Percutaneous suturing of the ruptured Achilles tendon under local anesthesia.

A prospective study of modified percutaneous Achilles tendon repair performed from 1991 to 1997 under local anesthesia with a minimum 2-year follow-up is presented. There were 134 procedures in 124 men and 8 women (mean age, 37 years) treated within 7 days after acute total rupture. Postoperative care consisted of wearing a cast or soft-cast immobilization for 6 weeks. The procedure was well tolerated in all patients. There was 1 (0.7%) complete and 4 (3%) partial reruptures. Six patients (4.5%) developed transient sural neuritis that spontaneously resolved in 3 to 10 months. One case of deep venous thrombosis was successfully treated. There were no cases of increased postoperative dorsiflexion, deep infection, or necrosis. Eighteen patients (14%) had a slightly decreased range of ankle motion; 129 (98%) patients, including all high-caliber athletes, resumed all their previous activities, 22 of them (17%) with some minor complaints. The mean American Orthopedic Foot and Ankle Society's ankle-hindfoot score was 96 points. The proposed method offers a reasonable treatment option for acute total Achilles tendon ruptures, with a low number of complications and a low risk of sural nerve injury. The rerupture rate and return to preinjury activities is comparable to open procedures.     

Suture of achilles tendon rupture under local anesthesia

We operated on a consecutive series of 30 closed Achilles tendon ruptures under local anesthesia and without the use of a tourniquet. We had no reruptures or major complications, and the results were comparable to other series of operatively treated achilles tendon ruptures.     

Suture of achilles tendon rupture under local anesthesia

We operated on a consecutive series of 30 closed Achilles tendon ruptures under local anesthesia and without the use of a tourniquet. We had no re-ruptures or major complications, and the results were comparable to other series of operatively treated achilles tendon ruptures.     

Vascular changes in the ruptured achilles tendon and paratenon

Summary Thirty patients with ruptures of the Achielles tendon were studied. There were 21 men and 9 women with an average age of 36 years. Specimens from the tendon and paratenon in 24 were examined histologically. Tissue samples of 20 were studied by electron microscopy. Marked degenerative, obliterative and/or inflammatory vascular changes were found in all the ruptured tendons and their paratenon. Our findings indicate that poor vascularity play a role in the aetiology of rupture of the Achilles tendon.

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Résumé Des prélévements tissulaires de 30 patients traités à l'Institut National Hongrois de Traumatologie pour rupture du tendon d'Achille ont fait l'objet d'une étude anatomopathologique. Dans 24 cas, des prélévements paratendineux ont également été examinés. Les prélévements de 20 patients ont été étudiés par microscopie électronique. 21 des patients étaient des hommes et 9 des femmes, d'un âge moyen de 36 ans. Dans la plupart des cas de rupture du tendon d'Achille (24 cas) et du tissu paratendineux (18 cas), des altérations dégénératives, oblitérantes et occasionnellement nécrotiques des artères et des capillaires ont été constatées. Dans les 6 cas restants (20%), des altérations vasculaires inflammatoires ont été retrouvées, aussi bien dans le tissu tendineux que paratendineux. Une prolifération vasculaire marquée a souvent été notée dans le tissu paratendineux; on a fréquemment retrouvé des exsudats tiches en fibronectine, indiquant une perméabilité vasculaire accrue. Dans 4 cas la rupture siégeait au niveau de la jonction myotendineuse et de notables altérations vasculaires ont également été constatées dans les muscles. Des altérations vasculaires profondes, dégénératives, oblitérantes et/ou inflammatoires ont été mises en évidence dans tous les cas de rupture du tendon d'Achille et du tissu paratendineux. Ceci indique que ce type de modifications joue un rôle important dans la phyio-pathologie de ces ruptures.

