Ilizarov技术矫正合并皮肤瘢痕挛缩的僵硬型足踝畸形

Application of Ilizarov technique in correction of stiff foot deformity combined with skin scar

目的探讨Ilizarov技术矫正合并皮肤瘢痕挛缩的僵硬型足踝畸形的手术方法、术后管理程序及疗效。方法2004年2月～2007年5月，根据Ilizarov张力一应力法则，应用自行研制的外固定矫形器治疗伴有皮肤瘢痕挛缩的足踝畸形12例，其中马蹄内翻足10例，马蹄外翻足2例。9例同期实施足跗骨的有限截骨术，3例实施足部肌腱转移肌力平衡术，1例同期实施胫骨延长术。术后5d开始旋转相应的螺纹牵拉杆，对器械进行三维空间的缓慢调整，足内翻者先矫正前足内收和后足内翻，后矫正足下垂畸形，直至达到矫形要求的标准，足外翻者牵拉矫形的方向与内翻足相反。在矫形的过程中定期进行x线检测，以防止发生踝关节前后移位。治疗期间鼓励患足负重行走。术后平均牵伸78d，停止牵伸后在外固定器维持下患足负重行走平均69d，拆外固定器后配矫形鞋行走2～3个月。结果12例患者术后随访5个月～2年4个月（平均1年5个月）。8例足畸形获满意矫正，能全足底负重，行走功能良好，患者满意。4例足下垂畸形出现部分复发，其中3例再次安装足踝牵伸器矫正。最终疗效11例满意，1例可。僵硬的瘢痕组织经牵拉后血液循环改善，皮肤瘢痕变软。无一例发生严重针道和皮肤切口感染，未并发踝关节脱位及血管、神经损伤等并发症。结论改良的Ilizarov微创技术能有效矫正合并皮肤瘢痕挛缩的僵硬型足踝畸形，合并骨性畸形者应配合有限截骨手术，但牵拉过程必须缓慢。足踝畸形达到矫形要求后，患足全负重行走不少于8周再拆除外固定器，可避免或减少畸形反弹。皮肤瘢痕组织在张应力作用下，可出现血液循环改善与组织再生的现象。

Objective To apply the Ilizarov technique in the correction of stiff foot deformity combined with skin scar. Methods From February 2004 to May 2007, 12 patients were treated with the Ilizarov device according to the Ilizarov＇s principle of tension-stress. There were 10 cases of talipes equinovarus and 2 cases of talipes equinovalgus. Nine cases underwent limited tarsal osteotomy, 3 cases had tendon transfer to restore muscle balance and 1 case had tibial lengthening. The three-dimensional structures of the apparatus were adjusted 5 days after the operation by telescopic rods. In cases of varus deformity, the varus at the forefoot was corrected first and foot drooping corrected later. The valgus deformity was corrected in the opposite direction. X-ray films were taken regularly to observe the ankle joint and avoid its dislocation. The patients were encouraged to have weight-bearing during the treatment period. The post-operative distraction lasted for an average of 78 days which was followed by a weight-bearing for an average of 69 days and a walking with a foot brace for 2-3 months after the removal of fixators. Results Twelve patients were followed up for 5 months to 2 years and 4 months. Eight patients had a satisfactory correction of the deformity with good walking on the whole foot. Four cases had partial recurrence of foot drooping for which 3 cases had a second application of fixators. Finally 11 cases achieved excellent results. The stiff skin scar became softer and blood circulation improved after the distraction. No infection in the pin sites and incisions, no dislocations in the ankle joint and no damage to nerves and blood vessels occurred. Conclusions Ilizarov technique is a minimally invasive and effective method of correcting stiff foot deformity combined with skin scar. Limited tarsal osteotomy is needed for bony deformity with a slow distraction. Weight-bearing with a fixator on the foot for more than 8 weeks is necessary for avoiding the recurrence of foot deformity. Distraction may lead to improved blood circulation and regenerated tissue for the skin scar.