Do you know the four commonly used suture repair methods for Achilles tendon rupture?
Achilles tendon rupture is often caused by a sudden turn around with the foot as the center, resulting in Achilles tendon rupture. This type of Achilles tendon rupture is caused by tearing, and the rupture is irregular in a ponytail shape. Another common type of Achilles tendon rupture is an open injury caused by direct violent action on the heel. Closed injuries are sometimes not noticed by the patient themselves and are mistakenly treated as leg contusions, resulting in delayed treatment. After diagnosing Achilles tendon rupture, timely surgical treatment should be performed.
Surgical incision and suture are currently the standard surgical procedures for repairing Achilles tendon rupture, with good clinical results. However, the incidence of complications such as incision infection, wound rupture, and even Achilles tendon exposure is high. The follow-up results of percutaneous minimally invasive suture method for Achilles tendon showed that it has minimal damage, low rate of re rupture, and most importantly, the incidence of wound complications is greatly reduced, approaching conservative treatment.
The treatment principle of whether to perform surgical repair and suturing for complete rupture of the closed Achilles tendon has always been a controversial topic. Some scholars believe that the repair method for Achilles tendon rupture is scar healing, and conservative treatment is chosen. As long as the ankle joint is in plantar flexion position, the ruptured Achilles tendon can eventually heal, while surgical incision carries the risk of incision infection; Another group of scholars insist on recommending surgical treatment, believing that precise suturing of the ruptured Achilles tendon after surgical treatment greatly increases the strength of postoperative Achilles tendon plantarflexion, and the optimal surgical plan can greatly reduce the incidence of surgical complications. For the recurrence and complications of conservative and surgical treatment, studies have reported that the incidence of Achilles tendon rupture is 12.6% for conservative treatment and only 3.5% for surgical treatment; The incidence of wound infection is 4% for surgical treatment and 0% for conservative treatment. The rate of re rupture in the percutaneous minimally invasive suture of Achilles tendon surgery is similar to that of traditional surgery, while the incidence of infection is lower, only 2.4%. 1. Non surgical treatment often uses Achilles tendon boots, cast or braces, which fix the foot in plantar flexion for 8-12 weeks. 2. Selection of incision and suture repair methods: (1) Fresh Achilles tendon rupture, with uneven ends mostly in the shape of a ponytail, and a defect of about 3cm in the proximal retraction of the rupture end. The Achilles tendon rupture ends can be in contact with each other and sutured end-to-end through ankle plantar flexion, such as Krackow method, Bunnell method, end end modified Kessler suture method with fine silk thread intermittent reinforcement suture; Percutaneous minimally invasive suturing can also repair acute Achilles tendon rupture.
(2) Subacute injury, Achilles tendon rupture for more than 10 days, Achilles tendon contracture often reaches 3-6cm, with mild degeneration and necrosis of the broken end. Relying solely on ankle plantarflexion cannot achieve end-to-end contact of the Achilles tendon broken end. Suggest Abraham V-Y suture repair.
(3) Old injury, Achilles tendon rupture lasting more than 3 weeks, at which point Achilles tendon contraction often exceeds 6cm. It is recommended to use the Lindholm method (gastrocnemius aponeurosis reversal surgery) to repair the Achilles tendon rupture defect. If it is found during surgery that the strength of the Achilles tendon after suture repair is insufficient, the following methods can be used to strengthen the Achilles tendon, such as White Krynick method, Rugg and Bogoe method, simple plantar muscle reinforcement, use of peroneal short muscle and artificial material repair, and fascia lata transplantation suture methods.
(4) Achilles tendon injuries caused by direct violence are often accompanied by defects in the heel bone and skin. It is difficult to successfully repair Achilles tendon defects through local loosening, tension reduction, suturing, or free skin graft transplantation. Currently, the following methods are commonly used: ① tendon transposition with muscle pedicle to repair Achilles tendon defects; ② Transposition of vascularized tissue flap for repairing Achilles tendon defects; ③ Free transplantation of composite tissue flap with vascular anastomosis for repairing Achilles tendon defects.
