第1跖列稳定术联合第2-5跖骨头切除术治疗晚期类风湿关节炎前足畸形

目的:介绍第1跖列稳定联合第2-5跖骨头切除术治疗晚期类风湿关节炎(rheumatoid arthritis,RA)前足畸形的手术方式并对中短期临床疗效进行评价。方法:2006年10月至2010年8月收治的晚期RA前足畸形97例患者进行回顾性分析。其中,男9例,女88例;单足65例,双足32例;年龄36～67岁,平均54岁;病程6～32年,平均17年。所有病例存在严重的拇外翻同时合并第1跖跗关节不稳,第2-5跖趾关节脱位及僵硬。采用第1跖列稳定联合第2-5跖趾关节成形术对其进行治疗。通过影像学资料测量拇外翻角(Hallux valgus angle,HVA),跖骨间角(intermetatarsal angle,IMA),并采用JSSF(Japanese Society for Surgery of the Foot)评分对临床疗效进行评估。结果:97例患者中失访5例(7足),平均随访37个月(6～52个月),其中1例术后1年因急性心肌梗死死亡。术前JSSF评分(33.2±8.2)分,末次随访时改善至(67.3±3.1)分(P<0.01);HVA由术前(50.0±11.8)°纠正至术后(21.2±3.2)°(P<0.01);IMA由术前(15.5±3.6)°纠正至术后(9.7±6.6)°(P<0.01)。发生跖趾关节骨不连4足;术后8～11月摄片发现第1楔骨内高密度改变3足;出现拇内侧切口延迟愈合9足;跖趾关节内固定感染2足;跖跗关节内固定感染1足;第2-5跖趾关节术后16足畸形复发。结论:晚期RA患者的前足病变涉及范围广,畸形严重。采用第1跖趾关节融合联合Lapidus术式重建第1跖列的外形及稳定性,跖骨头切除术纠正第2-5跖趾关节畸形的方式重建前足疗效可靠。该术式适用于重度拇外翻合并IMA增大及第1跖跗关节不稳,同时存在第2-5跖趾关节僵硬性半脱位的患者。

Clinical result of forefoot correction by the first ray stabilization combined with resection of the lesser metatarsal head procedure for patient with rheumatoid arthritis

Objective:To introduce the procedure of the 1st ray stabilization combined with resection of the lesser metatarsal heads for patient with severe forefoot deformity caused by rheumatoid arthritis(RA) and evaluate the short to mid-term clinical results. Methods:From Oct. 2006 to Aug. 2010,97 patients (129 feet) aged from 36 to 67 years (average 54),with forefoot deformity caused by rheumatoid arthritis were reviwed. There were 88 males and 9 females,65 single lateral involved and 32 bilateral involved,the average duration of disease was 17 years (6 to 32 years). The 1st ray instability and lesser metatarsophalangeal (MTP) joint stiff dislocation were found in all cases. The first ray stabilization combined with resection of the lesser metatarsal head procedure were performed for all cases. The radiographic Hallux valgus angle(HVA) and intermetatarsal angle (IMA) were measurde and the JSSF (Japanese Society for Surgery of the Foot) score were evaluated before operation and every follow up. Results:The average followed-up was 37 months(6 to 52 months) for all patients except 5 (7 feet) and 1 died for acute cardiac infarction 1 year after operation. The average JSSF score improved from(33.2±8.2) points preoperative to (67.3±3.1) points at final followed-up (P < 0.01); the average HVA was corrected from (50.0±11.8)° preoperative to (21.2±3.2)° at final follow up (P < 0.01);the average IMA was corrected from (15.5±3.6)° preoperative to (9.7±6.6)° at final follow up(P < 0.01). MTP joint nonunion was found in 4 feet. A radiographic high density mass was found in the 1st cuneiform bone during 8 to 11 months followed-up in 3 feet;delayed wound healing was happened in 9 feet;MTP joint infection was happened in 2 feet;tarsometatarsal joint infection was happened in 1 foot;lesser MTP joints deformity recurrence were found in 16 feet. Conclusion:The characters of forefoot with RA in later stage are the 1st ray deformity and instability compound with the lesser toes deformity. The 1st ray stability procedure which include the 1st MTP arthrodesis and the Lapidus procedure can correct the 1st ray deformities and rebuilt its stability. The lesser toes metatarsal head resection is effective in correct their deformity. This combined procedure is reliable. It is suitable for patients with severe Hallux valgus,increased IMA,tarsometatarsal joint instability and the lesser MTP joint stiff dislocation.