Mortensen H M, Skov O, Jensen P E
Department of Orthopaedics, Odense University Hospital, Denmark.
J Bone Joint Surg Am. 1999 Jul;81(7):983-90. doi: 10.2106/00004623-199907000-00011.
Different regimens of early motion of the ankle after operative treatment of a ruptured Achilles tendon have been suggested since the late 1980s. However, as far as we know, no controlled studies comparing these regimens with conventional immobilization in a cast have been reported.
In a prospective study, seventy-one patients who had an acute rupture of the Achilles tendon were randomized to either conventional postoperative management with a cast for eight weeks or early restricted motion of the ankle in a below-the-knee brace for six weeks. The brace was modified with an elastic band on the posterior surface, in a manner similar to the principle of Kleinert traction. Metal markers were placed in the tendon, and the separation between them was measured on serial radiographs during the first twelve weeks postoperatively. The patients were assessed clinically when the cast or brace was removed, at twelve weeks postoperatively, and at a median of sixteen months postoperatively.
The separation between the markers at twelve weeks postoperatively was nearly identical in the two groups, with a median separation of 11.5 millimeters (range, zero to thirty-three millimeters) in the patients managed with early motion of the ankle and nine millimeters (range, one to forty-one millimeters) in the patients managed with a cast. The separation was primarily correlated with the initial tautness of the repair (r[S] = 0.45). No patient had excessive lengthening of the tendon. The patients managed with early motion had a smaller initial loss in the range of motion, and they returned to work and sports activities sooner than those managed with a cast. Furthermore, there were fewer visible adhesions between the repaired tendon and the skin in the patients managed with early motion, and these patients were subjectively more satisfied with the overall result. The patients in both groups recovered a median of 89 percent of strength of plantar flexion compared with that of the noninjured limb, as measured with an isometric strain-gauge at 15 degrees of dorsiflexion. The heel-rise index was similar for both groups: 0.88 for the patients managed with early motion and 0.89 for those managed with a cast.
Early restricted motion appears to shorten the time needed for rehabilitation. There were no complications related to early motion in these patients. However, early unloaded exercises did not prevent muscle atrophy.
自20世纪80年代末以来，有人提出了跟腱断裂手术治疗后不同的早期踝关节活动方案。然而，据我们所知，尚无对照研究比较这些方案与传统的石膏固定。
在一项前瞻性研究中，71例急性跟腱断裂患者被随机分为两组，一组采用传统术后石膏固定8周，另一组采用膝下支具进行早期有限的踝关节活动6周。该支具后表面用弹性带进行改良，类似于Kleinert牵引原理。在肌腱中放置金属标记物，并在术后前12周通过系列X线片测量它们之间的间距。在拆除石膏或支具时、术后12周以及术后中位时间16个月时对患者进行临床评估。
术后12周时，两组标记物之间的间距几乎相同，踝关节早期活动组患者的间距中位数为11.5毫米（范围为0至33毫米），石膏固定组患者为9毫米（范围为1至41毫米）。间距主要与修复的初始张力相关（r[S]=0.45）。没有患者出现肌腱过度延长。早期活动组患者的初始活动范围损失较小，他们比石膏固定组患者更早恢复工作和体育活动。此外，早期活动组患者修复的肌腱与皮肤之间的可见粘连较少，这些患者对总体结果主观上更满意。两组患者与未受伤肢体相比，跖屈力量的中位数恢复率均为89%，这是在背屈15度时用等长应变仪测量的。两组的提踵指数相似：早期活动组患者为0.88，石膏固定组患者为0.89。
早期有限活动似乎缩短了康复所需时间。这些患者中没有与早期活动相关的并发症。然而，早期无负荷锻炼并不能防止肌肉萎缩。
