Effectiveness analysis of channel-assisted minimally invasive repair technique combined with flexor hallucis longus tendon transfer for Achilles tendon sleeve avulsion_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

KONG Lingtong ^1,2 , WANG Zhonghe ² , LIU Haoyu ^1,2 , ZHAN Nazhi ^1,2 ,  QI Hongzhe ^1,3 ,  CHEN Hua ^1,2

1. Chinese PLA General Hospital Medical School, Beijing, 100853, P. R. China;
2. Senior Department of Orthopedics, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, P. R. China;
3. Department of Orthopedics, the Ninth Medical Center of Chinese PLA General Hospital, Beijing, 100101, P. R. China;

Corresponding author：

QI Hongzhe, Email: qhz306@126.com; CHEN Hua, Email: chenhua0270@126.com

Keywords：

Achilles tendon rupture; Achilles tendon sleeve avulsion; suture anchor; bone tunnel; channel-assisted minimally invasive repair; flexor hallucis longus tendon transfer

DOI：

10.7507/1002-1892.202412038

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Objective To evaluate the effectiveness of the channel-assisted minimally invasive repair (CAMIR) technique combined with flexor hallucis longus (FHL) tendon transfer in the treatment of Achilles tendon sleeve avulsion. Methods A retrospective analysis was conducted on 17 patients with Achilles tendon sleeve avulsion who underwent CAMIR technique combined with FHL transfer between January 2019 and January 2023. The cohort comprised 13 males and 4 females, aged 32 to 65 years (mean, 49.7 years). Etiologies included sports-related injuries in 15 cases and blunt trauma in 2 cases. The interval from injury to surgery ranged from 4 to 368 days (median, 15 days). All patients exhibited calcification at the Achilles tendon insertion site, with 7 cases complicated by Haglund deformity. Postoperative complications were meticulously monitored, and tendon healing was assessed via MRI. Clinical outcome were evaluated using the visual analogue scale (VAS) score for pain, Tegner activity level rating scale, ankle activity score (AAS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Victorian Institute of Sport Assessment-Achilles (VISA-A) score, and subjective clinical scoring systems preoperatively and at last follow-up. Results The operation time was 50-62 minutes (mean, 56 minutes), and the intraoperative blood loss was 5-50 mL (mean, 19.7 mL). All patients were followed up 12-67 months (mean, 38 months). No postoperative complication, such as Achilles tendon re-rupture, incision infection, deep vein thrombosis, heel raise insufficiency, or sural nerve injury, was observed. At last follow-up, MRI examination confirmed satisfactory tendon healing in all cases. Significant improvements were noted in VAS scores, Tegner activity level rating scale, AAS scores, AOFAS ankle-hindfoot scores, and VISA-A scores compared to preoperative ones (P<0.05). At last follow-up, the subjective clinical score ranged from 6 to 10 (median, 9).Conclusion The CAMIR technique combined with FHL tendon transfer is a good treatment for repair of Achilles tendon sleeve avulsion, with good recovery of ankle function and few complications.

Citation： KONG Lingtong, WANG Zhonghe, LIU Haoyu, ZHAN Nazhi, QI Hongzhe, CHEN Hua. Effectiveness analysis of channel-assisted minimally invasive repair technique combined with flexor hallucis longus tendon transfer for Achilles tendon sleeve avulsion. Chinese Journal of Reparative and Reconstructive Surgery, 2025, 39(3): 264-270. doi: 10.7507/1002-1892.202412038 Copy

