RU2681056C1 - Method for the surgical treatment of acute achilles tendon rupture - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to the field of medicine, namely to traumatology, and can be used to treat complete acute Achilles tendon rupture. Access to the site of damage to the Achilles tendon is carried out by making a Z-shaped incision along the posterior surface of the tibia in the projection of the Achilles tendon rupture. Adaptation of the ends of a torn tendon is carried out, juxtaposition of the ends with an adaptive, epitopendose, blanket stitch. Tendon is conventionally divided into 3 equal parts in the longitudinal direction. Front surface of the tendon is stitched, for which a needle is inserted at the border of 1 and 2 parts of the proximal end of the torn tendon in the direction from the tendon rupture, without seizing the entire thickness of the tendon. Then, having passed 5 mm of tendon thickness, the needle is inserted at the border of 1 and 2 parts. Further, departing from the exit of 3–4 mm, the needle is inserted at an angle of 45° relative to the parallel course of the tendon fibers in the proximal direction, the exit point of the needle is the border of 2 and 3 parts of the tendon. Then the needle is inserted into the place of exit thereof at an angle of 45° so that the needle passes under the epitenon in the proximal direction and is visible through the epitenon. Then, in the place of exit, deep, perpendicular to tendon, but not intersected the entire thickness of the tendon thread is passaged with the exit point at the border of 2 and 3 parts. Then the needle is inserted into the place of exit thereof at an angle of 45° so, that the needle passes under the epitenon in the distal direction to the border of 1 and 2 parts and is visible through the epitenon of the intersection formed with the previous stitch. Next, the needle is inserted into the place of exit thereof at an angle of 45° in the distal direction to the border of 2 and 3 parts. Then, retreating 3–4 mm, the needle is inserted parallel to the fibers and perpendicular to the tendon rupture line in the distal direction until the needle is completely out of the proximal end of the tendon, and the length of the stitched tendon should not exceed 3.0 cm. Next, give the foot equinus position. Assistant holds the tendon with clamps, without locking the ratchet. Same thread steadily continues to sew the front surface of the distal end of the tendon, using the techniques outlined above. Then the transition to the relief surface is performed, at this juncture the assistant rotates the tendon with the help of clamps. Relief surfaces of the proximal and distal ends of the tendon are stitched in the same way as the front surfaces. Ends of the threads are interconnected. Knot is arranged between the broken ends of the stitched tendon. Wound is sutured in layers. Plaster immobilization is performed on the front surface of the leg by the splint in the equinus position of the foot on the upper third of the tarsus.EFFECT: method provides a reduction in the time of rehabilitation of the patient and a more rapid restoration of working capacity thereof due to steadily flashing of the front and relief tendon walls in four sectors.1 cl, 11 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and can be used to treat complete acute rupture of the Achilles tendon.

Achilles tendon ruptures are a common injury and according to M.L. Costa et al. (2006) account for 18 cases per 100 thousand people per year (see Crass J.R .; van de Vegte, G.L .; Harkavy, L.A .: Tendon echogenicity: ex vivo study. Radiology, 167: 499-501, 1988). These lesions can be associated, on the one hand, with the accumulation of degenerative changes in the tendon, a decrease in its elasticity, and on the other, with a relatively high level of physical activity (see Maffulli, N .: Simmonds' test letter. Acta Orthop. Scandinavica, 66: 574 , 1995).

Currently, there is still no agreement among surgeons on which method of treatment for Achilles tendon ruptures is most preferable. Existing methods of treatment can be divided into operational and conservative. Surgical treatment consists of various end-to-end tendon suture variations, in some cases supplemented by tendon repair. Conservative treatment involves immobilization with a longuet or brace in the equine position of the foot (see Klein, W .; Lang, D. M .; and Saleh, M .: The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendo Achillis. Chir org. mov., 76: 223-228, 1991; see Maffulli, N .: Clinical tests in sports medicine: more on Achilles tendon. British J. Sports Med., 30: 250, 1996; see Parker RG, Repinecz M. Neglected rupture of the achilles tendon. Treatment by modified Strayer gastrocnemius recession. J Am Podiatry Assoc. 1979; 69: 548-55; see Cetti, R., and Christensen, S.-E .: Surgical treatment under local anaesthesia of Achilles tendon rupture. Clin. Orthop., 173: 204-208, 1983).

