Funk J F, Lebek S, Seidl T, Placzek R
Klinik für Orthopädie, Sektion Kinder- und Neuroorthopädie, Centrum für Muskuloskeletale Chirurgie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
Orthopade. 2012 Dec;41(12):977-83. doi: 10.1007/s00132-012-1982-z.
Clubfoot deformity is one of the most common congenital musculoskeletal deformities and occurs in newborns with different neuromuscular diseases. To date the Ponseti method is the gold standard for the treatment of idiopathic clubfeet but not for non-idiopathic clubfeet which are associated with neuromuscular diseases. The results of the treatment for congenital idiopathic and non-idiopathic clubfeet according to Ponseti performed in our department since 2004 were compared concerning results and relapse surgery with particular reference to the compliance of the parents concerning the use of an abduction splint.
A total of 101 children (28 female and 73 male) with 159 clubfeet were treated with the Ponseti method and included in this prospective non-randomized cohort study. Of these children 27 with 48 affected feet suffered from neuromuscular diseases which are associated with clubfoot deformity, such as myelomeningocele (n=4), arthrogryposis (n=9) and various other syndromes (n=14). The degree of the deformity was evaluated with the Pirani score initially, after casting and at follow-up. Parents were asked at follow-up to state subjectively how compliant they were with the abduction splint treatment. The necessity of surgical treatment of relapses was recorded. Statistical analysis was performed applying χ(2) and Kruskal-Wallis tests for the comparison of idiopathic and non-idiopathic clubfeet.
The average period of follow-up was 36 month (range 6-75 months) and non-idiopathic clubfeet were initially significantly more severely deformed according to the Pirani-score (p=0.013). Treatment of non-idiopathic clubfeet was started significantly later than that of idiopathic clubfeet (p=0.003) and took significantly longer (p <0.001). A correlation between the initiation of casting and the duration of casting was not found (p=0.399). At the end of the casting period no significant differences were found between correction of idiopathic and non-idiopathic clubfeet with respect to the Pirani score (p=0.8). The mean score after casting was 0.1 in both groups. At mid-term follow-up the score increased in both groups but stayed below 0.5 with non-idiopathic clubfeet showing a significantly higher score than idiopathic clubfeet (p=0.014). Relapse surgery was necessary in 11% of the patients. No significant difference in the revision rate was found between the two groups (p=0.331) and peritalar release was not necessary in either group. The rate of revisions correlated with the compliance concerning the use of the abduction splint (p <0.001). Only 61% of the parents stated that they adhered strictly to the abduction splint treatment recommendations with no significant difference between the groups (p=0.398).
This study shows good initial results after Ponseti treatment for idiopathic as well as non-idiopathic clubfeet. Based on the good functional results all clubfeet should initially be treated with the Ponseti method regardless of the etiology.
马蹄内翻足畸形是最常见的先天性肌肉骨骼畸形之一，见于患有不同神经肌肉疾病的新生儿。迄今为止，庞塞蒂方法是治疗特发性马蹄内翻足的金标准，但不适用于与神经肌肉疾病相关的非特发性马蹄内翻足。比较了自2004年以来在我科按照庞塞蒂方法治疗先天性特发性和非特发性马蹄内翻足的结果，包括治疗效果和复发手术情况，尤其关注家长对使用外展支具的依从性。
共有101例儿童（28例女性，73例男性）、159只马蹄内翻足接受了庞塞蒂方法治疗，并纳入了这项前瞻性非随机队列研究。其中，27例儿童、48只患足患有与马蹄内翻足畸形相关的神经肌肉疾病，如脊髓脊膜膨出（4例）、关节挛缩症（9例）和其他各种综合征（14例）。最初、石膏固定后及随访时用皮拉尼评分评估畸形程度。随访时询问家长主观上对外展支具治疗的依从性。记录复发后手术治疗的必要性。应用χ²检验和克鲁斯卡尔-沃利斯检验对特发性和非特发性马蹄内翻足进行统计学分析比较。
平均随访期为36个月（范围6 - 75个月），根据皮拉尼评分，非特发性马蹄内翻足最初畸形明显更严重（p = 0.013）。非特发性马蹄内翻足的治疗开始时间明显晚于特发性马蹄内翻足（p = 0.003），且治疗时间明显更长（p <0.001）。未发现石膏固定开始时间与石膏固定持续时间之间存在相关性（p = 0.399）。在石膏固定期结束时，特发性和非特发性马蹄内翻足在皮拉尼评分方面的矫正情况无显著差异（p = 0.8）。两组石膏固定后的平均评分均为0.1。在中期随访时，两组评分均升高，但均低于0.5，非特发性马蹄内翻足的评分明显高于特发性马蹄内翻足（p = 0.014）。11%的患者需要进行复发手术。两组之间的翻修率无显著差异（p = 0.331），两组均无需进行距周松解术。翻修率与使用外展支具的依从性相关（p <0.001）。只有61%的家长表示他们严格遵守外展支具治疗建议，两组之间无显著差异（p = 0.398）。
本研究表明，庞塞蒂方法治疗特发性和非特发性马蹄内翻足均取得了良好的初步效果。基于良好的功能结果，所有马蹄内翻足最初均应采用庞塞蒂方法治疗，无论病因如何。
