锁定板结合骨修复材料植骨治疗SandersⅢ、Ⅳ型跟骨骨折

目的探讨跟骨锁定板结合骨修复材料植骨治疗SandersⅢ、Ⅳ型跟骨骨折的临床疗效。方法手术治疗30例SandersⅢ、Ⅳ型跟骨骨折患者(32足),骨缺损处植入骨修复材料,行跟骨锁定板内固定。结果患者均获得随访,时间11~30个月。Bhler角:术前为-12.7°~35.2°(12.5°±10.7°),末次随访时为20.0°~37.1°(28.6°±5.2°);Gissane角:术前为80.0°~127.7°(103.6°±14.1°),末次随访时为100.5°~130.5°(117.4°±8.7°);跟骨宽度:术前为36.8~48.6(40.5±2.7)mm,末次随访时为32.8~40.1 mm(36.9±2.0)mm;跟骨高度:术前为33.1~47.2(41.8±3.9)mm,末次随访时为41.0~52.3(46.5±3.0)mm;以上各项指标末次随访与术前比较差异均有统计学意义(P0.01)。参照AOFAS踝-后足评分标准评价手术效果:优10足,良18足,可4足,优良率87.5%。结论锁定板结合骨修复材料植骨治疗SandersⅢ、Ⅳ型跟骨骨折能够复位塌陷的跟骨关节面,固定牢靠,疗效满意。     

Evans跟骨外侧延长术治疗距跟联合合并后足外翻畸形

目的探讨Evans跟骨外侧延长术治疗距跟联合合并后足外翻畸形的疗效。方法2014年1月—2017年10月,采取Evans跟骨外侧延长术治疗10例(13足)距跟联合合并后足外翻畸形患者。男6例(8足),女4例(5足);年龄13~18岁,平均15.8岁。病程10~14个月,平均11.5个月。患侧跟骨外翻、前足外展、足弓低平。疼痛部位:跗骨窦4足、距跟联合5足、踝关节4足。Silverskiold试验腓肠肌腱膜紧张3例(4足),跟腱挛缩7例(9足)。术前美国矫形外科足踝协会(AOFAS)踝与后足评分为(46.54±9.08)分,行走1 km后疼痛视觉模拟评分(VAS)为(6.54±0.88)分。术后采用AOFAS踝与后足评分、VAS评分,以及X线片测量距骨-第1跖列角(talar-first metatarsal angle,T1MT)、距舟覆盖角(talonavicular coverage angle,TCA)、距骨倾斜角(talar-horizontal angle,TH)、跟骨倾斜角(calcaneal pitch angle,CP)、跟骨外翻角(heel valgus angle,HV),评价手术疗效。结果术后切口均Ⅰ期愈合。10例患者均获随访,随访时间12~30个月,平均18个月。末次随访时,AOFAS踝与后足评分为(90.70±6.75)分,VAS评分为(1.85±0.90)分,均较术前明显改善(t=-23.380,P=0.000;t=35.218,P=0.000)。X线片复查示截骨均达骨性愈合,愈合时间为2~4个月,平均3个月。末次随访时,T1MT、TCA、TH、HV均较术前明显降低,CP明显提高,差异有统计学意义(P<0.05)。随访期间1例(1足)疼痛缓解不明显,1例(1足)出现腓肠神经皮支损伤症状。结论对于距跟联合合并后足外翻畸形患者,Evans跟骨外侧延长术可以有效纠正畸形、缓解疼痛。     

