距下完全松解术治疗儿童先天性马蹄内翻足

目的：分析距下完全松解术治疗儿童先天性马蹄内翻足的临床疗效。方法：应用距下完全松解术治疗32例的儿童44只先天性马蹄内翻足。其中男15例19足，女17例25足。单侧发病者20例，双侧发病者12例(男4例，女8例)。术时平均年龄13个月(年龄范围8-18个月)，平均足长度为11．5cm(长度范围8．5-13cm)。平均随访时间为19个月，最短11个月，最长3年。用Gavceau评定标准来评定疗效。结果：本组无一例伤口感染，未出现过度矫正，无距骨坏死，足畸形矫正总优良率97．7％。结论：距下完全松解术对儿童先天性马蹄内翻足是一种良好的手术方法，值得临床推广使用。     

Prospective Study of Gross Motor Milestones in Children with Severe Idiopathic Clubfoot Treated by Ponseti Method

BackgroundA prospective study of motor milestones achieved in severe clubfeet treated by Ponseti method and comparison between unilateral and bilateral clubfoot will help us gain further insight of motor milestones in these children.MethodsProspective study of 150 consecutive children with idiopathic clubfoot who were treated by Ponseti method and in whom percutaneous tendoachilles tenotomy was performed. The gross motor milestones recorded were: rolls from back to stomach, sitting without support, standing with assistance, walks with assistance, standing alone, walking alone. This was compared with published regional and World Health Organization (WHO) normal data.Result15 patients were excluded due to non-compliance and recurrence. Children with unilateral clubfoot (80 children) and bilateral clubfoot (55 children) showed a delay of 0.2–2.1 months in various milestones, and this was statistically significant when compared with both normal data. 95% children with unilateral clubfoot had independent ambulation by 17 months and in bilateral ambulation by 17.8 months. There was also a statistically significant difference in unilateral and bilateral clubfeet in all variables except sitting without support and walking with support.ConclusionThere is a delay in achievement in all children with clubfoot, with more delay in bilateral clubfoot as compared to unilateral clubfoot. The probable reasons could be plaster treatment, possible weakness due to tendoachilles tenotomy, use of orthosis or the inherent pathology associated with clubfeet. Parents hence need to be explained about this delay.     

Congenital Diastasis of the Inferior Tibiofibular Joint With Clubfoot and Imperforate Anus

Congenital diastasis of the inferior tibiofibular joint is a rare condition of unknown etiology, first described in 1972. Although its clinical presentation at birth is a talipes equinovarus deformity of the foot, it may be associated with limb length discrepancy and other skeletal and visceral abnormalities. We present one such case of congenital inferior tibiofibular diastasis of Onimus type A variety (vertical diastasis) with talipes equinovarus, high imperforate anus, short first ray of the foot, intact superior tibiofibular joint, and no limb length discrepancy. Closed manipulation and casting had been unsuccessful, and at this time, the patient had not pursued any treatment during the past one year. A colostomy for the imperforate anus had been performed 36 hours after his birth and was planned for subsequent posterior sagittal anorectalplasty to reestablish continuity. His ankle joint was reconstructed along with soft tissue release for talipes equinovarus. Two years after surgery, he has a plantigrade stable foot with no limb length discrepancy. We propose that if the reconstructed joint is carried out in early childhood, it will provide better reciprocal joint surfaces with less chances of degenerative arthritis in later life. However, leg length inequality and recurrence of the deformities are not uncommon, necessitating further surgical interventions.     

Ilizarov外固定器治疗肥大性骨不连

 目的 探讨采用Ilizarov外固定器治疗肥大性骨不连的疗效。方法 回顾性分析2008年6月至2010年12月,采用Ilizarov环型外固定器直接牵张治疗肥大性骨不连患者的病例,男10例,女2例;年龄22～62岁,平均46.5岁;肱骨中段1例,股骨髁上2例,胫骨中段3例,胫骨中下1/3交界处6例;患肢畸形成角10°～35°,平均25°,其中2例为双平面畸形,10例为单平面畸形;肢体短缩2～6 cm,平均3.5 cm。所有患者术前均拍摄双下肢全长X线片。对骨断端尽量不切开,局部不植骨,直接安装预构的Ilizarov外固定器。对局部留存内固定物者,采用微创的方法取出,尽量保护骨断端血供。术后第7天开始进行矫形延长,断端处每天延长0.25 mm。在恢复肢体长度的同时,矫正成角畸形,对双平面畸形,先矫正冠状面畸形,再矫正矢状面畸形。结果 12例骨不连患者均通过断端直接牵张成骨而获得骨性愈合, 骨断端无需植骨。骨性愈合时间6～12个月,平均8个月。成角畸形和肢体不等长全部获得矫正。畸形矫正时间15～35 d,平均24 d。畸形矫正10°～30°,平均23°。患肢延长2.0～5.5 cm,平均3.0 cm。随访6～18个月,平均14个月,所有患者获得的矫形均未丢失。结论 肥大性骨不连断端间纤维骨痂有活跃的成骨潜能,采用Ilizarov外固定器治疗肥大性骨不连可取得满意的疗效。     

