Braunstein M, Baumbach S F, Herterich V, Böcker W, Polzer H
Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland.
Unfallchirurg. 2017 Dec;120(12):1007-1014. doi: 10.1007/s00113-017-0420-4.
The most favorable treatment for acute Achilles tendon ruptures remains controversial. In particular, three key questions are intensively debated: is operative or non-operative treatment superior? If surgery is performed, should open or minimally invasive percutaneous techniques be used? How should the follow-up treatment be carried out? The aim of this article is to answer these essential questions based on the currently available evidence. Non-operative treatment leads to a higher rate of re-ruptures and inferior functional results when compared to operative treatment. The major disadvantage of open surgery is the increased risk of wound healing problems and wound infections. Due to the development of minimally invasive percutaneous techniques, complication rates could be significantly reduced and patient satisfaction could be significantly improved, without increasing the risk of re-ruptures. The functional outcome is still partially unsatisfactory independent of the type of treatment. This is particularly expressed in weakness of the gastrocnemius-soleus muscle complex; therefore, the follow-up treatment is of fundamental importance. The available evidence clearly underlines the importance of early weight bearing and mobilization of the ankle joint, as it is safe and leads to better function, patient satisfaction and faster return to work or sport, compared with partial weight bearing and immobilization. Nevertheless, treatment protocols vary greatly with the majority still carrying out open suture and immobilizing follow-up treatment with fixed plantar flexion. Based on the available data the authors recommend minimally invasive percutaneous suture of the tendon followed by progressive functional rehabilitation. Implementation of the available evidence into routine practice is the next important step for successful treatment of this challenging injury.
急性跟腱断裂最适宜的治疗方法仍存在争议。特别是，有三个关键问题引发了激烈讨论：手术治疗还是非手术治疗更具优势？如果进行手术，应采用开放手术还是微创经皮技术？后续治疗应如何开展？本文旨在基于当前可得证据回答这些关键问题。与手术治疗相比，非手术治疗导致再断裂率更高，功能结果更差。开放手术的主要缺点是伤口愈合问题和伤口感染的风险增加。由于微创经皮技术的发展，并发症发生率可显著降低，患者满意度可显著提高，且不会增加再断裂风险。无论采用何种治疗方式，功能结局仍部分不尽人意。这尤其表现为腓肠肌 - 比目鱼肌复合体无力；因此，后续治疗至关重要。现有证据明确强调了早期负重和踝关节活动的重要性，因为与部分负重和固定相比，早期负重和踝关节活动安全，能带来更好的功能、患者满意度，并能更快回归工作或运动。然而，治疗方案差异很大，大多数仍采用开放缝合并在固定跖屈位进行后续固定治疗。基于现有数据，作者推荐采用肌腱微创经皮缝合，随后进行逐步的功能康复。将现有证据应用于常规实践是成功治疗这种具有挑战性损伤的下一个重要步骤。
