What Is Involved in Achilles Tendon Reconstruction?

The Achilles tendon is the tendon structure of the calf triceps, the gastrocnemius and soleus muscle, which migrates at the lower end of the abdomen. It stops at the calcaneal tubercle and is one of the thickest and largest tendons in the human body. It is important for the body to walk, stand and maintain balance The meaning of ^[1] .

Achilles tendinitis is very common clinically, and people who generally like running and mountain climbing will experience Achilles tendinitis. If there is local skin damage, there will be bacteria retention, mostly low-toxic bacteria, which will cause adverse effects. Attention should be paid to avoid repeated hormonal closure therapy to prevent spontaneous rupture of the Achilles tendon.

general

The Achilles tendon does not have a tendon sheath in the true sense, but is surrounded by the tissue around the tendon (fatty interstitial tissue to separate the tendon and tendon sheath). Early pain in Achilles tendinitis is mainly caused by damage to the tissue around the tendon. When the patient gets up or walks continuously, tendon activity in the tendon tissue increases, so the pain worsens. Pain can also worsen during training. There is tenderness in pressing the Achilles tendon with your fingers. If the patient continues to run despite the pain, the inflammation will spread to the tendons, causing degenerative changes and fibrosis, resulting in persistent pain, which intensifies when active.

Athletes should stop running, raise the heel to reduce the Achilles tendon tension, as long as it does not cause pain, strengthen the hamstring elastic exercises, wear soft-soled shoes to ensure the first metatarsophalangeal joint flexion. But the heel must be hard. If the Achilles tendon is painless, do a toe lift exercise to increase Achilles tendon muscle strength. Avoid running downhill quickly before the Achilles tendon heals.

Physical therapy is key. The most critical method is to stretch the gastrocnemius muscle with the knee straight, and stretch the soleus muscle with the knee flexed slightly. Strength training, ultrasound therapy, and electrical stimulation therapy can also be used in physical therapy. Anti-inflammatory drugs can speed healing. Using a heel lift to orthodontically fix the Achilles tendon can sometimes help. Fixing the ankle joint in a natural (90 °) night splint can help prevent tightness in your calf muscles. In some serious cases, some equipment may be needed to help reduce the tension on the Achilles tendon while walking.

Lift the heel with foam rubber or felt pads to remove the pressure from the upper. In order to control abnormal heel activity, shoe orthotics are required. In a small number of patients, stretching the upper or disassembling the heel stitches of the shoe can reduce inflammation, and placing a cushion around the bursa can reduce compression. Oral nonsteroidal anti-inflammatory drugs may temporarily relieve symptoms. Infiltration with soluble corticosteroids and local anesthetics can reduce inflammation. When conservative treatment fails, a posterolateral calcaneal surgery may be required.

Treatment of Achilles Tendon Rupture

1 conservative treatment

The Achilles tendon is self-healing, so after the Achilles tendon rupture, the Achilles tendon that is broken after fixing the ankle joint will gradually heal. The conservative treatment method is to use plaster to fix the ankle joint in the plantar flexion position, but there is no uniform standard for the specific fixation time and angle. Some scholars believe that after fixing the affected limb with long-leg plaster for 6 weeks, it is changed to short-leg plaster for 4 weeks, and then perform foot lift exercises of 2 to 4 months before the foot to restore Achilles tendon function. If long-term braking treatment is taken after Achilles tendon rupture, complications such as muscle atrophy are likely to occur, and the incidence of Achilles tendon rupture is higher, reaching 4.2% to 20.8%. However, recent studies have found that early functional exercise can significantly reduce the heel The occurrence of tendon rupture again requires early sexual function training to accelerate recovery. Garrick compared the clinical efficacy of early functional exercise during surgery and conservative treatment. A total of 144 patients were included in the study. After 2 years of follow-up, it was found that the incidence of Achilles tendon rupture after conservative functional treatment was similar to that of surgically treated patients.

2 Surgery

2.1 open surgery

In recent years, the suture method of the Achilles tendon has not been updated much, and the new open technique is mainly focused on the use of autologous or allogeneic tendons, tendon flaps, etc. The most classic suture methods for open surgery are Bunnell suture, Kessler suture, and Krackow suture.

(1) gift box technology

The gift box technology is an improvement of Krackow technology, but it only changes the position of the knot. Krackow technology is two sutures that are gradually stitched from both ends to the broken end, and finally knotted interactively. The gift box also uses stitched stitching to increase the strength after stitching, but after the stitching ends, the suture penetrates the contralateral end far away and then knots separately to keep the knot away from the repair area.Combined with stitched stitching, the repair strength is improved. This minimizes the concentration of stress on the Achilles tendon stump and knot reactions.

(2) Tendon flap reinforcement suture

(1) Gastrocnemius tendon flap turnover

Hamza et al. Chose to repair the Achilles tendon during the operation, cut the deep fascial compartment after the calf, and then use Krackow technique to reduce the suture of the Achilles tendon and plantar flexion of the ankle, and shorten the fracture to about 0.5cm. The proximal end is then made into a "single flip tendon flap", about 6 to 8 cm long and 1 to 1.5 cm wide. The tendon flap was turned 180 ° to the distal stump and maintained tension, and the donor site was directly sutured. The suture was strengthened at the stump, and the calf plaster was fixed at the ankle joint plantar flexion 20 °. Observation of the surgical patients, the results showed that they can return to the level of pre-injury activity.

