Arthroscopically assisted percutaneous repair of fresh closed achilles tendon rupture by Kessler's suture

BACKGROUND: Achilles tendon ruptures are difficult to repair, and the healing rate is low due to this structure's anatomic and physiological characteristics. It is essential to develop new techniques to increase the healing rate and decrease the rate of complications. OBJECTIVE: To propose and evaluate a new percutaneous method of repairing fresh closed Achilles tendon ruptures by Kessler's suture under arthroscopy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty patients were followed at least 12 months in this study. First, the torn ends of the Achilles tendon were debrided during arthroscopy. Then percutaneous repair of the Achilles tendon was performed using Kessler's suture by an inside-out technique. All cases were followed up for an average range of 21 months (range, 12-36 months). All patients were evaluated by clinical examination, magnetic resonance imaging, and the Lindholm scale. RESULTS: The torn ends were well aligned and sutured after the debridement under arthroscopy. According to the Lindholm scale, excellent results were seen in 15 cases and good in 5 cases. No patients had complications such as nerve injury, infection, or re-rupture at follow-up. Magnetic resonance imaging results showed that the ruptured Achilles tendons were repaired and remodeled very well in all patients. CONCLUSION: The present method is an effective surgical technique for repair of a closed rupture of the Achilles tendon. The short-term follow-up results were good, and recovery time was short. Few complications were found in our study cases.     

Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging

Objectives: The aim of this study was to determine whether ultrasound can correctly visualise partial ruptures of the proximal Achilles tendon. Method: This was a prospective study in which all chronic Achilles tendon injury patients seen at three centres in Germany from 1998 to 2003 were screened. All patients with clinical and/or sonographic signs of abnormalities in the region of the proximal third of the Achilles tendon and tendomuscular junction were included in the analysis. Each of these cases was evaluated by ultrasound following an assessment protocol. Patients with ambiguous ultrasound findings and/or clinical signs were additionally assessed by magnetic resonance imaging (MRI). Results: Sonomorphologic changes suggestive of an abnormality in the proximal third of the Achilles tendon were detected in 13 out of 320 patients (4.2%) with recurring Achilles tendon complaints. Thirteen patients had clinical signs but no sonographic changes in the tendon. The sonographic diagnosis was correct in 19 cases. In six of the 26 cases studied, MRI was needed to establish the correct diagnosis of partial intratendinous rupture of the proximal Achilles tendon. Sensitivity was 0.5, specificity was 0.81, and the overall agreement of the ultrasound examination was 61.5%. All patients were asymptomatic at follow up at a mean of 14 months (range 12–17 months) after surgery. Conclusions: Ultrasound is a useful tool for evaluation of proximal Achilles tendon complaints. However, ultrasound is not sufficiently reliable for diagnosis of all pathologies, especially partial ruptures of the Achilles tendon. Thus, the definitive diagnosis must be established by MRI.     

Nonoperative treatment of acute rupture of the achilles tendon: results of a new protocol and comparison with operative treatment

BACKGROUND: Excellent results are reported from both nonoperative and operative treatment of Achilles tendon rupture. PURPOSE: To describe a new nonoperative treatment protocol for Achilles tendon ruptures and compare outcomes with operative treatment. STUDY DESIGN: Retrospective cohort study. METHODS: We treated 23 patients nonoperatively with an equinus ankle cast and boot and compared their outcome with that of a group of 24 patients previously treated operatively. Muscle strengthening and walking with full weightbearing were started as soon as tolerated in both groups. Follow-up examinations were performed for 18 nonoperatively treated patients after 23 months and for 15 operatively treated patients after 49 months. RESULTS: Subsidence of pain, return to unaided walking, and return to work was faster in the nonoperatively treated group. Patient satisfaction, return to sports, and ultimate strength was the same for both groups. The complication rate was similar, except for reruptures: four early in the nonoperative group and one late in the operative group. Two types of reruptures occurred in the nonoperative group: 1). normally healing tendon subjected to new trauma, rerupturing in the healing zone, and achieving a good result with continued nonoperative treatment; and 2). tendon failing proximal to the initial rupture at the muscle-tendon junction, without trauma, requiring operative repair and augmentation. CONCLUSIONS: Results of operative and nonoperative treatment were equivalent.     

