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。     

腓肠肌腱瓣翻转修复跟腱断裂

[目的]评价腓肠肌腱瓣翻转治疗跟腱断裂的手术疗效及方法。[方法]对跟腱断裂的35例患者行手术治疗，手术方法采用腓肠肌腱瓣翻转修复断裂的跟腱，术后进行康复训练。平均随访18个月，根据Arner Lindholm评分标准对治疗效果进行评价。[结果]35例患者均获得随访，32例随访1年以上。患者终末评价结果：优：29例，良：2例，差：1例。优良率97．1％。[结论]腓肠肌腱瓣翻转修复跟腱断裂疗效良好，术后康复训练是保证术后疗效的重要环节。     

Repair of neglected Achilles tendon rupture using gastrocnemius fascial flaps

Background. Neglected Achilles tendon rupture is a rare disorder. In this article, we discuss the results of 10 patients with neglected Achilles tendon ruptures who were treated surgically. Methods. Between 1980 and 1997, we treated 10 patients (6 men and 4 women) using gastrocnemius fascial flaps according to the method described by Lindholm. The mean age of the patients at the time of the operation was 51 years (range 38–57 years). They were followed-up for 26–192 months. Results. There were significant differences between the American Orthopaedic Foot and Ankle Society (AOFAS) scale score before the operation (72.6±5.3) and the score at the most recent follow-up (98.1±2.5) (p<0.0001). On Cybex isokinetic strength testing, the peak torque deficiencies in plantar flexion ranged from 8% to 68% at the low setting and from 19% to 33% at the high setting preoperatively, and ranged from –9% to 17% at the low setting and from –13% to 23% at the high setting postoperatively. There were no re-ruptures. Conlusion. Our data indicate that the reconstructive technique using gastrocnemius fascial flaps can result in an excellent clinical and functional outcome.     

Reconstruction of chronic ruptures of the distal biceps tendon with use of an achilles tendon allograft

BACKGROUND: Chronic ruptures of the distal biceps tendon are uncommon and are complicated by the retraction and poor quality of the muscle and tendon. Surgical procedures that have been described for the treatment of this injury are limited by the quality and availability of the structures used for augmentation. The purpose of the present study was to describe the surgical technique for reconstruction of the tendon with an Achilles tendon allograft and to report our preliminary experience with this procedure. METHODS: An Achilles tendon allograft was used to reconstruct a chronic rupture of the distal biceps tendon in four patients. The patients were evaluated with regard to subjective satisfaction, pain, range of motion, and strength in flexion and supination. The results were graded with use of the Mayo elbow performance score. RESULTS: After an average duration of follow-up of 2.8 years (range, 2.0 to 3.7 years), all four patients had a satisfactory subjective result, a full range of motion, and an excellent Mayo elbow performance score. The strength of flexion and supination was comparable with that on the contralateral side in two patients and was slightly decreased in the other two. CONCLUSIONS: Reconstruction of chronic disruptions of the distal biceps tendon with an Achilles tendon allograft appears to offer a satisfactory technical solution for this challenging problem and has provided satisfactory clinical results to date.     

Repair of neglected Achilles tendon ruptures: procedures and functional results

Surgical repair of neglected Achilles tendon ruptures presents the challenge of restoring the function of the Achilles tendon complex while repairing the large defect that is created by the delay in appropriate treatment. We present our preferred technique for delayed repair and the results of six patients who were available for complete follow-up evaluation. The combined surgical technique includes: V-to-Y gastrocnemius recession or advancement, excision of the fibroadipose defect, end-to-end anastomosis, gastrocnemius aponeurotic flap to reinforce the anastomosis. Each of six patients were interviewed and examined clinically and by Cybex II isokinetic strength testing. All six patients have been able to return to their pre-injury activities. Cybex II isokinetic strength testing demonstrated peak torque deficiencies in plantar flexion ranging from 2.5%–22% as compared with the unaffected limb. The overall results of the technique described indicate that very satisfactory functioning of a neglected Achilles tendon rupture can be obtained.     

Combined flexor hallucis longus tendon transfer and gastrocnemius recession for reconstruction of gapped chronic achilles tendon ruptures

ObjectiveThe aim of this study was to assess the functional outcomes after a combined FHL transfer and a gastrocnemius recession for treatment of chronic ruptures of Achilles tendon with a gap and to investigate the patient's satisfaction about the great toe function after transfer.Material and methods19 patients with chronic rupture of the Achilles tendon with a gap were treated with a flexor halluces longus tendon transfer combined with a gastrocnemius recession, Clinical diagnosis depends on the presence of gap in the tendon on examination, inability of tip toe walking on the affected side and positive calf-squeeze test, MRI was used to confirm the clinical diagnosis. American Orthopedic Foot & Ankle Society hind foot score was used for assessment of the results.ResultsThe AOFAS score improved significantly from a mean of 65 preoperatively to 94 at the last follow up (p < 0.001), there was no significant difference in the final outcome between patients with FHL tendon weaved through the stump of the Achilles tendon and those with trans osseous tunnels, the mean AOFAS score at the last follow up was 94.2, 93.8 respectively, no patient complained of big toe dysfunction.ConclusionManagement of chronic rupture of the Achilles tendon with a gap with flexor halluces longus tendon transfer combined with a gastrocnemius recession is a safe and reliable method with a significantly improved functional outcome, muscle advancement through gastrocnemius recession decreases the length of the gap without affecting the muscle function, flexor halluces longus tendon transfer doesn't harm the big toe function.     

