腓骨长肌及胫骨后肌联合修复陈旧性跟腱断裂伴缺损

作者自行设计使用腓骨长肌及胫骨后肌联合修复陈旧性跟腱断裂伴缺损48例,获得完整随访资料43例。跟腱缺损长度为8～10cm,自身已无修复条件。手术方法的优点:联合转移的肌腱弥补了长距离跟腱缺损,保持了原有肌肉的动力,弥补了小腿三头肌的挛缩无力。保持了足内、外翻的肌力平衡,足外形正常。肌肉的血循环不受干扰,增加了修复跟腱后愈合的机会。手术后6周都能逐渐下地行走,肌力一般都能达到Ⅳ级～V级,功能恢复良好,未发生因愈合不良再次发生断裂。     

改良经皮与开放跟腱延长术治疗跟腱挛缩症疗效比较

目的通过与开放跟腱延长术比较,探讨改良经皮小切口跟腱延长术治疗跟腱挛缩症的疗效。方法回顾分析2008年5月-2012年5月收治并符合纳入标准的42例跟腱挛缩症患者临床资料。其中19例(19足)采用改良经皮小切口跟腱延长术(试验组),术中根据跟腱挛缩程度分别于跟腱内、外侧不同平面作长约0.5 cm横切口,根据足内、外翻畸形决定跟腱半切平面,在跟腱内、外侧分别半切跟腱;23例(24足)采用开放跟腱延长术(对照组)。两组患者性别、年龄、病程、踝关节背伸活动度、Hannover跟腱评分等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。结果与对照组比较,试验组手术时间及术后住院时间均缩短,术中出血量显著减少,比较差异均有统计学意义(P<0.05)。术后对照组1例发生切口感染,其余患者切口均Ⅰ期愈合。两组患者均获随访,试验组随访时间6～35个月,对照组8～34个月。试验组1例足内翻矫形不明显,其余足内外翻畸形均矫形满意。两组末次随访时踝关节背伸活动度及Hannover跟腱评分与术前比较,差异均有统计学意义(P<0.05),两组间比较差异均无统计学意义(P>0.05)。除对照组1例双足患者外,其余两组患者患侧踝关节背伸活动度及Hannover跟腱评分与健侧比较,差异均有统计学意义(P<0.05)。结论改良经皮小切口跟腱延长术治疗跟腱挛缩症疗效与开放跟腱延长术相似,且具有创伤小、恢复快、有效矫正足内、外翻畸形等优点。     

骨外固定牵引架联合跟腱延长矫治重度瘢痕性跟腱挛缩畸形

目的:探讨骨外固定牵引架联合跟腱延长术矫治重度瘢痕性跟腱挛缩畸形的临床治疗效果,为重度跟腱挛缩畸形提供新的治疗思路.方法:2004年3月～2008年10月,对9例重度瘢痕性跟腱挛缩患者进行矫治.手术分两期进行,第一期手术设计跟腱瘢痕瓣行跟腱延长术,同时上骨外固定牵引架,创面碘仿纱布覆盖,然后进行外固定支架牵引矫治跟腱挛缩畸形,待踝关节达到合适角度后,进行第二期手术,采用中厚皮片修复创面.结果:所有9例患者,跟腱挛缩畸形均得到良好的矫治,8例患者跟腱瘢痕瓣存活良好,1例患者出现不同程度的远端坏死,在第二期手术时一并修复,术后加强功能锻炼,术后随访3月～26月,直立行走活动自如.结论:采用骨外固定牵引架联合跟腱延长术矫正重度跟腱挛缩畸形的方法,避免了骨关节及血管神经损伤等并发症,较快地矫正踝关节至功能位,短时间恢复患者下地行走,可以作为重度跟腱挛缩畸形的理想治疗方法之一.     

