Introduction

The Achilles tendon is the largest and strongest tendon in the human body, connecting the calf muscles to the heel bone. It is essential for everyday mobility, enabling us to walk, run, jump, and perform countless other activities. When this tendon is ruptured or severely damaged, surgery is often required to restore strength and function.

There are two main surgical techniques to repair a damaged Achilles tendon: open Achilles repair and minimally invasive Achilles surgery. Open repair involves a larger incision, giving the surgeon direct access to the torn tendon. Minimally invasive surgery, on the other hand, uses smaller cuts or needle-like instruments to fix the tendon with less disruption to the surrounding tissue. This article will explore the key risks and benefits of both methods, helping those facing this surgery to make informed decisions.

Professor Paul Lee, a highly respected orthopaedic specialist, along with the experienced MSK Doctors team, are dedicated to providing excellent patient care and share their insights here.

Understanding the Surgical Techniques: Open vs Minimally Invasive Achilles Repair

Open Achilles tendon repair starts with making a relatively large incision — usually around 6 to 8 centimetres — along the back of the lower leg. This allows the surgeon to see the torn ends of the tendon clearly, remove any scar tissue, and carefully stitch the tendon back together. The wound is then closed in layers to encourage better healing. As Moore and colleagues describe, “Open Achilles tendon repair is performed in patients who have suffered an acute rupture... Typically, this injury — and the resulting open repair — are seen in young or middle-aged patients as well as athletes” (Moore et al., 2023).

By contrast, minimally invasive surgery involves smaller incisions or puncture-like entries, often with the surgeon using ultrasound imaging to guide the procedure. This reduces damage to nearby tissues, which can mean less pain and a quicker recovery. However, as highlighted by Sasaki and colleagues, while “minimally invasive surgery (MIS) offers notable advantages, including reduced rates of infection and wound necrosis, it also introduces the risk of sural nerve injury” due to the limited visibility during surgery (Sasaki et al., 2025).

It is also worth noting that some recent studies suggest that conservative, non-surgical treatment with functional rehabilitation may achieve similar rates of tendon healing without surgery in certain cases. However, surgery is generally advised for young, active patients who want to return to sport quickly or avoid muscle thinning associated with non-operative approaches. As one study puts it, “Surgical treatment is indicated in patients... who require early return to play or those who wish to avoid muscle atrophy” (Kanchanatawan et al., 2018).

The choice between open and minimally invasive repair can depend on factors like timing of injury, patient activity levels, and surgeon expertise.

Evaluating Risks: Complications of Achilles Tendon Surgery

Like all surgeries, both open and minimally invasive Achilles repairs carry risks. Open repair’s larger incision can increase the chance of wound healing problems and infection. Nerve injuries, particularly to the sural nerve—which runs near the tendon—are also a concern. Minimally invasive approaches usually have fewer wound complications but carry a slightly higher risk of nerve harm because the surgeon cannot directly see the area as clearly.

Encouragingly, advances in surgical imaging now make minimally invasive surgery safer. For example, “Intraoperative ultrasonography can mitigate this risk by providing real-time visualisation of the sural nerve and Achilles tendon, improving clinical outcomes” (Sasaki et al., 2025).

That said, open repair also comes with challenges; “the most common complication is soft-tissue infection due to the high tension of soft tissue affected from the bowstring of the repaired tendon being kept in the equinus position of the ankle” — where the ankle is pointed downwards after surgery (Kanchanatawan et al., 2018). In percutaneous (minimally invasive) procedures, “sural nerve entrapment and injury are the most commonly reported complications” (Kanchanatawan et al., 2018).

Patient-specific factors, such as age, weight, other medical conditions and how soon surgery happens after injury, also influence complication risks. Professor Paul Lee emphasises the importance of careful surgical technique and ongoing monitoring to minimise these risks.

Benefits and Outcomes: What Patients Can Expect

Both open and minimally invasive Achilles repairs are effective at restoring tendon strength and mobility. Open repair allows surgeons comprehensive access for a strong and durable tendon stitch, which can be especially beneficial for athletes wanting to return to intense activity. In one study, “88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no reruptures” (Moore et al., 2023).

Minimally invasive surgery tends to result in smaller scars, less postoperative pain, and often a quicker return to routine activities. Research shows that speed of recovery, re-rupture risk, and functional outcomes are broadly similar between the two approaches. Yet, for those involved in explosive sports, open repair might offer a slight edge.

Patients naturally care about pain, scarring, and how surgery will affect their daily lives. MSK Doctors provide a supportive environment, tailoring rehabilitation programmes to meet individual needs and maximise recovery.

Making an Informed Decision: Factors to Consider

Deciding on the best surgical option involves considering age, activity level, overall health, and personal preferences. Research advises that “younger patients hoping to return to more highly competitive athletics should consider operative repair” (Moore et al., 2023).

Some surgeons have developed hybrid techniques that combine open and percutaneous methods to balance benefits and reduce complications. As described by Kanchanatawan and colleagues, a “hybrid Achilles tendon repair ... provides a simplified and reproducible method... in which the complications of previous methods are avoided and can be done without special equipment” (Kanchanatawan et al., 2018).

Most patients want to know about long-term outlooks, return to work or sport, and risk of re-injury. Overall, outcomes are largely positive when surgery is matched to the patient’s profile and rehabilitation is followed carefully.

Consulting with skilled orthopaedic specialists, such as Professor Paul Lee at MSK Doctors, ensures personalised advice tailored to your unique situation.

Conclusion

To sum up, both open and minimally invasive Achilles tendon repairs have distinct pros and cons. Open repair offers direct access and possibly stronger fixation but carries higher risk of wound-related complications. Minimally invasive surgery cuts down soft tissue damage and scarring but requires advanced skill to avoid nerve injury. When selected appropriately, both approaches deliver excellent results.

Choosing the right treatment is a highly individual decision best made in consultation with a qualified healthcare professional. For personalised medical advice, please speak directly with your orthopaedic specialist.

References

Kanchanatawan, W., Densiri-aksorn, W., Maneesrisajja, T., Suppauksorn, S., Arirachakaran, A., Rungchamrussopa, P., & Boonma, P. (2018). Hybrid Achilles Tendon Repair. Arthroscopy Techniques, 7(6), e639-e644. https://doi.org/10.1016/j.eats.2018.02.011

Moore, M. L., Pollock, J. R., Karsen, P. J., Haglin, J. M., Lai, C., Elahi, M. A., Chhabra, A., O’Malley, M. J., & Patel, K. A. (2023). Open Achilles Tendon Repair. JBJS Case Connector, 13(1), e21.00054. https://doi.org/10.2106/jbjs.st.21.00054

Sasaki, T., Minamino, K., Nakagawa, Y., & Yamada, H. (2025). Ultrasound-Guided Percutaneous Achilles Tendon Repair for Acute Achilles Tendon Rupture: Modified Percutaneous Achilles Repair System Procedure for Achilles Tendon Repair Without a Jig. Cureus. https://doi.org/10.7759/cureus.77730