疼痛性跟距联合的治疗

目的 :探讨疼痛性跟距联合手术治疗适应证及术式。方法 :根据术前跟距轴位CT扫描所测量的跟距联合与跟距后关节二者横向切面之比率及跟骨外翻角度来决定采取跟距骨桥局部切除或三关节融合术。共治疗 12例 16足 ,其中男 8例 ,女 4例。平均随访时间 18个月。结果 :术后根据患者症状消失程度分为优良、可、差。单纯行跟距联合切除者 9例 12足 ,其中优 6例 ,可 3例 ;三关节融合者 3例 4足 ,均为优良。结论 :经保守治疗无效者可行手术治疗 ,跟距联合与跟距后关节二者横向切面之比率 <5 0 % ,跟骨外翻角 <2 1°时可行跟距骨桥局部切除术 ,反之则应行三关节融合术。     

Osseous and non-osseous coalition of the middle facet of the talocalcaneal joint.

Sixteen patients (eighteen feet) who had a coalition of the middle facet of the talocalcaneal joint had operative resection of the coalition because nonoperative treatment, such as casts, failed to relieve the symptoms. The patients were symptomatic for an average of one and a half years (range, four months to two years) before they were seen by us. The average age at the time of the operation was fourteen years (range, seven to nineteen years). Three feet had resection with no material interposed, six had resection with interposition of fat, and nine had resection with interposition of half of the tendon of the flexor hallucis longus muscle. The average length of follow-up was four years (range, two to eight years). The result was excellent for eight feet, good for eight feet, and fair for one foot; for one foot, the result was poor because the coalition recurred. Three types of coalition were identified on preoperative computed-tomography scans that correlated with the operative findings. Type I was an osseous bridging of the middle facet joint (five feet). Type II (cartilaginous coalition) was marked narrowing of the middle facet joint with cortical irregularity (three feet). In Type III (fibrous coalition), there was only slight narrowing of the middle facet joint (ten feet). The type of coalition did not influence the result. Fibrous coalitions were the most difficult to detect; bone scintigraphy was used to confirm the diagnosis when other tests were equivocal. We believe that symptomatic coalition of the middle facet of the talocalcaneal joint should be treated with resection when non-operative methods fail to relieve symptoms.     

Treatment of symptomatic talocalcaneal coalition

The cases of fourteen patients who had twenty-three symptomatic talocalcaneal coalitions were reviewed at a mean of 3.9 years (range, 2.2 to 9.5 years) after treatment. Five feet in three patients became completely asymptomatic after immobilization in a cast, and four feet underwent triple arthrodesis. Fourteen feet had resection of the coalition when the symptoms were not relieved by immobilization in a cast. The indications for resection of a talocalcaneal coalition include failure of non-operative treatment, a coalition that is less than one-half of the surface area of the talocalcaneal joint, and the absence of degenerative arthritic changes in the talonavicular joint. Good results were noted in thirteen feet and satisfactory results, in ten, for all forms of treatment.     

成人跟距联合术后功能的影响因素分析

背景：成人跟距联合手术治疗方案临床报道较少,术后的功能评估尚不明确。目的：探讨影响成人跟距联合术后功能的相关因素,从而决定更好的手术方案。方法：回顾性研究2011年1月至2013年7月我院收治且获得完整随访资料的24例行跟距联合术的患者资料,男13例,女11例;年龄19~53岁,平均31.5岁。根据术前症状及影像学检查决定手术方案。记录患者年龄、跟距联合分型、跗骨联合的大小、有无距下骨关节炎、后足的外翻角度。应用美国足踝医师协会踝-后足评分表（AOFAS-AH）和踝关节Karlsson-Peterson评分对患者术后的踝关节功能进行评估,并对上述因素进行相关性分析。结果：24例患者获得平均19.5个月的随访（4~33个月）。单纯联合切除术19例,其中4例进行三角韧带修补,1例行外侧韧带重建,1例行跟骨截骨内移术。距下关节融合术5例,其中3例患者仍有疼痛症状。术后的AOFAS评分和Karlsson-Peterson评分均明显改善。经Logistic回归分析,距下关节骨关节炎是术后踝关节功能的影响因素,而跟距联合分型、跗骨联合的大小和后足的外翻角度无明显相关性。结论：距下关节骨关节炎影响跟距联合患者术后的踝关节功能评分,即使行距下关节融合术,在一定程度上也影响患者术后踝关节功能。     

Arthrofibrosis involving the middle facet of the talocalcaneal joint in children and adolescents

