早期肌力平衡手术治疗先天性马蹄内翻足的临床及相关实验研究

Clnical and Rel ated Experunental Studles on theTreatntent of Congenital Clubfoot by Early DynamicMuscle-balance Operation

先天性马蹄内翻足（ｃｏｎｇｅｎｉｔａｌｃｌｕｂｆｏｏｔ，ＣＣＦ）病因、发病机理目前仍不清楚，治疗方法颇多，疗效不一。１９５７～１９９３年，作者采用早期肌力平衡为主的手术共治疗ＣＣＦ９７０例１３７３足，其中６４４例９２６足获０．５～３３年（平均５年４个月）随访。临床及Ｘ线研究结果表明，肌力平衡术后疗效好，总优良率为９０．９％，残余畸形及畸形复发率低。早期手术，彻底松解纠正畸形并建立动态肌力平衡是手术成功关键。肌力平衡手术０．５～１．５岁施行为宜；手术失败的主要原因是转移肌腱附丽点位置选择不当、张力不合适及术中定位错误等。强调在彻底松解纠正畸形的前提下选择发育良好的肌肉，正确的肌腱附丽点位置及合适的肌腱张力作肌力平衡手术，转移肌腱以附于第３楔状骨为宜。对７１个小腿肌肉标本进行组织化学研究，发现ＣＣＦ小腿胫后肌、腓肠肌有１型肌纤维增多及同型肌纤维聚集。提示有肌纤维失神经后神经再支配；肌纤维吖啶橙荧光染色及运动终板ＡｃｈＥ染色未发现明显异常。说明胚胎在生长发育过程中通过神经再支配，达到了神经与肌肉在结构和功能上的完整。本研究结果支持早期肌力不平衡学说，为早期肌力平衡手术提供了理论依据。

AbstractThere are a lot of controversies over the etioleogyand pathogenesis of congenital clubfcot( CCF),manyprocedures for the treatment of CCF have been adopatedsO far,and the results are varied. From 1957 to 1993,970 cases with 1373 feet were treatedbthe early opera.tion achi6Ving dynamic muscle balance in our depart-men;644 cases with 926 feet were followed up from6months to 33 years postoperatively with an average of 5years 4 months. From our clinical and radiological studieson the treatment of CCF, we have conformed that theearly operation by achieving dynamic muscle balance isthe methOd of choice in treating CCF. Excellent andgood results have been obtained in 9 0.9%with lowerrate of recurrence and residual deformities. A prerequistefor a better result is to correct the deformities as much aspossible and achieve dynamic muscle balance, The besttime for this prOcedure is from 6 months to 1.5 vears ofage. The cause of recurrence and overcorrection weremainly due to poor technique of operation,improper in-sert ion of tendon and in adequate tension. In order toprevent the procedure from recurrencc and overcorrection,the site of insertion of the tendon should be properlychoosen,the transferred tendon should be pul led in mod-erate tension. The third cuneiform is the optimum site oftendon insertion. Fifty-three muscles taken from anteriortibialis, posterior tibialis,peroneri,and gastrocnemius ofCCF were stud ied and 18 samples served as controls. Theexperimen tal studies shOwed that a const ant increase inTypeⅠ muscle fibres with muscle type grouping in tibialisposterior a nd gastroc nemius occured presumably duringfetus,However,Acridine orange and AchE stains showedno abnormality,which suggested that the early nervesprouting compensating for devervation have finished andgive rise to this resultant findings. Our experimentalfinding strongly support the clinical studies of CCF,andset a theoretical foundatiOn for the early operation byachieving dynamic muscle balance.