuropathic pain	3 (2.6)	5 (3.8)	0 (0)	1 (4)	.28
Other	0 (0)	1 (0.8)	0 (0)	0 (0)	≥.999

^aData are presented as n (%). Bolded values indicate statistically significant difference between groups (P < .05). DVT, deep vein thrombosis.

^bGroups were compared using the Fisher exact test.

PROs After Surgery

Of the 146 patients who had PROs available, the mean follow-up time from surgery was 23.8 ± 15.6 months (median, 21.7 months; range, 5.5-72 months). There was no significant difference in follow-up time between the time-to-surgery groups (Supplemental Table S1). Evaluating the time from injury to surgery, we found a significant difference in PF follow-up among groups (Table 3). A post-hoc Tukey test revealed that this difference was specifically found between the acute (56.3 ± 8.7) and subacute (51.9 ± 5.8) groups. Notably, there was an incremental decrease in PF between groups as the time from injury to surgery increased. Patients treated >42 days after injury (chronic) reported the lowest PF follow-up (51.3 ± 11.6). Patients treated for a chronic Achilles rupture repair similarly report the highest pain interference, although the trend is not statistically significant. The same trend is not observed in the FA SANE, which appeared more variable among groups. Limiting our analysis to percutaneous or open repairs, we similarly observed that PF was highest in the acute group after both percutaneous (P = .011) and open repair (P = .049) (Table 3). We also found that the acute group reported the lowest PI for the open repair group (P = .020); however, we did not emphasize these findings because of the small sample size for these statistics (Table 3).

Table 3.

PROs After Achilles Rupture Repair ^a

		Acute	Subacute	Delayed	Chronic	P b
All repairs	Sample size, n	48	64	25	9
	Follow-up, years	1.8	1.9	2.0	2.7
	PF score	56.3 ± 8.7	51.9 ± 5.8	52.1 ± 6.9	51.3 ± 11.6	.016
	PI score	46.2 ± 7.8	47.5 ± 7	46.2 ± 8.8	49.5 ± 9.5	.739
	FA SANE score	87.5 ± 10.5	81.7 ± 13.5	84.9 ± 16.4	81.3 ± 15.1	.076
Perc repairs	Sample Size, n	42	41	13	3
	Follow-up, years	1.6	1.5	1.6	1.6
	PF score	55.5 ± 8.4	51.7 ± 5.6	51.3 ± 6.5	44.1 ± 8.5	.011
	PI score	46.9 ± 7.7	45.8 ± 6.9	46.1 ± 10	54.8 ± 12.7	.591
	FA SANE score	86.8 ± 10.7	84 ± 10.2	84.5 ± 17.3	66.7 ± 15.3	.085
Open repairs	Sample size, n	6	23	12	6
	Follow-up, years	3.1	2.8	2.4	3.3
	PF score	62.7 ± 9.4	52.2 ± 6.3	53 ± 7.5	56.8 ± 11.4	.049
	PI score	38.7 ± 0	50.5 ± 6.4	46.3 ± 8	45.5 ± 4.8	.020
	FA SANE score	92 ± 8.4	77.4 ± 17.5	85.3 ± 16.1	88.7 ± 8.9	.085

^aData are presented as mean ± SD. Bolded P values indicate statistically significant difference between groups (P < .05). ANOVA, analysis of variance; FA SANE, foot and ankle single assessment numeric evaluation; PF, physical function; PI, pain interference.

^bGroups were compared using the ANOVA with post hoc Tukey test (normal distribution), or the Kruskal-Wallis with post hoc Dunn test (non-normal distribution).

Comparing Open and Percutaneous Repair Techniques

Total operative times from open to close were significantly shorter in the percutaneous group compared with the open group (Table 4). There was a mean total operative time of 67.7 ± 26 minutes in the open group compared with 56.1 ± 22.5 minutes in the percutaneous group (P < .001). There were no notable differences in complication rates when comparing open and percutaneous techniques, both in total complications and when broken down by complication type. All 3 PRO scales (PROMIS PI, PF, and Foot and Ankle SANE) were also found to have no difference between the open and percutaneous groups (P = .24, P = .41, and P = .74, respectively) (Table 4).

Table 4.