跟骨内移截骨治疗获得性扁平足临床分析

[目的]探讨跟骨内移截骨治疗扁平足的要点及临床疗效.[方法]自2006年1月～2009年12月,采取跟骨内移截骨及联合手术治疗扁平足3l例,男17例,女14例;年龄19～50岁(平均26.7岁).术前均摄足侧位及跟骨轴位X线片及跟骨CT,测量第1跖距角5°～32°(平均22.3°).均有跟腱挛缩、外移、跟骨外翻、前足旋前外展(负重位外观),有疼痛,根据美国矫形足踝协会(AOFAS)踝后足评分标准评分平均45.8分.胫后肌腱功能不全均二级.单纯跟骨内移截骨13例,跟骨内移截骨加跟腱延长4例,跟骨内移截骨加跟腱延长及趾长屈肌腱移位14例.[结果]术后随访6～26个月(平均18.8个月),内侧纵弓较手术前增加,内侧柱高度由术前(8.5±3.2)mm增至(16.3±4.1)mm(t=8.35,P≤0.001),10例疼痛消失,15例减轻,6例无明显改变.第1跖距角由术前5°～32°(平均22.3°±4.5°)降至0°～7°(平均3.2°±1.4°) (t=22.57,P≤0.001).足外翻及外展明显改善,有效率80.6%(25/31),(AOFAS)踝后足评分平均84.5分.[结论]跟骨体部截骨手术治疗可屈性平足疗,能够可靠地纠正平足症的跟骨外翻畸形,部分恢复其内侧纵弓,改善足的负重和足踝部生物力学特性,术中根据情况联合其他术式提高疗效,同时应严格掌握适应证.     

跟骨外侧U形切口入路治疗跟骨骨折

目的探讨跟骨外侧U形切口入路治疗跟骨骨折的临床疗效。方法采用跟骨外侧U形切口暴露治疗30例累及跟距关节、跟骰关节的单侧闭合跟骨骨折患者,术前术后测量Bhler角和Gissane角,按Maryland足部评分系统评价疗效。结果 Bhler角:术前-6°~20°(6.35°±10.34°),术后3个月20°~36°(28.32°±5.29°);Gissane角:术前71°~110°(89.76°±11.32°),术后3个月112°~140°(122.45°±7.89°);两项与术前比较差异均有统计学意义(P0.01)。30例均获随访,时间9~23(14.23±2.23)个月。患者骨折均愈合,时间为8~11(9.2±1.5)周。关节面复位满意,跟骨高度恢复正常。无创伤性关节炎发生,无内固定物折断等相关并发症。术后34~80(46.2±8.98)周取出钢板。按Maryland足部评分系统评价疗效:优15例,良12例,中3例,优良率为90%。结论跟骨外侧U形切口能很好暴露骨折部位,利于恢复跟骨解剖形态,对累及跟距关节、跟骰关节的跟骨骨折疗效较好。     

跟骨骨折畸形愈合的三维形态学评估及临床意义

目的探讨基于CT图像后处理技术的跟骨骨折畸形愈合的三维形态学特征。方法收集2010年5月-2015年6月期间18例19足跟骨骨折畸形愈合患者,男12例13足,女6例6足;年龄23~62岁,平均43.3岁;按Stephens-Sanders跟骨畸形愈合分型：Ⅰ型3足,Ⅱ型7足,Ⅲ型9足。根据跟骨畸形愈合类型,结合术前三维形态学评估,选择相应的跟骨骨折畸形愈合矫形术。采用表面重建法重建出跟骨及其周围骨性结构的三维图像,应用三维拓扑窄区分割技术将图像中各构成骨分离,应用三维空间点、线、面三元素结合的组合式跟骨三维测量体系进行跟骨形态学评估。参数指标采用SPSS 18.0统计软件分析,计量资料采用配对t检验。结果通过电话预约门诊就诊的方式对术后患者进行随访,所有病例获得平均19.1个月随访,美国骨科足踝外科协会(AOFAS)踝-足评分从术前的平均(31.4±6.1)分提高至末次随访时的(77.4±7.6)分。术前B?hler角、Gissane角平均分别为(17.5°±5.6°)、(96.6°±9.9°),末次随访时分别为(34.2°±3.2°)、(124.1°±8.9°),两组间比较差异均有统计学意义(P<0.001);术后末次随访的跟骨轴长、跟骨后关节面高度、跟骨后关节面长度均较术前明显改善(P<0.001)。结论跟骨三维形态学评估是评判跟骨骨折畸形愈合术后疗效的重要措施之一。本试验结果可为跟骨骨折畸形愈合的矫形手术计划提供了一组科学、客观的参考数据。     