腓骨长肌腱转移术治疗陈旧性跟腱断裂

[目的]探讨利用腓骨长肌腱治疗陈旧性跟腱断裂的手术方法和经验. [方法]将腓骨长肌腱在远端处切断,经皮下隧道移位修复跟腱断裂. [结果]根据Arner-Lindholm评定标准,优11例,良10例.未发生跟腱再次断裂.2例出现伤口延迟愈合,经康复训练,所有患者均在术后10周左右弃拐完全负重行走. [结论]用腓骨长肌腱治疗断端缺损较多,或者肌腱在跟骨结节附近断裂的陈旧性跟腱断裂是一种疗效满意,康复较快的手术方法.     

Bilateral achilles tendon ruptures in a patient with ochronosis: a case report

We report the case of a 67-year-old man with ochronosis who had bilateral Achilles tendon ruptures. We reconstructed the Achilles tendon using pull-out wiring for the right side and an anchoring system for the left side, and reinforced the repair site using the peroneus brevis tendon for both sides. He could walk without a cane at 3 months postoperatively. Tendon ruptures in patients with ochronosis should be treated as pathologic ruptures because histologic examination reveals that both ends of the ruptured tendon and the insertion site at the calcaneus have extensive black pigment depositions where homogentisic acid and its metabolites have accumulated, and there are no normal collagen bundles present. Even if an Achilles tendon rupture is clinically diagnosed as an acute injury, the ruptured Achilles tendon should be primarily repaired and reinforced with autologous tissue because there are a few viable cells at the ruptured site, and because the tendon ruptures mainly at the insertion site of the calcaneus. Although this is a preliminary report, the short-term result is good and the reconstructed sites have showed no rerupture.     

A survey on management of chronic achilles tendon ruptures

No controlled trials regarding management of chronic Achilles tendon ruptures have been published. We conducted an online survey of orthopedic surgeons affiliated with US medical schools. One hundred twenty-seven surgeons responded, but not all responded to each survey question. Thirty-six percent had foot and ankle fellowship training. Nearly all respondents diagnosed tendon rupture by using palpation of the tendon gap (97%) and the Thompson calf-squeeze test (96%). The Matles test was used by 37% of respondents, with foot and ankle specialists nearly 5 times more likely to use it than nonspecialists (P<.001). For surgical repair of a ruptured tendon, most surgeons used the end-to-end Bunnell technique for gaps of a few centimeters, transitioning to the flexor hallucis longus procedure or V-Y tendinoplasty for larger gaps. Ninety-three percent of respondents used nonabsorbable sutures; absorbable suture use tended to increase with years of practice. Most surgeons (72%) preferred postoperative immobilization for up to 6 weeks and non-weight-bearing for up to 6 weeks (96%). In most instances, the responses of foot and ankle specialists did not differ significantly from those of other orthopedic surgeons, allowing generalization of the survey results to practice trends among all orthopedic surgeons. Practice trends tended to follow published expert opinions.     

小切口微创治疗新鲜跟腱断裂

[目的]探讨通过小切口应用跟腱缝合引导器微创治疗新鲜跟腱断裂的临床效果.[方法]2006年3月-2008年3月,通过小切口应用跟腱缝合引导器微创治疗连续的26例新鲜跟腱断裂病人,术后早期功能锻练.男24例,女2例.年龄22～58岁,平均37.6岁.24例获得12～36个月(平均21个月)的随访.采用美国足与踝关节协会(AOFAS)踝与后足功能评分标准进行评分,测量双侧小腿最大周径及跟腱断裂平面的周径,询问恢复工作及伤前体育活动的时间.[结果]无跟腱再断裂、切口表浅或深部感染、皮缘坏死等并发症.腓肠神经支配区皮肤感觉正常.AOFAS 平均得分为97分(86～100分).23例恢复伤前工作与学习,恢复工作时间平均为10周(4～20周).24例均恢复伤前体育活动,恢复伤前体育活动时间平均为20周(18～24周).小腿最大周径伤侧较对侧平均减少0.4 cm(0.2～0.8 cm),跟腱断裂平面周径伤侧较对侧平均增粗0.5 cm(0.3～0.7 cm).[结论]应用跟腱缝合引导器微创修复新鲜跟腱断裂结合早期功能锻练可得到满意的临床效果,可较早恢复伤前状态,有较少的并发症.     

