# All-inside endoscopic and minimally invasive modified Bunnell suture yield favourable outcomes in acute midsubstance Achilles tendon ruptures: a comparative study

## TL;DR

This study compares two surgical techniques for repairing acute Achilles tendon ruptures and finds both are effective, though one causes less pain and has smaller incisions.

## Contribution

The study introduces a comparative analysis of all-inside endoscopic and minimally invasive modified Bunnell suture techniques for Achilles tendon repair.

## Key findings

- Both surgical techniques showed similar functional recovery at 2 years.
- Endoscopic repair had shorter incisions and less postoperative pain.
- Endoscopic repair allowed patients to return to work one week earlier.

## Abstract

This study compared the clinical outcomes of the all-inside endoscopic and the minimally invasive modified Bunnell suture configurations for the management of acute midsubstance Achilles tendon ruptures (AMATR).

A retrospective analysis was conducted on 63 AMATR patients (54 men and 9 women, with a mean age of 39.84 ± 10.40 years (range, 21–62 years). All patients underwent Achilles tendon repair using the modified Bunnell suture configuration using the all-inside endoscopic repair (n = 31) or a minimally invasive repair (n = 32). The primary endpoint was postoperative functional outcome, assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Achilles Tendon Total Rupture Score (ATRS) at 6, 12, and 24 months. Secondary endpoints included perioperative and short-term recovery parameters, including operative time, incision length, postoperative pain assessed by the Visual Analog Scale (VAS) on postoperative days 1 and 3, wound complications, and time to return to work and sports activities.

There were no intraoperative complications, and all patients in the endoscopic group achieved primary wound healing. At the 6-, 12-, and 24-month follow-up, both groups demonstrated significant improvement in AOFAS and ATRS scores over time, with no significant differences between groups. Regarding secondary endpoints, the all-inside endoscopic group had a significantly longer operative time but a significantly shorter incision length compared with the minimally invasive group (p < 0.05). VAS pain scores on postoperative days 1 and 3 were significantly lower in the endoscopic group (p < 0.05). No wound infections occurred in the endoscopic group, whereas three superficial infections were observed in the minimally invasive group; however, the difference was not statistically significant. Patients in the endoscopic group returned to work one week earlier (p < 0.05), while the time to return to sports was comparable between groups.

Both the all-inside endoscopic and the minimally invasive modified Bunnell suture configurations provide reliable repair for AMATR and support a successful return to occupational and athletic activity. While the all-inside endoscopic procedure was associated with a longer operative time, it offered advantages in terms of reduced early postoperative pain, smaller incisions, and earlier return to work, without compromising functional recovery at the 2-year follow-up.