BACKGROUND: Pain over the anterolateral aspect of the ankle in a patient with a history of repeated ankle sprains and with restricted subtalar movement may be associated with a tarsal coalition. Nineteen patients presented with such a history, but conventional imaging did not reveal a cartilaginous or osseous coalition. Since symptoms persisted despite nonoperative treatment, the middle facet was explored surgically. The purpose of this study was to discuss the operative findings and to report the results of treatment. METHODS: Nineteen patients (twenty-three feet) with pain over the anterolateral aspect of the ankle or a history of repeated ankle sprains had restricted subtalar joint motion and inconclusive findings on diagnostic imaging, except for bone-scanning. Their ages ranged from 9.1 to 18.5 years. The middle facet of the subtalar joint was explored surgically through a 3 to 4-cm-long incision centered over the sustentaculum tali. The results at a mean of 5.8 years were classified as good, fair, or poor on the basis of pain, talocalcaneal joint motion, and shoe wear. RESULTS: Routine radiographs, computed tomography, and magnetic resonance imaging revealed no major abnormality, whereas technetium-99m bone scintigraphy consistently showed slightly increased isotope uptake in the middle facet. Surgical removal of a hypervascular and thickened capsule and synovium in the area of the middle facet of the subtalar joint decreased pain and improved subtalar motion. The final result was good in seventeen patients (twenty feet) and fair in two patients (three feet). There were no poor results. CONCLUSIONS: A diagnosis of inflammatory arthrofibrosis should be considered when a patient with a painful rigid flatfoot has normal findings on radiographs and hematological studies but increased isotope uptake in the middle facet of the talocalcaneal joint on bone scintigraphy. Excision of the hypervascular capsule and synovium from this area can result in resolution of the symptoms. LEVEL OF EVIDENCE: Therapeutic Level IV.     

关节镜下改良后踝入路切除治疗成人疼痛性跟距骨桥

目的探讨采用关节镜下改良后踝入路切除治疗成人疼痛性跟距骨桥的疗效。方法 2015年1月-2017年12月,采用后踝高位外侧观察入路结合低位内侧操作入路切除治疗9例成人疼痛性跟距骨桥。男6例,女3例;年龄19~30岁,平均24岁。2例无明确局部外伤,7例有足踝部扭伤病史。病程6~30个月,中位病程12个月。跟距骨桥Rozansky分型:Ⅰ型5例(5足),Ⅱ型2例(2足),Ⅲ型2例(2足)。患者既往无肢体功能障碍后遗症、无肢体关节手术史。术后随访复查踝关节正侧位X线片、踝关节CT。比较手术前后疼痛视觉模拟评分(VAS)及美国矫形足踝协会(AOFAS)踝-后足评分。结果患者手术时间60~90 min,平均76 min。术后患者均获随访,随访时间12~24个月,平均18个月。术后切口均Ⅰ期愈合,无感染、皮肤坏死、下肢深静脉血栓形成、血管神经及肌腱损伤、骨桥复发等并发症发生。术后踝关节功能恢复良好,疼痛明显缓解;患者于术后3~5个月,平均3.9个月重返工作岗位。末次随访时VAS评分为(0.7±0.5)分,与术前(4.2±0.5)分比较差异有统计学意义(t=20.239,P=0.000);AOFAS踝-后足评分为(94±4)分,与术前(62±2)分比较差异有统计学意义(t=–27.424,P=0.000),末次随访时获优7例,良2例。结论后踝高位外侧观察入路结合低位内侧操作入路显露跟距骨桥更直观,操作空间更大,操作过程更灵活,术中根据特定解剖标志程序化切除跟距骨桥,操作具有可行性。     

Operative treatment of flatfoot with talocalcaneal coalition

Rigid flatfoot or peroneal spastic flatfoot often is associated with a congenital fibrous, cartilaginous, or osseous union of two tarsal bones or more, potentially causing great difficulties in its treatment. Since 1996, 12 patients (14 feet) with painful flatfoot and restricted motion of the hindfoot attributable to talocalcaneal coalition, were treated by resection of the coalition and subtalar arthroereisis by a bioreabsorbable implant. The results were evaluated by the ankle hindfoot clinical rating system of the American Orthopaedic Foot and Ankle Society. These clinical results also were evaluated statistically. Radiographs and computed tomography scans were taken preoperatively and postoperatively. Eight (57.1% of patients) had excellent results, three (21.4% of patients) had good results, and three (21.4% of patients) had fair results. No poor results, or subjective or objective complications were reported. On the basis of these early results, arthroereisis by implanting a bioreabsorbable device after removal of the tarsal coalition, seems to be an effective procedure for the treatment of symptomatic flatfoot associated with talocalcaneal coalitions: correcting the relationship between talus and calcaneus, restoring the alignment of the hindfoot, and reducing pain.     

