合并距骨副关节突撞击综合征的成人获得性平足症的治疗体会

The treatment for adult acquired flatfoot deformity combined with accessory talar facet impingement:a retrospective study

目的 本研究探讨了关节镜辅助下关节突切除联合韧带和骨平衡重建治疗持续性跗骨窦疼痛的成人获得性平足症患者的临床疗效。方法 2015年4月至2021年6月,宜昌市中心人民医院纳入了27例合并距骨副关节突撞击综合征(accessory talar facet impingement,ATFI)成人获得性平足症患者(年龄19~67岁,Ⅱ~Ⅳ期),所有患者经MRI证实了距骨前外侧副关节(accessory anterolateral talar facet,AALTF)的存在及距骨和跟骨颈的局灶性骨髓水肿(focal abutting bone marrow edema,FABME)。根据接受的手术方式不同分为两组,A组采取关节镜辅助下行AALTF切除联合韧带和骨平衡重建治疗,B组不处理AALTF,仅采取韧带和骨平衡重建治疗平足。比较两组患者术前和术后的影像学参数变化:足正位距跟角(anteroposterior talocancaneal angle,APTC)、足正位距骨-第一跖骨角(anteroposterior talocancaneal angle,APTMT)、足正位距舟覆盖角(talonavicular coverage angle,TNC)、足侧位距骨第一跖骨角(lateral talo-first metatarsal angle,LTMT)、后足力线位胫跟角(tibio-calcaneal angle,TB-C)。采用美国足踝外科协会(American Orthopaedic Foot and Ankle Sosiety,AOFAS)评分评估术后足部功能的改善情况。结果 本研究中平均末次随访时间为9.23(6~11)个月。关节镜组中,约37%的患者存在AALTF软骨表面有局灶性缺损,84%的患者存在后关节囊韧带松弛。末次随访时,A组的AOFAS评分术后改善显著(93.6 vs 81.6分,P <0.01),影像学参数A组与B组对比差异无统计学意义(P> 0.05)。结论 成人获得性平足症患者的跗骨窦区疼痛多伴有ATFI,对于此类患者,应积极处理距骨前外侧副关节突,这样能更好地改善患者术后症状。

Objective To the clinical effect of arthroscopic assisted facet arthroplasty combined with ligament and bone balance reconstruction in the treatment of adult acquired flatfoot patients with persistent tarsal sinus pain.Methods From April 2015 to June 2021,Yichang Central People's Hospital included 27 patients with adult acquired flatfoot syndrome(age 19~67 years,stageⅡ~Ⅳ)with accessory talar facet impingement(ATFI).All patients were confirmed by MRI to have the presence of the anterior lateral talar facet(AALTF)and focal bone marrow edema of the talus and calcaneal neck.They were divided into two groups according to the different operations.Group A was treated with arthroscopic assisted AALTF resection combined with ligament and bone balance reconstruction.Group B was not treated with AALTF,but only with ligament and bone balance reconstruction.The changes of imaging parameters before and after the operation were compared between the two groups anteroposterior talocancaneal angle(APTC),anteroposterior talocancaneal angle(APTMT),talonavicular coverage angle(TNC),lateral talo-first metatarsal angle(LTMT),tibio-calcaneal angle(TB-C).The American Orthopaedic Foot And Ankle Surgery(AOFAS)score was used to evaluate the improvement of foot function after operation.Results The average last follow-up time in this study was 9.23(6~11)months.In the arthroscopic group,about 37%of patients had focal defects on the surface of AALTF cartilage,and 84%of patients had posterior capsular ligament relaxation.At the last follow-up,the AOFAS score of group A improved significantly after operation(93.6 vs 81.6,P<0.01).There was no significant difference in imaging parameters between group A and group B(P>0.05).Conclusion The pain in the tarsal sinus region of adult acquired flatfoot patients is often accompanied by ATFI.For such patients,the anterolateral accessory process of the talus should be actively treated,which can better improve the postoperative symptoms of the patients.