ผ่าตัดยืดเอ็นร้อยหวายผ่านทางผิวหนัง
Percutaneous Achilles Tendon Lengthening
Percutaneous Achilles Tendon Lengthening
Introduction
Achilles tendon contracture is postulated to be a root of numerous foot and ankle pathology. The initial treatment consists of stretching exercise and night splint but it these fail, surgical treatment is indicated. The surgical treatment includes open, percutaneous, and endoscopic techniques. The traditional treatment is open and percutaneous technique and the endoscopic technique has gained increasing popularity in the past decade. The previous study demonstrated that the percutaneous is the shortest operative time but there are complications including Achilles tendon rupture, overlengthening, and weakness of plantarflexion. This chapter will be focusing on the surgical technique, outcomes, and complications of the percutaneous triple hemi-section (Hoke technique).
There are various techniques of percutaneous Achilles tendon lengthening including tenotomy, double, and triple hemisection. In 1914,5 Hibbs described percutaneous Achilles tendon lengthening for treatment of equinus contracture.5 Percutaneous Triple Hemisection of Achilles tendon (Hoke) was described by Hatt and Lamphier in 19473 and this technique is currently use to treat patient with equinus contracture. In addition, PATL is fastest procedure for lengthening of Achilles tendon.4 It can be performed conjunction with various foot and ankle pathology such as total ankle replacement, diabetic foot ulceration, flatfoot reconstruction, and cavovarus foot reconstruction. However, if a severe deformity is corrected by the triple hemisection method, there will be an increased chance of complete rupture, because the distance between the hemisections is too short for the deformity.
Surgical technique
The patient is placed supine on the operative table and it can be performed with or without tourniquet. The surgical site is marked and the limb is prepped and draped above the knee. The leg is elevated from the bed and held in maximum dorsiflexion by the assistant until the surgeon can see the posterior of the leg clearly. The skin overlying of the Achilles tendon and there are 3 stab incisions as shown in Figure 1. The first is approximately 3-4 cm proximal to the insertion site and the second is approximately 3-4 cm proximal to the first incision and the third stab incision is approximately 3-4 cm proximal to the second incision. The tendon cut is performed two medially and one laterally by starting the distal one medially, the middle one laterally, and the proximal one medially. The blade is inserted longitudinally perpendicular to the skin and tendon. Once the blade passes through the skin and the length of the Achilles tendon, it is turn 90 degrees toward the medial direction and cut approximately one third of the tendon for the proximal and distal incision and repeated the same manner but turns the blade laterally for the middle portal. Thereafter the ankle is manipulated to dorsiflex until the ankle has dorsiflex 10-15 degrees. Author usually does not suture the incision and the sterile dressing is applied with the long posterior splint in neutral position of the ankle joint.
The patient remains non-weight bearing in a splint or cast for 3 to 4 weeks and is then transitioned to partial weightbearing in a protective cam boot for an additional 4 to 6 weeks. At 8 to 10 weeks postoperatively, the patient is transitioned to a walking or running shoe. Progressively increased weight bearing activity is allowed as tolerated when the patient has pain free, and a gradual step-up program with physical therapy is initiated.
Figure
Fig 1: Three stab skin incision was created on the middle of the Achilles tendon, A=distal incision, B=Middle incision, C=Proximal incision.
Fig 2: Demonstrate the ankle is held in maximum dorsiflexion and No.15 blade is turned 90 degrees toward the medial side of the leg at the proximal stab incision.
Outcomes and Complications
The previous literature has been reported the successful treatment of patients with equinus contracture using percutaneous Achilles tendon lengthening technique with minimal complications.2,7-9 However, many complications have been reported following this procedure. There are approximately 13 percent of rupture rate after PATL.1 There is 2-10 percent of calcaneal gait due to overlengthening of the Achilles tendon.6 Other complication has been reported including sural nerve neuritis, infection, hematoma, painful scar, and weakness of plantar flexion.5
Conclusion
Percutaneous Achilles tendon lengthening is fastest procedure to lengthen the Achilles tendon; however, the precise surgical technique is required in order to prevent serious complications such as over lengthening and complete Achilles tendon rupture.
References
1. Berg, EE: Percutaneous Achilles tendon lengthening complicated by inadvertent tenotomy. J Pediatr Orthop. 12: 341-343, 1992.
2. Haro, AA, 3rd; DiDomenico, LA: Frontal plane-guided percutaneous tendo Achilles' lengthening. J Foot Ankle Surg. 46: 55-61, 2007. http://dx.doi.org/10.1053/j.jfas.2006.10.006
3. Hatt, RN; Lamphier, TA: Triple hemisection: a simplified procedure for lengthening the Achilles tendon. N Engl J Med. 236: 166-169, 1947. http://dx.doi.org/10.1056/NEJM194701302360502
4. Lee, WC; Ko, HS: Achilles tendon lengthening by triple hemisection in adult. Foot & ankle international. 26: 1017-1020, 2005.
5. MS., D: Ankle equinus. , 1992.
6. Nishimoto, GS; Attinger, CE; Cooper, PS: Lengthening the Achilles tendon for the treatment of diabetic plantar forefoot ulceration. Surg Clin North Am. 83: 707-726, 2003. http://dx.doi.org/10.1016/S0039-6109(02)00191-3
7. Piriou, P; Tremoulet, J; Garreau De Loubresse, C; Judet, T: [Subcutaneous tenotomy of Achille's tendon in adults for ankle stiffness. A review of 80 cases]. Rev Chir Orthop Reparatrice Appar Mot. 86: 38-45, 2000.
8. Willrich, A; Angirasa, AK; Sage, RA: Percutaneous tendo Achillis lengthening to promote healing of diabetic plantar foot ulceration. J Am Podiatr Med Assoc. 95: 281-284, 2005.
9. Yosipovitch, Z; Sheskin, J: Subcutaneous Achilles tenotomy in the treatment of perforating ulcer of the foot in leprosy. Int J Lepr Other Mycobact Dis. 39: 631-632, 1971.
