改良Ponseti方法治疗早期先天性马蹄内翻足的神经电生理研究

目的改良Ponseti方法治疗早期先天性马蹄内翻足（CCF）的神经电生理研究。方法应用改良Ponseti方法治疗年龄7天～12个月先天性马蹄内翻足25例31足,应用Nicolet公司VikingIV肌电图诱发电位仪对每期石膏矫形后的CCF患儿进行检测。检测包括双下肢胫神经、腓总神经、腓肠神经及H反射。分析比较运动神经传导速度（MCV）、感觉波（SCV）、传导波幅的变化情况。依据Dimeglio法分型和Pirani评分判定疗效。随访时间为12—36个月,平均15个月。结果31足在石膏矫形前神经电生理异常的有23足f74．19％）。神经电图检测显示21个病足结果异常（67．74哟,H反射异常15足（48．39%。第1～Ⅲ期石膏矫形后的神经电生理变化不明显,第4期石膏矫形后改变明显。28足神经电生理检测达到或接近正常后停止石膏矫形,带足部支具巩固治疗,3足神经电生理检测未接近正常,停止石膏矫形后3个月复发。再行石膏矫形后治愈。结论神经电生理检测可以直接、客观地判断改良Ponseti方法治疗早期先天性马蹄内翻足的治愈标准及预后。     

改良Ponseti方法治疗先天性马蹄内翻足疗效

[目的]评价改良Ponseti方法治疗先天性马蹄内翻足疗效.[方法]在Ponseti方法(连续石膏矫形加经皮跟腱切断加足外展矫形支具)的基础上稍加改良,并应用于治疗先天性马蹄内翻足76例116足,男52例80足,女24例36足;年龄5 d～4岁.[结果]本组病例76例均得到随访,平均随访25.5个月,最长46个月,按Dimeglio评分分级方法,76例116足中73例112足(96.5%)畸形矫正满意.[结论]改良Ponseti方法对4岁以内的婴幼儿先天性马蹄内翻足均可取得满意的效果.     

可调节支具在婴幼儿先天性马蹄内翻足治疗中的应用研究

[目的]探讨可调节支具治疗婴幼儿先天性马蹄内翻足的应用方法及效果。[方法]2014年1月~2016年2月在本科治疗的先天性马蹄内翻足患儿60例(96足),随机分为支具组30例(50足)和石膏组30例(46足),支具组采用ponseti手法矫形结合可调节支具治疗,石膏组采用典型Ponseti方法治疗,比较两组患者的临床疗效。[结果]所有患儿平均随访时间(13.4±3.5)个月,治疗后患足外观与功能均得到明显改善,支具组与石膏组Dimeglio评分分级及优良率比较差异无统计学意义(P>0.05)。[结论]可调节支具治疗婴幼儿先天性马蹄内翻足近期疗效明确,远期疗效尚待进一步研究。     

先天性马蹄内翻足Ponseti治疗初跟腱手术的预测

目的探讨先天性马蹄内翻足（CCF）患儿治疗前预测患儿行跟腱手术的可行性。方法96例CCF（148足）患儿,均依据Ponseti方法治疗,平均（5.7±1.3）次石膏矫正后,背屈活动≤15°或Pirani评分HS（后足评分）≥1,MS（中足评分）〈1的患足需行跟腱切断手术。石膏去除后需佩戴外展支具。结果经过系列石膏矫正后,148足中125足（84.5%）行跟腱切断术,23足（15.5%）未行跟腱手术。在治疗初有102足（68.9%）Pirani评分≥5分,其中93足（91.2%）经系列石膏矫正后行跟腱手术。手术组跟腱愈合佳,跖屈有力。结论在治疗初Pirani评分≥5分时91.2%患儿需要跟腱手术,CCF患儿初次来诊时,对患足行Pirani评分,即可预测其是否需行跟腱手术。在治疗初预先判断患儿是否需行跟腱手术则既有利于医师了解治疗进展,又能更好地与家长沟通配合治疗进程。     

