两种入路手术治疗闭合性跟腱断裂43例临床分析

Clinical analysis of two surgical approaches for treatment of closed rupture of Achilles tendon in 43 cases

目的总结分析两种跟腱断裂修复手术入路和方式,对术后并发症和疗效的临床影响。方法回顾笔者2002.1~2015.12收治的闭合性跟腱断裂手术治疗患者43例,其中传统入路组(25例)术中采用传统的跟腱后部正中偏内侧1 cm处的连续长切口,改良入路组(18例)采用新的踝后约3 cm长的"S"形短斜行切口加近段跟腱边缘处2对纵行小切口组合。跟腱缝合方法均采用Bunnell法。总结分析2种入路术后伤口不愈合、皮神经损伤、跟腱再断的发生率及疗效。结果术后随访9个月~5年,传统入路组术后伤口不愈合4例,跟腱再次断裂1例,无皮神经损伤病例。改良入路组术后发现腓肠神经损伤1例,无伤口不愈合及跟腱再次断裂发生。两组术后并发症的发生率比较,传统入路组伤口不愈合的发生率较高(P<0.05)。两组跟腱再次断裂及皮神经损伤发生率无明显差异(P>0.05)。跟腱修复术后6个月时按照Arner-indholm评分标准,改良入路组优良率较高(P<0.05)。结论采用改良手术入路,术中沿踝后部皮肤皱褶走向,采用斜跨跟腱的短S形切口,加近段跟腱边缘处成对小切口,术后并发症较少,功能恢复较好。

Objective To summarize and analyze the actions of two kinds of approaches and surgical methods on postoperative complications and curative effects of Achilles tendon rupture reparation. Methods From2002.1 to2015.12, 43 cases of patients with closed rupture of Achilles tendon underwent surgical treatment, 25 caseswith one long traditional continuous posterior median incision medial 1cm beside Achilles tendon was assigned into the conventional approach group, and 18 cases with 3cm long short oblique incision of S-shape on the posterior ankle and proximal 2 paired small incisions on the edge of proximal Achilles tendon were assigned into the modified approach group.Bunnell method was used in all Achilles tendon suture. The complications of wound dehiscence, cutaneous nerve injury and recurringAchilles tendon rupture and curative effects of 2 kinds of approaches were analyzed. Results All patients were followed up for 9 months to 5 years. In the conventional approach group, the wound dehiscence problem was found in 4 case, and recurring Achilles tendon rupture was found in 1 case, and no cutaneous nerve injury was found. In the modified approach group, sural nerve injury was found in 1 case, no wound healing was found in 4 cases and recurring Achilles tendon rupture was found in 1 case. The incidence of wound dehiscence in the two groups was higher than that in the conventional group （P〈0.05）. There was no significant difference between the two groups of Achilles tendon rupture and cutaneous nerve injury （P〉 0.05）. According to the Arner-indholm score standard, 6 months after the Achilles tendon repair, the excellent and good rate of the modified approach group was higher （P〈0.05）. Conclusion In the modified approach, one short S-shape incision obliquely across the Achilles tendon on posterior ankle along the direction of skin folds with pairs of small incision on the edge of proximal Achilles tendon resulted in less postoperative complications and better curative effect.