关节镜手术在顽固性跟痛症治疗中的应用

Application of arthroscopic surgery in the treatment of chronic heel pain

目的探讨关节镜下跟骨骨刺切除、跖筋膜松解、射频消融及跟骨减压术治疗顽固性跟痛症的临床疗效。方法回顾性分析2014年5月-2016年12月遂宁市中心医院关节外科手术治疗且有完整随访资料的47例（47足）顽固性跟痛症患者的临床资料。其中接受开放手术治疗21例21足（开放组），接受关节镜下骨刺切除、跖筋膜松解、射频消融及跟骨减压术治疗26例26足（关节镜组）。采用视觉模拟评分（VAS）和美国足踝外科协会（AOFAS）踝一后足功能评分对患者术前和术后1周及1、2、3、6个月疼痛和功能分别进行评估，同时观察围手术期并发症，术后半年根据患者在主观满意度评价疗效。结果47例患者手术均顺利完成，随访时间6-18个月，平均11．2个月。开放组出现并发症8例（38．1％），其中皮瓣发黑、伤口延期愈合4例，足内侧或外侧麻木4例；关节镜组出现并发症3例（11．5％），均为足外侧麻木；两组并发症比较差异无统计学意义（X^2=3．209，P〉0．05）。开放组住院时间和住院费用分别为（15．0±4．9）d和（9647．3±1039．7）元，关节镜组分别为（9．3±2．2）d、（11557．6±1099．6）元，差异均有统计学意义（t=4．944、6．066，P值均〈0．01）。VAS：切开组患者术后1个月开始疼痛明显缓解（P〈0．05），关节镜组从术后1周开始疼痛明显缓解（P〈0．05）、术后3个月达稳定状态，关节镜组术后1周达到切开组1个月时的疼痛缓解程度。AOFAS踝-后足功能评分：切开组术后3个月开始明显提高，关节镜组术后1个月开始明显提高（P〈0．05）、3个月达稳定状态，关节镜组患者术后1个月达到切开组3个月功能改善程度。随访半年时，关节镜组VAS、AOFAS踝-后足功能评分仍优于开放组。切开组患者满意率为85．7％（18／21），关节镜组为96．2％（25／26），差异无统计学意义（Z=0．542，P〉0．05）。结论关节镜手术治疗顽固性跟痛症较开放手术而言，住院时间短、疼痛缓解快、功能恢复快，但仍存在部分患者术后患足麻木及疗效不佳的缺陷，需进一步研究局部神经解剖及支配，达到更好的临床疗效。

Objective To compare the clinical efficacy of arthroseopic resection of ealcaneal spur, plantar fascia release, radiofrequeney ablation and calcaneal decompression in the treatment of chronic heel pain. Methods Clinical data of 47 patients （47 feet） underwent surgery in Suining Central Hospital from May 2014 to December 2016 were retrospectively analyzed, of whom 21 patients （21 feet） were treated with traditional incision and plantar fascia （incision group ）, and 26 patients （26 feet ） were treated with arthroseopic spur excision, plantar fascia release, radiofrequeney ablation and caleaneal decompression （arthroscopic group ）. Then VAS scores and American Orthopaedic Foot and Ankle Society （AOFAS） ankle-hindfoot scores were used to assess pain and function before and 1 week, 1 month, 2 months, 3 months, and 6 months after surgery. The efficacy and perioperative complications were evaluated. Results The procedures in 47 patients were successfully performed, and the follow-up ranged from 6 months to 18 months, with an average of 11.2 months. There were 8 patients （38.1%） surffering from perioperative complications in the incision group, including 4 patients of cutaneous necrosis and delayed wound healing, as well as 4 patients of medial or lateral numbness in foot. Together 3 patients（ 11.5% ） had complications in the arthroseopie group, and all had lateral numbness in the foot. There was no statistical significance between the groups （ X2=3. 209, P 〉 0.05 ）. The hospital stay and hospitalization cost were （ 15.0 ±4.9） days and （9 647.3 ± 1039.7） yuan in the incision group, as well as （9. 3± 2. 2） days and （ 11 557.6±1 099.6） yuan in the arthroscopie groups, respectively, and there were statistical differences （t = 4. 944, 6. 066, all P values 〈 0.01 ）. On the one hand, as for VAS scores, the pain in the incision group relieved significantly 1 month after surgery （P 〈 0.05 ） , while the arthroscopic group also relieved significantly from the first postoperative week （P 〈 0.05） , achieving stable state 3 months after surgery, and the level of pain relief in the arthroscopy group 1 week after procedures was equal to that in the incision group 1 month after surgery. On the other hand, for AOFAS ankle-hind foot scores, the incision group began to improve significantly 3 months after operation, while the arthroscopic group began to improve 1 month after surgery （P 〈 O. 05 ） , achieving stable state after 3 months, and the function improvement in the arthroscopic group 1 month after surgery was equal to that in the incision group 3 months after surgery. At the follow-up of 6 months, arthroscopic VAS score and AOFAS ankle-hind foot score were still better than those of the incision group; subjective satisfaction degree was 85. 7% （ 18/21 ） in the incision group and 96. 2% （25/26） in the arthroscopy group. There was no significant difference （Z = 0.542, P 〉 0.05）. Conclusions Compared to traditional therapy, arthroscopic treatment has short hospital stay, rapid pain relief and functional recovery, which also can avoid skin complications. However, there are still numbness and poor satisfactory in a few cases, so it is necessary to further study of local nerve anatomy and innervation, to achieve better clinical outcomes.