个体化手术治疗陈旧性跟腱断裂疗效分析

Curative analysis of individual surgery for chronic Achilles tendon rupture

目的探讨个体化手术治疗陈旧性跟腱断裂的临床疗效。方法 2009年9月—2016年3月,收治25例(26侧)陈旧性跟腱断裂患者。其中男22例,女3例;年龄18~59岁,平均38岁。病程4周~12年,中位病程12周。根据跟腱缺损大小,结合损伤部位及跟腱组织情况行个体化手术治疗。其中9侧跟腱行端端缝合术,8侧行腓肠肌腱瓣翻转术,9侧行自体游离肌腱跟腱重建术(4侧取同侧腘绳肌腱,5侧取同侧2/3腓骨长肌腱)。术后随访观察伤口等并发症情况,术前和末次随访时采用美国矫形足踝协会(AOFAS)踝-后足评分评价功能恢复情况,末次随访时观测患侧单足提踵活动、双侧踝关节主动屈伸活动度及双侧小腿最大周径等指标。结果术后1侧切口发生缝线异物反应,余25侧切口均Ⅰ期愈合。均无跟腱再断裂、伤口感染、神经损伤或静脉血栓形成等并发症发生。25例患者均获随访,随访时间8~85个月,平均34个月。AOFAS踝-后足评分由术前(50.54±5.52)分提高至末次随访时的(95.81±5.34)分,差异有统计学意义(t=–34.844,P=0.000);达优21例、良4例,优良率100%。末次随访时患侧和健侧踝关节主动背伸分别为(13.9±2.4)°和(16.7±2.0)°,差异有统计学意义(t=–9.099,P=0.000);踝关节主动跖屈分别为(39.8±3.2)°和(40.6±2.6)°,差异无统计学意义(t=–1.917,P=0.068)。末次随访时患侧和健侧小腿最大周径分别为(379.4±18.8)mm和(387.1±16.6)mm,差异有统计学意义(t=–5.053,P=0.000)。除1例患者因疼痛仅能完成部分单足提踵活动外,其余患者均能不受限完成单足提踵活动。所有患者均恢复受伤前生活和工作能力,12例恢复伤前运动。结论根据跟腱缺损大小,结合损伤部位及跟腱组织情况行个体化手术方式,可有效修复各类型陈旧性跟腱断裂,操作简便,并发症发生率低。

Objective To investigate the effectiveness of individual surgery for chronic Achilles tendon rupture. Methods A retrospective analysis was made on the clinical data of 25 patients （26 Achilles tendons） with chronic Achilles tendon rupture between September 2009 and March 2016, including 22 males and 3 females with a mean age of 38 years （range,18-59 years）. The median disease duration was 12 weeks （range, 4 weeks to 12 years）. The repairing method depended on the defect size, injury site, and tissue condition of the involved Achilles tendon： 9 Achilles tendons were repaired by end-to-end anastomosis, 8 by a gastrocnemius turndown flap, and 9 by auto free tendon （4 ipsilateral hamstring tendon and 5 ipsilateral 2/3 peroneus longus tendon）. The American Orthopedic Foot and Ankle Society （AOFAS） ankle-hind foot score, heel lifting of the affected leg, active ankle range of motion （plantar flexion and dorsiflexion）, maximum calf circumference, and complications were applied to assess the effectiveness. Results Hypersensitivity occurred in 1 incision, and stage I healing was obtained in the other incisions. No complication of re-rupture, infection, nerve injury, or deep venous thrombosis occurred. All the patients were followed up 8-85 months （mean, 34 months）. The AOFAS ankle-hind foot score was significantly improved to 95.81±5.34 at last follow-up from preoperative 50.54±5.52 （t=–34.844,P=0.000）; the excellent and good rate was 100% （excellent in 21 cases and good in 4 cases）. The active dorsiflexion of the operated side [（13.9±2.4）°] was significantly lower than that of normal side [（16.7±2.0）°] （t=–9.099,P=0.000）, but the active plantar flexion showed no significant difference between affected side [（39.8± 3.2）°] and normal side [（40.6±2.6°）] （t=–1.917,P=0.068）. The maximum calf circumference of the operated side [（379.4±18.8） mm] was significantly lower than that of normal side [（387.1±16.6） cm] （t=–5.053,P=0.000）. The other patients could finish heel lifting of the affected leg without limitation except for 1 patient. All patients returned to normal work and activity, and 12 patients returned to normal sports. Conclusion Individual surgery depending on the defect, injury site, and tissue condition of the involved Achilles tendon can repair all kinds of chronic Achilles tendon rupture with a low rate of complications.