关节镜下改良后踝入路切除治疗成人疼痛性跟距骨桥

目的探讨采用关节镜下改良后踝入路切除治疗成人疼痛性跟距骨桥的疗效。方法 2015年1月-2017年12月,采用后踝高位外侧观察入路结合低位内侧操作入路切除治疗9例成人疼痛性跟距骨桥。男6例,女3例;年龄19~30岁,平均24岁。2例无明确局部外伤,7例有足踝部扭伤病史。病程6~30个月,中位病程12个月。跟距骨桥Rozansky分型:Ⅰ型5例(5足),Ⅱ型2例(2足),Ⅲ型2例(2足)。患者既往无肢体功能障碍后遗症、无肢体关节手术史。术后随访复查踝关节正侧位X线片、踝关节CT。比较手术前后疼痛视觉模拟评分(VAS)及美国矫形足踝协会(AOFAS)踝-后足评分。结果患者手术时间60~90 min,平均76 min。术后患者均获随访,随访时间12~24个月,平均18个月。术后切口均Ⅰ期愈合,无感染、皮肤坏死、下肢深静脉血栓形成、血管神经及肌腱损伤、骨桥复发等并发症发生。术后踝关节功能恢复良好,疼痛明显缓解;患者于术后3~5个月,平均3.9个月重返工作岗位。末次随访时VAS评分为(0.7±0.5)分,与术前(4.2±0.5)分比较差异有统计学意义(t=20.239,P=0.000);AOFAS踝-后足评分为(94±4)分,与术前(62±2)分比较差异有统计学意义(t=–27.424,P=0.000),末次随访时获优7例,良2例。结论后踝高位外侧观察入路结合低位内侧操作入路显露跟距骨桥更直观,操作空间更大,操作过程更灵活,术中根据特定解剖标志程序化切除跟距骨桥,操作具有可行性。

Effectiveness of a modified posterior approach for arthroscopic resection on painful talocalcaneal coalition in adults

Objective To investigate the effectiveness of arthroscopic talocalcaneal coalition resection in painful adults via a modified posterior approach. Methods Between January 2015 and December 2017, 9 patients with painful talocalcaneal coalition accepted arthroscopic resection via the posterior malleolus high lateral observation approach combined with the lower medial operation approach. Of them, 6 were male and 3 were female, aged from 19 to 30 years(mean, 24 years). Among them, 2 cases had no definite local trauma and 7 cases had a history of sprain of foot and ankle.The disease duration ranged from 6 to 30 months, with a median of 12 months. Rozansky classification of talocalcaneal coalition for the 9 patients: 5 cases(5 feet) were type Ⅰ, 2 cases(2 feet) type Ⅱ, and 2 cases(2 feet) type Ⅲ. The patients had no sequelae of limb dysfunction and no limb joint surgery in the past. All the patients received anteroposterior and lateral X-ray films and CT scans of the ankle joint during follow-up. The visual analogue scale(VAS) score and American Orthopaedic Foot and Ankle Society(AOFAS) ankle-hind foot score were used to evaluate the effectiveness. Results The operation time was 60-90 minutes(mean, 76 minutes). All patients were followed up 12-24 months(mean, 18 months).All the incisions healed by first intention, without infection, skin necrosis, lower extremity deep vein thrombosis, vascular nerve and tendon injury, bone bridge recurrence, and other complications. The ankle function recovered well and the pain was relieved obviously after operation, and the patients returned to work at 3-5 months after operation, with an average of3.9 months. At last follow-up, the VAS score was 0.7±0.5, which was significantly improved(t=20.239, P=0.000) when compared with preoperative score(4.2±0.5);the AOFAS ankle-hind foot score was 94±4, which was significantly improved(t=-27.424, P=0.000) when compared with preoperative score(62±2). According to AOFAS ankle-hindfoot scoring system, the results were excellent in 7 cases and good in 2 cases at last follow-up. Conclusion It is more intuitive,more space, and more flexibility for operation via the modified posterior malleolus high lateral observation approach combined with the lower medial operation approach in talocalcaneal coalition. It is feasible to remove talocalcaneal coalition programmatically according to the specific anatomic signs during the operation.