跟骨钢板治疗跟骨关节内骨折

目的探讨跟骨钢板治疗跟骨关节内骨折的疗效。方法对45例跟骨关节内骨折患者(51足)采用跟骨外侧延长L形切口,跟骨钢板内固定治疗。测量术前、术后Bhler角和Gissane角,根据Maryland足功能评分标准进行疗效评定。结果 45例均获随访,时间6～16(10.3±2.1)个月。Bhler角术前为-9°～17°(5.6°±11.4°),术后恢复至15°～40°(27.5°±11.3°);Gissane角术前为75°～97°(85.6°±11.4°),术后恢复至110°～140°(127°±13.0°)。术后发生切口延迟愈合2例,皮瓣边缘坏死1例。结论选择好恰当的手术时机,掌握骨折复位技巧,采用跟骨外侧延长L形切口,跟骨钢板治疗跟骨关节内骨折可以获得满意的疗效。     

锁定钢板内固定加植骨治疗跟骨关节内骨折

目的探讨锁定钢板内固定加植骨治疗跟骨关节内骨折的疗效。方法采用锁定钢板内固定加陶瓷骨或人工异体骨植骨治疗40例跟骨关节内骨折患者共44足,分析临床疗效。结果切口一期愈合38足,切口持续渗液4足,皮瓣坏死2足。40例均获随访,时间6~20个月。骨折愈合时间3~6个月。Bhler角由术前-15°~5°(-4.16°±3.98°)恢复至术后25°~40°(32.18°±4.28°),Gissane角由术前73.9°~91.5°(84.1°±6.28°)恢复至术后108.8°~117.4°(112.8°±5.63°),跟骨宽度由术前38~45(40.9±2.2)mm恢复至术后30~34(31.2±2.1)mm。术后无骨折畸形愈合、足弓塌陷、腓骨下端撞击综合征等并发症的发生。按Maryland评分标准评定:优29足,良10足,可4足,差1足,优良率88.6%。结论锁定钢板内固定加植骨治疗跟骨关节内骨折,能重建跟骨的大体形态,临床疗效良好。     

手术治疗跟距骨桥临床疗效观察

目的探讨单纯性骨桥切除术治疗跟距骨桥的临床疗效。方法回顾性分析2008年7月~2013年8月我院收治的15例跟距骨桥患者的临床资料,均行单纯性骨桥切除术。手术前后分别采用视觉模拟评分法(VAS)进行疼痛评分,美国矫形足踝协会(AOFAS)后足评分标准评价踝关节功能。结果本组15例患者均获得随访,平均时间12.3(4~24)个月。术后所有患者切口均Ⅰ期愈合,无伤口或关节感染、血管神经损伤、跟距坏死等早期并发症发生。末次随访时VAS评分平均(1.7±1.2)分,明显低于术前的(8.7±0.3)分(P0.01);末次随访AOFAS后足评分平均(90.1±4.3)分,显著高于术前的(40.2±2.1)分(P0.001)。末次随访时X线检查示无骨桥复发及关节退变发生,未见关节间隙狭窄,患者进行负重行走时无明显不适。末次随访时对患者进行满意度调查:非常满意8例,满意5例,一般2例,满意率为86.7%。结论单纯性骨桥切除术是一种治疗跟距骨桥的有效方法。     

V形截骨联合距下关节融合术治疗StephensⅡ、Ⅲ型跟骨骨折畸形愈合

目的 探讨跟骨V形截骨联合距下关节融合术治疗StephensⅡ、Ⅲ型跟骨骨折畸形愈合的疗效。方法 回顾分析2017年1月—2021年12月采用跟骨V形截骨联合距下关节融合术治疗的24例严重跟骨骨折畸形愈合患者临床资料。男20例，女4例；年龄33～60岁，平均42.8岁。跟骨骨折保守治疗失败19例，手术治疗失败5例。跟骨骨折畸形愈合Stephens分型：Ⅱ型14例，Ⅲ型10例。术前跟骨B?hler角4.0°～13.5°，平均8.6°；Gissane角100°～152°，平均119.3°。受伤至该次手术时间6～14个月，平均9.7个月。术前及末次随访时采用美国矫形足踝协会（AOFAS）踝与后足评分及疼痛视觉模拟评分（VAS）评价疗效；观察骨愈合情况并记录愈合时间，并测量距跟高度、距骨倾斜角、跟骨倾斜角、跟骨宽度及后足力线角。结果 术后3例出现切口皮缘坏死，经换药及口服抗生素治疗后痊愈。其余切口均Ⅰ期愈合。24例患者均获随访，随访时间12～23个月，平均17.1个月。患者足部形态均恢复良好，穿鞋恢复至伤前尺码，无前踝撞击存在。所有患者均获骨性愈合，愈合时间12～18周，平均14.1周。末次随...     