Correlation between clinical outcome of surgically treated clubfeet and different radiological parameters

The goal of this study was to determine the relationship between the clinical outcome of surgically treated clubfeet and several radiological parameters. The talocalcaneal angle, talocalcaneal index, talo-first metatarsal angle and the calcaneo-first metatarsal angle were measured on anteroposterior and lateral radiographs of 54 children with 70 idiopathic clubfeet treated surgically between 2000 and 2004. Their age at surgery ranged from 4 to 23 months. These radiological parameters were compared with the clinical results. Follow-up was conducted after 24 to 69 months following surgery. Using the functional rating system of Laaveg and Ponseti, results were graded as excellent in 28.6% (20 feet), good in 40% (28 feet), fair in 17.1% (12 feet) and poor in 14.3% (10 feet). There was a statistically significant correlation between the clinical results and two angles: the talo-first metatarsal angle on the anteroposterior radiograph and the calcaneao-first metatarsal angle on the lateral radiograph. These two angles should be considered when designing an evaluation system of clubfeet.     

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。     

Effects of tarsal coalition resection on dynamic plantar pressures and electromyography of lower extremity muscles.

The goal of this study was to evaluate kinetic abnormalities in feet after tarsal coalition resection using plantar pressure measurements and electromyography of 4 muscle groups in the lower limb. Eleven subjects (14 feet) with tarsal coalition (3 feet with calcaneocuboid, 6 feet with calcaneonavicular, and 5 feet with talocalcaneal) underwent coalition excision. Patients ranged in age from 9 to 17 years, and mean follow-up was 20 months. Two feet underwent subsequent subtalar fusion and 1 had a triple arthrodesis. Plantar pressure and electromyography measurements were compared with data taken from 68 normal (control) subjects between the ages of 6 to 16 years. Feet with tarsal coalition showed significant differences in the midfoot region, with increases in contact area (40.36 cm2 +/- 14.7 vs 18.02 cm2 +/- 8.0, P < .001), loading (5.63 N/cm2 sec +/- 3.4 vs 1.83 N/cm2 sec +/- 0.9, P < .001) and peak pressure (13.38 N/cm2 +/- 5.8, 6.81 N/cm2 +/- 2.8, P = .01). Tarsal coalition feet also displayed reduced peak pressure and loading at the region of the fifth metatarsal head as compared with uninvolved feet (P < .05). Electromyography measurements were also performed on both the affected and unaffected feet of 9 subjects who had undergone resection of their coalition. These measurements revealed nearly consistent abnormal activity in the peroneal, gastrocnemius, and soleus muscles on both the surgically operated foot and the contralateral side, including either prolonged monophasic activity or biphasic activity. These findings suggest that although resection of coalition may have relieved symptoms of discomfort, it did not restore normal foot alignment or muscular balance.     

Early surgical treatment for congenital vertical talus

Congenital vertical talus is characterised by a dislocated talonavicular joint in association with an equinus position of the calcaneus. We report the results in 13 operated feet in 10 children, 3 of whom (5 feet) presented with a primary neurological disorder and 2 of whom (3 feet) suffered from arthrogryposis multiplex congenita. The other children were normal. All patients were surgically treated by a one-stage procedure which included reduction of the talonavicular joint and correction of the hindfoot equinus, trying to avoid tendon lengthenings and transfers. The age at operation was between the 3rd and the 6th month of life, with one child being operated on later due to other reasons. The patients were reviewed after an average time of 3.5 ± 2.2 years. The clinical results were good or excellent in ten feet. Two feet showed partial or complete recurrence and one foot was slightly over-corrected. Radiographic angle measurements (talo-metatarsal I angle and talocalcaneal angle on the anteroposterior radiograph; talocalcaneal, tibiotalar and tibiocalcaneal angles on the lateral radiograph) returned to normal values in the ten good or excellent feet. Early operative treatment for congenital pes vertical talus leads to very satisfactory functional and cosmetic results, usually avoiding extensive procedures including tendon lengthenings and tendon transfers.     

