磁共振成像在闭合性跟腱损伤诊断中的价值

目的探讨磁共振成像(MRI)在闭合性跟腱损伤中的诊断价值,包括判断损伤性质、损伤程度和疗效随访。方法2003年4月～2005年5月24例闭合性跟腱断裂伤患者经低场强MRI扫描,MRI采用矢状面T1WI、T2WI、GE-STIR和横断面TME,层厚和层距各为4mm。并根据MRI分级诊断标准确定是部分性损伤还是完全性损伤。其中4例4～8周后复查MRI。结果MRI能准确判断跟腱撕裂的程度、部位,跟腱撕裂主要发生在跟腱中部。16例跟腱完全断裂患者在所有序列上显示跟腱连续性中断,跟腱增粗,T2WI断端间呈高信号;8例跟腱部分断裂患者T2WI显示条状高信号。术后随访4例患者见跟腱变细,信号降低。结论MRI能对跟腱撕裂程度及部位做出准确判断,直接显示跟腱内的信号变化并提供丰富的信息,对临床治疗具有重要参考价值。     

Neglected Achilles tendon rupture with central insertional plantaris tendon hypertrophy: two cases

A neglected Achilles tendon rupture is often characterized by muscle weakness and an overlengthened repair by scar tissue. Reconstructive surgery is usually performed taking into account the patient’s required level of function. Two surgical cases of neglected Achilles tendon rupture are presented in this article. In both instances it was expected that central fibrosis, possibly after neglected tendon rupture, would be found. However, after longitudinal opening of the tendons, a thickened plantaris tendon was evident at the insertion on the calcaneus in both cases. This hypertrophic tendon occupied most of the diameter of the Achilles tendon. Due to partial or complete rupture of the Achilles tendon, there was notable weakening and tendon transfer-augmentation was performed. A thickened plantaris tendon as a reaction to a neglected rupture of the Achilles tendon is a rare presentation. It can be detected preoperatively by MRI and subsequently preoperative planning can be optimized.     

跟腱损伤治疗进展

目的介绍跟睫的解剖、损伤的病因、治疗策略及有关的最新进展。方法查阅国内外近年有关文献，并作综合分析。结果皮质类固醇对肌腱的影响仍存在争议，应用喹诺酮类药物治疗可能和肌腱疾病的发生有关。急性跟腱断裂治疗分为开放手术修复、经皮手术和非手术治疗。结论陈旧性跟腱断裂治疗及跟腱缺损的修复手术方式多种多样。多种生长因子的发现为跟腱损伤的治疗提供了新的途径。     

Combined conservative and orthotic management of acute ruptures of the Achilles tendon

BACKGROUND: There has been considerable debate about the best treatment for acute rupture of the Achilles tendon. At our institution, a well-documented and structured program of nonoperative management of Achilles tendon rupture with use of casts and a removable orthosis was developed. METHODS: We assessed the results in 140 consecutive patients with a complete rupture of the Achilles tendon who had been treated with our nonoperative regimen at our center between 1992 and 1998. Patients were evaluated on the basis of the subjective results and clinically with physiological testing. RESULTS: Overall, 56% of our patients had an excellent result; 30%, good; 12%, fair; and 2%, poor. The overall complication rate was 8%, with three complete and five partial tendon reruptures, two deep vein thromboses, and one temporary dropfoot. CONCLUSIONS: The results of our nonoperative orthotic treatment were better overall than published results of operative repair of acute Achilles tendon rupture. Our patients were quite satisfied with their treatment.     

Achilles tendon rupture: a case report and discussion of conservative versus surgical repair

The authors review the literature on Achilles tendon ruptures and discuss the conservative and surgical approaches to treatment of acute ruptures. A case history of acute Achilles tendon rupture is presented, including clinical signs not previously described. The primary complication of Achilles tendon rupture is the high incidence of rerupture after conservative therapy. The authors note that complications after surgical repair of an Achilles tendon rupture may be avoided by a surgeon skilled in the performance of this procedure and by the use of an appropriate surgical drain. The authors conclude that primary surgical repair is the treatment of choice for acute Achilles tendon ruptures.     

