Correlation of Postoperative Position of the Sesamoids After Chevron Osteotomy With Outcome

Glenn G. Shi, MD, Peter Henning, MD, and Richard M.Marks, MD

Abstract

Background: Postoperative incomplete reduction of the sesamoids has been identified as a potential risk factor for hallux valgus recurrence after proximal osteotomy. However, it is not known whether the postoperative sesamoid position is a risk factor in hallux valgus correction via distal chevron osteotomy with or without dorsal web space release (DWSR).

Methods: In this retrospective study, 169 patients who underwent distal chevron osteotomy with or without DWSR were reviewed. Preoperative and postoperative (6 weeks, 6months, 12 months) weightbearing radiographs were evaluated. Functional hallux valgus angle (HVA), intermetatarsal angle (IMA), and the position of the tibial sesamoid were graded using the center of head method. Seventy-six radiographs were available for review at the 12-month follow-up. Of these, 41 patients underwent DWSR procedure and 35 did not.

Results: In both groups, correction of all 3 parameters (HVA, IMA, tibial sesamoid position) were significant at the 12-month follow-up. Comparison of the postoperative results of the 2 groups showed no statistically significant differences. Four feet demonstrated displaced sesamoid position at the12-month follow-up, with radiographic evidence of recurrence in just one. No significant relationship was found between postoperative sesamoid position and hallux valgus recurrence that occurred in 4 feet.

Conclusion: Combining DWSR with a distal chevron osteotomy did not delay healing or increase risk of avascular necrosis, but it did not significantly improve angular measurements or sesamoid position. The concept that postoperative sesamoid position can be used to predict hallux valgus recurrence was not supported by our results when looking at distal chevron correction.

許多作者都指出不完美的術(shù)后籽骨位置往往是跖骨近端截骨術(shù)后癥狀復(fù)發(fā)的潛在危險因素,。但未有針對籽骨復(fù)位不良與遠(yuǎn)端Chevron截骨術(shù)后拇外翻復(fù)發(fā)之間相關(guān)性的研究,?？傮w來講，拇外翻手術(shù)最常見的并發(fā)癥為畸形復(fù)發(fā),，有報道指出約為3%到14%,。產(chǎn)生此并發(fā)癥的潛在危險因素有很多，此文即為評估籽骨復(fù)位與遠(yuǎn)端Chevron截骨術(shù)后復(fù)發(fā)拇外翻之間的關(guān)系,。本文分析了遠(yuǎn)端Chevron截骨術(shù)后籽骨解剖復(fù)位與不完全復(fù)位,，其各自的拇外翻畸形復(fù)發(fā)率，以確定籽骨不完全復(fù)位是否為術(shù)后拇外翻復(fù)發(fā)的潛在危險因素,。作者2004年1月到2011年1月間治療了169例患者,，其中女57例，男12例,，平均50歲（18-70歲）,。76例患者（72女，4男）獲得了12個月以上的隨訪,。有41例（54%）患者行伴軟組織松解的Chevron矯形術(shù),，35例（46%）患者行不伴軟組織松解的Chevron矯形術(shù)。術(shù)后若在負(fù)重位前后位X線片上出現(xiàn)超過20°的拇外翻角即為畸形復(fù)發(fā),。

圖1. 術(shù)前負(fù)重正位片上標(biāo)記拇外翻角(HVA)和跖骨間角(IMA)

圖2. 依脛側(cè)籽骨相對第一跖骨軸線位置所描述的分度

12個月后觀察伴或不伴軟組織松解的遠(yuǎn)端Chevron矯形術(shù)后拇外翻角,、功能性跖骨間夾角和籽骨位置均有明顯改善。籽骨復(fù)位程度與遠(yuǎn)端Chevron矯形術(shù)后拇外翻矯正程度和復(fù)發(fā)間并無對應(yīng)關(guān)系,。所以盡管籽骨復(fù)位好的患者有較低的復(fù)發(fā)率,，但本文并不支持把籽骨位置當(dāng)做預(yù)測拇外翻復(fù)發(fā)的指標(biāo)。本文也提出,，遠(yuǎn)端Chevron矯形術(shù)中同時行軟組織松解并未增加缺血性壞死的風(fēng)險,，但是也未明顯改善術(shù)后拇外翻角和籽骨位置,。

專 家 點(diǎn) 評

在中,、重度拇外翻病例,，往往需近端截骨術(shù)，術(shù)后籽骨的位置與拇外翻的復(fù)發(fā)是有聯(lián)系的,。即籽骨復(fù)位不良者,，拇外翻復(fù)發(fā)的機(jī)會增加。本文提出Chevron截骨后籽骨位置與拇外翻復(fù)發(fā)沒有關(guān)聯(lián),?？赡苁怯捎谳p度拇外翻軟組織的攣縮并不嚴(yán)重，籽骨脫位亦不嚴(yán)重,，故而籽骨位置與拇外翻復(fù)發(fā)并無顯著聯(lián)系,；另外跖骨的旋轉(zhuǎn)對籽骨位置的評價也有影響，由于跖骨旋轉(zhuǎn),，正常的籽骨-跖骨關(guān)系也可在X線正位上表現(xiàn)出移位,。事實(shí)上，關(guān)于籽骨位置與拇外翻復(fù)發(fā)間的聯(lián)系也有不同的研究結(jié)果,，尚有爭議,。我們的臨床經(jīng)驗也發(fā)現(xiàn)，在Chevron截骨術(shù)中如果軟組織松解不到位,，跖骨頭外側(cè)推移比較困難,，還需作進(jìn)一步研究。

點(diǎn)評：北京同仁醫(yī)院足踝外科中心  張建中 教授

翻譯：北京同仁醫(yī)院足踝外科中心   曲  峰  醫(yī)生 

編輯：北京同仁醫(yī)院足踝外科中心  李淑媛  醫(yī)生

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