跟腱损伤修补后的运动疗法：组织学及生物力学评价

背景：开放性跟腱断裂修复后康复时间长、并发症多、功能恢复不尽人意。目前尚缺乏系统、科学、简便、易行的运动疗法促进康复。 目的：观察运用运动疗法对跟腱损伤修补后的组织形态学和力学特性的影响。 方法：日本大耳白兔48只,随机分成制动组和运动组,在距跟腱止点2.0 cm处切断跟腱,建立跟腱损伤模型,缝合线缝合腱周组织后,制动组使用石膏绷带进行传统的重力垂足位长腿石膏固定;运动组不予固定处理。术后7,14,21d分别取跟腱标本,观察肌腱粘连情况及最大断裂应力。 结果与结论：制动组肌腱粘连较运动组明显(P < 0.05)。正常运动组跟腱的最大断裂应力明显高于制动组(P < 0.05)。说明在肌腱愈合的过程中,早期给予动态应力刺激,对促进组织的愈合、减少后遗症等十分有利。     

跟腱断裂修复后早期应用等速训练仪的康复测评

背景：传统跟腱断裂修复术后石膏固定时间长，效果不佳，存在较多的术后并发症。 目的：探讨跟腱断裂修复后早期应用等速训练仪进行康复训练的安全性和有效性。 方法：纳入2007-09/2009-09于青岛市立医院东区就诊的跟腱断裂患者11例，其中9例在跟腱修复4周后应用Isomed-2000等速训练仪进行康复训练，时间共8周。评价指标包括Arner-Lindholm评分、踝关节活动范围、屈伸肌峰力矩值等。 结果与结论：随访3~12个月，平均6个月。患者Arner-Lindholm评分优良率为88.9%，踝关节活动范围、屈伸肌峰力矩值等指标均较等速训练前显著改善(P < 0.05)，无感染和再断裂病例。结果提示跟腱断裂修复后4周应用等速训练仪行等速康复训练是安全和有效的，可为跟腱断裂后早期活动提供参考数据。     

生物补片材料进展与运动性跟腱断裂的修复

文章采用文献资料调查与分析的方法，根据研究目的查阅运动性跟腱损伤以及手术修复的相关论著, 为分析提供依据。结果表明运动性跟腱断裂与跟腱的解剖结构、跟腱局部的病变及运动技术等因素有关，当跟腱完全断裂时目前主张手术治疗。随着组织工程化肌腱研究的发展，临床上已经越来越多的将生物补片用于跟腱的修补治疗，从防止术后粘连到替代跟腱方面生物补片均有一定的优势。     

跟腱愈合过程中的力学生物学*☆

跟腱断裂修复后采用传统的重力垂足位长腿石膏固定,势必使跟腱处于无张力甚至是“失用性”的负性平衡体系下愈合,这种状态可能会抑制跟腱愈合过程中感应“主动”机械信号刺激的关键时机,在此过程中给予的超声波、振动等治疗,也只能使跟腱“被动、间歇”地接受机械刺激。如果在术后采用早期功能锻炼的运动疗法,可以提高跟腱在组织修复过程中功能维持及再塑形的能力,有助于跟腱生物力学特性的恢复。蛋白质组学技术便于从高通量的分子水平揭示运动疗法促进跟腱愈合的机制。     

局部注射肝素钠兔跟腱系统生物力学性质的变化

背景: 跟腱腱围炎会导致跟腱生物力学特性的改变，目前以局部注射肝素钠治疗较为普遍，但其对跟腱生物力学特性影响的报道甚少。 目的：观察跟腱劳损后生物力学性质及黏弹性的变化，同时验证肝素钠对跟腱生物力学特性及黏弹性的影响。 设计、时间及地点：于2005-03/12在四川省骨科医院生物力学实验室完成随机对照动物实验。 材料：50只成年日本大耳白兔，体质量(4.10±0.23) kg，用于制备跟腱劳损动物模型。 方法：50只动物随机分为对照组(n=20)、训练组(n=12)和肝素钠组(n=18)。动物3周运动训练后继续训练，同时开始跟腱腱围及跟腱止点的肝素局部注射，2次/周。6周后进行跟腱的循环蠕变和应力松弛测定，最后进行跟腱的断裂实验。 主要观察指标：测定不同运动后跟腱的生物力学特性及黏弹性的变化，包括跟腱的横截面积、循环蠕变、滞后环、应力松弛、强度特性和应力-应变。 结果：训练组和肝素钠组动物的滞后环明显减小，应力松弛加快。训练后跟腱的屈服载荷及能量、断裂能量、屈服应力、应变能力明显高于对照组。肝素钠组所有生物力学指标都得到改善。 结论：大强度运动可使跟腱的黏弹性下降，局部注射肝素钠可改善跟腱的强度特性和黏弹性。劳损后跟腱腱围和跟腱止点局部注射肝素钠对改善跟腱系统的强度特性和黏弹性有益。     

