组织工程肌腱修复陈旧性跟腱断裂伴缺损的疗效观察

目的探讨应用组织工程肌腱修复陈旧性跟腱断裂伴缺损的手术方法及临床效果。方法1999年8月～2002年6月,采用同种异体肌腱来源的成纤维细胞,以5×106/ml细胞密度接种在医用碳纤维与聚羟基乙酸纤维制作的编织带上,体外培养5d后,修复跟腱缺损7例,缺损长度为5～7cm。术后踝跖屈外固定4～6周后开始功能锻炼。结果7例均获随访22～56个月,平均46.9个月。除1例术后伤口延迟愈合外,其余6例均期愈合。无全身及局部不良反应,无跟腱粘连再手术患者。按尹庆水疗效评定标准,优5例,良1例,可1例。结论组织工程肌腱修复跟腱缺损可获较好临床效果,是一种可选择的新治疗方法。     

陈旧性跟腱断裂治疗进展

目的 总结陈旧性跟腱断裂治疗方法及进展.方法 查阅国内外近年关于陈旧性跟腱断裂治疗的文献,并进行综合分析.结果 陈旧性跟腱断裂手术修复方法的选择主要由肌腱断端间隙大小、小腿三头肌萎缩情况、患者的年龄和运动水甲决定.结论 陈旧性跟腱断裂大多需手术治疗以恢复良好功能,组织工程化修复肌腱缺损有广阔应用前景.     

同种异体肌腱修复跟腱断裂30例

目的探讨应用同种异体肌腱修复跟腱断裂的临床疗效。方法采用同种异体肌腱修复30例不同类型跟腱断裂患者,术后长腿管形石膏固定。疗效按Arner-Lindholm标准评定。结果切口长8～13 cm,手术时间35～80 min,出血量20～70 ml。术后切口获甲级愈合27例,乙级愈合3例。住院时间5～21 d。30例均获随访,时间12～36个月,无再断裂。2例出现异体排异,经对症治疗痊愈。疗效评定:优22例,良6例,差2例,优良率为93%。结论同种异体肌腱修复跟腱断裂可取得满意临床效果。     

应用同种异体肌腱加强修复治疗陈旧性跟腱断裂

目的探讨同种异体肌腱加强修复治疗陈旧性跟腱断裂的临床疗效。方法2005年1月至2011年12月,对26例陈旧性跟腱断裂患者,采用同种异体肌腱在跟腱断裂两侧的正常跟腱组织冠状面钻孔环扎,加强修复断裂的跟腱。结果26例均获随访9～52个月,平均30．7个月,除1例术后伤口延迟愈合外,其余伤口均I期愈合,无全身或局部不良反应,无跟腱黏连再手术者,无跟腱再断裂发生。采用Arner—Lindholm疗效评定方法,优22例（84．6％）,良4例（15．4％）。结论同种异体肌腱加强修复治疗陈旧性跟腱断裂疗效满意,并发症少,手术操作简单,是一种可行的手术方法。     

跖肌腱编织缝合法修复跟腱断裂的临床观察

目的总结采用跖肌腱编织缝合法治疗跟腱断裂的方法和经验。方法采用此法修复跟腱断裂10例,先将跖肌腱在远端止点处切断,用取腱器将其在近端切断,将取下的跖肌腱编织缝合于断裂跟腱远近端,同时将跖肌腱膜片包绕缝合跟腱形成光滑面。结果 10例患者术后随访6个月～1.5年,获得了良好的疗效。结论跖肌腱编织缝合修复跟腱断裂是一种有效的治疗方法。     

腓骨长肌腱移位修复闭合性跟腱断裂

目的探讨腓骨长肌腱移位修复闭合性跟腱断裂的应用解剖、生物力学和手术方法。方法在50侧动脉灌注红色乳胶的成人下肢标本上,观察腓骨长肌腱形态及血液供应,并进行肌腱拉伸破坏实验。设计腓骨长肌腱移位重建跟腱的术式,2001年3月~2004年7月临床应用10例闭合性跟腱断裂的患者,其中男7例,女3例;年龄32~54岁。跳跃伤6例,砸伤2例,踏空伤及自发伤各1例。新鲜伤7例,受伤至手术时间6h~7d;陈旧伤3例,受伤至手术时间21d~3个月。其中完全性断裂8例,不完全性断裂2例。结果腓骨长肌起于胫骨近端及腓骨头,止于第1跖骨基底及骰骨内侧表面,肌腱长13.5±2.5cm;起始部宽0.9±0.2cm,厚0.3±0.1cm;外踝尖平面宽0.7±0.1cm,厚0.4±0.1cm;骰骨头平面宽0.7±0.1cm,厚0.3±0.1cm。有多个血供来源。肌腱拉伸破坏实验示最大拉力:跟腱、腓骨长肌腱、腓骨短肌腱及胫骨后肌腱分别为2292.4±617.3、1020.4±175.4、752.0±165.4及938.2±216.7N。临床应用10例术后切口均期愈合;获随访18~24个月,无再断裂发生,无皮肤坏死等手术并发症。按照AmerLind-holm评定标准优7例,良3例,跟腱功能恢复良好。结论对于闭合性跟腱断裂,腓骨长肌腱移位修复跟腱是一种方法简便,疗效满意的手术方法。     

