RU2341219C1 - Method of achilles tendon plasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: make a longitudinal cut on an external edge of the Achilles tendons, with allocation of it's broken off extremities. Pull together the extremities of the broken off tendomuscular complex. Wrap with mesh implant. Stitch the tendomuscular complex and the implant. Take in the wound tightly in layers. Impose the plaster splint after operation. Stitch the extremities of the tendomuscular complex with nikelid-titanic threads and pull together. As a mesh implant use a quadrangular mesh implant from titanium-nickelide. Place it caterer along the longitudinal axis of an extremity under the pulled together extremities and turn around them, creating the cylinder. Stitch the tendomuscular complex wrapped by the implant by means of nikelid-titanic threads using a Cuneo tendinous stitch. Paratenot and dissociation of the extremities of a tendomuscular complex keep during operation and in addition wrap the sewed implant tendomuscular complex with them. Then them also stitch blanket seams a nikelid-titanic thread.

EFFECT: provides strong and reliable restoration of a tendon on all extent of rupture, depression of postoperative complications, reduction of terms of treatment.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used for ruptures of the ligament-tendon apparatus.

A known method of muscle-tendon plastic surgery according to Chernavsky (Yumashev GS Traumatology and orthopedics. - 2nd edition, revised and supplemented - M .: Medicine, 1983, p.159-160). A longitudinal section along the outer edge of the Achilles tendon reveals its torn ends, removes the hematoma, the ends of the tendon are refreshed. From the aponeurosis of the gastrocnemius muscle, a tongue-like flap is connected, which is connected with the bed in the distal section. The flap width is 2-2.5 centimeters. The length of the flap should slightly exceed the size of the defect between the ends of the tendon. The end of the tendon is split and a flap of aponeurosis is sewn into it. The defect of the aponeurosis of the calf muscle is sutured with rare sutures, the wound is sutured in layers tightly. After the operation, a plaster cast is applied from the middle of the thigh to the toes of the foot, in the position of its plantar flexion. After three weeks, the foot is brought to a normal position. The total period of immobilization is 8 weeks.

The disadvantages of the method.

1. Loss of volume and strength of the tendon throughout.

2. The difficulty in the allocation of the flap with plastic degeneratively altered tendons.

3. Lack of stimulus for the regeneration of tendon fibers.

A known method of achilloplasty, including the use of a carbon-containing implant. A woven tube of carbon-containing material TGN-2M with a width of three centimeters with a seam facing inwards was used. Hemming of a tubular implant worn over the tendon in the form of a stocking was performed, while the pulp ends of the torn tendon-muscle complex were immersed in the lumen of the implant.

Abstract of dissertation for the degree of candidate of medical sciences "Achiloplasty with carbon-containing implants" Melamed LA, Moscow Medical Academy. M.I.Sechenova, Moscow, 1996, p. 9-11.

The disadvantages of this method.

1. The surface of the TGN-2M filaments is smooth, which slows the regeneration of the tendon.

2. The diameter of the tube is fixed, and during the operation it is impossible to level the intensity of the implanted tendon-muscular complex coverage with the implant, which may cause additional tissue injury or worsen their trophism.

3. With TGN-2M tubular implant plastic surgery, the disengagement of the ends of a torn tendon-muscle complex is immersed in the tube lumen, which slows down regeneration and healing, and reduces the density of the stitched tendon-muscle complex.

The objective of the invention is to ensure the strength of the restored tendon throughout by strengthening it with a mesh implant made of titanium nickelide, reducing treatment time and reducing the number of complications of the postoperative period by stimulating and accelerating regeneration due to the microporous structure of the implant surface and threads.

The task is achieved by the method of plastic surgery of the Achilles tendon, including a longitudinal section along the outer edge of the Achilles tendon, the allocation of its torn ends, the convergence of the ends of the torn tendon-muscular complex, wrapping with a mesh implant, suturing of the tendon-muscular complex and the implant, suturing the wound layer-by-layer tightly on the tire, after operation.

The torn ends of the tendon-muscle complex are stitched with nickel-titanium threads, for which they are brought together. A tetragonal mesh implant made of titanium nickelide is used as a mesh implant, moreover, it is placed diagonally along the longitudinal axis of the limb under the converging ends and wrapped around them, creating a cylinder. The tendon-muscle complex, which is wrapped in an implant with the help of nickel-titanium filaments, is sutured with a tendon suture according to Kuneo. The parathenone and tearing of the ends of the tendon-muscle complex are maintained during the operation and they are additionally wrapped with a tendon-muscle complex sewn with the implant, after which they are also stitched with nickel-titanium thread in the upholstery.

