双“Z”形缝合与改良Kessler缝合技术修复急性闭合性跟腱断裂的疗效比较

Comparative efficacy of double Z‑shaped suture and modified Kessler suture in repair of acute closed Achilles tendon rupture

目的比较双“Z”形缝合与改良Kessler缝合技术修复急性闭合性跟腱断裂的疗效。方法采用回顾性队列研究分析2018年7月至2022年7月西安交通大学第二附属医院收治的27例急性闭合性跟腱断裂患者的临床资料,其中男24例,女3例;年龄14~53岁[(35.7±8.2)岁]。患者均首次接受跟腱断裂开放性修复手术治疗,其中16例行双“Z”形缝合技术治疗(双“Z”形缝合组);11例行改良Kessler缝合技术治疗(改良Kessler缝合组)。比较两组术前和术后2、4、6周及末次随访时视觉模拟评分(VAS)。术后2、4、6周及末次随访时,采用美国足踝外科协会(AOFAS)踝‑后足评分、跟腱总断裂评分(ATRS)、踝关节活动度(背屈角度和跖屈角度)和剪切波弹性成像技术(SWE)[结果记为剪切波弹性速度值(SWV)]评估跟腱功能及质量恢复情况;采用高频超声技术评估跟腱形态结构恢复情况及软组织黏连程度。比较两组术后2周时早期康复训练耐受性及术后并发症发生率。结果患者均获随访6~12个月[(9.6±1.3)个月]。双“Z”形缝合组和改良Kessler缝合组术前VAS差异无统计学意义(P>0.05);术后2、4、6周,双“Z”形缝合组VAS分别为4.6(4.0,5.0)分、1.6(1.0,2.0)分、0.5(0.0,1.0)分,均低于改良Kessler缝合组的6.9(6.0,8.0)分、2.5(2.0,3.0)分、1.4(1.0,2.0)分(P<0.05或0.01);末次随访时,两组VAS均降至0.0(0.0,0.0)分。双“Z”形缝合组VAS于术后2周即较术前显著降低,且术后各时间点均呈降低趋势(P<0.05)。改良Kessler缝合组VAS术后2周较术前差异无统计学意义(P>0.05),而术后4、6周及末次随访时均呈降低趋势(P<0.05)。术后2、4、6周及末次随访时,两组AOFAS踝‑后足评分、ATRS、SWV差异均无统计学意义(P>0.05)。术后2、4、6周,双“Z”形缝合组踝关节背屈角度分别为(-18.2±3.9)°、(-13.7±2.8)°、(-6.6±2.4)°,均优于改良Kessler缝合组的(-24.1±2.7)°、(-18.3±3.0)°、(-12.0±2.8)°(P<0.01);末次随访时,两组踝关节背屈角度差异无统计学意义(P>0.05)。术后2周及末次随访时,两组踝关节跖屈角度差异均无统计学意义(P>0.05);术后4、6周,双“Z”形缝合组踝关节跖屈角度分别为(37.5±3.8)°、(42.1±3.3)°,均优于改良Kessler缝合组的(34.6±2.0)°、(38.0±1.4)°(P<0.05或0.01)。术后4、6周及末次随访时,两组AOFAS踝‑后足评分、踝关节背屈角度和跖屈角度、SWV均呈逐渐升高趋势(P<0.05或0.01)。双“Z”形缝合组ATRS术后2、4周差异无统计学意义(P>0.05),而术后6周及末次随访时均较前明显升高(P<0.05或0.01)。术后2、4、6周,改良Kessler缝合组ATRS未见明显变化趋势(P>0.05),仅末次随访时较前明显升高(P<0.05)。术后2、4、6周及末次随访时,高频超声提示两组患者跟腱形态恢复良好,但双“Z”形缝合组软组织黏连程度较改良Kessler缝合组明显降低。双“Z”形缝合组和改良Kessler缝合组分别有13例(81.3%)、3例(27.3%)患者可按康复计划于术后2周时耐受早期康复训练(P<0.05)。两组术后并发症发生率差异无统计学意义(P>0.05)。结论与改良Kessler缝合技术相比,双“Z”形缝合技术修复急性闭合性跟腱断裂,可术后早期减轻患者疼痛、促进踝关节活动度恢复、降低术后软组织黏连风险、提高康复训练耐受性。

