本文選題：垂直距骨 + 先天性�。� 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景:先天性垂直距骨(Congenital vertical talus,CVT),也稱為“搖椅足”、“先天性凸底外翻足”,是一種發(fā)病罕見(發(fā)病率約為1/10,000[1])、畸形嚴(yán)重的先天性僵硬性扁平足,表現(xiàn)為后足外翻、跖屈(馬蹄);距骨頭凸出于中足跖內(nèi)側(cè);前足外展并相對(duì)于中后足背伸,外形如搖椅底座。典型影像學(xué)特點(diǎn)為:足側(cè)位片,距骨呈垂直位,且舟骨相對(duì)于距骨頭呈不可復(fù)性背外側(cè)脫位,跟骨跖屈(馬蹄)。CVT的具體病因尚不明確,據(jù)估計(jì),約有50%的病例合并神經(jīng)肌肉性異常[2]或已知的基因缺陷和(或)綜合征[3],另外約50%不合并其他先天性畸形的則被認(rèn)為屬于特發(fā)性[4,5]。對(duì)于該病的治療,目前已達(dá)成的共識(shí)是:越早越治療效果越好,單純保守治療不能治愈,手術(shù)可能是唯一有效的方法。而對(duì)于具體的手術(shù)矯形方法,目前尚未統(tǒng)一。傳統(tǒng)上CVT的手術(shù)治療包括一期或二期廣泛松解重建[6-8]、背側(cè)或后側(cè)入路松解重建[911]、舟骨切除手術(shù)[12]、距下關(guān)節(jié)融合術(shù)或三關(guān)節(jié)融合術(shù)[13,14]等。雖然這些廣泛松解重建手術(shù)都取得了良好的早期矯正效果,但長期隨訪結(jié)果并不如人意,遠(yuǎn)期并發(fā)癥多且發(fā)生率高,如皮膚壞死[1]、踝關(guān)節(jié)和距下關(guān)節(jié)僵硬[8]、距骨壞死[5,9]、畸形復(fù)發(fā)[5]、足壞死甚至截肢[15]等。2006年Dobbs等人[16]在參考了 Ponseti方法治療先天性馬蹄足的原理[17]后,首創(chuàng)了一種更加簡單的新方法治療CVT,即通過手法矯形序列石膏固定(矯形用力方向與Ponseti方法相反),經(jīng)皮穿針固定距舟關(guān)節(jié)或微創(chuàng)切復(fù)位距舟關(guān)節(jié)并固定,最后以經(jīng)皮延長跟腱——所謂的反式Ponseti法或Dobbs法,矯正CVT的所有畸形組分,獲得了良好的短期和長期效果[16,18-23]。然而,許多的前期研究都只單純分析特發(fā)性[16,24]或非特發(fā)性CVT[22]的療效,僅有少量的研究[20,25]比較了特發(fā)性和非特發(fā)性CVT的療效差異。而目前,國內(nèi)對(duì)于這種新的CVT治療方法報(bào)道較少,而對(duì)比研究更是空白,因此探討其治療方法、臨床療效及療效差異意義重大。目的:1.探討反式Ponseti方法聯(lián)合微創(chuàng)切開復(fù)位技術(shù)治療先天性垂直距骨的治療方法及臨床療效,2.比較反式Ponseti方法聯(lián)合微創(chuàng)切開復(fù)位技術(shù)治療特發(fā)性CVT與非特發(fā)性CVT的臨床療效,為今后的推廣應(yīng)用提供借鑒。方法:回顧性分析2012年7月至2015年12月就診于我院的先天性垂直距骨患兒11例(18足),其中男8例,女3例,特發(fā)性組5例(9足),非特發(fā)性組6例(9足),平均手術(shù)年齡10.9個(gè)月(3.9個(gè)月—31.2個(gè)月)。所有患兒均多次反式Ponseti序列石膏矯形,經(jīng)皮逆行穿針固定或微創(chuàng)切開復(fù)位固定距舟關(guān)節(jié),經(jīng)皮延長跟腱,石膏固定治療。比較兩組患兒末次隨訪時(shí)踝關(guān)節(jié)、距下關(guān)節(jié)活動(dòng)度,以及術(shù)前、術(shù)后即刻、末次隨訪時(shí)的影像學(xué)測(cè)量參數(shù)。采用Adelaar評(píng)分評(píng)估患兒治療后的整體療效。結(jié)果:11例(18足)患兒在平均隨訪27個(gè)月(12個(gè)月—57個(gè)月)后,所有足部畸形都得到不同程度矯正,內(nèi)側(cè)縱弓恢復(fù),后足無明顯外翻,踝關(guān)節(jié)和距下關(guān)節(jié)無明顯功能障礙。僅非特發(fā)性組中2例(4足)術(shù)后6個(gè)月內(nèi)出現(xiàn)畸形復(fù)發(fā),隨后再次經(jīng)序列石膏矯形、微創(chuàng)手術(shù)后畸形矯正,無需廣泛松解手術(shù)。末次隨訪時(shí),特發(fā)性組踝關(guān)節(jié)活動(dòng)度優(yōu)于非特發(fā)性組(P0.05),所有的影像學(xué)測(cè)量結(jié)果較術(shù)前均有改善(P0.05),兩組間差異無統(tǒng)計(jì)學(xué)意義(P0.05)。根據(jù)Adelaar評(píng)分,2足為優(yōu),15足為良,1足為中。所有患兒均無傷口壞死、關(guān)節(jié)僵硬、距骨壞死等并發(fā)癥。結(jié)論:反式Ponseti方法聯(lián)合微創(chuàng)切開技術(shù)治療先天性垂直距骨是一種有效治療幼齡先天性垂直距骨的新方法,就足的臨床外觀、功能以及影像學(xué)測(cè)量等方面,與傳統(tǒng)廣泛松解手術(shù)相比具有創(chuàng)傷小、療效可靠、并發(fā)癥少等優(yōu)點(diǎn),可獲得良好的早期臨床效果。
[Abstract]:Background: congenital vertical talus (Congenital vertical, talus, CVT), also known as the "rocker foot", "congenital convex pes valgus", is a rare disease (incidence rate is about 1/10000[1]), congenital malformation of severe rigid flatfoot, manifested as foot valgus, plantar flexion (horseshoe); from the bones protruding from the medial plantar foot and forefoot abduction; in relation to the dorsal extension, such as shape of a rocking. Typical imaging features: foot radiograph, vertical talus, scaphoid bone is relative to the distance and the irreducible dorsal lateral dislocation of bone with plantar flexion (horseshoe) concrete the etiology of.CVT is still not clear, it is estimated that about 50% of the patients and the gene defects in neuromuscular abnormalities or known [2] (or [3]) syndrome, another 50% is not associated with other congenital malformations are considered to belong to idiopathic [4,5]. for the treatment of the disease, has now reached a consensus more: The earlier the better treatment, conservative treatment can cure, surgery may be the only effective way for orthopedic surgery. The methods have not yet unified. The traditional surgical treatment of CVT include one or two stage solution for [6-8] reconstruction, dorsal or posterior approach release [911] reconstruction of scaphoid resection [12], subtalar arthrodesis arthrodesis or three [13,14]. Although these solution reconstruction have made early correction of good effect, but long-term follow-up results are not