连续Z形切口在跟腱断裂术中的应用

正2010年1月~2014年5月,我科采用跟腱连续Z形切口、V-Y成形减张缝合治疗18例急性跟腱闭合性断裂患者,疗效满意,报道如下。1材料与方法1.1病例资料本组18例,男14例,女4例,年龄21~53岁。均为新鲜闭合损伤。受伤至手术时间为1~8 d。1.2治疗方法硬膜外麻醉。以跟腱     

三种手术方法治疗新鲜跟腱断裂比较研究

目的比较传统切开跟腱吻合术、经皮微创跟腱吻合术以及应用跟腱吻合器有限切开术治疗新鲜闭合性跟腱断裂的疗效,为临床治疗方式的选择提供参考依据。方法 2007年12月-2010年3月将69例符合纳入标准的新鲜闭合性跟腱断裂患者随机分为3组,其中采用传统切开跟腱吻合术23例(传统切开组),经皮微创跟腱吻合术23例(经皮微创组),应用跟腱吻合器有限切开治疗23例(有限切开组)。3组患者性别、年龄、损伤机制、美国足踝外科协会(AOFAS)踝-后足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。结果经皮微创组及有限切开组住院时间及失血量明显优于传统切开组(P<0.01)。术后传统切开组发生2例(8.7%)切口感染坏死,其余两组患者切口均Ⅰ期愈合;传统切开组术后腱旁组织并发症发生率高于其余两组(P<0.05)。经皮微创组及有限切开组各1例(4.3%)发生跟腱再断裂,传统切开组跟腱再断裂发生率(0)低于其余两组(P<0.05)。69例均获随访,随访时间12～18个月,平均14.9个月。术后12个月3组踝关节AOFAS评分均>90分,较同组术前显著改善(P<0.05),组间比较差异无统计学意义(P>0.05)。结论 3种手术方式均能有效治疗新鲜跟腱断裂,有限切开或经皮微创手术方法创伤小,伤口愈合好,住院时间少,术后腱旁组织并发症少,但跟腱再断裂风险增加。     

应用双津下缝合法修复跟腱断裂疗效分析

目的探讨采用0号可吸收普迪思圈套线(PDS-Ⅱ线)双津下缝合法修复跟腱断裂的临床疗效。方法 2005年1月-2008年12月,收治36例跟腱断裂患者。男29例,女7例;年龄21～50岁,平均36岁。运动损伤25例,摔伤4例,锐器割伤6例,其他伤1例。新鲜闭合损伤22例,新鲜开放损伤6例,伤后至入院时间1～10 d,平均6 d;陈旧性闭合损伤8例,伤后至入院时间43～63 d,平均51 d。提踵试验及Thopmson征均呈阳性。患者均采用0号可吸收PDS-Ⅱ线双津下缝合法修复。术后于踝跖屈30°位短腿石膏固定6周后,开始功能锻炼。结果术后2例陈旧性跟腱断裂患者切口愈合不良,经对症治疗后切口愈合;其余切口均Ⅰ期愈合。患者均获随访,随访时间12～24个月,平均15个月。随访期间均未发生跟腱再次断裂及反射性交感神经营养不良。患者踝关节活动度与健侧相比,7例无减少,16例减少1～10°,12例减少10～20°,1例减少25°。根据Termann跟腱损伤临床评价标准,评分为74～96分,平均90分;获优24例,良11例,可1例,优良率为97.2%。结论双津下缝合法手术操作简便,缝线在腱内无横行交叉,修复断裂跟腱后对其血运影响小。PDS-Ⅱ线可提供高强度张力,并可完全吸收,不易发生局部粘连。采用该方法修复跟腱断裂术后并发症发生率较低,可获得较好疗效。     

