微创锁扣阻挡改良Krackow技术治疗跟腱断裂的疗效

A prospective clinical controlled study of minimally invasive-locking block modified Krackow technique for repairing achilles tendon rupture

目的探讨微创锁扣阻挡改良Krackow和开放giftbox缝合治疗跟腱断裂的临床效果。方法回顾性分析2016年1月至2018年12月收治的跟腱断裂患者56例, 男54例、女2例, 年龄(40.7±9.4)岁(范围26~65岁)。30例微创组采用不暴露断端的两个微创切口行锁扣阻挡改良Krackow缝合, 26例开放组采用后方纵行切口行giftbox缝合, 两组均加环绕缝合线, 构成6股缝合线修复跟腱。术后均采用早期康复方案, 于术后6周, 3、6、12、24个月随访记录跟腱休息角(Achilles tendon resting angle, ATRA)并计算相对ATRA(健侧与患侧的差值)、美国足踝外科协会(American Orthopaedic Foot and Ankle Society, AOFAS)踝与后足功能评分、跟腱完全断裂评分(Achilles tendon total rupture score, ATRS), 并于术后6周和3个月在矢状面MRI上测量断端间隙, 横断面测量跟腱断端横截面积。结果微创组与开放组年龄、体质指数、伤后至手术时间、跟腱断裂部位的差异均无统计学意义(P>0.05)。所有患者均随访至术后24个月。微创组无切口并发症, 开放组2例浅表感染、1例皮肤坏死, 两组均无再断裂发生。微创组相对ATRA在术后3、6、12、24个月分别为-6.32°±0.99°、-3.90°±1.05°、-2.38°±0.84°、-0.25°±1.37°, 高于开放组的-7.88°±3.71°、-6.16°±1.10°、-4.53°±0.95°、-3.01°±0.95°, 差异均有统计学意义(P<0.05);微创组术后6、12个月ATRS评分分别为(72.70±7.41)分、(92.97±3.35)分, 高于开放组的(68.08±6.64)分、(90.85±4.27)分, 差异均有统计学意义(P<0.05);术后3、6个月AOFAS评分(88.60±2.76)分、(93.83±1.98)分, 高于开放组的(85.77±3.20)分、(92.08±2.64)分, 差异均有统计学意义(P<0.05)。术后6周两组MRI矢状面T2WI示跟腱断端间隙分别为(1.35±0.96)和(1.15±0.61)mm, 差异无统计学意义(t=0.73, P=0.468);术后12周微创组跟腱横截面积为(2.78±0.24)cm2, 高于开放组的(2.55±0.21)cm2, 差异有统计学意义(t=3.70, P=0.010)。结论微创锁扣阻挡改良Krackow技术能够保护腱周组织, 手术切口并发症更低, 且术后跟腱的拉长程度更小, 跟腱功能恢复更快。

Objective To investigate the clinical effect of minimally invasive-locking block modified Krackow(MI-LBMK)and open giftbox technique in the treatment of Achilles tendon rupture.Methods Fifty-six patients with Achilles tendon rupture from January 2016 to December 2018 were collected,including 54 males and 2 females,aged 40.7±9.4 years(range 26 to 65 years).The MI group(30 patients)used two minimally invasive incisions without exposing the rupture site,and the LBMK technique was used to repair the Achilles tendon.The open group(26 patients)used a posteromedial longitudinal incision and the giftbox technique was used to repair the rupture tendon.The Achilles tendon was repaired with 6-strand sutures in both groups.Early rehabilitation programs were adopted for postoperative rehabilitation,and regular follow-up(6 weeks,3,6,12 and 24 months after operation)was performed to record the Achilles tendon resting angle(ATRA),American Orthopaedic Foot and Ankle Society ankle-hindfoot score(AOFAS),Achilles tendon total rupture score(ATRS).The rupture gap and cross-sectional area(CSA)were measured by MRI at 6 weeks and 3 months after surgery.Results A total of 30 patients in the MI group and 26 in the open group were enrolled.The differences between the two groups in age,body mass index,interval from injury to operation,and tendon rupture site were not statistically significant(P>0.05).All patients were followed up to 24 months after surgery.There were no wound complications in MI group,and 2 cases of superficial infection and 1 case of wound skin necrosis occurred in open group.There was no re-rupture in both groups.The relative ATRA of MI group was-6.32°±0.99°,-3.90°±1.05°,-2.38°±0.84°,-0.25°±1.37°at 3,6,12 and 24 months after operation,respectively.The relative ATRA of open group was-7.88°±3.71°,-6.16°±1.10°,-4.53°±0.95°,-3.01°±0.95°at 3,6,12 and 24 months after operation,respectively.The differences between the two groups were statistically significant(P<0.05).The ATRS of minimally invasive group at 6 months and 12 months were 72.70±7.41 and 92.97±3.35 respectively,and the ATRS of open group at 6 months and 12 months were 68.08±6.64 and 90.85±4.27 respectively,and the differences were statistically significant(P<0.05).The AOFAS of minimally invasive group at 6 months and 12 months were 88.60±2.76 and 93.83±1.98 respectively,and the AOFAS of open group at 6 months and 12 months were 85.77±3.20 and 92.08±2.64 respectively,and the differences were statistically significant(P<0.05).The difference in the gap between the tendon rupture ends measured by MRI sagittal plane T2WI between the two groups was not statistically significant(P>0.05).The cross-sectional area of Achilles tendon in the MI group was higher than that of the open group at 12 weeks(P<0.05).Conclusion The MI-LBMK technique may protect the peritendon tissue and has fewer complications,and can enable the patient to return to daily life faster,with lower postoperative Achilles tendon elongation and better recovery of Achilles tendon function.