Elsner A, Barg A, Stufkens S, Knupp M, Hintermann B
Klinik für Orthopädie und Traumatologie des Bewegungsapparates, Kantonsspital Liestal.
Oper Orthop Traumatol. 2011 Apr;23(2):121-30. doi: 10.1007/s00064-011-0027-9.
Treatment of adult instable drop foot by modified Lambrinudi arthrodesis (removal of a wedge between the talus and calcaneus), followed by a posterior tibial tendon transfer to the medial cuneiform in order to provide active dorsiflexion.
Severe drop foot (of various etiologies) in combination with hindfoot instability. Sufficient function of the posterior tibial muscle.
Neurologic dysfunction of the posterior tibial muscle, infection of foot/hindfoot, Charcot arthropathy, and insufficient patient compliance. RELATIVE CONTRAINDICATIONS: Previous surgery of posterior tibial tendon, critical soft tissues/skin conditions, insufficient neurovascular conditions.
Lateral skin incision. Debridement of sinus tarsi and removal of the bifurcate ligament to expose the subtalar, calcaneocuboidal, and talonavicular joints. Resection of a bone wedge from the calcaneus and talus (25-30°) to correct the drop foot deformity. Cartilage removal from the calcaneocuboid joint. Debridement of both the talar head and the navicular to allow adequate fitting. After reduction (neutral dorsiflexion and 10° foot abduction), preliminary fixation with Kirschner wires. Final fixation with canulated screws (talonavicular, calcaneocuboidal, and subtalar joints). Medial skin incision at the navicular tuberositas to deattach the posterior tibial tendon with a bony fragment. The tendon stump is harvested 10 cm proximal to the tibiotalar joint. Small skin incision at the anterolateral aspect of the distal lower leg. The posterior tibial tendon is transferred through the interosseous membrane and reattached to the medial cuneiform with a screw.
Immobilization with a removable short leg cast for 2-4 days. Ambulation with full weightbearing in a cast for 8 weeks. Radiographic assessment 8 weeks postoperatively. After bony healing, mobilization in normal shoes is allowed. Intensive physiotherapy to train the dorsiflexion.
The average correction of drop foot deformity was 18.7°. Active dorsiflexion increased significantly from 30° preoperatively to 10° postoperatively.
采用改良兰布林迪关节融合术（去除距骨和跟骨之间的楔形骨块）治疗成人不稳定垂足，随后将胫后肌腱转移至内侧楔骨以实现主动背屈。
各种病因导致的严重垂足合并后足不稳定。胫后肌功能良好。
胫后肌神经功能障碍、足部/后足感染、夏科氏关节病以及患者依从性不足。相对禁忌症：既往胫后肌腱手术史、关键软组织/皮肤状况不佳、神经血管条件不足。
外侧皮肤切口。清理跗骨窦并切除分歧韧带以暴露距下、跟骰和距舟关节。从跟骨和距骨切除一个骨楔（25 - 30°）以矫正垂足畸形。去除跟骰关节的软骨。清理距骨头和舟骨以实现充分贴合。复位后（中立位背屈和足部外展10°），用克氏针临时固定。用空心螺钉最终固定（距舟、跟骰和距下关节）。在舟骨粗隆处做内侧皮肤切口，连带一块骨碎片切断胫后肌腱。在胫距关节近端10厘米处获取肌腱残端。在小腿远端前外侧做小皮肤切口。将胫后肌腱穿过骨间膜，并用螺钉重新附着于内侧楔骨。
用可拆卸的短腿石膏固定2 - 4天。用石膏固定完全负重行走8周。术后8周进行影像学评估。骨愈合后，允许穿正常鞋子活动。进行强化物理治疗以训练背屈。
垂足畸形的平均矫正角度为18.7°。主动背屈从术前的30°显著增加至术后的10°。
