应用Ilizarov技术治疗青少年重度马蹄内翻足

目的 :探索青少年重度马蹄内翻足的治疗方法。方法 :应用足踝部有限软组织松解 ,结合术后外固定器缓慢牵伸松解关节挛缩 ,以及二期关节融合与肌力平衡手术治疗青少年重度马蹄内翻足 10例 (16足 )。结果 :16足均获得满意的畸形矫正及足底持重 ,3例遗有轻度前足内收。结论 :应用Ilizarov技术结合有限的手术治疗 ,可获得青少年重度马蹄内翻足的良好畸形矫正和功能恢复。     

Ilizarov技术微创治疗儿童僵硬型马蹄内翻足

目的探讨利用Ilizarov外固定架治疗儿童僵硬型马蹄内翻足畸形的临床疗效及影像学评估。方法 2009年1月至2012年6月利用Ilizarov外固定架治疗25例30足儿童僵硬性马蹄内翻足畸形患者,术前对患者进行常规足部X线检查,测量正位跟距角(talocalcaneal angle of anteroposterior radiograph,TCA-AP)、侧位跟距角(talocalcaneal angle of lateral radiograph,TCA-LAT)、正位距骨-第1跖骨角(talo-first metatarsal angle of anteroposterior radiograph,TMT1-AP),根据患者实际情况选择合适的外固定架,术中按照Ilizarov固定原则固定于患者胫骨及足部相应位置。术后第5天开始调整外固定架螺母,以1 mm/d,6次/d的幅度进行调整,直至畸形得到完全纠正,并适当过伸。将患足固定于过伸矫正位4~6周,期间佩戴外固定架行走。拆除外固定后定期复查X线,测量并对比相关数据。结果 25例患者均得到随访,随访时间8个月~2年,平均随访12个月。所有患者调整外固定架矫形期间均未见血管神经损伤等症状。术后5~7周踝关节恢复到中立位,平均固定时间14周。按Garceau标准评定,优23足,良4足,差3足。治疗前后比较,TCA-AP、TCA-LAT明显增大(P0.001),TMT1-AP明显减小(P0.001),差异均有统计学意义。结论 Ilizarov技术对于儿童僵硬型马蹄足治疗效果明显,具有微创、安全、操作简单等优点,且影像学数据改善明显,可作为评价矫形效果的有效指标。     

组合式外固定器治疗合并患肢短缩的足踝部畸形

背景：传统的足踝部畸形的矫正需要通过手术来完成,术后需要“静态”的维持。Ilizarov技术遵循的“张力-应力法则”和“牵拉组织再生技术”,在一定程度上打破了传统的矫形模式。目的：探讨Ilizarov技术治疗合并患肢短缩的足踝部畸形的临床疗效。方法：回顾分析2006年8月至2012年10月采用Ilizarov技术治疗的17例下肢及足踝部畸形患者的临床资料。其中男10例,女7例,年龄20~37岁,平均27.5岁。脊髓灰质炎后遗症导致患肢短缩合并足踝负重位外翻畸形患者5例,先天性马蹄内翻足合并患肢短缩7例,高弓足合并患肢短缩3例,跟腱挛缩、仰趾畸形合并患肢短缩2例。所有患者在有限手术重建足踝部软组织平衡或者截骨矫正畸形后安装Ilizarov组合式外固定支架,同时做胫骨的延长。结果：17例患者佩戴Ilizarov支架的时间是16~44周,足踝部矫形支架在3~6个月矫形满意、骨融合确实后单独拆除,骨延长支架根据需要继续佩戴。所有患者都获得随访,随访时间6~48个月,患肢延长2~6 cm,延长段骨矿化满意,足踝部矫形满意。足踝功能参照AOFAS评分：术前（43±5.1）分,术后（76±7.2）分。结论：对于各种原因导致的合并下肢短缩的足踝部畸形的矫治,Ilizarov技术灵活的器械组合可同时完成多方向的畸形矫正,在矫正畸形的同时实施骨延长术。     

Congenital Diastasis of the Inferior Tibiofibular Joint With Clubfoot and Imperforate Anus

