小切口跟骨内移截骨治疗胫后肌腱功能不全性柔韧性平足症

Medial displacement calcaneal osteotomy with mini-incision for the treatment of acquired flexible flatfoot caused by posterior tibial tendon dysfunction

目的探讨小切口跟骨内移截骨治疗胫后肌腱功能不全性柔韧性平足症的疗效。方法自2005年6月至2009年6月采用小切口跟骨内移截骨治疗10例（13足）胫后肌腱功能不全性柔韧性平足症，所有患者足跟存在明显外翻畸形。取外侧入路3．0—4．5cm暴露跟骨外侧壁，垂直于跟骨体截断跟骨，远端向内侧平行推移约跟骨体直径1／3～1／2，用两枚空心螺钉平行加压固定。术前，术后6周，3、6、12个月及以后每6个月进行1次临床及影像学评估。所有病人采用AOFAS评分表进行功能评估。站立位摄全足侧位片，了解截骨愈合情况，测定跟骨倾斜角、跟距角、距骨一第1跖骨角变化情况；站立位摄全足前后位片，了解跟距角、距骨一第1跖骨角变化情况；摄后跟轴位片评价外翻力线变化情况。结果所有病人均得到有效随访，平均随访20．3个月（7～55个月），临床与影像学证明10例13足全都获得骨性愈合。AOFAS评分由术前平均50．3分提高到术后随访84，2分。没有感染、神经损伤等并发症。术后侧位跟骨倾斜角、跟距角、距骨一第1跖骨角，前后位跟距角、距骨．第1跖骨角较术前明显改善，差异有统计学意义（P〈0．01）；后跟轴位提示所有病人后跟外翻畸形得到纠正。结论小切口跟骨内移截骨术治胫后肌腱功能不全性柔韧性平足症临床效果好，能有效纠正平足畸形，改善踝．后足功能，并发症少，是一种值得推荐的手术方法。

Objective To investigate the clinical outcomes of medial displacement calcaneal osteotomy with mini-incision for the treatment of acquired flexible flatfoot caused by posterior tibial tendon dysfunction. Methods From 2005 to 2009, 10 patients （ 13 feet） of acquired flexible flatfoot with obvious heel valgus underwent medial displacement calcaneal osteotomy with mini-incision. The lateral skin incision of 3.0-4.5cm was made to explore the lateral calcaneal wall. Calcaneal osteotomy was performed from inferior and lateral to superior and medial, perpendicular to the longitudinal axis of calcaneal body. The distal segment was displaced medially for 1/3 - 1/2 width of calcaneal body and fixed by two parallel cannulated screws. All patients were evaluated at 6 weeks, 3 months, 6 months, 12 months and every 6 months preand post-operatively by clinical examinations and radiologlcal studies. All patients were physically examined with an extended protocol of questionnaires and the AOFAS Ankle ＆ Hinclfoot Scales. The lateral view of full foot allowed an assessment of bone healing, calcaneus inclination angle （ CI ） , talocalcaneal angle （TC） and taler first metatarsal angle （TMT）. The AP view of full foot allows assessment of TC and TMT. The heel varus/valgus alignment could be evaluated on the axial radiographs of hindfoot. Results With a mean postoperative follow-up period of 20. 3 months （ range 7-55 Ms） , all patients had bone union as confirmed by clinical examination and radiology. The AOFAS rating scale improved from a pre-operative mean of 50. 3 to a mean of 80.2 at 6 months and a mean of 84. 2 at last follow-up, without any complication of infection, nerve injure and so on. All radiographic parameters were statistically significant （P 〈0. 001）, including CI, TC and TMT on the lateral view and TC and TMT on the AP view. The heel varus/valgus was corrected on the axial view. Conclusion The medial displacement calcaneal osteotomy with mini-incision is a recommended procedure for the treatment of acquired flexible flatfoot with excellent clinical outcomes, correction of deformity and fewer complications.