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This work was supported by the Ministry of Education, Finland, and the Sigrid Juselius Foundation     

Percutaneous suturing of the ruptured Achilles tendon with endoscopic control

Introduction  A prospective study of modified percutaneous Achilles tendon repair performed between 1999 and 2005 under local infiltration anesthesia is presented; the study evaluated the results of percutaneous repair technique by visualization of the synovia under endoscopic control, followed by early functional postoperative treatment for surgical intervention of acute Achilles tendon ruptures. Patients  Sixty-two patients (58 males, 4 females, mean age 32) were treated by percutaneous suturing with modified Bunnel technique under endoscopic control within 10 days after acute total rupture. Physiotherapy was initiated immediately after the operation and patients were encouraged to weight-bearing ambulation with a walking brace-moon boot as tolerated. Full weight-bearing was allowed minimum after 3 weeks postoperatively without brace. Results  The procedure was tolerated in all patients. There were no significant ROM limitation was observed. Two patients experienced transient hypoesthesia in the region of sural nerve that spontaneously resolved in 6 months. Fifty-nine patients (95%) including professional athletes returned to their previous sportive activities, while 18 of them (29%) had some minor complaints. The interval from injury to return to regular work and rehabilitation training was 11.7 weeks (10–13 weeks). At the latest follow-up (mean: 46 months; range: 12–78 months), all the patients had satisfactory results with a mean American Orthopedic Foot and Ankle Society’s ankle-hindfoot score of 94.6. No re-ruptures, deep venous thrombosis or wound problems occurred. Conclusion  The proposed method offers a reasonable treatment option for acute total Achilles tendon rupture with a low number of complications. The rerupture rate and return to preinjury activities are comparable to open and percutaneous without endoscopic control procedures.     

Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty

BACKGROUND: Rupture of the patellar tendon after total knee arthroplasty is a rare and debilitating complication. Proper surgical management of this condition remains controversial. The purpose of this study was to review the results of reconstruction of a ruptured patellar tendon with an Achilles tendon allograft following total knee arthroplasty. METHODS: We reviewed our experience with the use of a fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to restore extensor function in nine patients with patellar tendon rupture following total knee arthroplasty (five primary and four revision). All patients were examined clinically and radiographically at an average of twenty-eight months. RESULTS: The average knee and functional scores improved from 26 and 14 points, respectively, before the surgery to 81 and 53 points after the surgery. The average extensor lag decreased from 44 degrees preoperatively to 3 degrees postoperatively, and the average range of motion of the knee increased from 88 degrees to 107 degrees. Two grafts failed in the early postoperative period. Both were repaired successfully. Radiographs showed an average proximal patellar migration of 17.8 mm, which did not appear to affect extensor function. CONCLUSIONS: This short-term follow-up study showed that once an Achilles allograft has healed, it can serve as a reliable reconstruction of a ruptured patellar tendon following total knee arthroplasty. This technique may be particularly suited for patients in whom the extensor mechanism was compromised by multiple prior operations. Continued follow-up is necessary to determine the long-term durability of these results.     

Operative repair of ruptured achilles tendon and functional after-treatment--I. Acute rupture

The results are described of primary operative repair of acute achilles tendon rupture with a simple suture technique and functional after-treatment, followed by immobilisation after a few days in a lower leg walking plaster with the foot in right angle position. In our experience with two groups of patients (64 cases) the described method appeared simple and safe, after-treatment is convenient for the patient and the results are good.     

Operative repair of ruptured achilles tendon and functional after-treatment--II. Delayed rupture

Purpose of surgical treatment of delayed rupture of the achilles tendon is repair of normal continuity with restoration of original length and muscle tension. Our experiences are described with 10 patients, using different surgical techniques, all based on the three-tissue bundle procedure (sandwich-technique). After-treatment was functional, followed by immobilisation in a lower leg walking plaster. Wound healing disturbances influenced healing time, but not the end-results. In secondary reconstruction of achilles tendon rupture, simple operative repair is the best prevention of complications.     

Percutaneous repair of acute closed ruptured achilles tendon: a new technique.

The technique of percutaneous suturing repair of acute closed rupture of the Achilles tendon, as described in this article, can be performed under local anesthesia without using an arterioconstrictive tourniquet. Eighteen patients have been successfully treated with this technique, 12 having been closely followed for more than 12 months, and 8 for more than 24 months. Preliminarly, this technique for repairing acute closed Achilles tendon ruptures appears more promising than open surgical repair or short leg equinus casts alone due to tendon continuity restoration, tendon strength restoration,and minimization of postoperative complications.     

