足踝部的肌腱疾患的治疗进展.ppt

TendonProblemsoftheFootandAnkle,Reference,OrthopedicKnowledgeUpdate:FootandAnkle1994RockwoodandGreensFractureinAdults,4theditionAtlasofHumanAnatomy,Sobotta,BasicTendonPhysiologyandPathology,Tendon:-MatureFibroblast(Tenocyte)-ExtracellularMatrixCollagen,Mucopolysaccharides,GlycoproteinsEndotendon-Tenocyte+CollagenFibersEpitendon-ConnectiveTissueParatendon-OuterSheath(Visceral;Parietal)Mesotenon(TransverseVinculaeforBloodVessels),BasicTendonPhysiologyandPathology,BasicTendonPhysiologyandPathology,Tendonresponsetostimuli:-TensileLoadCollagen-Compressive;ShearstressCartilageExtracellularMatrixSpecialArchitecture:-HighFriction(Med.Malleolar)SynovialSheath-LowFriction(AchillesTendon)ThinParatenonBloodSupplyofTendon:-ThroughMusculotendinousTenocyteorganelles,MucoploysaccharideOsseousinsertion;Mesotenalvessels(Fewestat2-6cmProxismaltoinsertion)Densityofintratendinousvessels:4cmProxismaltoCalcaneusinsertion,AchillesTendon,AccessorySoleus:Fromant.surfaceofSoleusorFibulaFasciotomy,AchillesTendon,AccessorySoleus,AchillesTendon,Paratenonitis/Tendinosis/PartialRuptureCommoninRunners(6.518%)-Aging;PoortrainingtechniquesBiomechanism:-HindfootexcessVarusorValgus;RelativeweakanteroirmuscleIntramuralDegeneration;Partial/CompleteRuptureUltrasound-D/DParatenonitisfromRupture;DynamicEvaluationTreatment:NonSurgically-Rest,Phonophoresis,StretchingExercise,NSAID,1-2cmHeelliftSteroidinjectioninacutecase(RuptureorSubcutaneousatrophyrisk),AchillesTendon,Paratenonitis/Tendinosis/PartialRuptureSurgicalTreatment:-3-12weeksconservativeTxfailure-releaseorremoveofparatenonApproach:Medialincision(SuralNRecurrent:10-25%Repeatsurgery,AchillesTendon,Paratenonitis/Tendinosis/PartialRuptureSurgicalTreatment:Debridementofintratendinousdebris-Augmentationofdefect(2/3)TurndownflapoftendonGastrocnemius-soleusaponeurosisFDLorPlantarisTendonTransfer,AchillesTendon,AchillesTendon,CompleteRupture,OccurredinMiddle-agedmeninepisodicoveractivityIntrinsicFactors:Tendinosis,Age-relatedchange,Deconditioning,Impededtendonnutrition(2-6cmaboveCalcaneus;leastbloodsupplyarea)ExtrinsicFactors:Trauma,Mechanicaloverload,SimultaneouseccentriccontractionofMuscle,AchillesTendon,AcuteRupture,S/S:SharpTearingsensationwithPainandSwellingPalpableAchillestendondefect,HeelriseThompsonTest:+(Unabletoplantarflexionwhensqueezingsuperficialmuscle)Misdiagnosisrate:20-25%Treatment:NonsurgicalandSurgicalNonsurgical-rerupture;Surgical-higherrisk,AchillesTendon,AcuteRupture,Nonsurgical:1.LongLegCastimmobilizationShortLegNonweightbearingcastwithankleinequinus2.Earlyprotectedweightbearingshortlegcastat2WksNeutral6-8WksSurgical:1.MedialApproach+End-to-endBunnell-typeapproximationofstump2.EarlypassiveandactiveROM3.PercutaneousRepair-skincomplication,rerupture,AchillesTendon,ChronicRupture,S/S:Weakness,Difficultywithstairs,Pain,LargeGapTreatmentSurgicalIntervention,usuallyneedreconstruction1.Turndowngraft(TendonPlantaristendoncanbeusetoreinforce3.Tendontransfer-Flexorhallucislongus(FHL),Peroneusbrevis(PB),Flexordigitorumlongus(FDL)-formassivedefectoravulsionsfromcalcaneus4.FDLismostattractive-leastmuscleimbalance,nearnaturallineofpull,FlexorHallucisLongus,StenosingTenosynovitis/PosteriorImpingementOsTrigonumPosteriortalarprocess,medialMedialmalleolarcompressionforce;14mmhypovascularzone,1to1.5cmdistaltomedialmalleolusSystemicFactors-HTN,Obesity,DM,MedialfootOPhistory,Trauma,Steroid,SeronegativeSpondyloarthropathy,PosteriorTibialTendon,PosteriorTibialTendonDysfunction(PTTD),PTTDwithAdult-acquiredflatfootdeformity-withPTTD,theTransversetarsaljointdoesnotlockduringheelriseCalcanealeversion,forefootpronationTensiononmedial-plantarsideofTransversetarsaljointtosofttissueattenuation,ruptureofligament,flatfoot,PosteriorTibialTendon,PosteriorTibialTendonDysfunction(PTTD),StageI:Pain,Swelling,MildweaknessofPTTStageII:Disruptionwithflexible,secondaryflatfootStageIII:Rigidflatfoot,S/S:Pain,Swelling,TendernessatmedialAnkle,Deformity,CalcaneusimpingementLateralpainPE:InversionWeakness,Tenderness,Swelling,Deformitywithstanding,Painwithheelrise,Hindfootvalgus+Talarplantarflexion,forefootabduction“Toomanytoes“,PosteriorTibialTendon,PosteriorTibialTendonDysfunction(PTTD),WeightbearingXRay:APView-Lat.Subluxationoftalonavicularjoint/DivergenceoftalusandCalcaneusLatView-Saggingtalonavicular,naviculocuneiform,orMed.Metatarsocuneiformjoints,IncreasedtalocalcanealoverlapAcquiredFlatfootMRI:-MethodofchoiceSensitivetointratendinouschanges,Perdictiveofclinicaloutcome,PosteriorTibialTendon,PosteriorTibialTendonDysfunction(PTTD),Treatment:StageI:NSAID,Rest,Immobilization/Tenosynovectomy+SelectiveTendondebridementStageII:ControversialNonsurgical-MedialHeelwedge,Archsupport,Medialoutflare,ShortarticulatedAFO,RigidAFO,GermanleatherlacerSurgical-ReconstructionwithFDL,AnteriortibialtendontransferDependson:Amountofforefootdeformity,Hindfootflexibility,Obesity,Age,Activitylevel,Intrinsictissueelasticity,PosteriorTibialTendon,PosteriorTibialTendonDysfunction(PTTD),Treatment:StageIII:ArthrodesisThechoiceofthejoint(s)dependsonthedegreeandlocationofdeformityandarthriticchangesSubtarlararthrodesis:RecommendedforFixedhindfootdeformitywithsuppleforefoot,Placesubtalarjointin5to7ofvalgusTalonavicularfusion+/-calcaneocuboidfusion:ForPainfulhindfootinstabilitywithPTTDTriplearthrodesis:riskofdevelopingarthritis,Peroneals,Anatomy:PeroneusLongus(PL)liesPosteriorandlateraltothePeroneusBrevis(PB)atlateralmalleolusPLsheathinterruptedatCuboidandbeginagainexiststhecanalformedbyLongplantarLigandCuboidgroove,Peroneals,SuperiorPeronealRetinaculumconsistsof2bandsposteriorlyfromLateralmalleolus1.ToAchillesSheath2.ToPosteriolateralCalcaneusParallelstheinsertionofcalcaneofibularligament,predisposedtoinversionstressinjury,Peroneals,PLmakes3turnsbeforeinsertingon1stmetatarsal:1.TipofLateralMalleolus;2.Calcaneustrochlearprocess;3.LateralaspectofcuboidPartofthetendonisreplacedbyFibrocartilagioustissueorOsseoustissueatturningpointSesamoidComplex-ThickeningofPLwith4attachments1.Proximalplantaraspectof5thmetatarsal2.DorsaltendonsheathofPB3.Plantarfascia4.Cuboid,Peroneals,LongitudinalTears,Chronic,longitudinaltearofPBisrelativelycommonincadaver,average1.9cmatthetipofthefibula,associatedwithlow-lyingperonealmuscleorananomaloustendonPLteararelesscommonS/S:Pain,swellinginretromalleolararea;especiallyinpassiveinversionofankleorresistedeversionImage:MRINon-surgicalTreatment:NSAID,Stretching,Lateralheelwedge,Lateraloutflare,CastimmobilizationSurgicalTreatment:TenolysisorDebridement,Peroneals,LongitudinalTears,MRI,ExplorationofTendonwithTenolysis/Debridement,Peroneals,SubluxationorDislocation,MechanismofInjury-Debated;associatedwithanklesprainorfracture,lateraltalarprocessfractureorAchillestendonruptureAnatomicpredisposition-Shallow,flatorconvexretromalleolargroovePathoanatomicfinding-Intact