Magnetic resonance imaging after operative repair of achilles tendon rupture

We performed a magnetic resonance imaging (MRI) study in 16 consecutive patients who had undergone open repair of a unilateral Achilles tendon rupture (ATR) at an average of 32.5 (SD 3.2) (range 29-36) months from the operation. We measured the widest antero-posterior diameter of the tendon, the longest distance between the insertion of the Achilles tendon on the calcaneum and the musculo-tendinous junction of the soleus muscle on the Achilles tendon, the distance between the insertion of the Achilles tendon on the calcaneum and the point of maximal width of the tendon. We also ascertained whether areas of altered signal were present in and around the tendon. The operated tendons were always significantly thicker than the non-operated ones. There was a non-significant trend for the other measurements to be greater in the operated tendons. In five patients, areas of dishomogeneous signal were present in the operated tendon. These areas were less than 25% of the antero-posterior diameter of the tendon, and were clinically silent. These findings probably represent normal features of long-term tendon healing following open repair of an ATR.     

通道辅助微创与切开跟腱缩短术治疗陈旧性跟腱过长的疗效比较

目的 比较通道辅助微创跟腱缩短术与切开跟腱缩短术治疗陈旧性跟腱断裂愈合后跟腱过长的疗效.方法 回顾分析2013年12月-2015年12月符合入选标准的19例患者的临床资料,其中8例采用通道辅助微创跟腱缩短术,11例采用切开Krackow跟腱缩短术.两组患者性别、年龄、受伤至手术时间、术前小腿周径、术前美国矫形足踝协会(AOFAS)评分等一般资料差异无统计学意义(P>0.05),具有可比性.比较两组的手术时间、手术切口长度、术后住院时间,术后跟腱恢复情况,小腿周径和AOFAS评分.结果 微创组手术时间、手术切口长度及术后住院时间均显著少于切开组(P<0.05).术后8周随访时MRI显示两组患者跟腱均恢复连续性.两组末次随访时小腿周径和AOFAS评分均高于术前,差异有统计学意义(P<0.05),但两组间比较差异无统计学意义(P>0.05).结论 通道辅助微创缩短术治疗陈旧性跟腱断裂愈合后跟腱过长的疗效与切开跟腱缩短术相似,且具有手术时间短、切口小、住院时间短、可避免腓肠神经损伤等优点.     

改良Bosworth法联合Pulvertaft缝合治疗新鲜闭合性撕裂型跟腱断裂

目的探讨改良Bosworth法联合Pulvertaft缝合治疗新鲜闭合性撕裂型跟腱断裂的临床疗效。方法回顾性分析2011年9月～2015年3月武汉大学人民医院骨科收治的新鲜闭合性撕裂型跟腱断裂15例,其中男性12例12足,其中左足7例,右足5例;女性3例3足,其中左足1例,右足2例。年龄27～50岁,平均36岁。结果所有患者均得到随访,随访时间6～12个月,平均8.6个月。有2例患者术后出现伤口红肿,给予抗感染、换药处理后乙级愈合,其余伤口均甲级愈合。所有患者均无术后足外侧区感觉麻木。按照Arner Lindholm标准评定,优13例,良2例,优良率100%。结论改良Bosworth法联合Pulvertaft缝合治疗新鲜闭合性撕裂型跟腱断裂,术后功能恢复良好,临床疗效满意。     

Reconstruction of chronic achilles tendon rupture with the use of interposed tissue between the stumps

BACKGROUND: The gap between the tendon stumps in chronic Achilles tendon rupture has reportedly been filled with interposed scar tissue. In the authors' clinical experience, this interposed tissue is often thick and resists tension, so they considered it was possible to use the interposed tissue for reconstruction of Achilles tendon rupture. HYPOTHESIS: Scar tissue interposed between the tendon stumps has the capacity to form tendon-like repair tissue in patients with chronic Achilles tendon rupture. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Six patients with chronic rupture of the Achilles tendon underwent tendon reconstruction with the use of interposed tissue between the stumps. The average time from the primary injury to surgery was 22 weeks (range, 9 to 30 weeks). Preoperative magnetic resonance imaging (MRI), histology of the interposed tissue, and clinical results were evaluated. The average postoperative follow-up period was 31 months (range, 24 to 43 months). RESULTS: Preoperative T2-weighted MRI in all cases revealed that chronically ruptured Achilles tendons were thickened and fusiform-shaped with diffuse intratendinous high-signal alterations throughout. Longitudinal high-signal bands were seen throughout the tendon, except at the musculotendinous junction and insertion on the calcaneus. Histologically, scar tissue interposed between the tendon stumps consisted of dense collagen fibers, and degenerative changes were not seen. After surgery, no patient had difficulty in walking or stair climbing, and all were able to perform a single-limb toe raise. The mean preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were 88.2 and 98.3 points, respectively; the difference was statistically significant (P = .0277). CONCLUSION: Interposed tissue between the tendon stumps is suitable for repair of chronic Achilles tendon rupture if preoperative MRI shows a thickened fusiform-shaped Achilles tendon with diffuse intratendinous high-signal alterations throughout.     