Congenital diastasis of the inferior tibiofibular joint is a rare condition of unknown etiology, first described in 1972. Although its clinical presentation at birth is a talipes equinovarus deformity of the foot, it may be associated with limb length discrepancy and other skeletal and visceral abnormalities. We present one such case of congenital inferior tibiofibular diastasis of Onimus type A variety (vertical diastasis) with talipes equinovarus, high imperforate anus, short first ray of the foot, intact superior tibiofibular joint, and no limb length discrepancy. Closed manipulation and casting had been unsuccessful, and at this time, the patient had not pursued any treatment during the past one year. A colostomy for the imperforate anus had been performed 36 hours after his birth and was planned for subsequent posterior sagittal anorectalplasty to reestablish continuity. His ankle joint was reconstructed along with soft tissue release for talipes equinovarus. Two years after surgery, he has a plantigrade stable foot with no limb length discrepancy. We propose that if the reconstructed joint is carried out in early childhood, it will provide better reciprocal joint surfaces with less chances of degenerative arthritis in later life. However, leg length inequality and recurrence of the deformities are not uncommon, necessitating further surgical interventions.     

组织牵伸与有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形

目的探讨组织牵伸结合有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形的临床问题。方法 2004年6月至2009年2月共治疗17例成人足外伤后严重的马蹄内翻足畸形。Dimeglio分型：Ⅲ型,严重畸形13足;Ⅳ型,畸形非常严重4足。牵伸矫形器由胫骨外固定器和特殊形状的足部外固定器构成,在畸形状态能适应牵伸器顺利安装情况下,仅选择距下关节融合。如果畸形超出牵伸支架的可调空间,选择有限截骨三关节融合术,部分矫正足的内翻、内收畸形,至能顺利安装牵伸支架,残留的畸形通过牵伸逐渐矫正。结果治疗结束时所有病例的马蹄内翻足畸形均得到完全矫正。14例随访半年至3年,平均11个月;5足轻度复发,马蹄畸形均未大于20°,仍能跖行;踝关节活动度部分有一定改善。根据国际马蹄足畸形研究学组（ICFSG）的评分系统：优3足,良9足,可2足,差0足。结论组织牵伸结合有限截骨矫治成年人下肢外伤后严重马蹄内翻足畸形,便于外固定器的安装,更好地预防畸形复发、减少牵伸的时间,发挥Ilizarov技术的优势。     

Management of fibular hemimelia using the Ilizarov method

A comprehensive program for the correction of fibular hemimelia and associated deformities using the Ilizarov external fixator has been developed at the author's institution. This management involves classification of the deformity (type I, II, or III) and single or staged procedures with the goal to provide a stable plantigrade foot with correction of leg deformity and length discrepancy. The use of the Ilizarov external fixator allows correction of multiple deformities simultaneously. The initial experience with this correction with satisfactory functional and radiographic results in most patients. Final conclusions regarding treatment outcome will not be possible until a significant number of patients reach skeletal maturity.     

Ilizarov技术治疗儿童下肢畸形

目的 介绍Ilizaro技术治疗儿童下肢畸形的临床经验。方法 采用Ilizaro技术治疗31例下肢畸形患儿，2例为先天性胫骨假关节以往植骨内固定治疗失败，4例为骨髓为后骨不连，植骨后短缩，11例为下肢短缩，8例为先天性马蹄内翻足，4例为下肢骨折，1例为骨纤维发育异常，1例为软骨发育不全性侏儒。结果 31例均达到预期目的。结论 应用Ilizaro技术可以在修复骨缺损的同时矫正肢体不等工，假关节切除后延长与加压可以同时进行。Ilizaro三维相结合可矫正足内翻下垂畸形。双下肢同步延长可治疗软骨发育不全性侏儒。     

Complex foot deformities associated with soft-tissue scarring in children.

Two cases of deformities in scarred feet are presented. One case had an old, well healed forefoot amputation with severe equinovarus deformity, and the other had an equinus deformity following a burn injury 10 months prior. Both the cases were managed by primary release of the contracted joint capsules. The correction of the soft-tissue contractures was achieved by gradual distraction using the Ilizarov apparatus. The clinical presentation and surgical treatment of complex foot deformities, complicated by the presence of scar tissue, are presented. These cases illustrate the benefits of combining soft-tissue release with the Ilizarov technique of distraction histogenesis in the treatment of complicated foot deformities associated with scarring in pediatric patients.     

