两种术式治疗先天性马蹄内翻足的效果比较

目的应用Diméglio足评分方法,评价肌力平衡术和Mckay术治疗先天性马蹄内翻足（congenital clubfoot,CCF）的远期效果,以指导根据Diméglio分型合理地选择术式。方法1980年1月～2000年1月,收治CCF患儿37例54足,男27例38足,女10例16足;术时年龄5个月～3.5岁,平均1.2岁。左侧7例,右侧13例,双侧17例。按Diméglio足评分法分型,Ⅱ型（6～10分）3足,Ⅲ型（11～15分）26足,Ⅳ型（16～20分）25足。术前将所有足按畸形程度分为2组,A组（Ⅱ、Ⅲ型,29足）,B组（Ⅳ型足,25足）。按手术方式分组,肌力平衡术组31足,Mckay术组23足。术前Diméglio评分：A组12.55±1.84分,B组17.20±1.08分;肌力平衡术组14.16±2.83分,Mckay术组15.43±2.63分。结果所有患者获随访5年～10年6个月,平均8.2年。按Diméglio分型,Ⅰ型32足,Ⅱ型22足。2例行Mckay术后切口坏死感染,经多次换药愈合。术后Diméglio评分：A组4.07±1.25分,B组6.52±1.74分;肌力平衡术组5.29±1.97分,Mckay术组5.09±1.91分;与术前比较差异均有统计学意义（P〈0.05）。两种术式对A组足的畸形矫正程度比较差异无统计学意义（P〉0.05）;B组足的畸形矫正程度则有统计学意义（P〈0.05）。从对不同平面畸形的矫正程度看,对踝关节马蹄的矫正两术式比较差异无统计学意义（P〉0.05）,而对足内翻、前足内旋及内收畸形的矫正能力Mckay术明显强于肌力平衡术（P〈0.05）,其中Mckay术对前足内收畸形的矫正能力最强。结论DiméglioⅢ型以下的CCF,一期行肌力平衡术可取得良好效果,而对于Ⅳ型足则应采用Mckay术;但无论行何种术式,提倡同时切除外展肌,以防止前足内收矫正不良或复发。

COMPARISON OF LONG-TERM RESULTS BETWEEN MUSCLE-STRENGTH BALANCING PROCEDURE AND MCKAY PROCEDURE IN TREATING CONGENITAL CLUBFOOT

OBJECTIVE: To compare the long-term results between the Mckay procedure and the muscle-strength balancing procedure in treatment of congenital clubfoot (CCF). METHODS: Thirty-seven children with 54 clubfeet were treated by the muscle-strength balancing procedure (31 feet) or the Mckay procedure (23 feet). There were 27 males (38 feet) and 10 females (16 feet). The average age at the time of surgery was 1.2 years (range, 5 months to 3. 5 years). The deformity occurred on the left side in 7 patients, on the right side in 13, and on both sides in 17. During the muscle-strength balancing procedure, the anterior tibial tendon was transplanted to the middle or the lateral cuneiform, and the Achilles tendon was lengthened. During the Mckay procedure, the complete releasing of the soft tissues and the lengthening of the tendons were performed routinely; in addition, the abductor hallucis was also excised. The clinical outcomes were evaluated with the Diméglio classification method. According to the Diméglio scoring system, 3 clubfeet were at Grade I (score, 6-10); 26 clubfeet at Grade III (score, 11-15); 25 clubfeet at Grade IV (score, 16-20). Based on the Diméglio grading system, all the patients were divided into two groups before operation. Group A consisted of 29 feet at Grade II or III (score, 12.55 +/- 1.84); Group B consisted of 25 feet at Grade IV (score, 17.20 +/- 1.08). The score in the group undergoing the muscle-strength balancing procedure was 14.16 +/- 2.83, and the score in the group undergoing the Mckay procedure was 15.43 +/- 2.63. RESULTS: All the patients were followed up for an average of 8. 2 years (range, 5.0-10.5 years). According to the Diméglio grading system, 32 patients were at Grade I and 22 patients at Grade II, and none of the patients at Grade III or IV. Two patients undergoing the Mckay procedure developed the postoperative incision infection, but the incision wound healed after the dressing changes. The Diméglio score was 4.07 +/- 1.25 in Group A and 6.52 +/- 1.74 in Group B after operation, with a significant difference when compared with before operation (P < 0.05). In Group A the two procedures had no significant difference in effectiveness (P > 0.05); however, in Group B they had a significant difference (P < 0.05). Judging by the correction degrees for the deformity on the different planes, the two procedures had no significant difference for correcting the equinus of hind foot (P > 0.05); however, in the correction degrees for the cross-foot and supination or adduction of the anterior foot, the Mckay procedure was significantly finer than the muscle-strength balancing procedure. It has a good biocompatibility. The mechanical test has showed that the Mckay procedure had the best result in the correction of the forefoot adduction. CONCLUSION: For treatment of congenital clubfoot at Grades I - III, the muscle-strength balancing procedure can achieve an excellent correction result; for treatment of congenital clubfoot at Grade IV, the Mckay procedure should be performed. No matter which procedure, the abductor hallucis excision is recommended to prevent poor correction for the anterior foot adduction.