OBJECTIVE: To explore the methods of treatment for old achilles tendon rupture merging with skin defect. METHODS: By following up retrospectively 10 patients from February 1995 to December 2001, we analyzed the operative methods, the points for attention and the results. Gastrocnemius musculocutaneous flaps were used in 3 cases, foot lateral skin flaps in 4 cases, superior medial malleolus skin flaps in 2 cases, and sural neural skin flap in 1 case. The Achilles tendon was sutured directly in 8 patients, with Lindholm’s technique in 2 patients. RESULTS: All flaps survived and the wound healed well in 8 cases and reruptured in 2 cases. According to Yin Qing-shui’s criteria to test the efficacy, the results were excellent in 5 patients, good in 4 and poor in 1. CONCLUSION: Repairing the old Achilles tendon rupture merging with skin defect by use of microsurgery has good results and plays an important role in reducing joint contracture and stiffness, and in saving the ability to push forward and flex.
Objective To observe the clinical outcome of primary repair of the tissue defects of the Achilles tendon and skin by thigh anterolateral free flap and free iliotibial tract. Methods From January 2000 to January 2005, the thigh anterolateral free flap and the iliotibial tract were used to primarily repair the defects of the Achilles tendon and skin in 11 patients (7 males and 4 females, aged 6-45 years). The defects of the skin and Achilles tendon were found in 6 patients, and the defects of the Achilles tendonand skin accompanied by the fracture of the calcaneus were found in 5 patients.The defect of the Achilles skin was 6 cm×5cm-14 cm×8 cm in area. The defect of the Achilles tendon was 511 cm in lenth. The skin flap was 11 cm×6 cm-17 cm×11 cm in area.The iliotibial tract was 7-13 cm in length and 3-5 cm in width. The medial and lateral borders were sutured to from double layers for Achilles tendon reconstruction. The woundon the donor site could be sutured directly in 5 patients, and the others could be repaired with skin grafting. Results After operation, all the flaps survived and the wound healed by first intention. The followup of the 11 patients for 6 mouths-4 years (average, 30 months) revealed that according to Yin Qingshui’s scale, the result was excellent in 6 patients, goodin 4, and fair in 1. The excellent and good rate was 99%. The results showed a significant improvement in the “heel test” and the Thompson sign, and both were negative. No complications of ulceration on the heel and re-rupture of the Achiles tendon occurred. Conclusion The primary repair of the tissue defects of the Achilles tendon and skin by free grafting of the anterolateral femoral skin flap and the iliotibial tract is an effective surgical method.
Objective To investigate of effectiveness of free fascia lata flap assisted by indocyanine green angiography (ICGA) in treatment of Myerson type Ⅱ and Ⅲ chronic Achilles tendon ruptures. Methods A clinical data of 14 patients with Myerson type Ⅱ and Ⅲ chronic Achilles tendon ruptures between March 2020 and June 2024 was retrospectively analyzed. All Achilles tendon defects were repaired with the free fascia lata assisted by ICGA during operation. There were 12 males and 2 females with an average age of 45.4 years (range, 26-71 years). The causes of Achilles tendon rupture included sports injury in 10 cases, Achilles tendon-related tendinopathy in 3 cases, and glass laceration injury in 1 case. The time from Achilles tendon rupture to operation was 4-40 weeks (median, 4.5 weeks). Preoperative MRI examination showed that the defect length of the Achilles tendon was 2-5 cm (mean, 3.2 cm). The operation time and intraoperative blood loss were recorded. The color Doppler ultrasound (CDU) and MRI were taken to observe the foot blood vessels and the tendon healing. The visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, Achilles Tendon rupture score (ATRS), and range of motion of the ankle joint were used to estimate the pain and function of ankle joint. Results All operations of the 14 patients were successfully completed. The operation time ranged from 3.00 to 4.50 hours (mean, 3.60 hours). The intraoperative blood loss ranged from 10 to 50 mL (mean, 36.4 mL). After operation, 1 patient had exudation at the recipient site, which healed after dressing change; the other incisions healed by first intention. All incisions at the donor sites healed by first intention. All patients were followed up 6-36 months (mean, 11.4 months). The CDU of the foot at 1 month after operation showed that the blood flow signal of the perforating vessels of the fascia lata flap was clear. The ankle MRI at 2 months after operation showed the good continuity of the Achilles tendon. No complication such as the Achilles tendon re-rupture, ankle stiffness, or scar contracture occurred during follow-up. Compared with preoperative score, the AOFAS score, ATRS score, and plantar flexion range of motion significantly increased at 1, 3, and 6 months after operation (P<0.05), while the VAS score and dorsiflexion range of motion significantly decreased (P<0.05). The AOFAS score, ATRS score, and VAS score at 3 and 6 months further improved when compared with those at 1 month (P<0.05); however, there was no significant difference in the range of motion of the ankle joint (P>0.05). There was no significant difference in above indicators between 3 and 6 months after operation (P>0.05). Conclusion The treatment of Myerson type Ⅱ and Ⅲ chronic Achilles tendon ruptures with free fascia lata flaps under the guidance of ICGA has the advantages of precise design, fast healing, and a wide range of adaptability.
