Saltzman Charles L, Amendola Annunziato, Anderson Robert, Coetzee J Chris, Gall Randall J, Haddad Steven L, Herbst Steven, Lian George, Sanders Roy W, Scioli Mark, Younger Alistair S
Department of Orthopaedic Surgery, University of Iowa, Iowa City, IA 52246, USA.
Foot Ankle Int. 2003 Jun;24(6):514-8. doi: 10.1177/107110070302400612.
This study assessed the problems with initial use of ankle arthroplasty by surgeons who were trained by observing the surgeon/inventor (group I), who have completed a structured, hands-on surgical training course (group II), or who were trained during a 1-year foot and ankle fellowship (group III).
The perioperative records of the first 10 cases of nine surgeons were reviewed. We evaluated the 6-month-postoperative standing mortise and lateral radiographs for evidence of syndesmosis union and accuracy of tibial component implantation. Three surgeons were each in group I, group II, and group III. Average patient age at time of surgery was similar. Ankle arthritis was classified as rheumatoid arthritis (RA) or osteoarthritis (OA) as follows: group I (7 RA, 23 OA), group II (7 RA, 23 OA), and group III (3 RA, 27 OA).
In group I, there were nine intraoperative complications, four postoperative wound dehiscences, and three postoperative deep infections. Radiographic evaluation of the 26 cases with adequate postoperative roentgenograms revealed that 10/26 (38%) had a delayed union of the syndesmosis. In group II, there were six intraoperative complications and two postoperative wound problems: an early anterior wound problem and a delayed lateral wound breakdown. Radiographic evaluation of the 26 cases with adequate postoperative roentgenograms revealed that 13/26 (50%) had a delayed union of the syndesmosis. In group III, there were four intraoperative complications and four postoperative wound problems--all healed with local supportive care with one requiring lateral hardware removal. Radiographic evaluation of the 26 cases with adequate postoperative roentgenograms revealed that 5/30 (17%) had a delayed union of the syndesmosis. The initial series from these three groups are statistically indistinguishable with respect to rates of complications, revisions, or malalignment.
No identified training method had a statistically demonstrable positive impact on preparing surgeons for performing total ankle replacement. Some of these findings are likely generic for total ankle replacements and not restricted to any class or design of implant. Surgeon initial use of total ankle replacement needs to be done with caution and serious consideration.
本研究评估了通过观察外科医生/发明者接受培训的外科医生（第一组）、完成结构化实践手术培训课程的外科医生（第二组）或在为期1年的足踝专科进修期间接受培训的外科医生（第三组）在初次使用踝关节置换术时遇到的问题。
回顾了9位外科医生的前10例手术的围手术期记录。我们评估了术后6个月的站立位踝关节正位和侧位X线片，以确定下胫腓联合是否愈合以及胫骨假体植入的准确性。第一组、第二组和第三组各有3位外科医生。手术时患者的平均年龄相近。踝关节关节炎分为类风湿性关节炎（RA）或骨关节炎（OA），情况如下：第一组（7例RA，23例OA），第二组（7例RA，23例OA），第三组（3例RA，27例OA）。
在第一组中，有9例术中并发症、4例术后伤口裂开和3例术后深部感染。对术后X线片合格的26例患者进行影像学评估发现，10/26（38%）存在下胫腓联合延迟愈合。在第二组中，有6例术中并发症和2例术后伤口问题：1例早期前侧伤口问题和1例延迟的外侧伤口裂开。对术后X线片合格的26例患者进行影像学评估发现，13/26（50%）存在下胫腓联合延迟愈合。在第三组中，有4例术中并发症和4例术后伤口问题——所有问题经局部支持治疗后均愈合，1例需要取出外侧固定装置。对术后X线片合格的26例患者进行影像学评估发现，5/30（17%）存在下胫腓联合延迟愈合。这三组的初始系列在并发症发生率、翻修率或排列不齐方面在统计学上无显著差异。
未发现有哪种培训方法能在统计学上对外科医生进行全踝关节置换手术的准备工作产生明显的积极影响。其中一些发现可能普遍适用于全踝关节置换术，并不局限于任何类型或设计的植入物。外科医生初次使用全踝关节置换术时需谨慎并认真考虑。