跟腱挛缩的微创治疗

目的:探讨应用Ilizarov踝关节牵伸器微创治疗跟腱挛缩的方法与疗效。方法:用Ilizarov踝关节牵伸器治疗跟腱挛缩9例,手术时先将预先组装好的踝关节牵伸器套在小腿与足部,牵伸器的铰链式关节对准踝关节的关节间隙,在小腿和足部各穿2组克氏针与牵伸器的钢环固定。术后4d开始调整牵伸杆,直至踝关节达到中立位,并在此位置维持4周。结果:所有病例平均随访时间12个月,踝关节平均保持在跖屈3°位置,较术前平均改善39°,踝关节活动范围平均26°,比术前平均进步11°。无严重并发症,行走功能明显改善。结论:Ilizarov踝关节牵伸器微创治疗跟腱挛缩,能够避免一次性跟腱延长术可能出现的踝关节后部跟腱外的皮肤缺损。组织损伤小,并发症少,操作简便,安全可靠,疗效满意。     

新式跟腱延长术治疗儿童马蹄足

目的 介绍一种新式跟腱延长术治疗儿童马蹄足的手术方法和要点,并观察术后疗效.方法 对2002年1月至2007年12月收治的19例(23足)儿童马蹄足患者采用跟腱矢状位3份切断交错滑移的方法进行跟腱延长,术后小腿石膏固定踝关节于背伸90°位2周,2周后开始全负重功能锻炼.于术前、术后短期及术后中期随访测量患足背伸角度,并行Corry修正步态医师等级量表评分(PRS).结果 本组17例(20足)获得随访,时间为1～5年(平均3.5年).结果 显示患者均能在2周后全部负重功能锻炼、患足踝关节角度从术前平均116.1°±15.0°下降到术后短期随访时的68.5°±9.6°及中期随访时的71.3°±8.5°,术前与术后比较差异有统计学意义(P<0.05).PRS中的膝反曲、足着地方式、总体改变指标术前与术后比较差异均有统计学意义(P<0.05),蹲伏差异无统计学意义(P>0.05).本组患者未出现跟腱断裂、跟行足等并发症.结论 新式跟腱延长术能增进跟腱的强度、满足延长长度、达到早期功能锻炼的目的并促进功能快速恢复,是一种有效的跟腱延长术式.     

跟腱皮下切断滑行延长

脊髓灰质炎后遗症畸形多种多样,跟腱挛缩形成马蹄足畸形临床多见。近几年来笔者采用跟腱皮下切断滑行延长,效果良好,报道如下。临床资料本组共145例,男85例,女60例,164只足,左80只足,右84只足,0°～20°者25只足,21°～40°者59只足,41°～60°者62只足,60°以上者18只足。其中110例,125只足获得随访,时间6～48个月,平均27个月,效果满意。     

“骨康一体”理念下微创手术治疗跟腱断裂疗效观察

目的观察采用微创技术联合术后早期功能康复治疗新鲜闭合性跟腱断裂的临床疗效,并探讨"骨康一体"新理念的应用模式。方法回顾性分析自2018-01—2019-04在"骨康一体"理念下采用微创手术治疗28例新鲜闭合性跟腱断裂,术中采用通道微创技术与改良Bunnell缝合法完成跟腱断端缝合,术后开展早期功能康复锻炼。结果 28例均获得随访,随访时间平均13.5(12～16)个月。切口均一期愈合,无排异反应、腓肠神经损伤、下肢深静脉血栓形成、跟腱再断裂等并发症发生。术后12个月踝关节功能Arner-Lindholm评分:优21例,良7例。末次随访时所有患者患侧踝关节主动背伸21°～27°,跖屈41°～48°。结论 "骨康一体"理念下采用微创技术联合术后早期功能康复治疗新鲜闭合性跟腱断裂具有手术时间短、切口小、术后并发症少、康复进程快、跟腱愈合快、踝关节功能恢复好等优点。     

Sheffield足踝U型外固定支架治疗重度跟腱挛缩畸形

目的 探讨Sheffield足踝U型外固定架矫治跟腱挛缩畸形的临床疗效.方法 2010年9月至2011年1月共收治6例重度跟腱挛缩患者,男4例,女2例;年龄18～43岁,平均27岁.手术安置外固定牵引架,定期调整外固定支架矫治跟腱挛缩、足内收及内翻畸形,踝关节过度矫正,达到背屈15°、外翻0°后,可拆除外固定支架.结果 所有患者术后均获3～7个月(平均4.5个月)随访,跟腱挛缩畸形均得到良好的矫治,均无血管、神经损伤等并发症,术后加强功能锻炼,均能站立行走,功能基本正常.按Garceau评价标准:优5例,良1例,优良率为100%.结论 采用Sheffield足踝U型外固定牵引架矫正重度跟腱挛缩畸形,创伤小,可避免血管神经损伤等并发症,能较快地矫正踝关节跖屈畸形及相应的足部软组织挛缩畸形,患者短时间内可恢复下地行走,是跟腱挛缩、尤其是重度畸形的理想治疗方法之一.     

