Department of Women's and Children's Health. Karolinska University Hospital, 171 76 Stockholm, Sweden.
J Bone Joint Surg Am. 2013 Mar 6;95(5):400-7. doi: 10.2106/JBJS.L.00889.
There are many treatments for idiopathic toe-walking, including casts with or without injection of botulinum toxin A. Combined treatment with casts and botulinum toxin A has become more common even though there have been few studies of its efficacy and safety problems. Our aims were to conduct a randomized controlled trial to test the hypotheses that combined treatment with casts and botulinum toxin A is more effective than casts alone in reducing toe-walking by patients five to fifteen years of age, and that the treatment effect correlates with the extent of coexisting neuropsychiatric problems.
All patients who had been consecutively admitted to the pediatric orthopaedics department of our institution because of idiopathic toe-walking between November 2005 and April 2010 were considered for inclusion in the study. Forty-seven children constituted the study population. The children were randomized to undergo four weeks of treatment with below-the-knee casts either as the sole intervention or to undergo the cast treatment one to two weeks after receiving injections of botulinum toxin A into the calves. Before treatment and three and twelve months after cast removal, all children underwent three-dimensional (3-D) gait analysis. The severity of the idiopathic toe-walking was classified on the basis of the gait analysis, and the parents rated the time that their child spent on his/her toes during barefoot walking. Passive hip, knee, and ankle motion as well as ankle dorsiflexor strength were measured. Before treatment, all children were evaluated with a screening questionnaire for neuropsychiatric problems.
No differences were found in any outcome parameter between the groups before treatment or at three or twelve months after cast removal. Several gait-analysis parameters, passive ankle motion, and ankle dorsiflexor strength were improved at both three and twelve months in both groups, even though many children still demonstrated some degree of toe-walking. The treatment outcomes were not correlated with coexisting neuropsychiatric problems.
Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment.
特发性尖足有多种治疗方法，包括使用或不使用肉毒毒素 A 注射的石膏固定。尽管关于其疗效和安全性问题的研究较少，但联合使用石膏和肉毒毒素 A 的治疗方法已经越来越普遍。我们的目的是进行一项随机对照试验，以检验以下假设：对于 5 至 15 岁的特发性尖足患者，联合使用石膏和肉毒毒素 A 的治疗方法比单独使用石膏固定更能有效减少尖足，且治疗效果与并存的神经精神问题的严重程度相关。
所有因特发性尖足而于 2005 年 11 月至 2010 年 4 月期间连续被收入我院小儿矫形外科的患者均被认为适合参加该研究。47 名儿童构成了研究人群。这些儿童被随机分为两组，一组接受为期四周的膝下石膏固定治疗，另一组在小腿注射肉毒毒素 A 后一至两周内接受石膏固定治疗。在治疗前、去除石膏后 3 个月和 12 个月，所有儿童均接受三维（3-D）步态分析。根据步态分析结果对特发性尖足的严重程度进行分类，并由家长对其儿童赤脚行走时脚趾着地的时间进行评分。测量被动髋关节、膝关节和踝关节活动度以及踝关节背屈肌力量。在治疗前，所有儿童均接受神经精神问题筛查问卷评估。
在治疗前或去除石膏后 3 个月或 12 个月时，两组之间在任何结果参数上均无差异。两组在 3 个月和 12 个月时的多个步态分析参数、被动踝关节活动度和踝关节背屈肌力量均有所改善，尽管许多儿童仍存在一定程度的尖足。治疗结果与并存的神经精神问题无关。
在使用石膏固定治疗特发性尖足之前添加肉毒毒素 A 注射并不能改善单独使用石膏固定的治疗效果。
