改良 Silver手术联合Akin截骨术治疗老年踇外翻

目的报道改良Silver手术联合Akin截骨术治疗老年人拇外翻的临床效果。方法从2006年9月~2009年10月,共治疗老年人拇外翻64例﹙平均73.4岁﹚。取第一跖趾关节背内侧纵切口,切除内侧骨赘,松解外侧关节囊、拇内收肌斜头和跖籽骨间韧带。然后,在近节趾骨基底作Akin截骨,以骑缝钉或克氏针行内固定,紧缩缝合内侧关节囊。术后不采用任何外固定,尽快下床活动和恢复全足负重行走。术后均抗凝治疗。结果本组病例均具有不同程度的内科合并症,需要同时进行治疗。所有患者获得15~42个月﹙平均25.1个月﹚的随访,满意率达到81.3%。HVA由术前29.8±4.9矫正到10.1±3.1﹙=27.2,<0.01﹚,IMA由术前9.5±2.2矫正到8.3±2.0﹙=3.22,<0.01﹚。AOFAS评分由术前28.1±5.9提高到83.6±11.0﹙=35.6,<0.01﹚。1例畸形复发,7例患者术后出现小腿及足背肿胀严重,在3~12个月治疗后肿胀明显缓解或消失。1例患者出现下肢交感神经功能不全,经治疗后恢复。结论老年人拇外翻的手术治疗具有特殊性,而改良Silver手术联合Akin截骨术是治疗老年人轻中度拇外翻畸形的较好手术方法,具有矫正力强、复发率低的优点,同时不需外固定,允许早期负重,可以降低老年人围手术期的并发症。

Modified Silver procedure in combination with Akin osteotomy to treat older hallux valgus

Objective To report the results of modified Silver procedure in combination with Akin osteotomy for the treatment of older hallux valgus.Methods From September 2006 to October 2009,64 cases with an average age of 73.4 years older were treated.Longitudinal incision along the dorsomedial aspect of the first metatarsophalangeal joint was applied,followed by medial prominence removal and releases of the lateral capsule,oblique head of the hallucal adductor muscle and metatarso-sesamoid ligament.Proximal phalange basal Akin osteotomy was added and stabilized by staple or K-wire.Finally the medial capsule was plicated.No external fixator was needed postoperatively and the patients were encouraged to walk and resume full foot weight bearing as soon as possible.Anti-coagulation therapy was routinely used in all cases.Results All cases had varied degrees of associated medical diseases,which were treated at the same time.All were followed up for 15 to 42 months ﹙mean,25.1 months﹚and the satisfaction rate was 81.3%.HVA was corrected from 29.8 ± 4.9 preoperatively to 10.1 ± 3.1 at the last visit ﹙ t=27.2,P〈0.01,MA was corrected from 9.5 ± 2.2 preoperatively to 8.3 ± 2.0 at the last visit﹙t =3.22, P〈0.01﹚.AOFAS scores were improved to 83.6 ± 11.0﹙t =35.6, P〈0.01﹚atthelastvisit from28.1 ± 5.9beforetheoperation.1recurrenceoccurred.7casesdevelopedsevere edema below the knee postoperatively,which was significantly alleviated or disappeared after 3 to 12 months treatment.Lower extremity sympathetic nerve dysfunction was found in one patient and was successfully treated.Conclusion The surgical treatment for older hallux valgus has the special characteristics.Modified Silver procedure in combination with Akin oeteotomy is considered as a better procedure to treat light and moderate older hallux valgus.It has such advantages as strong capability of correction,lower incidence of recurrence,avoidance of external fixation,allowance of early weight bearing and decrease of perioperative complication.