Blood supply of the achilles tendon

The Achilles tendon is one of the most common sites of injury and rupture as a result of overuse. Evidence suggests that the pathogenesis of rupture could involve the pattern of its blood supply. With use of angiographic and histological techniques, the blood supply of the Achilles tendon was investigated in 12 human cadaveric specimens. Angiography confirmed Mayer's 1916 finding that the blood supply to the tendon is from three areas: the musculotendinous and osseotendinous junctions and the paratenon, with the posterior tibial artery providing the major contribution. However, qualitative and quantitative histological analyses in this study showed that the Achilles tendon has a poor blood supply throughout its length, as determined by the small number of blood vessels per cross-sectional area, which do not in general vary significantly along its length. In light of these findings, it is suggested that poor vascularity may prevent adequate tissue repair following trauma, leading to further weakening of the tendon.     

Arthroscopy under local anaesthesia

Sixty patients underwent arthroscopy of the knee as day cases using a local anaesthetic technique. This provided satisfactory operating conditions and high patient acceptability.     

Mini-cholecystectomy under local anaesthesia

OBJECTIVE: Reports of mini-cholecystectomy (MC) under general anaesthesia in the surgical treatment of gallbladder disease are common, but those of MC under local anaesthesia are much more limited. We report our experience of MC under local anaesthesia. METHODS: Forty-two patients with gallstone disease scheduled for MC under local anaesthesia were included in this study. Twenty-seven were female, with a median age of 54.5 years (range, 29-71) and median body mass index (BMI) of 20.5 (range, 17.6-23.4). None of the patients had evidence of acute cholecystitis on admission or previous upper abdominal surgery. MC was performed by a standardized technique and under the combination of local anaesthesia (1% xylocaine with adrenaline) and intravenous administrations of fentanyl (0.001-0.002 mg/kg) and midazolam (0.05-0.1 mg/kg). RESULTS: The median operative time was 40 minutes (range, 35-64). Local anaesthesia was converted to general anaesthesia in two patients owing to the discomfort caused by lysis of dense adhesions around the gallbladder, giving a success rate of 95%. MC was done successfully in all patients without any postoperative complications. The median hospital stay was 5 days (range, 2-7). CONCLUSION: MC under local anaesthesia is an effective surgical procedure for patients with BMI of less than 24, who have no evidence of acute inflammation of the gallbladder and no previous upper abdominal surgery.     

Ossification of a ruptured achilles tendon: a case report in a diabetic patient.

Ossification of the Achilles tendon is a rare condition to be distinguished from the more frequently occurring tendon calcification. Achilles tendon ossification is more common in males and is usually associated with prior surgery or trauma to the tendon. A case history of a ruptured ossified Achilles tendon in an elderly diabetic female is presented. Although Achilles tendon rupture with subsequent ossification and fracture of the ossified Achilles tendon have been reported individually, there is evidence to suggest that this patient may have both ruptured and fractured an ossified Achilles tendon.     

微创跟腱延长术联合系统康复治疗跟腱挛缩畸形

目的:分析微创跟腱延长术联合系统康复治疗跟腱挛缩患者的疗效和可行性。方法:2002年1月至2010年12月选择性地采用微创跟腱延长术联合系统康复治疗跟腱挛缩27例(31足),男11例,女16例;年龄3～65岁,平均35.5岁;右足13例,左足10例,双足4例;病程1～5年,平均2.3年。挛缩原因:胫骨骨折髓内钉治疗术后7足,小腿骨筋膜室综合征后遗症11足,先天性马蹄内翻足13足(双足4例)。手术前患者行走跛行,足跟落地困难,跖屈畸形成15°～50°,平均35.5°。术前股四头肌肌力Ⅴ级27足,Ⅳ级4足;小腿三头肌肌力Ⅴ级24足,Ⅳ级7足。结果:27例全部随访,时间6～24个月,平均11.3个月。按照Arner-Lindholm疗效标准进行踝关节功能评定:优29足,良2足。随访期间未发现跟腱挛缩复发,断裂,感染等并发症。结论:微创跟腱延长术联合系统康复治疗跟腱挛缩操作简单、并发症少、复发率低,有利于患者彻底康复。股四头肌肌力或者小腿三头肌肌力经过术前康复治疗仍然低于Ⅲ级的患者不选择该手术。     