Objective To investigate the effectiveness of modified percutaneous suture in repairing acute closed Achilles tendon rupture by comparing with conventional open suture. Methods Between January 2006 and October 2009, 50 patients with acute closed Achilles tendon rupture were treated with modified percutaneous suture by making 5 small incisions at both sides of Achilles tendon and zigzag suture (improved group, n=22) and with Kessler suture (conventional group, n=28), respectively. No significant difference was found in gender, age, time from injury to operation between 2 groups (P gt; 0.05). Results In improved group, the patients achieved healing of incisions by first intention after operation and nocomplication occurred; however, incision infection occurred in 1 case, Achilles tendon re-rupture in 1 case, and incision scar contracture in 2 cases in conventional group. The operation time of improved group [(38.7 ± 6.6) minutes] was significantly shorter (t= —12.29, P=0.00) than that of conventional group [(52.3 ± 6.9) minutes]; the blood loss of improved group [(4.9 ± 2.0) mL] was significantly less (t= —25.20, P=0.00) than that of conventional group [(40.7 ± 7.1) mL]. The patients were followed up 2-3 years (mean, 29.9 months). The American Orthopaedic Foot and Ankle Society (AOFAS) score was 99.6 ± 1.0 in improved group and was 98.4 ± 3.0 in conventional group, showing no significant difference between 2 groups (t=1.66, P=0.10). Conclusion Comparison with conventional open suture, modified percutaneous suture has some advantages, such as easy operation, less complications, rapid recovery of limb function, and so on. Modified percutaneous suture is one of the best choices for the treatment of acute closed Achilles tendon rupture.
Objective To evaluate the effectiveness of flexor hallucis longus tendon harvested using a minimally invasive technique in reconstruction of chronic Achilles tendon rupture. Methods Between July 2006 and December 2009, 22 patients (22 feet) with chronic Achilles tendon rupture were treated, including 16 males and 6 females with a median age of 48 years (range, 28-65 years). The disease duration was 27-1 025 days (median, 51 days). Twenty-one patients had hoofl ikemovement’s history and 1 patient had no obvious inducement. The result of Thompson test was positive in 22 cases. The score was 53.04 ± 6.75 according to American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system. MRI indicated that the gap of the chronic Achilles tendon rupture was 4.2-8.0 cm. A 3 cm-long incision was made vertically in the plantar aspect of the midfoot and a 1 cm-long transverse incision was made in a plantar flexor crease at the base of the great toe to harvest flexor hallucis longus tendon. The flexor hallucis longus tendon was 10.5-13.5 cm longer from tuber calcanei to the end of the Achilles tendon, and then the tendon was fixed to the tuber calcanei using interface screws or anchor nail after they were woven to form reflexed 3-bundle and sutured. Results Wound healed by first intention in all patients and no early compl ication occurred. Twenty-two patients were followed up 12-42 months (mean, 16.7 months). At 12 months after operation, The AOFAS ankle and hindfoot score was 92.98 ± 5.72, showing significant difference when compared with that before operation (t= —40.903, P=0.000). The results were excellent in 18 cases, good in 2 cases, and fair in 2 cases with an excellent and good rate of 90.9%. No sural nerve injury, posterior tibial nerve injury, plantar painful scar, medial plantar nerve injury, and lateral plantar nerve injury occurred. Conclusion Chronic Achilles tendon rupture reconstruction with flexor hallucis longus tendon harvested using a minimally invasive technique offers a desirable outcome in operative recovery, tendon fixation, and complications.