断端重叠间断横向缝合修复跟腱马尾状撕裂型损伤

目的探讨断端纵向重叠间断横向缝合修复急性闭合性跟腱马尾状撕裂的疗效。方法自2010-06—2014-06诊治23例急性跟腱马尾状撕裂,术中均将马尾状断端梳理后纵向牵拉重叠,应用4号丝线横向间断缝合撕裂跟腱,使用可吸收线修复跟腱鞘膜。术后进行循序渐进康复训练,应用美国足踝外科协会(AOFAS)踝与后足评分系统进行功能评价。结果手术时间平均为42(38~55)min,术后1例发生伤口浅表坏死,未培养出细菌,经换药3周后愈合。23例均获得随访,随访15个月~5年,平均33个月,未发生神经损伤、深静脉血栓、跟腱延长及再断裂等并发症。AOFAS踝与后足评分结果平均为93.4(76~100)分,优21例,良2例。22例主观满意。结论跟腱马尾状撕裂断端重叠间断横向缝合方法可保留自体跟腱组织,基本恢复跟腱正常形态,能够获得良好的强度、张力及弹性,达到满意临床效果。     

Rates of complications in Achilles tendon rupture repair using absorbable and nonabsorbable suture material; A systematic review

BackgroundThe impact of suture type on tensile strength, re-rupture rates and infection risk in Achilles tendon rupture repair is not been well established. The aim of this review is to evaluate existing literature on the associated risk of postoperative infection with absorbable and non-absorbable suture materials in Achilles tendon rupture repair.MethodsA systematic review of search databases PubMed; Google Scholar; and OVID Medline was made to identify studies related to complications associated with Achilles tendon rupture repair. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare rupture rates and infections following rupture repair.Results12 studies with a total of 460 patients, 230 in both nonabsorbable and absorbable suture groups were included for analysis. Risk of wound complications was significantly higher in patients with non-absorbable sutures (p < 0.001).ConclusionNonabsorbable braided sutures is associated with the highest risk of postoperative wound complications following Achilles tendon rupture repair.     

Achillon versus open surgery in acute Achilles tendon repair

Background

Open Achilles tendon repairs (OATR) are associated with high complication rates. Minimally invasive surgery (MIS) techniques like the Achillon Achilles tendon repair (AATR) were developed to reduce this. We performed a systematic review and meta-analysis to compare OATR with AATR.

Granuloma formation secondary to Achilles tendon repair with nonabsorbable suture

INTRODUCTION

Several complications can be observed after Achilles tendon repairs. In this study we aimed to report granuloma formation secondary to Achilles tendon repair with Ethibond (Ethicon INC, Somerville, New Jersey) suture.

PRESENTATION OF CASE

A 31 year-old man operated for Achilles tendon rupture. The Ethibond suture was used for primary repair. The patient attended to polyclinic with the complaints of swelling and discharge around the operation site four months after operation. A mass around distal portion of the Achilles tendon was detected. The granulomatous tissue was excised. Inside the mass Ethibond suture was detected. On histopathologic examination, typical findings of the foreign body reaction were observed. No microorganism was cultivated in the tissue culture. The patient has no complaint on the twelfth month control after surgery.

DISCUSSION

The results of primary repair of Achilles tendon are good but several complications were reported. In tendon repairs generally nonabsorbable sutures are used. The Ethibond is nonabsorbable, braided suture. In the literature, granuloma formations secondary to the suture materials such as polygylactine and braided polyethylen–polyester after Achilles tendon repair were reported but granuloma secondary to the Ethibond is very rare.

CONCLUSION

Although Ethibond suture is a strong and safe material for Achilles tendon repairs it may cause soft tissue problems such as granuloma.     

Endosopic Achilles tendon augmentation with a graft loop anatomic and radiologic study

Background

Mini-invasive techniques are commonly used for repair of tendon Achilles (TA) rupture. However, the use of these techniques is limited when graft augmentation is needed.

Method

A radiological study was conducted on 18 normal ankles using multi-slice CT scan with soft tissue reconstruction to determine the endoscopic landmarks for Achilles tendon insertion. The surgical procedure was performed on six whole lower limb formaldehyde preserved specimens. Endoscopic-assisted TA augmentation with a graft loop was done for all specimens. Postoperative assessment of the tunnel was done using multi-slice CT scan.

