外侧合页骨折对踝上截骨术早期疗效的影响及危险因素分析

Influence and risk factors of lateral hinge fracture on early effectiveness of supramalleolar osteotomy

目的评估外侧合页骨折(lateral hinge fracture,LHF)对踝上截骨术(supramalleolar osteotomy,SMO)早期疗效的影响,并探究导致其产生的相关危险因素。方法回顾分析2016年1月—2022年12月收治且符合选择标准的39例(39足)采用SMO治疗的踝内翻性骨关节炎患者。其中男10例,女29例;年龄41~71岁,平均57.7岁。Takakura分期:Ⅱ期6足,Ⅲa期19足,Ⅲb期14足。依据术后即刻X线片判断外侧合页位置是否并发LHF,比较发生与未发生LHF患者的截骨愈合时间及疼痛视觉模拟评分(VAS)、美国矫形足踝协会(AOFAS)评分、胫骨关节面角(tibial anterior surface angle,TAS)、胫骨外侧面角(tibial lateral surface angle,TLS)和距骨倾斜角(tibiotalar angle,TT)手术前后变化值。对发生与未发生LHF患者的年龄、性别、侧别、身体质量指数、Takakura分期、术前VAS评分、术前AOFAS评分、术前TAS、术前TLS、术前TT、SMO矫正角、截骨撑开量、截骨处内侧至踝关节线距离(distance from medial osteotomy to ankle joint line,MD)、截骨处外侧至踝关节线距离(distance from lateral osteotomy to ankle joint line,LD)等变量进行单因素分析,并进一步采用logistic回归分析筛选SMO术中发生LHF的危险因素。结果患者均获随访,随访时间12~54个月,平均27.1个月。术中13足发生LHF(A组),26足未发生LHF(B组)。X线片复查示A组1例合并胫骨关节面劈裂骨折患者出现截骨延迟愈合,予以石膏固定后成功愈合;其余患者截骨均愈合,两组患者愈合时间比较差异无统计学意义(P>0.05)。末次随访时,两组患者VAS评分、AOFAS评分及TAS、TLS、TT与术前比较差异均有统计学意义(P<0.05),上述指标手术前后变化值两组间比较差异均无统计学意义(P>0.05)。单因素分析示,发生与未发生LHF患者的SMO矫正角、截骨撑开量和LD比较差异有统计学意义(P<0.05);进一步logistic回归分析示,LD过大是SMO术中发生LHF的危险因素(P<0.05)。结论SMO术中外侧合页位置过高或过低都可能导致LHF发生,采取合适治疗和康复方案,术后可获得与未发生LHF患者相似的早期疗效。

Objective To evaluate the influence of lateral hinge fracture(LHF)on the early effectiveness of supramalleolar osteotomy(SMO)and to explore the related risk factors for LHF.Methods A total of 39 patients(39 feet)with varus-type ankle osteoarthritis treated with SMO between January 2016 and December 2022 were analyzed retrospectively.There were 10 males and 29 females,aged from 41 to 71 years(mean,57.7 years).According to Takakura stage,there were 6 feet in stageⅡ,19 feet in stageⅢa,and 14 feet in stageⅢb.The LHF was recognized by the immediate postoperative X-ray film.The osteotomy healing time and the changes of pain visual analogue scale(VAS)score,American Orthopaedic Foot and Ankle Society(AOFAS)score,tibial anterior surface angle(TAS),tibial lateral surface angle(TLS),and tibiotalar angle(TT)before and after operation were compared between patients with and without LHF.The age,gender,affected side,body mass index,Takakura stage,preoperative VAS score,preoperative AOFAS score,preoperative TAS,preoperative TLS,preoperative TT,SMO correction angle,osteotomy distraction,distance from medial osteotomy to ankle joint line(MD),and distance from lateral osteotomy to ankle joint line(LD)were compared between with and without LHF patients,and further logistic regression analysis was used to screen the risk factors of LHF during SMO.Results All patients were followed up 12-54 months(mean,27.1 months).During operation,13 feet developed LHF(group A)and 26 feet did not develop LHF(group B).X-ray film reexamination showed that 1 patient in group A complicated with tibial articular surface cleft fracture had delayed osteotomy and healed successfully after plaster fixation;the osteotomy of other patients healed,and there was no significant difference in healing time between the two groups(P>0.05).At last follow-up,there were significant differences in VAS score,AOFAS score,TAS,TLS,and TT of the two groups when compared with preoperative ones(P<0.05),but there was no significant difference in the changes of above indicators before and after operation between the two groups(P>0.05).The differences in SMO correction angle,osteotomy distraction,and LD between with and without LHF patients were significant(P<0.05),and further logistic regression analysis showed that excessive LD was the risk factor of LHF during SMO(P<0.05).Conclusion Too high or too low lateral hinge position during SMO may lead to LHF,but as long as appropriate treatment and rehabilitation measurements are taken,the early effectiveness is similar to that of patients without LHF.