Surgical reconstruction of chronic achilles tendon ruptures using various methods

The purpose of this study was to evaluate the surgical outcomes of reconstruction of chronic Achilles tendon ruptures using various methods, including Achilles tendon allograft. Between October 2003 and March 2010, twelve patients with chronic Achilles tendon ruptures and a defect gap of >4 cm underwent surgical reconstruction with V-Y advancement, gastrocnemius fascial turn-down flap, flexor hallucis longus tendon transfer, or Achilles tendon allograft. The study group comprised 11 men and 1 woman. At last follow-up, all patients were assessed with regard to postoperative complications, self-reported level of satisfaction, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score, repetitive single-heel rises, single-leg hopping test, and ankle range of motion. The AOFAS scores increased from an average of 68.7 (range, 50-87) preoperatively to 98.0 (range, 88-100) postoperatively. All patients were able to perform 10 repetitive single-heel raises and single-leg hops at last follow-up. No patient experienced wound complications or deep infection. Seven patients were rated as excellent, 4 as good, and 1 as fair. Chronic Achilles tendon ruptures can be successfully treated by careful selection of the reconstruction method according to the length of defect gap and state of the remaining tissue. With an extensive defect, use of an Achilles tendon allograft can be a good option.     

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 achilles tendon ruptures treated by a limited open technique

BACKGROUND: The optimal surgical management of Achilles tendon ruptures remains a topic of active debate. Recently, many authors have preferred the limited open method because it afforded sufficient visualization to ensure anatomic apposition of disrupted tendon fibers, minimized local blood supply disturbances, guaranteed free tendon movement, and produced excellent cosmesis. We report our initial experience with this technique and review the literature. MATERIALS AND METHODS: The outcomes of 30 consecutive patients that underwent limited open repair for Achilles tendon rupture using Achillon (Newdeal SA, Lyon, France) from June 2003 to May 2006 were retrospectively reviewed. There were 20 men and 10 women, of average age 38.6 years, and the average followup period was 18.5 months. Twenty of the injuries were sports-related, eight were caused by a fall, and two by a laceration. The clinical results were assessed using patient satisfaction, the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS), and the occurrence of complications. RESULTS: At last followup, sixteen patients were very satisfied, 11 were satisfied, and the remaining three were dissatisfied. Mean patient AOFAS score was 93.0 points. Surgical complications noted were re-rupture in two cases, deep infection in one, and sural nerve injury in one. All patients except the three patients with a re-rupture or infection, returned to work 2 months postoperatively and resumed light exercise at 3 months, and previous sporting activities by 6 months. CONCLUSION: The described limited open repair technique for Achilles tendon ruptures provided excellent cosmetic results, satisfactory functional results, and a high level of patient satisfaction.     

The lange operation for untreated remote ruptures of the achilles tendon

Surgical Principles Bridging of a small to medium-sized defect of the Achilles tendon using a 2 to 3 cm broad strip of tendinous tissue from the ipsilateral gastrocnemius muscle displaced distally. This technique has been first described by M. Lange [3].     

The treatment of total ruptures of the achilles tendon by plaster immobilisation

Summary Twenty patients with total rupture of the Achilles tendon were treated by immobilisation in plaster in the gravitation-equinus position for eight weeks. All were healthy persons with a mean age of forty-three years. After removal of the plaster, seven patients had a re-rupture, four of whom were treated by operation, whilst two others sustained a deep vein thrombosis with an associated pulmonary embolus in one case.At follow-up, between 6 and 29 months after the rupture, 16 patients had no complaints and the remaining four had only minor problems. The range of motion in the ankle joint was normal in all patients and the strength in the affected calf was restored to normal in the majority. However, the strength recovered less in those patients with re-rupture who were treated conservatively for the second time. Because of the high complication rate we consider plaster treatment inferior to surgical treatment of Achilles tendon rupture.

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Résumé Vingt sujets présentant une rupture complète du tendon d'Achille ont été traités par immobilisation dans un plâtre en équin pendant deux mois. Il s'agissait dans tous les cas d'individus bien portants, d'une moyenne d'âge de 43 ans. Après ablation du plâtre, sept malades ont vu survenir une rupture itérative, dont quatre ont dû être opérées, tandis que deux autres présentaient une thrombose des veines profondes, associée dans un cas à une embolie pulmonaire.Lors de la révision, entre 6 et 29 mois après la rupture, 16 malades ne se plaignaient de rien et les quatre autres n'avaient que des problèmes mineurs. La mobilité de l'articulation tibio-tarsienne était normale chez tous et la force du triceps était restaurée chez la majorité d'entre eux. Cependant la force musculaire restait diminuée chez ceux qui avaient présenté une rupture itérative, de nouveau traitée orthopédiquement. En raison du pourcentage élevé de complications, les auteurs considèrent que le traitement des ruptures du tendon d'Achille par immobilisation plâtrée est inférieur au traitement chirurgical.