Ilizarov技术矫正儿童僵硬性马蹄内翻足
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摘要
目的探讨Ilizarov技术矫正儿童僵硬性马蹄内翻足畸形的适应证、治疗方法和治疗效果。方法回顾分析2014年7月至2016年7月湖南省儿童医院应用Ilizarov软组织牵张技术联合(不联合)软组织松解术治疗DimeglioⅢ级和Ⅳ级学龄期儿童僵硬性马蹄内翻足15例(20足)的病历资料。其中男10例,女5例;平均年龄75个月(52～97个月);双侧5例,单侧10例;根据Dimeglio先天性马蹄内翻足分级标准进行分级,Ⅲ级9例(12足),Ⅳ级6例(8足)。其中未经治疗的先天性马蹄内翻足7例(9足),经Ponseti方案治疗后复发马蹄足畸形3例(4足),先天性多发性关节挛缩症所致马蹄足畸形1例(2足),Charcot-Marie-Tooth病所致马蹄足畸形1例(1足),脊髓拴系综合征所致马蹄足畸形1例(2足),创伤后瘢痕挛缩所致马蹄足畸形1例(1足),小腿神经鞘瘤术后马蹄足畸形1例(1足)。Ilizarov外固定架平均应用时间为18周(17～21周),Ilizarov外固定架拆除后,应用膝下管形石膏固定踝关节和足部6个月,之后夜间支具固定直至骨骼成熟。结果术后平均随访时间26个月(12～36个月),术后所有患儿畸形足获得满意的跖行足外观,行走无疼痛,踝关节平均活动范围15°(10°～30°),1例(2足)因患儿术后未能遵医嘱佩戴支具复发,需要再次行Ilizarov外固定矫形术。按Dimeglio先天性马蹄内翻足分级标准评定疗效,优14足,良4足,差2足,优良率为90%。结论 Ilizarov外固定矫形技术具有四维、微创、可重复、适用范围广泛等优点,对于矫正儿童僵硬性马蹄内翻足效果显著,尤其适用于8岁以下儿童的重度僵硬马蹄内翻足。但是该技术难度较大,学习曲线较长。
Objective To evaluate the results and indications of Ilizarov technique in treatment of the severe rigid clubfoot deformity of children. Methods From July 2014 to July 2016,15 cases( 20 feet) with Dimeglio's type Ⅲ or Ⅳ clubfoot deformity were treated by Ilizarov technique combined with or without soft tissue release in Hunan Children's Hospital. They were including 10 males and 5 females,with an average age of75 months( 52-97 months). Five patients were involved in bilateral feet,and 10 cases in unilateral. The clinical data of those patients were analyzed retrospectively. According to Dimeglio's classification system,12 feet in 9 cases were graded in type Ⅲ,and 8 feet in 6 cases were type Ⅳ. The foot deformity was resulted from untreated congenital clubfoot in 7 patients( 9 feet),recurrence after Ponseti method treatment in 3 cases( 4 feet),congenital multiple arthrogryposis in one patient( 2 feet),Charcot-Marie-Tooth syndrome in one case( one foot),tethered spinal cord syndrome in one patient( 2 feet),scar contracture after trauma in one case( one foot),and schwannoma involved in the calves in one case( one foot). Results All the patients were followed up for mean 26 months( 12-36 months),and the Ilizarov device were removed at average 18 weeks( 17-21 weeks) postoperatively. All the patients but one whose deformities were recurred,were treated satisfactorily with plantigrade,painless foot,and the range of motion in the involved ankle was average 15°( 10°-30°).Based on Dimeglio grade method,14 feet were excellent,4 feet were good,and 2 feet were poor,with a total of excellent and good grade of 90%. Conclusion The Ilizarov technique is an optional method for treating severe rigid clubfoot deformity in children,even though the technique is difficult and need a relative long learning cure to master.
