儿童马蹄足外架矫正后踝关节功能的影响因素分析

Influencing factors of ankle joint function after clubfoot correction by external fixator in Children

目的外固定架治疗儿童马蹄足,可矫正严重、僵硬的畸形并已得到大量的临床验证。但畸形矫正后踝关节活动范围 (range of motion,ROM) 如何,报道较少,存在哪些影响因素尚不明确。方法对外固定架矫正后的踝关节进行影像学测量,随访时踝关节最大背屈和最大跖屈时的胫跟角变化值认定为 ROM,并以 20°为分界,标记为优和差,通过多因素分析,评价不同变量对治疗结果的影响。设定可能影响结果的自变量包括:手术时年龄、发病原因、有无手术史、畸形 Dimeglio 评分、外固定架固定时长、术中是否做跟腱切断术 (tenotomy of achcilleus tendon,TAT)、随访时间。结果 2015 年 7 月至 2019 年 7 月,本院小儿骨科共 42 例 (46 足),符合试验设计,纳入本研究。至末次随访,经影像学验证,踝关节 ROM 20 例优 (43.5%),26 例差 (56.5%)。单因素分析结果显示,既往患足是否有手术史 (χ^(2)=8.248,P=0.004)、术中是否 TAT (χ^(2)=6.083,P=0.014)、不同病因对结果的影响差异有统计学意义 (χ^(2)=11.944,P=0.001)。而多因素分析结果显示,仅病因分类 (先天或后天畸形) 与活动度结果的关联差异有统计学意义 (P=0.021),与先天性畸形相比,后天性畸形患足活动度好的可能性是前者的 27 倍。结论外固定架是治疗儿童马蹄内翻足的有效手段,但并非所有患儿均可获得良好的关节功能,以影像学方法对踝关节活动度进行评估,在各种因素中,发病原因对活动度结果产生影响,先天性畸形患足活动度更差。

Objective External fixators can correct severe and rigid deformities in the treatment of clubfoot in children,and it has been extensively validated in clinical practice.However,there are few reports on the ankle range of motion (ROM) after malformation correction,and the influencing factors are still unclear.Methods Imaging measurements of the ankle were performed after external frame correction.The lateral tibiocalcaneal angle variation values between the maximum dorsiflexion and maximum plantar flexion of the ankle joint were identified as ROM,and 20° was taken as the boundary to mark as good or poor during follow-up.Effects of different variables on the treatment results were evaluated through multi-factor analysis.Independent variables that could influence the outcome included age at operation,cause of disease,surgery history,Dimeglio scores,duration of the frame,intraoperative tenotomy of Achcilleus tendon (TAT),and duration of follow-up.Results Forty-two patients (46 feet) in the department of pediatric orthopaedics in Jishuitan Hospital met the experimental design and were enrolled in this study from July 2015 to July 2019.Good ROM (43.5%) was observed in 20 cases by imaging verification,while poor in 26 cases(56.5%) till the latest follow-up.Univariate analysis showed that surgery history (χ^(2)=8.248,P=0.004),intraoperative TAT (χ^(2)=6.083,P=0.014),and cause of injury (χ^(2)=11.944,P=0.001) were statistically related to the results.Multi-factor analysis showed that only the etiology classification (congenital or acquired malformations)had a statistically significant correlation with articular motion results (P=0.021).Compared with congenital malformations,acquired malformations were 27 times more likely to have good ankle functions.Conclusions External fixator is effective in the treatment of children’s equinovarus as evaluated by imaging data,but not all cases can obtain good joint functions.The cause of the disease has a positive influence on the results among various factors,meanwhile,congenital malformationa will have worse results.