手术治疗跟距骨桥疗效观察

目的探讨跟距骨桥的手术治疗方法及疗效。方法 2008年7月-2010年10月,手术治疗跟距骨桥患者10例。男4例,女6例;年龄16～70岁,平均53.5岁。先天性骨桥2例,继发性骨桥8例。跟距中间关节面骨桥3例,后关节面骨桥7例。术前患者疼痛视觉模拟评分(VAS)为(9.0±0.4)分;根据美国矫形足踝协会(AOFAS)后足评分标准为(42.4±1.4)分。合并距下关节退变2例。8例单纯跟距骨桥患者行骨桥切除并脂肪组织植入,2例合并距下关节退变患者行骨桥切除联合距下关节融合术。结果术后切口均Ⅰ期愈合。8例获随访,随访时间12～36个月,平均18个月。末次随访时VAS评分为(2.0±0.7)分,与术前比较差异有统计学意义(t=6.425,P=0.000)。AOFAS后足评分为(86.9±2.3)分,与术前比较差异有统计学意义(t=7.634,P=0.000)。单纯骨桥切除者末次随访时X线片检查示无骨桥复发及关节退变发生,关节融合者X线片示达骨性融合。结论跟距骨桥根据不同发生部位和合并症,分别采用单纯骨桥切除或联合距下关节融合术可取得较好疗效。     

Use of the modified Stainsby procedure in correcting severe claw toe deformity in the rheumatoid foot: A retrospective review

IntroductionIn claw toe deformity, the plantar plate of the metarsophalangeal joint becomes displaced onto the dorsal aspect of the metatarsal head. The Stainsby procedure replaces the displaced plantar plate to its correct position beneath the metatarsal head.ObjectiveIn this study we assess the efficacy of a modified Stainsby procedure for the treatment of claw toe deformity.MethodsThirteen patients were operated on between 2002 and 2008. Eleven patients (13 feet) were available for review with the average follow-up period being 16 months. Clinical examination was performed and AOFAS forefoot scores were measured.ResultsAll 13 (100%) of the feet operated on had severe or moderate pain preoperatively. None had significant pain at review. Plantar callosities were reduced from 13 (100%) feet preoperatively to 1 (9%) foot postoperatively. The AOFAS forefoot score in the eleven patients improved significantly by 40.7 points from a preoperative mean of 20.1 to a mean of 50.2 at review (p < 0.001). Ten (91%) of the 11 patients were completely satisfied with the procedure, 1 patient was satisfied with some reservations.ConclusionThis study demonstrates the modified Stainsby procedure to be effective in correcting claw toe deformity in the rheumatoid patient. It relieves pain, skin callosities and improves overall forefoot function.     

外固定架尺骨延长治疗遗传性多发性骨软骨瘤所致前臂畸形

目的探讨采用外固定架尺骨延长治疗遗传性多发性骨软骨瘤(HMO)所致前臂畸形的疗效。方法回顾分析2014年4月至2018年4月北京积水潭医院创伤骨科采用外固定架尺骨延长治疗HMO所致前臂畸形患者5例。其中男4例,女1例;平均年龄14.5岁(12~16岁);右侧2例,左侧3例;MasadaⅠ型2例,MasadaⅡB型3例。5例患者均接受尺骨延长手术治疗。对3例MasadaⅡB型患者采用环形外固定架,另2例采用单边外固定架。1例合并桡骨骨折患者同时行桡骨骨折切开复位内固定术。截骨术后8~10 d开始行尺骨牵开延长。结果5例患者均获得随访,平均随访时间16个月(12~30个月)。3例MasadaⅡB型患者桡骨头均自行复位。5例患者尺骨平均延长37.5 mm(30~45 mm),平均应用外固定架时间162 d(122~274 d),平均外固定架指数48.9 d/cm。术前和术后平均梅奥肘关节评分分别为36.4分和92.7分,平均肘关节屈曲活动范围分别为118.0°(110°~130°)和130.0°(120°~150°),平均伸肘活动范围分别为12.7°(10°~20°)和3.5°(0°~10°),平均前臂旋前活动范围分别为18.6°(5°~30°)和44.7°(30°~65°),平均前臂旋后活动范围分别为71.2°(50°~85°)和86.5°(75°~90°)。1例桡骨干骨折患者术后3个月骨折愈合。2例出现针道感染;1例尺骨过早愈合,行第2次截骨手术后延长顺利。未见神经血管并发症。5例患者对治疗结果均满意。结论采用外固定架逐渐延长尺骨治疗HMO患者尺骨短缩畸形和桡骨头脱位安全有效。     