It is known that surgical treatment in comparison with conservative treatment can significantly reduce the likelihood of restructuring (relative risk 0.27), but it is associated with a much higher frequency of other complications, such as infectious and scar adhesions (relative risk 10.6). The frequency of restructures with conservative treatment is 12.6%, and with surgical - 3.5%. Moreover, the frequency of surface infections of the surgical area after surgical treatment in many studies is characterized as extremely high and can reach 35% or more (see Klein, W .; Lang, D. M .; and Saleh, M .: The use of the Ma-Griffith technique for percutaneous repair of fresh ruptured tendo Achillis. Chir. Org. Mov., 76: 223-228, 1991; see Maffulli, N .: Simmonds' test letter. Acta Orthop. Scandinavica, 66: 574, 1995 )

In this regard, other treatment methods were developed that combined the advantages of both surgical and conservative treatment. In particular, it was proposed to use the cutaneous suture of the tendon, however, the main disadvantage of this method was the high frequency of damage to the calf nerve. This can be avoided with the help of endovideo technologies, however, in general, this method has not yet been widely used (see Ustyantsev V.I., Kolomiyets A.A. Method for treating injuries of the Achilles tendon // Orthopedics, traumatology and prosthetics. 1991. - N2, - C 39-41; see Maffulli N, Regine R, Angelillo M, Capasso G, Filice S. Ultrasound diagnosis of Achilles tendon pathology in runners. Br J Sports Med. 1987; 21: 158-62; see Maffulli, N. : Simmonds 'test letter. Acta Orthop. Scandinavica 66: 574, 1995; see Tokmakov P. Treatment of ruptures of Achilles' tendons by an external fixator. Folia Med (Plovdiv). 1995; 37 (4A Suppl): 92) .

There is a stitching method first proposed by an English surgeon in 1918 Sterling (see S. Bunnell. "Repair of tendons in the fingers and description of two new instruments.) Surgery, Gynecology and Obstetrics, 1918, 26: 103-111). Known in Russia under the name - Bunnell-Cuneo suture, which has become the most popular for many decades among domestic surgeons not only for stitching the flexor tendons of the fingers, but also for stitching the Achilles tendon. Which suggested many modifications of this suture (see Dykhno AM “On suture of tendons in connection with the treatment of their wounds and two new methods of suture of tendons” / New chir. Archive, 1936. T. 37, Book 147. - P. 403- 416). In this suture, the connection of the ends of the tendon is performed by two intra-barrel, passing through the entire thickness of the tendon, zigzag sutures with the withdrawal of the ends of the threads in the plane of the tendon sections. The advantages of this method is that all suture material is in the thickness of the tendon.

The disadvantages of the existing method include: the seam Bunnell-Cuneo can not be called simple and less traumatic, since it requires a relatively large number of injections and punctures of the thread. And you need to do this on a relatively small segment; tendon deformation that occurs when the tendon suture is tightened, due to the resulting deformation, the tendon vessels are squeezed when tightened, which leads to the devascularization of the tendon ends; the deformation that occurs when the seam is tightened causes the reorientation of the course of tendon fibers, which will inevitably lead to a decrease in the biomechanical properties of the tendon, in particular its elasticity; tendon tissue excision; low tensile strength (see. "Achilles tendon." A.A. Gritsyuk, A.P. Sereda. Edition of the Russian Academy of Natural Sciences 2010; see Milford L. "Tendon Ijuries" / Campbell's Operative Ortopedics; Ed. AH Crenshaw. - St. Luis: Mosby Company, 1987. P. 149-182; see Semenov G.M. “Surgical suture” / A.V. Skoroglyadov // Sov.med. - 1979. - No. 3 - C. 111-114).

