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Operative Versorgung von Achillessehnenverletzungen

Surgical repair of Achilles’ tendon rupture

  • Standards in der Unfallchirurgie
  • Published:
Trauma und Berufskrankheit

Zusammenfassung

Rupturen der Achillessehne sind typische Sportverletzungen; die Inzidenz ist steigend. Der Altersgipfel liegt zwischen dem 30. und 45. Lebensjahr; Männer sind 5–10mal häufiger betroffen. Sie sind meist indirekte Folge einer plötzlichen Überdehnung der Sehne; eine direkte Gewalteinwirkung ist selten. Die Wahl der Therapie wird kontrovers diskutiert. Im Gegensatz zu den angloamerikanischen Ländern hat sich in Deutschland die operative Therapie durchgesetzt. Die offen-chirurgische Naht hat sich bewährt und gilt seit Jahrzehnten als Standardtherapie. Wesentlicher Vorteil der offenen Nahttechnik ist die geringe Rerupturrate; Nachteil der relativ hohe Anteil an Wundheilungsstörungen und Infekten. Durch Entwicklung perkutaner Nahttechniken konnte das Weichteiltrauma reduziert und die Wundheilungsstörungs- und Infektrate deutlich gesenkt werden; nachteilig ist jedoch eine deutlich erhöhte Rate an Läsionen des N. suralis. Die Entwicklung der Sonographie und der Magnetresonanztomographie bildet die Grundlage für die heute postulierte, differenzierte Therapie. Bei Adaptation der Sehnenstümpfe unter 20° Plantarflexion wird von vielen Autoren eine primär konservativ-funktionelle Behandlung empfohlen. Hohes Alter, Immunsuppression, pathologische Rupturen oder mangelnde Compliance des Patienten stellen Kontraindikationen zur Operation dar.

Abstract

Rupture of the Achilles tendon is typically associated with sportive activities with increasing tendency; it occurs most commonly in the third to fourth decade of life with a male-to-female ratio of 5–10:1. Ruptures are caused predominantly by a sudden, unexpected overextension of the tendon while direct trauma is less frequent. The recommended treatment of the injury remains controversial. In Germany, due to the good functional results, the open surgical repair represents the standard therapy since many years. The open suture technique offers the advantage of a lower re-rupture rate but is associated with the risk of wound-related complications including infection. By percutaneous suture techniques a significant decrease in the rate of infections and complications in wound healing could be achieved by minimal-access with reduced soft tissue trauma; on the other hand an increased rate of lesions of the sural nerve is reported. Dynamic imaging assessment of ultrasound or MRI allows a more accurate localisation of the ruptured ends of the tendons which is the prerequisite for the non-operative primary functional treatment of Achilles tendon ruptures. This conservative treatment regime is recommended when adaptation of the ends of the ruptured tendon is possible in 20° plantar flexion of the foot. Moreover, the desired level of daily activity and the patients’ degree of compliance has to be considered. Operative management should be avoided in the elderly patient or patients with risk factors like immunosuppressive therapy, diabetes mellitus, steroid use or failure to comply.

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  1. Klinik für Unfall- und Wiederherstellungschirurgie, BG-Unfallklinik Ludwigshafen, Unfallchirurgische Klinik an der Universität Heidelberg, Ludwigshafen

    C. Wagner, G. Zimmermann, A. Moghaddam, S. Studier-Fischer, B. Vock & A. Wentzensen

  2. Klinik für Unfall- und Wiederherstellungschirurgie, BG-Unfallklinik Ludwigshafen, Unfallchirurgische Klinik an der Universität Heidelberg, Ludwig-Guttmann-Straße 13, 67071 , Ludwigshafen

    C. Wagner

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  1. C. Wagner
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  2. G. Zimmermann
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  3. A. Moghaddam
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  4. S. Studier-Fischer
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Correspondence to C. Wagner.

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Wagner, C., Zimmermann, G., Moghaddam, A. et al. Operative Versorgung von Achillessehnenverletzungen. Trauma Berufskrankh 7, 168–174 (2005). https://doi.org/10.1007/s10039-005-1035-5

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