The 2Krackow suture incision repair method is suitable for acute Achilles tendon rupture. Achilles tendon rupture should be operated on before swelling appears, otherwise surgery should be performed after swelling subsides and skin wrinkles appear to avoid incision infection, skin necrosis, and adhesion between Achilles tendon and skin. [Position and Anesthesia] The patient should be in a prone position, under local anesthesia or continuous epidural or sciatic nerve block anesthesia, with an inflatable tourniquet tied to the upper and middle thighs. Disinfect the skin of the affected limb with regular iodine and ethanol, lay a sterile cloth sheet, and stick a sterile film. Drive blood with a tourniquet. [Incision] A longitudinal incision is made on the inner side of the Achilles tendon, with a length of 10-15 cm (the incision is 1 cm away from the Achilles tendon, meaning the incision is kept away from the center to prevent local irritation caused by shoe friction on the Achilles tendon). The Achilles tendon is exposed through three main incisions: the posterior midline approach, the lateral approach, and the medial approach. The midline approach provides better exposure of the Achilles tendon, but after long-term scar healing, the scar is prone to wear on the heel of the shoe and cause pain. In addition, the suture opening of the incision is at the highest tension point, which affects the healing of the incision and can easily lead to Achilles tendon exposure; The lateral approach can easily damage the heel branch of the sural nerve, causing a lack of skin sensation in the heel area and leading to long-term problems such as malnutrition in the nerve supply of the skin; The longitudinal approach on the inner side of the Achilles tendon is relatively safe, which can avoid the damage to the posterior cutaneous nerve of the calf caused by the lateral approach, and reduce the high rates of skin necrosis and incision infection in the posterior straight incision.
Cut open the skin, subcutaneous tissue, and deep fascia to protect the connection between the deep fascia and subcutaneous tissue (suture the skin and deep fascia with silk thread and fix them on the surrounding skin), that is to say, do not perform subcutaneous tissue dissection, and protect the peritendinous tissue to fully expose the ruptured Achilles tendon (Figure 1A, B).
Figure 1: Krackow suture incision for repairing acute Achilles tendon rupture: incision.
Sharp incision should be made to the deep fascia (tendon outer membrane) to avoid damage to the subcutaneous nutrient vascular network and fat liquefaction caused by blunt dissection, thereby reducing skin necrosis, infection, and adhesion at the incision site; Protect the peritendinous tissue and avoid damaging the vascular bundle that enters the Achilles tendon from the ventral side (Figure 2).
Figure 2 Surface anatomy around Achilles tendon A. Lateral view; B. Interior view. [Suture] Use Krakcow suture No. 2 to suture the ruptured Achilles tendon, and intermittently reinforce the suture with 2-0 absorbable antibacterial Pudis suture (Figure 3C). Strengthening suturing to embed the knot at the broken end, and intermittent suturing of the tendon outer membrane to locate the knot in subcutaneous tissue can reduce knot irritation. After repair, the Achilles tendon should have sufficient strength and tension, so as not to block the blood supply to the severed end and affect healing; Suture the tissue around the tendon and wrap it completely around the Achilles tendon to reduce postoperative adhesion of the Achilles tendon (Figure 3D); After surgery, the plaster tray is fixed in the flexed and plantar positions to reduce tension at the anastomotic site. Leave a negative pressure drainage tube in place, with a high position and the distal end of the drainage tube placed at the lowest point of the wound; If a rubber strip is used for drainage, the outlet should be located at the lowest position of the drainage, opposite to the negative pressure drainage tube. The deep fascia is tightly closed, and the effective method is to stitch it one needle at a time in an "8" shape without knotting. After complete suturing, the deep fascia is uniformly knotted and closed, while the knot is left under the skin (Figure 3E); Leave the suture knot deep during subcutaneous tissue suturing; Leave the suture knot deep during subcutaneous tissue suturing; Suture the skin to ensure a tight closure of the incision.
