The Clinical Research Of Individual Surgery For Chronic Achilles Tendon Rupture

Background With the rapid development of society,health had been paid much emphasis.Health played a vital role in a person's life.More and more people were participating in sports.So the incidence of sport injuries was increased.Achilles tendon rupture was one of the most common injuries in lower extremity injury.Acute Achilles tendon rupture can be diagnosed and treated easily in actual clinical practice.However,there was still a considerable number of cases which were neglected by clinicians or patients without proper diagnosis and treatment,leading to chronic Achilles tendon rupture.Chronic Achilles tendon rupture was usually defined as the rupture that occured in 4 to 6 weeks after injury(misdiagnosis or no effective treatment).Neglected Achilles tendon rupture can occur at rate as high as 25% clinically.The treatment of chronic Achilles tendon rupture was different from the treatment of acute Achilles tendon rupture.Most of the patients can be eff ectively treated by end-to-end suture for acute Achilles tendon and can get satisfactory effect after rehabilitation.Because of scar tissue and muscle retraction(gastrocnemius and soleus),the large gaps after scar tissue debridement can be showed.The large defects can not be repaired by direct suture technique.So the treatment of chronic Achilles tendon rupture was a challenge for most orthopedic surgeons.The reconstruction of chronic Achilles tendon rupture was complex,and it might affect the choice of procedures.In the literatures,no optimal treatments for chronic Achilles tendon rupture had been documented.No evidence of optima l treatments for chronic Achilles tendon rupture was showed in evidence-based Medicine.There was rarely research about clinical follow-up of chronic Achilles tendon rupture by MRI.Through this research,we can learn the characteristics about evidence-based Medicine and MRI on chronic Achilles tendon rupture.Carrying on retrospective study of the patients with chronic Achilles tendon rupture by individual surgery and postoperative evaluation by MRI,we can provide a help for the choice of individual treatment strategies and the reference of scientific exchange.Purpose(1)Systematic review of the validity and security of major surgical methods for chronic Achilles tendon rupture in the relevant literatures,to explain the differences among them and provide theoretical support for clinical research.(2)Retrospective study of the clinical efficacy of the patients with chronic Achilles tendon rupture by individual surgery in our department,so as to provide a scientific and simple strategy for the treatment of chronic Achilles tendon rupture.(3)To observe and analyze the imaging features of chronic Achilles tendon rupture in low field MRI,and to provide the reference information for the preoperative plan and postoperative rehabilitation.The methods(1)systematic evaluation of surgical treatment of chronic Achilles tendon rupture The databases(including Pub Med,EMbase,CNKI and so on)were systematically searched by computer through Internet.Me SH terms were used for retrieva in this study.According to the inclusion criteria and exclusion criteria,the literatures were selected.Data included the author(s)details,date of publication,operation method,the number of cases,AOFAS score,the defect after debridement length(including the largest defect length and average defect length),sports ability,a single-limb heel rise with the injured lower extremity,re-rupture and incidence of complications.The above data was recorded in Microsoft Excel spreadsheet.The some data was converted,and meta-analysis was conducted by Stata 15.0 statistical analysis software.(2)The clinical research of individual surgery and etiological features for chronic Achilles tendon rupture Between January 2010 and october 2017,26 patients with chronic Achilles tendon rupture had undergone operation in our department.Data included basic characteristics of cases(including medical history and personal history),BMI,the course of injury,injury factors and AOFAS score.The above data was recorded.MRI and X-ray was used to confirm the final diagnosis.The individual treatment strategy can be determined by evaluating the presence or absence of the Achilles tendon stumps and the gap length of rupture after Achilles tendon rupture.The directly end to end suture,V-Y advancement,gastrocnemius fascial turndown flap,or flexor halluces longus tendon transfer were selected for tendon repair.Patients were encouraged to perform physical exercises under rehabilitation guidelines.The function of ankle and foot was assessed by AOFAS scores,sports ability and single-limb heel rise with the injured lower extremity.post-operative MRI was obtained.The incidence of complications was recorded.