先天性马蹄内翻足患儿Ponseti法矫正后距骨-跟骨角和胫骨-跟骨角的变化

Evaluation of the lateral talocalcaneal angle and lateral tibiocalcaneal angle after using the Ponseti method for congenital clubfoot

目的探讨利用Ponseti方法 (手法矫正+系列石膏固定+经皮跟腱切断术+足外展矫形支具)治疗先天性马蹄内翻足(congenital talipes equinovarus,CTEV)后,足部站立位侧位X线片上距骨-跟骨角和胫骨-跟骨角的变化。方法回顾性分析2013年1月至2015年12月,应用Ponseti方法在我院小儿骨科治疗,且最近一次随访时拍摄双足站立位侧位X线片的24例CTEV患儿。男19例,女5例;左侧4例,右侧12例,双侧8例。5例(10足)正常儿童作为双侧病例的对照组。全部患儿的Ponseti系列石膏矫形和经皮跟腱切断术(percutaneous achilles tenotomy,PAT)均由同一医生完成。临床评价指标包括:初始治疗时年龄、性别、单(双)侧、治疗前和最近一次随访时Pirani严重性评分、石膏次数和是否行PAT。影像学评估指标包括:(1)侧位距骨-跟骨角(lateral talocalcaneal angle,LTCA);(2)侧位胫骨-跟骨角(lateral tibiocalcaneal angle,LTi CA);(3)距骨长轴比,即患侧距骨长轴/健侧距骨长轴×100%。单侧病例取其健侧作为对照组,双侧病例取正常儿童作为对照组。本研究得到中国医科大学附属盛京医院医学伦理委员会批准,患儿家长均签署知情同意书。结果单侧病例:初始治疗时年龄3~94天。平均随访14.75(6~35)个月。治疗前与最近一次随访Pirani严重性评分比较,P_50:6.0~0,P_25:5.25~0,P_75:6.0~0.375,P=0.000。LTCA:患侧27.81°(14°~40°),健侧51.25°(38°~66°),P=0.000。LTi CA:患侧82.19°(51°~102°),健侧79.00°(57°~89°),P=0.35。距骨长轴比81.94%(71.97%~96.70%)。双侧病例:初始治疗时年龄8~173天,平均随访21.63(3~71)个月。治疗前与最近一次随访Pirani严重性评分比较,左足P_50:6.0~0分,P_25:4.75~0分,P_75:6.0~0分,P=0.000;右足P_50:6.0~0分,P_25:5.63~0分,P_75:6.0~0.375分;P=0.000。左足LTCA:患侧30.38°(19°~46°),对照组53.40°(46°~66°),P=0.001;右足LTCA:患侧33.75°(20°~53°),对照组57°(45°~70°),P=0.001。左足LTi CA:患侧83.75°(50°~111°),对照组76.60°(65°~86°),P=0.456;右足LTi CA:患侧80.75°(60°~97°),对照组76.80°(69°~88°),P=0.588。结论 Ponseti方法治疗CTEV后,足部外观和Pirani评分显著改善。患足距骨变小,距骨-跟骨角仍小于正常值,而胫骨-跟骨角恢复接近正常值。

Objective To investigate the changes of the lateral talocalcaneal angle（ LTCA） and the lateral tibiocalcaneal angle（ LTi CA） seen on lateral radiographs taken in the standing position of the patients undergoing treatment for congenital talipes equinovarus by the Ponseti method（ serial manipulation, casting, tenotomy of the Achilles tendon and a foot abduction brace）. Methods From January 2013 to December 2015, 24 patients with congenital talipes equinovarus were treated by the Ponseti method in our department, whose clinical data were retrospectively analyzed. The lateral radiographs of bilateral feet were taken in the standing position of all the patients at the latest follow-up. The Ponseti manipulations, series of castings and percutaneous Achilles tenotomies（ PAT） were performed by the same pediatric orthopedic surgeon. Clinical assessment indicators included age at the time of initial treatment, sex, unilateral clubfoot or bilateral clubfeet involvement, and numbers of castings as well as PAT determined by the Pirani severity score system before treatment and at the latest follow-up. Radiographic indicators included LTCA, LTi CA and the ratios of the long axis of the talus, which were calculated by measuring the talus long axis of the clubfoot and then dividing this by the talus long axis of the normal foot. For the patients with a unilateral clubfoot, the normal side was used as the control. For the patients with bilateral clubfeet, normal children were chosen to be the control group. The Medical Ethics Committee of Shengjing Hospital of China Medical University approved this study, and informed consents were obtained from all the patients as well as from the children of the needed control group. Results A total of 24 patients（ 32 feet）, 19 males and 5 females, were included in the study. Four patients presented with a left clubfoot, 12 patients with a right clubfoot and 8 patients with bilateral clubfeet. Five normal children（ 10 feet） were chosen to be the control group for the patients with bilateral clubfeet. The mean number of castings were 5.8 times（ range： 4-12 times）. PAT were performed on all 32 clubfeet, and the immobilization time with casting was 3 weeks. In the patients with a unilateral clubfoot, the age at the time of initial treatment varied from 3 to 94 days. The average time of follow-up was 14.75 months（ range： 6-35 months）. The Pirani severity scores were compared between pre-treatment and in the latest follow-up： 6.0 versus 0 points（ P50）, 5.25 versus 0 points（ P25） and 6.0 versus 0.375 points（ P75）, P = 0.000. The average LTCA of the affected feet was 27.81°（ range： 14°-40°）, and the average LTCA of the normal feet was 51.25°（ range： 38°-66°）, P = 0.000. The average LTi CA of the affected feet was 82.19°（ range： 51°-102°）, and the average LTi CA of the normal feet was 79.00°（ range： 57°-89°）, P = 0.35. The ratio of the long axis of the talus was 81.94%（ range： 71.97%-96.70%）. In the patients with bilateral clubfeet, the age at the time of initial treatment varied from 8 to 173 days. The average time of follow-up was 21.63 months（ range： 3-71 months）. The Pirani severity scores recorded between pre-treatment and in the latest follow-up in the left foot of this group were 6.0 versus 0 points（ P50）, 4.75 versus 0 points（ P25）, and 6.0 versus 0 points（ P75）, P = 0.000; the Pirani severity scores recorded between pre-treatment and in the latest follow-up in the right foot of this group were 6.0 versus 0 points（ P50）, 5.63 versus 0 points（ P25）, and 6.0 versus 0.375 points（ P75）, P = 0.000. The average LTCA of the left foot in the bilateral clubfeet patient group was 30.38°（ range： 19°-46°）, and the average LTCA of the normal left foot in the control group was 53.40°（ range： 46°-66°）, P = 0.001. The average LTCA of the right foot in the bilateral clubfeet patient group was 33.75°（ range： 20°-53°）, and the average LTCA of the normal right foot in the control group was 57°（ range： 45°-70°）, P = 0.001. The average LTi CA of the affected left foot in the bilateral clubfeet patient group was 83.75°（ range： 50°-111°）, and the average LTi CA of the normal left foot in the control group was 76.60°（ range： 65°-86°）, P = 0.456. The average LTi CA of the affected right foot in the bilateral clubfeet patient group was 80.75°（ range： 60°-97°）, and the normal right foot of the control group was 76.80°（ range： 69°-88°）, P = 0.588. Conclusions The Pirani severity scores are significantly improved for the congenital talipes equinovarus treated by the Ponseti method, as well as the foot appearance. The dimensions of the affected talus are reduced. The LTCA is smaller than normal value and the LTi CA is closed to the normal value on the standing lateral radiographs of the feet after the treatment with the Ponseti method.