踝后正中入路锁定钢板内固定行胫距跟关节融合术

Posterior midline approach for tibiotalocalcaneal arthrodesis with locking plate

目的评估踝后经跟腱正中入路植骨锁定钢板内固定行胫距跟关节融合术的手术技巧和临床效果。方法从2008年1月至2012年12月,共收治123例踝关节合并距下关节创伤性关节炎,其中13例因踝周软组织条件不佳而选用踝关节后方入路胫距、距下关节清理、植骨、4.5 mm干骺端锁定钢板内固定行胫距跟关节融合术。其中男9例,女4例,平均年龄47.8岁（30~65岁）;平均病程7年（1~15年）。术后定期随访复查X线片以明确骨愈合情况,并采用直观模拟量表（Visual Analog Scale,VAS）评估术后疼痛改善情况,美国骨科足踝外科（American Orthopaedic Foot and Ankle Society,AOFAS）踝关节与后足评分及简明健康量表SF-36评分评估恢复效果,并记录相关并发症。结果术后所有患者伤口均一期愈合,未见感染、皮肤坏死等软组织并发症。11例获得最终随访,平均随访时间24个月（12~36个月）。随访复查X线片示术后平均12周融合端骨性愈合（10~15周）。末次随访时,AOFAS踝与后足评分及SF-36评分均较术前明显改善,疼痛症状明显缓解。随访期间未见内固定失效、融合失败等并发症,2例患者术后出现距舟关节骨关节炎,伴轻度疼痛,口服药物对症治疗后缓解。结论经踝后正中入路锁定钢板内固定行胫距跟关节融合安全、有效,特别适合于踝周软组织条件不佳的病例。

Objective To evaluate the surgical technique and clinical outcomes of the tibiotaloealcaneal （TTC） arthrodesis using the posterior midline approach with the locking plates. Methods From Jan 2008 to Dec 2012, 123 cases of the post-traumatic arthritis of the ankle joint and subtalar joint were treated in our department, 13 of which underwent the tibiotalocalcaneal arthrodesis via a direct posterior midline approach because of the compromised soft tissue around the ankle. This technique used the well vascularized, thick, posterior soft tissue envelope, to provide a very good exposure of the articular surface for debridement. The bone graft and the TTC fusion were performed with a 4.5ram locking plate. There were nine cases of men and four cases of women with a mean age of 47.8 years old （ 30 - 65 years old）. The average course of the disease was 7 years （ 1 - 15 years）. Regular X-rays were taken during the follow-up for the confirmation of the bone healing. The outcomes were assessed by a combination of pre-and post-operative clinical examinations, including AOFAS hind foot score, VAS score and SF-36 score. The complications were also recorded. Results All wounds were primary healing and no soft tissue complication such as infection, skin necrosis was occurred. 11 patients got final follow-up with a mean follow-up time of 24 months （12 -36 months）. The follow-up X-ray demonstrated the bone healing in the 12th week （10th -15th week） post-operatively on average. The AOFAS hind foot and ankle scores were improved and the pain was relieved significantly at the final follow-up. There was no complication ofimplant failure or fusion failure during the follow-up. Two cases suffered from mild pain because of the talonavicular arthritis post-operatively, which was relieved by conservative treatment. Conclusion The posterior midline approach with locking plate fixation is a safe and effective treatment for TTC fusion with compromised soft tissue around the ankle.