副舟骨植骨与髂骨植骨Cotton截骨术对儿童柔韧性平足症的疗效对比研究

Comparation of outcomes of iliac crest bone graft and accessory navicular bone graft in the Cotton osteotomy for pediatric and adolescent flexible flatfoot

目的对比副舟骨和髂骨在Cotton截骨术中植骨对儿童柔韧性平足症的疗效差异。方法回顾性队列研究。分析2018年7月至2022年3月在北京同仁医院接受手术治疗的伴有副舟骨痛及前足内翻的柔韧性平足症患者的临床资料,所有患者均接受了Cotton截骨术。根据Cotton截骨植骨来源不同,将患者分为髂骨植骨组和副舟骨植骨组。其中髂骨组共12例(19足),其中男9例,女3例,年龄M(Q_(1),Q_(3))为11(11,12)岁,随访36(6,48)个月;副舟骨组共9例(16足),其中男6例,女3例,年龄11(11,11)岁,随访12(6,17)个月。评估两组患者术前及末次随访的影像学资料,包括足正位X线片距骨第1跖骨角(T1MT)、距舟覆盖角(TNCA),距骨跟骨角(TCA),侧位距骨第1跖骨角(Meary角)、跟骨倾斜角(Pitch角),距骨跟骨角(Kite角),内侧楔骨关节面夹角(CAA)及跟骨长轴位的后足力线角(HAA)。采用美国足踝外科协会踝与后足评分(AOFAS),疼痛视觉模拟评分(VAS)及Maryland评分比较两组患者术前术后的足部功能变化情况。结果21例患者获得完整随访。两组末次随访时影像学指标,T1MT、TNCA、Meary角、Pitch角、Kite角、CAA、HAA均较术前有所改善,差异均有统计学意义(均P<0.05)。两组术后各功能评分,如AOFAS、VAS及Maryland评分均较术前有所改善,差异均有统计学意义(均P<0.05)。术后两组CAA角增加量差异有统计学意义(P=0.017),髂骨组ΔCAA为6.0°±2.6°,副舟骨组为4.3°±1.3°。两组其他影像学指标改善程度差异均无统计学意义(均P>0.05)。术后所有患者均获得骨性愈合。髂骨组2例患者术后出现供区疼痛,经保守治疗疼痛可缓解。结论与髂骨植骨相比,采用副舟骨植骨的Cotton截骨治疗柔韧性平足症可取得相似的X线随访效果以及相同的临床功能评分。

Objective To compare the outcomes between iliac crest and accessory navicular as different bone grafts in the Cotton osteotomy in the treatment of pediatric flexible flatfoot deformity.Methods A retrospective cohort study.The clinical data of pediatric flexible flatfoot patients with symptomatic accessory navicular received operations from July 2018 to March 2022 in Beijing Tongren Hospital were retrospectively analyzed.All the patients were treated with Cotton osteotomy.According to the different sources of bone grafting in Cotton osteotomy,the patients were divided into iliac crest group and accessory navicular group.There were 12 patients(19 feet)in iliac crest group,including 9 males and 3 females with a median age M(Q_(1),Q_(3))of 11(11,12)years and were followed-up for 36(6,48)months.There were 9 patients(16 feet)in accessory navicular group,including 6 males and 3 females,with a median age M(Q_(1),Q_(3))of 11(11,11)years and were followed-up for 12(6,17)months.Radiographic evaluations were reviewed and compared between the two groups before surgical treatment and at final follow-up,included talo-1st metatarsal angle(T1MT),talonavicular coverage angle(TNCA),talocalcaneal angle(TCA)in weight bearing anteroposterior view,and Meary angle,calcaneal Pitch angle,Kite angle,cuneiform articular angle(CAA)in weight bearing lateral view,and hindfoot alignment angle(HAA)in calcaneal long axial view.Functional scores included American Orthopedic Foot and Ankle Society(AOFAS),visual analog scale(VAS),and Maryland scores were recorded and compared before and after the operation.The complications were also recorded.Results Total of 21 patients were successfully followed in this study.The radiographic measurements in the two groups,such as T1MT,TNCA,Meary angle,Pitch angle,Kite angle,CAA,HAA,were all significantly improved at the last follow-up when compared with those before the surgery(all P<0.05);and the AOFAS,VAS,Maryland scores in both groups were all improved after the surgery(all P<0.05).There was a significant difference in CAA alteration(ΔCAA)after the operation between the two groups,theΔCAA in iliac crest group and the accessory navicular group was 6.0°±2.6°and 4.3°±1.3°,respectively(P=0.017).There was no significant differences in the improvement of other radiographic measurements between the two groups(all P>0.05).All the patients had a successful bone union.Two patients had donor site pain in the iliac crest group and were treated conservatively.Conclusion Compared with iliac crest bone graft,accessory navicular bone graft could achieve comparable outcomes in radiographic measurements and functional scores in the treatment of pediatric flexible flatfoot with accessory navicular pain.