Achillotomy

Achillotomy, complete or partial severing of the Achilles tendon, having as its purpose the elimination of flexor contracture of the foot (so-called 'clubfoot' or 'horse foot', pes equinus), caused by functional insufficiency of the calf muscles. In 1828, Delpesch was one of the first to perform Achillotomy, but his case resulted in suppuration and ended unsuccessfully. In 1831, Stromeyer showed that this operation, indispensable for eliminating most contractures, can be performed without risk if done subcutaneously. Dieffenbach, having established strict indications for Achillotomy, proposed a special tenotome knife for its performance (see Tenotome). Subcutaneous Achillotomy has retained its validity to the present day—especially as a final act in the redression (forcible straightening) of clubfoot in small children. Technique of subcutaneous Achillotomy. The foot is fixed in the position of maximum extension to obtain the greatest possible tension of the tendon; the tip of the tenotome pierces the skin and fascia medial to the edge of the Achilles tendon, and the knife is inserted deep into the connective tissue between the tendon and bone, after which the blade of the tenotome is turned 90° to the ventral surface of the tendon, and the tendon is severed transversely. This act is accompanied by a characteristic sound—a crunch. With the development of antiseptic methods, open Achillotomy, proposed by Volkmann, came into use; many still employ it today, for example, in Jones' method, which consists of placing two silk sutures on the tendon at a distance of 1-1½ cm, then severing the tendon transversely between the sutures, and tying the silk threads together. The advantage of open Achillotomy over closed is that it is safer and allows for thorough severing of all shortened tendon fibers; the disadvantage is that it cannot be dosed, i.e., there is a danger of developing calcaneal foot, and the scar subsequently stretches. Therefore, many authors reject it as a method of choice, replacing it with achiloplasty, which allows for precise dosing of tendon lengthening, and consequently, the position of the foot. Of achiloplasty methods, the one by Bayer is well-known and most frequently used; it consists of the following: the tendon is incised longitudinally in the sagittal plane for a length of 5-7 cm in the shape of the letter Z, then the foot is corrected to a position at a right angle, and the ends of the tendon are sutured together. Vulpius and Prio-leau modified Bayer's method: they incised the tendon in the frontal plane into two parts—ventral and dorsal, then severed both halves transversely (the ventral part somewhat higher than the site of tendon attachment to bone and the dorsal at the site of transition of the tendon to muscle), corrected the foot, and sutured the ends of the tendon. In a similar manner, Lange also performed Achillotomy, lengthening the tendon until, with the foot in a position at a right angle, he obtained moderate tension of the tendon. Hacker and Poncet mention ladder Achillotomy. Nevertheless, one or another method of achiloplasty in many cases usually resulted in scar adhesions of the tendon with surrounding soft tissues and limited free mobility of the foot. Only in the last decade has the work of Biesalski brought clarity to the technique of Achillotomy and generally of tenoplasty; his 'physiological transplantation' is based on the free gliding of the tendon in its own sheaths—mesotenon and paratenon. Achillotomy according to Biesalski briefly comes down to the following: a small skin incision medial to the midline. The tendon sheaths (meso- and paratenon) are opened; an elevator is introduced between them and the tendon, then two silk loops are placed on the tendon at a distance of 1 cm from each other, so that these loops strangulate the tendon, which is then severed transversely on the elevator between the loops. The foot is corrected, the silk threads are tied tightly. The tendon sheaths (meso- and paratenon) are carefully sutured, and skin sutures are applied.