Thorpe Steven W, Wukich Dane K
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Roesch Taylor Building, 2100 Jane Street, Suite 7100, Pittsburgh, PA 15203, USA.
Foot Ankle Clin. 2012 Jun;17(2):195-204. doi: 10.1016/j.fcl.2012.03.004. Epub 2012 Apr 6.
There is a paucity of information on adult coalitions without large, well-designed outcome studies. Current recommendations are thus similar to those for adolescents. Based on the available literature, current recommendations include an initial trial of adequate nonoperative treatment in symptomatic coalitions. Unlike adolescent coalitions, nonoperative treatment may be even more effective in the adult patient as many are asymptomatic or discovered after injury. If nonoperative treatment fails, then surgical intervention is considered and tailored to the location of the coalition, existing advanced arthrosis, and any existing deformity. Similar to the adolescent, surgical treatment for adult calcaneonavicular coalitions typically involves an attempt at resection with some type of interposition. Resection can be attempted for talocalcaneal coalitions that do not present with advanced arthrosis or significant hindfoot malalignment. For those patients with advanced arthrosis, more than 50% involvement of the joint hindfoot malalignment, subtalar or triple arthrodesis is recommended. The decision between resection and arthrodesis is controversial in the adolescent population. With few outcome studies in adults, it is even more difficult to make definitive treatment recommendations; however, the indications for resection are likely even more limited. It is likely that the adult subtalar coalition that becomes symptomatic and fails nonoperative treatment will require arthrodesis for full pain relief and improvement in objective outcome measures, such as the AOFAS hindfoot score. Our treatment algorithm focuses first on a trial of nonoperative treatment of at least 3 months regardless of coalition location. After failed nonoperative treatment, calcaneonavicular coalitions are in most cases treated with excision and interpositional fat graft. For talocalcaneal coalitions, resection is offered to patients with neutral hindfoot alignment, some preservation of subtalar joint motion and no adjacent joint arthrosis. The patients are advised that the outcome after resection of talocalcaneal coalitions is less predictable than resection of calcaneonavicular coalitions. Those patients with absent subtalar motion and relatively normal hindfoot alignment are candidates for in situ fusion of the subtalar joint. For those patients with greater than 15° of valgus hindfoot malalignment on a weight-bearing hindfoot alignment view or adjacent joint arthrosis, a triple arthrodesis is recommended with or without medial displacement osteotomy of the calcaneus. Adjacent joint arthrosis may be determined by radiographs, CT scan, or preoperative MRI.
对于没有大型、设计良好的结果研究的成人联合畸形，相关信息匮乏。因此，目前的建议与针对青少年的建议相似。基于现有文献，目前的建议包括对有症状的联合畸形进行充分的非手术治疗的初始试验。与青少年联合畸形不同，非手术治疗在成年患者中可能更有效，因为许多成年患者无症状或在受伤后才被发现。如果非手术治疗失败，则考虑手术干预，并根据联合畸形的位置、现有的晚期关节病以及任何现有的畸形进行调整。与青少年相似，成人跟舟联合畸形的手术治疗通常包括尝试某种类型的置入物切除。对于没有晚期关节病或严重后足畸形的距跟联合畸形，可以尝试切除。对于那些有晚期关节病、关节后足畸形超过50%、距下或三关节融合的患者，建议进行融合手术。在青少年人群中，切除和融合之间的决定存在争议。由于成人的结果研究较少，更难做出明确的治疗建议；然而，切除的指征可能更有限。有症状且非手术治疗失败的成人距下联合畸形可能需要进行融合手术，以完全缓解疼痛并改善客观结果指标，如美国足踝外科协会（AOFAS）后足评分。我们的治疗算法首先侧重于至少3个月的非手术治疗试验，无论联合畸形的位置如何。非手术治疗失败后，大多数情况下跟舟联合畸形采用切除和置入脂肪移植治疗。对于距跟联合畸形，对于后足对线中立、距下关节运动有一定保留且无相邻关节病的患者，提供切除手术。建议患者，距跟联合畸形切除后的结果比跟舟联合畸形切除后的结果更难预测。那些距下关节活动消失且后足对线相对正常的患者是距下关节原位融合的候选者。对于那些在负重后足对线视图上后足外翻畸形大于15°或有相邻关节病的患者，建议进行三关节融合手术，可伴有或不伴有跟骨内侧移位截骨术。相邻关节病可通过X线片、CT扫描或术前MRI确定。
