Iorio Matthew L, Han Kevin D, Evans Karen K, Attinger Christopher E
From the Department of Plastic Surgery, Georgetown University Hospital, Washington, DC.
Ann Plast Surg. 2015 Jan;74(1):121-5. doi: 10.1097/SAP.0b013e31828bb353.
Rupture of the Achilles tendon can be a debilitating event, affecting ankle stability and gait efficiency. When this rupture is combined with a large soft tissue defect, reconstruction of the tendon and free tissue transfer for wound resurfacing should be considered.
A systematic review of the MEDLINE and Cochrane databases from January 1950 to August 2012 was completed. Search criteria identified all reports of vascularized, autograft, and allograft Achilles tendon reconstruction in combination with free tissue transfer. Inclusion criteria included strict objective outcomes of ankle range of motion and/or dynamometer testing. Correlated outcomes for the affected and normal extremities were accomplished using a subgroup comparison for the vascularized and avascular tendon reconstruction techniques with a 2-tailed z test for independent proportions.
Fifteen retrospective studies fit the inclusion criteria, representing 44 patients at an average age of 33 years. Twenty-two (50%) patients had a localized infection before reconstruction. Average skin defect was 85.3 (74.4) cm2, and average tendon gap was 7.8 (1.7) cm. Thirty (68%) patients underwent free tissue transfer with vascularized tendon reconstruction, 7 (16%) had either nonvascularized autograft or allograft, 5 (11%) had a muscle interposition, and 2 (5%) patients had combined vascularized and nonvascularized tendon repair. Overall average total range of motion was 54.6 (11.5) degrees. Repairs with vascularized tendon had an overall range of motion 80% of the unaffected side (55.4 vs 69.4 degrees) compared to avascular tendon repairs, at an average range of motion 82% of the unaffected side (51.2 vs 62.3 degrees) (P = 0.73). Dynamometric comparison with the unaffected extremity gave an average deficit for avascular reconstructions at 21.2% and 24.8% for 30 to 60 and 120 degrees/s, respectively, compared to an average deficit of 32.3% and 31.5% in the vascularized reconstructions (P = 0.55 and P = 0.78, respectively).
For combined free tissue transfer and Achilles tendon reconstruction, there seems to be no functional superiority in ankle range of motion or strength when vascularized tendon repairs were compared to avascular autograft and allograft methods.
跟腱断裂是一种使人衰弱的病症，会影响踝关节稳定性及步态效率。当这种断裂合并大面积软组织缺损时，应考虑进行肌腱重建及游离组织移植以修复创面。
完成了对1950年1月至2012年8月MEDLINE和Cochrane数据库的系统综述。检索标准确定了所有关于带血管蒂、自体移植和同种异体移植跟腱重建联合游离组织移植的报告。纳入标准包括踝关节活动范围和/或测力计测试的严格客观结果。通过对带血管蒂和不带血管蒂肌腱重建技术进行亚组比较，并采用独立比例的双侧z检验，得出患侧和正常肢体的相关结果。
15项回顾性研究符合纳入标准，共44例患者，平均年龄33岁。22例（50%）患者在重建前存在局部感染。平均皮肤缺损面积为85.3（74.4）平方厘米，平均肌腱间隙为7.8（1.7）厘米。30例（68%）患者接受了带血管蒂肌腱重建的游离组织移植，7例（16%）采用了非带血管蒂自体移植或同种异体移植，5例（11%）进行了肌肉植入，2例（5%）患者进行了带血管蒂和非带血管蒂肌腱联合修复。总体平均总活动范围为54.6（11.5）度。与非带血管蒂肌腱修复相比，带血管蒂肌腱修复的总体活动范围为未受影响侧的80%（55.4对69.4度），非带血管蒂肌腱修复的平均活动范围为未受影响侧的82%（51.2对62.3度）（P = 0.73）。与未受影响肢体进行测力计比较，非带血管蒂重建在30至60度/秒和120度/秒时的平均力量缺失分别为21.2%和24.8%，而带血管蒂重建的平均力量缺失分别为32.3%和31.5%（P分别为0.55和0.78）。
对于联合游离组织移植和跟腱重建，与非带血管蒂自体移植和同种异体移植方法相比，带血管蒂肌腱修复在踝关节活动范围或力量方面似乎没有功能优势。
