Moore M Lane, Pollock Jordan R, Karsen Phillip J, Haglin Jack M, Lai Cara H, Elahi Muhammad A, Chhabra Anikar, O'Malley Martin J, Patel Karan A
Mayo Clinic Alix School of Medicine, Scottsdale, Arizona.
Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona.
JBJS Essent Surg Tech. 2023 Mar 9;13(1). doi: 10.2106/JBJS.ST.21.00054. eCollection 2023 Jan-Mar.
An open Achilles tendon repair is performed in patients who have suffered an acute rupture. All patients with this injury should be counseled on their treatment options, which include open operative repair and functional rehabilitation. We prefer the use of an open repair in high-level athletes and those who have delayed presentation. Typically, this injury-and the resulting open repair-are seen in young or middle-aged patients as well as athletes. Operative repair of a ruptured Achilles tendon is associated with a much faster return to activity/sport when compared with nonoperative alternatives. This surgical procedure is especially useful in allowing this patient population to return to their previous activity level and functional capacity as quickly as possible.
Open repair of a ruptured Achilles tendon begins with a 6 to 8-cm incision over the posteromedial aspect of the lower leg. Superficial and deep dissections are performed until the 2 ends of the ruptured tendon are identified. Adhesions are debrided to adequately mobilize and define the proximal and distal segments of the tendon. With use of a fiber tape suture, a modified locking Bunnell stitch is utilized to secure both ends. The fiber tape is tied securely, and the repair is reinforced with Vicryl suture (Ethicon). Once the tendon is repaired, the paratenon layer is identified and repaired with a running 0 or 2-0 Vicryl suture. This is an important step to minimize postoperative wound complications. The wound is then closed, and the extremity is splinted in maximum plantar flexion.
Alternative treatments include minimally invasive surgical techniques such as percutaneous Achilles tendon repair and nonoperative treatment with functional rehabilitation, which can provide excellent outcomes but can also lead to a slight decrease in explosiveness as the patient returns to sport.
Nonoperative and operative treatment of Achilles tendon rupture can both result in excellent patient outcomes. Appropriate patient selection is critical. Younger patients hoping to return to more highly competitive athletics should consider operative repair. Possible differences have been identified in peak torque when comparing operative versus nonoperative treatment, with patients who had undergone operative repair having greater peak torque (i.e., explosiveness). Otherwise, findings are similar between treatment options as long as the patients meet the criteria for nonoperative treatment.
Overall, the scientific literature demonstrates that the functional outcomes following operative repair are good to excellent. In a study by Hsu et al., 88% of patients were able to return to their baseline level of activity by 5 months postoperatively, with a complication rate of 10.6% and no reruptures. In a recent meta-analysis by Meulenkamp et al., the authors found that operative repair of Achilles tendon rupture was associated with a reduced risk of rerupture compared with primary immobilization (i.e., conventional cast immobilization with delayed weight-bearing for at least 6 weeks only). However, open surgical repair, minimally invasive repair, and functional rehabilitation all had similar risk of rerupture. In a review by Ochen et al. that analyzed 29 studies with a total of 15,862 patients, operative repair was associated with a significantly lower risk of rerupture compared with nonoperative treatment (2.3% versus 3.9%, respectively). However, operative treatment was also associated with a significantly higher complication rate compared with nonoperative treatment (4.9% versus 1.6%, respectively). Finally, in a meta-analysis by Soroceanu et al., the authors found that if early range-of-motion protocols and functional rehabilitation were utilized, operative and nonoperative treatment resulted in similar outcomes and equivalent rates of rerupture.
To prevent rerupture of an Achilles tendon, remind patients to engage in adequate stretching and warming prior to physical activity.Palpate and locate the tendon defect prior to making the first incision.Immobilize the ankle joint in a splint for 2 weeks postoperatively in maximum plantar flexion.Pitfalls include:○ Poor suture management leading to tangling in the repair.○ Undertensioning or overtensioning of the repair, which can be avoided by sterilely draping out both legs and checking resting tension intraoperatively.○ Failure to close the paratenon, causing scarring of the skin or surrounding tissues, which can be avoided by making a relieving incision on the deep surface of the paratenon.○ Leaving suture knots on the dorsal side of the repair that may aggravate the skin.
ACRONYMS & ABBREVIATIONS: MRI = magnetic resonance imagingESU = electrosurgical unit.
对于急性跟腱断裂患者，需进行开放性跟腱修复术。所有此类损伤患者均应接受关于治疗方案的咨询，治疗方案包括开放性手术修复和功能康复。我们更倾向于对高水平运动员以及就诊延迟的患者采用开放性修复。通常，这种损伤以及由此进行的开放性修复多见于年轻或中年患者以及运动员。与非手术治疗相比，跟腱断裂的手术修复能使患者更快恢复活动/运动。这种手术方法对于让这类患者尽快恢复到先前的活动水平和功能能力尤为有用。
开放性跟腱断裂修复术始于在小腿后内侧做一个6至8厘米的切口。进行浅部和深部解剖，直至识别出断裂肌腱的两端。清除粘连，以充分游离并界定肌腱的近端和远端。使用纤维带缝线，采用改良的锁定邦内尔缝合法固定两端。将纤维带牢固打结，并用薇乔缝线（爱惜康公司）加强修复。肌腱修复后，识别腱旁组织层，用连续的0号或2-0号薇乔缝线进行修复。这是减少术后伤口并发症的重要步骤。然后关闭伤口，将肢体固定在最大跖屈位。
替代治疗包括微创外科技术，如经皮跟腱修复术，以及功能康复的非手术治疗，这些方法可取得良好效果，但患者恢复运动时爆发力可能会略有下降。
跟腱断裂的非手术和手术治疗都能使患者取得良好预后。恰当的患者选择至关重要。希望恢复到更具竞争力运动水平的年轻患者应考虑手术修复。比较手术治疗与非手术治疗时，已发现峰值扭矩可能存在差异，接受手术修复的患者峰值扭矩更大（即爆发力更强）。否则，只要患者符合非手术治疗标准，两种治疗方案的结果相似。
总体而言，科学文献表明手术修复后的功能预后良好至极佳。在许等人的一项研究中，88%的患者术后5个月能够恢复到基线活动水平，并发症发生率为10.6%，且无再次断裂情况。在最近梅伦坎普等人的一项荟萃分析中，作者发现与初次固定（即仅采用传统石膏固定并延迟负重至少6周）相比，跟腱断裂的手术修复与再次断裂风险降低相关。然而，开放性手术修复、微创修复和功能康复的再次断裂风险相似。在奥琴等人的一项综述中，该综述分析了29项研究，共15862例患者，与非手术治疗相比，手术修复的再次断裂风险显著更低（分别为2.3%和3.9%）。然而，与非手术治疗相比，手术治疗的并发症发生率也显著更高（分别为4.9%和1.6%）。最后，在索罗恰努等人的一项荟萃分析中，作者发现如果采用早期活动范围方案和功能康复，手术和非手术治疗的结果相似，再次断裂率相当。
为防止跟腱再次断裂，提醒患者在体育活动前进行充分的拉伸和热身。在做第一个切口前触诊并定位肌腱缺损处。术后将踝关节固定在夹板中，在最大跖屈位固定2周。陷阱包括：
缝线管理不佳导致修复时缠结。
修复张力不足或过大，可通过双腿无菌铺巾并在术中检查静息张力来避免。
未关闭腱旁组织，导致皮肤或周围组织形成瘢痕，可通过在腱旁组织深面做减压切口来避免。
修复背侧留有线结，可能会加重皮肤问题。
MRI = 磁共振成像；ESU = 电外科设备