Results

Anatomic dissection showed that the sural nerve and neurovascular bundle were intact in all specimens.

Conclusion

With the technique described a graft loop can be delivered endoscopically for Achilles tendon augmentation. The technique was found to be safe for the sural nerve and medial neurovascular structures.     

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.     

Incidence and effect of calcifications after open-augmented Achilles tendon repair

Background and aims

The objective of this study was to analyse the incidence and effect on clinical outcome of post-operative Achilles tendon calcifications after open-augmented repair according to the Silfverskjöld technique.

Patients/methods

This retrospective study presents the results of follow-up examinations on 104 patients with Achilles tendon rupture who were treated according to the Silfverskjöld technique. Post-operative calcifications were identified by means of sonography, and clinical outcome was evaluated using the 100 points Thermann score. The average follow-up examination period was 3.7 years with an average patient age of 42.9 years. Two groups were identified and included those with (Group I) and those without (Group II) calcifications. Clinical outcome was evaluated using the Thermann score for both groups and was compared statistically by means of the two random sample t-test.

Results

Fifteen patients (Group I) developed tendon calcifications (14.4%) and 89 none (Group II). Group I scored 88.0 points and Group II 88.1 (good to very good outcome). There were no negative effects on clinical outcome (t = 0.98).

Conclusions

The incidence of tendon calcification after open-augmented repair of Achilles tendon rupture was 14.4% with no negative effects on clinical outcome as measured by the Thermann score.     

Open repair of the acutely torn Achilles tendon under local anaesthetic

Background: Where surgery has been preferred, the torn Achilles tendon (AT) has most commonly been repaired under general or spinal anaesthetic (GA). Repair using local anaesthetic (LA) has been reported, but does not appear to be widely used. Methods: We retrospectively reviewed 87 patients, following open repair using either GA or LA at Nelson Hospital, 2001–2005. Calf strength and ankle range of motion (ROM) were assessed. Subjective pain and function were assessed using the American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire. Complications, time off work and sport, time in theatre, and hospital were recorded. Results: Fifty‐nine tendons were repaired under GA (68%) and 28 under LA (32%). Outcomes were similar for each group. There was no significant difference in strength and ROM. Foot and Ankle Questionnaire scores were similar. Total theatre time averaged 57 min for GA and 37 min for LA (P = 0.01). LA repairs (82%) were performed as a day case compared with 10% of the GA repairs (P = 0.01). LA patients had a quicker return to work. GA complications included two deep vein thromboses and two pulmonary emboli. One patient from each group had a re‐rupture. Conclusion: A repair of the acutely ruptured AT under LA is at least as effective as repair under GA with regard to function, long‐term pain and patient satisfaction. LA repair results in significant cost savings due to less theatre time, fewer anaesthetic costs, and a shorter hospital stay.     

Endobutton联合双束跽长屈肌腱解剖止点重建治疗陈旧性跟腱断裂

背景：陈旧性跟腱断裂是足踝外科的常见疾病,目前临床以手术治疗为主。蹿长屈肌腱常被移植用作跟腱的修复,但存在单束重建时腱体单薄、双束重建时长度不足等问题。目的：观察Endobuuon联合双束蹿长屈肌腱于跟腱解剖止点重建跟腱治疗陈旧性跟腱断裂伤的临床疗效。方法：2010年1月至2011年6月,对21例MyersonIII型陈旧性跟腱断裂伤患者采用自体蹰长屈肌腱移植、双束蹿长屈肌腱联合Endobutcon跟腱解剖止点重建的方法进行治疗。男16例,女5例,年龄33-47岁,平均39．5岁。均为闭合性跟腱断裂。随访包括临床评价、X线及MR检查,采用美国足踝外科协会（American Orthopaedic Foot＆Ankle Society,AOFAS）踝与后足评分以及Leppilahti跟腱修复评分标准进行术后疗效评定。结果：21例获得平均16个月随访（12-30个月）。AOFAS—AH评分从术前63．2-8．3分提高到93．5±8．1分;Leppilahti跟腱修复评分从术前71．5±9．1分提高到93．2±5．9分。所有患者均无神经损伤、切口感染等并发症。术后6个月X线示Endobuaon固定位置良好,MRI示移植肌腱位置及形态良好。结论：Endobuaon联合双束蹰长屈肌腱解剖止点重建的方法可为跟腱提供强度和长度更为满意的自体移植物,术后功能恢复良好,无明显并发症。     