1.	Maffulli N, D’Addona A, Gougoulias N, et al. Ipsilateral free semitendinosus graft with interference screw fixation for surgical management of insertional acute Achilles tendon tears. Injury, 2020, 51 Suppl 3: S73-S79.
2.	Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or surgical treatment of acute Achilles’ tendon rupture. N Engl J Med, 2022, 386(15): 1409-1420.
3.	Gao S, Hu C, Wang Y, et al. Comparison of cortical versus cancellous bone fixation in tendon-to-bone healing with a rat trans-calcaneal suture model for Achilles tendon sleeve avulsion. J Orthop Surg Res, 2023, 18(1): 15. doi: 10.1186/s13018-022-03469-8.
4.	Kim JS, Kim MS, Kim DK, et al. Magnetic resonance imaging characteristics of a lateral ligament injury in acute ankle sprains among athletes. Orthop J Sports Med, 2023, 11(11): 23259671231207688. doi: 10.1177/23259671231207688.
5.	Yang YP, Wang DY, Wei LW, et al. Repair of Achilles sleeve avulsion: a new transosseous suture technique. J Orthop Surg Res, 2020, 15(1): 224. doi: 10.1186/s13018-020-01699-2.
6.	Choi JY, Lee SS, Song TH, et al. A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients. Arch Orthop Trauma Surg, 2023, 143(11): 6513-6520.
7.	Xiang N, Lin Y, Su X, et al. Assessing the application of barbed sutures in comparison to conventional sutures for surgical applications: a global systematic review and meta-analysis of preclinical animal studies. Int J Surg, 2024, 110(5): 3060-3071.
8.	Chen H, Ji X, Zhang Q, et al. Channel-assisted minimally invasive repair of acute Achilles tendon rupture. J Orthop Surg, 2015, 10: 167. doi: 10.1186/s13018-015-0310-9.
9.	Shamrock AG, Dreyer MA, Varacallo M. Achilles tendon rupture. Treasure Island (FL): StatPearls Publishing, 2024: 1-10.
10.	Lyons JG, Berkay FB, Minhas A. Epidemiology of sports-related tendon ruptures presenting to emergency departments in the United States. Am J Sports Med, 2024, 52(13): 3396-3403.
11.	Usman MA, Murtaza B, Winangun PAN, et al. Chronic rupture of achilles tendon caused by haglund’s deformity: A case report. Medicina (Kaunas), 2022, 58(9): 1216. doi: 10.3390/medicina58091216.
12.	Shi Q, Zhang T, Chen Y, et al. Local administration of metformin improves bone microarchitecture and biomechanical properties during ruptured canine achilles tendon-calcaneus interface healing. Am J Sports Med, 2022, 50(8): 2145-2154.
13.	Wu B, Zhang T, Chen H, et al. Exosomes derived from bone marrow mesenchymal stem cell preconditioned by low-intensity pulsed ultrasound stimulation promote bone-tendon interface fibrocartilage regeneration and ameliorate rotator cuff fatty infiltration. J Orthop Translat, 2024, 48: 89-106.
14.	吕晶同, 施又兴, 王云蛟, 等. 腱-骨结合部结构化界面修复的研究进展. 中国修复重建外科杂志, 2019, 33(9): 1064-1070.
15.	Kaneguchi A, Ozawa J, Yamaoka K. Effects of joint immobilization and treadmill exercise on articular cartilage after ACL reconstruction in rats. Orthop J Sports Med, 2022, 10(10): 23259671221123543. doi: 10.1177/23259671221123543.
16.	王旭, 杨腾云, 熊波涵, 等. 肩袖腱骨愈合中组织工程学再生的机制及问题. 中国组织工程研究, 2023, 27(18): 2928-2934.
17.	Xie Y, Li X, Liu S, et al. Quantitative magnetic resonance imaging-based tendon healing of different regions of the shoulder: Comparison between the suture-bridge and single-row techniques. Orthop J Sports Med, 2023, 11(1): 23259671221137835. doi: 10.1177/23259671221137835.
18.	Schumaier A, Kovacevic D, Schmidt C, et al. Defining massive rotator cuff tears: a Delphi consensus study. J Shoulder Elbow Surg, 2020, 29(4): 674-680.
19.	Fanter NJ, Davis EW, Baker CL. Fixation of the Achilles tendon insertion using suture button technology. Am J Sports Med, 2012, 40(9): 2085-2091.
20.	Işık Ç, Tahta M. Primary repair of Achilles tendon avulsions: Presentation of a novel technique and its comparison with suture anchor repair. J Orthop Surg (Hong Kong), 2017, 25(3): 2309499017739486. doi: 10.1177/2309499017739486.
21.	Wu H, Dong J, Dong D, et al. Correlation between the coaptation and regeneration of tendon stumps in endoscopic assisted Achilles tendon rupture repair. Orthop Surg, 2023, 15(10): 2627-2637.
22.	Bibbo C. Technique tip: limited dual incision technique for repair of Achilles sleeve avulsions. Foot Ankle Int, 2004, 25(7): 513-515.
23.	Longo UG, Candela V, Berton A, et al. Less invasive fixation of acute avulsions of the Achilles tendon: A technical note. Medicina (Kaunas), 2020, 56(12): 715. doi: 10.3390/medicina56120715.
24.	Liu CY, Wu TC, Yang KC, et al. Ultrasonography-guided minimally invasive surgery for Achilles sleeve avulsions. Foot Ankle Int, 2021, 42(5): 544-553.
25.	齐红哲, 朱正国, 常祖豪, 等. 新型跟腱缝合与常规跟腱缝合的生物力学特性对比研究. 解放军医学院学报, 2017, 38(6): 536-539.
26.	王中鹤, 曹文豪, 齐红哲, 等. 通道辅助微创吻合技术治疗急性跟腱断裂中保护套筒与腓肠神经位置关系解剖研究. 中国修复重建外科杂志, 2024, 38(11): 1325-1329.
27.	Mohd Rothi I, Åkerback M, Bister V. Bilateral distal Achilles tendon sleeve avulsion: a case report. J Med Case Rep, 2023, 17(1): 155. doi: 10.1186/s13256-023-03892-3.
28.	Ramelli L, Docter S, Kim C, et al. Single-row repair versus double-row repair in the surgical management of Achilles insertional tendinopathy: A systematic review. Orthop J Sports Med, 2024, 12(8): 23259671241262772. doi: 10.1177/23259671241262772.
29.	Challoumas D, Biddle M, Millar NL. Recent advances in tendinopathy. Fac Rev, 2020, 9: 16. doi: 10.12703/b/9-16.
30.	Maffulli N, Longo UG, Kadakia A, et al. Achilles tendinopathy. Foot Ankle Surg, 2020, 26(3): 240-249.
31.	Zhi X, Liu X, Han J, et al. Nonoperative treatment of insertional Achilles tendinopathy: a systematic review. J Orthop Surg Res, 2021, 16(1): 233. doi: 10.1186/s13018-021-02370-0.
32.	Khair RM, Stenroth L, Cronin NJ, et al. Exploration of muscle-tendon biomechanics one year after Achilles tendon rupture and the compensatory role of flexor hallucis longus. J Biomech, 2023, 152: 111586. doi: 10.1016/j.jbiomech.2023.111586.

