Yang Chonglin, Liu Ping, Cao Yongxing, Guo Changjun, Zhu Yuan, Xu Xiangyang
Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Ann Transl Med. 2022 Mar;10(6):270. doi: 10.21037/atm-22-997.
We often attribute the lateral ankle impingement to the valgus calcaneus, while ignoring the varus distal tibia. The diagnostic criteria, severity and treatment of distal tibia varus syndrome (DTVS) have not been reported. This retrospective study sought to propose a diagnosis and classification system for DTVS based on patients' clinical symptoms and imaging findings.
A total of 76 symptomatic patients with varus distal tibia and congruent ankle examined between 2010 and 2018 were involved to evaluate clinically based on their SF-36 scores, AOFAS ankle-hindfoot scores, and VAS scores. Each patient's history, symptoms, and MRI images were analyzed retrospectively, and their weight-bearing ankle radiographs were observed to measure the tibial anterior surface angle (TAS) and tibial tilt angle (TTA). Paired -test and Kruskal-Wallis test were used to compare the results above.
Forty-three men and 33 women with an average age of 46 years (range, 28-68 years) included. Besides the same symptom of intermittent subfibular pain, 3 types of DTVS were defined: (I) Type I: a sloped surface of the distal tibia with the congruent tibiotalar joint on radiographs; (II) Type II: a sloped surface of the distal tibia with the congruent tibiotalar joint on radiographs, and soft-tissue edema inferior to the lateral malleolus on MRI images; and (III) Type III: the same symptoms as Type II, plus osteochondral lesions of the talus on MRI images. Under our proposed classification system, 26 patients were classified as Type I, requiring conservative treatment, 22 as Type II, and 28 as Type III under supramalleolar valgus osteotomy. The ankle functional evaluation scores, such as the SF-36 (74.14±12.50 preoperatively and 85.22±8.83 postoperatively), AOFAS (71.14±15.19 preoperatively and 87.53±8.62 postoperatively), and VAS (5.41±1.10 preoperatively and 1.82±1.08 postoperatively) scores for all types were significantly improved (P<0.01). The TAS (80.38°±4.80° preoperatively and 90.44°±3.96° postoperatively) and TTA (13.02°±3.41° preoperatively and 0.62°±2.67° postoperatively) of all the patients on the weight-bearing ankle radiographs were significantly improved (P<0.01).
DTVS, causing lateral ankle impingement, can be diagnosed based on clinical manifestations and imaging findings. Our classification system can aid in the decision-making process in relation to the appropriate form of conservative or surgical treatments.
我们常常将外侧踝关节撞击归因于跟骨外翻，而忽略了胫骨远端内翻。目前尚未见有关胫骨远端内翻综合征（DTVS）的诊断标准、严重程度及治疗的报道。本回顾性研究旨在基于患者的临床症状及影像学表现，提出DTVS的诊断及分类系统。
纳入2010年至2018年间共76例有症状的胫骨远端内翻且踝关节匹配的患者，基于其SF-36评分、美国足踝外科协会（AOFAS）踝-后足评分及视觉模拟评分（VAS）进行临床评估。对每位患者的病史、症状及磁共振成像（MRI）图像进行回顾性分析，并观察其负重位踝关节X线片以测量胫骨前表面角（TAS）及胫骨倾斜角（TTA）。采用配对t检验及Kruskal-Wallis检验比较上述结果。
纳入43例男性及33例女性，平均年龄46岁（范围28 - 68岁）。除了间歇性腓骨下疼痛这一相同症状外，定义了3种类型的DTVS：（I）I型：X线片显示胫骨远端呈倾斜面且胫距关节匹配；（II）II型：X线片显示胫骨远端呈倾斜面且胫距关节匹配，MRI图像显示外踝下方软组织水肿；（III）III型：与II型症状相同，但MRI图像显示距骨有骨软骨损伤。在我们提出的分类系统下，26例患者被分类为I型，需保守治疗，22例为II型，28例为III型，后者接受了距上外翻截骨术。所有类型患者的踝关节功能评估评分，如SF-36评分（术前74.14±12.50，术后85.22±8.83）、AOFAS评分（术前71.14±15.19，术后87.53±8.62）及VAS评分（术前5.41±1.10，术后1.82±1.08）均显著改善（P<0.01）。所有患者负重位踝关节X线片的TAS（术前80.38°±4.80°，术后90.44°±3.96°）及TTA（术前13.02°±3.41°，术后0.62°±2.67°）均显著改善（P<0.01）。
导致外侧踝关节撞击的DTVS可根据临床表现及影像学表现进行诊断。我们的分类系统有助于在选择合适的保守或手术治疗方式时辅助决策。