Mechanical evaluation of different techniques for Achilles tendon repair

Introduction One aim of the surgical treatment of acute Achilles tendon ruptures is to obtain a maximum primary stability of the sutured tendon. Therefore, we investigated the primary stability of sutured human Achilles tendons depending on different applied techniques. Methods The strength of 60 repaired cadaveric human Achilles tendons was tested depending on either the suture technique (Bunnell or Kessler), the suture material (PDS-thread or PDS-cord) or an additional plantaris tendon augmentation (PDS-thread with or without augmentation). Following anatomic reconstruction the repaired specimens were loaded to failure. Results The use of Bunnell's technique resulted in a stronger primary suture stability compared to Kessler's technique. Sutures carried out with a PDS-thread were of lower strength than those accomplished with a PDS-cord (Bunnell: thread 139 N ± 29.8; cord 291 N ± 55.2/Kessler: thread 137 N ± 37.3; cord 180 N ± 41.1). Sutures performed according to Bunnell's technique with a PDS-thread and an additional autologous plantaris tendon augmentation reached the highest primary stability (326 N ± 124.9). Conclusions The findings identify the Achilles tendon suture with a PDS-cord according to Bunnell's technique as a mechanically strong method. A plantaris tendon augmentation in addition to a PDS-thread can even add more stability to the Achilles tendon suture.     

Early rehabilitation after open repair for patients with a rupture of the Achilles tendon

PurposeAs outdoor activities participation increase, Achilles tendon rupture incidence also tends to increase. There are a number of treatment and rehabilitation options for a ruptured Achilles tendon. However, the optimal rehabilitation protocols are still under debate. The purpose of this study is to determine whether early rehabilitation is more effective than conventional rehabilitation.MethodsMedical records of 56 patients who had been treated with open repair after a ruptured Achilles tendon were retrospectively reviewed. 24 patients were treated postoperatively with below knee cast immobilization for four weeks, and they started tolerable weight-bearing rehabilitation at four weeks’ follow-up. The remaining 32 patients were managed postoperatively with short leg splint immobilization for two weeks and started the tolerable weight-bearing at two weeks’ follow-up. We evaluated the patients several times to identify when the single heel raise was possible and measured the American Orthopedic Foot and Ankle Society (AOFAS) scores and Achilles tendon total rupture scores (ATRS) as a functional outcome.ResultsThe single heel raise test was positive in all patients at the last assessment. But there were no statistically significant differences between the groups (p = 0.137). The patients in the Cast group took significantly more time to return to work than did the patients in the Splint group (p = 0.032). And AOFAS scores and ATRS were slightly higher in the Splint group than in the Cast group. There were statistically significant differences (p = 0.042, p = 0.028) between the two groups.ConclusionThe early rehabilitation did not lead to greater endurance, but it showed better results in the return to work and the Achilles functional score. Early rehabilitation after open repair for patients with a ruptured Achilles tendon is helpful for functional recovery.Type of study / Level of evidence: Therapeutic, Level III.     