跟腱替代术治疗仰足畸形的体会

临床资料本组,男43例,女35例,年龄3.5～28岁。仰足仰趾畸形31例,小腿三头肌肌力0级,胫前肌,胫后肌,腓骨肌,伸(足母)长肌及伸趾总肌肌力均在4级以上。仰足合并外翻畸形28例,小腿三头肌、胫前肌和胫后肌肌力均     

跟腱延长加肌移位代跟腱治疗小腿三头肌瘫痪性下垂足

目的：探讨治疗小腱三头肌瘫痪下垂足的新手术方法及其疗效。方法：14例患者应用新设计的手术方案，即在延长跟腱矫正下垂足的同时加肌移位代跟腱术，并根据足部畸形的性质和有无合并其它畸形再附加其它软组织或骨性手术。结果：术后病人平均随访25个月，下垂足畸形皆达到满意矫正，替代的跟腱肌力皆增加2级以上，行走功能改善，无并发症。结论：该术式可一次轿正足的下垂畸形增加跟腱肌力，无并发症，符合优化组合的矫形手术方案制定原则。     

Transposition of the posterior tibial tendon

The posterior tibial tendon was rerouted by the technique described by Baker and Hill in 35 feet of children with a dynamic varus deformity due to spastic cerebral palsy. The average follow-up period was 11.4 years. In ten of the feet, rerouting of the posterior tibial tendon was the only procedure performed. Eight of the ten feet obtained a satisfactory correction. There were no overcorrection problems in these ten feet. In the remaining 25 feet, the Baker-Hill procedure was done concurrently with other procedures, such as lengthening of the triceps surae (22 feet), calcaneal osteotomy (two feet), or plantar fascia release (two feet). The dynamic equinovarus deformity was corrected in all 25, but three subsequently developed a cavus deformity. This was probably caused by excessive weakening of the triceps surae rather than transposition of the posterior tibial tendon. Based on this study, anterior rerouting of the posterior tibial tendon seems to be a simple, safe, and generally effective procedure for correction of dynamic varus of the spastic hindfoot in children with cerebral palsy.     

Percutaneous minimal invasive Achilles tendon lengthening improves clinical and radiographic outcomes in severe flexible flatfeet with shortened triceps sureae complex in early childhood: A retrospective study

BackgroundSevere flexible flatfeet with triceps surae complex shortening are prognostically unfavorable in early childhood and may compromise normal foot development.MethodsThis retrospective, IRB-approved study included 20 children (38 feet) under 6 years with severe flexible flatfeet and triceps surae complex shortening. Treatment included minimally invasive percutaneous achilles tendon lengthening followed by a 4-week cast fixation and corrective orthotic therapy under talo-navicular reposition for at least 6-months. Preoperative weightbearing x-rays and at the last available follow-up included anteroposterior talus-first metatarsal angle and lateral talus pitch, Meary’s and talocalcaneal angle and were compared to reference values. ROM, surgeon-rated clinical outcomes and complications/re-interventions were evaluated.ResultsAge at surgery was 3.7 years (1.3–5.9 y) and follow-up time was 4.3 years (1.1–8.9 y). No complications occurred. Clinical outcome was good (68 %) to very good (26 %). Ratio of normal angles increased significantly for three angles. Dorsiflexion ROM improved from ?5.0 ± 6.8° at baseline to 15.7 ± 7.6°.ConclusionsWith significant improvements in clinical and radiographic outcomes, minimal-invasive percutaneous Achilles tendon lengthening followed by orthotic therapy seems to be a valuable treatment option for selected preschool-aged patients with severe, flexible flatfeet with significantly shortened triceps surae.Level of EvidenceIV     