Objective To evaluate the results and indications of Ilizarov technique in treatment of the severe rigid clubfoot deformity of children. Methods From July 2014 to July 2016,15 cases( 20 feet) with Dimeglio's type Ⅲ or Ⅳ clubfoot deformity were treated by Ilizarov technique combined with or without soft tissue release in Hunan Children's Hospital. They were including 10 males and 5 females,with an average age of75 months( 52-97 months). Five patients were involved in bilateral feet,and 10 cases in unilateral. The clinical data of those patients were analyzed retrospectively. According to Dimeglio's classification system,12 feet in 9 cases were graded in type Ⅲ,and 8 feet in 6 cases were type Ⅳ. The foot deformity was resulted from untreated congenital clubfoot in 7 patients( 9 feet),recurrence after Ponseti method treatment in 3 cases( 4 feet),congenital multiple arthrogryposis in one patient( 2 feet),Charcot-Marie-Tooth syndrome in one case( one foot),tethered spinal cord syndrome in one patient( 2 feet),scar contracture after trauma in one case( one foot),and schwannoma involved in the calves in one case( one foot). Results All the patients were followed up for mean 26 months( 12-36 months),and the Ilizarov device were removed at average 18 weeks( 17-21 weeks) postoperatively. All the patients but one whose deformities were recurred,were treated satisfactorily with plantigrade,painless foot,and the range of motion in the involved ankle was average 15°( 10°-30°).Based on Dimeglio grade method,14 feet were excellent,4 feet were good,and 2 feet were poor,with a total of excellent and good grade of 90%. Conclusion The Ilizarov technique is an optional method for treating severe rigid clubfoot deformity in children,even though the technique is difficult and need a relative long learning cure to master.
引文
[1]Ponseti IV,Smoley EN.Congenital club foot:the results of treatment[J].J Bone Joint Surg Am,1963,45(2):261-275,344.
[2]Laaveg SJ,Ponseti IV.Long-term results of treatment of congenital club foot[J].J Bone Joint Surg Am,1980,62(1):23-31.
[3]Dwyer FC.Osteotomy of the calcaneum for pes cavus[J].J Bone Joint Surg Br,1959,41-B(1):80-86.
[4]Dwyer FC.The treatment of relapsed club foot by insertion of a wedge into the calcaneum[J].J Bone Joint Surg Br,1963,45-B(1):67-75.
[5]Evans D.Relapsed club foot[J].J Bone Joint Surg Br,1961,43-B(4):722-733.
[6]Japas LM.Surgical treatment of pes cavus by tarsal V-osteotomy:preliminary report[J].J Bone Joint Surg Am,1968,50(5):927-944.
[7]Herold HZ,Torok G.Surgical correction of neglected club foot in the older child and adult[J].J Bone Joint Surg Am,1973,55(7):1385-1395.
[8]Hofmann AA,Coustine RM,Mc Bride GG,et al.Osteotomy of the first cuneiform as treatment of residual adduction of the fore part of the foot in club foot[J].J Bone Joint Surg Am,1984,66(7):985-990.
[9]Jahss MH.Tarsometatarsal truncated-wedge arthrodesis for pes cavus and equinovarus deformity of the fore part of the foot[J].J Bone Joint Surg Am,1980,62(5):713-722.
[10]Carroll N.Clubfoot[M]//Morrissy R.Lovell and Winter’s pediatric orthopedics.3rd ed.Philadelphia:Lippincott,1990:927-956.
[11]Ippolito E,Farsetti P,Caterini R,et al.Long-term comparative results in patients with congenital clubfoot treated with two different protocols[J].J Bone Joint Surg Am,2003,85(7):1286-1294.
[12]Dobbs MB,Nunley R,Schoenecker PL.Long-term follow-up of patients with clubfeet treated with extended soft tissue release[J].J Bone Joint Surg Am,2006,88(5):986-996.DOI:10.2106/JBJS.E.00114.
[13]Wetmore RS,Drennan JC.Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease[J].J Bone Joint Surg Am,1989,71(3):417-422.
[14]Ilizarov GA.The tension-stress effect on the genesis and growth of tissues part I.The influence of stability of fixationand soft tissue preservation[J].Clin Orthop Relat Res,1989(238):249-281.
