陈旧性跟腱断裂V-Y腱成形术的实验研究与临床应用

目的为陈旧性跟腱断裂V-Y腱成形术的临床应用提供实验依据,从而达到推广此手术方式的目的。方法用73只新西兰白兔,建立陈旧性跟腱断裂模型后行V-Y腱成形术和Lindholm术,术后分别行组织学观察和生物力学测试。对平均135d的12例陈旧性跟腱断裂患者行V-Y腱成形术后,行X线、B超等影像学检查,随访时间1年10个月～11年,平均6年5个月,并用Arner-Lindholm疗效评定标准进行评定。结果(1)实验研究发现,V-Y腱成形术对跟腱血运无明显影响,组织学修复好,术后生物力学性能恢复优于Lindholm术。(2)按Arner-Lindholm疗效评定标准,优10例(83.3%),良2例(16.7%),优良率达100%。(3)术后X线、B超检查显示跟腱普遍增粗,腱纤维排列已趋于正常,2例患者有跟腱钙化。结论根据实验和临床研究结果表明,V-Y腱成形术疗效佳,可以作为治疗陈旧性跟腱断裂的首选术式。     

带蒂筋膜瓣重建腱鞘治疗跟腱断裂

带蒂筋膜瓣重建腱鞘治疗跟腱断裂汤桂明＊１９８９年～１９９３年，我院在跟腱断裂手术修补的同时应用带蒂筋膜瓣重建腱鞘１７例，术后辅以早期被动活动，取得满意疗效。本组男１２例，女５例。年龄１７～５０岁，平均３２岁。开放性跟腱断裂１１例，闭合性跟腱断裂６例。...     

自体半腱肌加强并V-Y肌瓣修补术治疗陈旧性跟腱断裂

[目的] 研究自体半腱肌加强并V-Y肌瓣修补术治疗陈旧性跟腱断裂的手术方法和临床效果.[方法] 对16例陈旧性跟腱断裂患者,取自体半腱肌对已行端端吻合的跟腱在吻合处两侧的正常跟腱组织冠状面上钻洞形成环扎,分散跟腱吻合处的分离张力.[结果] 3例患者直接行端端缝合并自体半腱肌加强,13例患者行V-Y肌瓣延长后,断端吻合并自体半腱肌加强,所有切口均Ⅰ期愈合,皮肤切口平整,随访9～38个月,平均18个月,无跟腱再断裂发生,按Arner-Lindholm疗效评定标准,优14例(87.5%),良2例(12.5%),优良率100%.[结论] 自体半腱肌加强并V-Y肌瓣修补术治疗陈旧性跟腱断裂疗效满意,并发症少,且手术操作简单,值得进一步临床研究应用.     

带线锚钉联合V－Y腱成形术治疗陈旧性跟腱断裂

目的:探讨带线锚钉联合V-Y腱成形术治疗陈旧性跟腱断裂的临床疗效。方法:2014年5月至2018年3月采用带线锚钉联合V-Y腱成形术治疗陈旧性跟腱断裂患者26例,男18例,女8例;年龄19～56(36.0±11.7)岁;病程42～62(49.0±5.3) d;跟腱短缩2～7(4.0±1.6) cm。观察术后并发症情况,手术前后采用美国足踝外科协会踝与后足评分(American Orthopaedic Foot and Ankle Soviety,AOFAS)进行临床疗效评价。结果:所有患者获得随访,时间8～18(12.0±2.5)个月。术后无跟腱再断裂。术后3个月AOFAS评分(93.37±3.48)分较术前(57.26±5.06)分明显提高(t=9.564,P0.05),其中优14例,良11例,差1例。结论:带线锚钉联合V-Y腱成形术治疗陈旧性跟腱断裂,跟腱固定强度可靠,可明显改善患者的疼痛、行走功能,提高患者生活质量,功能恢复良好。     

跟腱伴皮肤缺损的一期腓肠肌肌皮瓣修复

目的介绍腓肠肌推进皮瓣一期修复跟腱伴腱周皮肤缺损的方法。方法对8例跟腱伴腱周皮肤缺损,采用双蒂腓肠肌皮瓣V-Y推进下移修复。结果随访4个月～6年。8例缺损均一期愈合。患肢均恢复行走能力。膝踝功能满意。结论双蒂腓肠肌皮瓣V-Y推进下移可一期修复跟腱伴腱周皮肤缺损。     