Complications and PROs Compared Between Open and Percutaneous Repairs ^a

		Open	Perc
	n = 166	n = 184	P b
Operative time	67.7 ± 26	56.1 ± 22.5	<.001
Complications
Total complications	31 (19)	33 (18)	.86
DVT	7 (4.2)	8 (4.3)	.95
Major complications	3 (1.8)	6 (3.3)	.51
Minor complications	7 (4.2)	7 (3.8)	.84
Reruptures	8 (4.8)	5 (2.7)	.30
Sural nerve injury	0 (0)	3 (1.6)	.25
Neuropathic pain	5 (3)	4 (2.2)	.74
Other complications	1 (0.6)	0 (0)	.47
PROs
PI score, n = 134	48 ± 7	47 ± 8	.24
PF score, n = 137	54 ± 8	53 ± 7	.41
FA SANE score, n = 146	83 ± 16	85 ± 12	.74

^aData are presented as mean ± SD or n (%). The bold P value indicates a statistically significant difference between groups (P < .05). DVT, deep vein thrombosis. FA SANE, foot and ankle single assessment numeric evaluation; PF, physical function; PI, pain interference; PRO, patient-reported outcomes.

^bGroups were compared using the t test (normal distribution), or the Mann-Whitney U test (non-normal distribution) for continuous variables, and the Fisher exact test for categorical variables (P < .5).

Discussion

Overall, Achilles tendon repair is a safe and effective procedure for treating Achilles tendon ruptures. When evaluating outcomes in the context of time from Achilles rupture injury to surgical repair, we found similar complication rates in patients undergoing Achilles tendon repair in all groups. We did find a significantly lower rerupture rate in the subacute repair group (7-13 days). However, given that we observed 3 reruptures in patients 14 days after surgery, we believe this finding should be considered skeptically, despite statistical significance. PROs from our cohort were higher, on average, for acute repair over subacute repair, particularly for PROMIS PF. Both open and percutaneous techniques were found to have similar complications and outcomes.

Time to Surgery

Although many aspects of Achilles tendon ruptures and their subsequent treatment have been extensively researched, studies regarding the optimal timing from injury to repair are lacking in number, population size, and consistency of the time frame comparison. To our knowledge, this study is the largest of its kind and the first to utilize PROMIS metrics to assess PROs in the comparison of time to surgery groups. It is also the first to compare time to surgery in a North American population. Svedman et al ³⁷ compared time to surgery in a 2018 study of a Swedish patient cohort, comparing those who received surgical repair at <48 hours (n = 74), between 48 and 72 hours (n = 49), and >72 hours (n = 105) from the time of injury. They found that delayed time to surgery was associated with lower PROs and an increased incidence of adverse events. In a similar study, Park et al ²⁹ compared time to surgery among a South Korean patient cohort in those who received repair at <24 hours (n = 25), between 24 and 48 hours (n = 18), and >48 hours but <1 week (n = 22). These studies provide helpful insight into time-to-surgery decisions within the first several days to 1 week after injury. However, they do not provide insight into the many patients who receive surgery outside of the subacute timeframe. Because of various clinical or patient-specific factors, it is often not feasible to operate within the same week of injury. Sociodemographic factors such as health care access may also delay patient presentation to an orthopaedic surgeon despite a known injury. Recent literature has highlighted the dearth of orthopaedic surgeons across many regions of the United States.^11,28 Thus, for many patients with limited access to care, it may not be possible to be seen acutely in the case of an Achilles injury. Nonetheless, the findings within our cohort highlight that surgery is a safe and efficacious intervention for the appropriate patient with Achilles rupture, even when the intervention occurs in a delayed fashion.

Complications

We found that the overall complication rate did not significantly differ among the time-to-surgery groups. A previous systematic review and meta-analysis of acute versus chronic Achilles tendon repair found significantly higher complication rates in patients treated later than 28 days from injury. ¹⁵ However, the 5 studies included in the meta-analysis had limited sample sizes, and the categorization of acute and chronic was highly variable. ¹⁵ A recent study also found that prolonged time to surgery was associated with increased risk for sural nerve injury, and reduced time to surgery was associated with a reduction in reruptures. ¹⁷ We found a total rerupture rate of 3.7% in our surgical cohort. Previously conducted meta-analyses suggest that rerupture rates for surgically treated patients vary from 3.5% to 4% versus 8.8% to 12.6% for nonsurgically treated patients.^19,21,25 We also found that surgical treatment on days 7 to 13 after injury did not result in any reruptures. However, 3 of the 13 repairs in this subgroup occurred 14 days after surgery, leading us to conclude that this finding may be due to chance despite statistical significance. Furthermore, 12 of the 13 reruptures occurred within 80 days of surgical repair, which suggests that most reruptures may occur within a 3-month window. However, in a recent epidemiological study of 783 patients treated for Achilles rupture, Maempel et al ²² found that the median rerupture date was 98.5 days. These findings, examined in conjunction with the previous literature,^13,22 highlight the need for clinicians to remain vigilant for rerupture within the first few months after surgery. We believe that there should be a low threshold for reimaging if signs or symptoms concerning for rerupture are present.