Objective To compare the efficacy of double Z‑shaped suture and modified Kessler suture in the repair of acute closed Achilles tendon rupture.Methods A retrospective cohort study was conducted to analyze the clinical data of 27 patients with acute closed Achilles tendon rupture admitted to the Second Affiliated Hospital of Xi′an Jiaotong University from July 2018 to July 2022,including 24 males and 3 females,aged 14‑53 years[(35.7±8.2)years].All the patients underwent primary open surgical repair of the Achilles tendon,among whom 16 patients were treated with the double Z‑shaped suture technique(double Z‑shaped suture group)and 11 with the modified Kessler suture technique(modified Kessler suture group).Visual analogue scale(VAS)scores preoperatively and at 2,4,and 6 weeks postoperatively as well as at the last follow‑up were compared between the two groups.American Orthopedic Foot&Ankle Society(AOFAS)ankle‑hindfoot scores,Achilles tendon total rupture scores(ATRS),ankle range of motion(dorsiflexion and plantarflexion angles),and shear wave elastography(SWE)[with its results recorded as shear wave velocity(SWV)]were applied to evaluate the recovery of tendon function and quality.High‑frequency ultrasonography was also used to evaluate the recovery of morphological structure of the Achilles tendon and soft tissue adhesion.Tolerance to early rehabilitation at 2 weeks postoperatively and the incidence of postoperative complications were compared between the two groups.Results All the patients were followed up for 6‑12 months[(9.6±1.3)months].There was no statistically significant difference in preoperative VAS scores between the two groups(P>0.05).At 2,4,and 6 weeks postoperatively,the VAS scores in the double Z‑shaped suture group were 4.6(4.0,5.0)points,1.6(1.0,2.0)points,and 0.5(0.0,1.0)points respectively,significantly lower than those in the modified Kessler suture group[6.9(6.0,8.0)points,2.5(2.0,3.0)points,and 1.4(1.0,2.0)points](P<0.05 or 0.01).At the last follow-up,the VAS decreased to 0.0(0.0,0.0)points in both groups.VAS score in the double Z‑shaped suture group significantly decreased at 2 weeks postoperatively compared to that preoperatively,with a consistent downward trend observed at all the postoperative time points(P<0.05).In the modified Kessler suture group,there was no significant difference in VAS scores preoperatively and at 2 weeks postoperatively(P>0.05),but a downward trend was noted at 4 and 6 weeks postoperatively and at the last follow‑up(P<0.05).There were no significant differences in AOFAS ankle‑hindfoot scores,ATRS or SWV at 2,4,and 6 weeks postoperatively and at the last follow‑up(P>0.05).At 2,4,and 6 weeks postoperatively,dorsiflexion angles in the double Z‑shaped suture group were(-18.2±3.9)°,(-13.7±2.8)°,and(-6.6±2.4)°respectively,significantly better than those in the modified Kessler suture group[(-24.1±2.7)°,(-18.3±3.0)°,and(-12.0±2.8)°](P<0.01).No significant difference in dorsiflexion angles was observed between the groups at the last follow‑up(P>0.05).No significant differences in plantarflexion angles were noted at 2 weeks postoperatively and at the last follow‑up(P>0.05).At 4 and 6 weeks postoperatively,plantarflexion angles in the double Z‑shaped suture group were(37.5±3.8)°and(42.1±3.3)°respectively,significantly better than those in the modified Kessler suture group[(34.6±2.0)°and(38.0±1.4)°](P<0.05 or 0.01).Both groups showed increasing trends in AOFAS ankle‑hindfoot scores,dorsiflexion and plantarflexion angles,and SWV at 4 and 6 weeks postoperatively,as well as at the last follow‑up(P<0.05 or 0.01).No significant differences were noted in ATRS at 2 and 4 weeks postoperatively in the double Z‑shaped suture group(P>0.05),but significant improvements were observed at 6 weeks postoperatively and at the last follow‑up(P<0.05 or 0.01).In the modified Kessler suture group,no significant changes in ATRS scores were observed at 2,4 and 6 weeks postoperatively(P>0.05),except a significant increase at the last follow‑up(P<0.05).High‑frequency ultrasonography at 2,4,and 6 weeks postoperatively as well as at the last follow‑up indicated good morphological recovery of the Achilles tendon in both groups,while soft tissue adhesion was significantly less in the double Z‑shaped suture group compared with that of the modified Kessler suture group.Thirteen patients(81.3%)in the double Z‑shaped suture group and 3 patients(27.3%)in the modified Kessler suture group were observed to tolerate the early rehabilitation at 2 weeks postoperatively as scheduled in the rehabilitation plan(P<0.05).There was no statistically significant difference in the incidence of postoperative complications between the groups(P>0.05).Conclusion Compared with the modified Kessler suture technique,the double Z‑shaped suture technique can reduce postoperative pain at an early stage,enhance the restoration of ankle joint mobility,lower the risk of postoperative soft tissue adhesion,and improve tolerance to rehabilitation in the repair of acute closed Achilles tendon rupture.