Isokinetic functional outcomes of open versus percutaneous repair following Achilles tendon tears

BackgroundRupture of the Achilles tendon (AT) is frequent in young recreational athletes. Conservative management, open surgery and percutaneous/minimally invasive approaches are all advocated, and conflicting data are available. This study compared functional and anthropometric outcomes of patients who underwent open or percutaneous repair.MethodsA retrospective comparative study, in which 38 patients underwent open and percutaneous techniques to manage AT ruptures. For functional assessment, the calf circumference of both injured and uninjured legs was evaluated. Isokinetic testing included total plantar flexion work, peak plantar flexion torque, total dorsiflexion work peak and dorsiflexion torque. The Achilles Tendon Rupture Score (ATRS) and the American Orthopedic Foot and Ankle Score (AOFAS) were evaluated at a final minimum follow-up of 12 months.ResultsNo major complications were observed. The average time to return to sport was 9 months. AOFAS and ATRS values did not differ statistically between groups. Isokinetic variables and circumference were similar in the operated and non-operated limb in both groups, and did not differ either when comparing open and percutaneous repair.ConclusionsOpen and percutaneous repair of a torn Achilles tendon produced similar functional outcomes.     

Biomechanical and histologic comparison of Achilles tendon ruptures reinforced with intratendinous and peritendinous plantaris tendon grafts in rabbits: an experimental study

Introduction We hypothesized that the closer the reinforcing graft was to the repair zone, the more strength the healed tendon would achieved. Therefore, we compared the ruptured rabbit Achilles tendons reinforced with intratendinous and peritendinous plantaris grafts.Materials and methods The experimental study was performed on Achilles tendons of 20 rabbits. First, they were divided into two groups: group I (n=10) underwent intratendinous graft and end-to-end tenorraphy, and group P (n=10) were repaired end-to-end and then reinforced with a peritendinous plantaris graft. An above-knee cast was applied during 6 weeks postoperatively. The two groups were compared to each other biomechanically and histologically. Seven randomly selected rabbits from each group were used for biomechanical evaluation. The remaining six rabbits (three from each group) were used for histologic comparison. Non-operated sides (n=20) served as the control group.Results The mean maximum load at rupture of the repaired and control groups was 159.9±31 N, 83±7.5 N, and 207.5±35 N for group I, group P, and the control group, respectively. Values between groups were significantly different considering maximum load and absorbed energy to rupture. There was no significant difference between groups I and P in respect to strain. Control group tendons (groups I-C and P-C) had significantly more lengthening capability than operated tendons. Macroscopically, group I tendons were thicker and stiffer than group P tendons. Histologically, differences between the group I and group P specimens revealed that the healing process was faster in tendons augmented intratendinously.Conclusions In reinforcing Achilles tendon repair, the site of the tendon graft affected the result. When the graft was used intratendinously, the healed tendon was more similar biomechanically to normal tendon and had more graft-tendon orientation histologically than the tendon augmented peritendinously.This study was performed at the Biomechanic Laboratory of Middle East Technical University (METU) and Animal Experimental Research Laboratory of Osmangazi University in Turkey. The experiments comply with the current law of our country     

Outcomes of flexor digitorum longus (FDL) tendon transfer in the treatment of Achilles tendon disorders

BackgroundIn patients with chronic Achilles tendon disorders, Achilles tendon debridement can be supplemented with a tendon transfer, with the flexor hallucis longus tendon (FHL) transfer representing the most common used technique. Our study describes clinical and functional results of patients treated with flexor digitorum longus (FDL) tendon transfer in the treatment of patients with chronic Achilles tendon disorders.MethodsRetrospective study of prospectively collected data of thirteen patients (15 feet) that underwent FDL tendon transfer as part of the treatment of chronic Achilles tendon disorders. Preoperative and postoperative assessment included visual analogue score (VAS) for pain, SF-36 survey and lower extremity functional scale (LEFS). The average follow-up was 26.4 (range, 14–56) months. Patients were also assessed for ability to perform single leg heel rise test, muscle power for plantar flexion of the lesser toes, surgical scar condition and associated complications.ResultsAt final follow-up, we found significant postoperative improvement in VAS score (6.6 ± 2.99 vs 1.06 ± 1.43; p < .0001), SF-36 physical component summary (PCS) (28.20 ± 10.71 vs 45.04 ± 11.19; p < .0001) and LEFS (36.13 ± 20.49 vs 58.73 ± 18.19; p < .0001). Twelve patients (92%) could perform a single leg heel rise test in the operated extremity, although there was significant difference when comparing operated and uninvolved sides (4.86 ± 3.36 cm vs 7.18 ± 3.40 cm; p = .0002). One patient reported weakness for plantar flexion of the lesser toes, without balance or gait disturbances. Two patients (2 feet, 13.3%) had superficial infections and one patient (one foot, 6.6%) needed operative debridement for a deep infection.ConclusionsFDL tendon transfer represent an operative alternative in the treatment of chronic Achilles tendon disorders. Our study showed good clinical outcomes with low complications and donor site morbidity.Level of evidenceObservational study, case series – level IV.     