Closest to the proposed method for the treatment of fresh Achilles tendon ruptures is the method proposed by R. Savage in 1985 for the treatment of acute rupture of the flexor tendons of the fingers (see Savage R. "In vitro studies of a new method of flexor tendon repair" J Hand Surgery Br . Jun. 1985; P. 135; see Savage R. Risitano G. “Flexor tendon repair using a six-strand method of repair and early active mobilization)) J Hand Surgery 1989; 14B: 383-390)

The advantage of this seam is its high tensile strength and resistance to polycyclic loads. And also the superficial arrangement of the threads minimally disrupts the blood supply to the stitched tendon.

The disadvantages of the existing method include the following: the Savage seam can also not be called simple and less traumatic, since it requires a large number of injections and punctures of the thread, and this must be done in a relatively small segment; when performing this suture - the threads located on the surface of the tendon reduce the sliding properties of the tendon, which helps to reduce the functional results of treatment.

Based on the current level of technology for the treatment of Achilles tendon rupture and to eliminate the shortcomings of known methods of treatment, the following tasks were set:

1) to restore the Achilles tendon and the full function of the lower limb at an earlier date;

2) reduce the risk of repeated rupture of the Achilles tendon;

3) improve the sliding properties of the seam;

4) reduce compression and reorientation of tendon fibers;

5) improve the adaptation of the edges of the torn tendon;

6) to avoid deformation of the tendon when tightening the suture;

7) due to the high strength characteristics of the suture, reduce the negative effects of immobilization, such as muscle atrophy, joint contractures, degenerative arthritis, adhesions and deep vein thrombosis.

Surgical treatment of Achilles tendon rupture includes access to the site of injury, adaptation of the ends of the Achilles tendon, stitching of the Achilles tendon, layered wound closure.

The technical result is to restore the Achilles tendon at an earlier date, to improve the functional results of surgical treatment, as well as to reduce the number of complications in the postoperative period.

The technical result is achieved by the fact that the tendon is conditionally divided into 3 equal parts in the longitudinal direction, the front surface of the tendon is sutured, for which a needle is inserted at the border of 1 and 2 parts of the proximal end of the torn tendon in the direction from the tendon rupture, without capturing the entire thickness of the tendon, then passing 5 mm in the thickness of the tendon insert a needle at the border of 1 and 2 parts, then stepping back from the exit point 3-4 mm insert the needle at an angle of 45 ° relative to the parallel travel of the tendon fibers in the proximal direction, the exit point of the needle is the boundary of the 2nd and 3rd part of the tendon, then the needle is inserted into the place of its exit of the needle at an angle of 45 ° so that the needle only passes under the epithenone in the proximal direction and is visible through the epithenonone, then at the exit point they produce a perpendicular tendon, deep but not intersecting the entire thickness of the tendon, the thread is held with the exit point at the border of 2 and 3 parts, then the needle is inserted into the exit point at an angle of 45 ° so that the needle only passes under the epithenone in the distal direction to the border of 1 and 2 parts and can be seen through the epithenon cross , about developed with the previous stitch, the needle is subsequently introduced into the place of its exit at an angle of 45 ° in the distal direction to the border of 2 and 3 parts, then, retreating 3-4 mm, the needle is inserted parallel to the fibers and perpendicular to the tendon rupture line in the distal direction until the needle exits the proximal the end of the tendon, while the section of the stitched tendon should not exceed 3.0 cm, then give the foot an equine position, the assistant holds the tendon with clamps, without snapping crimmals, the same thread continues to flash the bottom surface of the distal end of the tendon, using the techniques described above, then go to the back surface, at this moment the assistant rotates the tendon with the help of the clamps, the posterior surfaces of the proximal and distal ends of the tendon are stitched as well as the front surfaces, the ends of the threads are connected , the site is located between the torn ends of the stitched tendon.