Figure 3: Krackow suture and incision repair of acute Achilles tendon rupture: suturing and fixation. [Fixation] Long leg cast or braces (Figure 8-5-1F, G, H) are used to fix the knee joint in a flexed position of 10 ° -15 ° and an ankle plantar flexion position of 30 ° (this position can relax the gastrocnemius muscle, with the lowest tension at the site of Achilles tendon rupture anastomosis, creating conditions for Achilles tendon healing under tension-free conditions). 3. Percutaneous minimally invasive suturing is suitable for the repair of acute Achilles tendon rupture, but the biggest problem is that suturing can cause damage to the sural nerve. Technological improvements can help reduce this complication. In 1977, Dr. Ma&Griddith first used and reported this method, but the sural nerve injury rate reached 13%. So some physicians have invented auxiliary suturing surgical instruments such as Mayo needle (BL059N), Achillon Achilles tendon stapler, etc. by using absorbable sutures or modified surgical incisions, in an attempt to reduce the risk of injury to the sural nerve. The most promising tool among them
It is an Achillon Achilles tendon stapler, which uses a "box" suture method. In clinical practice, we have found that the suture is prone to cutting the Achilles tendon, and there are doubts about the mechanical strength of early suture; The latest research shows that it cannot provide sufficient initial mechanical strength, only 1/10 of the Krackow suture method, so postoperative fixation and protection with plaster or braces are necessary; In addition, research on cadaveric surgical procedures has shown that the risk of sural nerve injury is extremely high, with a high incidence of 25.6% for direct suture puncture injury and suture on nerve injury. In 2007, China introduced the Achillon stapler. However, due to its unreliable suturing and damage to the gastrocnemius nerve, it has not been widely promoted and has been abandoned in clinical practice. Nevertheless, some of its concepts have provided new ideas for our research on percutaneous minimally invasive suturing technology for Achilles tendon.
1. Development and design of channel assisted suturing system In order to avoid iatrogenic damage to the sural nerve and concerns about the mechanical strength of suturing, Chen Hua et al. designed and developed a channel assisted minimally invasive Achilles tendon suturing system (CAMIR) based on the improved Bunnel suture method. In 2015, it was granted a national invention patent, and some literature has confirmed that this method has advantages over traditional suturing methods in reducing intraoperative bleeding and wound complications. This method (Figure 4) achieves percutaneous minimally invasive suturing of the Achilles tendon through five major techniques, which can avoid iatrogenic damage to the sural nerve.
Figure 4: Processing design diagram of the Achilles tendon channel assisted suturing system (CAMIR) using A. ProE software; B. Physical picture. 1. Specially designed auxiliary channel, through the skin, subcutaneous tissue, Achilles tendon sheath, with the sural nerve located outside the channel; 2. Center and eccentric guides guide suture stitching to avoid suture cutting caused by suture crossing; 3. The specially designed Trocar has a transverse blade with a 30 ° angle on the tip side that can cut the tendon sheath after passing through the deep fascia, allowing the channel and stapler to move together on the surface of the Achilles tendon, similar to sewing with a sewing machine.
(1) Technique 1 enables relative movement between the stapler and the Achilles tendon: Under normal circumstances, opening and exposing the Achilles tendon requires passing through the skin, subcutaneous tissue, and deep fascia, which wraps around the Achilles tendon to form a fiber
The Achilles tendon moves through this channel to complete plantarflexion and dorsiflexion of the ankle joint. The skin of the Achilles tendon has a certain degree of mobility, so to achieve relative sliding between the stapler and the Achilles tendon, a longitudinal incision must be made in the deep fascia. The side of the specially designed core of this system has a transverse blade with an angle of 30 ° that can be cut after passing through the deep fascia.
(2) Technology 2: Creating a safe suture channel to avoid damage to the sural nerve: Sharp incision of 5mm of the skin is made at the insertion point of the channel, and hemostatic forceps are inserted to bluntly separate the tissue from the deep fascia, especially the sural nerve; Then insert a specially designed sheath, penetrate the deep fascia, and enter the sheath of the Achilles tendon; Insert the same method into the contralateral channel; Adjust the cutting edge of the sheath to parallel the Achilles tendon direction, push the stapler up and down, and cut 1cm deep into the fascia; Insert the sleeve along the core and establish a suture channel. (3) Technology 3: Horizontal threading to prevent cross cutting of sutures: Specially designed neutral and eccentric suture guides to avoid cutting between horizontal threading sutures and causing suture breakage.
