类风湿性关节炎前足畸形重建手术的近期疗效

RHEUMATOID FOREFOOT RECONSTRUCTION WITH FIRST METATARSOPHALANGEAL FUSION AND ARTHROPLASTY OF LESSER METATARSAL HEADS

目的探讨类风湿性关节炎前足畸形的手术治疗方法及近期疗效。方法 2007年1月-2009年8月,采用第1跖趾关节融合术联合第2～5跖趾关节成形术治疗7例类风湿性关节炎前足畸形女性患者。年龄56～71岁,平均62岁。病程5～30年,平均16年。患者均表现为双足外翻,第2～5趾合并锤状趾或槌状趾畸形,其中5足合并第2跖趾关节半脱位。根据美国矫形足踝协会(AOFAS)改良标准评分为(36.9±6.4)分。术前负重位X线片测量,第1跖趾关节外翻角度(46±5)°,第1、2跖骨间夹角(12±2)°。结果术后切口均Ⅰ期愈合。术后3～4个月X线片复查示第1跖趾关节达骨性融合。7例均获随访,随访时间2～4年,平均2.9年。患者跛行步态均较术前明显改善,行走时足部疼痛明显缓解。术后3个月X线片测量第1跖趾关节外翻角度为(17±4)°,第1、2跖骨间夹角为(11±2)°,与术前比较差异均有统计学意义(P<0.05)。术后2年根据AOFAS改良标准评分为(85.3±5.1)分,与术前比较差异有统计学意义(t=4.501,P=0.001)。1例于术后4年前足转移性跖骨痛复发,继续随访中未作特殊处理。结论第1跖趾关节融合术联合第2～5跖趾关节成形术治疗类风湿性关节炎前足畸形,可获得较好外翻矫形,重塑前足负重面,有效缓解行走时疼痛。

Objective To evaluate the surgical treatment and effectiveness of rheumatoid forefoot reconstruction with arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads.Methods Between January 2007 and August 2009,7 patients with rheumatoid forefoot were treated by reconstruction with arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads.They were all females with an average age of 62 years（range,56-71 years） and with an average disease duration of 16 years（range,5-30 years）.All patients manifested hallux valgus,hammer toe or mallet toe of 2-5 toes,5 feet complicated by subluxation of the second metatarsophalangeal joint.The improved American Orthopaedic Foot Ankle Society（AOFAS） score was 36.9 ± 6.4.The hallux valgus angle was（46 ± 5）°,and the intermetarsal angle was（12 ± 2）° by measuring the load bearing X-ray films preoperatively.Results All incisions healed by first intention after operation.The X-ray films showed bone fusion of the first metatarsophalangeal joint at 3-4 months after operation.Seven patients were followed up 2.9 years on average（range,2-4 years）,gait was improved and pain was relieved.The hallux valgus angle decreased to（17 ± 4）° and the intermetarsal angle was（11 ± 2）° at 3 months postoperatively,showing significant differences when compared with preoperative values（P 0.05）.The improved AOFAS score was 85.3 ± 5.1 at 2 years postoperatively,showing significant difference when compared with preoperative score（t=4.501,P=0.001）.One patient had recurrent metatarsalgia at 4 years after operation.Conclusion Arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads for rheumatoid forefoot reconstruction can correct hallux valgus,remodel the bearing surface of the forefoot,and relieve pain,so it can be considered as a procedure that provides improvement in the clinical outcome.