Movement Science Lab (K.A.J., A.L.E., and W.R.S.) and Department of Orthopaedics (L.A.K.), Texas Scottish Rite Hospital for Children, Dallas, Texas.
University of Texas Southwestern, Dallas, Texas.
J Bone Joint Surg Am. 2018 Dec 5;100(23):2015-2023. doi: 10.2106/JBJS.18.00317.
The purpose of this study was to assess function, at the age of 10 years, of children initially treated nonoperatively for clubfoot with either the Ponseti or French physiotherapy program and to compare outcomes in feet that had undergone only nonoperative treatment with those that required subsequent surgery.
Gait analysis, isokinetic ankle strength, parent-reported outcomes, and daily step activity data were collected when patients who had been treated for idiopathic clubfoot reached the age of 10 years. Patients who had undergone only nonoperative treatment were compared with those who subsequently underwent extra-articular surgery or intra-articular surgery (posterior release or posteromedial release). The clubfoot groups were compared with age-matched controls.
Of 263 treated clubfeet in 175 patients, 148 had only been treated nonoperatively, 29 underwent extra-articular surgery, and 86 underwent intra-articular surgery (posterior release in 42 and posteromedial release in 44). Significant abnormalities were found in ankle kinetics and isokinetic ankle strength in the feet treated with intra-articular surgery compared with the nonoperatively treated feet (p < 0.017). Compared with controls (n = 40 feet), all groups showed reduced ankle plantar flexion during gait, resulting in a deficit of 9% to 14% for dynamic range of motion, 13% to 20% for ankle moment, and 13% to 23% for power (p < 0.013). Within the intra-articular group, feet that underwent posteromedial release had decreased plantar flexion strength (15%; p = 0.008), dorsiflexion strength (6%; p = 0.048), and parent-reported global function scores (p = 0.032) compared with the posterior release group. The patients with clubfoot took 10% fewer steps (p = 0.015) and had 11% less total ambulatory time (p = 0.001) than the controls.
Examination of patients when they had reached the age of 10 years showed better ankle power and isokinetic strength for clubfeet treated without surgery compared with those that underwent intra-articular surgery for residual deformity or recurrence. Compared with controls, both nonoperatively and surgically treated clubfeet had significant limitations in ankle plantar flexion resulting in decreased range of motion, moment, and power. Gastrocnemius-soleus complex strength was decreased after both nonoperative and surgical treatment of clubfeet. Although activity was diminished in the clubfoot population, no differences in function were perceived by the patients' parents.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
本研究旨在评估初始接受 Ponseti 或法国物理疗法非手术治疗的马蹄足患儿在 10 岁时的功能，并比较仅接受非手术治疗与随后需要手术治疗的足部的结果。
当接受特发性马蹄足治疗的患者达到 10 岁时，收集步态分析、等速踝关节力量、家长报告的结果以及日常步活动数据。仅接受非手术治疗的患者与随后接受关节外手术或关节内手术（后外侧松解或后内侧松解）的患者进行比较。将马蹄足组与年龄匹配的对照组进行比较。
在 175 名患者的 263 只治疗性马蹄足中，有 148 只仅接受非手术治疗，29 只接受关节外手术，86 只接受关节内手术（42 只行后外侧松解，44 只行后内侧松解）。与非手术治疗的足部相比，接受关节内手术治疗的足部的踝关节动力学和等速踝关节力量存在显著异常（p < 0.017）。与对照组（n = 40 只足）相比，所有组在步态中均表现出踝关节跖屈运动受限，导致动态运动范围减少 9%至 14%，踝关节力矩减少 13%至 20%，功率减少 13%至 23%（p < 0.013）。在后内侧松解组中，与后外侧松解组相比，行后内侧松解的足部跖屈力量下降（15%；p = 0.008），背屈力量下降（6%；p = 0.048），家长报告的整体功能评分下降（p = 0.032）。与对照组相比，马蹄足患儿的步数减少了 10%（p = 0.015），总步行时间减少了 11%（p = 0.001）。
对已达到 10 岁的患者进行检查发现，与因残余畸形或复发而接受关节内手术治疗的患者相比，未接受手术治疗的马蹄足患儿的踝关节力量和等速力量更好。与对照组相比，非手术和手术治疗的马蹄足都存在显著的踝关节跖屈受限，导致运动范围、力矩和功率下降。跟腱-比目鱼肌复合体的力量在非手术和手术治疗马蹄足后均下降。尽管马蹄足患者的活动量减少，但患者家长并未察觉到功能上的差异。
治疗性 III 级。有关证据等级的完整描述，请参见作者指南。