Figure 5: Bunnel Stitching Method A. Classic Stitching Method; B. Improve the Bunnel sewing method. (4) Technique 4: The suture inside the tendon sheath is pulled out from the incision site without increasing the incision: the uniquely designed inner arm strap thread pulls the suture out of the tendon sheath from the incision site. (5) Technique 5: Reconstruction of Achilles tendon insertion using a distal reconstruction sleeve: For injuries close to Achilles tendon insertion rupture, a specially designed stapler arm can establish a percutaneous channel between the deep fascia and the calcaneus, insert the sleeve, place sutures in the calcaneus drilling channel, and pull out the sutures using the stapler. 2. Minimally invasive repair of acute Achilles tendon rupture using Channel Assisted Suture (CAMIR) [Position and Anesthesia] The patient is placed in a prone position and subjected to sciatic nerve/lumbar plexus block anesthesia. A tourniquet is tied to the upper and middle thighs, and the lower limbs are drained with a tourniquet pressure of 320mmHg (1mmHg=0.133kPa).
After successful anesthesia, intravenous injection of 1g cefmetazole sodium is administered to prevent infection. [Suture Channel Establishment] Firstly, touch the site of Achilles tendon rupture and make a longitudinal incision perpendicular to the direction of Achilles tendon movement on its surface
A 1.5cm transverse incision. Cut open the skin, subcutaneous tissue, and Achilles tendon fascial sheath to expose the ruptured end of the Achilles tendon. Use Kocker forceps to clamp the proximal end of the ruptured Achilles tendon, pull out the incision, insert the CAMIR inner arm into the Achilles tendon fascial sheath, and clamp the Achilles tendon. Along the outer arm guide hole, make a 5mm long forceps incision on the skin surface. Use hemostatic forceps to push open the sural nerve that may be running inside the incision (Figure 6A). Insert a double-sided side blade pointed cone with a sleeve and a length of 1.5cm through the outer arm guide hole (Figure 6B), bluntly pierce the Achilles tendon fascial sheath, and push CAMIR towards the proximal and distal ends of the Achilles tendon (Figure 6C). Cut the fascial sheath 1.0-1.5cm with the side blade at the end of the pointed cone. Rotate the sleeve into the inner arm of the stapler along the pointed cone to complete the establishment of the suture channel (Figure 6D).
Figure 6: CAMIR minimally invasive repair of acute Achilles tendon rupture: channel establishment.
Suture: Thread the needle along the central or eccentric guide to complete the improved Bunnel suture method for grasping the proximal end of the ruptured Achilles tendon (Figure 7E). Pull out the CAMIR inner arm from the incision and draw out the suture (No. 2 Treasure Bond suture) from the incision to grasp the proximal end of the ruptured Achilles tendon (Figure 7F, G). Using the same method, grasp the distal end of the ruptured Achilles tendon with suture (Figure 7H), extract the suture, tighten the suture, tie the knot, and complete the suture fixation of the Achilles tendon (Figure 7I). Using 3-0 absorbable Weiqiao eight needle absorbable suture to intermittently strengthen the closure of the Achilles tendon stump and suture the surrounding tissue of the Achilles tendon. Close the incision layer by layer, apply pressure with elastic bandage, and loosen the tourniquet. Postoperative management and rehabilitation are the same as incision and repair methods.
Figure 7 CAMIR minimally invasive repair of acute Achilles tendon rupture: suturing. The 4Abraham V-Y suture method is suitable for repairing subacute Achilles tendon rupture. [Position and Anesthesia]
The patient is placed in a prone position, with a tourniquet attached to the proximal thigh. A straight incision of approximately 15cm is made on the inner side of the Achilles tendon attachment to the middle, paying attention to protecting the sural nerve and superficial peroneal nerve.