[15]Ilizarov GA.The tension-stress effect on the genesis and growth of tissues part II.The influence of rate and frequency of distraction[J].Clin Orthop Relat Res,1989(239):263-285.
[16]Grill F,Franke J.The Ilizarov distractor for the correction of relapsedor neglected club foot[J].J Bone Joint Surg Br,1987,69(4):593-597.
[17]Franke J,Grill F,Hein G,et al.Correction of clubfoot relapse using Ilizarov's apparatus in children 8-15 years old[J].Arch Orthop Trauma Surg,1990,110(1):33-37.
[18]Paley D.The correction of complex foot deformities using Ilizarov's distraction osteotomies[J].Clin Orthop Relat Res,1993(293):97-111.
[19]Choi IH,Yang MS,Chung CY,et al.The treatment of recurrent arthrogrypotic club foot in children by the Ilizarov method.A preliminary report[J].J Bone Joint Surg Br,2001,83(5):731-737.
[20]Segev E,Ezra E,Yaniv M,et al.V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet[J].J Orthop Surg(Hong Kong),2008,16(2):215-219.DOI:10.1177/230949900801600218.
[21]Hosny GA.Correction of foot deformities by the Ilizarov method without corrective osteotomies or soft tissue release[J].J Pediatr Orthop B,2002,11(2):121-128.
[22]Prem H,Zenios M,Farrell R,et al.Soft tissue Ilizarov correction of congenital talipes equinovarus-5 to 10 years postsurgery[J].J Pediatr Orthop,2007,27(2):220-224.DOI:10.1097/BPO.0b013e31803173bf.
[23]Lohia LK,Meena S,Kanojia RK.Comparative study of complete subtalar release and Joshi’s external stabilization system in the management of neglected and resistant idiopathic clubfoot[J].Foot Ankle Surg,2015,21(1):16-21.DOI:10.1016/j.fas.2014.08.007.
[24]Diméglio A,Bensahel H,Souchet P,et al.Classification of clubfoot[J].J Pediatr Orthop B,1995,4(2):129-136.
[25]Cosma D,Vasilescu DE.A clinical evaluation of the Pirani and Dimeglio idiopathic clubfoot classifications[J].J Foot Ankle Surg,2015,54(4):582-585.DOI:10.1053/j.jfas.2014.10.004.
[26]Davidson RS.Clubfoot salvage:a review of the past decade’s contributions[J].J Pediatr Orthop,2003,23(3):410-418.
[27]Hassan A,Letts M.The management of the neglected congenital foot deformity in the older child with the Taylor spatial frame[J].J Pediatr Orthop,2012,32(1):85-92.DOI:10.1097/BPO.0b013e318237c2c7.
[28]Tripathy SK,Saini R,Sudes P,et al.Application of the Ponseti principle for deformity correctionin neglected and relapsed clubfoot using the Ilizarov fixator[J].J Pediatr Orthop B,2011,20(1):26-32.DOI:10.1097/BPB.0b013e32833f33fe.
[29]Khanfour AA.Ilizarov techniques with limited adjunctive surgical procedures for the treatment of preadolescent recurrent or neglected clubfeet[J].J Pediatr Orthop B,2013,22(3):240-248.DOI:10.1097/BPB.0b013e32835f1f99.
[30]Gourdine-Shaw MC,Lamm BM,Paley D,et al.Distraction osteogenesis for complex foot deformities:U-osteotomy with external fixation[J].J Bone Joint Surg Am,2012,94(15):1420-1427.DOI:10.2106/JBJS.K.00360.
[31]Burns JK,Sullivan R.Correction of severe residual clubfoot deformity in adolescents with the Ilizarov technique[J].Foot Ankle Clin,2004,9(3):571-582.DOI:10.1016/j.fcl.2004.05.011.
[32]Conti SF,Kirschner JS,van Sickle D.Midfoot ostetomies[J].Foot Ankle Clin,2001,6(3):519-532.
[33]Mahan J,Seligson D,Henry SL,et al.Factors in pin tract infections[J].Orthopedics,1991,14(3):305-308.
