Asil Tendon Sorunlari

.: PREFACE
Ön Söz
Preface
Prof. Dr. Mahmut Nedim DORAL
Ufuk Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji ABD, Ankara
Article Language: TR
AŞİL; canlı vücudunun en kalın, en uzun ve de en sağlam tendonudur.1

Hepimizin bildiği gibi Kalkaneus'un yaklaşık olarak 5-6 cm yukarı seviyesinden, 'medial- lateral Gastrocnemius' ve 'Soleus'dan oluşur ve 'Triceps Surae' adını alır.2

Orijinal yazılışı ile 'Achilles' ismi, M.Ö. 750-650 yılları arasında, Yunan şair Homeros tarafından yayımlanmış olan 'İlyada Destanı'ndaki tanımlamadan köken almıştır. Annesi Thetis, oğlunu ölümsüzlük nehri Styx'de yıkarken elini suya değdirmemesi öğütlendiği için onu sol topuğundan tutup suya batırmıştır. Yalnızca oradan vurulursa öleceğine inanılır. Efsaneye göre öleceğini bildiği halde Helen'i geri almak için yapılan ve en büyük savaş kabul edilen Truva Savaşı'na adının sonsuza kadar anılması için katılmış ve Truvalı prens Paris tarafından sol topuğundan zehirli bir okla vurularak ölmüştür.3

Kirkup, 'Achilles'in topuğu ile Aşil tendonu arasındaki karışıklığın, muhtemelen 1693'lere uzandığını ve Flaman anatomist, Phillippe Verheyen'in (1648-1710) Hipokrat tarafından kullanılan 'tendo magnus' ve sonraki yazarlar tarafından kullanılan 'chorda Hippocratis'in yerine Aşil tendonu terimini kullanmasıyla ilişkili olabileceğine dikkat çekmiştir.4,5 Bugünün anatomistleri Aşil tendonunu 'kalkaneal tendon' olarak da adlandırmaktadır.

Aşil tendonunun ilk yırtık duyurusu, Fransız cerrah Ambroise Paré (1510-1590) tarafından tanımlanmıştır.6 Açıklamasına göre, bu nadir bir durum değildi, ancak tedaviler etkisizdi. Paré, aynı zamanda, bu büyük tendonun kesici aletlerle kesilmelerinde, yaraların zor ve uzun sürede iyileştiğinden bahsetmiştir.7

Paris'in önde gelen cerrahlarından Jean Louis Petit (1674-1750), 1736'da biri bilateral olmak üzere üç olgu sunmuş, bilateral olan bir olgunun ayrıntılı hikâyesine de ayrıca yer vermiştir çalışmasında.8 Bir sirk cambazı olan ve yüksekten düşme sonrası Aşil tendonu yırtılan bu hasta, yüzüstü konumda; dizlerini fleksiyonda ve ayak bileğini plantar fleksiyonda tutan bandajlar ile tedavi edilmiş, bandajlar 8 ve 15 gün sonra çıkartılıp tekrar uygulanmış, iyileşme 22 günden sonra başlamış ve bu arada yük vermeye 10 gün sonra izin verilmiştir. Çalışmasında destek kullanımı belirtilmemiş, ama iyi sonuçlar elde edildiği vurgulanmıştır.

John Hunter (1728-1793) 'Yırtılmış Aşil Tendonu'nu not defterlerinde 355 no'lu olgu olarak tanımlamıştır.9 Parmakları üzerinde sıçrayıp, topukları yere değmeyecek şekilde yere indiği sırada, büyük bir gürültü ve acıyla Aşil tendonunun koptuğunu anlatmış, 5 gün boyunca ayağı ekstansiyonda ve dizi hafif fleksiyonda tutan bir bandaj uygulamış, ardından Monro Bandajı'na geçmiştir.

Monro bandajı, Alexander Monro (1697-1767) tarafından, 1781 yılında oğlunun yayımladığı Monro'nun çalışmaları hakkındaki bir kitapta tanımlanmıştır.10 Bu bandaj plantar fleksiyon derecesinin ayarlanmasına izin verecek şekilde tasarlanmıştır.

Aşil tendonunun yırtılmasını tanımlayan ilk dikkat çekici seri, 1929'da Qenu ve Stoianovitch tarafından yayımlanmıştır.11Opere edilen 29 hastanın sonuçlarını, konservatif tedavi edilen 39 hasta ile karşılaştırmışlardır. Operasyonlarda tendonun uçları tazelenmiş ve keten dikişler yerleştirilmiş, hastaların üç hafta boyunca yük vermesine izin verilmemiştir. Her iki tedaviyle de mükemmel sonuçlar elde edilmiştir; ancak yazarlar açıkça, ilki 1888 yılında Polaillon tarafından gerçekleştirilen açık onarım taraftarıdırlar.11 Bu başlık ÖN SÖZ bugün de hâlâ devam eden uzun bir tartışmanın başlangıcı olarak dikkat çekmektedir.