Okkulte Fraktur einer Achillessehnenossifikation ohne begleitende Sehnenruptur

Ossification of the Achilles tendon is the result of a traumatic, hypoxic injury of the tendon. The usually asymptomatic ossification has a clinical importance only in case of a new trauma. We report about a patient with an isolated fracture of the ossification without an accompanying rupture of the Achilles tendon. Because of the radiologically "occult" fracture the diagnosis could only be verified by MRI. With a conservative treatment without resection of the ossification we could reach painless recovery.     

急性跟腱断裂的微创外科治疗研究进展

急性跟腱断裂是常见的运动损伤,目前针对急性跟腱断裂最佳治疗方案在临床上存在较多争议,其治疗方式主要分保守治疗及手术治疗。保守治疗时间长,跟腱再断裂率较高,术后功能恢复慢。传统的开放式手术治疗存在一系列并发症,而微创手术是近年来发展起来的一种新的技术,它最大限度地减少伤口的暴露,降低手术损伤范围,缩短手术时间并且降低伤口感染发生率,在临床上日益得到重视,值得临床推荐。     

Conservative treatment of Achilles tendon rupture

One hundred patients with Achilles tendon rupture subjected to conservative treatment were studied clinically and radiologically. Follow-up studies lasted from 6 months to 6 years with the average of 3 years and 2 months. Ninety-eight percent of all patients were evaluated as excellent or good clinically. According to the distribution of sole pressure measured by foot print, the distribution of weight-bearing area was observed on the first toe at 6 months after initial treatment the same as on the normal side. In computed radiograms, the shadow of the rupture site of Achilles tendon has become clear and similar to those on the normal side at 6 months after initial treatment. These findings could be used as a criterion for permitting patients to resume sports activity. Based on the results of this study, it was concluded that a fresh Achilles tendon rupture should be treated conservatively.     

闭合性跟腱断裂微创腱皮缝合的远期疗效观察

[目的]通过对长期疗效和可能并发症的观察,介绍并评价微创腱皮缝合术治疗急性闭合性跟腱断裂的临床效果。[方法]自1996年1月～2005年4月间,随机选取跟腱断裂的患者28名,经术前查体和MRI证实,均为新鲜完全性闭合性跟腱断裂。首先微创暴露跟腱断端,清除断端的瘢痕和血凝块,梳理对合两断端,在皮外经跟腱断端以远健康部位做减张缝合。患者常规术后随访,平均随访4年（1～7年）。随访包括常规的临床评价和术后MRI检查,并应用Arner-Lindholm疗效评定标准对术后效果进行评定。其中2例未能按时随访。[结果]对所有26例患者,按Arner-Lindholm疗效评定标准进行评定,其中优19例,良6例,差1例,优良率为97%,无感染发生,再断裂1例,为长期局部类固醇封闭患者。术后MRI显示,全部患者的跟腱得到了良好的修复,跟腱断端连续性好,疤痕小。[结论]通过长期随访,微创腱皮缝合是一种修复急性闭合性跟腱断裂较好的方法,具有创伤小,有效保护跟腱血运,术后并发症少的优点。     

Achilles tendon rupture

Whereas Achilles tendon rupture is usually treated operatively in central Europe, conservative treatment is felt to be indicated in Britain, North America and the Scandinavian countries. In a prospective randomized trial we compared conservative functional treatment and operative functional treatment with a newly developed boot. Forty-four patients (19 with operative, 25 with conservative treatment) were entered in the study. The initial evaluation included dynamic ultrasonography and MRI in a neutral position and at 20 degrees of plantar flexion to determine the amount of tendon diastasis. Follow-up clinical examination and ultrasonography revealed, no significant differences between the two groups. After 25 months all patients in both groups had complete healing with no rerupture. Functional treatment allows an earlier return to work and earlier resumption of active sport. We observed stable tendon healing, optimal functional results, and a high level of patient satisfaction. Primary functional treatment does not appear to be inferior to operative functional treatment when no more than 5 mm tendon diastasis is observed on the initial ultrasonography in the neutral position.     