A Modified Ponseti Method for the Treatment of Rigid Idiopathic Congenital Clubfoot

This study reviewed the efficacy of a modified Ponseti method (MP) for treating rigid clubfeet insufficiently corrected by the classic Ponseti method. Briefly, the MP consisted of 3 procedures. First, Achilles tenotomy, abductor hallucis tenotomy, and plantar fasciotomy were conducted through 3 small incisions. Second, the talocalcaneal and talonavicular joints were manually reduced. Third, plaster immobilization was introduced to maintain the initial correction. Dimeglio scores, radiographs, and pain evaluations were used to analyze outcomes. All 38 patients with 56 clubfeet enrolled in the present study achieved initial correction after the MP, followed by a mean of 3.68 ± 0.77 (range 3 to 5) cast immobilizations, which were changed each week. The average duration of treatment was 30.63 ± 6.45 days (range 23 to 47), and 6 (10.71%) clubfeet exhibited cast-related pressure injury. After a mean follow-up period of 19.71 ± 4.83 months (range 12.47 to 31.33), no child presented foot pain, and except for 1 patient with relapse, all patients received correction, with Dimeglio scores of 0.55 ± 1.06 points (range 0 to 7). The recurrence rate was 1.79% (1 of 56) at the first year. The anteroposterior talocalcaneal angle was 34.83° ± 10.65°, and the lateral talocalcaneal angle was 31.38° ± 9.86° at the last follow-up period, and both were significantly improved compared with the corresponding preoperative angles (p < .001). The anteroposterior talus-first metatarsal angle was 12.33° ± 10.04°, and the lateral calcaneal tibial angle was 74.15° ± 14.12°, which were significantly decreased compared with the preoperative values (p < .001). In conclusion, the present short-term evaluation of this minimally invasive soft-tissue release method showed promising results for treating rigid clubfoot that was not responsive to the traditional Ponseti method.     

Ilizarov Treatment of Congenital Pseudarthrosis of the Tibia: A Multi-Targeted Approach Using the Ilizarov Technique

Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging problems in pediatric orthopaedics. The treatment goals are osteosynthesis, stabilization of the ankle mortise by fibular stabilization, and lower limb-length equalization. Each of these goals is difficult to accomplish but regardless of the surgical options, the basic biological considerations are the same: pseudarthrosis resection, biological bone bridging of the defect by stable fixation, and the correction of any angular deformity. The Ilizarov method is certainly valuable for the treatment of CPT because it can address not only pseudarthrosis but also all complex deformities associated with this condition. Leg-length discrepancy can be managed by proximal tibial lengthening using distraction osteogenesis combined with or without contralateral epiphysiodesis. However, treatment of CPT is fraught with complications due to the complex nature of the disease, and failure is common. Residual challenges, such as refracture, growth disturbance, and poor foot and ankle function with stiffness, are frequent and perplexing. Refracture is the most common and serious complication after primary healing and might result in the re-establishment of pseudarthrosis. Therefore, an effective, safe and practical treatment method that minimizes the residual challenges after healing and accomplishes the multiple goals of treatment is needed. This review describes a multi-targeted approach for tackling these challenges, which utilizes the Ilizarov technique in atrophic-type CPT.     

累及距下关节跟骨骨折并发症的防治

目的探讨累及距下关节的跟骨骨折并发症的防治。方法回顾性分析2003年1月至2008年7月我院收治累及距下关节的跟骨骨折52例63足,按Sanders分型,Ⅰ型6足,Ⅱ型13足,Ⅲ型26足,Ⅳ型18足。采用保守治疗6足,撬拨复位空心拉力螺钉固定、管型石膏托外固定8足,切开复位跟骨钢板内固定加自体髂骨植骨39足,钢板内固定未植骨10足。结果63足均获得随访,平均随访23个月。按M ary land足部功能评分系统进行疗效评定,优20足,良36足,可5足,差2足,优良率88.9%。出现皮肤坏死3例,浅表感染2例,腓肠神经损伤1例,腓骨肌腱炎2例,创伤性骨关节炎4例。结论累及距下关节的跟骨骨折应根据骨折类型选择恰当的治疗方案,可有效减少并发症,获得满意的疗效。     