Konservatif ve cerrahi yönetim konusundaki tartışma hâlâ devam etse de, cerrahi tedaviye olan eğilim artmaktadır ve son zamanlarda cerrahi sonrası botlu, botsuz veya alçı desteği ile erken kontrollü yük verme tercih edilmektedir.12

Son yıllarda ise açık cerrahiye alternatif olarak perkütan cerrahi yöntemler de gündeme gelmiştir. Bu teknik, infiltratif anestezi ile, turnike uygulamadan, hasta ile iletişim içinde Aşil tendonunun endoskopi destekli perkütan dikilmesi, hem atletik hem de atletik olmayan kişilerin akut Aşil tendon yırtıklarının tedavisi için olabilecek bir çözüm sunmaktadır.

Endoskopik görüntü bizlere, tendonun kanlanması ve paratenonun yırtık olup olmaması hakkında da bilgi vermektedir. Bazen, paratenon bütünlüğü korunmuş, tendon bu zarf içinde prob yani kanca ile ortaya çıkarılmaktadır, bazen de tendon paratenonla yırtık olmaktadır. Paratenonun sağlam, tendonun yırtık olduğu olgularda spora dönüşün 4 ay içinde olabildiği dikkatimizi çekmiş, çekmeye devam etmektedir.

Geçtiğimiz 20 sene içinde uygulamış olduğum bu teknikten; erken aktif mobilizasyona izin vermekte ve ciddi bir komplikasyon olmadan tatminkâr klinik iyileşme ve kozmetik bir görünüm ve hasta memnuniyeti ile yararlanmaktayım. Bu uygulama ile paratenon ve böylece tendonun kanlanması korunmakta ve biyolojik iyileşme artmaktadır.13

Aşil tendon yırtıkları 16. yüzyılda tanımlanmış olmasına ve uzunca bir tarihçeye sahip olmasına rağmen, tedavi seçenekleri hâlâ gelişmektedir. Bunda özellikle son yıllardaki hücresel düzeydeki gelişmeler ile hücrenin ve biyolojik yanıtların daha iyi anlaşılmasının payı büyüktür.14,15

Bu çalışmanın hazırlanmasında bana destek veren tüm yazarlara, Dr. Naile Babayeva, Dr. Şeyma Torgutalp, Dr. Hakan Kara, Dr. Barış Can Kuzuca, Dr. Cem Güneri ve Dr. Gürhan Dönmez'e teşekkür ediyorum.

Prof. Dr. Mahmut Nedim DORAL
Editör


KAYNAKLAR
1. Apaydın N, Ünlü S, Bozkurt M, Doral MN. Aşil tendonunun fonksiyonel anatomisi ve biyomekanik özellikleri. TOTBİD Dergisi. 2011;10(1):61-8.
2. Agur AM, Dalley 2nd AF. Lower limb. In: Agur AM, Dalley 2nd AF, eds. Grant's Atlas of Anatomy. 12th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 353-475.
3. Diab M. Lexicon of orthopaedic etymology. Singapore: Harwood Academic Publishers; 1999.
4. Kirkup J. Mythology and history. In: Helal B, Wilson D, eds. The Foot. Edinburgh: Churchill Livingstone; 1988. p.2.
5. Eustachius B. Tabulae Anatomicae. Rome: Gonzagae; 1714. p.82.
6. Rang M. The Story of Orthopaedics. Philadelphia: WB Saunders; 2000. p.392.
7. Paré A. The Works of that famous Chirurgion Ambrose Parey. In: Johnson TH, ed. Translated out of Latin and compared with the French. London: Richard Cotes; 1649:36.
8. Petit JL. Trait des Maladies des Os Paris. 3rd ed. Vol. 2. Cavalier; 1736. p.289-353.
9. Allen E, Turk JL, Murley R. The case books of John Hunter FRS, eds. London: Royal Society of Medicine Services Limited; 1993.
10. Monro A. The Works of Alexander Monro MD. In: Elliott C, Robinson G, eds. London; 1781. p.661.
11. Qenu J, Stoianovich. Les ruptures du tendon dAchille. Rev de Chirurg. 1929;67:647-78.
12. Costa ML, MacMillan K, Halliday D. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone Joint Surg [Br]. 2006;88-B:69-77.
13. Doral MN, Bozkurt M, Turhan E, Ayvaz M, Atay OA, Uzümcügil A, et al. Percutaneous suturing of the ruptured Achilles tendon with endoscopic control. Arch Orthop Trauma Surg. 2009;129(8):1093-101.
14. Doral MN, Alam M, Bozkurt M, Turhan E, Atay OA, Dönmez G, et al. Functional anatomy of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):638-43.
15. Doral MN. What is the effect of the early weight-bearing mobilisation without using any support after endoscopy-assisted Achilles tendon repair' Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1378-84.
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