筋膜蒂V - Y提升皮瓣修复指端缺损

目的 介绍应用筋膜蒂V-Y提升皮瓣修复指端软组织缺损的手术疗效。方法 1999年10月至2002年6月，采用筋膜蒂V-Y提升皮瓣修复指端皮肤缺损16例18指。该皮瓣最大可提升12mm，覆盖较大范围的指端皮肤缺损。结果 术后皮瓣全部存活，12指术后随访6个月～3年，6指失访。修复后指腹的感觉均在S4级以上，外形满意，患者均恢复了原工作。结论 筋膜蒂V-Y提升皮瓣适合于指端横形缺损及指腹部皮肤缺损10mm左右的患者。该术式具有手术简便，外形及手功能恢复满意等优点。     

陈旧性跟腱断裂合并皮肤缺损的一期修复

陈旧性跟腱断裂合并皮肤缺损的治疗较为复杂，常规治疗应在局部创面愈合后３个月行二期跟腱修复。１９８５年６月～１９９６年６月采用自体肌腱或筋膜瓣移植修复跟腱，同时用伤肢邻近带血管、神经蒂岛状皮瓣覆盖，石膏托外固定，治疗陈旧性跟腱断裂合并皮肤缺损１８例。结果表明，创面Ⅰ期愈合１６例，移植皮瓣远端皮缘坏死０．５ｃｍ～１ｃｍ的２例，经早期修复治愈。术后１年以上随访１５例，其中１２例关节功能恢复正常，３例跟腱与邻近组织粘连，影响踝关节过度背屈，足部蹬力下降。认为，采用肌腱或筋膜瓣加带血管神经蒂岛状皮瓣一期修复陈旧性跟腱断裂合并皮肤缺损，可缩短疗程，减轻患者的痛苦和经济负担，更快恢复伤肢的功能     

改进带蒂腱膜修补术治疗再发性跟腱断裂

目的：了解改进带蒂腱膜修补术治疗再发跟腱断裂的长期疗效。方法：对平均病程为3个月的12例再发跟腱断裂患者进行了平均6．15年的术后随访，所有患者均采用改进带蒂腱膜修补术的手术方法，并用Amer-Lindholm疗效评定标准进行评定。结果：术辱疗效优8例(65．8％)，良3例(25％)，差1例(9．2％)，优良率达90．8％。结论：再发跟腱断裂手术较为困难，本术式涪疗再发跟腱断裂取得了良好的手术疗效。     

腓肠肌腱瓣V-Y成形术和内踝上筋膜皮瓣修复陈旧性跟腱断裂伴皮肤缺损

急性跟腱断裂临床并不少见，非专科医生往往易误诊，或处理不当导致陈旧性跟腱断裂伴感染及缺血引起皮肤坏死，跟腱外露给后期处理带来一定的困难。我院2000年6月～2005年6月，共收治32例跟腱断裂，有11例陈旧性跟腱断裂伴皮肤缺损，清创换药后采用腓肠肌腱瓣V-Y成肜术加内踝上筋膜皮瓣移位术进行修复，效果满意。报告如下。     

陈旧性跟腱断裂手术治疗及康复指导

目的 :探讨陈旧性跟踺断裂的手术治疗和康复指导。方法 :对 3 8例陈旧性跟腱断裂患者 (其中误诊 2 0例 ,手术失败 18例 )分别采用V—Y缩短、水平重叠缩短、“Z”缩短、冠状纵劈缩短等成型 ,并在此基础上应用腓肠肌腱瓣翻转或跖肌腱转移加固术。术后按A—B—C—D—E顺序进行功能练习 ,同时辅以中药熏洗康复治疗。平均随坊 4.3年 ,按Arner -Lindholm疗效标准进行评定。结果 :优 2 8例 ,良 7例、差 3例 ,优良率为 92 .1%。结论 :陈旧性跟腱断裂多为运动伤 ,容易误 (漏 )诊。手术方法主要应用各种缩短成型 腱瓣加固术 ,同时采用带蒂筋膜包裹跟腱吻合处 ,以增加局部血液循环 ,促进愈合 ,并减少与皮肤的粘连。术后中药熏洗并按照A—B—C—D—E顺序进行功能练习是提高治疗效果防止再断裂的关键。     

