Die Impingementläsion der distalen Achillessehne bei Bursitis subachillae und Haglund-Pseudoexostose - eine therapeutische Herausforderung

 

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Zusammenfassung

Die Bursitis subachillae ist ein häufig fehldiagnostizierter Sportschaden. Der Wert der konservativen Therapie scheint besonders im Vergleich zu anderen achillären Schmerzsyndromen begrenzt. Die exakte präoperative Diagnostik mit MRT und Ultraschall zeigt bei 85 % der hier vorgestellten Patienten eine operationswürdige, bislang nicht beschriebene korrespondierende „Impingementläsion” der ventralen Achillessehne (fokale Degeneration, Partialrisse). Die Nachuntersuchung von 39 konsekutiven Operationen (38 Patienten) nach durchschnittlich 32 Monaten zeigt eine Erfolgsrate von 54 %. Der erreichte VISA-A-Score lag bei 80,6 Punkten. Mit dem Lauftraining wurde nach durchschnittlich 16 Wochen wieder begonnen. Die Wettkampffähigkeit wurde nach 9 Monaten erreicht. Die Analyse unbefriedigender Ergebnisse lässt neben einer unvollständigen Haglund-Resektion die Möglichkeit einer iatrogenen, intraoperativen Sehnenschädigung, induziert durch den kappenartig auf den medialen und lateralen Kalkaneus umgreifenden Achillessehnenansatz als wahrscheinlich erscheinen. Zwei kalkaneare Stressfrakturen waren während des Laufbelastungsaufbaues aufgetreten.

Abstract

Retrocalcaneal bursitis in athletes is frequently misdiagnosed. Results of conservative treatment are not very promising. This investigation evaluates the results of 39 consecutive cases in 38 patients surgically treated due to chronic retrokalkaneal bursitis in a sport specific population. Preoperative MRI and ultrasound investigation showed corresponding lesions (focal degeneration, partial rupture) of the anterior Achilles tendon. This is possibly the result of a previously undescribed impingement lesion produced by the Haglund's bone and the chronically inflamed retrocalcaneal bursa. During operation this lesion was additionally adressed in 85 % of the cases. Follow up was done after 32 months. Success rate was 54 %. VISA-A Score at follow up was 80,6 points. Training and competitional activities were started at 16 weeks and 9 months respectively. Unsatisfying results were analysed. In two cases Haglund's bone resection was incomplete and had to be removed in a reoperation. Additionally one deep wound infection had to be revised. Due to the distal Achilles tendon fiber extensions around the medial and lateral calcaneal bone, an unintended Achilles tendon lesion, induced by the edge of the osteotome seems to be possible. Two calcanear stress fractures complicated the postoperative rehabilitation.

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Dr. med. Heinz Lohrer

Sportmedizinisches Institut Frankfurt am Main e.V.

Otto-Fleck-Schneise 10

60528 Frankfurt/Main

Phone: + 49-69-678009-33

Fax: + 49-69-678009-51

Email: Lohrer@smi-frankfurt.de