《Achilles Tendon Disorders：跟腱疾病》由会员分享，可在线阅读，更多相关《Achilles Tendon Disorders：跟腱疾病（29页珍藏版）》请在金锄头文库上搜索。
1、Achilles Tendon DisordersDaniel PenelloFoot & Ankle RoundsAnatomylLargest tendon in the bodylOrigin from gastrocnemius and soleus muscleslInsertion on calcaneal tuberosityAnatomylLacks a true synovial sheathlParatenon has visceral and parietal layerslAllows for 1.5cm of tendon glideAnatomylParatenon
2、lAnterior richly vascularizedlThe remainder multiple thin membranesAnatomylBlood supply1)Musculotendinous junction2)Osseous insertion on calcaneus3)Multiple mesotenal vessels on anterior surface of paratenon (in adipose)Transverse vinculalFewest 2 to 6 cm proximal to osseous insertionPhysiologylRema
3、rkable response to stresslExercise induces tendon diameter increaselInactivity or immobilization causes rapid atrophylAge-related decreases in cell density, collagen fibril diameter and densitylOlder athletes have higher injury susceptibilityBiomechanicslGastrocnemius-soleus-Achilles complexlSpans 3
4、 jointslFlex kneelPlantar flex tibiotalar jointlSupinate subtalar jointlUp to 10 times body weight through tendon when runningAchilles Tendon RupturelPathophysiologyl Repetitive microtrauma in a relatively hypovascular area.lReparative process unable to keep uplMay be on the background of a degenera
5、tive tendonAchilles Tendon Rupture: Textbook FactslAntecedent tendinitis/tendinosis in 15%l75% of sports-related ruptures happen in patients between 30-40 years of age.lMost ruptures occur in watershed area 4cm proximal to the calcaneal insertion. Achilles Tendon RupturelHistorylFeels like being kic
6、ked in the leglCase reports of fluoroquinolone use, steroid injectionslMechanismlEccentric loading (running backwards in tennis)lSudden unexpected dorsiflexion of anklel(Direct blow or laceration)Physical ExamlProne patient with feet over edge of bedlPalpation of entire length of muscle-tendon unit
7、during active and passive ROMlCompare tendon width to other sidelNote tenderness, crepitation, warmth, swelling, nodularity, palpable defectsAchilles Tendon RupturelPhysicallPartiallLocalized tenderness +/- nodularitylCompletelDefectlCannot heel raiselPositive Thompson testAchilles Tendon RupturelDi
8、agnostic Pitfallsl23% missed by Primary Physician (Inglis & Sculco)lTendon defect can be masked by hematomalPlantar-flexion power of extrinsic foot flexors retainedlThompson test can produce a false-negative if accessory ankle flexors also squeezedImaginglUltrasoundlInexpensive, fast, reproducable,
9、dynamic examination possiblelOperator dependentlBest to measure thickness and gaplGood screening test for complete ruptureImaginglMRIlExpensive, not dynamiclBetter at detecting partial ruptures and staging degenerative changes, (monitor healing)Management GoalslRestore musculotendinous length and te
10、nsion.lOptimize gastro-soleous strength and function lAvoid ankle stiffnessConservative ManagementCast in PlantarflexionCAM Walker or cast with plantarflexion q 2 wks2 wksAllow progressive weight-bearing in removable castRemove cast and walk with shoe lift. Start with 2cm x 1 month, then 1cm x1 mont
11、h then D/C4 weeksStart physio for ROM exercisesWhen WBAT and foot is plantigradeStart a strengthening program2- 4 weeksSurgical ManagementlPreserve anterior paratenon blood supplylBeware of sural nervelDebride and approximate tendon endslUse 2-4 stranded locked suture techniquelMay augment with abso
12、rbable suturelClose paratenon separatelySurgical ManagementlBunnell SuturelModified KesslerlMany techniques availableSurgical Management : Post op CarelAssess strength of repair, tension and ROM intra-op.lApply cast with ankle in the least amount of plantarflexion that can be safely attained.lPatien
13、t returns to fracture clinic 2 weeks post-op.Variations in Post-op ProtocolsFunctional BracingPost- Op CareCast applied in ORRemove sutures, apply a walking cast with heel lift2 wksAllow progressive weight-bearing in removable castRemove cast and walk with a 1cm shoe lift x 1 month then D/C. 2 weeks
14、Start physio for ROM exercises. No active plantarflexionWhen WBAT and foot is plantigradeStart a strengthening program2- 4 weeksTouch WBSurgical Management:Post-op CareJ Trauma. 2003 Jun;54(6):1171-80; discussion 1180-1. Kangas J et al.Early functional treatment versus early immobilization in tensio
15、n of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study.50 pts had repair of Achilles ruptureCasted in neutral x 6 weeks. WBAT at 3 weeksImmediate active ROM from PF to neutral. WBAT at 3 wkBetter calf strength only for first 3 months.One re-ruptureTwo
16、 re-rupturesOne deep infectionSame satisfaction2525Conservative vs SurgicalAcute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment.Moller M, et al. J Bone Joint Surg Br. 2001 Aug;83(5):863-8112 patientsSurgery +Early functional rehab in braceCasted x 8 wks21 % re-rupture1.7% re-rupture5% infection2% Sural nerve inj.No difference in functional outcomeSummary of Pooled Outcome MeasuresRisk of Re-RupturelSurgery = 68% risk reduction for re-rupture
