先天性马蹄内翻足足骨生长发育特点研究
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摘要
目的: 先天性马蹄内翻足(congenital clubfoot, CCF)是足部常见先天畸形之一。其治疗方法分为手术和非手术治疗。发展至今天，近期疗效多较满意，远期疗效却并非理想，后遗症发生率较高。本文旨在对其足骨生长发育特点和骨关节改变及由此引起的骨关节间压应力传导特点作一分析研究，为CCF的手术治疗提出一个统一的治疗原则，简化疗效评价，为远期疗效的巩固提出原则性思考。
方法: 采用6m~4y左右的单侧患儿，用自身健侧与患侧对照。统一采用标准的X线摄片方法对CCF患儿行双足正侧位摄片及部分患儿行螺旋CT三维成像。采用统一的测量标准测量相应跗骨骨化部分纵径及结合CT三维图像分析骨关节间改变，作双侧跗骨发育比较及患足骨关节间压应力传导特点分析。根据足印图粗略分析足底压应力分布，结合影像学上骨关节改变，分析患足骨关节改变导致的力线传导特点改变，就可找出畸形发生和维持及后遗症发生的解剖学因素及可能的力学原因。
结果: 1 CCF患儿患足跗、跖骨均有发育滞后，距、跟、舟骨形状有改变，尤其距骨改变明显而且最早。距骨头颈角增大，体小，滑车弧形缩短，顶较扁平。距跟关节脱位，两骨间角度改变；跗骨间排列紊乱；较大儿童可以看出载距突不明显，跟腱附着的牵拉骨骺内移；舟骨发育滞后，骨化中心出现延迟，呈楔形变，外缘变薄；距舟关节在正位和侧位片上均有脱位；楔骨一起略内翻，有叠加趋势，外侧楔骨骨化中心出现与健侧基本一致，无明显改变；跟骰关节略有脱位，骰骨骨化中心出现也有延迟，发育略滞后，至患儿行走后双侧对比改变不明显；除第一跖骨外均较健侧短小，在楔骨水平与足纵轴向外成角，跖骨延长线交于足外，与正常交于距跟不同。跟骨内翻，跟骨发育较健侧滞后。
2 骨关节改变导致力线的传导路径改变。足印对比可以看出患足足跟和外侧边着色较深，提示压应力较大。内侧模糊，甚至消失。
结论：CCF患足跗骨发育不平衡、滞后，跗骨关节间脱位和异常发育足骨导致力线传导途径改变。应力的异常传导阻止畸形矫正，加速畸形发展。骨与关节的改变导致后遗症的发生。跗骨的应力异常可能是其生长发育滞后的一个原因。
结合骨关节改变、肌肉牵拉力不平衡，手术中恢复骨关节正常关节解剖，保持力线传导途径正常，平衡压应力分布。在长期负重行走中处于矫正位，可以提高其远期疗效。简单的疗效评价即是是否足底压应力分布基本正常。基本正常的骨关节关系可以减少足痛等后遗症的发生。
Objective: Congenital clubfoot(CCF) is one kind of common congenital deformities in children foot, lots of the treatment cannot consolidate the long-term effect but offer more satisfactory short-term effect. We want to analyze the component of skeleton of the CCF by X-imagings and CT 3D-imagings and analyze the cause of reserving deformities and hampering correction.
Methods: We studied 65 children(28boys, 27girls. Mean age 20.7m) with one CCF. Measure their tarsal bone and compare with the normal feet by X-imagings and CT 3D-imagings with an uniform measurement standard and method. We analyze the correlations and the force distribution pathes among the feet bone. Based on podogram imagings, we can roughly know the force distribution on sole of the feet. From them we can find the factors which reserve deformities and hamper deformities to be corrected.
Results:1 in children with CCF, Their tarsal bone nucleus development lag
of the normal’s and their talus，calcaneums and navicular bones shapes change. TC joint dislocate on 3 planes. Tarsal arrange is disordered with cancaneum inversion. In the older CCF childrern we can find the sustentaculum talus disappear. TN joint dislocate on 2 planes.
2 the skeleton and joint deformities change the force distribution pathes and hamper deformities to be corrected. It may be the cause of the deformities reverved. The abnormal forces distribution may be the cause of bone nucleus lessened.
Conclusion In CCF children correction, recovered the feet bone arranging and nearly the normal force distribution pathes and reserved in corrected location walking maybe able to consolidate the long-term effect.