Percutaneous Versus Open Repair Technique

Consistent with previous studies in the literature,^3,7,14,36 we found shorter operative times in percutaneous repair compared with open repair, with no difference in outcomes or complication rates between groups. An open technique was more often selected as the time from injury to surgery increased. The open technique provides improved ability to visualize the tendon ends and debride early scar tissue, improved ability to identify and protect the sural nerve, and perceived enhanced ability to achieve anatomic apposition of disrupted tendon fibers and restore anatomic length to the myotendinous unit. A systematic review and meta-analysis comparing outcomes and complication rates between open and minimally invasive repair techniques found that the minimally invasive technique had a statistically significant increased risk for sural nerve injury (mean rate 3.4%). In comparison, the open technique ³ had a statistically significant increased risk for superficial infection (mean rate 6%). Other studies have also highlighted an increased risk of sural nerve injury with percutaneous techniques. ³² When compared with the previously referenced studies, we found a lower rate of sural nerve injury at 1.6% among patients treated percutaneously. However, the difference in sural nerve injury between patients treated via percutaneous and open techniques in our cohort was not statistically significant at P = .25. Similar to the findings of Rozis et al, ³² there were no cases of sural nerve injury identified among patients in our open repair cohort. Given our findings and taken in conjunction with the previous literature, we believe that sural nerve injury is a complication that should be highlighted when discussing percutaneous repair options with patients.

Within our cohort, a higher rate of rerupture was observed among the open repair group, although this difference was not statistically significant. A similar trend toward higher rerupture after open repair has been observed in previous comparative studies.^3,34 We posit that within our cohort, open surgical technique selection and the longer surgical times observed in this group are likely surrogates for the complexity of the repair. This can ultimately have implications for the risk of rerupture if a weaker repair is achieved, limiting the extrinsic and intrinsic repair modalities of the tendon. VTE was the most reported complication in our study, and it occurred most often chronologically in the subacute treatment group. There was no difference in the incidence of this complication between the percutaneous and open repair groups. A previous meta-analysis comparing percutaneous and open repair reported that in the percutaneous treatment group, the rate of DVT was 1.6%. In contrast, it was 0.5% in the open surgery group. ³⁶ These rates are lower than those reported in our cohort, perhaps because of a more effective diagnosis or the higher elevation at which our cohort underwent treatment. Previous evidence suggests that surgeries performed at higher altitudes are generally associated with an increased risk of developing postoperative DVT and venous thromboembolism. ³⁷ Nonetheless, these findings highlight the imperative nature of effective venous thromboembolism prophylaxis protocols immediately after surgical intervention.

Limitations

This study has several limitations that should be considered when evaluating the generalizability of our findings. First, although the overall sample size is quite large, the total number of chronic repairs was limited to 25. This limitation is amplified by the further reduction in sample size when analyzing PROs, which were based on survey responses. In addition, we found significant differences in covariates—such as BMI and surgical technique (open versus percutaneous)—when comparing our groups for the time-to-surgery analysis. While we did not find any differences in outcomes in open versus percutaneous repairs, the heterogeneity of our data may have introduced statistical noise. Additional factors—such as socioeconomic status or health care access—may affect surgical timing and confound survey responses and PROs. A limitation of our study design is that patients were reviewed for complications based on the clinical follow-up. If a patient moved or chose to see a different out-of-network provider after experiencing a complication, their complication would not be included in our study. Finally, over 10 surgeons contributed patients to this study, resulting in a heterogeneous study population, diverse experiences, and varied surgical techniques. While the nature of this heterogeneous patient group may enhance the generalizability of our findings across the broader orthopaedic patient population, it also introduces the possibility of confounding variables affecting the outcomes we observed. Future studies evaluating the time from injury to surgery in a controlled and randomized population would greatly benefit the literature.

Conclusion

Previous literature has reported mixed results regarding the importance of the time interval between Achilles rupture and surgical repair. While our study found a slight improvement in PF after acute repair, no significant differences in complication rates were observed among patients treated surgically in the subacute, acute, delayed, or chronic time frames. Percutaneous repair was associated with a shorter operative time, with no difference in outcomes compared with the open technique.