踝上弧形截骨联合关节牵伸治疗内翻型踝关节炎

目的 评估踝上弧形截骨联合关节牵伸治疗内翻型踝关节炎的临床效果。方法 回顾性分析2009年12月至2021年4月北京市垂杨柳医院骨二科治疗的8例内翻型踝关节炎病人的临床资料,男5例,女3例,年龄为（35.2±9.1）岁（27~45岁）。其中有踝部骨折史者5例,骨骺损伤后遗踝内翻畸形3例。应用踝上胫腓骨弧形截骨矫正踝内翻后安装Ilizarov踝关节牵伸器,术后行踝关节牵伸,维持关节间隙至5~8 mm行走3个月以上。根据病人手术前后胫骨远端关节面角（tibial articular surface angle,TAS）及美国足踝外科医师协会（American Orthopaedic Foot and Ankle Society,AOFAS）踝与后足功能评分评估临床治疗效果。结果 8例病人随访时间为（31.5±17.9）个月（12~72个月）,外固定佩戴时间为（29.4±5.1）周（20~32周）。拆除外固定时截骨处均达到临床骨愈合标准,末次随访时AOFAS评分为（82.0±7.7）分（76~90分）,TAS角度为91.1°±2.4°（89.6°~95.0°）,与术前比较［（47.6±3.7）分（41~65分）,82.9°±4.7°（72°~87°）］,差异有统计学意义（P＜0.05）。8例术后均出现局部针道感染,5例给予局部酒精敷料缠绕包扎,3例拔出感染固定针后感染控制。2例固定针折断,去除外固定装置时给予拔除,无其他严重并发症。结论 踝上弧形截骨术联合踝关节牵伸成形治疗内翻型踝关节炎,矫正踝内翻效果满意,避免植骨内固定,截骨愈合良好。结合Ilizarov外固定牵伸,允许术后全负重行走锻炼,显著改善病人足踝功能,值得临床推广应用。     

改良Ilizarov外固定器治疗复杂踝关节骨折脱位

目的 :应用改良Ilizarov外固定器治疗复杂的踝关节骨折脱位。方法 :对 2 4例复杂踝关节骨折脱位采用手法复位 ,闭合穿针改良Ilizarov外固定器固定进行治疗。结果 :本组2 4例中优 12例 ,良 10例 ,差 2例 ,总优良率 91.67%。骨折的平均愈合时间为 7.5周。结论 :应用改良Ilizarov外固定器治疗复杂踝关节骨折脱位疗效满意 ;应用橄榄针穿针弹性固定下胫腓联合分离 ,符合生物学固定的原则 ,是治疗下胫腓联合分离的一种有效方法。     

Arthrography as a Guide in the Treatment of Congenital Clubfoot: Findings and Treatment Results in a Consecutive Series

Simultaneous arthrography of the talocrural and talonavicular joints performed on 32 out of a consecutive series of 48 congenital clubfeet revealed a talar dysplasia that varied considerably both in type and degree.

This great variability meant that no simple and practically useful classification could be made on the basis of arthrographic findings. It indicated, further, that the deformation forces varied correspondingly. Each case therefore has to be analysed separately and treated individually.

The primary treatment was conservative in all cases, but 28 feet were later operated upon because of unsatisfactory correction or recurrence. the operations varied in extent from lengthening of the tendo Achillis to extensive soft-tissue procedures, in some cases combined with correction osteotomy through the neck of the talus and the calcaneus. the results were relatively good, but the investigation showed that in many cases the talar dysplasia places a definite limit on the achievable result.

Arthrography is not indicated in easily corrigible cases. This examination should always be carried out, however, in clubfeet that are difficult to correct or are recurrent, before making a decision about surgical treatment. in these cases the arthrographic findings can be used as a guide in the choice of therapeutic method. the talar dysplasia seems not to alter appreciably during the first year of life, and it would therefore seem appropriate and advisable to perform the examination, and if necessary the operation, at the age of 6–12 months. A programme for examination and treatment is briefly described.     

Comparison of Initial Compression Force Across the Subtalar Joint by Two Different Screw Fixation Techniques

The purpose of this study was to compare the magnitude of compressive force across the posterior facet of the subtalar joint between 2 different screw orientations in a simulated subtalar fusion model fixated with cannulated 7.3-mm screws. Eight paired fresh, frozen cadaver feet were used. Before testing, the bone mineral density of the calcanei and tali was measured with dual energy x-ray absorptiometry to ensure comparable bone mineral density. The paired cadaver calcanei and tali were noted to have less than .05 g/cm(2) difference in bone mineral density. The paired specimens were each randomly assigned to 1 of 2 methods of fixation across the subtalar joint: a plantar approach, where the screw was oriented vertically from the plantar aspect of the calcaneus, distal to the tuberosity; and a posterior approach, where the screw was oriented obliquely from the posterior calcaneal tuberosity. A load-sensing washer was placed under the cancellous screw head before insertion of the screw to measure the magnitude of the compression force across the simulated fusion site. The mean compression force for the posterior-to-anterior approach was 581 N, with a standard deviation of 242 N. The mean force for the plantar-to-superior approach was 604 N, with a standard deviation of 276 N. The compression force obtained by the 2 approaches was not significantly different (P = .74). The plantar-to-superior fixation technique represents an alternative subtalar arthrodesis technique to the posterior-to-anterior approach, potentially allowing one to revise a previously failed arthrodesis when the standard fixation techniques cannot be applied.     

