微创治疗婴幼儿先天性垂直距骨的临床研究

Clinical efficacies of mini-invasive procedure for congenital vertical talus in young children

目的评价早期应用手法＋石膏矫形结合小切口微创方法治疗先天性垂直距骨的临床疗效。方法回顾自2011年6月至2015年6月我院治疗的先天性垂直距骨16例30足给予手法＋跖屈内翻位系列石膏矫形固定和小切口微创方法治疗的患儿，术后石膏固定12周，拆去石膏后佩戴跖屈内翻位支具，最初3个月每天23 h，随后佩戴20 h至行走期，会行走后夜间佩戴至4岁。术后定期随访观察及X线检查，采用Adelaar临床体征评分及Hamanishi的X线参数，结果比较进行t检验。结果16例30足随访时间12-63.6个月，平均43.2个月，所有CTV具有良好外观和足弓，踝关节无明显功能障碍，背屈：术前/术后10°（0°-20°）/22.5°（5°-35°）（P〈0.01），跖屈：术前/术后－10°（－20°-0°）/22.5°（5°-35°）（P〈0.001），术后效果为优83.7%，良10%，可3.3%，均可穿日常鞋行走。结论应用手法按摩及系列石膏固定结合不切开或小切口切开复位距舟关节治疗先天性垂直距骨，具有微创、手术瘢痕少、术后近期足踝功能恢复满意的优点，同时也为远期足踝功能恢复提供保障。支具的运用有利于防止畸形的复发。

Objective To assess the clinical efficacies of patients with congenital vertical talus （CVT） undergoing mini-invasive procedure （MIP） and incorporating early treatment of manipulation and serial casting. Methods From June 2011 to June 2015, the clinical records of 16 CVT infants （30 feet） were retrospectively reviewed. They underwent manipulation and serial casting plus MIP. Casting was applied for 12 weeks postoperatively and followed by wearing plantar flexion position orthosis for 23 hours daily over 3 months, 20 hours subsequently until walking age and then nightly until 4 years old. All of them were available for clinical and radiological follow-ups. And the Adelaar scoring system was utilized for assessing clinical outcomes and Hamanishi system for analyzing radiological parameters. Results The average follow-up period was 43.2 （12-63. 6） months. All cases achieved good appearances and arches without obvious dysfunctions. Profiles of subtalar joint and ankle dorsiflexion： preoperative/postoperative 10°（0°to 20°）/22.5 （5°to 35°） （P〈0. 01） and plantar flexion： preoperative / postoperative - 10° （- 20° to 0°）/22. 5 （5°to 35°） （P〈0.001）. The outcomes were excellent （83. 7%）, good （10%） and fair （3. 3%）. All could walk with normal shoes. Radiology showed one case of ischemic necrosis of talus head. Radiologically there was a statistically significant postoperative improvement of measured angles as compared to preoperative values （P〈 0. 001）. All radiological parameters were within normal ranges. Conclusions Manipulation and serial casting plus MIP （close reduction or small-incision open reduction of talonavicular joint） for CVT yield excellent outcomes. And mini-invasiveness and little scarring offer better long-term ankle functions and using orthosis prevents the recurrence of deformities.