跖骨短小症的治疗 | 前中足专辑

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各位读者，大家好！

近期，我们将制作一期来源于「河南足踝」和「山东足踝」的前中足常见足病专辑，该专辑由郑州市骨科医院的王翔宇教授团队和山东大学第二医院的胡勇教授团队，从多年临床诊疗和经验积累出发，针对前中足的临床解剖和生物力学等基础知识、临床诊断和治疗、手术治疗中的术式及其组合应用等，以及临床典型病例分别进行分享。

今天，由山东大学第二医院的胡勇教授团队为大家带来的「跖骨短小症的治疗」。

本文介绍了跖骨短小症、流行病学及解剖、临床表现及其治疗方法。

一、跖骨短小症

1

概述

▶  跖骨短小症是因为先天性或后天性原因导致的跖骨异常短小。

▶  第1和第4跖骨最常受累^[1]。

▶  跖骨短小症可能是先天性的、获得性的、病理性的或者是其他的一些综合征的一种临床表现。

▶  先天性跖骨短小症有明显的遗传倾向^[1，2]。

2

流行病学

▶ The largest published series investigated healthy Japanese school children and reported the incidence of brachymetatarsia to be between 0.022% (1 in 4586) and 0.05% (1 in 1820) with a female predominance of 25:1. 

▶ Bilateral shortening is noted in 72% of congenital cases and short fourth or fifth metacarpals was associated with fourth brachymetatarsia in 14% of patients. 

▶ Hereditary patterns have been described in some families and may occur as recessive traits that skip several generations^[1].

3

解剖

▶  正常足的5个跖骨头顶点连线呈圆滑的抛物线。当跖骨离抛物线相距大于等于5mm时，就可以诊断为跖骨短小。

▶  文献中对于第1和第2跖骨的长度的关系是有争议的。

Harris and Beath studied 7167 military recruits and found that the first metatarsal was longer than the second in 40%, shorter than the second in 38%, and equal in length in 22%^[3].

图 | AP radiograph of both feet.The rigid foot shows first- and fourth-ray brachymetatarsias and the left has a normal parabola.

▶  骨化中心：第1跖骨-跖骨基底、其他跖骨-跖骨头

▶  各种先天性和后天性原因（包括各种综合征）导致的骨骺早闭引发足趾的畸形。一般在10岁左右可以显现出来^[1]。

二、临床表现

▶ 先天性跖骨短小症的外观表现为相对应脚趾短小，其实质是跖骨短缩。

▶ 常表现为脚趾畸形、仰趾畸形、爪形趾、足弓塌陷、胼胝形成，严重者行走出现疼痛等^[4]。

▶ 第3跖骨短小还会导致拇外翻。

▶ 慢性的畸形会出现趾伸肌腱、屈肌腱、皮肤的挛缩等^[5,6]。

▶ 需要注意有无其他身体异常，做一个全身检查。病人就诊多因为外观或者疼痛^[1]。

三、治疗

1

治疗选择

▶  保守治疗：跖骨垫、趾套、矫形护具等

▶  当出现疼痛时，选择手术治疗^[7,8]

2

手术方法

最常用的手术方法为一次性延长术和外固定架延长术^[1]。

Syndactylization has been described as a possible surgical correction for brachymetatarsia.

If cosmesis is not a concern,the fourth ray can be disarticulated from the metatarsal,which,in turn,can undergo syndactylization to the third digit.This procedure renders the fourth digit nonfunctional and would not be an option for a patient who has cosmetic concerns^[9,10].

▶  一次性延长术

Descriptions include osteotomy with one-stage lengthening without bone graft and osteotomy with interposition of autogenous bone graft,synthetic substitutes,or allograft interposition^[13,14].

● 适应征：跖骨短缩1.5cm以内并引起足底痛性胼胝，临床症状显著，保守治疗无效

● 禁忌征：严重骨质疏松症者；跖骨基底部跖骨直径小于1cm者及有一般外科手术禁忌证者

● 延长极限：1.5cm^[11,12]

图 | 术前（左图）与术后（右图）

图 | 术前（左图）与术后（右图）

● 自体骨移植

MeGlamry and Cooper first described one-stage lengthening of a short metatarsal in 1969 using autogenous bone graft from the calcaneus.

Nine years later,Urano and Kobayashi used autogenous iliac crest and tibial bone grafts to fashion＂spindle-shaped＂grafts that were placed into the MTP joint.

Since these first two studies,reports have described the use of autogenous bone grafts frrom several sites ,including the calcaneus ,navicular,iliaccrest,tibia,fibula,and adjacent metatarsals.

Some investigators have suggested shortening adjacent metatarsals or proximal phalanxes to require less lengthening of the involved metatarsal^[15].

●注意事项

1、术后应该注意患趾血运，延长长度不要超过血管神经的最大牵拉限度。可以做肌腱和皮肤的延长。

Baek and Chung advocated one-stage lengthening with gradual distraction at the metatarsal diaphyseal osteotomy site for 20 to 30 minutes intra-operatively before interposition of a bicortical iliac bone graft.

Initial distraction of 7mm to 8mm was applied using a bone spreader,incremental increases of 1.5mm were applied with 3-minute intervals between incremental increase.

