RU2703184C2 - Minimally invasive method of surgical treatment of subcutaneous rupture of achilles tendon and device for its implementation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology, and can be used for treating subcutaneous rupture of Achilles tendon. Method involves application of a perineal suture of Cuneo on a proximal and distal fragments of an Achilles tendon and further immobilization of a limb. Suture is performed by puncturing the skin at four points of the proximal end of the Achilles tendon with one polymeric monofilament. Both ends of monofilament are passed through distal end of tendon in-series at 45–46 degrees to a vertical axis with an outlet on the opposite side of the tendon such that the distal and proximal ends of the tendon are connected on two parallel polymeric monofilament, which through skin punctures on the heel of the heel are fixed through the distraction mechanism of the device according to paragraph 2 to foot retainer with tension force providing for comparison of tendon ends. Complete removal of monofilament is performed 4–5 weeks after the operation with subsequent therapeutic exercises. Device for implementing method of treating subcutaneous rupture of Achilles tendon according to paragraph 1 consists of a sock, a collar with an adjustable fastener, a thickened sole and a rigid heel. Distraction mechanism connected to a winded polymer monofilament is mounted into the toe part of the thickened sole. Distraction mechanism is calibrated by the tension of the polymer monofilament in kilograms and consists of a housing, a rotary stock, a mechanism of a ratchet and a button lock.

EFFECT: invention provides accuracy of comparison of ends of an Achilles tendon, reduced injuries and reduced length of rehabilitation due to suturing of the tendon and use of a device for foot fixation.

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Description

The proposed invention relates to medicine and can be used in traumatology and orthopedics for the treatment of Achilles tendon ruptures, both in acute and chronic ruptures.

A known method for the surgical treatment of acute subcutaneous rupture of the Achilles tendon, including the application of a Cuneo transdermal suture to the proximal and distal tendon fragments, strand bonding and subsequent immobilization, characterized in that an additional cruciate suture is placed on the proximal and distal fragments in the frontal plane. Adaptation loops are formed from the connected ends of the threads, two on each side, in the proximal tendon fragment and then passed through the formed tunnels into the distal tendon fragment to the level of the calcaneus, where they are fixed by the periosteum to meet each other, the ends of the threads on each side are connected to each other ( Kotelnikov G.P., Chernov A.P., Losev I.D., Dolgushin D.A. Method for surgical treatment of fresh subcutaneous rupture of the Achilles tendon // Patent RU No. 2393804 C1 A 17B 17/59 from 2009; Kotelnikov G. P., Chernov A.P., Losev I.D., Bykhovets V.I. Spo of surgical treatment of fresh subcutaneous Achilles tendon rupture // Patent RU №2433795 C1 A61V 17/59 of 2010)

The disadvantage of this method is the low strength of the tendon suture, possible damage to the stitching thread about the edges of the formed channels in the calcaneus, the functional insufficiency of the triceps, technical difficulties in eliminating diastasis of the ends of the tendon along the length, cumbersome immobilization in the postoperative period.

There is a method of applying a loop tendon suture, which consists in conducting folded in half through the trunk through the center of the proximal and distal ends of the tendon with the formation of loops and free ends on opposite sides of different ends of the tendon. Spend the free ends of the threads over the tendon subcutaneously. Pass one free end of the thread through the loop with the formation of a subcutaneous tendon loop at both ends of the tendon and tie knots on one side of the different ends of the tendon (Vlasov M.V. Method of applying a percutaneous submersible suture of the Achilles tendon // Patent RU No. 2398543 A61B 17/56 from 2009).

The disadvantages of the proposed method is the uncontrolled nature of the tension of the stitched thread in the thickness of the tendon, suggesting poor adaptation of the ends of the tendon, prolonged and cumbersome immobilization in the postoperative period.

With chronic ruptures of the Achilles tendon, an open method of surgical treatment is known, which includes an incision above the rupture area of up to 6 cm, with cutting off the short fibular muscle and moving its tendon to the diastasis between the ends of the Achilles tendon, tensioning the muscle-tendon complex and fixing the proximal stump tendons to the calcaneus with a screed of two U-shaped loop-shaped sutures, then the end of the displaced tendon of the short fibular muscle is carried out longitudinally upward in the thickness and along the surface of the imalnoy stump, cut through the intermuscular septum and extend fascial bed Achilles tendon. After that, the tendon is fixed to the tendon stretch of the calf muscle and to the tendon stumps (Shimbaretsky A.N. Restoration of the Achilles tendon during ruptures. Methodical recommendations. Nizhny Novgorod 2003; Shimbaretsky A.N. Method for surgical treatment of chronic Achilles tendon ruptures // Patent for the invention RU No. 2289345 C1 АВВ 17/56 dated 2005)

The disadvantages of the proposed method is the availability of surgical access to the area of rupture of the Achilles tendon, the use of their own tissues to close the defect, which leads to the loss of another function of the foot. The proposed suture is also static, it requires a large amount of suture material, which can be a source of infection, which increases the risk of secondary complications, in the postoperative period, prolonged and cumbersome immobilization is used.