【 Incision 】 Cut open the Achilles tendon aponeurosis, investigate the extent of the injury, thoroughly remove the scar tissue at the severed end, and measure the length of the tendon defect in the knee joint at 30 ° flexion and ankle joint at 20 ° plantar flexion. If the defect length is 3-6cm, perform Abraham V-Y method (Figure 8). Make an inverted "V" - shaped incision about 1cm distal to the junction of the triceps muscle tendon in the calf, and the length of the two incisions that make up the "V" - shaped incision should be at least 1.5 times longer than the defect. Suture: Cut open the tendon sheath and move it downwards to complete end-to-end anastomosis. Use No. 2 polyester suture to improve the Kessler method for end-to-end suturing of Achilles tendon rupture, and use No. 2-0 polysaccharide 910 absorbable suture with eight needles to suture the inverted "V-Y" incision, repair the Achilles tendon fascia, and suture the wound. Postoperative treatment and rehabilitation are the same as incision repair.
Figure 8 Abraham V-Y suture repair for subacute Achilles tendon rupture. The Lindholm method is suitable for repairing old Achilles tendon rupture. [Position and exposure] The patient lies prone and makes a posterior arc-shaped incision from the middle of the calf to the heel bone. A deep fascia incision is made in the midline direction to expose the ruptured Achilles tendon. Clean up, repair and suture the broken end
First, clean the wound, repair the broken end, and use coarse silk thread or fine stainless steel thread for mattress suture, or use fine silk thread for intermittent suture.
Flip the gastrocnemius tendon and Achilles tendon flap: Cut a 7-8cm long and approximately 1cm wide gastrocnemius tendon and Achilles tendon flap from both sides of the proximal end of the ruptured Achilles tendon, flip them towards the distal end, keep the base at the proximal section of the Achilles tendon, and suture them onto the distal Achilles tendon. Suture the edges of the tendons and completely cover the ruptured area of the Achilles tendon by suturing the two tendons together. When the tension is high and there is a gap, the gastrocnemius tendon flap can be directly anastomosed with the distal end, and the proximal end can be reinforced and sutured. If there is a plantar tendon present, this tendon can be used for reinforcement. Suture the defect of the aponeurosis to close the gap left by the downward flipping of the tendon strip. Suture the tendon sheath and surrounding tissues and skin (Figure 9).
Figure 9 Lindholm method for repairing old Achilles tendon rupture. The infection rate after acute Achilles tendon rupture surgery is 7.15% due to the shallow location of the Achilles tendon, which is only covered by skin and thin subcutaneous tissue. It is recommended to avoid making a posterior midline incision on the surface of the Achilles tendon and performing sharp dissection
Pay attention to repairing the tissue around the Achilles tendon and thoroughly stop bleeding before closing the incision. However, the incidence of old injuries is even higher, reaching 27.78%, which may be due to the long time of seeking medical attention after injury and poor blood flow caused by scar formation at the severed end; There is a history of closed treatment at the Achilles tendon site before surgery; It is related to factors such as excessive local tension when closing the incision. The longitudinal incision on the inner side of the Achilles tendon causes less damage to the blood supply near the tendon, which not only avoids postoperative pain caused by shoe friction scars, but also avoids the incision being located in the area with the highest tension.
