反式Ponseti方法联合微创切开复位技术治疗先天性垂直距骨：特发性与非特发性的临床疗效对比

发布时间：2018-04-15 22:38

  本文选题：垂直距骨 + 先天性　； 参考：《南方医科大学》2017年硕士论文

【摘要】：研究背景:先天性垂直距骨(Congenital vertical talus,CVT),也称为“摇椅足”、“先天性凸底外翻足”,是一种发病罕见(发病率约为1/10,000[1])、畸形严重的先天性僵硬性扁平足,表现为后足外翻、跖屈(马蹄);距骨头凸出于中足跖内侧;前足外展并相对于中后足背伸,外形如摇椅底座。典型影像学特点为:足侧位片,距骨呈垂直位,且舟骨相对于距骨头呈不可复性背外侧脱位,跟骨跖屈(马蹄)。CVT的具体病因尚不明确,据估计,约有50%的病例合并神经肌肉性异常[2]或已知的基因缺陷和(或)综合征[3],另外约50%不合并其他先天性畸形的则被认为属于特发性[4,5]。对于该病的治疗,目前已达成的共识是:越早越治疗效果越好,单纯保守治疗不能治愈,手术可能是唯一有效的方法。而对于具体的手术矫形方法,目前尚未统一。传统上CVT的手术治疗包括一期或二期广泛松解重建[6-8]、背侧或后侧入路松解重建[911]、舟骨切除手术[12]、距下关节融合术或三关节融合术[13,14]等。虽然这些广泛松解重建手术都取得了良好的早期矫正效果,但长期随访结果并不如人意,远期并发症多且发生率高,如皮肤坏死[1]、踝关节和距下关节僵硬[8]、距骨坏死[5,9]、畸形复发[5]、足坏死甚至截肢[15]等。2006年Dobbs等人[16]在参考了 Ponseti方法治疗先天性马蹄足的原理[17]后,首创了一种更加简单的新方法治疗CVT,即通过手法矫形序列石膏固定(矫形用力方向与Ponseti方法相反),经皮穿针固定距舟关节或微创切复位距舟关节并固定,最后以经皮延长跟腱——所谓的反式Ponseti法或Dobbs法,矫正CVT的所有畸形组分,获得了良好的短期和长期效果[16,18-23]。然而,许多的前期研究都只单纯分析特发性[16,24]或非特发性CVT[22]的疗效,仅有少量的研究[20,25]比较了特发性和非特发性CVT的疗效差异。而目前,国内对于这种新的CVT治疗方法报道较少,而对比研究更是空白,因此探讨其治疗方法、临床疗效及疗效差异意义重大。目的:1.探讨反式Ponseti方法联合微创切开复位技术治疗先天性垂直距骨的治疗方法及临床疗效,2.比较反式Ponseti方法联合微创切开复位技术治疗特发性CVT与非特发性CVT的临床疗效,为今后的推广应用提供借鉴。方法:回顾性分析2012年7月至2015年12月就诊于我院的先天性垂直距骨患儿11例(18足),其中男8例,女3例,特发性组5例(9足),非特发性组6例(9足),平均手术年龄10.9个月(3.9个月—31.2个月)。所有患儿均多次反式Ponseti序列石膏矫形,经皮逆行穿针固定或微创切开复位固定距舟关节,经皮延长跟腱,石膏固定治疗。比较两组患儿末次随访时踝关节、距下关节活动度,以及术前、术后即刻、末次随访时的影像学测量参数。采用Adelaar评分评估患儿治疗后的整体疗效。结果:11例(18足)患儿在平均随访27个月(12个月—57个月)后,所有足部畸形都得到不同程度矫正,内侧纵弓恢复,后足无明显外翻,踝关节和距下关节无明显功能障碍。仅非特发性组中2例(4足)术后6个月内出现畸形复发,随后再次经序列石膏矫形、微创手术后畸形矫正,无需广泛松解手术。末次随访时,特发性组踝关节活动度优于非特发性组(P0.05),所有的影像学测量结果较术前均有改善(P0.05),两组间差异无统计学意义(P0.05)。根据Adelaar评分,2足为优,15足为良,1足为中。所有患儿均无伤口坏死、关节僵硬、距骨坏死等并发症。结论:反式Ponseti方法联合微创切开技术治疗先天性垂直距骨是一种有效治疗幼龄先天性垂直距骨的新方法,就足的临床外观、功能以及影像学测量等方面,与传统广泛松解手术相比具有创伤小、疗效可靠、并发症少等优点,可获得良好的早期临床效果。
[Abstract]:Background: congenital vertical talus (Congenital vertical, talus, CVT), also known as the "rocker foot", "congenital convex pes valgus", is a rare disease (incidence rate is about 1/10000[1]), congenital malformation of severe rigid flatfoot, manifested as foot valgus, plantar flexion (horseshoe); from the bones protruding from the medial plantar foot and forefoot abduction; in relation to the dorsal extension, such as shape of a rocking. Typical imaging features: foot radiograph, vertical talus, scaphoid bone is relative to the distance and the irreducible dorsal lateral dislocation of bone with plantar flexion (horseshoe) concrete the etiology of.CVT is still not clear, it is estimated that about 50% of the patients and the gene defects in neuromuscular abnormalities or known [2] (or [3]) syndrome, another 50% is not associated with other congenital malformations are considered to belong to idiopathic [4,5]. for the treatment of the disease, has now reached a consensus more: The earlier the better treatment, conservative treatment can cure, surgery may be the only effective way for orthopedic surgery. The methods have not yet unified. The traditional surgical treatment of CVT include one or two stage solution for [6-8] reconstruction, dorsal or posterior approach release [911] reconstruction of scaphoid resection [12], subtalar arthrodesis arthrodesis or three [13,14]. Although these solution reconstruction have made early correction of good effect, but long-term follow-up results are not satisfactory, and the high incidence of complications such as skin necrosis, [1], ankle and subtalar joint stiffness [8], ofosteonecrosis [5,9]. [5] foot deformity recurrence, necrosis and [15].2006 Dobbs et al. [16] in reference to the principle of [17] Ponseti method for the treatment of congenital clubfoot, pioneered a new method for the treatment of CVT is