The novelty of the invention.

- The torn ends of the tendon-muscle complex are stitched with nickel-titanium threads, for which they are brought together. The thread has a microporous structure that stimulates healing. This ensures the convenience of manipulation in the wound and reduces tissue trauma.

- A tetragonal mesh implant made of titanium nickelide is used as a mesh implant, moreover, it is placed diagonally along the longitudinal axis of the limb under the proximal ends of the tendon-muscle complex and wrapped around them, creating a cylinder. The microporous surface structure of the implant accelerates tissue regeneration by increasing the reaction surface area and creates conditions for directed tendon growth. A quadrangular mesh implant is easy to wrap around the proximal ends of a torn tendon-muscular complex without injuring them, unlike a tube with a fixed diameter, and an adequate density of coverage of the ends is ensured, which ensures stability. The location of the implant allows you to evenly distribute the load on the entire created complex.

- Sew the tendon-muscle complex wrapped in the implant using nickel-titanium filaments with a tendon suture according to Kuneo. Stitching allows you to further strengthen the tendon-muscle complex and evenly distribute the load on it, which reduces the risk of thread eruption.

- Paratenon and the tearing of the ends of the tendon-muscle complex are preserved during the operation and they are additionally wrapped with the tendon-muscle complex sewn with the implant, after which they are also stitched with nickelide stitching seams - a titanium thread. The use of paratenone allows you to accelerate tissue regeneration and level out the possible abrasive effect of the mesh implant.

The combination of essential features allows you to get a new technical result.

A durable and reliable tendon restoration is created throughout the gap by strengthening it with a mesh implant. The terms of limb immobilization are reduced to 6 weeks. The number of such complications of the postoperative period as repeated tendon rupture, degenerative-dystrophic tissue changes is reduced. The invention is illustrated by drawings, in which Fig. 1 shows the approach of the torn ends of the tendon-muscle complex using nickel-titanium filaments and the location of the rectangular mesh implant of titanium nickelide under the stitched complex.

Figure 2 shows the stitching by nickel-titanium filaments according to Kuneo of the tendon-muscle complex, wrapped in a rectangular mesh implant of titanium nickelide and brought together by nickel-titanium filaments.

Figure 3 shows a tendon-muscle complex stitched with an implant, additionally wrapped with paratenon and stitched with nickel-titanium filament stitching seams.

The operation is performed in the patient’s position on the operating table, lying on his stomach, under combined anesthesia. A roller is placed under the distal third of the operated lower leg, the surgical field is treated three times with an alcohol solution of chlorhexidine bigluconate. A longitudinal incision is made along the outer edge of the Achilles tendon, isolation of its torn ends, removal of the hematoma. The sections of paratenon and razvolennosti ends of the tendon-muscle complex 1 and 2 save for the final stage of the operation. The ends of the torn tendon-muscular complex 3 and 4 are brought together using threads made of nickel-titanium 5. Then the close ends are wrapped with a tetragonal mesh implant of titanium nickelide 6, placing it diagonally along the longitudinal axis of the limb. The proximal ends of a torn tendon-muscular complex together with a mesh implant 6 wrapped around them are flashed with nickel-titanium threads according to Kuneo 7. Then, all stored sections 1 and 2 of the paratenon and the ends are used for additional wrapping of 6 ends of the tendon-muscular complex 3, sewn with the implant. 4 followed by stitching them with nickel-titanium filaments 8. Hemostasis is performed, layer-by-layer suturing of paratenone, subcutaneous fat and skin with further installation of drains, the limb is fixed g with a ipsus splint in the knee flexion position of 130 degrees and in the equinus position of the foot for two weeks. After that, the foot is brought to a normal mid-physiological position. Then the patient wears an ankle joint with a heel of 2-3.5 cm under the heel in women, or an insert and arch support in men.

After removing the gypsum tire, physiotherapy, physiotherapy exercises, and massage are performed.