Cavovarus foot treated with combined calcaneus and metatarsal osteotomies

Twenty-one feet in fifteen patients underwent osteotomies of the calcaneus and one or more metatarsals for symptomatic cavovarus foot deformity. Seven (nine feet) were male, and eight (twelve feet) were female. The etiology included hereditary motor sensory neuropathy (HMSN) (fifteen feet), post-polio syndrome (two feet), sacral cord lipomeningocele (two feet), parietal lobe porencephalic cyst (one foot), and idiopathic peripheral neuropathy (one foot). Presenting complaints were metatarsalgia (fifteen feet), ankle instablility (five), and ulceration beneath the second metatarsal head (one foot). Eleven feet were assessed using the Maryland Foot Rating Score. Maryland Foot Rating Score (University of Maryland, Baltimore, MD) improved from 72.1 (avg.) preoperatively to 89.9 (avg.) post-operatively (follow-up 70.9 months avg.). Eight feet were assessed using the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot and Midfoot Scores. The AOFAS Ankle-Hindfoot Score improved from 46.3 (avg.) pre-operatively to 89.1 (avg.) post-operatively, and the AOFAS Midfoot Score improved from 40.9 (avg.) pre-operatively to 88.8 (avg.) post-operatively (follow-up 20.8 months avg.). The postoperative AOFAS Ankle-Hindfoot Score for all nineteen feet was 90.8 (avg.) and the post-operative AOFAS Midfoot Score for all nineteen feet was 90.2 (avg.). Two patients were lost to follow-up and were not included in the study. Ankle, hindfoot, and midfoot motion was maintained or improved in sixteen feet. Complications included delayed union in two and nonunion in three of 66 metatarsal osteotomies. While three patients required an AFO (ankle-foot orthosis) for ambulation preoperatively, all patients were brace free postoperatively. All patients expressed willingness to undergo the same procedure again if it were necessary. Weight-bearing radiographs were available for 17 feet. Radiographic analysis revealed a decrease in forefoot adduction (9.6 degrees avg.) and a reduction in both hindfoot (9.1 degrees avg.) and forefoot cavus (10.6 degrees) leading to an overall 13 percent reduction in the height of the longitudinal arch. Lateral sliding elevating calcaneal osteotomy combined with dorsolateral closing wedge osteotomies of one or more metatarsal bases in the severe symptomatic cavovarus foot can provide a pain-free, plantigrade foot with a lowered longitudinal arch and a stable ankle without sacrificing motion.     

Ludloff截骨治疗中重度拇外翻的临床疗效观察

目的研究Ludloff截骨术对中、重度拇外翻的治疗效果。方法 2007年9月至2008年10月对26例（34足）中、重度拇外翻患者使用Ludloff截骨配合远端软组织手术进行矫形手术治疗,截骨使用螺钉固定。男4例,女22例,年龄48～67岁,平均58岁。术后采用AOFAS评分对患足进行临床功能评价,同时拍负重位足的正侧位X线片进行影像学评价,比较术后AOFAS评分及跖拇角和第一二跖间角的变化,了解患者的满意程度。结果平均随访时间25个月（19～36个月）。在最后一次随访时,31足基本无痛,3足偶有疼痛或轻微疼痛。患者对拇外翻畸形纠正满意。AOFAS评分为从术前的51分（27～65分）提高到术后的88分（72～96分）,HVA从术前的31°（21°～42°）改善为10.3°（7°～15°）,IMA从术前的17°（16°～23°）改善为术后的7.8°（6°～10°）。23例（31足）患者对治疗效果满意,3例（3足）比较满意。所有患者均对外形满意。没有严重的并发症出现。结论 Ludloff截骨术是治疗中重度拇外翻可靠有效的方法。     

