Mulligan Ryan P, Adams Samuel B, Easley Mark E, DeOrio James K, Nunley James A
1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
Foot Ankle Int. 2017 Dec;38(12):1343-1351. doi: 10.1177/1071100717731728. Epub 2017 Sep 27.
A variety of operative approaches and fixation techniques have been described for tibiotalocalcaneal (TTC) arthrodesis. The intramedullary (IM) nail and lateral, fixed-angle plating are commonly used because of ease of use and favorable biomechanical properties. A lateral, transfibular (LTF) approach allows for direct access to the tibiotalar and subtalar joints, but the posterior, Achilles tendon-splitting (PATS) approach offers a robust soft tissue envelope. The purpose of this study was to compare the results of TTC arthrodesis with either a PATS approach with IM nailing or LTF approach with fixed-angle plating.
A retrospective review was performed on all patients who underwent simultaneous TTC arthrodesis with minimum 1 year clinical and radiographic follow up. Patients were excluded if they underwent TTC arthrodesis through an approach other than PATS or LTF, and received fixation without an IM nail or fixed-angle plate. Primary outcomes examined were union rate, revisions, and complications. Thirty-eight patients underwent TTC arthrodesis with a PATS approach and IM nailing, and 28 with a LTF approach and lateral plating.
The overall union rate was 71%; 76% (29 of 38 patients) for the PATS/IM nail group, and 64% (18 of 28) for LTF/plating group ( P = .41). Symptomatic nonunion requiring revision arthrodesis occurred in 16% (6 of 38) of the PATS/IM nail group versus 7% (2 of 28) in the LTF/lateral plating group ( P = .45). There were no significant differences in individual tibiotalar or subtalar union rates, superficial wound problems, infection, symptomatic hardware, stress fractures, or nerve irritations.
Union, revision, and complication rates were similar for TTC arthrodesis performed with a PATS approach and IM nail compared with an LTF approach and fixed-angle plate in a complex patient population. Both techniques were adequate, especially when prior incisions, preexisting hardware, or deformity preclude options.
Level III, retrospective comparative study.
对于胫距跟（TTC）关节融合术，已经描述了多种手术入路和固定技术。髓内（IM）钉和外侧的角钢板因其使用方便和良好的生物力学性能而被广泛应用。外侧经腓骨（LTF）入路可直接显露胫距关节和距下关节，但后方经跟腱劈开（PATS）入路能提供更坚实的软组织覆盖。本研究的目的是比较采用PATS入路联合IM钉与LTF入路联合角钢板行TTC关节融合术的结果。
对所有接受同期TTC关节融合术且有至少1年临床及影像学随访的患者进行回顾性研究。若患者采用PATS或LTF以外的入路行TTC关节融合术，或未使用IM钉或角钢板进行固定，则被排除。主要观察指标为融合率、翻修情况及并发症。38例患者采用PATS入路联合IM钉行TTC关节融合术，28例采用LTF入路联合外侧钢板。
总体融合率为71%；PATS/IM钉组为76%（38例中的29例），LTF/钢板组为64%（28例中的18例）（P = 0.41）。PATS/IM钉组有16%（38例中的6例）因症状性骨不连需要翻修关节融合术，而LTF/外侧钢板组为7%（28例中的2例）（P = 0.45）。在胫距关节或距下关节的个体融合率、浅表伤口问题、感染、症状性内固定物、应力性骨折或神经刺激方面，两组间无显著差异。
在复杂患者群体中，采用PATS入路联合IM钉与采用LTF入路联合角钢板行TTC关节融合术的融合、翻修及并发症发生率相似。两种技术均可行，特别是在既往有手术切口、存在内固定物或畸形而限制其他选择时。
III级，回顾性比较研究。
