关节镜和开放性手术治疗跖筋膜炎型顽固性跟痛症的疗效比较

Open plantar fasciotomy versus arthroscopic approach for recalcitrant calcaneodynia

目的对比分析关节镜和开放性手术在跖筋膜炎型顽固性跟痛症中的临床应用价值和效果。方法回顾性分析2013年5月至2017年10月东部战区总医院(原八一医院)骨科收治且有完整随访资料的47例(51足)经过保守治疗无效行跖筋膜松解+跟骨骨刺切除的跖筋膜炎型顽固性跟痛症患者的临床资料。根据手术方式分为关节镜组(28例,31足)和开放手术组(19例,20足)。统计术后1、3、6个月和1年随访结果,对比2组患者的手术时间、住院时间和伤口持续渗出时间,并观察2组患者的伤口延迟愈合和伤口感染情况;比较2组患者术前以及术后1、3、6个月和1年时“第一步”VAS疼痛评分和美国足踝外科协会后足评分(AOFAS-AH);统计2组患者近期疗效(术后1个月)和远期疗效(术后6个月),比较2组有效率。结果开放手术组较关节镜组住院时间[(8.8±0.7)d vs(4.5±0.5)d]和伤口持续渗出时间[(3.2±0.5)d vs(1.5±0.4)d]更长,差异均有统计学意义(P<0.05)。开放手术组出现伤口延迟愈合3例,伤口感染1例,足部麻木3例;关节镜组出现足部麻木2例,未出现伤口延迟愈合和伤口感染。术前2组患者的“第一步”VAS疼痛评分差异无统计学意义(P>0.05);术后1、3、6个月和1年时,2组患者的“第一步”VAS疼痛评分与术前比较差异均有统计学意义(P<0.05);关节镜组术后1个月的“第一步”VAS疼痛评分明显低于开放手术组(P<0.05);但2组患者术后3、6个月和1年时的“第一步”VAS疼痛评分差异无统计学意义(P>0.05)。术前2组患者的AOFAS评分比较差异无统计学意义(P>0.05);术后1个月时,开放手术组的AOFAS评分较术前无明显变化,而关节镜组的AOFAS评分明显高于术前(P<0.05);术后3、6个月和1年时,2组患者的AOFAS评分均明显高于术前(P<0.05);术后1、3个月时,关节镜组的AOFAS评分明显优于开放手术组(P<0.05),但在术后6个月和1年时,2组患者的AOFAS评分差异无统计学意义(P>0.05)。开放手术组术后1个月有效率明显低于关节镜组(75.0%vs 93.5%,P<0.01),但2组术后6个月有效率比较差异无统计学意义(70.0%vs 77.4%,P>0.05)。结论关节镜手术治疗跖筋膜炎型顽固性跟痛症安全有效,且在疼痛缓解时间、伤口渗出、早期功能恢复和近期临床疗效方面要明显优于传统开放性手术。

Objective To compare the clinical value and effect of arthroscopic and open surgery for the treatment of recalci trant calcaneodynia(plantar fasciitis type).Methods Clini cal data of 47 patients(51 feet)underwent surgery in Jin Ling Hospital from May 2013 to October 2017 were retrospectively an alyzed.By the surgical procedures,patients were divided into two groups:the incision group(19 patients,20 feet)and the ar throscopic group(28 patients,31 feet).The operation time,hospitalization time,continuous exudation time,delayed healing and wound infection of the two groups were compared at baseline and 1 month,3 months,6 months and 1 year after operation.The“first step”VAS pain score was used to assess the degree of pain in the weight of the two-legged weight.The American Foot and Ankle Surgery Association Foot Score(AOFAS-AH)was used to assess the functional status of the affected foot before and after treatment;By the efficacy criteria of plantar fasciitis,the short-term efficacy(1 month after surgery)and long-term efficacy(6 months after surgery)was assessed.Results The hospitalization time and the contin uous exudation time of incision group were longer than those of arthroscopic group[(8.8±0.7)d vs(4.5±0.5)d,(3.2±0.5)d vs(1.5±0.4)d],the differences were statistically significant(P<0.05).There were 3 cases of delayed wound healing,1 case of wound infec tion,and 3 cases of foot numbness in incision group.No delayed wound healing and wound infection,as well as 2 patients of foot numb ness occurred in the arthroscopic group.There was no significant difference in the“first step”VAS pain score between the two groups before surgery(P>0.05),and the score at 1 month,3 months,6 months,and 1 year after surgery in both the two groups were significant ly lower than that before surgery.At 1 month after surgery,the arthroscopic group was more effective in improving the pain of patients with plantar fasciitis heel pain than that of incision group(P<0.05).However,at 3 months,6 months,and 1 year follow-up,there was no significant difference in the“first step”VAS pain score between the two groups(P>0.05).There was no significant difference in the AOFAS score between the two groups before surgery(P>0.05).At 1 month postoperatively,the AOFAS score of the incision group was not significantly different from that of the preoperative(P>0.05),while the AOFAS score of the arthroscopic group was significantly higher than that of the preoperative(P<0.05);At 3 months,6 months and 1 year follow-up,the AOFAS scores of the two groups were significantly higher than those before surgery(P<0.05).At 1 month and 3 months after surgery,the AOFAS scores of the arthroscopic group were significantly better than those of the incision group(P<0.05),however,there was no significant difference in AOFAS scores between the two groups at 6 months and 1 year after surgery(P>0.05).At 1 month after the surgery,the effective rate of incision group was 75.0%,which was significantly lower than that of arthroscopic group(93.5%)(P<0.01).At 6 months after the surgery,the effec tive rate was 70.0%in incision group and 77.4%in the arthroscopic group,with no significant difference(P>0.05).Conclusion The arthroscopic approach can be safely and effectively treat recalcitrant calcaneodynia(plantar fasciitis type),and that the safety,pain relief time,wound exudation,early functional recovery and recent clinical efficacy is significantly better than that of the traditional open surgery.