The modified Ludloff osteotomy for correction of severe metatarsus primus varus with hallux valgus deformity

AIM: The present study investigates the clinical and radiological mid-term results of the modified Ludloff osteotomy, a proximal metatarsal osteotomy for surgical correction of severe metatarsus primus varus with hallux valgus deformity. METHOD: 70 feet in 67 patients from 25 to 78 years (average age 56 years) were included in this prospective study. The patients were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot metatarsophalangeal interphalangeal score, which was used preoperatively and at an average follow-up of 37 +/- 6 months. Weight-bearing foot radiographs were analysed according to AOFAS guidelines and statistical evaluation was made with the Wilcoxon signed-rank test. RESULTS: The average AOFAS score improved significantly (p < 0.0001) from 55.2 +/- 15.2 points preoperatively to 86.6 +/- 15.2 points at follow-up. Preoperatively, all patients complained of pain (20.2 +/- 9.6 points) which had improved significantly (p < 0.0001) at the latest follow-up (37.3 +/- 5.7 points). The average hallux valgus angle (HVA) was 37 +/- 8 degrees preoperatively and improved significantly to 12 +/- 11 degrees at follow-up (p = 0.0001). The intermetatarsal angle (IMA) improved significantly from 18 +/- 2 degrees preoperatively to 8 degrees +/- 4 degrees after 37 +/- 6 months (p = 0.0002). The sesamoid position improved significantly from preoperative to follow-up (p = 0.0003). Radiographic evaluation of the patients indicated that all examined osteotomies had healed after 37 +/- 6 months. CONCLUSION: This prospective investigation at intermediate follow-up using currently available outcome measures suggests that the Ludloff osteotomy is a suitable procedure for the surgical correction of severe metatarsus primus varus (IMA > 15 degrees ) with hallux valgus deformity.     

选择性跖骨远端截骨治疗中重度(足母)外翻

[目的]探讨选择性跖骨远端截骨治疗(足母)外翻的手术适应证、手术方法及疗效.[方法]对2007年3月～2011年1月本院60例(101足)中度及重度(足母)外翻进行回顾性分析.双足41例,单足19例.其中女性57例,男性3例;年龄23～81岁,平均62.6岁.[结果]本组60例(101足)均获随访,随访时间6～48个月,平均22个月.参照美国足踝外科协会Maryland(足母)跖趾关节百分评分系统,90～ 100分40例(66足);80～89分16例(30足);70～79分4例(5足);优良率95％.术前HVA 30°～44°,平均36°;术后10.5°～21°,平均15.3°.IMA 13°～18°,平均16°;术后6°～10°,平均8.5°.第1跖趾关节活动度术前0°～30°,平均16°;术后为25°～50°,平均35°.第1跖骨长度较术前减少3 ～6 mm,平均4.2mm.[结论]本术式为软组织合并骨性手术,手术方法简单,创伤较小,跖骨头成形充分,术后不需要辅助内固定等优点,是一种值得推广的术式.     