more simple, namely by hands. Method of orthopedic plaster fixation sequence (orthopedic force direction and Ponseti method instead), percutaneous pin fixation of talonavicular joint or minimally invasive cut reduction of talonavicular joint and fixed, and finally to extend the percutaneous Achilles tendon - the so-called trans Ponseti method or Dobbs method, correction of deformity all components of CVT, the [16,18-23]. of short and long term effects good however, many of the previous research only curative effect analysis of idiopathic [16,24] or non idiopathic CVT[22], only a few studies on [20,25] efficacy comparison of idiopathic and non idiopathic CVT. At present, the domestic reports about the new CVT treatment method is less, while comparison is blank therefore, to explore the methods of treatment, clinical efficacy and the difference is significant. Objective: To investigate the effect of treatment for the 1. trans Ponseti method combined with minimally invasive open reduction technique for the treatment of congenital vertical talus and clinic, 2. Comparison of the clinical efficacy of trans Ponseti method combined with minimally invasive open reduction technique for the treatment of idiopathic and nonidiopathic CVT CVT, provide a reference for future application. Methods: a retrospective analysis from July 2012 to December 2015 in our hospital for treatment of congenital vertical talus in 11 cases (18 feet), of which 8 cases were male, 3 female cases of idiopathic group 5 cases (9 feet), nonidiopathic group of 6 cases (9 feet), the average age of surgery was 10.9 months (3.9 months to 31.2 months). All patients were repeatedly trans Ponseti series orthopedic plaster, percutaneous retrograde transfixation or minimally invasive open reduction and fixed talonaviculare joint extension of Achilles tendon percutaneous plaster fixation. Two groups were compared at the end of the follow-up ankle and subtalar joint activity, and preoperative, immediate postoperative, measurement parameters at the end of the follow-up imaging. Adelaar score was used to evaluate the overall curative effect after treatment. Results: 11 cases (18 feet the children in the flat) All patients were followed up for 27 months (12 months to 57 months), all have different degrees of foot deformity correction, the medial longitudinal arch after recovery, no significant foot valgus, ankle and subtalar joint no obvious dysfunction. Only nonidiopathic group in 2 cases (4 feet) within 6 months after operation deformity recurrence, then again by the sequence of orthopedic plaster after minimally invasive surgery, deformity correction, without extensive lysis operation. At the end of the follow-up, idiopathic group of ankle activity than non idiopathic group (P0.05), all the imaging measurement results than before were improved (P0.05), no statistically significant significant differences between the two groups (P0.05). According to Adelaar score, 2 feet were excellent, 15 feet good, 1 feet. All patients had no wound necrosis, joint stiffness, talus necrosis and other complications. Conclusion: trans Ponseti method combined with minimally invasive incision technique in the treatment of congenital vertical talus is an effective treatment for the young congenital vertical distance The new method of bone has many advantages, such as less trauma, reliable effect and fewer complications. It can achieve good early clinical effect compared with the traditional loosening surgery.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3
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本文编号：1756145