腓肠肌腱膜翻转术在陈旧性跟腱断裂中的应用

目的探讨应用腓肠肌腱膜翻转法治疗陈旧性跟腱断裂的疗效。方法对18例陈旧性跟腱断裂患者应用腓肠肌腱膜翻转术重建跟腱。术中于小腿中部腓肠肌腱膜-肌移行处切取一条长8～10 cm、宽3 cm带蒂腓肠肌筋膜瓣,其基底留在离断端上方约1.5～2 cm处,于蒂上方跟腱中心作一纵切口,把腱膜瓣从此切口中穿过,再反折向下,由跟腱两侧向浅面包绕跟腱远近端及其缺损。自跟骨结节撕脱者将跟骨结节咬成粗糙面,腱膜条拉紧,根据缺损长度修剪腱膜条远端,使之与跟骨结节相接触。然后用Bunnell抽出钢丝法将重建跟腱拉紧,使踝关节跖屈约20°。结果本组有3例切口延迟愈合,无皮肤及肌腱坏死、无深部感染及再断裂病例。所有患者平均随访26（24～40）个月,按Arner-Lindholm标准评定,优13例,良5例,临床疗效良好。结论腓肠肌腱膜翻转术治疗陈旧性跟腱断裂具有手术操作简单、固定牢固、愈合率高、并发症少等优点,是一种较为理想的重建方法。     

Reconstruction of combined defects of the Achilles tendon and the overlying soft tissue with a fascia lata graft and a free fasciocutaneous lateral arm flap

A new approach to reconstruction of the Achilles tendon and overlying soft tissue is presented. A fascia lata graft is used to reconstruct the tendon and is enwrapped by the fascia that is included in a fasciocutaneous lateral arm flap. Five patients were treated with this technique; three of them after surgical Achilles tendon repair, rerupture, and consecutive infection, one after a full-thickness burn with loss of the tendon and one with a history of ochronosis and necrosis of the whole tendon and overlying soft tissue. There were no anastomotic complications and all flaps healed primarily. Functional evaluation with the Cybex II dynamometer was done at least 49 months after reconstruction. A good functional and cosmetic result was obtained in all patients and donor site morbidity was acceptable. These results are well within the results of other surgical treatment options reported in the literature.     

Bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing Achilles tendon and overlying skin defect： the anatomic basis and clinical application

Objective: To study the anatomic basis of the bi-pedicled V-Y gastrocnemius myocutaneous flap for repairing the composite Achilles tendon defect. Methods : The pedicle anatomy of the bi-pedicled V-Y gastrocnemius myocutaneous flap was examined on 30 cadaver specimens. The sliding distances of the flap were measured at different knee flexion degrees. The bi-pedicled V-Y gastrocnemius myocutaneous flap was applied in 12 cases of Achilles tendon defect with simultaneous skin and soft tissue defect. Results: The sural arteries could be classified into four types. After cutting off the gastrocnemius origin with a " Z-shaped" incision, the sliding distance of the flap reached (3. 7±0. 5) cm when the knee flexed 0°, (4.9±0.7) cm when the knee flexed 30°, (6. 7±0. 7) cm when the knee flexed 60 and (9.2±0.9) cm when the knee flexed 90°. All the defects healed. The patients recovered ambulation with satisfactory knee and ankle function. The follow-up was 4 months -12 years. Conclusions: Different sural artery types should be noticed during the harvest of the bi-pedicled V-Y gastrocnemius myocutaneous flap. With 90°knee flexion, this flap is suitable for one-stage repair of composite Achilles tendon defect within 9.2 cm±0.9 cm.     