Preserving plantar flexion strength after surgical treatment for contracture of the triceps surae: A computer simulation study

Contractures of the triceps surae commonly are treated by surgical lengthening of the gastrocnemius aponeurosis or the Achilles tendon. Although these procedures generally relieve contractures, patients sometimes are left with dramatically decreased plantar flexion strength (i.e., decreased capacity to generate plantar flexion moment). The purpose of this study was to examine the trade-off between restoring range of motion and maintaining plantar flexion strength after surgical treatment for contracture of the triceps surae. A computer model representing the normal moment-generating characteristics of the triceps surae was altered to represent two conditions: isolated contracture of the gastrocnemius and contracture of both the gastrocnemius and the soleus. The effects of lengthening the gastrocnemius aponeurosis and the Achilles tendon were simulated for each condition. The simulations showed that nearly normal moment-generating characteristics could be restored when isolated gastrocnemius contracture was treated with lengthening of the gastrocnemius aponeurosis. However, when isolated gastrocnemius contracture was treated with lengthening of the Achilles tendon, the moment-generating capacity of the plantar flexors decreased greatly. This suggests that lengthening of the Achilles tendon should be avoided in persons with isolated gastrocnemius contracture. Our simulations also suggest that neither lengthening of the gastrocnemius aponeurosis nor lengthening of the Achilles tendon by itself is an effective treatment for combined contracture of the gastrocnemius and soleus. Lengthening the gastrocnemius aponeurosis did not decrease the excessive passive moment developed by the contracted soleus. Lengthening the Achilles tendon restored the normal passive range of motion but substantially decreased the active force-generating capacity of the muscles. Our simulations indicate that independent lengthening of the contracted gastrocnemius and soleus, rather than lengthening of their common tendon, accounts for differences in the architecture of these muscles and may be a more effective means to restore range of motion and maintain plantar flexion strength when combined contracture of the gastrocnemius and soleus is present.     

小切口微创技术治疗急性闭合性跟腱断裂

目的:探讨采用小切口行微创缝合治疗急性闭合性跟腱断裂的临床效果。方法:2012年4月至2013年10月,对14例14足急性闭合性跟腱断裂的患者采用小切口微创技术修复跟腱,其中男9例,女5例;年龄25～49岁,平均30.5岁;受伤至手术时间1～13 d,平均8 d.在跟腱断裂处正中偏内侧行1.5～2.0 cm小切口,用卵圆钳导入缝针,微创缝合修复跟腱断裂。术后常规康复锻炼。结果:14例中2例创口局部持续渗出,经换药好转,其余均Ⅰ期愈合。所有患者获随访,时间6～24个月,平均11个月。美国足踝外科协会(AOFAS)踝与后足评分92.71±6.58(82～100分).结论:小切口微创修复急性闭合性跟腱断裂损伤小,并发症少,恢复快,操作简单,适合在基层医院开展。     

Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking

Fifteen children who were diagnosed with idiopathic toe walking that cannot be corrected by nonoperative treatment were assessed by clinical examination and computer-based gait analysis preoperatively and approximately 1 year after Achilles tendon lengthening. Passive dorsiflexion improved from a mean plantarflexion contracture of 8 degrees to dorsiflexion of 12 degrees after surgery. Ankle kinematics normalized, with mean ankle dorsiflexion in stance improving from -8 to 12 degrees and maximum swing phase dorsiflexion improving from -20 to 2 degrees. Peak ankle power generation increased from 2.05 to 2.37 W/kg but did not reach values of population norms. No patient demonstrated clinically relevant triceps surae weakness or a calcaneal gait pattern. Seven patients had a stance phase knee hyperextension preoperatively, and 6 of these corrected after surgery. Achilles tendon lengthening improves ankle kinematics without compromising triceps surae strength; however, plantarflexion power does not reach normal levels at 1 year after surgery.     