肌腱损伤修复过程及粘连的预防

肌腱损伤后愈合包括内源性愈合、外源性愈合两种形式。防止肌腱粘连的理想途径,是通过改善肌腱的营养状况和周围环境,来促进内源性愈合,抑制或减轻外源性愈合。常用的预防肌腱粘连方法有：全身或局部应用药物、保护和修复腱鞘、采用自体组织或合成材料代腱鞘、肌腱移植与腱鞘再造等,均取得了一定效果。采用可降解吸收的高分子生物材料屏障预防肌腱粘连,是近年来临床应用的热点。采用中医中药疗法、康复理疗及早期保护性活动,均可一定程度预防粘连发生。组织工程化肌腱移植,可能是今后研究的一个方向。在肌腱损伤早期,采用无创技术、非绞窄性缝合,手术中尽量保留或修复腱鞘,外周应用高分子生物材料包裹,术后结合康复理疗及早期保护下功能锻炼的综合治疗方法,可明显预防粘连发生,最大限度地恢复肌腱的滑动功能。     

链霉素缓释复合降解膜植入损伤肌腱局部腱周结缔组织的变化

背景：国内外学者曾用生物、非生物及药物等方法,诸如生物膜、透明质酸钠、纤维素密封胶等材料进行大量肌腱修复防粘连研究,但到目前为止尚未取得突破性进展。 目的：观察肌腱损伤局部植入链霉素复合降解膜后腱周结缔组织的增生。 方法：切断SD大鼠跟腱后,随机数字表法分为3组,分别在肌腱断端缝合处植入链霉素复合缓释降解膜、维生素C复合缓释降解膜、空白缓释降解膜。术后90 d行肌腱损伤局部组织学观察、羟脯氨酸含量和生物力学指标检测。 结果与结论：链霉素复合缓释降解膜组肌腱缝合处内部的成纤维细胞、胶原纤维均较其腱周围、维生素C复合缓释降解膜组、空白缓释降解膜组多;腱缝合处肌腱周围多为正常结构的疏松结缔组织,很少有增生的结缔组织长入肌腱内部;肌腱与周围组织分界清晰,最大抗拉强度、羟脯氨酸含量明显优于其他两组。表明链霉素复合缓释降解膜通过抑制腱周结缔组织增生,防止腱周结缔组织增生长入腱内,从而减轻或防止粘连形成。     

Measurement of the Achilles tendon reflex for the diagnosis of lumbosacral root compression syndromes.

The Hoffmann reflex and the Achilles tendon reflex were measured in a group of 194 subjects suspected of having a lumbosacral root compression syndrome. The Achilles tendon reflex was elicited manually with a metal hammer. There was a high correlation between the H-M interval and the Achilles tendon reflex-M interval. The usefulness of the Achilles tendon reflex was evaluated in a selected sub-group of 61 patients with proven L5 or S1 root compression. Neither the H-reflex nor the Achilles tendon reflex appeared to be of any value in detecting L5 root compression. Both the H-reflex and the Achilles tendon reflex proved to be useful for diagnosis of S1 root compression syndromes, the latter being the more sensitive method.     

About the origin of cerebral somatosensory potentials evoked by Achilles tendon taps in humans

This study examines the effects of ischemic hypoxia and cooling of the leg, muscle contraction and vibration on cerebral potentials evoked by Achilles tendon taps and posterior tibial nerve stimulation to obtain indirect evidence leading to the identification of receptors activated by tendon taps. Experiments performed during ischemia of the leg showed that these receptors lie between the ankle and the knee. Cooling of the leg showed that they are located deep in muscles or bone. Experiments performed during vibration and muscle contraction suggest that muscle stretch receptors provide the afferent input responsible for Achilles tendon tap evoked potentials. All of these experiments point to primary muscle spindles in the proximal gastrocnemius-soleus muscle belly as the main source of afferent input for evoking cerebral potentials to Achilles tendon taps in humans.     