自体半腱肌及股薄肌肌腱桥接修补陈旧性MyersonⅢ型跟腱断裂疗效分析

目的:探讨半腱肌及股薄肌肌腱桥接修补陈旧性MyersonⅢ型跟腱断裂的临床疗效。方法:2006年4月至2008年10月,根据术前MRI检查测量跟腱缺损长度,共收治陈旧性MyersonⅢ型跟腱断裂患者共24例,运用自体半腱肌及股薄肌肌腱进行桥接修补,术后给予石膏外固定,进行常规康复治疗。采用Amer-Lindholm法评定疗效。结果:所有患者均获得随访,随访时间12～30个月,平均18个月。依据Amer-Lindholm疗效评定标准,优21例,良2例,差1例,优良率95.8%。随访期内无跟腱再断裂、周围神经损伤及切口深部感染等并发症。结论:自体半腱肌及股薄肌肌腱桥接修补陈旧性MyersonⅢ型跟腱断裂是一种安全、疗效满意的方法。     

Isolated tear of the plantaris tendon: ultrasound and MRI appearance

We report a retrospective analysis of the ultrasound and magnetic resonance imaging appearance of five patients with isolated plantaris tendon tears. Both imaging techniques allowed detection of the tear, assessment of its severity and of its location. Compared with magnetic resonance imaging, ultrasound resulted in a less expensive and time-consuming evaluation. Isolated plantaris tendon tears can clinically mimic Achilles tendon tears or thrombophlebitis. Unlike these conditions, plantaris tear has a benign outcome and does not need surgical treatment or anticoagulation.     

Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI

BACKGROUND: Satisfactory treatment results have been reported after eccentric calf muscle strength training in patients with chronic Achilles tendinopathy. HYPOTHESIS: Magnetic resonance imaging may be a useful adjunct in the evaluation of the effect of 3 months of eccentric calf muscle strength training. STUDY DESIGN: Prospective cohort study. METHODS: Using magnetic resonance imaging, the Achilles tendons were investigated in 25 patients (16 men and 9 women) ranging in age from 28 to 70 years (median, 51 years) before and after training. Five different magnetic resonance imaging sequences were used. Tendon volume and mean intratendinous signal were calculated using a new seed-growing technique showing 99.3% and 96.6% intraobserver reliability, respectively. The clinical outcome was categorized according to pain level and performance using a questionnaire completed by the patient. RESULTS: The eccentric training resulted in a 14% (mean) decrease of tendon volume measured on T1-weighted images, from 6.6 +/- 3.1 cm3 to 5.8 +/- 2.3 cm3 (P < .05). The intratendinous signal in the symptomatic Achilles tendon measured on proton density-weighted images decreased 23% (mean), from 227 +/- 77 signal units to 170 +/- 83 signal units (P < .05). The gadolinium contrast agent-enhanced images did not add further value compared with other sequences. CLINICAL OUTCOME: The clinical outcome was categorized as excellent in 10, good in 3, fair in 5, and poor in 8 patients. The Delta signal correlated significantly with the pain level (P < .05). CONCLUSIONS: Eccentric training resulted in decreased tendon volume and intratendinous signal and was correlated with an improved clinical outcome. Magnetic resonance imaging techniques can be used as an adjunct to clinical evaluation by monitoring morphologic effects in clinical treatment studies of Achilles tendinopathy.     

Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study

There is no agreement on the ideal type of surgical management for Achilles tendon rupture. The present randomized prospective study was performed to compare outcome data of open and percutaneous repair in the treatment of Achilles tendon rupture. Forty consecutive patients with acute rupture of Achilles tendon were recruited. Patients were randomized to receive open (group A) or percutaneous repair with Tenolig^® (group B). All patients followed the same rehabilitation protocol except for slight differences in the duration of immobilization. Follow-up included objective evaluation (at 4 and 12 months), subjective evaluation using the SF-12^® questionnaire (at 24 months), and bilateral ultrasound scanning and isokinetic testing (at 12 months). The differences in the parameters evaluated clinically were not significant except for ankle circumference, which was significantly greater in group B. There were two minor complications in the open repair group and one case of failed repair in the percutaneous group. SF-12^® questionnaire, ultrasound and isokinetic test data did not show significant differences between the groups. The present study demonstrates that the open and the percutaneous technique are both safe and effective in repairing the ruptured Achilles tendon and that both afford the same degree of restoration of clinical, ultrasound and isokinetic patterns. Medium-term results were substantially comparable. Percutaneous repair is performed on a day-surgery basis, it reduces cutaneous complications and operation times, and enables faster recovery, enhancing overall patient compliance. To us, these characteristics make it preferable to open repair in managing subcutaneous ruptures of Achilles tendon in non-professional sports practicing adults.     