Achillessehnenruptur

Achilles tendon ruptures are part of a continuum starting with the healthy Achilles tendon, including the thickened and painful tendinopathic Achilles tendon with neovascularization, and extending to complete tendon rupture. Often times chinolone antibiotics, cortisone therapy and valgus foot axis are associated risk factors. The incidence of Achilles tendon ruptures is estimated to be 10/100 000 per year with a mean age of 35–40 years. Physical activity is encountered in 75% cases of Achilles tendon ruptures. Running is associated with Achilles tendinopathy as the predominant overuse injury. Physical examination must include the calf squeeze test, followed by dynamic ultrasound examination: if an adaptation of the tendon's stump up to 20° ankle flexion is achieved and a patient is highly compliant, early functional conservative treatment in Achilles tendon ruptures can be performed. In almost all other patients percutaneous Achilles tendon repair is indicated, where nervus suralis lesions have to be appreciated. The vulnerable zone is 10–12 cm proximal to the calcaneus at the lateral border of the Achilles tendon with the sural nerve in close proximity to the tendon. As casts are not indicated anymore, early functional rehabilitation leads to improvement and should therefore be advocated.     

Open Re-rupture of the Achilles Tendon Following Minimally Invasive Repair: A Case Report

In this report, we describe a rare complication of an open re-rupture of the Achilles tendon following a minimally invasive Achilles tendon repair on a healthy 29-year-old active male. The reinjury happened 19 weeks following the primary surgical repair of a spontaneous rupture, performed by minimally invasive technique with the help of a jig using partially absorbable sutures and four locking stitches. The wound of the open re-rupture was transverse, in a perpendicular orientation relative to the longitudinal approach used in the index procedure. Increased scar tissue formation, the absence of an adequate layer of paratenon overlying the primary tendon repair, and foreign-body reaction to the suture may have been involved in the occurrence of this unusual complication in the surgical treatment of Achilles tendon rupture.     

Does Clinical Exam and Ultrasound Compare With MRI Findings When Assessing Tendon Approximation in Acute Achilles Tendon Tears? A Clinical Study

The purpose of this study was to determine if clinical palpation and ultrasound determination of apposition compares with magnetic resonance imaging (MRI) findings in patients with an acute Achilles tendon rupture. A review of 18 consecutive patients presenting with an acute Achilles tendon tear was performed. All tears were diagnosed by clinical exam and confirmed by ultrasound. Ankles were then plantarflexed to a point where tendon apposition was achieved as determined by palpation and ultrasound. Dorsally based equinus splints were applied, and approximation was reconfirmed by palpation and ultrasound. MRI was performed on all patients for comparison to the exam/ultrasound for any residual gapping after splinting. Demographic and clinical comparisons were made between those with <0.5 cm and ≥0.5 cm of residual gapping found on MRI. Eighteen patients with acute Achilles tears were splinted at a mean of 41° ± 11°, with presumed, complete tendon approximation confirmed with palpation and ultrasound. Post-splinting MRI demonstrated that 9/18 (50%) of these patients had residual gapping at a mean of 2.2 ± 1 cm. Mean time to MRI from splinting was not different between those with gapping (1.3 ± 2 days) and those without (1.2 ± 1 days). No other clinical or demographic differences were observed between these groups. In conclusion, clinical exam and ultrasound did not routinely relate to MRI in assessing tendon approximation after splinting of an acute Achilles tendon tear. For surgeons who use approximation as a determination of nonoperative treatment, varying results can be obtained depending on the clinical utility used.     

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。     

A novel minimally invasive surgery combined with early exercise therapy promoting tendon regeneration in the treatment of spontaneous Achilles tendon rupture

ObjectiveAcute closed spontaneous Achilles tendon rupture often occurs in elderly individuals and is usually accompanied with many complications. Conventional surgical approaches to remove the tendon lesions and enthesophytes are highly traumatic and cause complications. In this study, a previously established minimally invasive surgical approach was modified and combined with a Kazakh exercise therapy to reduce trauma, improve wound healing, and promote tendon regeneration in the management of acute closed spontaneous Achilles tendon rupture.MethodsFifty-two patients with acute closed spontaneous Achilles tendon rupture were randomly classified into 2 groups. Group A included 23 patients that were treated with the novel approach. Group B included 29 patients that were treated with a continuous medial oblique surgical approach. Follow-up examinations were performed at post-operative weeks 12 and 24, and year 2. Outcomes were assessed by Achilles tendon rupture score (ATRS), a heel-rise endurance test, and ultrasonographic and multislice spiral computerized tomography.ResultsMean ATRS in Group A was 68.6 and 86.0 at post-operative week 12 and 24, respectively, significantly higher than that in Group B (55.9 and 72.0, respectively). Recovery of patients in Group A was significantly better compared to Group B (p < 0.01), allowing them to participate in early rehabilitating kinesiotherapy. Patients in Group A rarely experienced complications after surgery, such as infection and Achilles tendon exposure, while in Group B, the wound healing was slower, the inside flaps were prone to necrosis and infection, and Achilles tendon exposure occurred in 10% of patients.ConclusionsThe novel minimally invasive surgery is more advantageous in the treatment of acute closed spontaneous Achilles tendon rupture over previous approaches by promoting wound healing and tendon regeneration.     

