终末期踝及距下关节病胫距跟融合两种固定比较

Comparison of two internal fixations in tibiotalocalcaneal arthrodesis for end-stage ankle and subtalar arthropathy

[目的]比较全螺纹无头加压螺钉与髓内钉胫距跟融合术(tibiotalocalcaneal arthrodesis,TTCA)治疗终末期踝及距下关节病的临床疗效。[方法]回顾性分析2018年—2022年本院采用TTCA治疗的52例(52足)患者。根据医患沟通结果,28例采用全螺纹无头加压螺钉固定(螺钉组),24例采用髓内钉固定(髓内钉组)。比较两组患者围手术期、随访及影像学资料。[结果]所有患者均顺利完成手术。两组患者在手术时间、切口总长度、术中失血量、术中透视次数、下地行走时间、切口愈合、皮神经损伤、住院时间方面差异均无统计学意义(P>0.05)。两组患者均获随访12个月以上,螺钉组完全负重时间显著早于髓内钉组[(125.7±38.9)d vs(149.2±23.6)d,P=0.013]。与术前相比,两组患者末次随访时VAS评分均显著减少(P<0.05),与术后3个月相比,末次随访时,两组AOFAS评分显著增加(P<0.05)。螺钉组AOFAS评分术后3个月和末次随访时均显著优于髓内钉组[(61.5±4.8)vs(57.3±7.0),P=0.015;(75.2±6.7)vs(70.7±8.5),P=0.036]。影像方面,与术前相比,末次随访时两组胫跟角(tib⁃iocalcaneal angle,TCA)、跟骨偏移(calcaneal offset,CO)、侧位内侧足弓角(internal arch angle,IAA)均显著减小(P<0.05),相应时间点,两组上述影像指标的差异无统计学意义(P>0.05)。螺钉组影像关节融合时间显著早于髓内钉组(P<0.05)。[结论]相较髓内钉,全螺纹无头加压螺钉行TTCA在AOFAS评分、完全负重时间及关节面融合情况方面取得了更好的效果,是一种治疗终末期踝及距下关节病的较好方法。

[Objective]To compare the clinical outcomes of the fully threaded headless compression screws(FTCS)versus intramedullary nails(IMN)used as internal fixations in tibiotalocalcaneal arthrodesis(TTCA)for end-stage ankle and subtalar arthropathy.[Methods]A retrospective study was conducted on 52 patients(52 feet)who received TTCA for end-stage ankle and subtalar osteoarthritis in our hospital from 2018 to 2022.Based on the preoperative patient-doctor discussion,28 patients had tibiotalocalcaneal joints fixed with multiple FTCSs,while the remaining 24 patients were fixed with IMN.The documents regarding to perioperative period,follow-up and images were compared between the two groups.[Results]All the patients in both cohorts had TTCA performed successfully,without statistically significant differences between the two groups in terms of operation time,total length of incision,intraoperative blood loss,number of intraoperative fluoroscopy,ambulation time,incision healing grade,ratio of percutaneous nerve injury,and hospital stay(P>0.05).The follow-up period lasted for more than 12 months,and the FTCS group resumed full weight-bearing activity significantly earlier than the IMN group[(125.7±38.9)days vs(149.2±23.6)days,P=0.013].The VAS scores significantly decreased at the last follow-up compared with that preoperatively(P<0.05),while the AOFAS scores significantly increased at the last follow-up compared with that 3 months postoperatively in both groups(P<0.05).The FTCS group proved significantly superior to the IMN group in term of AOFAS score 3 month postoperatively and at the latest follow-up[(61.5±4.8)vs(57.3±7.0),P=0.015;(75.2±6.7)vs(70.7±8.5),P=0.036].As for imaging,the tibiocalcaneal angle(TCA),calcaneal offset(CO)and internal arch angle(IAA)significantly improved in both groups at the latest follow-up compared with those preoperatively(P<0.05),whereas which were not statistically significant between the two groups at any time points accordingly(P>0.05).However,the FTCS group got bony fusion on images significantly earlier than the IMN group(P<0.05).[Conclusion]The FTCS achieved considerably better outcome in terms of AOFAS scores,time to regain full weight bearing activity,and bony fusion time on images over the IMN for end-stage ankle and subtalar arthropathy in this paper.