胫侧籽骨位置对外翻矫形手术后功能恢复影响的研究

Effects of tibial sesamoid position on the functional recovery after the hallux valgus surgery

目的探讨术后胫侧籽骨位置(tibial sesamoid position,TSP)对外翻矫正术后跖趾关节功能恢复的影响。方法本研究纳入了2008年1月至2015年6月,在我科接受外翻矫形术患者300例,并术后随访2年。通过手术前后患足负重下的前后位X射线检查结果评估患者的TSP、外翻角(hallux valgus angle,HVA)和第1~2跖骨间角(intermetatarsal angle,IMA)的改变。通过对术后TSP分级进行患者分组,比较正常型TSP(Ⅰ~Ⅳ级)患者与异常型TSP(Ⅴ~Ⅶ级)患者的术后疼痛视觉模拟评分法(visual analog scale,VAS)和AOFAS拇趾跖趾关节评分(AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale)的差异性,并通过Logistics多因素回归分析寻找影响外翻矫形术后跖趾关节功能恢复的独立危险因素。结果 TSP比例,异常型术前85.0%,术后24.3%(P<0.001)。HVA角度:术前(30.8±10.8)°,术后(13.6±7.4)°,(P<0.001)。IMA:术前(14.3±4.0)°术后(7.9±3.5)°,(P<0.001)。VAS评分,正常型术前(5.5±2.0)分、术后6个月(0.8±0.5)分、术后2年(0.5±0.5)分;异常型术前(5.8±2.5)分、术后6个月(2.0±1.3)分、术后2年(2.0±0.8)分。术后6个月和术后2年,正常型TSP组的VAS评分均低于异常型TSP组,差异有统计学意义(P<0.001、P<0.001)。AOFAS评分,正常型术前(56±5)分、术后6个月(80±4)分、术后2年(87±2)分;异常型术前(55±7)分、术后6个月(72±5)分、术后2年(76±2)分,术后6个月和术后2年,正常型TSP组的AOFAS评分均分别低于异常型TSP组,差异有统计学意义(P<0.001、P<0.001)。术后异常型TSP是影响术后跖趾关节功能恢复的独立危险因素(OR=1.974,95%CI:1.706~2.211,P<0.001)。结论外翻矫形术后TSP分级对外翻患者术后跖趾关节功能恢复具有重要的影响,TSP分级为Ⅰ~Ⅳ级的患者术后跖趾关节功能恢复优于Ⅴ~Ⅶ级患者。

Objective Hallux valgus surgery can change the tibial sesamoid position （ TSP ） and the first metatarsal bone, so this study aims to investigate effects of TSP on the functional recovery after the hallux valgus surgery. Methods This study enrolled 300 patients who underwent hallux valgus surgery in our department from January 2008 to June 2015. All of them were followed up for 2 years. The TSP, hallux valgus angle （ HVA ） and intermetatarsal angle （ IMA ） were assessed by weight-bearing anteroposterior X-ray examination pre- and post- operation. All patients were divided into the normal sesamoid group （ I - IV ） and outlier sesamoid group （ V - VII ） according to the postoperative TSP grade. Visual Analog Scale （ VAS ） and AOFAS Haltux Metatarsophalangeal- Interphalangeal Scale （ AOFAS ） in 2 groups were compared respectively. Multivariate Logistics regression analysis was used to determine the independent risk factors of functional outcomes after hallux valgus surgery. Results The TSP ratio of the tibial sesamoid bone was 85.0% preoperatively and 24.3% postoperatively （ P 〈 0.001 ）. The HVA angle of the valgus angle was （ 30.8 ± 10.8 ）° preoperatively and （ 13.6 ± 7.4 ）° postoperatively （ P 〈 0.001 ）; IMA was （ 14.3 ± 4.0 ）° preoperatively and （ 7.9 ± 3.5 ）° postoperatively （ P 〈 0.001 ）; VAS score was （ 5.5 ± 2.0 ） preoperatively, （ 0.8 ± 0.5 ） 6 months postoperatively and （ 0.5 ± 0.5 ） 2 years postoperatively in the normal TSP group, and （ 5.8 ± 2.5 ） preoperatively, （ 2.0 ± 1.3 ） 6 months postoperatively and （ 2.0 ± 0.8 ） 2 years postoperatively in the outlier TSP group. The VAS scores of the normal TSP group were significantly lower than those of the outlier TSP group 6 months and 2 years after the operation respectively （ P 〈 0.001, P 〈 0.001 ）. AOFAS score was （ 56 ± 5 ） preoperatively, （ 80 ± 4 ） 6 months postoperatively and （ 87 ± 2 ） 2 years postoperatively in the normal TSP group, while （ 55 ± 7 ） preoperatively, （ 72 q- 5 ） 6 months postoperatively and （ 76 ± 2 ） 2 years postoperatively in the outlier TSP group. The AOFAS scores of the normal TSP group were significantly higher than those of the outlier TSP group 6 months and 2 years after the operation respectively （ P 〈 0.001, P 〈 0.001 ）. The post-operative outlier sesamoid was the only independent risk factor for the postoperative functional recovery （ OR = 1.974, 95% CI： 1.706 - 2.211, P 〈 0.001 ）. Conclusions The TSP grade after the hallux valgus surgery has an important influence on the functional recovery of patients with hallux valgus. Functional recovery of TSP grade I - IV patients was better than that of the V - VII patients.