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Die akute Achillessehnenruptur

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Acute achilles tendon rupture

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Zusammenfassung

Die optimale Behandlung der akuten Achillessehnenruptur ist nach wie vor nicht abschließend geklärt. Insbesondere 3 Schlüsselfragen werden kontrovers diskutiert: Soll die Therapie konservativ oder operativ erfolgen? Wenn operativ, ist die offene oder die minimalinvasive/perkutane Naht zu favorisieren? Wie sieht die Nachbehandlung aus? Ziel dieses Beitrags ist es, diese Fragen anhand der aktuellen Evidenz zu beantworten. Die konservative Therapie geht mit höheren Rerupturraten und schlechteren funktionellen Ergebnissen im Vergleich zur operativen Versorgung einher. Die offene Technik birgt ein hohes Risiko für Wundheilungsstörungen und -infektionen. Durch die Entwicklung minimalinvasiver/perkutaner Verfahren konnten die Komplikationsraten signifikant gesenkt und die Patientenzufriedenheit signifikant gesteigert werden – ohne erhöhtes Rerupturrisiko. Unabhängig von der Therapieform sind die funktionellen Ergebnisse immer noch teilweise unbefriedigend. Dies äußert sich v. a. in einer Schwäche des Gastrocnemius-Soleus-Komplexes. Daher ist die Nachbehandlung entscheidend. Das frühfunktionell-progressive Vorgehen, bestehend aus früher Vollbelastung und Mobilisierung des oberen Sprunggelenks, ist, verglichen mit einer Teilbelastung und Immobilisierung, sicher und resultiert in sehr guter Funktion, höherer Zufriedenheit und schnellerer Rückkehr zu Arbeit/Sport. Trotz der Datenlage werden noch immer häufig die offene Naht und die immobilisierende Nachbehandlung in fixierter Plantarflexion durchgeführt. Basierend auf den verfügbaren Daten empfehlen die Autoren eine minimalinvasive/perkutane Naht, gefolgt von frühfunktionell-progressiver Nachbehandlung. Die Umsetzung der vorhandenen Evidenz in der täglichen Praxis ist der nächste wichtige Schritt in der erfolgreichen Behandlung dieser anspruchsvollen Verletzung.

Abstract

The most favorable treatment for acute Achilles tendon ruptures remains controversial. In particular, three key questions are intensively debated: is operative or non-operative treatment superior? If surgery is performed, should open or minimally invasive percutaneous techniques be used? How should the follow-up treatment be carried out? The aim of this article is to answer these essential questions based on the currently available evidence. Non-operative treatment leads to a higher rate of re-ruptures and inferior functional results when compared to operative treatment. The major disadvantage of open surgery is the increased risk of wound healing problems and wound infections. Due to the development of minimally invasive percutaneous techniques, complication rates could be significantly reduced and patient satisfaction could be significantly improved, without increasing the risk of re-ruptures. The functional outcome is still partially unsatisfactory independent of the type of treatment. This is particularly expressed in weakness of the gastrocnemius-soleus muscle complex; therefore, the follow-up treatment is of fundamental importance. The available evidence clearly underlines the importance of early weight bearing and mobilization of the ankle joint, as it is safe and leads to better function, patient satisfaction and faster return to work or sport, compared with partial weight bearing and immobilization. Nevertheless, treatment protocols vary greatly with the majority still carrying out open suture and immobilizing follow-up treatment with fixed plantar flexion. Based on the available data the authors recommend minimally invasive percutaneous suture of the tendon followed by progressive functional rehabilitation. Implementation of the available evidence into routine practice is the next important step for successful treatment of this challenging injury.

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  1. Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland

    M. Braunstein, S. F. Baumbach, V. Herterich, W. Böcker &  H. Polzer

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Braunstein, M., Baumbach, S.F., Herterich, V. et al. Die akute Achillessehnenruptur. Unfallchirurg 120, 1007–1014 (2017). https://doi.org/10.1007/s00113-017-0420-4

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