1. Maffulli N, D’Addona A, Gougoulias N, et al. Ipsilateral free semitendinosus graft with interference screw fixation for surgical management of insertional acute Achilles tendon tears. Injury, 2020, 51 Suppl 3: S73-S79.
2. Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or surgical treatment of acute Achilles’ tendon rupture. N Engl J Med, 2022, 386(15): 1409-1420.
3. Gao S, Hu C, Wang Y, et al. Comparison of cortical versus cancellous bone fixation in tendon-to-bone healing with a rat trans-calcaneal suture model for Achilles tendon sleeve avulsion. J Orthop Surg Res, 2023, 18(1): 15. doi: 10.1186/s13018-022-03469-8.
4. Kim JS, Kim MS, Kim DK, et al. Magnetic resonance imaging characteristics of a lateral ligament injury in acute ankle sprains among athletes. Orthop J Sports Med, 2023, 11(11): 23259671231207688. doi: 10.1177/23259671231207688.
5. Yang YP, Wang DY, Wei LW, et al. Repair of Achilles sleeve avulsion: a new transosseous suture technique. J Orthop Surg Res, 2020, 15(1): 224. doi: 10.1186/s13018-020-01699-2.
6. Choi JY, Lee SS, Song TH, et al. A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients. Arch Orthop Trauma Surg, 2023, 143(11): 6513-6520.
7. Xiang N, Lin Y, Su X, et al. Assessing the application of barbed sutures in comparison to conventional sutures for surgical applications: a global systematic review and meta-analysis of preclinical animal studies. Int J Surg, 2024, 110(5): 3060-3071.
8. Chen H, Ji X, Zhang Q, et al. Channel-assisted minimally invasive repair of acute Achilles tendon rupture. J Orthop Surg, 2015, 10: 167. doi: 10.1186/s13018-015-0310-9.
9. Shamrock AG, Dreyer MA, Varacallo M. Achilles tendon rupture. Treasure Island (FL): StatPearls Publishing, 2024: 1-10.
10. Lyons JG, Berkay FB, Minhas A. Epidemiology of sports-related tendon ruptures presenting to emergency departments in the United States. Am J Sports Med, 2024, 52(13): 3396-3403.
11. Usman MA, Murtaza B, Winangun PAN, et al. Chronic rupture of achilles tendon caused by haglund’s deformity: A case report. Medicina (Kaunas), 2022, 58(9): 1216. doi: 10.3390/medicina58091216.
12. Shi Q, Zhang T, Chen Y, et al. Local administration of metformin improves bone microarchitecture and biomechanical properties during ruptured canine achilles tendon-calcaneus interface healing. Am J Sports Med, 2022, 50(8): 2145-2154.
13. Wu B, Zhang T, Chen H, et al. Exosomes derived from bone marrow mesenchymal stem cell preconditioned by low-intensity pulsed ultrasound stimulation promote bone-tendon interface fibrocartilage regeneration and ameliorate rotator cuff fatty infiltration. J Orthop Translat, 2024, 48: 89-106.
14. 吕晶同, 施又兴, 王云蛟, 等. 腱-骨结合部结构化界面修复的研究进展. 中国修复重建外科杂志, 2019, 33(9): 1064-1070.
15. Kaneguchi A, Ozawa J, Yamaoka K. Effects of joint immobilization and treadmill exercise on articular cartilage after ACL reconstruction in rats. Orthop J Sports Med, 2022, 10(10): 23259671221123543. doi: 10.1177/23259671221123543.
16. 王旭, 杨腾云, 熊波涵, 等. 肩袖腱骨愈合中组织工程学再生的机制及问题. 中国组织工程研究, 2023, 27(18): 2928-2934.
