RU2627293C1 - Method for achilles tendon plasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: in the thickness of the proximal and distal ends of a ruptured Achilles tendon, sagittal incisions are made into which a fine-celled lavsan band is laid, which is sutured to the sides of the convergent ends of the ruptured tendon side to side, and the preserved parathyon and ruptured tendon filaments are stitched with thin lavsan threads.

EFFECT: method allows to create favorable conditions for tendon regeneration, reduce the risk of relapse.

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Description

The invention relates to medicine, namely to traumatology, and is intended for the treatment of a complete rupture of the Achilles tendon with its diastasis.

Fractures of the heel (Achilles) tendon account for 19-32% of the total number of injuries of the large tendons of the musculoskeletal system. At the outpatient stage, from 20 to 58% of Achilles tendon injuries are not diagnosed, which is the reason for contacting traumatologists with a large number of patients with chronic Achilles tendon ruptures with defects (diastases) in the lesion area. Conservative treatment of patients with Achilles tendon rupture is not possible. Tendon suture is the most common surgical procedure. The choice of tendon suture option from numerous varieties depends on a number of factors. The most important of these are the size of the diastasis, the location of the lesion, the time and mechanism of the rupture, the age and profession of the patient, as well as the nature of the tissues and skin surrounding the tendon in the lesion area. In advanced cases, tendon plastic surgery is the choice of operations, which involves replacing the tendon defects with biological materials or an endoprosthesis made of polymer threads in various ways (D. Kolovertov Abstract for the degree of candidate of medical sciences. Endoprosthetics of the Achilles tendon, 2009, p. 14).

There are a large number of tendon sutures for restoring the Achilles tendon. The most common is the classic seam proposed by the French surgeon B. Cuneo (Yumashev GS Traumatology and orthopedics. M., Medicine, p. 159) with fresh tears. The essence of this operation is to restore the integrity of the torn tendon by connecting the ends of the tendon with two zigzag tendon sutures with the ends of the threads in the damage zone from both ends of the torn tendon with their subsequent tightening and tying. Autochilloplasty according to Chernovsky is known, according to which for chronic injuries with significant (more than 3-4 cm) defects, it is proposed to cut a muscle flap in the proximal area of the Achilles tendon and throw it distally through the damage zone and stitch it into the cleft of the distal tendon (Yumashev G.S. Traumatology and orthopedics. M., Medicine, p. 159).

The main disadvantages of the described methods is a change in interstitial pressure, a violation of the orientation of the regenerating fibers, as well as compression of the thin blood and lymph vessels.

There is a method of applying a tendon suture, in which a thread is conducted intra-barrel through the ends of a damaged tendon with access to the end. A nickel-titanium tubular mesh implant is used as a thread. The implant is fixed and tightened until the damaged ends of the tendon are compared (Method for applying a tendon suture. RF patent №2524126, IPC АВВ 17/56 / authors Konilov D.N., Popov I.V .; application 2013113532/14, application. 26.03.2013; publ. 07.27.2014). This method is probably acceptable when suturing the tendons of the flexors of the hand, however, it is not physiologically suitable for the plastic surgery of the Achilles tendon, because this requires a material that is uniform in density, extensibility and elasticity with the tendon, which is not titanium nickelide.

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 3 cm with a seam facing inwards was used. Hemming of a tubular implant worn at the end of the tendon in the form of a stocking was performed. (Abstract of dissertation for the degree of candidate of medical sciences "Achiloplasty with carbon-containing implants" Melamed LA, Moscow Medical Academy named after MI Sechenov, Moscow, 1996, p. 9-11). However, the method is physiologically unacceptable due to the fact that coating the ends of a torn tendon in the form of a “stocking” tube dramatically disrupts the lymph and blood supply to the tendon.

The closest in technical essence to the claimed and adopted as a prototype is a 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 a torn tendon-muscle complex, wrapping a mesh implant, flashing of the tendon-muscle complex and the implant followed by suturing the wound in layers tightly and applying a gypsum tire after surgery (Method for plastic surgery of the Achilles tendon. RF Patent No. 2341219. MKI A61B 17/56 / authors ANTONOV AA Lanshakov VA, Günter V.E .; 2007119059/14 application, appl 22.05.2007;. published 20.12.2008)..

The disadvantage of this method is that the wrapping with a mesh implant significantly disrupts lymph and blood circulation, which is already impaired in a torn tendon. To confirm the authors' claim about accelerating tendon regeneration when using the method, an evidence base based on the results of histological studies in animals is needed. Unfortunately, it is not possible at this stage to accelerate the regeneration of a torn tendon for biological reasons. The task of surgeons is to create conditions for normalizing the natural regeneration of tendons. In addition, nickel-titanium is an expensive material, and it is damaged, unable to withstand the daily load on the Achilles tendon.

The technical result of the invention is the creation of favorable conditions for the regeneration of the tendon, the prevention of its shortening and relapse breaks.