异种小肠黏膜下层浓度水平对跟腱断裂修复的影响

背景：用猪的小肠黏膜下层重建各种组织结构是目前研究的热点,但是对于匀浆可注射形式的小肠黏膜下层的相关研究很少。 目的：观察不同浓度水平的匀浆可注射形式的异种小肠黏膜下层在修复和构建跟腱组织时是否对修复和重建结果产生影响。 设计、时间及地点：随机对照动物实验,于2006-09/2008-12在河北医科大学第三医院骨科研究所(河北省骨科研究所)完成。 材料：45只国产公山羊,1.0~2.0岁,体质量35~47 kg。小肠黏膜下层均来自同一只猪,去抗原处理后用均浆机打浆制备小肠黏膜下层悬液。 方法：切断45只山羊右后肢跟腱,随机分为25%,50%,100%浓度组,分别注射25%,50%,100%浓度的猪的小肠黏膜下层 2 mL于山羊的断裂跟腱处。注射前观察一般状况及注射侧肢体的情况,于2,4,6周各取5只切取修复后的跟腱。 主要观察指标：①生物力学测试。②踝关节后凸角。③组织学分析结果。 结果：各时间点25%浓度组生物力学测试值均大于50%浓度组和100%浓度组 (P < 0.01)。各组踝关节后凸角注射前左侧后肢、右侧后肢和注射后右侧后肢的差别无显著性意义(P > 0.5)。 4周和6周,25%浓度组几乎全为成纤维细胞,修复跟腱与正常的跟腱几近相同,100%和50%为大量的成纤维细胞,尚存浸润的炎细胞。 结论：结果表明可以在浓度水平调控匀浆形式的小肠黏膜下层在跟腱修复中的作用,以达到最佳浓度效果。     

The irrelevance of fusimotor activity to the Achilles tendon jerk of relaxed humans

In two normal subjects the sciatic nerve was blocked completely using concentrated lidocaine. The muscle afferent and reflex electromyographic responses to reproducible percussion of the Achilles tendon were recorded while the blocks developed. The intensity of percussion was sufficient to produce an Achilles tendon jerk in one subject when at rest and in the other during reinforcement. The block did not alter the muscle afferent response to tendon percussion in either subject. It is concluded that background fusimotor activity is not a prerequisite for the tendon jerk and that, during complete relaxation, there may be no significant fusimotor drive directed to the triceps surae. The varying ease with which tendon jerks can be elicited in different normal subjects or in different muscles of the same subject appears to be related not to fusimotor activity but to differences in the "central excitability state."     

Dependence of the Achilles tendon reflex on the excitability of spinal reflex pathways

Muscle afferent activity from the triceps surae was recorded during experimentally induced alterations in amplitude of the Achilles tendon jerk. No changes in the neural afferent response to tendon percussion or in the background level of neural activity occurred when the reflex response was altered by discomfort, distraction, changes in attention, or changes in the rate of tendon percussion. Reinforcement of the Achilles tendon jerk by forceful contraction of the forearm muscles did not alter the relationship between intensity of the tendon tap and amplitude of the evoked neural afferent volley. Nevertheless, such maneuvers lowered the reflex threshold and raised reflex sensitivity so that a smaller afferent volley was required to produce a tendon jerk, and an increase in the afferent volley produced a disproportionately greater increase in reflex electromyographic activity than would have occurred at rest. Reinforcement maneuvers potentiated the H-reflex but did not alter the electrically induced afferent volley or the background level of neural activity. It is concluded that these changes in reflex responsiveness occurred through intrinsic spinal mechanisms independent of the fusimotor system.     

Impaired mechanical properties of Achilles tendon in spastic stroke survivors: an observational study

Background: The spasticity could lead to decreased functional capacity and changes in musculoskeletal tissue.

Objective: To compare the Achilles tendon properties between the affected and contralateral limbs of participants with spasticity due to stroke and the healthy subjects.