[34]Ahlborg HG,Josefsson PO.Pin-tract complications in external fixation of fractures of the distal radius[J].Acta Orthop Scand,1999,70(2):116-118.
[35]Camathias C,Valderrabano V,Oberli H.Routine pin tract care in external fixation is unnecessary:A randomised,prospective,blinded controlled study[J].Injury,2012,43(11):1969-1973.DOI:10.1016/j.injury.2012.08.010.
[36]Moroni A,Vannini F,Mosca M,et al.Techniques to avoid pin loosening and infection in external fixation[J].J Orthop Trauma,2002,16(3):189-195.
[37]Green SA.Complications of external skeletal fixation[J].Clin Orthop Relat Res,1983(180):109-116.
[38]Aronson J,Tursky EA.External fixation of femur fractures in children[J].J Pediatr Orthop,1992,12(2):157-163.
[2]Laaveg SJ,Ponseti IV.Long-term results of treatment of congenital club foot[J].J Bone Joint Surg Am,1980,62(1):23-31.
[3]Dwyer FC.Osteotomy of the calcaneum for pes cavus[J].J Bone Joint Surg Br,1959,41-B(1):80-86.
[4]Dwyer FC.The treatment of relapsed club foot by insertion of a wedge into the calcaneum[J].J Bone Joint Surg Br,1963,45-B(1):67-75.
[5]Evans D.Relapsed club foot[J].J Bone Joint Surg Br,1961,43-B(4):722-733.
[6]Japas LM.Surgical treatment of pes cavus by tarsal V-osteotomy:preliminary report[J].J Bone Joint Surg Am,1968,50(5):927-944.
[7]Herold HZ,Torok G.Surgical correction of neglected club foot in the older child and adult[J].J Bone Joint Surg Am,1973,55(7):1385-1395.
[8]Hofmann AA,Coustine RM,Mc Bride GG,et al.Osteotomy of the first cuneiform as treatment of residual adduction of the fore part of the foot in club foot[J].J Bone Joint Surg Am,1984,66(7):985-990.
[9]Jahss MH.Tarsometatarsal truncated-wedge arthrodesis for pes cavus and equinovarus deformity of the fore part of the foot[J].J Bone Joint Surg Am,1980,62(5):713-722.
[10]Carroll N.Clubfoot[M]//Morrissy R.Lovell and Winter’s pediatric orthopedics.3rd ed.Philadelphia:Lippincott,1990:927-956.
[11]Ippolito E,Farsetti P,Caterini R,et al.Long-term comparative results in patients with congenital clubfoot treated with two different protocols[J].J Bone Joint Surg Am,2003,85(7):1286-1294.
[12]Dobbs MB,Nunley R,Schoenecker PL.Long-term follow-up of patients with clubfeet treated with extended soft tissue release[J].J Bone Joint Surg Am,2006,88(5):986-996.DOI:10.2106/JBJS.E.00114.
[13]Wetmore RS,Drennan JC.Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease[J].J Bone Joint Surg Am,1989,71(3):417-422.
[14]Ilizarov GA.The tension-stress effect on the genesis and growth of tissues part I.The influence of stability of fixationand soft tissue preservation[J].Clin Orthop Relat Res,1989(238):249-281.
[15]Ilizarov GA.The tension-stress effect on the genesis and growth of tissues part II.The influence of rate and frequency of distraction[J].Clin Orthop Relat Res,1989(239):263-285.
[16]Grill F,Franke J.The Ilizarov distractor for the correction of relapsedor neglected club foot[J].J Bone Joint Surg Br,1987,69(4):593-597.
[17]Franke J,Grill F,Hein G,et al.Correction of clubfoot relapse using Ilizarov's apparatus in children 8-15 years old[J].Arch Orthop Trauma Surg,1990,110(1):33-37.
[18]Paley D.The correction of complex foot deformities using Ilizarov's distraction osteotomies[J].Clin Orthop Relat Res,1993(293):97-111.
[19]Choi IH,Yang MS,Chung CY,et al.The treatment of recurrent arthrogrypotic club foot in children by the Ilizarov method.A preliminary report[J].J Bone Joint Surg Br,2001,83(5):731-737.