跟腱断裂修补术后再断裂与感染的发病率、危险因素及临床预后

目的:探讨跟腱断裂修补术后再断裂与感染的发病率、危险因素及临床预后。方法:回顾性研究1994年1月至2008年12月在我所行跟腱断裂修补术后发生再断裂和(或)感染的患者,记录其性别、年龄、职业、生活习惯、内科合并症、受伤机制、断裂及手术时间、断裂形态、治疗方式、术后康复等数据,分析总结跟腱再断裂与感染的发病率、危险因素与临床预后。结果:跟腱断裂行修补手术共计916例,术后发生跟腱再断裂和(或)感染28例(其中4例再断裂合并感染),再断率2.3%(21例),感染率1.2%(11例)。跟腱再断裂多发生于运动员或戏剧演员;跟腱感染多见于高龄,合并糖尿病、高脂血症,跟腱炎、局部激素治疗以及断裂后治疗延迟(>14天)的患者。术后随访16例(9例再断裂,5例感染,2例再断裂合并感染),平均随访49.4个月(12～124个月),优良率87.5%。其中3年以上患者全部为优,结果明显好于1～3年的患者(P=0.019),感染组预后略差于再断组。结论:跟腱术后再断裂和感染是跟腱断裂修补术后的两大常见且严重的并发症。从事运动或戏剧表演职业的患者易于发生跟腱术后再断裂,而高龄、高脂血症、跟腱炎、激素治疗史,及伤后延迟治疗等是跟腱术后感染的高危险因素。治疗得当,长期(3年以上)临床预后较好;跟腱感染患者预后略差于跟腱再断裂患者。     

Sonographic appearance of nonoperatively treated Achilles tendon ruptures

Objective. This report describes the gray-scale and color Doppler sonographic appearance of healed Achilles tendon ruptures that have been treated nonoperatively. Design and patients. Eleven patients with acute Achilles tendon ruptures were studied with sonography in the acute setting and following nonoperative management of their torn tendon. Results. On sonographic examination, healed tendons treated nonoperatively are characterized by mild residual distortion of the normal fibrillar architecture of the tendon, anterior bulging or irregularity of the healed tendon, and a hypoechoic area about the site of rupture. Less frequent observations include mildly increased color flow and calcification at the rupture site. The previously described findings of acute tears, including hematomas, gaps at the rupture site, hyperemic torn tendon ends, and markedly distorted fibrillar architecture, were seen to have resolved in this series. Conclusion. The Achilles tendon tear treated nonoperatively has a different sonographic appearance from that of a normal or acutely ruptured tendon. Received: 24 November 1999 Revision requested: 23 January 2000 Revision received: 8 February 2000 Accepted: 8 February 2000     

急性跟腱撕裂的影像学诊断

目的探讨跟腱撕裂的X线平片和MRI诊断价值。方法分析21例有急性踝关节损伤病史、经手术证实为跟腱完全撕裂或部分撕裂患者的X线平片和MRI表现，并与手术结果对照。结果21例MRI均有异常表现，诊断跟腱完全撕裂7例，部分撕裂14例，MRI表现为跟腱增粗，腱内信号增高，腱束连续性完全中断或部分中断。X线片5例诊断跟腱撕裂，12例疑似撕裂，4例正常。手术结果完全撕裂9例，部分撕裂12例。结论MRI能准确显示跟腱撕裂的程度和部位，对临床治疗具有重要的指导意义；X线可作为跟腱撕裂初诊的辅助检查，但明确诊断还有赖于MRI。     

Ossification of the Achilles tendon: imaging abnormalities in 12 patients

Ossification of the Achilles tendon is a rare clinical entity that is characterized by the presence of an ossific mass contained within the fibrocartilaginous substance of the tendon. Because the radiographic features of this condition have not been documented entirely and the magnetic resonance (MR) imaging findings have not been determined, a review of 16 affected tendons in 12 patients was performed in an attempt to characterize the imaging abnormalities associated with this process. MR imaging was performed in three Achilles tendons which demonstrated thickening of the tendons at the level of the ossifications and a lack of intratendinous signal abnormalities compatible with acute tendinitis. Signal intensity similar to that of bone marrow was present in the ossifications.     

