踝上截骨术治疗内翻型踝关节炎的有效性与危险因素分析

Effectiveness and risk factors of supramalleolar osteotomy in treatment of varus-type

目的 评价踝上截骨术(supramalleolar osteotomy,SMOT)治疗内翻型踝关节炎的临床疗效,分析其治疗失败的相关危险因素。方法 回顾分析2016年1月—2020年12月采用SMOT治疗的82例(89足)内翻型踝关节炎患者临床资料。男34例38足,女48例51足;年龄43~72岁,平均54.3岁。身体质量指数为20.43~30.15 kg/m^(2),平均24.43 kg/m^(2)。术前胫骨远端前侧关节面角(tibial articular surface angle,TAS)为77.6°~88.4°,平均84.4°。改良Takakura分期:Ⅱ期9足,Ⅲa期41足,Ⅲb期39足。采用Maryland评分、疼痛视觉模拟评分(VAS)、简明健康调查12条量表(SF-12量表)进行临床功能评估;影像学评估包括TAS、距骨倾斜角(talar tilt,TT)、胫骨踝穴角(tibiocrural angle,TC)、胫骨内踝角(tibial medial malleolars,TMM)、踝穴距离(tibiocrural distance,TCD)、胫骨远端外侧关节面角(tibial lateral surface angle,TLS)及后足力线角(hindfoot alignment angle,HAA)。统计临床失败、功能失败、影像学失败结果,并进行相关危险因素分析。结果 手术时间45~88 min,平均62.2 min。术中未发现骨折及神经、血管损伤等并发症。术后7足出现内侧切口愈合不良,使用外固定架患者中6足出现9处针道感染,同种异体骨和自体骨植骨患者中分别有20足和3足存在影像学骨吸收;除1足严重感染使用骨水泥旷置二期植骨外,余88足均一期骨愈合,且骨愈合面积均>80%。患者均获随访,随访时间24~82个月,平均50.2个月。末次随访时,患者Maryland评分、VAS评分、SF-12量表心理评分及生理评分以及TAS、TC、TLS、TCD、TT、TMM、HAA和Takakura分期均较术前显著改善(P<0.05)。术后发生临床失败13足、功能失败15足、影像学失败23足。单因素分析示,肥胖、TT>10°和Takakura Ⅲb期是临床失败的影响因素,HAA≥15°、Takakura Ⅲb期是功能失败的影响因素,TT>10°是影像学失败的影响因素,差异均有统计学意义(P<0.05);进一步行logistic回归分析示,TT>10°、HAA≥15°、TT>10°分别是临床失败、功能失败、影像学失败的危险因素(P<0.05)。结论 SMOT治疗内翻型踝关节炎中远期疗效肯定,然而对于肥胖、后足内翻严重、距骨倾斜严重以及Takakura Ⅲb期患者应谨慎使用。

Objective To assess the effectiveness of supramalleolar osteotomy(SMOT)as a therapeutic intervention for varus-type ankle arthritis,while also examining the associated risk factors that may contribute to treatment failure.Methods The clinical data of 82 patients(89 feet)diagnosed with varus-type ankle arthritis and treated with SMOT between January 2016 and December 2020 were retrospectively analyzed.The patient cohort consisted of 34 males with 38 feet and 48 females with 51 feet,with the mean age of 54.3 years(range,43-72 years).The average body mass index was 24.43 kg/m^(2)(range,20.43-30.15 kg/m^(2)).The preoperative tibial anterior surface angle(TAS)ranged from 77.60 to 88.4°,with a mean of 84.4°.The modified Takakura stage was used to classify the severity of the condition,with 9 feet in stage Ⅱ,41 feet in stage Ⅲa,and 39 feet in stage Ⅲb.Clinical functional assessment was conducted using the Maryland sore,visual analogue scale(VAS)score,and psychological and physical scores in Health Survey 12-item Short From(SF-12).Radiology evaluations include TAS,talar tilt(TT),tibiocrural angle(TC),tibial medial malleolars(TMM),tibiocrural distance(TCD),tibial lateral surface angle(TLS),and hindfoot alignment angle(HAA).The results of clinical failure,functional failure,and radiology failure were statistically analyzed,and the related risk factors were analyzed.Results The operation time ranged from 45 to 88 minutes,with an average of 62.2 minutes.No complication such as fractures and neurovascular injuries was found during operation.There were 7 feet of poor healing of the medial incision;9 pin tract infections occurred in 6 feet using external fixator;there were 20 cases of allograft and 3 cases of autograft with radiographic bone resorption.Except for 1 foot of severe infection treated with bone cement,the remaining 88 feet were primary healing,and the healing area was more than 80%.All patients were followed up 24-82 months,with an average of 50.2 months.Maryland score,VAS score,SF-12 psychological and physiological scores,and TAS,TC,TLS,TCD,TT,TMM,HAA,and Takakura stage were significantly improved at last follow-up(P<0.05).Postoperative clinical failure occurred in 13 feet,functional failure in 15 feet,and radiology failure in 23 feet.Univariate analysis showed that obesity,TT>10°,and Takakura stage Ⅲb were risk factors for clinical failure,HAA≥15°and Takakura stage Ⅲb were risk factors for functional failure,and TT>10°was risk factor for radiographic failure(P<0.05).Further logistic regression analysis showed that TT>10°,HAA≥15°,and TT>10°were risk factors for clinical failure,functional failure,and radiographic failure,respectively(P<0.05).Conclusion SMOT is effective in the mid-and long-term in the treatment of varus-type ankle arthritis,but it should be used with caution in patients with obesity,severe hindfoot varus,severe talus tilt,and preoperative Takakura stage Ⅲb.