牵张成形术治疗中重度踝关节炎中远期疗效分析

Mid-and long-term effectiveness analysis of distraction arthroplasty in treatment of moderate to severe ankle arthritis

目的 探讨外固定支架牵张成形术治疗中重度踝关节炎的中远期临床疗效。方法 回顾性分析2007年1月—2019年11月符合选择标准的23例行外固定支架牵张成形术治疗的中重度踝关节炎患者临床资料。男20例,女3例;年龄21~65岁,平均43.7岁。病因:原发性踝关节炎8例,5例伴有内翻畸形;创伤性踝关节炎15例,致伤原因:踝关节骨折术后5例,Pilon骨折术后3例,慢性踝关节不稳反复扭伤5例,其他原因2例。踝关节炎Takakura分期:ⅢA期4例,ⅢB期12例,Ⅳ期7例;Giannini分期:Ⅱ期5例,Ⅲ期18例;Cheng分期:Ⅲ期16例,Ⅳ期7例。术前及末次随访时采用美国矫形足踝协会(AOFAS)踝-后足评分及疼痛视觉模拟评分(VAS)评价踝关节疼痛和功能改善情况,并按不同病因分组进行分析;末次随访时,患者对疼痛情况进行主观及客观评估;比较术前及末次随访时踝关节间隙变化。根据年龄将患者分成年龄≤45岁组[青年组,10例,年龄(35.62±7.41)岁]和>45岁组[中老年组,13例,年龄(54.20±6.20)岁],比较手术前后AOFAS踝-后足评分和VAS评分,分析年龄对牵张成形术的影响。结果 外固定支架持续牵张3个月后拆除。术后12例患者出现钉道感染。23例患者均获随访,随访时间13~143个月,平均56.9个月;青年组和中老年组随访时间分别为(43.46±32.77)个月和(69.80±37.79)个月。末次随访时,AOFAS踝-后足评分及VAS评分均较术前显著改善(P<0.05);按病因分析,除Pilon骨折术后患者AOFAS踝-后足评分及VAS评分与术前比较差异无统计学意义(P>0.05)外,其余患者手术前后两评分差异均有统计学意义(P<0.05)。青年组和中老年组术前AOFAS踝-后足评分差异有统计学意义(t=2.110,P=0.040);两组术前VAS评分以及AOFAS踝-后足评分、VAS评分手术前后差值比较,差异均无统计学意义(P>0.05)。末次随访时患者主观及客观疼痛评价示,无疼痛4例、疼痛中度缓解12例、疼痛轻度缓解5例、疼痛无明显缓解2例;10例随访5年以上患者分别为2、5、2、1例;2例获10年以上随访患者均为疼痛中度缓解。末次随访时患者踝关节间隙为(3.7±0.4)mm,较术前(1.5±0.2)mm明显增加,差异有统计学意义(t=1.791,P=0.002);10例随访5年以上患者踝关节间隙为(2.9±0.5)mm,2例获10年以上随访患者分别为3.3 mm和3.0 mm。结论 外固定支架牵张成形术治疗中重度踝关节炎(Pilon骨折术后引发的关节炎除外)可获得较满意疗效,而且年龄对牵张成形术疗效无明显影响。

Objective To investigate the mid-and long-term effectiveness of external fixator distraction arthroplasty in the treatment of moderate to severe ankle arthritis.Methods The clinical data of 23 patients with moderate to severe ankle arthritis treated with external fixation distraction arthroplasty who met the selection criteria between January 2007 and November 2019 were retrospectively analyzed.There were 20 males and 3 females;the age ranged from 21 to 65 years,with an average age of 43.7 years.Etiology included 8 cases of primary ankle arthritis,in which5 cases combined with varus deformity;15 cases of traumatic ankle arthritis,the cause of injury was 5 cases after ankle fracture surgery,3 cases after Pilon fracture surgery,5 cases of chronic ankle instability and repeated sprain,and 2 cases of other causes.According to Takakura staging system,there were 4 cases of stage ⅢA,12 cases of stage ⅢB,and 7 cases of stage Ⅳ;according to Giannini staging system,there were 5 cases of stage Ⅱ and 18 cases of stage Ⅲ;according to Cheng staging system,16 cases were in stage Ⅲ,and 7 cases stage Ⅳ.American Orthopaedic Foot and Ankle Society(AOFAS)ankle-hindfoot score and visual analogue scale(VAS) score were used to evaluate the improvement of ankle pain and function before operation and at last follow-up,and the data were analyzed according to different etiological groups.At last follow-up,the surgical results were evaluated subjectively and objectively.The changes of ankle joint space before operation and at last follow-up were compared.The patients were divided into two groups according to their age:≤45years old group [young group,10 cases,aged(35.62±7.41) years old] and >45 years old group [middle-aged and elderly group,13 cases,aged(54.20±6.20) years old].The AOFAS ankle-hindfoot score and VAS score were compared before and after operation between the two groups,and the influence of age on distraction arthroplasty was analyzed.Results The external fixator was removed after 3 months of continuous distraction,12 patients got infection around the wire tunnels.All the 23 patients were followed up 13-143 months,with an average of 56.9 months;the follow-up time was(43.46±32.77)months and(69.80±37.79) months in the young group and middle-aged and elderly group,respectively.At last follow-up,the AOFAS ankle-hindfoot score and VAS score significantly improved when compared with those before operation(P<0.05).According to etiological analysis,there was no significant difference in AOFAS ankle-hindfoot score and VAS score before and after operation(P>0.05) in Pilon fracture patients,while the significant difference was found in remaining patients(P<0.05).There was significant difference in AOFAS ankle-hindfoot score before operation between the young group and the middle-aged and elderly group(t=2.110,P=0.040),but no significant difference in preoperative VAS score and the differences in VAS score and AOFAS ankle-hindfoot score before and after operation between the two groups(P>0.05).The subjective and objective results of pain evaluation at last follow-up showed that 4 patients had no pain,12 patients had moderate pain relief,5 patients had mild pain relief,and 2 patients had no significant pain relief;among the 10 patients who were followed up more than 5 years,there were 2,5,2,and 1 patient,respectively;2 patients who were followed up more than 10 years had moderate pain relief.At last follow-up,the ankle joint space was(3.7±0.4) mm,which significantly increased when compared with before operation [(1.5±0.2) mm](t=1.791,P=0.002).The ankle joint space was(2.9±0.5)mm in 10 patients who were followed up more than 5 years,and 3.3 mm and 3.0 mm in 2 patients who were followed up more than 10 years.Conclusion Distraction arthroplasty of the ankle joint can achieve satisfactory results in patients with moderate to severe ankle arthritis(except for arthritis caused by Pilon fracture),and age has no significant effect on distraction arthroplasty.