(3)The clinical study of low field MRI characteristics in chronic Achilles tendon rupture Between January 2010 and October 2017,26 patients with chronic Achilles tendon rupture had undergone operation in our department.The result of physical examination an d personal medical history was recorded by specialized doctor.MRI and X-ray examination was performed before surgery.By the individual treatment strategy of this study,all patients were treated with the reconstruction surgery for chronic Achilles tendon r upture according to the characteristics of their conditions.The preoperative and postoperative MRI images of the patients were observed and recorded.The length of gap between the ruptured ends in sagittal position was measured by the INFINITT-PACS system tool.At the same time,the length between the rupture end and the calcaneal bone was measured.The length of gap after scar tissue debridement and the site of rupture was consulted from the operative documents.Results(1)systematic evaluation of surgical treatment of chronic Achilles tendon rupture About the AOFAS function score among V-Y,FHLT,turndown flap,semitendinosus transfer,FHLT+ turndown flap and FHLT+V-Y,the mean differences before and after treatment were 26.43(95%CI:17.26-35.60),32.63(95%CI:25.54-39.71),41.09(95%CI:10.57-71.61),22.00(95%CI:18.33-25.67),38.50(95%CI:28.38~44.63)and 38.58(95%CI:33.34~44.02);The difference in the combined mean score of all surgical methods was 33.41(95% CI:27.25~39.58),P<0.05.The increase in AOFAS score of semitendinosus trans fer before and after operation was significantly lower than which of FHLT +turndown flap and FHLT+V-Y,P<0.05.About the proportion of restoring to pre-injury sportlevel,V-Y,FHLT,turndown flap,semitendinosus transfer,FHLT+turndown flap and FHLT+VY were respectively 90%(95%CI:76%~100%),93%(95%CI:88%~97%),97%(95%CI:92%~100%),96%(95%CI:89%~100%),89%(95%CI:81%~98%)and94%(95%CI:81%~98%);The combined recovery rate of all surgical methods was 94%(95%CI:91%~97%),P<0.05.Most of the literatures reported that all patients can perform single-limb heel rise with the injured lower extremity,but only individual literatures showed less than 100%,and 69% can be observed at least.About the percentage of postoperative complications,V-Y,FHLT,turndown flap,semitendinosus transfer,FHLT+turndown flap and FHLT+V-Y were respectively 13%(95%CI:0%~26%),2%(95%CI:0%~5%),9%(95%CI:0%~33%),14%(95%CI:0%~33%),9%(95%CI:2%~17%)and 11%(95%CI:1%~21%).The complication rate of all operation was 5%(95%CI:3%~8%),P<0.05.At present,only 1 case of Achilles tendon re-rupture was reported in the literature.The mean value of the combined maximum defect length of all surgical methods of V-Y,FHLT,turndownflap,FHLT+turndownflap was 8.93cm(95%CI:8.22cm~9.64cm),P<0.05.The combined average defect length of the above surgical methods was 5.83cm(95%CI:5.36cm~6.31cm),P<0.05,and the average defect length of V-Y was significantly shorter than which of FHLT and FHLT+V-Y,P<0.05.(2)The clinical research of individual surgery and etiological feat ures for chronic Achilles tendon rupture This study showed that the majority of the injured were male,with the average age of 39.7 years old and the average course of illness of 26.8 weeks.The average BMI of the patients was 25.01(range:19.6-30.9),according to the Chinese BMI standard,more than 50% of the patients had exceeded the normal range.Types of injuries:13 cases(50% in all)were injured in strenuous sports,including 4 cases in basketball,4 cases in badminton,3 cases in fast running and 2 cases in football.There were 7 injury cases(26.9% in all)in daily activities,including 3 cases on stairs and 4 sprain cases.There were 6 cases(23.1% in all)of instrument injury,by among which 5 cases were cut and 1 case was striked by the weight.Chronic causes:12 cases(46.2% in all)were misdiagnosed,9 cases(34.6% in all)were delayed treatment,3 cases(11.5% in all)were suffered failed conservative treatment,and 2 cases were rerupture after surgery(7.7% in all).The average length of defect after removing scar from the Achilles tendon was 4.8cm(range:2-10cm),and the number of cases without Achilles tendon stumps or no obvious residual tendon was 8.There were 15 cases(57.7% in all)with defect greater than 2cm,4 cases(15.38% in all)with defect greater than 6cm,and 3 cases(11.54% in al)with defect greater than 2cm.Surgical options: 3 cases of direct was chose Krackow suture;there were 11 cases with V-Y lengthening,among which 2 cases had the defect more than 6cm.There were 4 cases used turndown flap,among which 2 cases had the defect more than 6cm.Eight patients needed reconstruction of the Achilles tendon stumps,among which 7 cases were treated with FHLT,one patient was treated with the LARS.All patients received postoperative follow-up,with the average follow-up time of 38 months(range:12-103 months).At the last follow-up,25 patients were able to perform single-limb heel rise with the injured lower extremity,and one patient was unable to do it due to psychological factors.All the patients were able to recover to their daily life and 24 patients were able to reach their pre-injury exercise level.Only 2 elderly patients were unable to reach the pre-injury level due to their age above 70 years old.At the last follow-up,the average AOFAS score was 95.38 ±4.7,which was significantly higher than which of the preoperative AOFAS score of 59.23±9.9(P< 0.05).There were no nerve injuries,no DVT,no deep infection and no re-ruptures recorded in any patient within the follow-up period.All the postoperative MRI patients showed a continuous pattern of Achilles tendon when they were reviewed.The MRI at 6 months after surgery showed inflammatory signals.During the follow-up 1-2 years after surgery,the inflammatory signals of the Achilles tendon could disappear and the sign was uniform.