跟腱再断裂的修复重建

 目的 总结跟腱再断裂的原因, 探讨野V-Y冶推进瓣及长屈肌腱(flexor hallucis longus, FHL)转位修复重建跟腱再断裂的适应证、疗效及其相关并发症。方法 2006年 3月至 2010年 1月手 术修复重建跟腱再断裂患者 16例 16足, 男 12例, 女 4例;年龄 35~72岁, 平均 50.9岁。再断裂距初次 手术时间为 6~49周(平均 21.8周), 随访时间 6~52个月(平均 27.5个月)。充分清除断端瘢痕及坏死组 织4例断端缺损4 cm者采用 FHL转位修 复重建。结合患者病史、康复方式及再次手术术中所见跟腱形态, 分析其发生再断裂原因。观察术后局 部外观及功能恢复情况, 并采用美国足踝外科协会踝-后足评分(American Orthopaedic Foot &; Ankle Society-ankle and hindfoot score,AOFAS-AH)及 Leppilahti跟腱修复评分进行疗效评价。结果 跟腱再 断裂的原因主要为手术切口感染、术后跟腱愈合不良发生液化坏死、术后过早负重或活动不当致跌倒。 采用野V-Y冶推进瓣或 FHL转位修复跟腱再断裂术后局部外观及功能恢复良好, AOFAS-AH评分从术前 (70.2±8.5)分提高到(92.4±6.1)分;Leppilahti跟腱修复评分从术前(74.8±6.2)分提高到(91.7±4.8)分。踝 部 MRI显示跟腱部信号均匀, 无撕裂或积液表现。结论 跟腱再断裂后需彻底清创, 导致大范围缺损。 腓肠肌腱膜野V-Y冶推进瓣可修复4 cm的缺损, 术后踝足部功能外形恢复良好。     

Persistent disability despite sufficient calf muscle strength after rerupture of surgically treated acute achilles tendon ruptures

Rerupture after treatment of acute Achilles tendon rupture is considered a serious complication. Yet data on long-term outcome after rerupture are limited. This study evaluated outcome after rerupture and compares it to a reference of uncomplicated cases. Thirteen patients with a rerupture following minimally invasive surgical Achilles tendon rupture repair were evaluated using Leppilahti score and resumption of work and sport. Mean follow-up was 8.7 years. Results were compared with a reference group of 23 uncomplicated cases with a follow-up of at least 1 year. The study was designed as a follow-up study. The relative risk for a fair/poor outcome by Leppilahti score after a rerupture when compared with uncomplicated cases is 2.83 (95% confidence interval=1.17-6.87; P=.0185). Although rerupture did not affect ultimate resumption of professional life, the relative risk for quitting sport or resuming sport at a lower level after a rerupture is 3.33 (95% confidence interval=1.71-6.51; P=.0001). In contrast, the plantar flexion strength deficit is 5% to 10% in the rerupture group and up to 20% in the reference group. Despite sufficient recovery of calf muscle strength, rerupture after acute Achilles tendon rupture treatment results in significant long-term functional disabilities.     

Interwoven wire suture with fascia lata-plasty in the treatment of subcutaneous rupture of the Achilles tendon--an obsolete method?

Lately there has been an increased incidence of rupture of the Achilles tendon following the general increase in mass sports. Surgery is the treatment of choice, and various methods are being described. We have been using the wire suture method with fascia lata plasty for more then twenty years. The rate of infection is 3.8% and that of rerupture 1.2%, figures that correspond to those stated for other surgical methods. Moreover, 87% of the patients were very satisfied with the result of the operation; they are fit for work without any restriction, and some of them even practise their sports activities as before. For this reason we consider that wire suturing with fascia lata plasty is by no means obsolete in the treatment of rupture of the Achilles tendon.     

Treatment of the neglected Achilles tendon rupture

Achilles tendon ruptures are best managed acutely. Neglected Achilles tendon ruptures are debilitating injuries and the increased complexity of the situation must be appreciated. Surgical management is recommended, and only in the poorest surgical candidate is conservative treatment entertained. Numerous treatment algorithms and surgical techniques have been described. A V-Y advancement flap and flexor halluces longus tendon transfer have been found to be reliable and achieve good clinical outcomes for defects ranging from 2 cm to 8 cm. This article focuses on the treatment options for the neglected Achilles tendon rupture.     

Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata

Segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with coverage of the defect by soft tissue flaps, creating an entity that meets up to three predetermined goals: (1) approaching preinjury functionality, (2) resisting shearing forces, and (3) achieving an esthetic result. From June 2009 to June 2011, our center submitted six patients to a one-stage procedure correcting the Achilles tendon using a composite free anterolateral thigh (ALT) flap with vascularized fascia lata. The flap sizes ranged from 5 to 8 cm in width and 16 to 20 cm in length and all flaps included vascularized fascia lata which was rolled to serve as an Achilles tendon. After reconstruction our patients showed good functional results, these patients could walk, climb stairs, and tiptoe again without support. Moreover, normal footwear could be worn. A free composite ALT flap with vascularized fascia lata is a reliable option for coverage of Achilles tendon and overlying soft tissue defects, even in elderly patients.