Ilizarov技术矫治复杂僵硬性马蹄内翻足

 目的 探讨Ilizarov技术矫治复杂僵硬性马蹄内翻足的临床疗效。方法 回顾性分析2005年7月至2011年7月28例（41足）僵硬性马蹄内翻足患者的病例,男18例（26足）,女10例（15足）;年龄3~45岁,平均15.3岁;左足8例,右足7例,双足13例。根据Diméglio畸形分级：Ⅲ级31足,Ⅳ级10足。23足采用有限软组织松解、18足配合有限截骨后均安装Ilizarov外固定牵伸器。比较术前及末次随访时踝关节跖屈及背伸角度、踝关节活动度、正侧位X线片上患足距跟角的变化。结果 28例患者均获得随访,随访时间5~38个月,平均25个月。术后外固定支架佩戴2~14个月,平均5.1个月;去除支架后所有患足均获跖行步态,外形接近正常,无足短缩。足背伸角度：术前-45.0°±12.0°,末次随访9.5°±5.5°;跖屈角度：术前67.0°±14.0°,末次随访45.5°±7.8°;正、侧位X线片距跟角：术前分别为6.5°±4.5°和5.5°±11.0°,末次随访分别为22.5°±5.5°和40.6°±8.5°。1足术后发生急性血管痉挛性缺血,予减缓牵伸速度后缓解;5足发生针道感染,予更换针道及换药后感染控制。去支架后3个月,1足出现畸形复发,予二次矫形;3足畸形残留,5足趾屈曲挛缩,均给予二次软组织矫形术,未再复发。结论 Ilizarov技术矫治复杂僵硬性马蹄内翻足疗效确切,能最大程度保留足外形和功能,避免足短缩,不影响足发育。     

Ilizarov技术矫正足踝畸形的器械研究与临床应用

[目的]根据Ilizarov技术的基本原理,研究、探讨矫正不同类别足踝畸形的器械构型、适应证扩展、手术方法与临床应用的效果。[方法]根据中国患者马蹄足、高弓足、跟行足和前足内收或外翻畸形足的病理改变特点与矫形要求,在Ilizarov环形外固定器构型的基础上,设计完成了标准的矫正马蹄足、高弓足、跟行足和前足内收或外翻的4种外固定矫形器构型,并进行了力学测试。创新的扩展了Ilizarov矫正瘢痕性马蹄足、类风湿性关节炎和先天性腓骨缺如所致的重度足外翻畸形。[结果]新设计的4种足踝外固定器,经过临床应用,证实了器械结构合理,安装与调节方便,牵张应力根据需要能进行适度调整,临床治疗105例足踝畸形患者,均获得满意的畸形矫正与功能恢复,无1例出现较严重的并发症。[结论]新设计的4种足踝矫形器构型,结构简便、实用,性能优良、能够满足Ilizarov技术的矫形需求。Ilizarov技术对严重足、踝畸形的矫正,具有其它技术不能替代的满意疗效。     

个体化治疗对高弓马蹄内翻足畸形的疗效分析

目的探讨个体化治疗对高弓马蹄内翻足畸形的临床疗效。方法笔者回顾性分析自2014-04—2016-02诊治的15例(24足)高弓马蹄内翻足畸形的临床资料,根据患者的发病原因和畸形的情况实施个体化治疗,行软组织手术(松解、转位和延长)、骨性手术(截骨和融合)或Ilizarov外固定架固定手术。手术前后采用美国矫形足踝协会(AOFAS)踝与后足评分系统评价足踝部功能,采用疼痛视觉模拟评分(VAS)评定疼痛改善情况,采用李克特量表评价患者主观满意度。结果全部患者均获随访6~20个月,平均13.8个月。所有患者术后切口均一期愈合,未出现切口感染。AOFAS评分术前(35.6±7.6)分,术后12个月(81.2±9.3)分,VAS评分术前(8.5±1.1)分,术后12个月(3.2±1.0)分,术后1年AOFAS评分和VAS评分较术前明显改善,差异均有统计学意义(t=14.700,P=0.010;t=-13.928,P=0.015)。末次随访疗效按AOFAS评分评定:优9例,良4例,可1例,差1例,优良率86.7%。末次随访患者主观满意度采用李克特量表评价:所有患者主观满意率86.7%。结论高弓马蹄内翻足畸形的种类多样,可合并多种足部畸形,治疗的难度较大,在临床上应根据个体的发病原因和畸形的情况有针对性选择软组织手术、骨性手术或者Ilizarov外固定架手术等联合的组合术式,实施个体化治疗,有助于矫正畸形,提高患者满意度,疗效确切。     