The technical result is achieved by the fact that the method of plastics of the Achilles tendon includes a longitudinal section along its outer edge, isolation, drawing together and suturing of the torn ends and the implant of the tendon, while in the thickness of the proximal and distal ends of the torn Achilles tendon, sagittal sections are made into which the small-mesh lavsan tape is laid , which is sewn to the edges of the adjacent ends of the torn tendon side to side, and the saved sections of paratenon and torn tendon fibers are sutured with thin lavs ovymi threads.

The novelty of the invention lies in the isolation of the torn ends of the Achilles tendon with a cut in the sagittal direction at each end of the torn tendon up to 3 cm, holding a finely meshed lavsan ribbon inside the cuts of the tendon, followed by stitching it along the edges of the tendon side to side, and the tendon itself in this case tightened, suture end to end. At the same time, a thin mesh tape of small sizes (5-6 cm) remains inside the restored Achilles tendon, guaranteeing strength, allowing avoiding repeated tendon rupture during early movements. In this way, a strong reinforced joint of the torn ends of the Achilles tendon is obtained using a thin cellular lavsan tape to restore the torn tendon. The flexibility of the lavsan ribbon physiologically and biomechanically is more consistent with the flexibility of the Achilles tendon than the flexibility of nickel-titanium.

The combination of essential features allows us to obtain a new technical result - to achieve a strong tendon suture without squeezing a torn Achilles tendon, while guaranteeing the most minimal circulatory disturbance, which leads to good treatment results for patients after achilloplasty using a thin, fine mesh dacron tape. This technique is of particular value for old tears and fresh tears with a significant defect (3-4 cm or more), especially for athletes or for people with heavy physical labor.

The method is as follows. An incision is made in the skin and soft tissues with a size of 10 cm along the medial edge of the Achilles tendon. Torn ends of the tendon are distinguished, at both ends of which cuts of 3 cm in length are performed in the longitudinal sagittal direction. After that, the area of rupture and paratenone is thoroughly washed with an antiseptic solution to prevent suppuration and the development of adhesions. Then, in the sagittal sections of the Achilles tendon, a small-meshed dacron tape 6 cm long is inserted into the sections of the tendon. Then the ends of the tendons are pulled together and sutured to their sides. To enhance the strength of the tendon, the proximal end is sutured to the distal end. The result is a strong connection of the torn ends with minimal disturbance of the blood supply to the tendon, which prevents repeated breaks at an early load. After hemostasis, the wound is sutured in layers. In the postoperative period, the operated lower limb is immobilized with a plaster cast in an equinus position for three weeks. After that, the longuet is removed for physical therapy. In this case, patients step on the operated limb with a partial load on the sore leg in the very first day after the operation. Repeated tendon ruptures in patients were not observed.

Clinical example

Patient S., 36 years old, was admitted February 24, 2016 to the State Clinical Hospital named after Buyanova a week after an injury received during a game of football. I didn’t go to the doctors right away, believing that he had a sprain. Clinical and ultrasound examinations revealed a gap and a defect of the Achilles tendon of 5 cm. After a clinical examination, the operation of achiloplasty was carried out according to the method of reinforcing it using a fine mesh lavsan tape. Under epidural analgesia, a longitudinal incision was made along the outer edge of the Achilles tendon. During exposure and revision of the edges of the gap, a hematoma and fracture of the gap from the distal end were detected. Hematoma removed. Sagittal sections of both ends of the tendon 2.5-3.0 cm long were made on each side. In the thickness of the ends of the torn tendon close to each other, a thin, fine-mesh dacron tape was laid 6 cm long and 3 cm wide, which was sewn with acrylic threads on the atraumatic needle to the tendons "side to side", and the torn ends of the tendon sewed "end to end" in a tense state . The preserved areas of paratenon and torn tendon fibers were additionally flashed with thin dacron threads. Conducted hemostasis and layer-by-layer suturing of tissues. The limb is fixed with a plaster cast in the equinus position. Dressings were performed. Postoperative wound healing without complications. Plaster cast immobilization was carried out for 3 weeks from the day of surgery, and then the foot was brought to a normal mid-physiological position. Therapeutic exercise was carried out. Re-examination after three months. The result of the treatment is good.

According to this technique, in the trauma department of the City Clinical Hospital named after Buyanova operated on 5 patients for 2013-2016. The age of patients ranged from 32 to 54 years. In this group of patients, repeated rupture of the tendon suture was not observed.

Claims (1)

A method of plastic surgery of the Achilles tendon, including a longitudinal section along its outer edge, isolation, rapprochement and suturing of the torn ends and the implant of the tendon, characterized in that in the thickness of the proximal and distal ends of the torn Achilles tendon, sagittal sections are made into which a finely meshed lavsan tape is laid, which to the edges of the adjacent ends of the torn tendon side to side, and the preserved areas of paratenon and torn tendon fibers are sutured with thin dacron threads.