Ilizarov技术联合Ponseti方法治疗儿童僵硬性马蹄内翻足的临床研究

目的 探讨Ilizarov技术联合Ponseti方法治疗大龄儿童僵硬性马蹄内翻足畸形的临床疗效。方法 回顾性分析2012年7月至2016年7月玉林桂南医院收治的36例（49足）儿童僵硬性马蹄内翻足病例的临床资料,术前均行负重位踝关节正侧位X线检查,根据安装Ilizarov外固定架治疗前是否进行Ponseti石膏矫正分为A组（未进行Ponseti石膏矫正）和B组（进行Ponseti石膏矫正）。A组18例（24足）,男13例,女5例,年龄为（9.5±2.3）岁（6~14岁）。B组18例（25足）,男12例,女6例,年龄为（9.8±2.1）岁（6~15岁）。A组患儿直接安装Ilizarov外固定架治疗,B组患儿予Ponseti系列石膏矫正4~10次后行经皮跟腱松解术,然后安装Ilizarov外固定架治疗。两组患儿术后均佩戴足踝矫形器固定8~10周。两组患儿术后随访时行负重下踝关节正侧位X线片检查,测量并记录胫距角变化。采用国际马蹄内翻足研究会评定标准（ICFSG）评价术后疗效。记录并比较两组病人马蹄足畸形矫正时间、佩戴外固定架时间。结果 患儿平均随访时间为58个月（36~75个月）。术后2年随访,两组胫距角比较,差异有统计学意义（t=2.468,P=0.017）。A组24足,ICFSG评分优11足、良5足、可4足、差4足,优良率为66.7%;B组25足,优20足、良1足、可4足,优良率为84.0%,两组优良率的差异有统计学意义（χ²=8.667,P=0.034）。B组马蹄足畸形矫正时间、佩戴外固定架时间均小于A组,差异均有统计学意义（P均＜0.05）。A组有2例出现皮肤坏死,3例血管神经损伤,2例钉道感染;B组无相关并发症。结论 应用Ilizarov技术联合Ponseti方法治疗儿童僵硬性马蹄内翻足可取得良好疗效,矫形效果满意,能最大程度保留足的外形和功能,值得临床推广。     

先天性马蹄内翻足经皮跟腱切断手术时机的选择

目的应用Ponseti方法早期治疗先天性马蹄内翻足（先天性马蹄内翻足）,探讨经皮跟腱切断手术时机的选择。方法60例（91足）先天性马蹄内翻足患儿,随机分为A、B两组,每组30例,治疗初评分≥4分（僵硬型）。A组患足矫形外展至70°、背屈〈15°、同时HS〉1、MS〈1和距骨被覆盖;B组患足矫形至前足内收纠正但无法背屈,同时HS〉1、MS≤1,行跟腱切断术;以Pirani评分标准比较两组治疗结果。结果患儿均得到随访,时间6～30（15±5）个月。A、B两组手术前石膏矫形次数分别为（5.1±0.91）次、（2.42±0.56）次（P〈0.05）,治疗时间分别为（36.8±4.98）d、（19.3±5.09）d（P〈0.01）,差异有统计学意义。两组跟腱均获得愈合,跖屈有力,术后患足背屈活动度差异无统计学意义（P〉0.05）。结论在Ponseti方法矫正僵硬型马蹄足过程中,畸形愈严重跟腱挛缩愈严重,早期行经皮跟腱切断手术可明显减少石膏矫形次数、缩短疗程,不影响疗效。     

Ponseti方法对6个月以上婴幼儿与小婴儿先天性马蹄内翻足治疗的比较

[目的]比较Ponseti方法对6个月以上婴幼儿(大龄组)与6个月以内婴儿(小龄组)先天性马蹄内翻足治疗的不同.[方法]应用Ponseti方法治疗大龄组患儿157例227足,小龄组患儿221例317足.对所有患足进行Pirani评分,将0～0.5分判为优良,比较两组的优良率、应用石膏次数及跟腱切断的病足数,并进行随访.[结果]两组患儿优良率无显著性差异(P＞0.05).小龄组应用石膏次数及行跟腱切断的百分比较大龄组多,两组间有显著性差异(P＜0.01).平均随访2年5个月,两组间复发率无明显差异(P＞0.05).[结论]Ponseti方法对6个月以上婴幼儿及小婴儿先天性马蹄内翻足均可取得优良效果.     