2、注意跖骨的倾斜度，倾斜度过大易造成跖骨头下沉而导致过度负重，反之跖骨头上抬，造成转移性跖痛^[11,12]。

▶  牵拉延长术

● 适应征：跖骨短缩在1.5cm以上并引起足底痛性胼胝，临床症状显著，保守治疗无效

● 禁忌征：跖骨直径小于1cm、跖骨有成角或弯曲等畸形难以骨延长者，严重骨质疏松者及有一般外科手术禁忌者^[11,13]。

● 术后：术后当天起，每天2次沿跖骨纵轴牵开外固定架，每次0.25mm；2周后增加至每天3次，每次0.25mm。

● Ilizarov外固定架：术后5-7天开始以每天0.5-1mm速率分3-4次进行延长^[13]。

● 待延长长度达到要求，延长部位已临床愈合时，可去除外固定器，但克氏针要到骨性愈合后方可拔除。

● 优点：不易发生血管危象；有效维持跖骨的力线；神经和皮肤并发症少。

● 缺点：时间长，针道感染^[14]。

3

并发症

 

Recent studies demonstrated that most complications occur when the metatarsal is lengthened beyond 40% of its native length ,regardless of the lengthening method that is used.

▶  一次性延长术：

血管痉挛-坏疽；内固定松动；关节僵硬；再骨折；骨不连等。

▶  牵拉成骨延长术：

针道感染；跖趾关节活动度；跖趾关节脱位；骨不连；延迟愈合；提前愈合；成角畸形等。

总结

① Because each presenting problem is unique, each clinical case of brachy - metatarsia should be approached individually.

② In our opinion , surgical intervention for brachymetatarsia should only be used to treat symptoms of pain secondary to the deformity. 

③ Transfer metatarsalgia , deformities that result in problems with shoewear , and intractable pain are indications for surgery in the correct patient population. We do not believe cosmesis is an appropriate indication for correctional surgery  .

④ Patient selection is of utmost importance for treatment for brachymetatarsia , especially for gradual lengthening procedures. The patient must be compliant and reliable .

⑤ Smoking cessation is encouraged strongly because smoking increases nonunion rates and complication rates in both types of procedures.  

⑥ Decreased range of motion at the MTP joint is common postoperatively and must be discussed with the patient at the preoperative clinic appointment .

⑦ For these reasons. cosmesis is not considered by the authors to be an appropriate indication for surgery because the postoperative result may not be acceptable to the patient who is concerned only with the appearance  of their toe^[1].

⑧ 对于小于15mm的跖骨短小可以选择一次性延长术，对于需要延长较长或者需要同时进行软组织延长的可以选择牵拉成骨延长术。

⑨ 在做延长的同时可以做临近跖骨的短缩手术，以恢复跖骨头的正常弧度。

⑩ 对于不同的病人，根据病人的病情和期望值需要制定不同的治疗方案。

⑪ 病人的选择对于术后的满意度非常重要^[1]。

参考文献：

[1]Aimee Schimizzi,MD,Michael Brage,MD.Brachymetatarsia.Foot Ankle Clin N Am 9(2004)555-570

[2]Bartolomei FJ.Surgical correction of brachymetatarsia,J Am Podiatry Med Assoc 1990;80:76-82

[3]Harris RI,Beath T,The short first metatarsal;its incidence and clinical significance,J Bone Joint Surg 1949;31A:553-65.

[4]Davidson RS,Metatarsal lengthening.Foot Ankle Clin 2001；6(3):499-518.

[5]Levine SE,Davidson RS,Drummond DS,Distration osteogenesis for congenitally short lesser metatarsals.Foot Ankle Int 1995;16(4):196-200.

[6]Johnson HA.Correction of a congenitally short fourth metatarsal.Br J Plast Surg 1972;25(2):201.

[7]McGlamry ED,Cooper CT,Brachymetatarsia:a surgical treatment,J Am Podiatry Assoc 1969,59(7):259-64.

[8]Biggs EW,Brahm TB,Efron BL.Surgical correction of congenital hypoplastic metatarsals,J Am Podiatr Assoc 1979;69(4):241-4.

[9]Jimenez AL,Brachymetatarsia:a study in surgical planning,J Am Podiatry Assoc 1979;69(4):245-51.

[10]Anklt Desal,Surjit Lidder. Brachymetatarsia fourth metatarsal,Lengthening scarf osteotomy with bone graft.Orthopedic Reviews 2013;volume 5:e21.

[11]王正义 主编《足踝外科手术学》人民卫生出版社，2009年

[12]Baek GH1,Chung MS.The treatment of congenital brachymetatarsia by one stage lengthening.J Bone Joint Surg Br.1998 nov;80(6):1040-4.

[13]Keun-Bae Lee,et al. How to avoid complications of distraction osteogenesis for first brachymetatarsia.Acta Orthop.2009 Apr;80(2):220-5.

[14]Gamal A Hosny M,D,1,Abdel-Salam A,Ahmed M,D,Distraction osteogenesis of fourth brachymetatarsia.Foot and Ankle Surgery 22(2016)12-16.

[15]Lamm, B. M., & Gourdine-Shaw, M. C. (2010). Problems, Obstacles, and Complications of Metatarsal Lengthening for the Treatment of Brachymetatarsia. Clinics in Podiatric Medicine and Surgery, 27(4), 561–582.