Department of Orthopaedic Surgery, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA.
Department of Surgery (Plastic Surgery), Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA.
Foot Ankle Int. 2022 Mar;43(3):353-362. doi: 10.1177/10711007211041336. Epub 2021 Oct 22.
The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis.
Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up.
TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2).
In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems.
Level IV, case series.
需要进行骨块距下跟骰关节（TTC）融合术的患者常伴有骨科疾病和系统性合并症，这使得该手术的并发症发生率高于正常水平，包括不愈合、移植物塌陷、内固定失败和截肢。在这里，我们介绍一种使用辅助成骨剂和延长保护负重时间的新型骨块 TTC 融合术方法，以评估是否可以改善既往的结果。我们还评估了带血管的股骨内侧髁（MFC）游离皮瓣在增强 TTC 融合中的效果。
14 名成年患者接受了使用新鲜冷冻股骨头同种异体骨、骨髓抽吸浓缩物和脱钙骨基质皮质纤维进行生物增强的骨块 TTC 融合术。3 名软组织缺损患者接受了带血管的 MFC 游离皮瓣重建。在随访时评估 TTC 融合的 X 线片、足部功能指数（FFI）、PROMIS 疼痛干扰（PI）和躯体功能（PF）评分。
14 例患者中有 13 例（92.9%）在 X 线片上和 11 例患者中有 10 例（90.9%）在 CT 上显示 TTC 融合。平均融合时间为 183.2±83.2 天。1 例（7.1%）患者发生不愈合和持续性感染，需要截肢。接受带血管骨移植的患者融合时间明显缩短（112.3±31.7 天与 204.4±82.7 天，P=0.05）。患者报告的结果显示，1 年后疼痛和功能轻度至中度（平均 FFI=41.0%±23.1%，PROMIS PI=58.3±1.8，PROMIS PF=39.0±2.2）。
在这个相对较小的系列中，使用成骨剂和保护性负重对骨块 TTC 融合进行生物增强，结果显示融合率高、疼痛适度且下肢功能保留良好。应用 MFC 皮瓣似乎可以增强和加速骨愈合。我们认为，这种方法为这些具有挑战性的临床问题提供了一种可行的挽救方案。
IV 级，病例系列。