Equinovarus of the foot in adults treated with tibiocalcaneal arthrodesis. Review of 18 cases

The authors have retrospectively studied 18 cases of tibiocalcaneal arthrodesis performed to treat a fixed equinovarus deformity of the foot in 13 adult patients. The operations were performed between 1981 and 1998; there were 9 neurologic and 9 post-traumatic deformities. The mean calcaneal varus deformity was 50 degrees and the mean equinus deformity was 75 degrees. The results were evaluated using Kitaoka's criteria. We noted one postoperative cutaneous necrosis, two nonunions, one of which was reoperated by bone freshening and osteotomy of the midfoot. All rearfeet were in neutral alignment and were stable. Shortening was on average 2.8 cm. Plantar support was achieved in 10 feet, with improved autonomy, walking capacity and footwear. Overall, there were 10 good, 2 fair and 1 poor result. In the group with neurologic deformities there were 4 good, 1 fair and 1 poor result. In the group with post-traumatic deformities, there were 6 good and one fair results. Other series published also showed satisfactory results comparable to or better than those obtained with triple arthrodesis, which generates severe stiffness of the rear- and midfoot, disturbing gait. Fixed equinovarus deformity of the foot in the adult is a good indication for tibiocalcaneal arthrodesis, allowing in the majority of cases to achieve stable and painless plantar support.     

Surgical treatment of orthopedic deformities due to spasticity in the lower limb

Orthopedic deformities in the lower limb concern all joints (hip, knee, ankle, foot) with a wide range of clinical forms. Spasticity, contracture, stiffness, laxity, neurological deficit are assessed to establish the surgical procedure. Surgical techniques are adapted to the goals that are detailed with the patient and his family: standing, transferring, walking, hygiene, devices (shoes, orthosis, canes, wheelchair). Surgical procedures can associate: lengthening of contractured muscles (tenotomy with or without sutures, fractional lengthening at the musculo-tendinous junction or desinsertion), strengthening of antagonists (passive or active tendon transfer) and correction of joint deformity (arthrolysis, arthrodesis, arthroplasty). In adults, the most common deformities are the equinus or equinovarus foot, toe curling, hip adductum, knee flessum. Talus or knee recurvatum are less frequently observed. The association of various deformities raises questions concerning the hierarchy of surgical procedure, from an anatomical point of view (do we start with proximal or distal joint first?) as from chronological concerns (shall we do one or more procedures?). Pluridisciplinary assessment using neurological anesthetic blocs and dynamic EMG or gait analysis is necessary to detail the aims of surgery and choose the surgical procedures.     

Ilizarov external fixator in treatment of severe recurrent congenital talipes equinovarus

Aim  

Severe recurrent congenital talipes equinovarus deformity remains a significant problem in orthopedic surgery particularly in the developing countries with limited facilities. Surgical treatment of patients with severe recurrent congenital talipes equinovarus is difficult and has many complications. This study discusses the results of using Ilizarov external fixator in treatment of severe recurrent congenital talipes equinovarus deformity.     

Wiederherstellung der Gehfähigkeit durch beidseitige Korrekturtriplearthrodese bei hochgradigem Pes equinovarus und Tetraspastik

A tendon transfer is the method of choice in easily reducible pes equinovarus. However, in long-time persisting deformities with spasms, a plantigrade position can not be maintained with these procedures. Therefore, we perform an additional bilateral triple arthrodesis in a patients with such bilateral deformities. A 55-year-old woman developed, within the scope of several surgical procedures on the cervical spine, marked bilateral pes equinovarus and flexion contractures of the knees. The patient's ambulation was limited to a wheelchair for 3 years. Then, in an interval of 1 year, we performed an unilateral soft tissue release, z-tenotomy of the Achilles tendon, triple arthrodesis with correction of the deformity, and posterior tibial tenden transfer. At follow-up 5 years after the second procedure, the 61-year-old patient was able to walk alone with two walking sticks. In the case described, the correction of a marked pes equinovarus with spasms, which was achieved by an extensive soft tissue release, could be stabilized through a triple arthrodesis in such way that the plantigrade position of the foot could be controlled through a posterior tibial tendon transfer.     