The effect of triceps surae contracture force on plantar foot pressure distribution

BACKGROUND: Triceps surae contractures have been associated with foot and ankle pathology. Achilles tendon contractures have been shown to shift plantar foot pressure from the heel to the forefoot. The purpose of this study was to determine whether isolated gastrocnemius contractures had similar effects and to assess the effects of gastrocnemius or soleus contracture on midfoot plantar pressure. METHODS: Ten fresh frozen cadaver below-knee specimens were loaded to 79 pounds (350 N) plantar force with the foot unconstrained on a 10-degree dorsiflexed plate. Combinations of static gastrocnemius or soleus forces were applied in 3-lb increments and plantar pressure recordings were obtained for the hindfoot, midfoot, and forefoot regions. RESULTS: The percentage of plantar force borne by the forefoot and midfoot increased with triceps surae force, while that borne by the hindfoot decreased (p相似文献   

Correction of the pes equinus component in congenital clubfoot by freeing the triceps surae muscles and by tibiocalcaneal distraction

20 children, average age 9 months, were treated of 27 inborn deformed feet by a new method. It consists in a wide release of m. triceps surae and its tendon, posterior lateral and posterior medial release and lengthening of the muscle with the help of a personal distraction apparatus, leaving the tendon untouched. Control examinations from 9 months to 4.7 years after operation showed correction of the equinus component by an average of 49 degrees and correction of the profile of the talocalcaneal angle by an average of 34 degrees.     

改良手术治疗脑瘫痉挛性双侧下肢瘫

[目的]2004年以来对重症脑瘫痉挛性双侧瘫治疗方法进行改进,探索提高其治疗效果的方法.[方法]23例重症脑瘫痉挛性双侧瘫.男14例,女9例;年龄3～12岁,平均5.7岁;主要症状不能独自站立和行走,双下肢肌紧张,家长扶持站立,双下肢呈剪刀步态,双髋、膝关节屈曲,踝关节跖屈,双足马蹄内翻畸形,足尖着地行走.体格检查双髂腰肌、内收肌、腘绳肌、小腿三头肌、胫前肌、胫后肌、(足母)长屈肌、趾长屈肌部分或多数不同程度肌张力增高.依Ashworth分级,为3～4级.治疗方法对动态性肌痉挛,采用肌内肌腱切断或肌筋膜切断;对静态性肌痉挛行肌腱滑动延长,胫前肌腱劈开外侧1/2移位.然后用自制外固定器矫形固定,保持膝关节伸直,双踝、足中立位,双下肢外展30°,6周后去除外固定康复训练.[结果]本组病例随访1～3年,平均2.2年.优良21例,有效2例.[结论]严重脑瘫痉挛性双侧瘫,一期多关节软组织松解,肌力平衡,外固定矫形,术后配合家庭长期康复训练,是一种有效的治疗方法.     

Subcutaneous suturing of the ruptured achilles tendon under local anaesthesia

Debate concerning the appropriate treatment of ruptures of the Achilles tendon still continues. Conservative treatment can be associated with a high incidence of re-rupture and with relative weakness and lengthening of the triceps surae but with low costs. Surgical treatment contributes to a much lower incidence of re-rupture but can be associated with significant complications as well as with time loss and high costs of hospitalization. Subcutaneous reconstruction combines the advantages of surgical and non-surgical management. Operating with local anaesthesia reduces hospitalization time and operative costs; there are also almost no contraindications for the operation. The functional results in 36 patients operated on in this way are encouraging.     

Gastrocnemius Recession as an Alternative to TendoAchillis Lengthening for Relief of Forefoot Pressure in a Patient with Peripheral Neuropathy: A Case Report and Description of a Technical Modification

The gastrocnemius recession is a popular surgical procedure for the treatment of equinus contracture. Lengthening the gastrocnemius tendon has been show to be an effective means of reducing pressure to the plantar forefoot by weakening the triceps surae complex. The more traditional method of weakening the triceps surae is a modification of Hoke's triple hemisection through the tendoAchillis. This technique unfortunately carries a serious risk of the development of a calcaneal gait. The purpose of this case report is to demonstrate that the gastrocnemius recession is an effective and safe alternative to the traditional tendoAchillis lengthening. The authors also describe a minimally invasive technique that uses a pediatric speculum for a self-retrained retractor and portal for instrumentation and visualization.