Hybrid骨外固定结合Ilizarov骨段延长术治疗股骨开放性骨折

目的探讨Hybrid骨外固定结合Hizarov自体骨延长治疗股骨开放骨折伴大段骨缺损的疗效.方法自1999～2003年本院共收治股骨开放骨折伴大段骨缺损患者12 例,根据Gustilo Andersen开放骨折分型,其中ⅢA型5 例,ⅢB型7 例;MESS评分在7分或者7分以下伴骨缺损的患者被选择,骨缺损均在4 cm以上.12 例患者均采用Hybrid骨外固定结合Ilizarov自体骨延长治疗.结果术后随访8个月～4 a（平均20个月）,12 例患者均获随访,所有患者均获稳定骨折愈合,平均骨折愈合时间26周（18～30周）,平均外固定时间34周（32～44周）.其中针道感染8 例,皮肤过敏1 例,骨折畸形愈合2 例;无深部感染、骨折不愈合病例,术后膝关节僵直3 例.根据Paley骨折愈合评分,优8 例,良1 例,可2 例,差1 例,优良率为75%;根据膝关节HSS评分,优7 例,良3 例,可1 例,差1 例,优良率为83.33%.结论 Hybrid骨外固定结合自体Ilizarov骨延长是治疗大段骨折的一种有效方法.     

Treatment of Severe and Neglected Clubfoot With a Double Zigzag Incision: Outcome of 21 Feet in 15 Patients Followed Up Between 1 and 5 Years

Patients presenting late for treatment of clubfoot deformity are still common in many parts of the world. These feet are often rigid and severely deformed. Surgical correction is the prevailing option to attain a plantigrade foot, and the extent of correction required predisposes to wound-healing problems. We present the results of treatment of 15 patients (21 feet) with severe, untreated congenital talipes equino varus, who underwent operations using a double zigzag incision as a single-stage procedure. These patients ranged in age from 6 months to 4 years and presented late, having received no treatment or inadequate treatment since birth. The desired end point of the study was a fully corrected foot with a wound that would heal primarily without complications. The etiology was isolated congenital talipes equino varus in 11 patients and arthrogryposis multiplex congenita in 4 patients. Eleven patients were boys and 4 were girls; 6 patients underwent bilateral procedures. The patients were graded preoperatively and postoperatively using the Dimeglio classification, with 10 feet classified preoperatively as grade 3 and 11 graded as grade 4. Desired correction was achieved in all feet, and all wounds healed uneventfully with no complications. This single-stage technique is very safe and cost-effective and is an easy alternative to standard techniques for dealing with late-presenting untreated severe clubfoot deformities.     

The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method

The purpose of this study was to demonstrate the effectiveness of the Ilizarov method and circular external fixator in order to eradicate the infection and restore bone union, limb anatomy and functionality in cases with infected nonunion of the tibia following intramedullary nailing.During 7 years nine patients suffering from infected nonunion of the tibia after intramedullary nailing were treated in our department. The series comprised seven men and two women with an average age of 39.7 years (range 21-75 years). The patients had previously undergone an average of 4.8 operations (range 3-6 operations). Active purulent bone infection occurred in all nine patients. Bone defect was present in all patients with a mean size of 5 cm (range 2-12 cm). In three cases with bone defect less than 2 cm, monofocal compression osteosynthesis technique was used. In the rest cases where bone defect exceeded 2 cm, bifocal consecutive distraction-compression osteosynthesis technique was applied. Three patients required a local gastrocnemius flap. The mean follow-up period was 26.6 months (range 13-42 months). Results were evaluated using Paley's functional and radiological scoring system.Bone union was achieved in all nine patients without recurrence of infection during the follow-up period. Bone results were graded as excellent in five cases and good in the rest four cases. Functional results were graded as excellent in three cases, good in four and fare in two cases. Mean external fixation time was 187.4 days (range 89-412 days) and mean lengthening index was 32 days/cm (range 27-39 days/cm). Complications observed included eight grade II pin tract infections, axial deformity at the lengthening site in two cases and at the nonunion site in another two cases. Ankle joint stiffness was detected in five cases.The Ilizarov method may be an effective method in infected nonunions of the tibia following intramedullary nailing.