Midterm results following revision surgery in clubfeet

Relapse rates of surgically treated clubfeet are about 25%. We reviewed 43 patients (57 feet) treated for relapsed clubfoot deformity between 1992 and 2001 in our department. The average age of the patients at the time of revision surgery was 5.1 years, the mean follow-up was 6.6 years. Surgical therapy was performed using an algorithm according to age groups. The mean Atar score at follow-up was 77 points, representing a good outcome. Out of 57 feet, 20 (35%) were rated excellent, 24 (42%) good, 5 (9%) fair, and 8 (14%) poor. The number of previous surgical interventions had no influence on the outcome. Using an age related surgical algorithm, good postoperative results could be achieved in most of our patients, thus improving their functional situation. This emphasises the usefulness of the proposed algorithm in the difficult situation of recurrent clubfoot, while thorough analysis of the underlying deformity remains essential.     

Talo-calcaneal coalition treated with resection

Three cases of symptomatic talocalcaneal coalition (medial or posterior) have been treated successfully with resection of the connecting bar and fat interposition without fusion. At follow-up (ranging from 1 1/2 to 14 years), the patients had no pain, good function, good range of joint motion, and no regeneration of the bar. Computed tomography scanning was the method of choice for roentgenological diagnosis of talocalcaneal coalition.     

Computed tomography in suspected tarsal coalition. Examination of 26 cases

Coronal plane computed tomography (CT) was performed in 26 consecutive patients with clinical suspicion of tarsal coalition. Twenty patients had plain CT and 6 had CT talocalcaneonavicular arthrography. Fifteen patients were found to have coalition. Of these 15 patients, 12 had talocalcaneal coalition (9 bilateral, 3 unilateral), 2 patients had combined talocalcaneal and calcaneonavicular coalitions, and the remaining patient had bilateral calcaneonavicular coalitions. Surgical findings corroborated the CT diagnosis in 9 patients with talocalcaneal coalition and in 2 patients with calcaneonavicular coalition. Ossified talocalcaneal coalitions were found in children aged 6 and 10 years, i.e., well below the conventionally stated age range of 12 to 16 years. CT is the investigation of choice in suspected tarsal coalition if plain radiography is not diagnostic. CT arthrography did not generally provide further information, but may be useful if plain CT is equivocal.     

Tarsal tunnel syndrome. Causes and results of operative treatment

From 1975 to 1988, operative treatment was performed on 50 feet in 45 patients with tarsal tunnel syndrome. The causes of this syndrome were correlated with operative findings and included ganglia in 18, and a bony prominence from talocalcaneal coalition in 15. Five feet had sustained an injury, tumours were found in three and there was no obvious cause in nine. In most cases in need of operative treatment, there was a space-occupying lesion. Classifying the results according to causes, those with coalition or a tumour fared better, and idiopathic and traumatic cases had a worse outcome. In cases with a definite lesion, an excellent result can be expected from surgical treatment carried out soon after onset of the condition.     

Computed tomography in suspected tarsal coalition: Examination of 26 cases

Coronal plane computed tomography (CT) was performed in 26 consecutive patients with clinical suspicion of tarsal coalition. Twenty patients had plain CT and 6 had CT talocalcaneonavicular arthrography. Fifteen patients were found to have coalition. Of these 15 patients, 12 had talocalcaneal coalition (9 bilateral, 3 unilateral), 2 patients had combined talocalcaneal and calcaneonavicular coalitions, and the remaining patient had bilateral calcaneonavicular coalitions. Surgical findings corroborated the CT diagnosis in 9 patients with talocalcaneal coalition and in 2 patients with calcaneonavicular coalition.

Ossified talocalcaneal coalitions were found in children aged 6 and 10 years, i.e., well below the conventionally stated age range of 12 to 16 years.

CT is the investigation of choice in suspected tarsal coalition if plain radiography is not diagnostic. CT arthrography did not generally provide further information, but may be useful if plain CT is equivocal.     

Fibulocalcaneal Impingement in a Growing Child With Otherwise Asymptomatic Talocalcaneal Coalition

