Kirkpatrick J S, Goldner J L, Goldner R D
Duke University Medical Center, Durham, NC 27710.
Clin Orthop Relat Res. 1991 Jul(268):29-36.
Pseudarthrosis after failed tibiotalar arthrodesis was successfully treated surgically in nine of 11 patients between 1980 and 1987. The indication for the initial attempted arthrodesis was traumatic arthrosis in seven patients, traumatic arthrosis with osteonecrosis of the talus in two patients, degenerative arthrosis in one patient with cavovarus foot (Charcot-Marie-Tooth), and myelodysplasia with progressive valgus deformity of the foot and ankle in one. The surgical technique planned for revision arthrodesis provided firm coaptation of tibia to talus with internal fixation that maintained the foot at right angles to the tibia with the forefoot in neutral position. Seven feet in 11 patients were treated using a transfibular approach that allowed excision of fibrous tissue and sclerotic bone, decortication of the media malleolus, fixation of the tibia to the talus with cancellous screws, and onlay/inlay fibular graft. Of the remaining four patients, one was treated with medial compression plate, a second was treated using an anteromedial cortical graft, a third was treated by a combination of sliding anteromedial corticocancellous graft and tibiotalar compression screw, and a fourth was treated with tibiotalar compression screw. Clinical and roentgenographic union occurred in nine of 11 patients. One patient developed a painless, fibrous union and one patient with persistent pseudarthrosis had myelodysplasia and severe valgus deformity and required amputation. Adequate exposure was possible through the transfibular approach to provide cancellous bone opposition, to excise the pseudarthrosis membrane and sclerotic bone, and to remove necrotic segments of the talus. In addition, supplemental bone graft, internal fixation, and postoperative cast immobilization were also helpful in obtaining union.
1980年至1987年间，11例距下关节融合术失败后发生假关节的患者中，有9例通过手术成功治愈。初次尝试关节融合术的指征包括：7例为创伤性关节炎，2例为创伤性关节炎合并距骨缺血性坏死，1例为伴有高弓内翻足（夏科-马里-图斯病）的退行性关节炎，1例为脊髓发育不良合并足踝部进行性外翻畸形。计划用于翻修关节融合术的手术技术通过内固定实现胫骨与距骨的牢固对合，使足部与胫骨保持直角，前足处于中立位。11例患者中的7足采用经腓骨入路进行治疗，该入路可切除纤维组织和硬化骨，对内踝进行去皮质处理，用松质骨螺钉将胫骨固定于距骨，并进行腓骨贴附/嵌入植骨。其余4例患者中，1例采用内侧加压钢板治疗，1例采用前内侧皮质骨移植治疗，1例采用滑动前内侧皮质松质骨移植联合距下关节加压螺钉治疗，1例采用距下关节加压螺钉治疗。11例患者中有9例实现了临床和影像学愈合。1例患者形成了无痛性纤维性愈合，1例假关节持续存在的患者患有脊髓发育不良和严重外翻畸形，需要截肢。经腓骨入路能够提供足够的显露，以实现松质骨对合，切除假关节膜和硬化骨，并去除距骨的坏死节段。此外,补充植骨、内固定和术后石膏固定也有助于实现愈合。