Achilles tendon rupture: experimental results on spontaneous repair in a sheep-model

We studied the course of spontaneous healing of Achilles tendons in a sheep model after transection and partial resection of the tendon by means of histological and biomechanical analyses. In 18 sheep used for another animal study the operated knee had to be excluded from weight-bearing; therefore the Achilles tendons were transected and for 1.5 cm partially resected in the middle substance of the tendon. For evaluation these spontaneously healed tendons (n = 18) were compared with the contralateral noninvolved tendons (n = 18). Specimens were analyzed 3, 6, and 12 months postoperatively by means of histology, polarized light, angiography, and mechanically analyzing the specific tensile strength and absolute tensile strength. We found that in all animals the resected tendon healed spontaneously. All animals exhibited a normal gait pattern at least 6 weeks postoperatively. Histologically, the tendinous area of healing demonstrated after 3 months a fibrous collagenous tissue with a loose fiber orientation. The cross-sectional area had at 3 months increased to maximum but decreased later. Concomitantly the fiber orientation improved with time and 12 months after transection the specimens showed a nearly normal histological structure of the healed tendon. Biomechanically the specimens exhibited a rather low specific rupture force after 3 months (28.8% of normal tendons) and 6 months (30.2%) but increased after 12 months (56.7%). In regard to the resulting total rupture force the decrease in the spontaneously healed tendons was less (75.6% after 3 months, 56.1% after 6 months, 81.18% after 12 months), because the cross-sectional area of the healing tendon had significantly (P < 0.05) increased to maximum after 3 and 6 months. Sheep Achilles tendons thus healed spontaneously without any immobilization. The initial healing mechanism is thickening of the scar tissue with improvement of the fiber orientation towards a tendonlike structure within 1 year. Parallel to this, the specific rupture force increased and the thickness of the newly tendonlike area decreased.     

Magnetic resonance imaging in acute tendon ruptures

The diagnosis of acute tendon ruptures of the extensor mechanism of the knee or the Achilles tendon of the ankle may usually be made by clinical means. Massive soft tissue swelling accompanying these injuries often obscures the findings, however. Magnetic resonance imaging (MRI) can rapidly demonstrate these tendon ruptures. Examples of the use of MRI for quadriceps tendon, and Achilles tendon rupture are presented.     

急性闭合跟腱断裂端端缝合术后远期疗效观察

目的 评价急性闭合跟腱断裂端端缝合术后的远期疗效.方法 2000年11月-2006年6月收治28例急性闭合跟腱断裂患者,其中男20例,女8例,年龄19～48岁,平均36.5岁,术前MRI提示跟腱完全断裂,所有病例均在伤后4d内行手术治疗.跟腱断端稍做修整后,采用Kessler法或Bunnell法行端端缝合,术后随访12～36个月,平均20个月,参照Arner-Lindholm评分标准进行疗效评定,并对术后并发症进行记录.结果 28例患者中优19例,良9例,优良率100%,术后3个月均恢复正常行走并开始康复训练.随访期内无周围神经损伤,无跟腱再断裂.术后并发症包括浅表伤口感染1例、伤口皮缘坏死l例,并发症发生率7.1%.结论 端端缝合术修复急性闭合跟腱断裂术后并发症少,长期随访疗效优良.     

Conservative treatment of a partial Achilles tendon rupture with an intratendinous lesion

The Achilles tendon is a common site of acute and oversuse injuries in runners. A case is described here in which the diagnosis of a post-traumatic intratendinous lesion was based on clinical examination and magnetic resonance imaging (MRI), and where conservative treatment was given. After a 6 months follow-up, symptoms as well as the MRI verified that intra-tendinous structural abnormalities had disappeared. This case report demonstrates that conservative treatment may be sufficient to cure Achilles injury with severe structural changes inside the tendon.     

MRI在跟腱撕裂的诊断价值

目的：探讨不同程度跟腱撕裂的MRI表现的具体特点,评估MRI在跟腱损伤病例中的诊断价值。方法：本院自2007年8月-2009年10月MRI共诊断跟腱损伤11例,所有患者均行MRI常规TSE序列轴位、矢状、冠状位扫描,并追加矢状SPIR序列。结果：全部病例均显示相应跟腱撕裂MRI表现,其中完全撕裂4例,部分撕裂7例,表现为跟腱周围及腱旁脂肪垫积液、跟腱形态的改变、跟腱信号异常以及在完全性撕裂中显示缺口的范围及大小。结论：利用MRI诊断跟腱撕裂,可以精确判定其撕裂程度、范围以及是否合并骨髓水肿。