Richards B Stephens, Faulks Shawne, Razi Ozan, Moualeu Amanda, Jo Chan-Hee
1Texas Scottish Rite Hospital for Children, Dallas, Texas 2University of Texas-Southwestern Medical Center, Dallas, Texas.
J Bone Joint Surg Am. 2017 Jan 18;99(2):155-160. doi: 10.2106/JBJS.16.00693.
Nonoperative treatment of idiopathic clubfoot is standard. The purpose of this study was to determine if measurements made on standing lateral radiographs of successfully treated clubfeet made at 18 to 24 months of age were predictive of late recurrence.
Inclusion criteria were idiopathic clubfoot with an age at presentation of ≤3 months, nonoperative treatment resulting in a clinically plantigrade foot at 2 years of age, standing lateral radiograph of the involved foot made at 18 to 24 months of age, and a minimum age of 4 years at the time of follow-up. The radiographs were assessed for the talocalcaneal angle and the tibiocalcaneal angle, with measurements made by 2 trained practitioners. The average values of the 2 raters were used. The interobserver reliability was calculated using intraclass correlation coefficients (ICCs). A total of 211 patients with 312 clubfeet were evaluated. The average age at the time of follow-up was 8.0 years (range, 4.0 to 13.3 years). Results at the time of follow-up were rated as good (maintained plantigrade foot), fair (required limited surgery to maintain, or return to, a plantigrade position), or poor (required posteromedial release).
Over time, 75% of the feet had a good result, 19% had a fair result, and 6% had a poor result. With regard to radiographic assessment, the ICCs were 0.97 (talocalcaneal angle) and 0.98 (tibiocalcaneal angle), demonstrating excellent agreement between the raters. The mean talocalcaneal angle differed significantly between the feet with a good clinical outcome and those with a fair outcome (28° versus 24°; p < 0.02), but did not differ significantly between those with a good versus poor outcome (28° versus 26°), or a fair versus poor outcome (24° versus 26°). There were no significant differences in the mean tibiocalcaneal angle among the groups (86°, 90°, and 84°, respectively) (p = 0.17).
Most clubfeet that were clinically plantigrade at 2 years of age remained so, while one-fourth subsequently required some surgery for late recurrence, primarily limited procedures. The tibiocalcaneal angle and talocalcaneal angle from standing lateral radiographs made at 18 to 24 months of age were not helpful in predicting future relapse.
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
特发性马蹄内翻足的非手术治疗是标准治疗方法。本研究的目的是确定在18至24个月大时对成功治疗的马蹄内翻足站立位侧位X线片进行的测量是否能预测后期复发。
纳入标准为：就诊时年龄≤3个月的特发性马蹄内翻足；非手术治疗后2岁时临床检查足能负重行走；18至24个月大时患侧足的站立位侧位X线片；随访时最小年龄为4岁。由2名经过培训的医生对X线片进行距跟角和胫跟角的评估，并取两人测量值的平均值。采用组内相关系数（ICC）计算观察者间的可靠性。共评估了211例患者的312只马蹄内翻足。随访时的平均年龄为8.0岁（范围4.0至13.3岁）。随访结果分为良好（足保持负重行走）、一般（需进行有限手术以维持或恢复负重行走姿势）或差（需进行后内侧松解术）。
随着时间推移，75%的足预后良好，19%的足预后一般，6%的足预后差。在影像学评估方面，ICC分别为0.97（距跟角）和0.98（胫跟角），表明观察者间的一致性极佳。临床预后良好的足与一般的足之间，平均距跟角有显著差异（28°对24°；p<0.02），但预后良好与差的足之间（28°对26°）或预后一般与差的足之间（24°对26°）无显著差异。各组间平均胫跟角无显著差异（分别为86°、90°和84°）（p = 0.17）。
大多数2岁时临床检查足能负重行走的马蹄内翻足保持了这一状态，而四分之一的足随后因后期复发需要进行一些手术，主要是有限的手术。18至24个月大时站立位侧位X线片的胫跟角和距跟角对预测未来复发并无帮助。
预后水平IV。有关证据水平的完整描述，请参阅作者指南。