腓骨长肌及胫骨后肌联合修复陈旧性跟腱断裂伴缺损

作者自行设计使用腓骨长肌及胫骨后肌联合修复陈旧性跟腱断裂伴缺损48例,获得完整随访资料43例。跟腱缺损长度为8～10cm,自身已无修复条件。手术方法的优点:联合转移的肌腱弥补了长距离跟腱缺损,保持了原有肌肉的动力,弥补了小腿三头肌的挛缩无力。保持了足内、外翻的肌力平衡,足外形正常。肌肉的血循环不受干扰,增加了修复跟腱后愈合的机会。手术后6周都能逐渐下地行走,肌力一般都能达到Ⅳ级～V级,功能恢复良好,未发生因愈合不良再次发生断裂。     

陈旧性跟腱断裂的诊治进展

陈旧性跟腱断裂诊断治疗发展迅速,目前有多种诊治方案可供选择,具体方案的选择根据伤情、患者年龄、自我期望及经济水平等决定。目前对陈旧性跟腱断裂的病因研究已经深入到基因水平。陈旧性腱断裂手术治疗的预后较保守治疗好,干细胞疗法、基因工程及组织工程技术在修复肌腱缺损方面取得了较大的进步并且显示着广阔的应用前景。     

腓骨长肌腱移位修复陈旧性跟腱断裂16例体会

跟腱断裂在小腿和足部肌腱损伤中较常见,陈旧性跟腱断裂手术修复较困难。笔者于2001年2月~2007年7月,利用腓骨长肌腱移位重建跟腱术治疗陈旧性跟腱断裂16例,取得满意效果。1临床资料1.1一般资料本组16例,男14例,女2例;年龄16~48岁。左侧4例,右侧12例;闭合性损伤15例,开放性1例;     

腓骨长肌及胫骨后肌联合修复陈旧性跟腱断裂伴缺损

作者自行设计使用腓骨长肌及胫骨后肌联合修复陈旧性跟腱断裂伴缺损４８例，获得完整随访资料４３例。跟腱缺损长度为８－１０ｃｍ，自身已无修复条件。手术方法的优点：联合转移的肌腱弥补了长距离跟腱缺损，保持了原有肌肉的动力，弥补了小腿三头肌的挛缩无力。     

不剥离骨膜法肋骨钉内固定治疗多发肋骨骨折的随机对照研究

目的 分别运用Achillon吻合器和改良Kessler缝合法治疗急性闭合性跟腱断裂,随访比较患者的临床效果和功能恢复情况.方法从2009年3月至2012年2月,随机采用 Achillon吻合器微创修复与改良Kessler缝合法治疗49例急性闭合性跟腱断裂.其中Achillon 微创修复28例,改良Kessler法缝合21例.两组均无需行拇长屈肌或腓肠肌延长术.本研究平均随访21个月,分别在术后1周、第6个月、第12个月、随访结束期4个时间段,对两组患者的手术时间、住院时间、切口长度、踝关节运动范围、美国足踝外科协会（AOFAS）踝-后足疗效评分进行评价.结果在术后1周内,Achillon组发生1例神经损伤,改良Kessler组发生2例创口浅表感染,1例延迟愈合.两组并发症发生率差异无统计学意义（P=0.41）.在第6月,Achillon组AOFAS评分要优于改良Kessler组,第12月时两组无明显差异.术后两组踝关节运动范围,差异无统计学意义.截止随访结束时,所有患者均恢复到受伤前运动水平.结论两种缝合方法均能取得良好的疗效,相比改良Kessler缝合法,采用Achillon吻合器具有切口小、住院时间短、功能恢复快、术后美观等优点.     

Achilles tendon healing: long-term biomechanical effects of postoperative mobilization and immobilization in a new mouse model.