ObjectiveTo investigate the effectiveness of channel-assisted minimally invasive repair system (CAMIR) in treatment of the Myerson types Ⅰ and Ⅱchronic Achilles tendon rupture.MethodsBetween May 2016 and August 2017, 19 patients with Myerson types Ⅰ and Ⅱchronic Achilles tendon ruptures were treated with CAMIR. There were 14 males and 5 females, aged from 21 to 48 years, with an average age of 34.5 years. The disease duration was 5-9 weeks (mean, 7.5 weeks). The preoperative Thompson tests of affected ankles showed positive. There were 11 cases of Myerson type Ⅰwith the gaps of Achilles tendon defect of 1-2 cm (mean, 1.58 cm), and 8 cases of Myerson type Ⅱwith the gaps of Achilles tendon defect of 2.5-4.0 cm (mean, 3.16 cm). The ankle dorsiflexion and plantarflexion range of motion were measured before and after operation; the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to assess the patients’ ankle joint function.ResultsNo major blood vessels, nerves, and other tissue structures were damaged during the operation; 3 cases of Myerson type Ⅰ were converted to Myerson type Ⅱ according to the gaps of the defect after the scar tissue was removed during the operation. After operation, the depressed part of the Achilles tendon disappeared, the continuity of the tendon was restored, and the Thompson tests were negative. All 19 patients were followed up 12-25 months, with an average of 14 months. All incisions healed by first intention, and no infection and skin necrosis occurred; all the pre-injury activities and exercise were restored at 6 months after operation. During the follow-up period, no heel pain or re-rupture occurred. At last follow-up, except that there was no significant difference in ankle dorsiflexion range of motion of Myerson type Ⅰ patients (t=2.118, P=0.071), the AOFAS ankle and hindfoot score, ankle plantarflexion range of motion of Myerson types Ⅰ and Ⅱ patients, and ankle dorsiflexion range of motion of Myerson type Ⅱ patients were significantly improved when compared with preoperative values (P<0.05). According to AOFAS ankle and hindfoot function score, the ankle joint function of type Ⅰ patients was excellent in 7 cases and good in 1 case, and of type Ⅱ patients were excellent in 8 cases, good in 2 cases, and fair in 1 case.ConclusionCAMIR is safe and effective in the treatment of Myerson types Ⅰ and Ⅱ chronic Achilles tendon rupture with fewer complications and better functional recovery of ankle joint.
Old achilles tendon rupture accompanied by skin defect was a common amp; annoying problem in clinic. From June, 1985 to June, 1996, 18 cases with this kind of injury were treated by one stage repair of the tendon and skin defect. In this series, there were 15 males and 3 females, the length of tendon defects were ranged from 4 cm-6.1 cm, and the area of skin defect were ranged from 5.9 cm x 3 cm to 8.2 cm x 6 cm. The procedures were: (1) to debridement of the wound thoroughly; (2) to repair the achilles tendon; (3) to repair the skin defect with kinds of pedicle flap; (4) immobilization of ankle and knee for 6 weeks. No infection was occured after the operation. The flaps survived in all cases. After follow-up for one year in 15 cases, 12 patients went back to their work. It was concluded that (1) achilles tendon rupture should be treated carefully and properly during the emergency operation; (2) different methods should be selected according to the length of tendon defect; (3) because of its high survival and retained sensation after operation, the flap pedicled with posterior lateral malleolar artery is the best choice for repairing the skin defect.
Objective Platelet-rich plasma (PRP) can promote wound heal ing. To observe the effect of PRP injection on the early heal ing of rat’s Achilles tendon rupture so as to provide the experimental basis for cl inical practice. Methods Forty-six Sprague Dawley rats were included in this experiment, female or male and weighing 190-240 g. PRP and platelet-poor plasma (PPP) were prepared from the heart arterial blood of 10 rats; other 36 rats were made the models of Achilles tendon rupture, and were randomly divided into 3 groups (control group, PPP group, and PRP group), 12 rats for each group. In PPP and PRP groups, PPP and PRP of 100 μL were injected around the tendons once a week, respectively; in the control group, nothing was injected. The tendon tissue sample was harvested at 1, 2, 3, and 4 weeks after operation for morphology, histology, and immunohistochemistry observations. The content of collagen type I fibers also was measured. Specimens of each group were obtained for biomechanical test at 4 weeks. Results All the animals survived till the end of the experiment. Tendon edema gradually decreased and sliding improved with time. The tendon adhesion increased steadily from 1 week to 3 weeks postoperatively, and it was relieved at 4 weeks in 3 groups. There was no significant ifference in the grading of tendon adhesion among 3 groups at 1 week and at 4 weeks (P gt; 0.05), respectively. The inflammatory cell infiltration, angiogenesis, and collagen fibers were more in PRP group than in PPP group and control group at 1 week; with time, inflammatory cell infiltration and angiogenesis gradually decreased. Positive staining of collagen type I fibers was observed at 1-4 weeks postoperatively in 3 groups. The positive density of collagen type I fibers in group PRP was significantly higher than that in control group and PPP group at 1, 2, and 3 weeks (P lt; 0.05), but no significant difference was found among 3 groups at 4 weeks (P gt; 0.05). The biomechanical tests showed that there was no significant difference in the maximal gl iding excursion among 3 groups at 4 weeks postoperatively (P gt; 0.05); the elasticity modulus and the ultimate tensile strength of PRP group were significantly higher than those of control group and PPP group at 4 weeks (P lt; 0.05). Conclusion PRP injection can improve the healing of Achilles tendon in early repair of rat’s Achilles tendon rupture.
