Schimmel Janneke J P, Walschot Luc H B, Louwerens Jan Willem K
Sint Maartenskliniek Nijmegen, Nijmegen, The Netherlands.
Foot Ankle Int. 2014 Apr;35(4):326-33. doi: 10.1177/1071100713518187. Epub 2013 Dec 26.
Total ankle replacement (TAR) is presently considered to be an acceptable alternative to ankle fusion for patients with debilitating conditions of the ankle. The placing of a total ankle prosthesis is a technically demanding procedure. We hypothesized that the challenging conditions could cause a longer learning curve (>30 cases), and therefore the short-term results of the first and the last 50 cases in a consecutive series of 134 cases were compared.
The first and last consecutive 50 cases by a single surgeon in a series of 134 Scandinavian Total Ankle Replacements (STAR; Waldemar Link, Hamburg, Germany), inserted between May 1999 and May 2008, were evaluated. Operation characteristics, clinical outcome (Foot Function Index [FFI], Kofoed score), complications, and the component alignment on X-rays were assessed. The outcome measures for both groups were compared using independent Student t tests, chi-square tests, and nonparametric alternatives (P < .05).
Surgery time decreased from a median of 125 (83-160) to 100 (65-170) minutes (P < .001), and fewer perioperative complications were observed (12 vs 4, P = .04). The sagittal alignment of the tibial component was closer to normal in the last series (P < .001). The clinical outcome did not differ between the 2 series (median FFI: 32 [0-74] vs 25 [0-75], Kofoed score: median 71 [21-96] vs 80.5 [23-100]). The major underlying pathology did change from rheumatoid arthritis (60%) to osteoarthritis (44%; P = .002). No differences in type and number of complications were reported.
The surgery time did decrease, there were fewer perioperative fractures, and the tibial component orientation improved, suggesting the presence of a learning curve. Operative experience and a shift in major underlying pathology did not influence clinical outcome. In view of this learning curve we suggest more restrictive patient selection for at least the first 50 TARs.
Level III, comparative series.
对于踝关节患有致残性疾病的患者，全踝关节置换术（TAR）目前被认为是踝关节融合术的一种可接受的替代方案。植入全踝关节假体是一项技术要求很高的手术。我们推测，具有挑战性的手术条件可能会导致较长的学习曲线（超过30例），因此，我们比较了连续134例手术中前50例和后50例的短期结果。
对1999年5月至2008年5月间由同一位外科医生连续进行的134例斯堪的纳维亚全踝关节置换术（STAR；德国汉堡的Waldemar Link公司）中的前50例和后50例进行评估。评估手术特征、临床结果（足部功能指数[FFI]、科福德评分）、并发症以及X线片上假体的对线情况。使用独立样本t检验、卡方检验和非参数检验方法比较两组的结果指标（P < 0.05）。
手术时间从中位数125（83 - 160）分钟降至100（65 - 170）分钟（P < 0.001），围手术期并发症减少（12例对4例，P = 0.04）。在后一组中，胫骨假体的矢状面对线更接近正常（P < 0.001）。两组的临床结果无差异（FFI中位数：32[0 - 74]对25[0 - 75]，科福德评分中位数：71[21 - 96]对80.5[23 - 100]）。主要潜在病理情况从类风湿性关节炎（60%）转变为骨关节炎（44%；P = 0.002）。并发症的类型和数量无差异。
手术时间确实缩短了，围手术期骨折减少，胫骨假体的方向得到改善，表明存在学习曲线。手术经验和主要潜在病理情况的转变并未影响临床结果。鉴于此学习曲线，我们建议至少在前50例全踝关节置换术中对患者选择采取更严格的标准。
III级，比较系列研究。