The aim of the study was to investigate the long-term effects of postoperative immobilization as opposed to mobilization on the biomechanical attributes of healing Achilles tendons in a new experimental mouse model. In 114 Balb-C-mice the left Achilles tendon was transected and sutured by the Kirchmayr-Kessler technique. The tendons healed either under postoperative immobilization effected by fixing the upper ankle joint in equinus position or under mobilization through a limited range of movement. The contralateral Achilles tendons served as internal control. All tendons were tested biomechanically at short intervals up to the 112th postoperative day in terms of load to failure [N], tendon deflection [mm] and tendon stiffness [N/mm], and were evaluated histologically after 8 and 112 days. Postoperative mobilization resulted in a continuous and significantly more rapid restoration of load to failure in comparison to the immobilization group. Tendon deflection was decreased by postoperative mobilization, whereas under immobilization it paradoxically increased still further in the later course. After 112 days the tendons of the mobilization group had regained their original tendon stiffness, whereas the tendons after immobilization reached only about half the values seen in the control tendons. Histologically, postoperative mobilization led to increased immigration of inflammatory cells in the early phase. In the late phase, as compared to immobilization, tendon structure was more mature, with fibre bundles arranged in parallel and interposed tendocytes. Tensile loading of the healing tendon by postoperative mobilization leads to fundamental changes in the biological process of tendon healing resulting in accelerated restoration of load to failure and reduced tendon deflection.     

Functional outcome of gastrocnemius advancement flap augmented with short flexor hallucis longus tendon transfer in chronic Achilles tear

BackgroundThere are various techniques of Achilles tendon (TA) repair and reconstruction in chronic Achilles tear. However, there is no clear consensus on the relevance of one method over the other. The short flexor hallucis longus tendon (FHL) transfer has recently gained popularity because of its same phasic action, ease of harvesting and tensile strength.MethodologyFifteen chronic Achilles tear (>6 weeks) were treated with tendon repair using gastrocnemius advancement flap augmented with FHL transfer. The patients were followed-up at 1.5, 3, 6, 12 and 24 months. The clinical outcome at latest follow-up was evaluated using the American Orthopedic Foot and Ankle Score (AOFAS) and the Achilles Tendon Rupture Score (ATRS).ResultsThe mean age was 43.5 ± 12.4 years and the median time from injury to surgery was 17.13 ± 9.64 weeks. The mean gap between the retracted ends of the ruptured tendon was 5.67 ± 1.63 cm (range 4–10 cm). The mean follow-up was 19.07 ± 3.15 months (range, 13–24 months). The mean AOFAS and ATRS improved from 72.07 ± 8.29 (62–83) to 98.4 ± 2.03 (94–100) and 61.73 ± 8.16 (52–70) to 98 ± 1.85 (94–100) respectively (paired t-test, p-value 0.0001). All patients resumed their pre-injury daily activities, and there was no donor site morbidity. Two patients had sterile serous discharge, and one patient had a staphylococcus infection. These patients responded to debridement with prolonged antibiotic therapy. There were no nerve injuries or re-rupture.ConclusionThe functional outcome of chronic Achilles tear treated with gastrocnemius advancement flap augmented with short FHL transfer is rewarding.     

Evolution of the Achilles tendon: The athlete's Achilles heel?

The Achilles tendon is believed to have first developed two million years ago enabling humans to run twice as fast. However if the Achilles tendon is so important in terms of evolution, then why is this tendon so prone to injury – especially for those more active like athletes. The Achilles tendon had an integral role in evolving apes from a herbivorous diet to early humans who started hunting for food over longer distances, resulting in bipedal locomotion. Evolutionary advantages of the Achilles tendon includes it being the strongest tendon in the body, having an energy-saving mechanism for fast locomotion, allows humans to jump and run, and additionally is a spring and shock absorber during gait. Considering these benefits it is therefore not surprising that studies have shown athletes have thicker Achilles tendons than subjects who are less active. However, contradictory to these findings that show the importance of the Achilles tendon for athletes, it is well known that obtaining an Achilles tendon injury for an athlete can be career-altering. A disadvantage of the Achilles tendon is that the aetiology of its pathology is complicated. Achilles tendon ruptures are believed to be caused by overloading the tensed tendon, like during sports. However studies have also shown athlete Achilles tendon ruptures to have degenerative changes in the tendon. Other flaws of the Achilles tendon are its non-uniform vascularity and incomplete repair system which may suggest the Achilles tendon is on the edge of evolution. Research has shown that there is a genetic influence on the predisposition a person has towards Achilles tendon injuries. So if this tendon is here to stay in our anatomy, and it probably is due to the slow rate of evolution in humans, research in genetic modification could be used to decrease athletes’ predisposition to Achilles tendinopathy.     

