Halanski Matthew A, Abrams Sam, Lenhart Rachel, Leiferman Ellen, Kaiser Teresa, Pierce Emily, Franklin Rachel Rebekah, Opel Dayton, Noonan Kenneth J, Crenshaw Thomas D
American Family Children's Hospital, University of Wisconsin, Madison, WI, USA.
Department of Animal Science, University of Wisconsin, Madison, USA.
J Child Orthop. 2016 Dec;10(6):705-714. doi: 10.1007/s11832-016-0799-4. Epub 2016 Nov 30.
Tibialis anterior tendon transfers (TATT) are commonly performed in young children following Ponseti casting for clubfeet. The classic TATT involves advancing the tendon through a hole drilled in the ossified cuneiform. The aim of this study was to determine if tendons transferred through unossified bones have untoward effects on subsequent bone development.
Twenty-five piglets underwent one of five surgical procedures. An 18-gauge needle was then used to place a tunnel through the bony or cartilaginous portion of the calcaneus (through direct visualization) and isolated slips of the flexor digitorum superficialis (FDS) were placed through the tunnels, as determined by surgical procedure. Radiographic and/or histologic evaluations of the calcaneal apophyses were then performed. A discrete (1-4) and dichotomous "Normal" or "Abnormal" scoring system was developed and its reliability assessed to grade the appearance of the calcanei. Calcaneal appearances following the surgical procedures were then compared with controls. The average load to failure of a subset of transferred tendons was then compared using an MTS machine.
The proposed apophyseal grading system (1-4) demonstrated an intraclass correlational coefficient (ICC) for consistency of 0.92 [95% confidence interval (CI) 0.88 < ICC < 0.95] and ICC for agreement of 0.91 (95% CI 0.86 < ICC < 0.95), indicating strong agreement and consistency. Similarly, Fleiss' kappa for the 1-4 scoring system was found to be 0.67, indicating substantial agreement between reviewers. When the 1-4 system was translated into the dichotomous scheme "Normal" and "Abnormal", the kappa value increased to 0.94, indicating strong agreement. Forty-six apophyses (13 control and 33 operative) were assessed using this scoring scheme. Apophyseal transfers were significantly more abnormal than controls (p < 0.0001), while no difference in abnormalities was found following tunnel placement alone (p = 1). Mechanical testing of the tendons transferred to bone or through the cartilaginous apophysis demonstrated no significant differences (p = 0.2).
Tendon transfers through unossified bones altered subsequent bone development.
While the long-term consequence of these structural changes is unknown, these findings suggest that tendon transfers through unossified bones should be avoided and alternative methods of tendon fixation explored.
对于接受庞塞蒂石膏固定法治疗的小儿马蹄内翻足患者，通常会进行胫前肌腱转移术（TATT）。经典的胫前肌腱转移术包括将肌腱穿过在已骨化的楔骨上钻出的孔。本研究的目的是确定通过未骨化的骨骼转移肌腱是否会对后续骨骼发育产生不良影响。
25只仔猪接受了五种手术操作之一。然后使用18号针头在跟骨的骨质或软骨部分（通过直接可视化）钻出一个隧道，并根据手术操作，将分离的趾浅屈肌（FDS）肌腱条穿过这些隧道。随后对跟骨骨骺进行影像学和/或组织学评估。开发了一个离散的（1 - 4）和二分法的“正常”或“异常”评分系统，并评估其可靠性，以对跟骨外观进行分级。然后将手术操作后的跟骨外观与对照组进行比较。然后使用MTS机器比较一部分转移肌腱的平均破坏载荷。
所提出的骨骺分级系统（1 - 4）显示组内相关系数（ICC）的一致性为0.92 [95%置信区间（CI）0.88 < ICC < 0.95]，一致性的ICC为0.91（95% CI 0.86 < ICC < 0.95），表明具有高度一致性。同样，1 - 4评分系统的Fleiss' kappa值为0.67，表明评审者之间具有实质性一致性。当将1 - 4系统转换为二分法方案“正常”和“异常”时，kappa值增加到0.94，表明具有高度一致性。使用该评分方案评估了46个骨骺（13个对照和33个手术）。骨骺转移明显比对照组更异常（p < 0.0001），而仅进行隧道置入后未发现异常差异（p = 1）。对转移到骨骼或穿过软骨骨骺的肌腱进行的力学测试未显示出显著差异（p = 0.2）。
通过未骨化的骨骼进行肌腱转移会改变后续骨骼发育。
虽然这些结构变化的长期后果尚不清楚，但这些发现表明应避免通过未骨化的骨骼进行肌腱转移，并探索肌腱固定的替代方法。