Diffuse-Type Giant Cell Tumor of the Paratenon of Achilles Tendon Requiring Reconstruction Using Bilateral Autografts: A Case Report

Although a diffuse-type giant cell tumor is a rare benign lesion, when it develops it tends to localize to the tendons of the hand and foot. In this study, we report the case of a 41-year-old male patient who was diagnosed with diffuse-type paratenon giant cell tumor involving the Achilles tendon. The duration of the bilateral tumors was 8 years. He visited first affiliated Hospital of Wenzhou Medical University for medical attention. Both his Achilles tendons required removal. The reconstructed Achilles tendon was replaced using tissue derived from the knee and foot. Postoperatively, the patient recovered well and regained full range of motion in the ankle. The use of autografts may shorten patients’ recovery period.     

Achilles tendon rupture. Occurrence with a closed ankle fracture

A 61-year-old man, involved in an automobile accident, sustained a complete Achilles tendon rupture with an ipsilateral, closed slightly displaced medial malleolus ankle fracture. The tendon rupture was not diagnosed before operation but was recognized at the time of open reduction of the ankle. This rare combination of injuries was apparently secondary to hyperdorsiflexion of the foot. The tendon rupture would have been missed had surgical treatment not been required. Unrecognized tendon ruptures associated with closed ankle fractures may be a cause of residual ankle-foot weakness, pain, loss of motion, or a combination thereof.     

Acute Achilles Tendon Ruptures: Efficacy of Conservative and Surgical (Percutaneous,Open) Treatment—A Randomized,Controlled, Clinical Trial

There is controversy regarding the best treatment for acute ruptures of the Achilles tendon. Multiple treatments present good results in the short and long term, none being superior to the other if a protocol of rehabilitation with full early weightbearing rehabilitation is followed. The objective of this study was to provide evidence on the efficacy and safety of conservative or surgical (percutaneous or open) treatment for acute Achilles tendon rupture. A randomized, controlled, parallel-groups, pilot clinical trial was performed in patients aged ≥18 years who arrived at the emergency room of our center experiencing acute Achilles tendon rupture. Patients were randomized via a computer-generated list to receive 1 of 3 treatments (conservative, percutaneous surgery, or open surgery). All patients followed the same protocol of rehabilitation with early weightbearing. A responder (i.e., successful treatment) was defined as capable of standing heelrise mono- and bipodally for 3 seconds, having a pain score ≤2 (verbal numerical rating scale) after walking, and having returned to active previous life (sport) at 1-year follow-up. From 2014 to 2017, 34 consecutive patients (median age, 41 years [range 18 to 59]; 32 male [94%]) were included: 11 conservative treatment, 11 percutaneous surgery, and 12 open surgery. At 1-year follow-up, the proportion of responders was 100% (11/11, 95% confidence interval [CI] 74% to 100%), 82% (9/11, 95% CI 52% to 95%), and 83% (10/12, 95% CI 55% to 95%), respectively. There was no case of total rerupture. Similar efficacy was found for conservative, percutaneous, and open surgery treatments for acute Achilles tendon rupture at 1-year follow-up with an early weightbearing rehabilitation program.     

Surgical repair of Achilles tendon rupture

Achilles tendon suture combined with a triceps surae tendon tip-over graft was performed in 314 patients with acute rupture of the Achilles tendon between 1980 and 1991. Analysis of these cases showed a low tissue complication rate compared with that reported in the literature. An average of 8.1 years after repair, 223 patients were examined using Holz’s scale of clinical assessment after Achilles tendon repair. The results were ‘good’ in 87.4%, ‘fair’ in 11.2% and ‘poor’ in 1.4%. The re-rupture rate was very low (0.4%). These results are better than the re-rupture rate after surgical repair with solely end-to-end suture or after conservative immobilizing or conservative functional treatment. In conclusion, these data show that the fascial reinforcement is a valuable complement to the tendon suture. Received: 14 January 1997