Ponseti法治疗先天性马蹄内翻足疗效分析

[目的]评价采用Ponseti法治疗1岁以内先天性马蹄内翻足的疗效。[方法]2005年4月~2008年10月,本院骨科共收治先天性马蹄内翻足病例125例138足,男98例106足,女27例32足,年龄7 d~12个月。按年龄分为新生儿期(7~28 d)、小婴儿期(29 d~6个月)、婴儿期(6~12个月)三组,均按D im eglio评分系统进行评分,应用Ponseti法(手法矫正+石膏固定+经皮跟腱切断+足外展支具)治疗。[结果]病例随访13~42个月,平均25.3个月。按D im eglio评分系统评价疗效,120例132足矫形效果满意,5例6足残余部分畸形行手术治疗。各年龄组治疗优良率无显著差异(P0.05)。[结论]Ponseti法治疗先天性马蹄内翻足疗效确切,是一种很好的保守治疗方法。对于1岁以内先天性马蹄足均可取得优良效果。     

肌力平衡术治疗儿童先天性马蹄内翻足

[目的]探讨肌力平衡术治疗儿童先天性马蹄内翻足(CCF)的临床应用及近期疗效。[方法] 2013～2018年采用肌力平衡术治疗儿童先天性马蹄内翻足33例共46足,所有患儿均采取肌力平衡术治疗,即保持踝关节背伸5°～1O°,"Z"字型延长跟腱,外移胫骨前肌腱,适当松解足后方软组织,术后长腿矫形石膏屈膝90°制动。术后6周拆石膏、拆线,不需要穿戴Dennis-Brown支具,行功能锻炼。[结果]所有患儿均顺利完成手术。术后平均随访(23.79±6.43)个月,本组33例共46足CCF均采用Pirani评分分类,矫正后接近正常39足,轻度异常7足,无中度、重度异常者。所有病例均无伤口感染、皮肤坏死和顽固性疼痛等。[结论]肌力平衡术是治疗儿童先天性马蹄内翻足的一种理想手术方式,其特点是术中充分松解,术后并发症少,畸形纠正彻底,矫形效果好。     

儿童僵硬型马蹄内翻足的治疗策略

目的探讨儿童僵硬型马蹄内翻足的治疗策略,评估其临床疗效。方法回顾性分析2013年7月至2016年9月广州新海医院治疗的47例(84足)僵硬型马蹄内翻足患儿的临床资料,对足畸形类型、发生机制和僵硬程度进行综合判断,结合患儿年龄采用针对性的矫形手术(Ponseti系列石膏固定和/或跖筋膜松解、跟腱和关节周围软组织松解、Ilizarov外固定等),按照国际马蹄内翻足研究会(ICFSG)评定标准评估手术效果。结果平均随访时间18个月(6～36个月)。根据ICFSG评定标准,优26例48足、良15例28足、可6例8足,总优良率90%(76/84)。无一例发生皮肤坏死、神经血管损伤并发症。结论在综合诊断僵硬型马蹄内翻足的基础上采取有针对性的矫形治疗策略,并发症少,矫形效果满意。     

Ponseti method in the treatment of post-operative relapsed idiopathic clubfoot after posteromedial release. A short term functional study

BackgroundRelapsed clubfeet deformity after surgical treatment by posteromedial release are frequently encountered in pediatric orthopedic practice and further revision surgery may be needed. As surgery adds more fibrosis and scaring, complication may be devastating and treatment is challenging. Ponseti method, the gold standard technique for treatment of clubfoot may be of a value in the management of postoperative relapses.Aim of the studyDetermine the effectiveness of Ponseti casting Method in treatment of relapsed idiopathic clubfoot in children after being treated with surgical posteromedial release.Materials and methodsProspective interventional study of 17 patients (25 feet) presented with a relapsed idiopathic clubfoot deformity after previous surgical posteromedial release. The patients were reviewed using Pirani and Dimeglio score. Ponseti method was done to obtain supple, flexible foot rather than a fully corrected foot, the residual deformity were treated by, heel cord lengthening or tenotomy, tibialis anterior transfer, follow up was for a minimum of 12 months.Result17 Patients (25 feet) their age ranging from 1 to 10 years were evaluated and treated. Casts were applied until the only deformities remaining were either hindfoot equinus and/or dynamic supination.22 feet required a heel cord procedure for equinus and 13 required tibialis anterior transfer for dynamic supination. The follow up (average 56.1 months) was for a minimum of one year. 4 feet had persistent heel varus deformity which required Calcaneal osteotomy later. Three feet didn’t need more casting and 2 feet were resistant cases that required further Ilizarov procedure, 4 needed lateral arch shortening and other 4 needed posterior capsulotomy. Improvement in the Pirani and Dimeglio scores was highly statistically significant.ConclusionPonseti method for treatment of relapsed clubfeet after a previous posteromedial soft tissue surgical release is an effective, non invasive, with excellent results.     