Example 1. Patient Z., 48 years old, diagnosis: closed traumatic rupture of the Achilles tendon on the right, is established on the basis of clinical examination data, radiography. Under conduction anesthesia, an achilloplasty operation was performed using a mesh implant made of titanium nickelide 40 mm long and 40 mm wide. A longitudinal incision was made along the outer edge of the Achilles tendon. Hematoma, rupture of the gap from the distal end. Hematoma removed. The ends of the torn tendon-muscle complex were stitched with nickel-titanium threads, followed by drawing the ends together using threads. The adjacent ends were wrapped with a titanium nickelide mesh implant; the implant is located diagonally along the longitudinal axis of the limb. The proximal ends of the tendon-muscle complex, wrapped with a mesh implant made of titanium nickelide, are stitched with tendon sutures according to Kuneo nickel-titanium threads. The stored sections of paratenon are used for additional wrapping of the ends stitched with the implant, additionally stitched with nickel-titanium threads. Hemostasis was performed, layer-by-layer suturing of tissues, the limb was fixed with a plaster splint in the position of flexion in the knee joint of 130 degrees and in the “equinus” position of the foot for 18 days. Dressings, anesthesia, magnetotherapy were carried out. Sutures removed on the twelfth day. The postoperative wound is healed initially, with no signs of inflammation. Immobilization with a gypsum splint was carried out 14 days from the day of surgery, then the foot was brought to a normal mid-physiological position. Then the patient wore an anesthesia LAB-201 of the ankle joint with an insert 3 cm high for 16 days. Physiotherapy exercises, physiotherapy, and massage were carried out. After removing the gypsum tire, walking with a cane of 10 days was recommended. On the fortieth day the patient was discharged to work. There were no repeated tendon ruptures in the early rehabilitation period. Repeated examination after 6 months, degenerative-dystrophic changes in the form of contractures, scars, muscle hypotrophy were not detected.

Example 2. Patient V., 38 years old, diagnosis: closed traumatic rupture of the Achilles tendon on the left, is established on the basis of the anamnesis, data of a clinical and radiological examination, examination. Under combined anesthesia, an achilloplasty operation was performed using a mesh titanium nickelide implant 46 millimeters long and 36 millimeters wide. A longitudinal incision was made along the outer edge of the Achilles tendon. Hematoma, rupture of the gap from the distal end. The ends of the torn tendon-muscle complex were stitched with nickel-titanium filaments, followed by drawing them closer together, then wrapping the adjacent ends with a mesh implant of titanium nickelide 36 mm wide and 46 mm long, the implant is located diagonally along the longitudinal axis of the limb. The proximal ends of the tendon-muscle complex are wrapped with a mesh implant of titanium nickelide to create a cylinder, stitched with a tendon suture along Kuneo with nickel-titanium filaments. Sections of paratenon are wrapped around the stitched tendon-muscle complex and are stitched with twisted nickel-titanium filament sutures. The tissue was sutured in layers, the limb was fixed with a gypsum splint in the position of flexion in the knee joint of 130 degrees and in the “equinus” position of the foot for 20 days. Dressings, anesthesia, magnetotherapy were carried out. Sutures removed on the eleventh day. The postoperative wound is healed initially, with no signs of inflammation. The plaster splint immobilization was carried out for 16 days from the day of the operation, then after the foot was elevated to the mid-physiological position, the immobilization was carried out for 14 days. Physiotherapy exercises, physiotherapy, and massage were carried out. After removing the gypsum tire, walking with a cane of 10 days was recommended, wearing shoes with a heel of 4 cm. On the forty-sixth day, the patient was discharged to work. There were no repeated tendon ruptures in the early rehabilitation period.

Thus, the proposed method allows to reduce the time of immobilization from 8 weeks to 6, to reduce the likelihood of postoperative complications in the form of repeated tears, to reduce the risk of degenerative-dystrophic tissue changes by increasing the surface area of the healing reaction, accelerating the regeneration and leveling of the abrasive effect of the mesh implant.

Claims (1)

Achilles tendon plasty method, including a longitudinal section along the outer edge of the Achilles tendon, isolation of its torn ends, drawing together the ends of a torn tendon-muscle complex, wrapping a mesh implant, suturing the tendon-muscular complex and the implant, suturing the wound in layers tightly, after applying a gypsum splint, characterized in that the torn ends of the tendon-muscle complex are stitched with nickel-titanium filaments, for which they are brought together, as a mesh implant a quadrangular mesh implant made of titanium nickelide, and placed diagonally along the longitudinal axis of the limbs under the proximal ends and wrapped around them, creating a cylinder, stitching the tendon-muscle complex wrapped with the implant using nickel-titanium filaments with a Kuneo tendon suture, paratenon and dry ends -muscular complex is preserved during the operation and an additional tendon-muscle complex sewn with an implant is wrapped with them, after which they are also stitched with nickname upholstery lead-titanium thread.

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