satisfactory, and the high incidence of complications such as skin necrosis, [1], ankle and subtalar joint stiffness [8], ofosteonecrosis [5,9]. [5] foot deformity recurrence, necrosis and [15].2006 Dobbs et al. [16] in reference to the principle of [17] Ponseti method for the treatment of congenital clubfoot, pioneered a new method for the treatment of CVT is more simple, namely by hands. Method of orthopedic plaster fixation sequence (orthopedic force direction and Ponseti method instead), percutaneous pin fixation of talonavicular joint or minimally invasive cut reduction of talonavicular joint and fixed, and finally to extend the percutaneous Achilles tendon - the so-called trans Ponseti method or Dobbs method, correction of deformity all components of CVT, the [16,18-23]. of short and long term effects good however, many of the previous research only curative effect analysis of idiopathic [16,24] or non idiopathic CVT[22], only a few studies on [20,25] efficacy comparison of idiopathic and non idiopathic CVT. At present, the domestic reports about the new CVT treatment method is less, while comparison is blank therefore, to explore the methods of treatment, clinical efficacy and the difference is significant. Objective: To investigate the effect of treatment for the 1. trans Ponseti method combined with minimally invasive open reduction technique for the treatment of congenital vertical talus and clinic, 2. Comparison of the clinical efficacy of trans Ponseti method combined with minimally invasive open reduction technique for the treatment of idiopathic and nonidiopathic CVT CVT, provide a reference for future application. Methods: a retrospective analysis from July 2012 to December 2015 in our hospital for treatment of congenital vertical talus in 11 cases (18 feet), of which 8 cases were male, 3 female cases of idiopathic group 5 cases (9 feet), nonidiopathic group of 6 cases (9 feet), the average age of surgery was 10.9 months (3.9 months to 31.2 months). All patients were repeatedly trans Ponseti series orthopedic plaster, percutaneous retrograde transfixation or minimally invasive open reduction and fixed talonaviculare joint extension of Achilles tendon percutaneous plaster fixation. Two groups were compared at the end of the follow-up ankle and subtalar joint activity, and preoperative, immediate postoperative, measurement parameters at the end of the follow-up imaging. Adelaar score was used to evaluate the overall curative effect after treatment. Results: 11 cases (18 feet the children in the flat) All patients were followed up for 27 months (12 months to 57 months), all have different degrees of foot deformity correction, the medial longitudinal arch after recovery, no significant foot valgus, ankle and subtalar joint no obvious dysfunction. Only nonidiopathic group in 2 cases (4 feet) within 6 months after operation deformity recurrence, then again by the sequence of orthopedic plaster after minimally invasive surgery, deformity correction, without extensive lysis operation. At the end of the follow-up, idiopathic group of ankle activity than non idiopathic group (P0.05), all the imaging measurement results than before were improved (P0.05), no statistically significant significant differences between the two groups (P0.05). According to Adelaar score, 2 feet were excellent, 15 feet good, 1 feet. All patients had no wound necrosis, joint stiffness, talus necrosis and other complications. Conclusion: trans Ponseti method combined with minimally invasive incision technique in the treatment of congenital vertical talus is an effective treatment for the young congenital vertical distance The new method of bone has many advantages, such as less trauma, reliable effect and fewer complications. It can achieve good early clinical effect compared with the traditional loosening surgery.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3
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本文編號(hào)：1756145