Carroll Norris C
Northwestern University, Medical School, Chicago, Illinois, USA.
J Pediatr Orthop B. 2012 Jan;21(1):1-6. doi: 10.1097/BPB.0b013e32834a99f2.
In the twentieth century clubfoot was one of the commonest congenital deformities of the musculoskeletal system with an incidence in some races as low as 0.6 and in others as high as 6.8 per thousand live births (Polynesia). Males have the deformity twice as often as females. In the early 1900s forceful correction of the deformity as espoused by Hugh Owen Thomas was in vogue. In the 1930s Joseph Hiram Kite, like Hippocrates (400 BC), recommended repeated gentle manipulations to achieve a correction. Instead of bandages Kite used serial plaster casts to maintain the correction. During the late 1940s Ignatio Ponseti developed his technique of correction through the normal arc of the subtalar joint. In a clubfoot the soft tissues are more resistant to pressure than the bones. With this concept in mind soft tissue procedures were developed in which the capsules and ligaments were released surgically. With safer pediatric anesthesia the 1960s, 1970s, and 1980s saw surgical approaches that were more and more aggressive even including a complete subtalar release. The improved imaging modalities and computer graphics of the 1980s led to a better understanding of the pathoanatomy. Long-term follow-up studies demonstrating malcorrection, overcorrection, pain, and stiffness dampened the enthusiasm for very aggressive surgery. The main problem with surgery is that clubfoot wounds heal by a patching up process called repair. The losses are made good not with the original tissue but with a material that is biologically simple, cheap, and handy - connective tissue scar! As the century drew to a close there was a major swing of the pendulum to the Ponseti method. Surgeons are now learning the limitations of this method. Finally, the author tries to imagine what may happen in the future prevention, classification, and treatment of clubfoot with all the advances in cell biology, molecular biology, biomechanics, biomaterials, surgery, orthotics, and evidence-based medicine.
在20世纪，马蹄内翻足是肌肉骨骼系统最常见的先天性畸形之一，在某些种族中的发病率低至每千例活产中有0.6例，而在其他种族中则高达6.8例（波利尼西亚）。男性患这种畸形的几率是女性的两倍。在20世纪初，休·欧文·托马斯所倡导的对畸形进行强力矫正颇为流行。在20世纪30年代，约瑟夫·海勒姆·凯特像希波克拉底（公元前400年）一样，建议通过反复轻柔的手法来实现矫正。凯特不用绷带，而是使用连续的石膏模型来维持矫正。在20世纪40年代后期，伊格纳西奥·庞塞蒂开发了通过距下关节正常活动弧度进行矫正的技术。在马蹄内翻足中，软组织比骨骼更能抵抗压力。基于这一概念，人们开发了软组织手术方法，通过手术松解关节囊和韧带。随着儿科麻醉安全性的提高，在20世纪60年代、70年代和80年代，手术方法越来越激进，甚至包括完全的距下关节松解。20世纪80年代改进的成像方式和计算机图形学使人们对病理解剖有了更好的理解。长期随访研究显示出矫正不足、过度矫正、疼痛和僵硬等问题，这减弱了人们对非常激进手术的热情。手术的主要问题在于，马蹄内翻足伤口是通过一种叫做修复的修补过程愈合的。损失并非由原来的组织修复，而是由一种生物学上简单、便宜且方便的材料——结缔组织瘢痕来弥补！随着世纪接近尾声，钟摆大幅转向庞塞蒂方法。如今外科医生正在了解这种方法的局限性。最后，作者试图想象随着细胞生物学、分子生物学、生物力学、生物材料、手术、矫形器和循证医学的所有进展，马蹄内翻足在未来的预防、分类和治疗中可能会发生什么。