During surgery, attention should be paid to: (1) When repairing the ruptured Achilles tendon, it is required to plantarly flex the ankle joint as much as possible (at this time, the Achilles tendon should be relaxed, and excessive overlapping or shortening should be avoided. As long as the continuity of the Achilles tendon is restored, a certain tension should be maintained after the Achilles tendon is sutured. After suturing, the Thompson test should be performed on both sides, indicating that the tightness is appropriate). (2) The strength of Achilles tendon suture can independently maintain the ankle joint in a neutral position. (3) The Achilles tendon sheath must be fully repaired, and the deep fascia must be well aligned. The deep fascia can resist the tension of the Achilles tendon moving backwards towards the bowstring, reducing the tension on the skin and allowing it to be sutured without tension, avoiding the formation of edge wrinkles and ischemic necrosis caused by excessive local pressure on the skin. (4) Unless the tendon sheath is not sutured satisfactorily, try not to implant anti adhesion film to avoid increasing the difficulty of suturing. (5) Postoperative ankle joint plantarflexion fixation to avoid local compression; Using Kessler suture method, the ruptured ends of the Achilles tendon are anastomosed separately to repair the tendon membrane and reduce interference with blood circulation inside and outside the tendon. Emphasis is placed on minimally invasive procedures during postoperative adhesion surgery, with the principle of protecting and restoring blood circulation at the severed end as much as possible. Some surgical experience is as follows: (1) The blood supply of the Achilles tendon mainly comes from the tendon belly junction, tendon bone junction, and adjacent tissues. When making an incision on the inner side of the Achilles tendon, the skin, subcutaneous tissue, and deep fascia should be cut in sequence without separating them, and they should be pulled apart on both sides to expose the Achilles tendon sharply. Rough operation should be avoided to reduce the damage to the blood supply of the Achilles tendon, and blood circulation at the site of the rupture should be protected and restored as much as possible. (2) There is a semi-circular avascular area within 10-18mm proximal to the Achilles tendon insertion point, accounting for 1/2-2/3 of the ventral side of the Achilles tendon. Therefore, surgery should minimize operations in this area as much as possible. (3) Traditional Achilles tendon suturing with silk thread can easily cause tissue reactions and adhesion; Although steel wire has a light tissue reaction and high tensile strength, it is easy to cut tendons and requires secondary removal. Suggest Kessler suture with No.2 polyester suture, then intermittently strengthen the suture with 8-0 polysaccharide 910 eight needle absorbable suture, and close the tendon group with 3-0 polysaccharide 910 eight needle absorbable suture
Weaving; Smooth the fascia and Achilles tendon as much as possible, and repair the deep fascia around the Achilles tendon as much as possible to reduce postoperative adhesions.
(4) Thoroughly remove the ischemic necrotic tissue at the Achilles tendon stump, and remove the scar tissue at the stump for relatively old injuries. Rinse the surgical field with physiological saline before cutting the gastrocnemius fascia flap.
(5) The tension adjustment during Achilles tendon anastomosis is the most critical issue in Achilles tendon repair surgery. The tension during Achilles tendon anastomosis should be the same as that of the contralateral Achilles tendon. Excessive tension can lead to difficulty in dorsiflexion of the ankle joint, while insufficient tension can result in weak plantar flexion. Our suggestion is to check the tension of the healthy Achilles tendon at rest position (knee flexion 20 °, ankle plantar flexion 30 °) before surgery, and perform anastomosis and knotting under basically the same Achilles tendon tension during surgery to achieve satisfactory results.
(6) The timing of surgery is generally more than 3 weeks after rupture, with loss of tendon sheath elasticity, reduced inner diameter, prolonged tendon retraction, difficulty in traction, and significantly increased repair difficulty. There is a research report that patients who undergo surgical treatment within one week after fracture have an average plantar flexion of 91% of the healthy side, while those who undergo surgery for more than one week have a plantar flexion of only 74% of the healthy side. Our suggestion is that once the diagnosis is clear, relevant examinations should be further improved and surgery should be performed as soon as possible.
Reference: [1] Orthopedic Suture Tutorial/Edited by Tang Peifu, Gu Liqiang, Wu Kejian. -2nd edition. - Beijing: Tsinghua University Press, November 2020 [2] Chen Hua, Hao Ming, Zhang Wei, Gao Yuan, Liang Xiangdang, Zhang Qun, Guo Yizhu, Zhang Lihai, Tang Peifu Observation of the therapeutic effect of minimally invasive repair of acute closed Achilles tendon rupture using a channel assisted suturing system [J]. Chinese Journal of Reconstructive Surgery, 2015, 29 (1): 35-38. [3] Yang Ying, Cheng Anyuan, Xu Li, Song Qi Analysis of the therapeutic effect of minimally invasive surgery with channel assisted suturing system for acute closed Achilles tendon rupture [J]. Chinese Journal of Bone and Joint Injury, 2020, 35 (6): 647-649
