距下关节融合术治疗粉碎性跟骨关节内骨折预后的临床研究

目的通过观察距下关节融合术治疗严重跟骨关节内粉碎性骨折的临床预后,探讨该手术适应证及优、缺点。方法1999年10月～2004年6月,对69例78足严重跟骨关节内粉碎性骨折患者进行距下关节融合术,采取跟骨外侧手术入路,取自体松质骨植骨距下关节融合。结果58例65足获得随访,随访时间8～31个月,平均19.8个月。术后根据美国足踝学会HindfootScores评分:优良率达到87.69%。结论自体松质骨植骨距下关节融合术是治疗跟骨关节内粉碎性骨折的一种有效方法,能恢复后足外形及功能,但不能完全缓解后足疼痛。     

Arthroscopic Subtalar Arthrodesis: The Posterior Approach in the Prone Position

Arthroscopic subtalar arthrodesis, as reported by Tasto, is done in the lateral decubitus position, and the portal sites are lateral. This report describes a new alternative method in which the patient is in the prone position and a posterior 2-portal approach is used, as described by van Dijk et al. The initial debridement and synovectomy are performed with 4- and 5-mm resectors. Debridement and decortication are done posterior to the interosseous ligament because only the posterior facet is fused. Denudation of the articular surfaces is performed with curettes, as well as 4.5- and 5.5-mm burs, to remove 2 mm of subchondral bone. Stabilization in 5° of hindfoot valgus is accomplished with 2 percutaneous cannulated headless screws from the non–weight-bearing portion of the calcaneal tuberosity directed to a point 5 to 10 mm posterior to the anterior margin of the posterior facet. The advantages of this alternative treatment are better intra-articular visualization, more thorough preparation of the fusion site, and minimal bone removal of the lateral side with better control of the arthrodesis position and with less chance of malunion, as well as the possibility to perform a concomitant surgical fusion or debridement of the ankle joint during the same operative procedure with no need for additional portals or orientation.     

小切口经皮空心螺钉内固定行距下关节融合术治疗距下关节炎

目的 探讨单纯小切口经皮空心螺钉内固定行距下关节融合术治疗距下关节炎的临床疗效.方法 2006年1月至2009年12月对26例(27足)保守治疗6个月以上无效的距下关节炎患者行距下关节融合治疗,男13例,女13例;平均年龄38.7岁(26～73岁);左侧11足,右侧16足.其中创伤性关节炎16例16足,类风湿关节炎6例7足,骨关节炎4例4足.术前平均病程8.3个月(6～25个月).手术采用外侧约4 cm切口,通过经皮穿针平行钻入2枚空心螺钉予以固定.术前和末次随访时采用视觉模拟法(VAS)疼痛评分和美国足踝外科协会(AOFAS)踝与后足评分分别对疼痛和功能进行评估.同时采用X线摄片和CT扫描进行影像学评估. 结果 26例患者术后获平均18 5个月(6～47个月)随访.术前与末次随访时VAS疼痛评分分别为(6.9±0.7)、(1.5±0.3)分,差异有统计学意义(t=17.000,P=0.000);AOFAS踝与后足评分分别为(54.3±12.1)、(82.6±11.3)分,差异有统计学意义(t=6.308,P=0.000).术后X线片或CT示26例患者全部获骨性融合,平均融合时间为10.8周(10～14周). 结论 小切口经皮穿针空心螺钉内固定行距下关节融合术治疗距下关节炎具有创伤小、恢复快、并发症少等优点,易于推广.     

A Posterior 3-Portal Arthroscopic Approach for Isolated Subtalar Arthrodesis

Arthroscopic subtalar arthrodesis was developed to improve on open methods of fusion. A posterior 3-portal arthroscopic approach with the patient in the prone position provides a new and optimal method for isolated subtalar arthrodesis. It facilitates safe access to the posterior talocalcaneal facet. The posterolateral portal was established using blunt dissection. The 3-mm, 30° arthroscope was inserted, the posterolateral portal was made, and synovectomy carried out. A large 4-mm arthroscope was used to improve fluid flow. The third portal was then established approximately 1 cm proximal and 1 cm posterior to the tip of the lateral malleolus. This portal was used for distraction by inserting a large blunt trocar into the joint. Most of the procedure was performed with the arthroscope in the posterolateral portal and the instruments posteromedial. Allograft was inserted through the posterolateral portal. Fixation was achieved using 2 cannulated 6.5- or 7.3-mm cancellous screws, inserted under fluoroscopic control. Postoperatively, patients were assigned to non-weight bearing cast immobilization with crutch ambulation for 6 weeks, followed by gradual weight bearing until radiographs showed union. Preliminary results have shown high patient satisfaction, an excellent fusion rate, and less postoperative morbidity than with open subtalar arthrodesis.     