局部麻醉下的膝关节镜术

[目的]探讨采用局部麻醉行膝关节镜术的方法和效果。[方法]2000～2005年采用局部麻醉的方法行膝关节镜术978例。术前关节腔内注入0．5％利多卡因50～60ml，同时对关节镜入路的皮肤、皮下及关节囊进行逐层浸润麻醉。保留10—15min后连接灌注管道，关节腔内灌注生理盐水（内含。肾上腺素1mg／3000ml），使关节腔充盈扩张。[结果]止痛效果满意，所有病人无明显疼痛或可以忍受，手术均顺利完成，术中视野清晰，无不良反应发生。[结论]绝大多数的膝关节镜手术均可以在局部麻醉下完成，且安全有效，手术费用较低，特别适用于门诊的关节镜手术。因此，作者建议局部麻醉可以作为大多数膝关节镜手术的标准麻醉方法。     

Ilizarov牵张技术对挛缩跟腱组织学改变的实验研究

 目的 探讨 Ilizarov牵张技术的牵拉应力对挛缩跟腱组织学的影响。方法 18只狗右后肢应用 Ilizarov外固定支架中立位固定 1周后开始牵拉, 1 mm /d, 分 2次调整, 连续 3周, X线摄片确定 足下垂 15°, 再维持固定 3周, 随机选取 9只动物处死取材(挛缩组);余动物再以同样的速度和方法牵 拉矫正 3周后处死取材(牵拉组);所取健侧标本合并为对照组。(1) HE染色观察腱细胞排列分布, 胶 原纤维形态, 并分析腱网膜厚度变化;(2)以苦味酸-天狼猩红染色法, 偏振光显微镜观察玉、芋胶原, 并 分析二者含量变化;(3)采用间苯三酚分光光度法, 测定蛋白多糖(主要为葡糖氨基葡聚糖)含量。结果 (1)挛缩组腱细胞与胶原纤维间隙不明显, 腱细胞呈梭形, 囊状, 胶原纤维束扭曲, 排列散乱, 难见细胞 间质。腱网膜厚度与健侧(对照组)有明显差异;牵拉组, 腱细胞呈圆形或卵圆形, 在胶原束间成串排列, 细胞与胶原纤维间有基质间隔, 见炎症细胞, 形态与正常腱组织相似。腱网膜厚度与健侧无明显差异。 (2)偏振光显微镜下, 挛缩组玉、芋胶原构成比与对照组有明显差异, 牵拉组玉、芋胶原构成比与健侧无 明显差异。(3)挛缩组跟腱蛋白多糖含量明显减少, 牵拉组基本恢复到正常水平。结论 在 Ilizarov牵张 技术牵拉下, 挛缩退化的跟腱组织在组织学上可基本恢复正常。     

关节镜下应用同种异体跟腱重建前十字韧带

目的探索一种应用同种异体跟腱重建前十字韧带(anteriorcrucialligament,ACL)的新方法,避免自体髌腱取材造成的膝周组织再损伤及由此引起的并发症。方法关节镜下应用经深低温冷冻处理的同种异体跟腱,采用等长重建、生物固定方法,重建受损的ACL。同时还可充分利用跟腱的长度重建受损的内侧副韧带(medialcollateralligament,MCL)。结果1996年1月～2000年6月,共31例患者被施行了关节镜下应用同种异体跟腱重建ACL,25例(26侧)获得12个月以上的随访,随访时间12～49个月,平均18.9个月。其中4例同时实施了受损MCL的重建,5例行半月板缝合,6例行半月板部分切除或完全切除。采用Lysholm评分法评估患者手术前后的功能,术前平均53.5分,术后平均84分,优良率为84.6%。客观检查:前抽屉试验阳性,术前23侧,术后1侧;Lachman征阳性,术前25侧,术后1侧,2侧弱阳性。术后遗留膝关节运动后疼痛2例;膝关节活动受限(5°～20°)3例。结论应用同种异体跟腱重建ACL,供材可提前制作,减少了自体取材造成的损伤及其相应的并发症,并可同时重建MCL。该技术取材方便,手术方法简单,无须内固定。     

Stapes surgery under local anaesthesia

In the UK, stapes surgery is performed almost universally under general anaesthesia. In 1984 there was consensus that local anaesthesia should be the technique of choice in stapes surgery. Despite reports of successful use of local anaesthesia for middle ear surgery, this is still not widely accepted practice in the UK. We describe the senior author’s technique for local anaesthetic stapes surgery and present the hearing results for a series of 100 consecutive cases.