Objective To explore the value of wide-awake local anesthesia no tourniquet (WALANT) technique in the treatment of acute Achilles tendon rupture. MethodsIn a prospective randomized controlled trial, 48 patients with acute Achilles tendon rupture who met the criteria between March 2020 and October 2020 were randomly divided into two groups according to 1∶1 distribution, with 24 cases in each group. The study group used WALANT technique and the control group used epidural anesthesia with tourniquet for channel-assisted minimally invasive repair (CAMIR). There was no significant difference between the two groups in gender, age, injured side, cause of injury, distance from broken end of Achilles tendon to calcaneal tubercle, and time from injury to hospitalization (P>0.05). The operating room use time (from patients entering the operating room to leaving the operating room), intraoperative blood loss, hospital stay, and the highest pain score [using Numerical Rating Scale (NRS)] during operation and at 1 day after operation were recorded and compared between the two groups. The tourniquet adverse reactions in the control group were recorded. The functional recovery was evaluated by the scoring method of American Orthopedic Foot and Ankle Society (AOFAS) at 12 months after operation. ResultsThe operation was successfully completed in both groups. The operating room use time and hospital stay in the study group were significantly less than those in the control group (P<0.05), but the difference in the intraoperative blood loss between the two groups was not significant (t=0.429, P=0.670). There was no significant difference in the highest NRS score during operation between the two groups (t=1.671, P=0.101); the highest NRS score in the study group at 1 day after operation was significantly lower than that in the control group (t=−6.384, P<0.001). In the control group, 13 patients had different degrees of tourniquet adverse reactions, including tourniquet regional pain, local swelling, blisters, thigh numbness, and discomfort. The patients in both groups were followed up 12-18 months, with an average of 13.9 months. The motor function of all patients returned to normal at 12 months after operation. The difference in AOFAS scores between the two groups was not significant (t=0.345, P=0.731). There was no complication such as sural nerve injury, local infection, and secondary rupture in both groups. ConclusionThe application of WALANT combined with CAMIR technique in the treatment of acute Achilles tendon rupture has good anesthetic and effectiveness, avoids the adverse reactions of tourniquet, and reasonably saves social medical resources.
Objective To evaluate the biomechanical property of tendons repaired with the modified Kessler suture combined with " 8” suture, and to provide evidence for the clinical application of this suture methods in repairing acute Achilles tendon rupture. Methods Forty frozen flexor digitorum longus tendons from fresh pork hind leg were randomly assigned into 4 groups, 10 specimens each group. In group A, the tendons were dissected transversely at the midpoint to forming the model of tendon with transversely cutting injury. The tendons in groups B, C, and D were dissected transversely at the midpoint, then a 2 cm segment of tendon from the incision in each side was dissected longitudinally with 1 mm internal to forming " frayed tendon” model. All the tendons were sutured with2-0 non-absorbable suture material with different suturing methods: in group A, the tendons with transversely cutting injury model with Krackow suture, and in the groups B, C, and D with Krackow suture, Kessler suture, and the modified Kessler suture combined with " 8” suture separately. All repaired tendons were fixed onto the biomechanical testing machine. The length, width, and thickness of each side and midpoint of the tendons were recorded, and the cross-sectional area was calculated. The tendons were stretched at a speed of 15 mm/minutes until failure (suture avulsion or rupture). The computer automatically recorded the maximum load, stress, strain, the failure displacement, and the stiffness. These biomechanical parameters of tendons in different groups were analyzed and compared. Results There was no significant difference in the length and cross-sectional area of each tendon among 4 groups (F=0.245, P=0.863; F=0.094, P=0.963). Two tendons in group B, 1 in group C, and 1 in group D were excluded because of tendon slipping; all tendons in group A and 8 tendons in group B failured due to suture rupture, 9 tendons in group C due to suture slipping, and 9 tendons in group D due to 3 sutures slipping from tendon tissue together. The maximum load, the maximum stress, the maximum strain, the failure displacement, and the stiffness of the tendons between groups A and B showed no significant difference (P>0.05). The maximum load, the maximum stress, and the stiffness of the tendons in group D were larger than those in both groups B and C (P<0.05), but no significant difference was found in the maximum strain and the failure displacement between groups B, C, and D (P>0.05). The maximum load, the maximum stress, the failure displacement, and the stiffness of the tendons in group B were larger than those in group C (P<0.05), but the difference of maximum strain between groups B and C was not significant (P>0.05). Conclusion The modified Kessler suture combined with " 8” suture can provide better biomechanical property of the repaired tendon compared with other suture approaches.