Dierauer S, Schäfer D, Hefti F
Kinderorthopädische Universitätsklinik, Basel, Germany.
Orthopade. 1999 Mar;28(2):117-124. doi: 10.1007/PL00003588.
There are no clear guidelines on the treatment of relapsed clubfoot, which is a relatively frequent and difficult problem in paediatric orthopaedics. Numerous operative interventions are mentioned in the literature as suitable for correction of a residual deformity of the food. There are numerous soft tissue procedures (release operations, tendon extensions, tendon transfers and redressement by means of a fixateur externe) and osseous interventions (osteotomies, arthrodeses) that can be carried out in isolation or in combination. In the present article two types of osteotomy are described that make it possible to correct the most frequent forms of relapsed clubfoot: combined closing wedge cuboid and opening wedge cuneiform osteotomy for correction of adductus and supination of the forefoot and the calcaneal osteotomy after Dwyer for correction of varus positon of the calcaneal part of the foot. The combined osteotomy in the midfoot involves shortening of the lateral ray with simultaneous lengthening of the medial ray, with the wedge out of the cuboid bone inserted into the medial cuneiform bone, which leads mainly to correction of the adductus, but does also make it possible to achieve partial correction of the supination with an osteotomy right through the cuneiform bone. In the case of rigid foot deformities it is advisable to carry out preliminary stretching by means of a fixateur externe, while in the case of a bean-shaped foot a combination of osteotomy and medial and lateral release is recommended. Results of a follow-up study of our own patients treated with this operation have shown that no revision operations were necessary in any of the patients with idiopathic clubfoot. Other types of osteotomy described in the literature as suitable for correction of residual forefoot adductus and supination are also mentioned in this paper. Thecalcaneal osteotomy after Dwyer, for which a lateral approach is always used, generally leads to satisfactory correction of varus position of the calcaneal part of the foot. It the calcaneus is found to have a short posterior part this osteotomy is modified so that instead of taking the form of a wedge osteotomy with lateral closing it is followed by a lateral displacement. In this way it is possible to prevent making the already short posterior calcaneus even shorter. Both the combined midfoot osteotomy and the calcaneal osteotomy after Dwyer can be performed alone or in combination with each other or with different operative interventions.
对于复发性马蹄内翻足的治疗，目前尚无明确的指导方针，这在小儿骨科中是一个相对常见且棘手的问题。文献中提及了许多适用于矫正足部残留畸形的手术干预方法。有众多软组织手术（松解手术、肌腱延长术、肌腱转移术以及借助外固定器进行矫正）和骨手术（截骨术、关节融合术），这些手术可以单独进行，也可以联合实施。在本文中，描述了两种截骨术，它们能够矫正复发性马蹄内翻足最常见的畸形类型：联合闭合楔形骰骨截骨术和开放楔形楔骨截骨术用于矫正前足内收和旋后畸形，以及德怀尔（Dwyer）跟骨截骨术用于矫正足部跟骨部分的内翻畸形。中足联合截骨术包括缩短外侧列同时延长内侧列，将从骰骨取出的楔形骨块插入内侧楔骨，这主要可矫正内收畸形，但通过贯穿楔骨的截骨术也能实现部分旋后畸形的矫正。对于僵硬性足部畸形，建议先通过外固定器进行初步拉伸，而对于舟状足，则推荐采用截骨术与内外侧松解术相结合的方法。对接受此手术治疗的我们自己的患者进行随访研究的结果表明，特发性马蹄内翻足患者均无需进行翻修手术。本文还提及了文献中描述的其他适用于矫正残留前足内收和旋后畸形的截骨术类型。德怀尔跟骨截骨术总是采用外侧入路，通常能使足部跟骨部分的内翻畸形得到满意矫正。如果发现跟骨后部较短，则对该截骨术进行改良，使其不是采用外侧闭合的楔形截骨形式，而是改为外侧移位。这样可以防止使原本就短的跟骨后部变得更短。中足联合截骨术和德怀尔跟骨截骨术既可以单独进行，也可以相互联合或与不同的手术干预措施联合进行。