What is new in achieving the technical result is that when stitching a tendon, the needle inlet and further threading does not capture the entire thickness of the tendon, when forming a seam, part of the threads pass under the epithenone, as well as making the seam four-core, not only the front wall is stitched continuously, but and back so that the threads are located in four different sectors of the tendon.

We explain the significant distinguishing features of the proposed method of treatment. The initial entry of the needle and the further passage of the thread without capturing the entire thickness of the tendon, avoids significant deformation of the tendon when tightening the suture, which will not disturb the orientation of the tendon fibers, and therefore reduce the effect of the suture on the biomechanical properties of the tendon and its elasticity, reduce the compression of the tendon, which in turn, it will allow not to disturb the intracranial blood supply to the tendon, which in turn leads to faster scar formation, and therefore restored as soon as possible NIJ torn tendon integrity.

Holding part of the threads under epithenone allows not to violate the sliding properties of the tendon, which leads to better functional results of surgical treatment.

Sewing continuously not only the front wall, but also the back, so that the threads are located in four different sectors of the tendon, allows you to evenly distribute the load, which increases the strength characteristics of the seam, and also improves the adaptation of the edges of the torn tendon. All this allows you to activate the muscle-tendon complex in the early postoperative period, which in turn helps to reduce the patient’s rehabilitation period and reduce the number of complications associated with prolonged immobilization of the limb, such as muscle atrophy, joint contracture, degenerative arthritis, adhesions and deep vein thrombosis .

These actions lead to a faster restoration of the integrity of the Achilles tendon, as well as improve the functional results of surgical treatment.

Conducted patent research and analysis of scientific and medical information, which reflects the known level of treatment for Achilles tendon ruptures, did not reveal technologies identical to the proposed one. Thus, the proposed method of surgical treatment is new.

The relationship and interaction of the essential techniques of the proposed method ensure the achievement of a new technological medical result in solving the problems.

The method of surgical treatment of Achilles tendon rupture can be used repeatedly by specialists in traumatologists.

The proposed method for surgical treatment of Achilles tendon rupture is illustrated by drawings, which show:

FIG. 1 - the entry point of the needle at the proximal end of the torn tendon (a - spatial orientation of the entry point in the cross section of the tendon; 1, 2, 3 - conditional division of the tendon into 3 parts).

FIG. 2 - flashing of the proximal end of the tendon (A - the point of exit of the needle; 1, 2, 3 - conditional division of the tendon into 3 parts).

FIG. 3 - holding the thread from point B to point C1 (A is the needle exit point; B is the needle entry point; C1 is the needle exit point).

FIG. 4 - holding the thread under the epithenone from point C1, point D (A is the needle exit point; B is the needle entry point; C1 is the needle exit point, and the needle entrance is under the epithenone; D is the needle exit point).

FIG. 5 - holding the thread from point D to point D1 (A is the needle exit point; B is the needle entry point; C1 is the needle exit point and then the needle entry under the epithenone; D is the needle exit point and then the needle entrance; D1 is the point needle exit).

FIG. 6 - holding the thread under the epithenone from point D1 point C (A is the needle exit point; B is the needle entry point; C is the needle exit point; C1 is the needle exit point and then the needle entry point under the epithenone; D is the needle exit point, and then the entrance of the needle; D1 is the point of exit of the needle, and then the entrance of the needle under epithenone).

FIG. 7 - holding the thread from point C to point B1 (A is the needle exit point; B is the needle entry point; B1 is the needle exit point; C is the needle exit point and then the needle entry; C1 is the needle exit point and then the needle entry under epithenone; D - the exit point of the needle and then the entrance of the needle; D1 - the exit point of the needle and then the entrance of the needle under the epithenone).

