Department of Orthopaedics, Seattle Children's Hospital, Seattle, WA 98105, USA.
J Bone Joint Surg Am. 2012 Sep 5;94(17):1584-94. doi: 10.2106/JBJS.K.00926.
Surgical resection of persistently painful talocalcaneal tarsal coalitions may not reliably relieve symptoms in patients with large coalitions associated with excessive hindfoot valgus deformity and subtalar posterior facet narrowing. Since 1991, calcaneal lengthening osteotomy, with or without coalition resection, has been used at our institution to relieve symptoms and to preserve motion at the talonavicular and calcaneocuboid joints.
We retrospectively reviewed the records for eight patients with thirteen painful talocalcaneal tarsal coalitions who had undergone a calcaneal lengthening osteotomy for deformity correction with or without coalition resection between 1991 and 2005. Preoperative and postoperative clinical, radiographic, and computed tomographic records were reviewed. The duration of clinical follow-up ranged from two to fifteen years.
Calcaneal lengthening osteotomy fully corrected the valgus deformity and provided short-to-intermediate term pain relief for the five patients (nine feet) in whom the talocalcaneal tarsal coalition was unresectable. The patient with resectable coalitions but excessive valgus deformities underwent calcaneal lengthening osteotomies along with coalition resections and had excellent deformity correction and pain relief in both feet. One of the two patients who underwent calcaneal lengthening osteotomy years after coalition resection had excellent correction and pain relief. The other patient had a coincident calcaneonavicular coalition and severe degenerative arthritis in the talonavicular joint. He underwent concurrent arthrodesis of the talonavicular joint and, although he had excellent deformity correction, had persistent pain. All feet underwent concurrent gastrocnemius or Achilles tendon lengthening.
It is generally accepted that resection is the treatment of choice for an intractably painful small talocalcaneal tarsal coalition that is associated with a wide, healthy posterior facet and minimal valgus deformity of the hindfoot. Although triple arthrodesis has been recommended for those who do not meet all three criteria, the present study suggests that an algorithmic treatment approach is justified. Treatment of the valgus deformity appears to be as important as that of the coalition. Calcaneal lengthening osteotomy with gastrocnemius or Achilles tendon lengthening is effective for correcting deformity and relieving pain in rigid flatfeet, just as it is in flexible flatfeet.
对于与后足过度外翻畸形和距下关节后关节面狭窄相关的大的距跟舟骨联合的持续性疼痛，单纯行手术切除通常无法可靠地缓解症状。自 1991 年以来，我们机构一直采用跟骨延长截骨术，联合或不联合联合切除，以缓解症状并保留距跟舟关节和跟骰关节的活动度。
我们回顾性分析了 1991 年至 2005 年间接受跟骨延长截骨术以矫正畸形（联合切除或不切除）治疗的 8 例 13 个疼痛性距跟舟骨联合患者的临床、影像学和计算机断层扫描（CT）检查记录。回顾了术前和术后的临床、影像学和 CT 检查记录。临床随访时间为 2 至 15 年。
跟骨延长截骨术完全矫正了外翻畸形，并为 5 例（9 足）无法切除距跟舟骨联合的患者提供了短期至中期的疼痛缓解。2 例接受跟骨延长截骨术的患者，联合切除了可切除的骨联合，但存在严重的外翻畸形，2 足的畸形矫正和疼痛缓解均良好。1 例在距跟舟骨联合切除多年后接受跟骨延长截骨术的患者矫正和疼痛缓解效果良好。另 1 例患者存在跟舟骨联合，且距舟关节有严重的退行性关节炎。他同时进行了距舟关节融合术，虽然畸形矫正良好，但仍有持续性疼痛。所有患者均同时行腓肠肌或跟腱延长术。
对于与宽而健康的后关节面和后足轻度外翻畸形相关的无法缓解的疼痛性小距跟舟骨联合，一般认为切除是治疗的首选方法。对于不符合所有三个标准的患者，建议采用三关节融合术，但本研究表明，采用算法治疗是合理的。治疗外翻畸形似乎与治疗联合一样重要。跟骨延长截骨术联合腓肠肌或跟腱延长术对于矫正僵硬性平足畸形和缓解疼痛是有效的，与治疗柔韧性平足畸形一样有效。