距下关节融合对中后足周围关节活动度影响的生物力学实验研究

目的分析研究正常新鲜足标本在正常情况下进行距下关节融合后对跟骰、距舟关节和踝关节的三维运动度的影响程度。方法采用新鲜足标本12例，将距下关节融合后，通过加载使足产生某种形式的运动，用三维数字化坐标仪测量跟骰、距舟关节和踩关节各关节组成骨在某种运动状态下的相对三维坐标位移，通过矩阵转换和求解非线性函数方程计算其三维旋转角度，了解跟骰、距舟关节和踝关节在距下关节融合前后2种状态下的相对运动范围，确定距下关节融合后对于周围足踝关节运动的影响程度。结果距下关节融合前后跟骰、距舟关节和踝关节在背屈一跖屈、内翻一外翻、内收一外展轴的三维运动范围之间的统计学分析显示存在显著性差异（P＜0．01），各关节平均三维运动范围受限程度分别为36．14％、38．36％、21．84％。结论距下关节融合后对跟骰、距舟关节和踝关节的活动度存在一定的限制作用，降低了前足与后足的协同性，可能增加足跗关节间退行性关节炎发生，但保留了距舟、跟骰关节的大部分活动。     

跟骨截骨形态重建治疗严重跟骨骨折畸形愈合

目的探讨跟骨截骨形态重建治疗严重跟骨骨折畸形愈合的方法及临床疗效。方法经外侧L形入路跟骨体部截骨、形态重建与后距下关节重建或融合治疗严重陈旧性跟骨骨折畸形愈合27例(30足)。损伤至本次手术时间3～35个月,平均4.2个月。手术中进行距下关节融合11足,重建19足;取髂骨植骨7足;跟腱松解或延长7足。结果术后随访12～36个月。疗效根据Maryland足部评分系统,优10足,良15足,差5足,优良率83.3%。手术后测量跟骨长度、宽度、Bhler角、Gissane角和轴位角,与手术前比较,差异均有统计学意义(P<0.01)。结论跟骨截骨形态重建能较好地恢复后足大体形态及功能,是治疗严重跟骨骨折畸形愈合的一种有效方法。     

距下关节融合钢板内固定治疗Sanders IV型跟骨骨折

目的总结距下关节融合钢板内固定术对SandersIV型跟骨骨折的手术经验。方法对16例(17侧)SandersIV型跟骨骨折在行切开复位的同时根据粉碎程度行距下关节融合跟骨钢板内固定,疗效采用AOFANS评分标准。结果16例获得6~47个月随访(平均19.7个月),AOFANS评分平均为84.6分。结论对于SandersIV型跟骨骨折根据其粉碎程度可行距下关节融合跟骨钢板内固定术。     

Subtalar versus triple arthrodesis after intra-articular calcaneal fractures

Depending upon initial treatment, between 2 and 30% of patients with a displaced intra-articular calcaneal fracture require a secondary arthrodesis. The aim of this study was to investigate the effect of subtalar versus triple arthrodesis on functional outcome. A total of 33 patients with 37 secondary arthrodeses (17 subtalar and 20 triple) with a median follow-up of 116 months were asked to complete questionnaires regarding disease-specific functional outcome (Maryland Foot Score, MFS), quality of life (SF-36) and overall satisfaction with the treatment (Visual Analogue Scale, VAS). Patient groups were comparable considering median age at fracture, initial treatment (conservative or operative), time to arthrodesis, median follow-up, and post-arthrodesis radiographic angles. The MFS score was similar after subtalar versus triple arthrodesis (59 vs. 56 points; P = 0.79). No statistically significant difference was found for the SF-36 (84 vs. 83 points; P = 0.67) and the VAS (5 vs. 6; P = 0.21). Smoking was statistically significantly associated with a non-union (χ² = 6.60, P = 0.017). The current study suggests that there is no significant difference in functional outcome between an in situ subtalar or triple arthrodesis as a salvage technique for symptomatic arthrosis after an intra-articular calcaneal fracture. Smoking is a risk factor for non-union.     

Extraarticular Subtalar Arthrodesis for Pes Planovalgus: An Interim Result of 50 Feet in Patients with Spastic Diplegia

Background

There are no reports of the pressure changes across the foot after extraarticular subtalar arthrodesis for a planovalgus foot deformity in cerebral palsy. This paper reviews our results of extraarticular subtalar arthrodesis using a cannulated screw and cancellous bone graft.

Methods

Fifty planovalgus feet in 30 patients with spastic diplegia were included. The mean age at the time of surgery was 9 years, and the mean follow-up period was 3 years. The radiographic, gait, and dynamic foot pressure changes after surgery were investigated.

Results

All patients showed union and no recurrence of the deformity. Correction of the abduction of the forefoot, subluxation of the talonavicular joint, and the hindfoot valgus was confirmed radiographically. However, the calcaneal pitch was not improved significantly after surgery. Peak dorsiflexion of the ankle during the stance phase was increased after surgery, and the peak plantarflexion at push off was decreased. The peak ankle plantar flexion moment and power were also decreased. Postoperative elevation of the medial longitudinal arch was expressed as a decreased relative vertical impulse of the medial midfoot and an increased relative vertical impulse (RVI) of the lateral midfoot. However, the lower than normal RVI of the 1st and 2nd metatarsal head after surgery suggested uncorrected forefoot supination. The anteroposterior and lateral paths of the center of pressure were improved postoperatively.

Conclusions

Our experience suggests that the index operation reliably corrects the hindfoot valgus in patients with spastic diplegia. Although the operation corrects the plantar flexion of the talus, it does not necessarily correct the plantarflexed calcaneus and forefoot supination. However, these findings are short-term and longer term observations will be needed.     

Subtalar arthroscopy: When,why and how

Technique of subtalar arthroscopy is rapidly evolving. Increasing number of traditional open procedures for the subtalar joint can now be done arthroscopically. It is hoped that less wound complications, faster rehabilitation and better cosmetic outcomes can be achieved with this minimally invasive technique.