The prototype of the proposed method is the Trachuk-Dedushkin-Erokhov method (patent for the invention of the Russian Federation No. 20088833, Cl. A61B 17/56, 1990; Trachuk A.P. Treatment of patients with closed injuries of the Achilles tendon with a percutaneous removed suture: Abstract for the study. senior candidate of medical sciences - St. Petersburg, 1995, p. 23, KHAN). Suture is carried out percutaneously (without cutting and exposing the tendon), through the proximal end of the tendon, the threads are cross-shaped to the lateral surfaces of the tendon and further under the skin along the distal end of the tendon and lateral surfaces of the calcaneus to the calcaneal region, where the ends of the threads are fixed on a gypsum pad with tension. As a piercing thread, kapron monofilament (fishing line) with a diameter of 0.7 m is used, which is then removed from the tendon by crossing one end and pulling it after the other. Fixation of the lower limb in a plaster cast with fixation of the knee and ankle joints for 4 weeks with the equinus position of the foot, after which the dressing is shortened, and the foot is brought to the correct position for another 4 weeks.

This method has a number of significant drawbacks. It, like the previous methods, uses a static suture, which generally depends on the tactile muscle strength of the operating surgeon and, after tying the knots, completely eliminates further impact on the gap zone. Another distinctive disadvantage of this method is the intra-barrel threading only through the proximal end of the tendon, which fundamentally violates the accuracy of matching the ends of the tendon, since the distal end goes into subluxation when tensioning, which creates additional diastasis of the ends in the rupture zone. In clinical conditions, this suture is not used if more than 6 hours have passed after the injury, which significantly narrows the possibilities of this method. As a result, the periods of immobilization of the lower limb are increased, the rehabilitation period is delayed.

The objective of the proposed group of inventions is the development of a minimally invasive method for surgical treatment of subcutaneous rupture of the Achilles tendon and a device for its implementation, which allows for accurate matching of the ends of the Achilles tendon, low-invasiveness of the operation, reduction of the healing time with an increase in the cosmetic effect.

To solve this problem, the percutaneous suture of Kuneo is performed by puncture of the skin at four points of the proximal end of the Achilles tendon with one polymer monofilament, both ends of the monofilament are passed through the distal end of the tendon alternately through the walls at an angle of 44-46 degrees, with the exit on the opposite side of the tendon so that the and the proximal ends of the tendon are connected on two parallel polymer monofilaments, which are fixed with optimal force through the punctures of the skin on the plantar surface of the heel Iya, depending on the weight of the patient in the device for supporting the foot.

Another difference is that the device consists of a toe, socks with an adjustable fastener, a thickened sole and a stiff heel, characterized in that a distraction mechanism is mounted in the heel part of the thickened sole, and a distraction mechanism mounted in the heel part of the thickened sole is connected to the nylon wound monofilament, consisting of a rotary rod, ratchet mechanism and push-button lock. This allows you to compare the distal and proximal ends of the tendon and hold them throughout the entire period of immobilization.

Another difference is that the thickness of the nylon monofilament is from 0.7 mm to 0.9 mm, depending on the muscle mass and weight of the patient, for which the distraction mechanism is calibrated by the tensile strength of the polymer monofilament in kilograms. The relationship and interaction of the essential features of the proposed method and device for its implementation ensure the achievement of a new technological medical result, based on the accuracy of matching the Achilles tendon with the possibility of walking the patient with the device and full load on the leg immediately after the operation.

The invention is illustrated in FIG. 1-3

The proposed method and device is used as follows:

A long needle made of mild steel makes a puncture of the skin and Achilles tendon in the transverse direction above the gap zone by 4-5 cm, through and through. The thickness of the polymer monofilament may vary from 0.7 to 0.9 mm. The length of the polymer monofilament is distributed in half and amounts to a total of 70-80 cm. Alternately, the right 1 and left 2 ends of the polymer monofilament are drawn through the previous puncture on the skin, through the thickness of the proximal end of the tendon at an angle of 46 degrees, with access to the skin on the opposite side. Next, the needle bends in an arcuate manner, through the same holes on the skin, the needle with fishing line is alternately passed through the distal end of the tendon intrasternally, on the opposite side of the tendon with a puncture of the skin on the opposite side of the heel 3, 4. Both ends of the polymer monofilament 3 and 4 are at a distance from each other the other 2-2.5 cm. The ends of the polymer monofilament are fixed in the device (distractor) 5, fixed in a shortened individually made thickened sole 6, through the holes 7 and 8 are tied together. The polymer monofilament is screwed onto the pivot rod 9, and with the help of a ratchet 10 of the disk attractor, it is fixed in tension by turning the lock button 11. Thus, the monofilament is tensioned, which in turn acts on the proximal end of the Achilles tendon approaches the distal end along the line, while adapts and directs both ends of the tendon, preventing the distal end from leaving in subluxation. After elimination of diastasis, the monofilament distraction stops and a full load on the leg with crutches is allowed until the pain is stopped, after which walking without crutches is allowed, and movements in the knee and ankle joints are not limited. Ultrasound control and elastography is carried out 1 time in 10-14 days. At 4-5 weeks, the fishing line is completely removed, the device and the patient are engaged in exercise therapy for 2 to 3 weeks. In the same way, diastasis is eliminated with acute, chronic ruptures and with primary gunshot defects of the Achilles tendon.

