Biomechanical Comparison And Clinical Studies Of Minimally Invasive "Locking Block Modified Krackow" For Repairing Achilles Tendon Rupture

PART I Biomechanical Comparison of Locking Block Modified Krackow and Other 3 Techniques for repairing Achilles Tendon During a Simulated Early Rehabilitation ProtocolObjective:To compare the biomechanics of LBMK with Giftbox,Kessler and PARS for repairing Achilles tendon rupture during a simulated early rehabilitation protocol.Methods:Forty fresh bovine Achilles tendon specimen were randomly assigned to LBMK group,Giftbox group,Kessler group and PARS group.The LBMK technique and Giftbox technique were used as the main suture configurations,and transverse sutures were used as secondary suture configurations in the LBMK group and Giftbox group.3 Kessler sutures were used in the Kessler group.2 transverse sutures and a locking suture were used in the PARS group.Each repaired specimen was subjected to two cyclic loading protocols(20?100 N,20?190 N).The gapping between the tendon ends was measured after each stage of loading.Finally,all specimens underwent a load-to-failure test at a stretching rate of 25 mm/s,the catastrophic failure load and stiffness were measured.Results:After the first loading stage,the mean tendon gapping of the LBMK group were the smallest(0.76±0.44mm),there was no statistically significant difference with Giftbox group(p>0.05),but significantly lower than the Kessler group and PARS group(p<0.05).All specimen gapping was less than 5 mm.The elongation of the first 10 cycles accounted for more than 50%of the of the total elongation observed.After the second stage,the average gapping of the LBMK group was 3.68±1.08 mm,the Giftbox group was 4.07±1.28mm(p>0.05).but significantly lower than the Kessler group and the PARS group(p<0.05).There were only 2 specimen with a gap of more than 5 mm in the LBMK group,3 specimen in the Giftbox group,8 specimen in the Kessler group,and all specimen were more than 5 mm in the PRAS group.Finally,the catastrophic load to failure of LBMK group was significantly higher than the other three groups,and the difference was statistically significant(p<0.05).The stiffness of LBMK group was significantly higher than the Kessler group and PARS group(p<0.05),however,the difference was not statistically significant compared with the Giftbox group(p>0.05).Conclusion:The biomechanical strength of LBMK suture method is significantly higher than the other groups,but the four methods can meet the early movement of the ankle after Achilles tendon repair.The LBMK and Giftbox suture methods can allow for early full weight-bearing immediately.PART2 Minimally Invasive "Locking Block Modified Krackow" and Open "Giftbox" repair Achilles Tendon Rupture with the early rehabilitation:Prospective TrialObjective:To investigate the clinical effects of Minimally Invasive-LBMK(MI-LBMK)technique and Open-Giftbox(Open-GB)technique for repairing Achilles tendon rupture with the early rehabilitation by a prospective comparative study.Methods:From March 2015 to January 2018,38 patients met the inclusion criteria,22 patients underwent MI-LBMK repair,and 16 patients underwent Open-GB repair.In the MI-LBMK group,two 2?3cm minimally invasive incisions were used,and the LBMK technique was performed.In the Open-GB group,the Giftbox technique was performed with a surgical incision of about 8?10 cm in the posterior medial side.Both groups were added a transverse suture to form a 6-strand and reinforcement repair.Early rehabilitation was used after operation in both groups.Postoperative complications,MRI images of the tendon gap and cross-sectional area(CSA),relative Achilles tendon rest angle(ATRA),heel-rise repetition ratio(HRRR),heel-rise height ratio(HRHR),ROM of dorsiflexion and plantarflexion,calf circumference ratio(CCR),AOFAS score and Achilles tendon Total Rupture Score(ATRS)were used to compare between the two groups.Results:The incidence of complications in the MI-LBMK group was 9.1%,and that in the Open-GB group was 25%.There was no re-rupture in both groups.The MRI sagittal T2 phase showed that Achilles tendon gap was 1.32±1.01 mm in MI-LBMK group and 1.02±0.66mm in Open-GB group(p>0.05)at 6 weeks.While at 3 months,the T2 phase showed that the Achilles tendon continuity was intact and no obvious gap was observed in both groups,and the tendon cross-section area(CSA)of the MI-LBMK group was higher than Open-GB group(p<0.05).There was no significant difference in the relative ATRA between the both groups at each follow-up period(p>0.05).At 3 months after surgery,The ATRA was the highest at postoperative 3 month and did not fall to normal after 12 months..There was no statistically significant difference in the HRRR,HRHR and ATRS score(p>0.05).The ROM of ankle dorsiflexion in the MI-LBMK group were higher than Open-GB at 3 months.The AOFAS score of MI-LBMK was significantly higher than Open-GB,but the two groups were almost normal after 12 months,but the ATRS score still did not rise normal.Conclusion:1.The MI-LBMK technique and Open-GB technique are both safe and effective methods for repairing Achilles tendon,but the MI-LBMK technique has a lower incidence of wound complications2.The gap of the Achilles tendon rupture site in the MI-LBMK repair is small and does not affect the tendon healing.3.There was a correlation between the ATRA and Achilles tendon function after surgery.4.MI-LBMK repair had less effect on the daily function of patients within 6 months after surgery,but the two groups tended to be consistent at 12 months.PART 3 Endoscopic Assisted LBMK Combined with V-Y Advancement or Tendon Transfer for Chronic Achilles Tendon RuptureObjective:To investigate the clinical efficacy of endoscopic assisted LBMK combined with V-Y advancement or tendon transfer for the treatment of chronic Achilles tendon rupture.Methods:Eight patients with chronic Achilles tendon rupture were admitted from July 2016 to May 2018,they were all male.There were 4 cases of badminton injury,3 cases basketball injury,1 case hiking injury.The mean interval from rupture to surgery was 9.1 w(range,4?30w)of injury to surgery,MRI examination showed a mean tendon gap of 4.2±0.7cm(range,3?5.6 cm).Take 2 portals beside the rupture site,and debride the scar tissue and the hematoma with the endoscope.Make 2 separate longitudinal incisions at 2.5 cm from the rupture site to completely release the gastrocnemius muscle and the tendon.Then sutured the tendon with LBMK technique and reinforced with V-Y advancement or FHL transfer.Results:Of the 8 patients,6 cases underwent V-Y advancement,1 case underwent FHL transfer,and 1 case underwent V-Y advancement combined with FHL transfer.All patients were followed up to 9 to 15 months(mean 12.2 months)after surgery.All the incisions were healed.MRI examination showed that the Achilles tendon continuity was intact and no obvious gap was observed at 3 months postoperative.At the last follow-up,the relative Achilles tendon rest angle(ATRA)was-5.51±0.36°,The heel-rise height ratio(HRHR)of the affected side was 0.82±0.05,which did not return to the healthy side.The heel-rise repetition ratio(HRRR)was 0.96±0.04,which was close to the healthy side.The mean AOFAS score improved from 55.63±7.95 points preoperatively to 93.13±3.04 points at last follow-up.The mean ATRS score improved from 52.63±6.76 preoperatively to 89.5±2.62 points at last follow-up,which was significantly improved compared with preoperative.The difference was statistically significant(p<0.05).Conclusion:Endoscopically assisted LBMK combined with V-Y advancement or tendon transfer for the treatment of old Achilles tendon rupture has the advantages of minimally invasive,less complications and quick recovery,but it needs the support of endoscopic technology.