17. Xie Y, Li X, Liu S, et al. Quantitative magnetic resonance imaging-based tendon healing of different regions of the shoulder: Comparison between the suture-bridge and single-row techniques. Orthop J Sports Med, 2023, 11(1): 23259671221137835. doi: 10.1177/23259671221137835.
18. Schumaier A, Kovacevic D, Schmidt C, et al. Defining massive rotator cuff tears: a Delphi consensus study. J Shoulder Elbow Surg, 2020, 29(4): 674-680.
19. Fanter NJ, Davis EW, Baker CL. Fixation of the Achilles tendon insertion using suture button technology. Am J Sports Med, 2012, 40(9): 2085-2091.
20. Işık Ç, Tahta M. Primary repair of Achilles tendon avulsions: Presentation of a novel technique and its comparison with suture anchor repair. J Orthop Surg (Hong Kong), 2017, 25(3): 2309499017739486. doi: 10.1177/2309499017739486.
21. Wu H, Dong J, Dong D, et al. Correlation between the coaptation and regeneration of tendon stumps in endoscopic assisted Achilles tendon rupture repair. Orthop Surg, 2023, 15(10): 2627-2637.
22. Bibbo C. Technique tip: limited dual incision technique for repair of Achilles sleeve avulsions. Foot Ankle Int, 2004, 25(7): 513-515.
23. Longo UG, Candela V, Berton A, et al. Less invasive fixation of acute avulsions of the Achilles tendon: A technical note. Medicina (Kaunas), 2020, 56(12): 715. doi: 10.3390/medicina56120715.
24. Liu CY, Wu TC, Yang KC, et al. Ultrasonography-guided minimally invasive surgery for Achilles sleeve avulsions. Foot Ankle Int, 2021, 42(5): 544-553.
25. 齐红哲, 朱正国, 常祖豪, 等. 新型跟腱缝合与常规跟腱缝合的生物力学特性对比研究. 解放军医学院学报, 2017, 38(6): 536-539.
26. 王中鹤, 曹文豪, 齐红哲, 等. 通道辅助微创吻合技术治疗急性跟腱断裂中保护套筒与腓肠神经位置关系解剖研究. 中国修复重建外科杂志, 2024, 38(11): 1325-1329.
27. Mohd Rothi I, Åkerback M, Bister V. Bilateral distal Achilles tendon sleeve avulsion: a case report. J Med Case Rep, 2023, 17(1): 155. doi: 10.1186/s13256-023-03892-3.
28. Ramelli L, Docter S, Kim C, et al. Single-row repair versus double-row repair in the surgical management of Achilles insertional tendinopathy: A systematic review. Orthop J Sports Med, 2024, 12(8): 23259671241262772. doi: 10.1177/23259671241262772.
29. Challoumas D, Biddle M, Millar NL. Recent advances in tendinopathy. Fac Rev, 2020, 9: 16. doi: 10.12703/b/9-16.
30. Maffulli N, Longo UG, Kadakia A, et al. Achilles tendinopathy. Foot Ankle Surg, 2020, 26(3): 240-249.
31. Zhi X, Liu X, Han J, et al. Nonoperative treatment of insertional Achilles tendinopathy: a systematic review. J Orthop Surg Res, 2021, 16(1): 233. doi: 10.1186/s13018-021-02370-0.
32. Khair RM, Stenroth L, Cronin NJ, et al. Exploration of muscle-tendon biomechanics one year after Achilles tendon rupture and the compensatory role of flexor hallucis longus. J Biomech, 2023, 152: 111586. doi: 10.1016/j.jbiomech.2023.111586.

Chinese Journal of Reparative and Reconstructive Surgery

Effectiveness analysis of channel-assisted minimally invasive repair technique combined with flexor hallucis longus tendon transfer for Achilles tendon sleeve avulsion

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