短节段固定融合术治疗退变性腰椎侧凸合并腰椎管狭窄疗效观察

目的探讨短节段固定融合术治疗退变性腰椎侧凸(DLS)合并腰椎管狭窄的手术策略、影像学及临床疗效。方法选择性减压、短节段固定融合术治疗68例DLS合并腰椎管狭窄患者,比较患者术前及末次随访时的Cobb角、腰椎前凸角、冠状面躯干偏移及矢状面躯干偏移。以Oswestry功能障碍指数(ODI)评估患者功能改善情况。结果患者均获得随访,时间36~60个月。Cobb角术前12°~28°(15.9°±4.6°),末次随访3.6°~9.8°(5.2°±3.1°);腰椎前凸角术前1.2°~3.3°(1.9°±2.9°),末次随访-28.1°~4.6°(-23.6°±3.7°);冠状面躯干偏移术前8.2~13.7(10.8±5.2)mm,末次随访2.8~5.6(4.3±1.8)mm;矢状面躯干偏移术前10.2~15.6(12.6±3.7)mm,末次随访3.1~6(4.6±2.2)mm;ODI评分术前25.2~29.8(27.6±2.1)分,末次随访2.1~4.2(3.6±1.3)分。以上各项指标末次随访与术前比较差异均有统计学意义(P0.05)。术后早期并发症发生率为7.3%。末次随访时未发现钉棒松动或断裂等情况。结论对于冠状面Cobb角30°且躯干失平衡较小的DLS合并腰椎管狭窄患者,行选择性减压、短节段固定融合可获得良好的中期临床疗效。     

Total knee replacement with intra-articular resection of bone after malunion of a femoral fracture: can sagittal angulation be corrected?

Intra-articular resection of bone with soft-tissue balancing and total knee replacement (TKR) has been described for the treatment of patients with severe osteoarthritis of the knee associated with an ipsilateral malunited femoral fracture. However, the extent to which deformity in the sagittal plane can be corrected has not been addressed. We treated 12 patients with severe arthritis of the knee and an extra-articular malunion of the femur by TKR with intra-articular resection of bone and soft-tissue balancing. The femora had a mean varus deformity of 16° (8° to 23°) in the coronal plane. There were seven recurvatum deformities with a mean angulation of 11° (6° to 15°) and five antecurvatum deformities with a mean angulation of 12° (6° to 15°). The mean follow-up was 93 months (30 to 155). The median Knee Society knee and function scores improved from 18.7 (0 to 49) and 24.5 (10 to 50) points pre-operatively to 93 (83 to 100) and 90 (70 to 100) points at the time of the last follow-up, respectively. The mean mechanical axis of the knee improved from 22.6° of varus (15° to 27° pre-operatively to 1.5° of varus (3° of varus to 2° of valgus) at the last follow-up. The recurvatum deformities improved from a mean of 11° (6° to 15°) pre-operatively to 3° (0° to 6°) at the last follow-up. The antecurvatum deformities in the sagittal plane improved from a mean of 12° (6° to 16°) pre-operatively to 4.4° (0° to 8°) at the last follow-up. Apart from varus deformities, TKR with intra-articular bone resection effectively corrected the extra-articular deformity of the femur in the presence of antecurvatum of up to 16° and recurvatum of up to 15°.     

Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity

BACKGROUND: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. METHODS: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). RESULTS: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. CONCLUSIONS: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.     

改良McBride手术联合Akin截骨术治疗轻度拇外翻

目的报道改良McBride手术联合Akin截骨术治疗轻度拇外翻的临床效果。方法 2004年6月至2007年12月,共治疗轻度拇外翻36例（拇外翻角≤30°,跖间角≤13°）。采用内侧纵切口,切除第一跖骨头内侧骨赘,松解拇内收肌腱斜头、外侧关节囊和跖籽骨间韧带,于近节趾骨基底行闭式外翻截骨,以克氏针固定截骨处。术后即可负重行走。结果所有病例随访18～41个月,平均25.3个月,未见拇囊炎复发病例。所有患者在术后3～8周（平均4.1周）恢复原工作。术前拇外翻角为28.4°±4.2°,术后为8.6°±1.8°,最后1次随访时,拇外翻角的矫正较术后有所丢失（10.6°±2.1°）,但与术前相比,差异仍有显著性（t=22.7,P〈0.01）。术前IMA 11.4°±1.8°,术后9.0°±1.7°,最后1次随访时,IMA增大（10.4°±1.9°）,但与术前相比,差异有统计学意义（t=2.3,0.01〈P〈0.05）。术前AOFAS评分为（38.4±7.2）分,最后1次随访时为（89.1±5.8）分,差异具有显著性（t=32.9,P〈0.01）。结论 Akin截骨术可以降低软组织手术的复发率,同时缩短术后康复时间。只要严格掌握手术适应证,可以取得优良的手术效果。