Weil截骨术与Jacopy截骨术治疗应力性跖痛症的临床疗效对比观察

背景：跖痛症是指发生于跖骨头下方的前足疼痛，可由解剖结构异常、病理性或医源性因素诱发。其病变主要是因为前足集中的局部应力负荷反复作用造成。治疗可分为保守治疗与手术治疗，对大部分跖痛症而言，采用保守治疗即可取得较好的疗效，若保守治疗无效，则可采取手术治疗，其目的是恢复前足正常的应力分布。目的：探讨跖骨远端weil截骨术与Jacoby截骨术治疗应力性跖痛症的临床疗效，从而为临床上更加合理有效的治疗跖痛症提供方法和依据。方法：2010年5月至2012年9月，我院收治应力性跖痛症患者65例，其中42例（63足）患者资料完整，得到随访，男8例（13足），女34例（50足）；年龄39～78岁，平均56-3岁。单侧11例，双侧31例；病变于第2跖骨头下24例，第3跖骨头下ll例，第2、3跖骨头下同时累及7例。合并跖趾关节脱位12例，跽外翻畸形16例，跖间神经瘤5例。所有病例随机分为A、B两组，A组19例（32足），B组23例（31足）。A组采用跖骨远端Weil截骨术、B组采用Jacoby截骨术治疗，经过平均18个月的随访，对手术前后局部疼痛症状、患者足底应力变化、足部功能改善情况进行比较分析。结果：两种手术前后疼痛缓解均有显著性差异，以Weil截骨组疼痛缓解更明显，但两组间疼痛缓解无明显统计学差异。两组患者手术前后患趾跖骨头下应力峰值明显下降。Weil截骨组，手术前后立位时和足跟抬高时的病变跖骨头下应力分别下降35％和51％；Jacoby截骨组分别下降25％,n45％。根据美国足踝外科协会Maryland跖趾关节百分评分法对两组患者进行评定：优，A组24足（占75％），B组22足（占71％）；良，A组6足（占18．8％），B组5足（占16．1％）；可，A组2足（占6．2％），B组4足（占12．9％）。A组优良率为93．8％，B组为87．1％。结论：对于应力性跖痛症患者，跖骨远端Weil截骨术与Jacoby截骨术治疗均可取得满意确切的效果。但weil截骨术手术操作技巧要求更高，Jacoby截骨术对初学者更易掌握。临床需要根据患者的实际情况及个体需求灵活选择。

A comparison of therapeutic effect between Weil osteotomy and Jacoby osteotomy for stress metatarsalgia

Background： Metatarsalgia is a kind of forefoot pain originating from the bottom of metatarsal head. The lesion is commonly caused by overloading local stress on forefoot from abnormal anatomy, pathological or iatrogenic factors. It can be treated by conservative and surgical means. For most of metatarsalgia, conservative treatment can obtain good curative effect. Howev- er, if conservative treatment is invalid, surgical treatment can be applied to restore the normal stress distribution on forefoot. Objective： To compare clinical outcomes of distal Weil osteotomy and Jacoby osteotomy in treatment of stress metatarsalgia so as to treat this disease reasonably and effectively. Methods： From May 2010 to September 2012, 65 stress metatarsalgia patients were treated in our hospital. Complete data of follow-up were obtained from 42 cases of them. There were 8 males （13 feet） and 34 females （50 feet） with mean age of 56.3 years （range, 39-78 years）. One foot was affected in 11 cases and two feet in 31 cases. The lesions were located at the bottom of the second metatarsal head in 24 cases, under the third metatarsal head in 11 cases, and both under the second and third head in 7 cases. Complications were as follows： dislocation of metatarsophalangeal joint in 12 cases, hallux valgus in 16 cases, and Morton neuroma in 5 cases. All the patients were randomly divided into group A （19 cases treated by distal Weil osteotomy, 32 feet） and group B （23 cases treated by Jacoby osteotomy, 31 feet）. Pain relief, footplate stress distribu- tion and foot function recovery were compared between the two methods during an average follow-up of 18 months.Results： Pain was significantly decreased after both surgical methods, but there was no significant difference in pain relief between two groups. Stress peak under the metatarsal head significantly reduced after treatment for all patients. The stress was decreased by 35% and 51% when the patients stood and the heels were raised after Weil osteotomy, respectively, while the stress decreased by 25% and 45% after Jacoby osteotomy. According to the American Association of Foot and Ankle Surgery （AOFAS） Maryland rating systems, excellent result in 24 feet in group A （75%） and 22 feet in group B （71%）, good in 6 feet in group A （18.8%） and 5 feet in group B （16.1%）, fair in 2 feet in group A （6.2%） and 4 feet in group B （12.9%）. The excellent and good rate was 93.8% in group A and 87.1% in group B. Conclusions： Both distal Weil metatarsal osteotomy and Jacoby osteotomy can achieve satisfactory therapeutic effect in pa- tients with stress metatarsalgia. Operative technique is a little complicated for Weil osteotomy. Therefore, Jacoby osteotomy is fit for beginners. Individualized treatment should be applied according to patient＇s condition and requirements.