(2) Gastrocnemius tendon flap rotation

Corradino et al. Reported the method of rotating tendon flaps: the tendon flaps were freed from the outside of the proximal tendon of the gastrocnemius muscle, with a width of about 2.0cm and a length of 7 ~ 8cm, and the rotation spanned the stump. The bottom of the tendon valve is sutured more than 3 to 4 cm beyond the stump, and sutured at the maximum plantar flexion of the ankle. Two weeks after the ankle plantar flexion fixation, no stiffness or relaxation of the ankle joint was observed, and no Achilles tendon rupture occurred.

(3) Autogenous tendon transplantation

The hamstring tendon transplantation, the plantar long flexor tendon, and the peroneus longus tendon translocation are often used for reconstruction of old Achilles tendon rupture, but rarely for fresh Achilles tendon rupture. Fresh Achilles tendon ruptures are mostly used for autologous plantar tendon transplantation.

(4) Allogeneic tendon transplantation

(1) Huang et al. Used an allogeneic tendon with a length of 20-28 cm to penetrate the distal stump, and then sutured the stump with a lace-weaving technique. After weaving is completed, the distal end of the Achilles tendon is fixed under appropriate physiological tension and sutured. The patients were followed up for 1, 3, 6 and 12 months after operation, and the patients recovered well. (2) Minimally invasive surgery with small incisions.

(5) Semi-open technology

Sanjay et al. Used a para Achilles tendon incision, which did not cross the stump, was "L" shaped, cut the surrounding tissue of the tendon to expose the stump, and then sutured the stump with a modified Kessler's method, while strengthening the diaphragm tendon.

(6) Tendon skin suture

Ding et al. Used a small lateral incision at the stump to first expose the stump minimally, and then used a decompression tube to reduce the suture to treat the acute Achilles tendon rupture. This study considers the advantages of tendon skin suture technology, but has not yet explained the time of removing the extracutaneous decompression tube.

(7) Suture exporter suture

Keller et al. Made a lateral incision with a length of about 2 cm in the middle and lower segments of the lower leg, and the lower edge was 2 cm on the stump of the Achilles tendon. Insert two suture extractors into the distal Achilles tendon at the interval of the tendon. Three sutures are inserted into the distal end of the Achilles tendon through the hole in the distal end of the extractor, and the intervals are about 0.5-1.0cm. Then the suture remover on both sides pulls the thread toward the incision, and sutures the knot at the proximal end under the plantar flexion position. The ankle joint maintains plantar flexion postoperatively, without weight bearing within 2 weeks, using a 3 cm high insole after 2 weeks, and allowing the patient to tolerate weight bearing, 4 weeks after physical therapy and lowering the heel cushion by 1 cm every week, recovering in 7 weeks Everyday, jogging for 12 weeks.

(8) Achilles tendon navigator suture

The navigation stapler is inserted into the Achilles tendon through a transverse incision at the broken end to guide the sutures, while the suture exporter is a longitudinal incision. At the same time, the device shapes are also significantly different. The navigator has the advantage of reducing wounds and gastrocnemius nerve damage.

(9) Percutaneous minimally invasive surgery

A number of studies have shown that percutaneous minimally invasive incisions for Achilles tendon rupture are not significantly different from traditional incisions in terms of ankle plantar flexion strength and endurance. Percutaneous minimally invasive incisions have less bleeding and less trauma. In addition, there was no significant difference between the percutaneous minimally invasive and conventional incision groups in terms of Achilles tendon healing time, re-fracture rate, total postoperative weight bearing time, and time to return to work.

However, percutaneous minimally invasive surgery also has disadvantages: it is impossible to accurately locate the gastrocnemius nerve, which may damage the gastrocnemius nerve.

2.2 Visual suture technology

(1) Minimally invasive suture under ultrasound guidance

Although ultrasound is not a real visualization, it can show the height, degree, and severity of the Achilles tendon stump, which is of great significance in the suture of Achilles tendon rupture.

Intraoperative ultrasound makes surgery more accurate, and is a non-invasive exploration method that is easy to use and inexpensive, and it does not cause infection. Intraoperative ultrasound can guide the repair of Achilles tendon, and postoperative ultrasound can observe changes in blood flow at the suture. All in all, ultrasound guidance can provide a relatively more intuitive understanding, can make the stump better aligned, not only can increase the risk of re-fracture due to separation, but also reduce the subcutaneous nodules caused by excessive overlap of the stump.

(2) Endoscopic visual suture

Endoscopes provide true full visualization. Its advantages are more intuitive, clearer, and less damaging. Endoscopic assisted surgery can avoid the blindness and uncertainty of percutaneous surgery, and can also confirm whether the stump is tightly aligned.

Endoscopic surgery can avoid nerve damage, and it can also prevent tendon circumference injury. Endoscopic-assisted percutaneous suture may be the first choice for patients with cosmetic wound healing and shortened recovery time. However, the operation needs to be performed with the aid of endoscope. The technique is complicated, the learning curve is long, and there are few clinical reports, but it must be an important direction for future development.

Achilles tendon injuries are preventable.
First, be sure to warm up before exercising and fully stretch the Achilles tendon.
Secondly, people who are overweight and people who have not exercised for a long time are better to lose some fat and then play.
Third, don't get too tired, especially if your calf muscles are stiff, it's best to take a break.
Fourth, strengthen leg strength exercises.
Fifth, people over 35 should pay special attention to:
The number of blood vessels in the Achilles tendon decreases with age, and it is obvious after 35 years of age, and Achilles tendon injury is more likely to occur.
Sixth, pay attention to exercise posture and maintain correct body shape and pace. ^[14]