关节镜下清理结合微骨折术治疗慢性顽固性跟腱止点炎

Arthroscopic debridement combined with microfracture for chronic enthesiopathy of achilles tendon

目的探讨关节镜下清理结合跟腱止点微骨折治疗慢性顽固性跟腱止点炎的临床疗效。方法回顾性分析2013年1月至2016年1月采用关节镜下清理结合跟腱止点微骨折治疗15例慢性顽固性跟腱止点炎患者资料，男11例，女4例；年龄45~70岁，平均（55．5±8．9）岁；左侧5例，右侧10例；病程18个月至10年。患者均经3个月以上保守治疗，但效果均不佳。术中在关节镜下使用刨刀清理皮下跟腱表面增生的病变组织，而后用直径1．5-2mm克氏针经皮在跟腱止点进行微骨折术，微骨折间距3-4mm，深度5-10mm，可见到脂滴或血液自微骨折处渗出。采用视觉模拟评分（visualana-loguescale，VAS）评价患足疼痛情况，采用美国足踝外科协会（American Orthopaedic Foot and Ankle Society，AOFAS）踝-后足评分评价踝关节功能。结果15例患者的平均手术时间为（30．6±15．4）min，平均住院时间为（6．2±2．8）d；切口均一期愈合，无一例发生感染、神经及血管损伤等并发症。15例患者均获得随访，平均随访时间13．5个月。末次随访时，无一例发生跟腱断裂及足跟痛症状复发。术前、术后6个月及末次随访的平均VAS评分分别为（7．3±1．6）分、（2．4±1．3）分、（2．3±1_3）分；术前、术后6个月及末次随访的平均AOFAS踝-后足评分分别为（38．5±7．8）分、（92．9±6．9）分、（91．6±7．1）分。术后各时间点VAS疼痛评分均较术前显著降低，AOFAS踝-后足评分较术前显著增加，比较差异有统计学意义；术后各时间点间比较，差异无统计学意义。末次随访时，15例患者均对疼痛缓解程度均表示满意；根据AOFAS踝-后足评分，优10例，良4例，可1例，优良率为93．3％（14／15）。结论关节镜清理结合微骨折术治疗慢性顽固性跟腱止点炎是一种安全的手术治疗方法，临床效果良好。

Objective To evaluate the efficacy of arthroscopic debridement combined with microfracture on management of chronic enthesiopathy of Achilles tendon. Methods Fifteen cases of chronic enthesiopathy of Achilles tendon were enrolled in this study from January 2013 to January 2016. There were 11 males and 4 females, with an average age of 55.5±8.9 years. Five were in left side, and 10 in right side. All the patients failed to recover after conservative treatments for 18 months to 10 years. Pathological tissue was eliminated by blade. Then microfracture was made. Arthroscopic awls （1.5 or 2 mm in diameter） were used for making multiple holes at the footprint of achilles tendon. These holes were made far enough （3-4 ram） apart so they do not break into each other. Fat droplets and bleeding from the marrow cavity were seen when the appropriate depth （approximately 5 to 10 mm） has been reached. The patients were evaluated preoperatively and postoperatively using American Orthopaedic Foot and Ankle Society （AOFAS） Ankle-Hindfoot scores and visual analogue scale （VAS） scores. Results Average operation time and length of stay were 30.6±15.4 min and 6.2±2.8 d, respectively. Postoperative incisions were I stage healing for all patients. There were no perioperative and postoperative complications related to the procedure, such as rupture of achilles tendon, blood vessel and nerve injury. No infection and recurrence was found in all cases. All patients were followed up for an average time of 13.5 months. No rupture of achilles tendon or relapsing symptom was found. Average VAS scores before surgery, 6 month after surgery and at the lattest follow-up were 7.3±1.6, 2.4±1.3, and 2.3±1.3, respectively. Average AOFAS Ankle-Hindfoot scores were 38.5±7.8, 92.9±6.9, and 91.6±7.1, respectively. Average postoperative VAS scores and AOFAS Ankle-Hindfoot scores were significantly improved compared with those before surgery. There was no statistically significant difference among all check point after operation in VAS scores and AOFAS Ankle-Hindfoot scores. At the latest follow-up, all patients were satisfied with the degree of painful relief. According to AOFAS Ankle-Hindfoot scores, overall excellent and good rate was 93.3% （excellent in 10 cases, good in 4 cases, and fair in 1 case）. Conclusion Clinical results of arthroscopic debridement combined with microfracture for treatment of chronic enthesiopathy of Achilles tendon are good. This technique is easy and safe to perform.