FIG. 8 - holding the thread from point A1 to the full exit from the tendon (A - the point of exit of the needle; A1 - the point of entry of the needle; B - the point of entry of the needle; B1 - the point of exit of the needle; C - the point of exit of the needle and then the entrance of the needle; C1 - point the exit of the needle, and then the entrance of the needle under the epithenone; D - the exit point of the needle and then the entrance of the needle; D1 - the exit point of the needle, and then the entrance of the needle under the epithenone).

FIG. 9 is the final view of the stitched front walls of the proximal and distal ends of the torn tendon (A is the needle exit point; A1 is the needle entry point; B is the needle entry point; B1 is the needle exit point; C is the needle exit point and then the needle entrance; C1 is the exit point of the needle, and then the entrance of the needle under the epithenone; D is the exit point of the needle and then the entrance of the needle; D1 is the exit point of the needle, and then the entrance of the needle under the epithenone).

FIG. 10 is a final view of the stitched front and rear walls of the proximal and distal ends of a torn tendon.

FIG. 11 is a cross section of the tendon (b is the spatial orientation of the distribution of threads by sectors in the cross section of the tendon).

The essence of the proposed "Method of surgical treatment of Achilles tendon rupture" is as follows.

Under conduction anesthesia in the position of the patient lying on his stomach. Patient's feet hang from the edge of the operating table. A movable stand is mounted on the operating table, on which during the operation you can put the patient’s foot in order to give it an equine position. For this purpose, an operating sister's table can be used. The foot and the entire lower leg are treated.

A surgical marker is applied to draw the lines of the intended incision. A Z-shaped incision is made along the posterior surface of the lower leg in the projection of a torn Achilles tendon.

After dissection of the skin, paratenone is exposed, which is opened along the course of the tendon. In this case, it is necessary to minimize dissection between parathenone and subcutaneous fat in order to preserve the vasculature of both structures.

If the calf nerve is visualized in the wound, then it is removed in the lateral direction. A targeted search for the gastrocnemius nerve is not practical.

After dissection of paratenon, a hematoma is opened at the site of the gap, which, depending on the age of the gap, can be at various stages of connective tissue degeneration.

In any case, it is evacuated completely. Next, the proximal and distal stumps of a torn tendon that are imbibed with blood are exposed. Degeneratively altered tendon ends adapt.

An atraumatic suture with a pricking needle (EthibondExele 2/0) is used to complete the suture. They begin to flash from the distal part of the torn tendon.

The tendon is conditionally divided into 3 equal parts. The entrance of the needle is made at the border of 1 and 2 parts, without capturing the entire thickness of the tendon, which allows not to disturb the orientation of the tendon fibers and not to disturb the intra-blood supply to the tendon (see Fig. 1). Then, having passed 5 mm in the thickness of the tendon, the needle is released at point A (see Fig. 2).

Further, departing from the exit point 3-4 mm, the needle enters at point B at an angle of 45 ° relative to the angle formed by the parallel course of the tendon fibers and the transverse gap. The exit point of the needle is point C1 (see Fig. 3).

Then the needle enters the point C1 at an angle of 45 ° so that the needle only passes under the epithenone in the proximal direction. In this case, the thread should be visible through the epithenonone, which will indicate the correctness of the performed action, which will increase the sliding properties of the tendon. The exit point of the needle is made at point D (see Fig. 4).

Then, point D is made perpendicular (horizontal) to the tendon, deep but not crossing the entire thickness of the tendon, the thread is held with the exit point at the border of 2 and 3 parts at point D1 (see Fig. 5).

Then the needle enters the exit point of the needle at an angle of 45 ° so that the needle only passes under the epithenone in the distal direction to point C at the border of 1 and 2 parts. In this case, a cross formed with the previous stitch should be visible through the epithenonone (see Fig. 6).

Then the needle is deeply guided to point C at an angle of 45 ° in the distal direction to point B1 at the border of 2 and 3 parts (see Fig. 7).

Then, stepping back 3-4 mm, the entrance to point A1 is performed parallel to the fibers and perpendicular to the tendon rupture line in the distal direction until complete exit (see Fig. 8).