Methods: Fifteen individuals with ankle spasticity due to stroke and 15 healthy subjects were recruited. Maximal isometric ankle joint torque was obtained with an isokinetic dynamometer, and an ultrasound was used to determine tendon length, tendon cross-sectional area, and the medial gastrocnemius myotendinous junction displacement. The Achilles tendon strength, displacement, stress, strain, stiffness, and Young’s modulus were obtained during a maximum voluntary isometric plantarflexion contraction.

Results: There were no differences between Achilles tendon length among participants. Both limbs of participants with stroke showed reduced tendon cross-sectional area (~18%) compared to healthy limb. The affected limb showed decreased tendon strength (686 ± 293.3 N), displacement (10.6 ± 1.7 mm), Young’s modulus values (849 ± 235.6 MPa), and lower stiffness (196.6 ± 67.6 N/mm) compared to the contralateral limb (strength, 1357.1 ± 294.8 N; displacement, 15.2 ± 5.5 mm; Young’s modulus, 1431.8 ± 301.9 MPa; stiffness, 337.5 ± 98.1 N/mm) and to the healthy limb. The contralateral limb also showed decreased tendon strength (~26.2%) and stiffness (~21.5%) compared to the healthy group.

Conclusion: There is a decrement in Achilles tendon morphological and mechanical properties of the affected limb in individuals with spasticity due to stroke. The contralateral limb had a thinner tendon more compliant likely to physical activity reduction.     

无水甘油保存同种异体肌腱的移植

背景：如何处理和保存同种异体肌腱,使之尽可能保留生物活性并降低其免疫原性是近年研究热点。 目的：将保存于无水甘油的兔肌腱进行同种异体移植,观察移植后肌腱的组织学变化。 方法：将兔肌腱经特殊处理后,常温避光保存在无水甘油中,保存7,12个月后取出肌腱,移植到兔后腿屈肌腱中。饲养3个月后处死并取出移植的肌腱,进行苏木精-伊红染色石蜡切片及透射电镜观察。 结果与结论：苏木精-伊红石蜡切片示肌腱纤维排列尚整齐,细胞形态正常,切片某些区域细胞密度较正常组低,未见明显的炎性细胞浸润。透射电镜示肌腱纤维排列整齐,细胞形态正常。结果提示经无水甘油保存的肌腱进行同种异体移植后,在组织学上与正常肌腱相似,无明显的免疫排斥反应。     

微创吻合器小切口跟腱吻合修复急性跟腱断裂★

背景：切开手术治疗急性跟腱断裂对跟腱的血运和腱周组织造成较大的破坏，容易发生跟腱粘连，延缓跟腱愈合。 目的：观察跟腱微创吻合器吻合修复急性跟腱断裂的效果。 方法：对2008-02/2009-08采用跟腱微创吻合器治疗的急性跟腱断裂并获得随访的22例患者，进行早期功能操练，并按照美国骨科协会足踝外科分会的标准评价踝关节功能，评价跟腱微创吻合器的治疗效果。 结果与结论：22例均获得随访，随访期为7~14个月(平均11.4个月)，所有患者伤口愈合良好，未发生跟腱再断裂，无腓肠神经支配区的感觉缺失，吻合后3个月AOFAS标准评分为95分，吻合后6个月为98分。说明跟腱微创吻合器能微创治疗急性跟腱断裂并获得良好效果。     

7-Nitroindazole potentiates c-fos expression induced by muscle tendon vibration in the spinal cord

Introduction: Expression of c‐fos initiated by muscle proprioceptive signaling was studied in rats after inhibition of neuronal nitric oxide synthase (nNOS) with administration of 7‐nitroindazole (7‐NI). Methods: Fos‐immunoreactive (Fos‐ir) neurons were visualized immunohistochemically in the lumbar cord after vibration of the Achilles tendon and/or 7‐NI systemic injections. Results: The total number of Fos‐ir interneurons and motoneurons (per slice) was significantly greater in the 7‐NI‐pretreated and tendon‐vibrated (7‐NI + Tv) group than in the isolated tendon vibration group (Tv group). The greatest increases in the number of Fos‐ir neurons were found in the L4 (+100%) and L5 (+105%) segments (P < 0.05). Conclusions: Suppression of NO release after introduction of 7‐NI was associated with potentiation of Fos immunoreactivity induced by muscle proprioceptive signaling within distinctive regions of the spinal cord. Muscle Nerve, 2012     

Diabetic polyneuropathy. Corneal sensitivity, vibratory perception and Achilles tendon reflex in diabetics

In a controlled study, corneal sensitivity, vibratory perception of the left index finger and great toe and achilles tendon reflex were examined in 100 diabetes patients and 100 controls. The result showed significantly reduced corneal sensitivity, vibratory perception and increased number of areflexi in the diabetic group. Furthermore, the decrease of corneal sensitivity, vibratory perception and presence of areflexi correlated well to one another and to age, duration of D. M. above 15 years and diabetic retinopathy. Significant intercorrelations suggest that a reduced corneal touch threshold forms part of a polyneuropathy in diabetes. A corneal hypesthesia cannot be considered a valuable index in screening a population for diabetes as previously has been suggested.     

