不同踝上截骨术在内翻型踝关节骨关节炎外科治疗中的应用

目的 探讨采用不同的踝上截骨术治疗不同程度内翻型踝关节骨关节炎的临床疗效。方法 回顾性分析2012年4月—2016年4月西安交通大学附属红会医院足踝外科54例54足内翻型踝关节骨关节炎患者临床资料,其中男22例、女32例,年龄32~67(56.5±10.7)岁;左侧23例,右侧31例。根据改良Takakura踝关节骨关节炎分期,2期11例,3A期29例,3B期14例。均采用踝上截骨术治疗,其中传统踝上截骨27例、踝上斜形截骨21例、关节内截骨6例。术后均随访至少1年,通过对比末次随访与术前美国足踝骨科协会(AOFAS)踝与后足评分及踝关节骨关节炎量表(AOS)疼痛、功能评分进行临床疗效评估,在踝关节X线片上测量并比较手术前后胫骨前侧关节面角(TAS)、距骨倾斜角(TT)、胫骨踝穴角(TC)、胫骨内踝角(TMM)以及胫骨侧位关节面角(TLS)。结果 54例患者随访14～65个月,平均34.9个月。2例因术后疼痛和功能障碍行踝关节融合。术前相比,术后AOFAS评分明显提高(54.6±14.2)分和(83.7±9.8)分],AOS疼痛评分(43.6±6.4)分和(26.6±5.2)分]与功能评分(52.7±11.3)分和(35.4±10.3)分]较术前明显下降,差异均有统计学意义(P值均＜0.01)。59%(32/54)的患者Takakura分期较术前有改善。影像学评估除TLS外,TAS、TT、TC及TMM术后均较术前有明显改善(P值均＜0.01)。术前9例TT≥10°的患者中,有7例术后关节面协调性得到恢复。结论 根据不同程度内翻型踝关节骨关节炎的解剖学特征,选择合适的踝上截骨方式治疗,并辅助相应的术式来充分矫正力线和稳定关节,其临床疗效肯定。

Clinical application of different types supramalleolar osteotomy for varus ankle osteoarthritis

Objective To evaluate the anatomical variations and clinical application of supramalleolar osteotomy(SMOT). Methods From April 2012 to April 2016, 54 mid-staged varus ankle osteoarthritis patients were treated with SMOT and followed at least one year were included. Among them, 27 patients received traditional ankle osteotomy, 21 patients received oblique ankle osteotomy, and 6 patients received intra-articular osteotouly. Twenty-two males and 32 females with a mean age of 56.5 (range, 32-67) years. According to the modified Takakura ankle osteoarthritis stage, there were 11 stage-2, 29 stage-3A and 14 stage-3B. The American orthopedic foot and ankle society (AOFAS) ankle-hind score and Ankle Osteoarthritis Scale (AOS) were used for pre- and postoperative functional evaluation. The tibial anterior surface angle (TAS), talar tilt (TT), tibiocrural angle (TC), tibial medial malleolus angle (TMM), and tibial lateral surface angle (TLS) were evaluated pre- and postoperatively. Results The mean follow-up time was 34.9 (range, 14-65) months. Two cases with postoperative pain and dysfunction were treated with ankle fusion. At last follow-up time, the mean AOFAS score was improved (54.6±14.2 vs. 83.7±9.8, P<0.01). The mean AOS pain(43.6±6.4 vs. 26.6±5.2) and function scores(52.7±11.3 vs. 35.4±10.3) were decreased (all P values<0.01). For radiological evaluation, all of included parameters were improved (P<0.01) except TLS. The mean Takakura stage was improved in 59%(32/54) of cases. Of the 9 cases with preoperative TT≥10°, 7 cases were corrected to normal. Conclusions According to the anatomical characters of varus ankle OA, selection of different types of SMOT, also combined with appropriate joint stable procedures can reach promising clinical outcomes.