Maranho Daniel A C, Nogueira-Barbosa Marcello H, Simão Marcelo N, Volpon Jose B
Pediatric Orthopaedic Division, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil.
J Pediatr Orthop. 2009 Oct-Nov;29(7):804-10. doi: 10.1097/BPO.0b013e3181b76a5f.
Most cases of congenital clubfoot treated with the Ponseti technique require percutaneous Achilles tenotomy to correct the residual equinus. Clinical evidence suggests that complete healing occurs between the cut tendon stumps, but there have not yet been any detailed studies investigating this reparative process. This study was performed to assess Achilles tendon repair after percutaneous section to correct the residual equinus of clubfoot treated with the Ponseti method.
A prospective study analyzed 37 tenotomies in 26 patients with congenital clubfoot treated with the Ponseti technique, with a minimum follow-up of 1 year after the section. The tenotomy was performed percutaneously with a large-bore needle bevel with patient sedation and local anesthesia. Ultrasonographic scanning was performed after section to ascertain that the tenotomy had been completed and to measure the stump separation. In the follow-up period, the reparative process was followed ultrasonographically and assessed at 3 weeks, 6 months, and 1 year posttenotomy.
The ultrasonography performed immediately after the procedure showed that in some cases, residual strands between the tendon ends persisted, and these were completely sectioned under ultrasound control. A mean retraction of 5.65 mm+/-2.26 mm (range, 2.3 to 11.0 mm) between tendon stumps after section was observed. Unusual bleeding occurred in one case and was controlled by digital pressure, with no interference with the final treatment. After 3 weeks, ultrasonography showed tendon repair with the tendon gap filled with irregular hypoechoic tissue, and also with transmission of muscle motion to the heel. Six months after tenotomy, there was structural filling with a fibrillar aspect, mild or moderate hypoechogenicity, and tendon scar thickening when compared with a normal tendon. One year after tenotomy, ultrasound showed a fibrillar structure and echogenicity at the repair site that was similar to a normal tendon, but with persistent tendon scarring thickness.
There is a fast reparative process after Achilles tendon percutaneous section that reestablishes continuity between stumps. The reparative tissue evolved to tendon tissue with a normal ultrasonographic appearance except for mild thickening, suggesting a predominantly intrinsic repair mechanism.
大多数采用Ponseti技术治疗的先天性马蹄内翻足病例需要经皮跟腱切断术来纠正残留的马蹄足畸形。临床证据表明，切断的肌腱残端之间会完全愈合，但尚未有任何详细研究调查这一修复过程。本研究旨在评估经皮切断跟腱以纠正Ponseti法治疗的马蹄内翻足残留马蹄足畸形后的跟腱修复情况。
一项前瞻性研究分析了26例采用Ponseti技术治疗的先天性马蹄内翻足患者的37次跟腱切断术，切断术后至少随访1年。跟腱切断术在患者镇静及局部麻醉下经皮使用大口径针斜面进行。切断术后进行超声扫描以确定切断术已完成并测量残端间距。在随访期间，通过超声对修复过程进行跟踪，并在切断术后3周、6个月和1年进行评估。
术后立即进行的超声检查显示，在某些病例中，肌腱断端之间残留的条索依然存在，并在超声引导下将其完全切断。切断术后观察到肌腱残端之间平均回缩5.65 mm±2.26 mm（范围为2.3至11.0 mm）。1例出现异常出血，通过指压控制，未对最终治疗造成干扰。3周后，超声检查显示肌腱修复，肌腱间隙充满不规则低回声组织，且肌肉运动可传导至足跟。跟腱切断术后6个月，与正常肌腱相比，可见纤维状结构填充，回声轻度或中度减低，肌腱瘢痕增厚。跟腱切断术后1年，超声显示修复部位具有纤维状结构和回声，与正常肌腱相似，但肌腱瘢痕厚度仍持续存在。
经皮切断跟腱后有快速的修复过程，可重建残端之间的连续性。修复组织演变为具有正常超声表现的肌腱组织，只是轻度增厚，提示主要为内在修复机制。