Open minimally invasive Achilles tendon repair with early rehabilitation: Functional results of 25 consecutive patients

Background

Various treatment techniques have been described for the treatment of acute Achilles tendon rupture. However, there is no consensus among orthopaedic surgeons regarding the surgical technique and the postoperative rehabilitation program. Mid-term functional outcome results of the patients who had undergone open minimally invasive repair of fresh Achilles tendon ruptures followed by an early rehabilitation programme were evaluated.

Methods

Twenty-five consecutive patients who underwent open minimally invasive repair of Achiles tendon ruptures during January 2004-October 2005 were independently reviewed at an average follow-up of 34 months (range 24-45 months). The mean age of the patients was 41 (35-47). A functional rehabilitation protocol based on early range of motion exercises was used after surgery. The American Orthopaedic Foot and Ankle Society score was used to evaluate the outcomes of the patients. Ankle range of motion; thigh, calf and ankle circumferences of the injured leg and the contralateral side, return to work and sports activities time were evaluated.

Results

One patient had a partial rerupture and one had superficial wound infection. The mean American Orthopaedic Foot and Ankle Society score was 93 (80-100). Patients returned to work at 3 weeks (range 1-5 weeks) and to preinjury sportive activities at 3 months (range 2-4 months). Ankle ROM and circumference measurements did not reveal a significant difference between the two sides.

Conclusion

These results suggest that open minimally invasive Achilles tendon repair and an early rehabilitation programme provides satisfactory results with early return to previous functional status with low complication rates.     

微创切取长屈肌腱重建慢性跟腱断裂

目的探讨微创切取长屈肌腱转移重建慢性跟腱断裂的临床效果。方法 2006年7月-2009年12月,收治22例22足慢性跟腱断裂患者。男16例,女6例;年龄28～65岁,中位年龄48岁。21例有患足用力蹬地史,1例无明显诱因。患者出现症状至手术时间为27～1 025 d,中位时间51 d。均有走路无力症状,Thompson试验呈阳性。根据美国矫形足踝协会(AOFAS)踝与后足疗效评价标准评分为(53.04±6.75)分。MRI示跟腱缺损长度为4.2～8.0 cm。术中作中足足底内侧切口和趾间关节跖侧平行横纹的小切口分步切取长屈肌腱,切取长度为超过跟骨结节10.5～13.5 cm,作3束反折编织缝合。界面螺钉或锚钉于跟骨后结节固定肌腱。结果术后患者切口均Ⅰ期愈合,无早期并发症发生。22例均获随访,随访时间12～42个月,平均16.7个月。术后12个月根据AOFAS踝与后足疗效评价标准评分为(92.98±5.72)分,与术前比较差异有统计学意义(t=—40.903,P=0.000);获优18例,良2例,可2例,优良率90.9%。随访期间均未见胫、腓肠神经损伤、跖底部痛性瘢痕、足底内外侧神经损伤。结论微创切取长屈肌腱转移重建慢性跟腱断裂具有切口小、术后恢复快、肌腱固定强度高以及并发症少的优点。