(3)The clinical study of low field MRI characteristics in chronic Achilles tendon rupture Preoperative MRI imaging showed the irregular flaky low-signal areas in T1-weighted images at the sagittal sequence,and irregular flaky high-signal changes in the Achilles tendons and around the Achilles tendons in the fat-suppressed T2-weighted images.MRI imaging results in diagnosis was consistent with intraoperative exploration results,and there was no case of misdiagnosis.MRI showed the length of the distal stump of the Achilles tendon rupture.The average length of the distal stump was 1.998cm(range:0-4.382cm),among which 5 cases had the length of 0 cm(19.2% in all),and 6 cases had no residual in the actual operation.MRI measurements showed that there were no residual cases in 5 cases of Achilles tendon insertion.Theoretically,reconstruction of the Achilles tendon stump should be selected,while in practice the reconstruction of the Achilles tendon stump was selected in 8 cases,because among which 3 cases were converted to reconstruction of the Achilles tendon stump because the stump was not enough for suture.About the tendon defect length,preoperative MRI measurements show the tendon of the average length of the defect in the 4.67±2.03 cm(range,2-9.477 cm)while after removal of scar tissue the average defect length was 4.8± 2.12 cm(range,2-10 cm)in operation.The results was no statistical difference between the MRI data and actual data,P>0.05.MRI measurements showed the presence of Achilles tendon stump,with the defects in 3 cases was within 2cm.There were 18 cases with the defect above 2cm(6 cases with the defect length greater than 6cm,23.08% in all).There were 15 cases with V-Y and turndown flap,the deviation was 3 cases,and the 3 cases were converted to reconstruction of the Achilles tendon stump because the stump was not enough for suture.Based on the above MRI observation and measurement results(presence or absence of Achilles tendon stumps and the length of the defect),the total deviation was only 3 cases(11.5% in all).MRI image analysis after Achilles tendon reconstruction.In terms of morphological expression,we can find that the Achilles tendon was in a continuous manner on the sagittal image,and it is clearly demarcated from surrounding tissue.In terms of MRI signal changes,6 months after operation MRI showed some signs of inflammation in the reconstruction area of the Achilles tendon in the T2-weighted at the sagittal sequence.In the T1-weighted image,continuous low-signal shadow can be seen after the tendon repaired.After 1 to 2 years of surgery,at the reconstructive region of the Achilles tendon the inflammation signal could disappear and signal was uniform in the tendon.Conclusions: According to literature reports and meta-analysis,all the major surgical methods currently used for chronic Achilles tendon rupture can enable patients to obtain better functional scores,and most of the patients can recover to the sport level pre-injury.The overall complication rate of each operation was low.The length of defect was related to the choice of surgical method.From etiological features of this study,chronic Achilles tendon rupture occured mainly in male,over 50% of the patients had abnormal BMI value,and the main factors of chronic Achilles tendon rupture included strenuous exercise and iatrogenic.A clear treatment strategy can be determined by evaluating the presence or absence of the Achilles tendon stumps and the gap length of rupture after Achilles tendon rupture,whic h can avoid using the nearby tendon and yield satisfactory functional results by making the most of the local Achilles tendon and gastrocnemius fascial.Low field MRI in this study can provide accurate imaging diagnostic information and was a practical diagnostic tool.The results of MRI imaging before surgery for chronic Achilles tendon rupture was nearly consistent with the actual situation in surgery,which can provided reliable reference information for the preoperative plan of individual treatment strategy.MRI can also provide useful rehabilitation guidance for postoperative follow-up.It would take a long time for the inflammatory signals in the repaired area of the Achilles tendon rupture to completely disappear,and it is necessary to be alert to the m isdiagnosis of re-rupture in the early MRI after surgery.