Use of the foot abduction orthosis following Ponseti casts: is it essential?

The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant group's scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique.     

Modified Ponseti method of management of neonatal club feet

The aim of this study was to assess the outcome of a new protocol for the management of neonatal clubfeet that can be considered as a modification of the Ponseti method. The modifications consisted of performing the tenotomy of the Achilles tendon prior to the application of the first cast and using only one cast for a period of 3 weeks following tenotomy. We applied the modified method in 50 children (82 club feet) and assessed the degree of deformity using the Pirani and the Dimeglio scoring systems. The minimum follow-up period was 28 months (range: 24-32). The intermediate range follow-up results of this study showed that the modified Ponseti method was associated with a good outcome in 85% of cases of neonatal club feet with a Pirani score of 5 or less and a Dimeglio score of 15 or less. Persistently high Pirani or Dimeglio scores immediately after tenotomy and poor compliance with splintage were predictors of failure of the modified technique.     

Results of operative therapy of idiopathic clubfoot using a dorsomedial approach with soft tissue preparation "à la carte"

INTRODUCTION: Several concepts have been published for therapy of idiopathic clubfoot. Actually the Cincinnati approach is the "gold-standard" in operative treatment of idiopathic clubfoot. Using this approach delayed wound healing and overcorrection are wellknown complications. During the last 30 years a dorsomedial approach is used in operative treatment of idiopathic clubfoot in our clinic. Using this approach a dorsal, medial and/or lateral release can be performed. Postoperatively a plaster cast is used. The following years a rigid therapy with orthosis and support is requested. PATIENTS AND METHOD: Between June 1986 and December 2000 130 clubfoot operations with soft tissue release were performed. 119/130 (91 %) patients could be clinically and radiologically followed-up after a mean of 4.5 years (min: 2, max: 17) including 65.5 % male and 34.5 % female patients. Average age at time of operation was 7.6 months. The findings were classified according to Dimeglio. To evaluate the clinical results the score according to Laaveg and Ponseti was used. X-rays with load (a. p. and lateral view) were evaluated preoperatively and at follow-up for a. p. and lateral talocalcaneal angle, talometatarsal-I-angle, calcaneometatarsal-V-angle and the angle of the first ray. Additionally complications and recurrences were documented. RESULTS: 21.8 % of the feet were classified IV degrees , 39.5 % III degrees and 38.7 % II degrees according to Dimeglio. Recurrent clubfoot was found in 7.6 % of all cases. All angles showed a significant improve. At latest follow-up 95.6 +/- 9.2 points according to the score of Laaveg and Ponseti were achieved. Flat top talus was found in 37 cases. CONCLUSION: The dorsomedial approach allows an excellent correction of clubfeet with a low rate of complications and recurrences in comparison to other studies.     

Use of Ankle Dorsiflexion and the Dimeglio and Pirani Scores in Predicting Relapse of Clubfoot Treated With the Ponseti Method

Although Dimeglio and Pirani scores are frequently employed to rate the severities of clubfoot and to evaluate treatment outcomes, it is unclear if these scores predict relapse after treatment. Ankle dorsiflexion has been suggested in recent years to be a promising predictor of relapse. The aim of this study was to investigate ankle dorsiflexion and Dimeglio and Pirani scores in predicting the relapse of clubfoot after treatment with the Ponseti method. We included patients with clubfoot previously treated by the Ponseti method, and retrospectively analyzed their initial ankle dorsiflexion, Pirani and Dimeglio scores, number of castings, and the occurrence of relapse. We analyzed 218 feet of 176 infants with clubfoot who showed an incidence of relapse of 17.0% (30/176). The mean initial Pirani and Dimeglio scores of the feet showing recurrence were significantly higher than individuals with non-recurrence (p < .001 each). We observed a robust association between Pirani and Dimeglio scores and the recurrence of clubfoot at the last follow-up (γ = 0.53, p = .001). In contrast, ankle dorsiflexion was negatively correlated with recurrence of clubfoot (γ = -0.21, p = .001). Dimeglio scores significantly predicted the recurrence of clubfoot (p = .014). Receiver operating characteristic curve analysis exhibited slightly better performance regarding the Dimeglio score relative to the Pirani score and ankle dorsiflexion in predicting recurrence. Ankle dorsiflexion and Pirani and Dimeglio scores were related to recurrence in patients with clubfoot. However, the Dimeglio score reflected superior accuracy in predicting the prognosis of clubfoot treated with the Ponseti method.     

Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities

Introduction: The aim of this study is to evaluate the effectiveness of the Ponseti method in children presenting before 1 year of age with either untreated or complex (initially treated unsuccessfully by other conservative methods) idiopathic clubfeet. Patients and methods: The authors report 134 feet of 92 patients with Dimeglio grade 2, 3, or 4 deformities treated with the Ponseti method. Twenty-four percent of feet were of complex deformities at initial presentation to the authors’ clinics. Results: At a mean follow-up of 46 months (range 24–89) we avoided joint release surgery in 97% of feet. Sixty-seven percent required a percutaneous tenotomy of the Achilles tendon. Relapse rate was 31% (41 feet). We treated 2 relapses by restarting the use of orthosis, 17 with re-casting, 18 with anterior tibial tendon transfer following a second relapse, and 4 feet with extensive joint surgery. Compliance with the use of orthosis was identified as the most important risk factor (P<0.0001) for relapses. Previous unsuccessful treatment attempts by other conservative methods did not adversely affect the results unless the cases had iatrogenic deformities. Cases with iatrogenic deformities from previous treatment had a significantly increased risk of non-compliance and relapse. Experience of the treating surgeon and cast complications were also related to relapses. Conclusion: Our results show that the Ponseti technique is reproducible and effective in children at least up to 12 months of age. It can also produce good correction in children presenting with complex idiopathic deformities. Therefore, extensive joint releases should not be considered immediately in such cases. The treating surgeon should be meticulous in using the technique and ensure compliance to foot abduction brace in order to avoid recurrences.     

Predicting the need for tenotomy in the Ponseti method for correction of clubfeet

The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores > or = 5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of > or = 5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.     

组织牵伸与有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形

目的探讨组织牵伸结合有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形的临床问题。方法 2004年6月至2009年2月共治疗17例成人足外伤后严重的马蹄内翻足畸形。Dimeglio分型：Ⅲ型,严重畸形13足;Ⅳ型,畸形非常严重4足。牵伸矫形器由胫骨外固定器和特殊形状的足部外固定器构成,在畸形状态能适应牵伸器顺利安装情况下,仅选择距下关节融合。如果畸形超出牵伸支架的可调空间,选择有限截骨三关节融合术,部分矫正足的内翻、内收畸形,至能顺利安装牵伸支架,残留的畸形通过牵伸逐渐矫正。结果治疗结束时所有病例的马蹄内翻足畸形均得到完全矫正。14例随访半年至3年,平均11个月;5足轻度复发,马蹄畸形均未大于20°,仍能跖行;踝关节活动度部分有一定改善。根据国际马蹄足畸形研究学组（ICFSG）的评分系统：优3足,良9足,可2足,差0足。结论组织牵伸结合有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形,便于外固定器的安装,更好地预防畸形复发、减少牵伸的时间,发挥Ilizarov技术的优势。     

Initial severity rating of idiopathic clubfeet is an outcome predictor at age two years

This study was performed to determine if rating the severity of clubfeet before Ponseti treatment was predictive of the outcomes at age two years. Four hundred and seventy-nine idiopathic clubfeet (323 patients) were numerically rated for severity using Dimeglio classification. Eighty-six feet rated moderate, 305 feet rated severe, and 88 feet rated very severe. Outcomes were classified as Good (plantigrade foot with or without a tendoachilles lengthening), Fair (limited surgery), or Poor (posteromedial release). Significant correlation existed between initial severity of the foot and outcomes, with moderate better than severe and very severe, and severe better than very severe. Initial numerical severity rating strongly correlated with the probability of a good outcome (P<0.0001). Evaluating the severity of clubfeet before Ponseti treatment provides prognostic information for parents.