Effects of bilateral Achilles tendon vibration on postural orientation and balance during standing.

OBJECTIVE: Altering proprioceptive information in the lower limbs by vibration produces direction-specific falling and postural instability, which can persist after vibration stops. The objectives of this study were to describe the changes in trunk and lower limbs postural orientation and muscles activities during and after the end of bilateral Achilles tendon vibration (TV). METHODS: Twelve healthy young subjects were exposed to 30s periods of TV while blindfolded. Whole-body kinematics, kinetics and EMG of eight lower limb and trunk muscles were recorded prior, during and 5 or 25s after TV. RESULTS: TV during quiet standing produced a whole-body backward shift characterized by greater extension in the trunk and lower limbs. Five seconds after TV, two trends of recovery could be observed, either an overcorrection or undercorrection of the initial position. CONCLUSIONS: A continuum of postural orientations are adopted during and after vibration and the movements are not restricted to the ankle joints, despite the local nature of the proprioceptive stimulation. SIGNIFICANCE: The widespread influence of vibration as a proprioceptive stimulation when assessing its effects on posture and balance needs to be considered. Further studies should include whole-body analyses to document more thoroughly the postural strategies for balance maintenance during vibration.     

关节镜下异体跟腱单双束重建后交叉韧带的随机对照*☆

背景：关节镜下重建后交叉韧带主要有单束重建和双束重建两种方式。 目的：随机对比应用异体跟腱单双束重建后交叉韧带损伤的临床疗效。 方法：选择青岛市市立医院骨科2006-01/2009-01的后交叉韧带损伤患者共70例，随机分为单束重建组和双束重建组，分别行异体跟腱单束重建及双束重建。 结果与结论：术后顺利完成康复计划并获得随访的病例共52例。双束重建组手术时间较单束重建组长，行关节腔穿刺的病例数较单束重建组多(P < 0.05)。手术后18个月随访结果显示，单束组重建及双束重建组的膝关节活动度、Lysholm评分、IKDC评分与术前比较有明显提高(P < 0.05)，两组膝关节屈曲30°和90°时用KNEELAX3测量胫骨端后移距离明显低于术前(P < 0.05)。两组术后Lysholm评分、 IKDC评分、两组膝关节屈曲30°和90°时用KNEELAX3测量胫骨端后移距离未见明显差别(P > 0.05)。说明与单束重建比较，双束重建后的早期临床疗效无明显提高，且双束重建的手术创伤大，手术时间长，术后关节肿胀重，故不推荐作为首选手术方式，其远期疗效优待进一步观察。     

Attenuated dynamic responses of primary endings of muscle spindles: a basis for depressed tendon responses in acrylamide neuropathy.

Depressed or lost tendon reflexes commonly observed in patients with peripheral neuropathies may result partly from attenuation of the dynamic discharge from the primary endings of muscle spindles. This possibility was investigated in cats with an experimental neuropathy induced with acrylamide (30 mg/kg/day intramuscularly). Achilles tendon reflexes and the dynamic discharge from primary muscle spindles were evaluated after five or ten injections of acrylamide. After five injections the animals were moderately impaired neurologically, the Achilles tendon reflex was difficult to elicit in 2 of 5 animals, and the dynamic responses of primary endings of soleus muscle spindles to stretch were depressed. Following ten injections of acrylamide the cats were severely impaired neurologically; tendon responses were either absent or difficult to elicit, and the dynamic responses of their muscle spindles to stretch were reduced by 50% (p less than 0.01). Additionally, the spindels responded to stretch with only 20 to 30% the normal number of afferent impulses. These data suggest that lost tendon responses in acrylamide neuropathy result in part from inadequate activation of motoneurons by spindle afferent discharge.