[20]Segev E,Ezra E,Yaniv M,et al.V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet[J].J Orthop Surg(Hong Kong),2008,16(2):215-219.DOI:10.1177/230949900801600218.
[21]Hosny GA.Correction of foot deformities by the Ilizarov method without corrective osteotomies or soft tissue release[J].J Pediatr Orthop B,2002,11(2):121-128.
[22]Prem H,Zenios M,Farrell R,et al.Soft tissue Ilizarov correction of congenital talipes equinovarus-5 to 10 years postsurgery[J].J Pediatr Orthop,2007,27(2):220-224.DOI:10.1097/BPO.0b013e31803173bf.
[23]Lohia LK,Meena S,Kanojia RK.Comparative study of complete subtalar release and Joshi’s external stabilization system in the management of neglected and resistant idiopathic clubfoot[J].Foot Ankle Surg,2015,21(1):16-21.DOI:10.1016/j.fas.2014.08.007.
[24]Diméglio A,Bensahel H,Souchet P,et al.Classification of clubfoot[J].J Pediatr Orthop B,1995,4(2):129-136.
[25]Cosma D,Vasilescu DE.A clinical evaluation of the Pirani and Dimeglio idiopathic clubfoot classifications[J].J Foot Ankle Surg,2015,54(4):582-585.DOI:10.1053/j.jfas.2014.10.004.
[26]Davidson RS.Clubfoot salvage:a review of the past decade’s contributions[J].J Pediatr Orthop,2003,23(3):410-418.
[27]Hassan A,Letts M.The management of the neglected congenital foot deformity in the older child with the Taylor spatial frame[J].J Pediatr Orthop,2012,32(1):85-92.DOI:10.1097/BPO.0b013e318237c2c7.
[28]Tripathy SK,Saini R,Sudes P,et al.Application of the Ponseti principle for deformity correctionin neglected and relapsed clubfoot using the Ilizarov fixator[J].J Pediatr Orthop B,2011,20(1):26-32.DOI:10.1097/BPB.0b013e32833f33fe.
[29]Khanfour AA.Ilizarov techniques with limited adjunctive surgical procedures for the treatment of preadolescent recurrent or neglected clubfeet[J].J Pediatr Orthop B,2013,22(3):240-248.DOI:10.1097/BPB.0b013e32835f1f99.
[30]Gourdine-Shaw MC,Lamm BM,Paley D,et al.Distraction osteogenesis for complex foot deformities:U-osteotomy with external fixation[J].J Bone Joint Surg Am,2012,94(15):1420-1427.DOI:10.2106/JBJS.K.00360.
[31]Burns JK,Sullivan R.Correction of severe residual clubfoot deformity in adolescents with the Ilizarov technique[J].Foot Ankle Clin,2004,9(3):571-582.DOI:10.1016/j.fcl.2004.05.011.
[32]Conti SF,Kirschner JS,van Sickle D.Midfoot ostetomies[J].Foot Ankle Clin,2001,6(3):519-532.
[33]Mahan J,Seligson D,Henry SL,et al.Factors in pin tract infections[J].Orthopedics,1991,14(3):305-308.
[34]Ahlborg HG,Josefsson PO.Pin-tract complications in external fixation of fractures of the distal radius[J].Acta Orthop Scand,1999,70(2):116-118.
[35]Camathias C,Valderrabano V,Oberli H.Routine pin tract care in external fixation is unnecessary:A randomised,prospective,blinded controlled study[J].Injury,2012,43(11):1969-1973.DOI:10.1016/j.injury.2012.08.010.
[36]Moroni A,Vannini F,Mosca M,et al.Techniques to avoid pin loosening and infection in external fixation[J].J Orthop Trauma,2002,16(3):189-195.
[37]Green SA.Complications of external skeletal fixation[J].Clin Orthop Relat Res,1983(180):109-116.
[38]Aronson J,Tursky EA.External fixation of femur fractures in children[J].J Pediatr Orthop,1992,12(2):157-163.