经腓骨外侧入路行胫距跟关节融合术治疗胫距关节和距下关节病变

Tibiotalocalcaneal arthrodesis via lateral transfibular approach to treat tibiotalar and subtalar arthropathy

目的探讨经腓骨外侧入路行胫距跟关节融合术(tibiotalocalcaneal arthrodesis,TTC)治疗胫距关节和距下关节病变的手术疗效。方法回顾性分析2015年1月至2017年12月采用经腓骨外侧入路行TTC的18例患者资料,男11例,女7例;年龄39~76岁,平均53.4岁;创伤性关节炎3例,骨关节炎10例,距骨坏死3例,胫距关节融合术后失败1例,腓骨肌萎缩症1例。其中10例踝关节和后足合并内翻畸形,6例合并外翻畸形,1例合并马蹄足畸形,1例合并马蹄足内翻畸形。所有病例依Morrey-Wiedeman关节炎影像学分期均为Ⅲ期。患者均存在踝和后足疼痛、僵硬及行走障碍。比较术前与术后1年的视觉模拟评分(visual analogue scale,VAS)、美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝-后足评分,观察术后关节融合情况以及并发症。结果18例患者均获得随访,随访时间12~47个月,平均25.4个月。VAS评分由术前6~9分[平均(7.1±1.0)分]减少至术后1年随访时的0~2分[平均(0.9±0.8)分]。AOFAS评分由术前24~59分[平均(40.6±11.5)分]增加至术后1年随访时的68~84分[平均(75.3±5.8)分];其中良8例,可10例,优良率44.4%(8/18)。18例患者的胫距跟关节均骨性融合,关节融合率为100%,无一例发生内固定松动或断裂。术后1年随访时,询问患者对手术的满意度,所有患者均对手术效果表示满意。1例创伤性关节炎患者术后出现外侧伤口不愈合,经清创术和真空负压引流术后伤口愈合;2例骨关节炎患者术后出现足背外侧感觉减退,经营养神经药物治疗后恢复;1例骨关节炎患者术后足跟外侧伤口周围皮肤出现摩擦感和局部异物感,考虑为内固定激惹足跟外侧皮肤所致,术后1年二次手术取出内固定物后症状消失;并发症的发生率为22.2%(4/18)。结论经腓骨外侧入路采用空心钉结合锁定钢板技术行TTC融合术安全而有效,关节融合率高且并发症发生率低。

Objective To observe operative results of tibiotalocalcaneal arthrodesis(TTC)via lateral transfibular approach in the treatment of severe ankle and subtalar diseases.Methods Eighteen patients treated with TTC via lateral transfibular approach from January 2015 to December 2017 were retrospectively analyzed.There were 11 males and 7 females from 39 to 76 years old,with an average age of 53.4 years.Preoperative diagnoses included traumatic arthritis(3 cases),osteoarthritis(10 cases),talar necrosis(3 cases),failure of ankle fusion(1 case)and Charcot-Marie-Tooth disease(1 case).Ankle and hindfoot deformity included varus(10 cases),valgus(6 cases),equinus(1 case)and equinovarus(1 case).All cases were classified into stage-3 arthritis according to Morrey-Wiedeman classification.All patients sustained pain and stiffness in the ankle and hindfoot as well as walking dysfunction.Preoperative and 1 year postoperative visual analogue scale(VAS)and American Orthopaedic Foot and Ankle Society(AOFAS)ankle-hindfoot scale were collected.Postoperative joint fusion and complications were observed.Results Follow-up ranged from 12-47 months,averaging 25.4 months.Preoperative VAS scores were 6-9,averaging 7.1±1.0,while postoperative VAS scores at 1 year follow-up were 0-2,averaging 0.9±0.8,which decreased significantly.Preoperative AOFAS scores were 24-59,averaging 40.6±11.5,while postoperative AOFAS scores at 1 year follow-up were 68-84,averaging 75.3±5.8,which increased significantly.8 cases were good and 10 cases were fair according to AOFAS scores at 1 year follow-up.The excellent and good rate was 44.4%(8/18).All joints were fused successfully without implants loosening or breakage.All patients satisfied with operative results at 1 year follow-up.Lateral distal wound dehiscence happened in 1 case of traumatic arthritis and the wound was finally healed after debridement and vacuum assisted closure(VAC).Two cases of osteoarthritis presented with dorsal lateral foot numbness and became asymptomatic after neurotrophic medication.One case of osteoarthritis complained of discomfort in the lateral heel caused by implants prominence and implants were removed at 1 year after surgery.Postoperative complication rate was 22.2%(4/18).Conclusion TTC via lateral transfibular approach with cannulated screws and locking plate system is safe and effective.Joint fusion rate is high and complication rate is low.During operation,attention should be paid to restoring hindfoot alignment,soft tissue balance,proper bone graft and joint compression.