Subfibular impingement has been described in patients with flatfoot. It possibly occurs with valgus deformity associated with talocalcaneal coalition. We observed symptomatic unilateral fibular impingement initially on the left foot of an 11-year-old female with an otherwise asymptomatic bilateral talocalcaneal coalition. From the age of 8 years, she had complained of pain around the left fibular tip. Magnetic resonance imaging showed a partial talocalcaneal coalition. At 10 years of age, it was questioned whether the pain was related to the coalition. However, imaging of the asymptomatic right foot also showed a talocalcaneal coalition, with the coalition in both feet appearing equal. Additionally, the peroneal trochlea appeared particularly prominent, more so on the left than on the right foot. Therefore, the symptoms were suspected to have been caused only by fibulocalcaneal impingement owing to a relatively long fibula. Subperiosteal shortening of the fibula was performed at when she was 11 years old. A bed for the peroneal tendons was created around the remaining epiphysis of the fibula, and the fibular ligaments were reattached with Arthrex^® anchors (Arthrex, Naples, FL). At 14 months postoperatively, the patient was free of pain with unrestricted movement, although the follow-up imaging studies showed complete bony fusion on the medial aspect of the coalition between the talus and calcaneus. Approximately 1.5 years after surgery, our female patient at 12.5 years old complained of the same problems on her right foot, definitely occurring only around the fibula. The same procedure was performed as she had undergone on the left foot. At the last follow-up examination, she was asymptomatic 2.5 years after the initial surgery of the left foot and 11 months after surgery on the right. Talocalcaneal coalition can cause moderate to severe hindfoot deformity, leading to fibulocalcaneal impingement. Hence, treatment should be determined accordingly.     

Tarsal coalition resection with pes planovalgus hindfoot reconstruction

Tarsal coalitions often present in young adults as a painful pes planovalgus hindfoot deformity. Resection of moderate and even large coalitions has become accepted as an alternative to arthrodesis. A review of the literature, however, suggests that coalitions with severe preoperative planovalgus malposition treated with resection are associated with continued disability and deformity. The authors believe that malposition contributes to persistent pain and disability after simple coalition resection. The hypothesis is that resection of the coalition with simultaneous hindfoot reconstruction can improve clinical and radiographic outcomes. Seven consecutively treated patients (eight feet) were retrospectively reviewed from the senior author's practice. Clinical exam, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, and radiographic measurements were evaluated after talocalcaneal coalition resection with simultaneous hindfoot reconstruction. All patients were satisfied and would have the same procedure again. All patients were either active students or gainfully employed at last follow-up. Clinical and radiographic hindfoot alignment was corrected reliably. The average increase in medial longitudinal arch height was 8.7 mm. After 2 years the average AOFAS hindfoot score was 88. Most patients had only mildly progressive arthrosis. There were two postoperative complications that resolved (superficial wound breakdown and calf deep vein thrombosis). This hindfoot reconstruction with coalition resection increased motion, reliably corrected malalignment, and improved pain. The authors believe that coalition resection and concomitant hindfoot reconstruction is a better option than resection alone or hindfoot fusion in patients with talocalcaneal coalition and painful pes planovalgus hindfoot deformity. Triple arthrodesis should be reserved as a salvage procedure.     

Subtalar fusion for isolated subtalar disorders. Preliminary report

Retrospective observations on subtalar fusions performed for isolated subtalar disorders in 11 feet were performed to determine whether a satisfactory result could be obtained without significant changes to the talonavicular and calcaneocuboid joints. Preoperative diagnoses included five feet with degenerative arthritis secondary to a calcaneal fracture, four feet with a talocalcaneal bar, one foot with a degenerative subtalar arthropathy of unknown cause, and one foot with an unstable subtalar joint secondary to a peroneal tendon rupture. The average follow-up period was 41.5 months (range, 23-103 months). The hindfoot was fused in a average of 6 degrees of valgus. The feet maintained approximately 50% of their transverse tarsal motion, compared with the contralateral side. No foot developed hypermobility of any tarsal joint. Three feet fused for degenerative joint disease developed very mild talar beaking, and two feet fused for a tarsal coalition developed a mild progression or increase in talar beaking. Three feet demonstrated very minimal osteophyte formation at the calcaneocuboid joint. Functional and pain ratings for patients who had fusions for talocalcaneal bars or degenerative joint disease were good to excellent. Minimal radiographic changes at the talonavicular and calcaneocuboid joints secondary to increased stress brought about by the fusion did not seem to be clinically significant. Isolated subtalar fusion for lesions limited to the subtalar joint, which includes talocalcaneal bars, is a satisfactory method of treatment.     

Tarsal tunnel syndrome caused by ganglia.

We describe in 30 feet the occurrence of a tarsal tunnel syndrome caused by a ganglion. The presenting symptom was numbness or pain in the toes and the sole with paraesthesiae in the distribution of the medial plantar nerve in 63% of the patients. Swellings which were not palpable were detected by ultrasonography. Twenty-nine patients were treated by operation. Most ganglia originated from the talocalcaneal joint, and five were associated with a talocalcaneal coalition. The surgical outcome was satisfactory in all patients except one who had a further operation for a recurrence of the ganglion.