Anatomic relationship of the sural nerve when performing Achilles tendon repair using the percutaneous Achilles repair system,a cadaveric study

BackgroundMinimally invasive techniques for Achilles tendon repair are increasing due to reports of similar rerupture rates using open and percutaneous techniques with fewer wound complications and quicker recovery with percutaneous methods. The goal of this study was to investigate quantitatively the relationship and risk of injury to the sural nerve during Achilles tendon repair when using the Percutaneous Achilles Repair System (PARS) (Arthrex®, Naples, FL), by recording the distance between the passed needles and the sural nerve as well identifying any direct violation of the nerve with needle passage or nerve entrapment within the suture after the jig was removed. The hypothesis of the study is that the PARS technique can be performed safely and without significant risk of injury to the sural nerve.MethodsA total of five needles were placed through the PARS jig in each of 10 lower extremity cadaveric specimens using the proximal portion after simulation of a midsubstance Achilles tendon rupture. Careful dissection was performed to measure the distance of the sural nerve in relation to the passed needles. The sutures were then pulled out through the incision as the jig was removed from the proximal portion of the tendon and observation of the suture in relation to the tendon was documented.ResultsOf the 10 cadaveric specimens, none had violation of the sural nerve. Zero of the 50 (0%) needles directly punctured the sural nerve. In addition, upon retraction of the jig, all sutures were noted to reside within the tendon sheath with no entrapment of the sural nerve noted.ConclusionThis study demonstrated the variable course of the sural nerve and identifies the potential risk for sural nerve injury when using the PARS for Achilles tendon repair. However, this study provides additional evidence of safety from an anatomic standpoint that explains the outcomes demonstrated in the clinical trials. With this information the authors believe surgeons should feel comfortable they can replicate those outcomes while minimizing risk of sural nerve injury when the technique is used correctly.     

High-dose vitamin C supplementation accelerates the Achilles tendon healing in healthy rats

Introduction  This experimental study was performed to assess, whether or not, vitamin C, required during the collagen synthesis, would influence the Achilles tendon healing in a healthy rat model. Materials and methods  The right Achilles tendons of 42 healthy female Wistar Albino rats were completely ruptured. The rats were randomly divided into the vitamin C and control groups and both groups included third, tenth and twenty-first day subgroups. One hundred and fifty milligrams (1.5 cc) of vitamin C and 1.5 cc % 0.9 NaCl were injected once for every 2 days for the vitamin C and control groups, respectively. Qualitative and quantitative microscopic comparisons of the repair tissues of both groups were made on the mentioned days. Results  Angiogenesis was more evident on the third day in the vitamin C group. There was a significant difference between the control and vitamin C groups regarding the type I collagen production on the tenth day. The structure of the repair tissue was almost in the form of regular dense connective tissue at the end of twenty-first day in the vitamin C group. Mean collagen fiber diameter was considerably higher, and the number of active fibroblasts in the repair tissue was slightly elevated in the vitamin C group during the entire healing process. Conclusion  High-dose vitamin C supplementation once for every 2 days has stimulating effects on the Achilles tendon healing because of early angiogenesis and increased collagen synthesis in a healthy rat model. Further studies are needed to make clear the mentioned encouraging effects of the vitamin C on the Achilles tendon healing. Gazi University Scientific Research Project Foundation provided the financial support for this study (project no. 01/2003-01).     

Outcomes of flexor digitorum longus (FDL) tendon transfer in the treatment of Achilles tendon disorders

BackgroundIn patients with chronic Achilles tendon disorders, Achilles tendon debridement can be supplemented with a tendon transfer, with the flexor hallucis longus tendon (FHL) transfer representing the most common used technique. Our study describes clinical and functional results of patients treated with flexor digitorum longus (FDL) tendon transfer in the treatment of patients with chronic Achilles tendon disorders.MethodsRetrospective study of prospectively collected data of thirteen patients (15 feet) that underwent FDL tendon transfer as part of the treatment of chronic Achilles tendon disorders. Preoperative and postoperative assessment included visual analogue score (VAS) for pain, SF-36 survey and lower extremity functional scale (LEFS). The average follow-up was 26.4 (range, 14–56) months. Patients were also assessed for ability to perform single leg heel rise test, muscle power for plantar flexion of the lesser toes, surgical scar condition and associated complications.ResultsAt final follow-up, we found significant postoperative improvement in VAS score (6.6 ± 2.99 vs 1.06 ± 1.43; p < .0001), SF-36 physical component summary (PCS) (28.20 ± 10.71 vs 45.04 ± 11.19; p < .0001) and LEFS (36.13 ± 20.49 vs 58.73 ± 18.19; p < .0001). Twelve patients (92%) could perform a single leg heel rise test in the operated extremity, although there was significant difference when comparing operated and uninvolved sides (4.86 ± 3.36 cm vs 7.18 ± 3.40 cm; p = .0002). One patient reported weakness for plantar flexion of the lesser toes, without balance or gait disturbances. Two patients (2 feet, 13.3%) had superficial infections and one patient (one foot, 6.6%) needed operative debridement for a deep infection.ConclusionsFDL tendon transfer represent an operative alternative in the treatment of chronic Achilles tendon disorders. Our study showed good clinical outcomes with low complications and donor site morbidity.Level of evidenceObservational study, case series – level IV.