Avilucea Frank R, Szalay Elizabeth A, Bosch Patrick P, Sweet Katherine R, Schwend Richard M
University of New Mexico Carrie Tingley Hospital, 1127 University Boulevard N.E., Albuquerque, NM 87102, USA.
J Bone Joint Surg Am. 2009 Mar 1;91(3):530-40. doi: 10.2106/JBJS.H.00580.
Nonoperative management of clubfoot with the Ponseti method has proven to be effective, and it is the accepted initial form of treatment. Although several studies have shown that problems with compliance with the brace protocol are principally responsible for recurrence, no distinction has been made with regard to whether the distance from the site of care affects the early recurrence rate. We compared early recurrence after Ponseti treatment between rural and urban ethnically diverse North American populations to analyze whether distance from the site of care affects compliance and whether certain patient demographic characteristics predict recurrence.
One hundred consecutive infants with a total of 138 clubfeet treated with the Ponseti method were followed prospectively for at least two years from the beginning of treatment. Early recurrence, defined as the need for subsequent cast treatment or surgical treatment, and compliance, defined as strict adherence to the brace protocol described by Ponseti, were analyzed with respect to the distance from the site of care, age at presentation, number of casts needed for the initial correction, need for tenotomy, and family demographic variables.
Of eighteen infants from a rural area who had early recurrence, fourteen were Native American. The families of these children, like those of all of the children with early recurrence, discontinued orthotic use earlier than was recommended by the physician. Discontinuation of orthotic use was related to recurrence, with an odds ratio of 120 (p < 0.0001), in patients living in a rural area. Native American ethnicity, unmarried parents, public or no insurance, parental education at the high-school level or less, and a family income of less than $20,000 were also significant risk factors for recurrence in patients living in a rural area. Intrinsic factors of the clubfoot deformity were not correlated with recurrence or discontinuation of bracing.
Compliance with the orthotic regimen after cast treatment is imperative for the Ponseti method to succeed. The striking difference in outcome in rural Native American patients as compared with the outcomes in urban Native American patients and children of other ethnicities suggests particular problems in communicating to families in this subpopulation the importance of bracing to maintain correction. An examination of communication styles suggested that these communication failures may be culturally related.
已证实采用庞塞蒂方法对马蹄内翻足进行非手术治疗是有效的，且这是公认的初始治疗方式。尽管多项研究表明，支具方案依从性问题是复发的主要原因，但对于距治疗地点的距离是否会影响早期复发率，尚未进行区分。我们比较了北美不同种族农村和城市人群接受庞塞蒂治疗后的早期复发情况，以分析距治疗地点的距离是否会影响依从性，以及某些患者人口统计学特征是否可预测复发。
对连续100例共138只马蹄内翻足采用庞塞蒂方法治疗的婴儿，从治疗开始进行至少两年的前瞻性随访。分析早期复发（定义为需要后续石膏治疗或手术治疗）和依从性（定义为严格遵守庞塞蒂描述的支具方案）与距治疗地点的距离、就诊年龄、初始矫正所需石膏数量、是否需要跟腱切断术以及家庭人口统计学变量的关系。
在18例有早期复发的农村地区婴儿中，14例为美洲原住民。这些儿童的家庭，与所有有早期复发的儿童家庭一样，比医生建议的时间更早停止使用矫形器。在农村地区患者中，停止使用矫形器与复发相关，比值比为120（p<0.0001）。美洲原住民种族、父母未婚、有公共保险或无保险、父母教育程度为高中及以下以及家庭收入低于20,000美元也是农村地区患者复发的重要危险因素。马蹄内翻足畸形的内在因素与复发或支具停用无关。
对于庞塞蒂方法的成功，石膏治疗后遵守矫形器方案至关重要。与城市美洲原住民患者和其他种族儿童相比，农村美洲原住民患者的治疗结果存在显著差异，这表明在向该亚人群家庭传达支具对维持矫正的重要性方面存在特殊问题。对沟通方式的检查表明，这些沟通失败可能与文化有关。
