Ponseti方法治疗先天性马蹄内翻足复发的原因分析及对策

Relapsing clubfoot with Ponseti method： cause and treatment

目的分析Ponseti方法治疗先天性马蹄内翻足复发的原因，并探讨相应的治疗对策。方法收集自2000年1月至2008年4月采用Ponseti方法正规治疗的先天性马蹄内翻足病例478例（不包括多关节挛缩马蹄足及未行皮下跟腱切断术的轻型病例），男386例，女92例；双侧236例，单侧242例，共714足。按照Dimglio评分标准分型：Ⅰ型21例29足，Ⅱ型186例275足，Ⅲ型215例308足，Ⅳ型56例102足。所有病例经Ponseti方法给予连续矫形石膏，经皮跟腱切断术后佩戴矫形支具，进行定期随访，关注畸形有无复发，复发与分型及支具佩戴关系，复发的年龄和类型，并做出相应治疗。通常再次给予4～5次连续矫形石膏后根据畸形复发的类型行经皮跟腱切断术，胫前肌转移术或二者的联合。结果所有病例获不同程度随访。共复发89足：Ⅰ型0足，Ⅱ型26足，Ⅲ型30足，Ⅳ型33足。支具佩戴顺从632足，复发38足，复发率6．01％；不顺从82足，复发51足，复发率62．20％。复发年龄集中在2～3岁。复发畸形的类型主要为马蹄和足内翻旋后。复发足再给于4～5次矫形石膏后，18足再行经皮跟腱切断术，61足行胫前肌转移术，10足行两者联合。术后平均随访3年2个月，复发畸形纠正良好。结论先天性马蹄内翻足采用Ponseti方法治疗后复发的两大原因为：原发畸形严重以及家长和患儿对支具佩戴的不顺从。畸形复发通常在自行放弃支具治疗后2～4个月开始。复发类型主要为马蹄和足内翻旋后，根据畸形复发的不同类型再给于4～5次连续矫形石膏后，再行经皮跟腱切断术，胫前肌转移术或两者联合，可以矫正复发畸形，取得良好治疗效果。

Objective To analyze the cause and treatment of relapsing clubfoot with Ponseti method. Methods Four hundred and seventy eight cases （male 386 and female 92） with 714 feet （bilateral in 236 cases, single foot in 242） were managed with Ponseti method in this hospital from Jan. of 2000 to Apr. of 2008. According to the Dimeglio classification：Type Ⅰ 29 feet, Type Ⅱ 275 feet, Type m 308 feet and Type IV 102 feet. All were treated with serial cast,pereutaneous Achilles tenotomy and brace with an abduction orthosis. All cases got regular follow-up. Relapsing were recorded, the relation between the type, using of brace and the recurrence were analyzed. The relapsing patients were treated with recasting for 4 or 5 times, and then percutaneous Achilles tenotomy and/or anterior tibial tendon transfer according to the different types. Results All cases were given follow-up visit. Eighty-nine feet of 714 feet recurred （12. 46%）, 26 in type Ⅱ, 30 in type Ⅲ, and 33 in type Ⅳ. Relapses occurred in 6. 01% （38 feet） of the 632 feet which were compliant with brace while 62. 20% （52 feet） of 82 un-compliant patients. The main age of recurrence was 2 to 2. 5 years old and the main deformities were equino and varus. These recrudescent ones were corrected with advance casting for 4 or 5 times. Eighteen feet underwent percutaneous Achilles tenotomy, 61 feet underwent anterior tibial tendon transfer and 10 got both surgery. All the patients got excellent results at last （average 38 months of follow-up）. Conclusions The two factors for the recurrence of clubfoot treated with the Ponseti method are the compliance with the brace and the severity of the deformity. The recurrence is usually expected 2 to 4 months after the brace was given up and the main deformities were equino and varus. All the recrudescent would be corrected with recasting for 4 or 5 times, then undergoing percutaneous Achilles tenotomy and/or anterior tibial tendon transfer in the light of the different types.