At the same time, the length of the stitched tendon should not exceed 3.0 cm. Then, using the stand or with the help of an assistant, we give the foot an equine position, which will eliminate diastasis between the ends of the torn Achilles tendon. At the same time, the assistant holds the tendon with the help of soft clamps without snapping crimmlers. With the same thread, we continue to continuously sew according to the principle described earlier the distal end of the tendon (see Fig. 9).

Having stitched the distal end, the transition to the back wall is performed. At the same time, the assistant with the help of clamps, rotates the tendon. Continuing continuously, the posterior walls of the proximal and distal tendons are stitched (see Fig. 10).

As a result, the ends of the threads are connected with each other, the knot is hidden between the torn ends. The edges are precisely matched by an adaptive epitendinous twisted seam blocked using a monofilament thread Prolene 5/0 or 6/0.

The wound is sutured in layers and drained. An aseptic dressing is applied. Plaster immobilization is performed along the front surface of the leg with a splint in the equinus position of the foot to the upper third of the leg. In the postoperative period, daily, 2 times a day, the patient performs exercise therapy. Skin sutures are removed 10-12 days after surgery. After 2 weeks, the gypsum span is replaced by a new functional span, which allows performing active plantar flexion within 20 °, gradually reducing the equinus to the plantar position.

By the end of the 4th week, gypsum immobilization is completely removed, the dosed load is allowed by the weight of the limb. By the end of 6, a metered load on the operated lower limb and walking with additional support on a cane are allowed.

The essence of the proposed method of surgical treatment is illustrated by a clinical example.

Patient K., 36 years old, trauma. When playing soccer, the jump time felt a sharp pain in the lower third of the right lower leg on the back surface. He sought medical help at the MBUZ GBSM Rostov-on-Don. Fresh Achilles tendon damage was diagnosed in the lower third of the right lower leg, surgical treatment was recommended, hospitalized in the traumatology and orthopedic department.

09/14/16, the operation was performed according to the proposed technology - the suture of the Achilles tendon of the right lower leg.

In aseptic conditions, after processing the surgical field with antiseptic solutions under conduction anesthesia, in the patient’s position while lying on his stomach. A Z-shaped skin incision was made along the posterior surface of the lower leg in the projection of a torn Achilles tendon up to 10 cm. The gastrocnemius nerve was visualized and laterally retracted. Naked paratenon, opened along the course of the tendon.

After dissection of paratenon, a hematoma was opened at the rupture site, which was completely evacuated. The proximal and distal stumps of a torn tendon are exposed. Degeneratively altered tendon ends are adapted. The proximal and distal ends of the calcaneal tendons are brought together, a suture is made according to the technology we offer.

An atraumatic suture with a pricking needle (EthibondExele 2/0) was used to perform the suture. The edges are precisely matched by an adaptive epitendinous twisted seam blocked, for its implementation, monofilament thread Prolene 5/0 was used.

Intraoperatively verified the consistency of the tendon suture by passive foot movements. Seams are wealthy. The wound is sutured in layers and drained by a rubber graduate. Aseptic dressing. Plaster immobilization with a longeta in the equinus position of the foot to the upper third of the lower leg was performed.

In the postoperative period, daily, 2 times a day, the patient underwent exercise therapy. Skin sutures were removed 12 days after surgery. Every week, a plaster cast was replaced by a new one.

By the end of the 2nd week, the gypsum span was replaced by a functional span, which allows performing active plantar flexion within 20 °, gradually reducing the equinus to the plantar position. By the end of the 4th week, gypsum immobilization was completely removed, a dosed load of limb weight was allowed. By the end of the 6th week, the exercise therapy was continued for this period, the dosed load on the operated lower limb and walking with additional support on a cane were allowed.

