先天性胫骨假关节:Charnley-Williams手术技术变化的结果

C. Johnston
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引用次数: 99

摘要

背景:Charnley-Williams髓内固定法治疗先天性胫骨假关节的结果不同,部分原因是手术技术的不同。我们比较了三种不同手术的结果,以确定哪种技术最有可能愈合。方法:回顾了23例连续的先天性胫骨假关节患者在首次髓内棒手术治疗后的4至14年的结果。进行了三种类型的手术:A型,包括切除胫骨假关节并缩短,将髓内棒插入胫骨,胫骨植骨结合腓骨切除或截骨并将髓内棒插入腓骨;B型,与A型相同,但不包括腓骨固定;C型包括胫骨棒插入和植骨,但不进行腓骨手术。结果被分类为1级,当有明确的愈合,完全的负重功能和维持对齐不需要额外的手术治疗;2级:关节愈合不明确,功能正常,肢体有支架保护,外翻或矢状弓,需要或预期进行额外手术;3级:持续性骨不连或再骨折,需要全时间的外部支持来缓解疼痛和/或不稳定。结果:11例患者(48%)最终达到1级预后;九,成绩二级;第三,成绩为3级。最终结果与病变的初始x线表现或患者在初始手术时的年龄无关。a、B类手术后的疗效优于c类手术后的疗效。完整腓骨手术导致3级预后的发生率低于未完整腓骨手术的发生率(p = 0.05)。髓内棒内穿固定踝关节并没有降低3级预后的发生率。结论:c型手术几乎没有理由,因为在每个病例中,c型手术要么导致持续不愈合,要么未能改善模棱两可的结果。在这个系列中,留下完整的腓骨不受干扰以保持稳定性或长度也不成功。此外,腓骨功能不全(骨折或假关节前病变)的存在对随后的外翻畸形(12例中有10例发生)具有高度的预后影响,无论腓骨最终是否愈合。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Congenital Pseudarthrosis of the Tibia: Results of Technical Variations in the Charnley-Williams Procedure
Background: Results of the Charnley-Williams method of intramedullary fixation for treatment of congenital pseudarthrosis of the tibia have varied, in part because of variations in surgical technique. The outcomes of three variations of this procedure were compared to determine which technique was the most likely to result in union. Methods: The results in twenty-three consecutive patients with congenital pseudarthrosis of the tibia were reviewed at four to fourteen years following initial surgical treatment with an intramedullary rod. Three types of procedures were performed: type A, which consisted of resection of the tibial pseudarthrosis with shortening, insertion of an intramedullary rod into the tibia, and tibial bone-grafting combined with fibular resection or osteotomy and insertion of an intramedullary rod into the fibula; type B, which was identical to type A except that it did not include fibular fixation; and type C, which consisted of insertion of a tibial rod and bone-grafting but no fibular surgery. The outcome was classified as grade 1 when there was unequivocal union with full weight-bearing function and maintenance of alignment requiring no additional surgical treatment; grade 2 when there was equivocal union with useful function, with the limb protected by a brace, and/or valgus or sagittal bowing for which additional surgery was required or anticipated; and grade 3 when there was persistent nonunion or refracture, requiring full-time external support for pain and/or instability. Results: Eleven patients (48%) ultimately had a grade-1 outcome; nine, a grade-2 outcome; and three, a grade-3 outcome. The final outcome was not associated with either the initial radiographic appearance of the lesion or the age of the patient at the time of the initial surgery. The results following type-A and B operations were better than those after type-C procedures. Surgery on an intact fibula resulted in a lower prevalence of grade-3 outcomes than was found when an intact fibula was not operated on (p = 0.05). Transfixation of the ankle joint by the intramedullary rod did not decrease the prevalence of grade-3 outcomes. Conclusions: There is little justification for a type-C operation, as it either resulted in a persistent nonunion or failed to improve an equivocal outcome in every case. Leaving an intact fibula undisturbed to maintain stability or length also was not successful in this series. In addition, the presence of fibular insufficiency (fracture or a pre-pseudarthrotic lesion) was highly prognostic for subsequent valgus deformity (occurring in ten of twelve cases), whether or not the fibula eventually healed.
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