关节镜下后踝三入路切除术治疗疼痛性跟距骨桥

doi:10.3877/cma.j.issn.1674-6899.2023.02.009

目的

研究关节镜下后踝三入路法切除治疗成人疼痛性跟距骨桥的疗效，以期为临床该病患者的治疗提供方案。

方法

选择首都医科大学附属北京同仁医院从2021年2~12月收治的11例成人疼痛性跟距骨桥患者。所有受试者均开展经典后踝内外侧入路联合外侧高位入路切除术治疗。术前及术后随访，均行患侧踝关节负重正侧位X线片，CT检查。采用疼痛视觉模拟评分(visual analogue scale, VAS)及美国足踝外科协会(American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, AOFAS)踝-后足评分评价疼痛及足部功能改善情况。

结果

11例患者术后全部获得随访，随访时间6~14个月，平均11个月。术后切口均Ⅰ期愈合，无伤口感染、血管神经肌腱损伤、下肢深静脉血栓形成等并发症发生。术后踝关节疼痛及足部功能显著改善。末次随访VAS中位数1.0分，与术前VAS中位数6.0分比较，差异有统计学意义(P<0.05)；末次随访AOFAS踝-后足评分(93.7±4.6)分，与术前(62.4±9.7)分比较，差异有统计学意义(P<0.001)。

结论

关节镜下后踝三入路可更好显露跟距骨桥，视野更广阔，空间感更好，操作过程更灵活，切除时不易伤及血管神经，有利于获得更好疗效。

关键词: 疼痛性跟距骨桥, 关节镜, 后踝三入路, 骨桥切除术, 视觉模拟评分法, 疗效

Objective

To study the efficacy of arthroscopic triple-approach posterior malleolectomy for the treatment of painful talocalcaneal coalition and provide treatment options for such patients clinically.

Methods

Eleven adult patients with painful talocalcaneal coalition admitted to the hospital from Feb.to Dec. 2021 were selected. All subjects underwent classical posterolateral approach combined with lateral high approach. Postoperative follow-up included X-ray and CT examination of the affected ankle joint, and comparison of pre- and postoperative pain visual analogue score (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score.

Results

All the 11 patients were followed up for 6-14 months, with an average of 11 months. All incisions healed well with no complications such as infection, skin necrosis, deep vein thrombosis of the lower limb, vascular, nerve or tendon injury. Postoperative ankle pain was significantly relieved, and function was restored well. At the last follow-up, the median VAS score was 1.0, which was statistically significantly improved compared to the preoperative score of 6.0 (P<0.05). the AOFAS ankle-hindfoot score was (93.7±4.6) points, which was significantly improved from the preoperative score of (62.4±9.7) points (P<0.001).

Conclusion

Arthroscopic posterior ankle triple approach can better expose the coalition, with a wider field of view, better spatial sense, more flexible operation process, and less risk of vascular, nerve or tendon injury, which is beneficial to obtain better treatment efficacy.

Key words: Painful talocalcaneal coalition, Arthroscopy, Posterior ankle triple approach, Coalition resection, Pain visual analogue score, Efficacy

图1 关节镜下后踝三入路法切除跟距骨桥手术方法注：A.后踝滑膜组织，充分暴露拇长屈肌腱；B.常规后内后外入路，磨钻切除增大的距骨后内侧突；C.后踝后内、后外、外侧高位入路示意；D.微型骨膜剥离器剥离松解骨桥表面周围软组织；E.找到跗骨管内口，前方即载距突，插入克氏针加以标记；F.使用骨刀及髓核钳摘除跟距骨桥的内侧部分，以扩大操作间隙；G.关节镜置于后外或外侧高位入路，监视下使用磨钻进一步清理成型骨桥；H.探查见距下关节软骨清晰显露，距下关节活动完全恢复。

图2 术前、术后CT对比注：A.术前可见跟距骨桥；B.术后可见骨桥完全切除。

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Arthroscopic triple-approach posterior malleolectomy for the treatment of painful talocalcaneal coalition

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Arthroscopic triple-approach posterior malleolectomy for the treatment of painful talocalcaneal coalition