脊椎裂后遗足踝畸形的临床分析

目的 分析脊椎裂后遗足踝畸形的发病情况、临床特点、畸形类别与矫形治疗状况.方法 对我科1990年1月至2009年7月接受手术治疗脊椎裂后遗足踝部畸形患者进行回顾性研究,对资料进行总结分析.结果 手术治疗脊椎裂后遗足踝部畸形共107例患者.其中男性44例,女性63例;手术年龄1.3～52.0岁,平均17.7岁,其中18岁以上者50.5%(54/107).隐性脊椎裂50.5%(54/107),显性(囊性)脊椎裂49.5%(53/107).1例为胸椎裂(T3～8),余106例为腰骶椎裂.单侧足受累49例(左侧22例,右侧27例),双侧足受累58例,共165足.畸形类型:内翻足76足,外翻足23足,夏科连枷足15足,其他类足畸形51足.合并其他受累部位:膝部屈曲或膝反屈畸形4例,髋部畸形17例(包括髋内收、屈曲或髋关节脱位,骨盆倾斜、双下肢不等长等),合并大小便功能障碍30例.本组54例隐性脊椎裂致足踝畸形患者中,29例既往在多个医院未能确诊发病原因,误诊或漏诊的比率高达53.7%(29/54).107例患者中,既往接受过足踝畸形矫形手术者仅26例.18岁以上既往未能实施合理矫形外科治疗遗留严重足踝畸形者50.5%(54/107).结论 脊椎裂继发畸形主要在足踝部.由于缺乏对此病的整体认识与矫形治疗经验,延误了对此类疾病的早期诊断、早期干预的治疗时机,遗留了很多未经矫形外科治疗的严重足踝畸形.     

Correction of knee and ankle valgus in hereditary multiple exostoses using the Ilizarov apparatus

Background Hereditary multiple exostoses (HME) is a genetic disorder that causes limb deformities due to disturbance at the growth plates. Materials and methods Six adolescents, whith symptomatic valgus deformity at the ankle and knee (seven affected legs) underwent correction procedures using the Ilizarov apparatus. In 5 legs, a bifocal Ilizarov apparatus was used, whereas in 2 legs the use of a monofocal apparatus was sufficient. Results Correction of the mechanical axis was achieved in all cases, and limb length discrepancy was equalized in the 3 cases that underwent limb elogation. The average knee and ankle corrections were 15° and 18°, respectively. The average time from application to removal of the Ilizarove apparatus was 4.6 months. No major complication occurred. Conclusions The use of the Ilizarov method in adolescents with HME enables successful simultaneous correction of multiplanar, multifocal complex limb deformities.     

Clinico-Radiological and Functional Outcome of Difficult Talipes Equinovarus Deformity Corrected With an Ilizarov Fixator

Relapsed, resistant, and untreated congenital talipes equinovarus poses significant challenges in view of functional outcome following conventional serial casting and soft tissue release procedures. The Ilizarov ring fixator here offers significant possibilities as an extended conservative treatment modality. The aim of the present study was to critically evaluate effectiveness of the Ilizarov ring fixator with regard to radiological, clinical, and functional outcomes, in the difficult clubfeet. The study was carried out on patients presenting with relapsed, resistant, or untreated congenital talipes equinovarus deformity, who underwent deformity correction using the Ilizarov ring fixator application. All patients were reviewed at 6 monthly intervals for over 3 years following fixator removal with an objective clinical, radiological, and functional assessment. Twenty-three patients with 30 clubfeet were enrolled in our study. The mean age was 8.3 ± 3.6 (range 4-17) years. The postoperative clinical, radiological, and functional scores showed statistically significant improvement among all patients when compared with the preoperative data. All 30 feet developed varying complications during treatment with pin track infections being the most common. However, they were managed while continuing the distraction correction process. The Ilizarov ring fixator is an effective and reliable solution for difficult and challenging clubfeet. However, one must be aware of a strict adherence to a bracing protocol to avoid recurrence of deformities. A regular periodical functional and clinical follow up must be ensured among these children for a favorable outcome.