Clinical example 1 - Patient A. with an acute rupture - born in 1953, was treated at the trauma unit from 06/13/2013 to 06/18/2013. Diagnosis: Subcutaneous complete rupture of the left Achilles tendon from 06/08/2013. while playing football I felt a sharp pain in the lower third of the left lower leg on the back surface, restriction of plantar flexion. 06/14/2013, the operation was performed - subcutaneous, distraction, the removed suture of the left Achilles tendon, with the fixation of the left foot and lower leg in the holder of the foot with a distraction device. According to the control ultrasound of the left Achilles tendon from 06/14/2013 - diastasis of the ends of the tendon is eliminated. 5 weeks after the operation, the fishing line was removed, a positive result was obtained.

Clinical example 2 - A patient with a chronic rupture - Patient B., born in 1947 was treated at the department from 02.24.2015 to 03.03.2015. Diagnosis: An old subcutaneous complete rupture of the right Achilles tendon from 01/12/2015. According to the patient, he was injured on 01/12/2015, while downhill skiing fell, while the ski did not come off. At the time of the injury, I felt a sharp pain in the area of the right Achilles tendon. Surgical treatment denied. It is recommended to wear an orthosis bandage for fixing the ankle joint, limiting the load on the right leg. Within 2–3 weeks there were repeated injuries with an unsuccessful load on the fingers of the right foot. An ultrasound of the Achilles tendon was performed again on February 16, 2015 - a complete rupture of the tendon with end diastasis of up to 5.5 cm was revealed. On February 26, 2015, an operation was performed - a subcutaneous distraction removed suture of the right Achilles tendon, fixation of the right foot in a device consisting of a sock, socks with an adjustable fastener of a thickened sole and a rigid heel; a distraction mechanism is mounted in the heel part of the thickened sole. Inpatient treatment for 8 days. Ultrasound of the right Achilles tendon from 02/28/2015 - diastasis between the ends of a torn tendon is completely eliminated. Outpatient treatment for 7 weeks.

Clinical example 3 - Achilles tendon gunshot defect. Patient I., born 1983 Clinical diagnosis: Combined fragmentation wound of the lumbar region and limbs, laceration of the lower third of the left leg with damage to the Achilles tendon from 02/14/2015. On 12.03.2015, the operation was performed - a suture of the left Achilles tendon according to the above method, immobilization. In the postoperative period, the wound in the left Achilles tendon healed by primary intention, the sutures were removed on the 14th day. According to ultrasound data dated March 16, 2015, the diastasis of the tendon ends was eliminated. The fishing line was removed after 6 weeks.

The developed minimally invasive method for treating Achilles tendon ruptures and a device for its implementation are reliable, durable, low traumatic, have a good cosmetic effect, can be used for acute and chronic ruptures, and the consequences of military injuries and wound complications. It allows you to restore the physiological tone of the gastrocnemius muscle and the length of the Achilles tendon using dynamic damper tension.

A device for implementing this method is reliable and easy to manufacture.

Claims (4)

1. A minimally invasive method for surgical treatment of subcutaneous rupture of the Achilles tendon, including the application of a percutaneous Kuneo suture to the proximal and distal fragments of the Achilles tendon and subsequent immobilization of the limb, characterized in that the percutaneous suture is performed by puncture of the skin at four points of the proximal monovial end of the Achilles, both ends of the monofilament through the distal end of the tendon are alternately intra-barrel at an angle of 45-46 degrees. to the vertical axis with access on the opposite side of the tendon so that the distal and proximal ends of the tendon are connected on two parallel polymer monofilaments, which are fixed through the skin punctures on the plantar surface of the heel through the distraction mechanism of claim 2 to the stopper with tension force providing the comparison of the ends of the tendon, and the complete removal of monofilament is carried out 4-5 weeks after surgery with subsequent physical therapy. 2. A device for implementing a minimally invasive method for surgical treatment of subcutaneous rupture of an Achilles tendon according to claim 1, consisting of a sock, a vamp with an adjustable fastener, a thickened sole and a stiff heel, characterized in that a distraction mechanism is connected to the heel part of the thickened sole connected to a wound polymer monofilament. 3. The device according to p. 2, characterized in that the distraction mechanism is calibrated by the tensile strength of the polymer monofilament in kilograms. 4. The device according to p. 2, characterized in that the distraction mechanism consists of a housing, a rotary rod, a ratchet mechanism and a push button lock.

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