The proposed technology treated 17 patients with fresh Achilles tendon ruptures. Rehabilitation time in this group of patients decreased on average by 3 weeks compared with those patients who used the well-known standard technique of Achilles tendon suture, which gives an average savings of 14 working days per person.

Thus, the proposed "Method of surgical treatment of acute Achilles tendon ruptures" in comparison with other known technologies allows to restore the Achilles tendon at an earlier date, improve the functional results of surgical treatment, as well as reduce the number of complications in the postoperative period.

The absence of significant deformation of the tendon when the suture is tightened, allows you to not disturb the orientation of the tendon fibers, and therefore reduce the effect of the suture on the biomechanical properties of the tendon and its elasticity, reduce tendon compression, which in turn preserves the intra-blood supply to the tendon and leads to faster scar formation, and therefore , the speedy restoration of the integrity of a torn tendon.

Holding part of the thread under epithenone allows not to violate the sliding properties of the tendon, which leads to better functional results of surgical treatment.

The technical and economic efficiency of the method for the surgical treatment of acute Achilles tendon ruptures consists in continuously flashing not only the front wall, but also the back so that the threads are located in four different sectors of the tendon, allows you to evenly distribute the load, which increases the strength of the seam, improves the adaptation of the edges torn tendon - this allows you to activate the muscle-tendon complex in the early postoperative period, reduce the patient's rehabilitation period by an average of 3 weeks, and also restore Tanova disabled after 6 weeks after the operation, reduce the number of complications associated with prolonged immobilization of a limb, such as muscle atrophy, joint contractures, degenerative arthritis, adhesions and deep vein thrombosis.

Claims (1)

A method for the surgical treatment of acute Achilles tendon ruptures, including access to the site of damage to the Achilles tendon by performing a Z-shaped incision along the posterior surface of the lower leg in the projection of the rupture of the Achilles tendon, adapting the ends of a torn tendon, matching the ends with an adaptive, epitendinous, stitching blocked suture, layered subsequent immobilization of the limb with a gypsum string in the equine position, characterized in that the tendon is conditionally divided into 3 equal parts in the longitudinal direction stitch the front surface of the tendon, for which a needle is inserted at the border of 1 and 2 parts of the proximal end of the torn tendon in the direction from the tendon rupture, not capturing the entire thickness of the tendon, then, passing 5 mm in the thickness of the tendon, the needle is removed at the border of 1 and 2 parts then, departing from the exit point 3-4 mm, the needle is inserted at an angle of 45 ° relative to the parallel path of the tendon fibers in the proximal direction, the exit point of the needle is the border of 2 and 3 parts of the tendon, then the needle is inserted into the exit point at an angle of 45 ° so to needle passed under the epithenone in the proximal direction and was visible through the epitenonone, then at the exit point a deep, but not crossing the entire thickness of the tendon, thread is held perpendicular to the tendon with the exit point at the border of 2 and 3 parts, then the needle is inserted into the exit point at an angle of 45 ° so that the needle passes under the epithenone in the distal direction to the border of 1 and 2 parts and the cross formed by the previous stitch is visible through the epithenonone, then the needle is introduced into the place of its exit at an angle of 45 ° in the distal direction to the 2 and 3 parts, then, 3-4 mm apart, insert the needle parallel to the fibers and perpendicular to the tendon rupture line in the distal direction until the needle exits completely from the proximal end of the tendon, while the length of the stitched tendon should not exceed 3.0 cm, then attach the foot is in an equine position, the assistant holds the tendon with the help of clamps, without catching the criminals, the same thread continuously continues to stitch the front surface of the distal end of the tendon using the techniques described above, then go to the back the surface, at this moment the assistant rotates the tendon using the clamps, the posterior surfaces of the proximal and distal ends of the tendon are sutured in the same way as the front surfaces, the ends of the threads are tied together, the knot is placed between the torn ends of the stitched tendon, the wound is sutured in layers, the gypsum is performed immobilization of the anterior surface of the leg with a splint in the equinus position of the foot along the upper third of the leg.

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