Van de Velde Samuel K, Graham H Kerr, Ye Ken, Chambers Henry, Rutz Erich
Columbia University Medical Center, New York, NY.
The Royal Children's Hospital, Parkville, Victoria, Australia.
J Bone Joint Surg Am. 2024 Dec 18;106(24):e49. doi: 10.2106/JBJS.24.00092. Epub 2024 Aug 22.
A dorsal bunion may occur in nonambulatory adolescents with cerebral palsy (CP) and a Gross Motor Function Classification System (GMFCS) level of IV or V. The deformity can cause pain, skin breakdown, and difficulty wearing shoes and braces. A consensus on the biomechanics and surgical management of dorsal bunions in persons with severe CP has not been established.
This retrospective cohort study included 23 nonambulatory adolescents with CP, GMFCS level IV or V, and symptomatic dorsal bunions requiring surgery. The median age at surgery was 17 years, and the median follow-up was 56 months. Reconstructive surgery included the excision of a 2 to 3-cm segment of the tibialis anterior tendon to correct the elevation of the first metatarsal. The fixed deformity of the first metatarsophalangeal joint was managed with use of corrective arthrodesis and dorsal plate fixation. Clinical and radiographic outcomes were assessed preoperatively and postoperatively at the transition to adult services.
There were significant improvements in the clinical and radiographic outcome measures (p < 0.001). Pain was relieved, and there were no further episodes of skin breakdown. The elevation of the first metatarsal was corrected from a mean of 3° of dorsiflexion to a mean of 19° of plantar flexion. The deformity of the first metatarsophalangeal joint was corrected from a mean of 55° of plantar flexion to a mean of 21° of dorsiflexion. Six patients had complications, all of which were grade I or II according to the modified Clavien-Dindo system.
The surgical reconstruction of a dorsal bunion via soft-tissue rebalancing of the first ray and corrective arthrodesis of the first metatarsophalangeal joint resulted in favorable medium-term clinical and radiographic outcomes in nonambulatory adolescents with CP.
Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
拇背囊肿可能发生在非行走型脑瘫（CP）青少年中，且其粗大运动功能分类系统（GMFCS）为IV级或V级。该畸形可导致疼痛、皮肤破损以及穿鞋和佩戴支具困难。对于重度CP患者拇背囊肿的生物力学和手术治疗尚未达成共识。
这项回顾性队列研究纳入了23例非行走型CP青少年，GMFCS为IV级或V级，且有症状性拇背囊肿需要手术治疗。手术时的中位年龄为17岁，中位随访时间为56个月。重建手术包括切除2至3厘米长的胫前肌腱段以纠正第一跖骨抬高。第一跖趾关节的固定畸形采用矫正关节融合术和背侧钢板固定进行处理。在向成人服务过渡时，于术前和术后评估临床和影像学结果。
临床和影像学结果指标有显著改善（p < 0.001）。疼痛缓解，且未再出现皮肤破损情况。第一跖骨抬高从平均背屈3°矫正至平均跖屈19°。第一跖趾关节畸形从平均跖屈55°矫正至平均背屈21°。6例患者出现并发症，根据改良Clavien-Dindo系统，所有并发症均为I级或II级。
通过第一跖骨软组织平衡和第一跖趾关节矫正关节融合术对拇背囊肿进行手术重建，在非行走型CP青少年中取得了良好的中期临床和影像学结果。
治疗性IV级。有关证据水平的完整描述，请参阅作者须知。