方法: 采用6m~4y左右的单侧患儿，用自身健侧与患侧对照。统一采用标准的X线摄片方法对CCF患儿行双足正侧位摄片及部分患儿行螺旋CT三维成像。采用统一的测量标准测量相应跗骨骨化部分纵径及结合CT三维图像分析骨关节间改变，作双侧跗骨发育比较及患足骨关节间压应力传导特点分析。根据足印图粗略分析足底压应力分布，结合影像学上骨关节改变，分析患足骨关节改变导致的力线传导特点改变，就可找出畸形发生和维持及后遗症发生的解剖学因素及可能的力学原因。
结果: 1 CCF患儿患足跗、跖骨均有发育滞后，距、跟、舟骨形状有改变，尤其距骨改变明显而且最早。距骨头颈角增大，体小，滑车弧形缩短，顶较扁平。距跟关节脱位，两骨间角度改变；跗骨间排列紊乱；较大儿童可以看出载距突不明显，跟腱附着的牵拉骨骺内移；舟骨发育滞后，骨化中心出现延迟，呈楔形变，外缘变薄；距舟关节在正位和侧位片上均有脱位；楔骨一起略内翻，有叠加趋势，外侧楔骨骨化中心出现与健侧基本一致，无明显改变；跟骰关节略有脱位，骰骨骨化中心出现也有延迟，发育略滞后，至患儿行走后双侧对比改变不明显；除第一跖骨外均较健侧短小，在楔骨水平与足纵轴向外成角，跖骨延长线交于足外，与正常交于距跟不同。跟骨内翻，跟骨发育较健侧滞后。
2 骨关节改变导致力线的传导路径改变。足印对比可以看出患足足跟和外侧边着色较深，提示压应力较大。内侧模糊，甚至消失。
结论：CCF患足跗骨发育不平衡、滞后，跗骨关节间脱位和异常发育足骨导致力线传导途径改变。应力的异常传导阻止畸形矫正，加速畸形发展。骨与关节的改变导致后遗症的发生。跗骨的应力异常可能是其生长发育滞后的一个原因。
结合骨关节改变、肌肉牵拉力不平衡，手术中恢复骨关节正常关节解剖，保持力线传导途径正常，平衡压应力分布。在长期负重行走中处于矫正位，可以提高其远期疗效。简单的疗效评价即是是否足底压应力分布基本正常。基本正常的骨关节关系可以减少足痛等后遗症的发生。
Objective: Congenital clubfoot(CCF) is one kind of common congenital deformities in children foot, lots of the treatment cannot consolidate the long-term effect but offer more satisfactory short-term effect. We want to analyze the component of skeleton of the CCF by X-imagings and CT 3D-imagings and analyze the cause of reserving deformities and hampering correction.
Methods: We studied 65 children(28boys, 27girls. Mean age 20.7m) with one CCF. Measure their tarsal bone and compare with the normal feet by X-imagings and CT 3D-imagings with an uniform measurement standard and method. We analyze the correlations and the force distribution pathes among the feet bone. Based on podogram imagings, we can roughly know the force distribution on sole of the feet. From them we can find the factors which reserve deformities and hamper deformities to be corrected.
Results:1 in children with CCF, Their tarsal bone nucleus development lag
of the normal’s and their talus，calcaneums and navicular bones shapes change. TC joint dislocate on 3 planes. Tarsal arrange is disordered with cancaneum inversion. In the older CCF childrern we can find the sustentaculum talus disappear. TN joint dislocate on 2 planes.
2 the skeleton and joint deformities change the force distribution pathes and hamper deformities to be corrected. It may be the cause of the deformities reverved. The abnormal forces distribution may be the cause of bone nucleus lessened.
Conclusion In CCF children correction, recovered the feet bone arranging and nearly the normal force distribution pathes and reserved in corrected location walking maybe able to consolidate the long-term effect.
引文
第一部分
吉士俊，潘少川，王继孟. 小儿骨科学[M].山东: 山东科学技术出版社2000.177-179.
Sering R. Congenital equinovarus clubfoot[J]. Acta Orthop Belg, 1999,5(2): 127-53.
Greider MD, Siff SJ, Gerson P, et al. Arteriography in clubfoot[J]. J Bone Surg Am 1982; 64:57-62.
Hanan W, Tiberias, Israel. Congenital clubfoot[J]. J Bone and Jiont Surg; 55(4): 796-801.
Settle GW, The anatomy of congenital talipes equinovarus: sixteen dissected specimens[J]. J Bone and Jiont Surg[Am]; 1963;45:1341-54.
Shapiro F,Glimcher MJ. Gross and histological abnormalities of the talus in clubfoot[J]. J Bone and Jiont Surg[Am]; 1979;61:522-30.
Turco V.J. surgical correction of the resistant clubfoot. One-stage posteromedial release with internal fixation: A prelimilary report[J]. J Bone and Jiont Surg 1971;53-A: 477-497.
McKay D.W. New concept of and approach to clubfoot treatmeamt: sectionⅡ-correction of the clubfoot[J].J Pediat orthop 1983; 3:10-21.
George W, Simons MD, Milwaukee, et al. Complete subtalar release in clubfeet[J]. 1985; 67-A:1044-1055.
Otremski I, Salarma R, Residual adduction of the forefoot: a review of the Turco procedure for congenital clubfoot[J]. J Bone and Jiont Surg(Br),1987;69:832-4.
R Jay C, Christopher J,Bsshore, et al. Avascular necrosis of the talus after McKay clubfoot release for idiopathic congenital clubfoot[J]. J Pediat orthop, 2001; 21(2):221-224.
Tuncay C, Erdem B, Tahir O,et al. Comparison of the soft-tissue release method in idiopathic clubfoot[J]. J Pediat orthop, 2000; 20: 648-651.
McKay D.W. New concept of and approach to clubfoot treatmeamt: sectionⅠ -principles and morbid anatomy[J]. J Pediatr orthop, 1982;2:347-356.
Kowalczyk B,Lejman T. Pathological anatomy of congenital clubfoot-review of the literature and personal observations[J]. Chir Naradow Ruchu Othop Pol 2002;11(2): 134-8.
Cauhuzac JP, Baunin C, Luu S.Assessment of hidfoot deformity by three-dimension MRI in infant clubfoot[J]. J Bone and Jiont Surg(Br), 1999;81(1):97-101.
Pirani S,Zeznik L,Hodeges D. Magnetic resonance imaging study of the congenital clubfoot treated with the Ponseti method[J]. J Pediatr orthop,2001;21(6):719-26.
George W, Simons, Settle,et al. Analytical radiography of clubfeet[J]. J Bone and Jiont Surg,1977;59-B(4):485-489.
P.M.Hutchins.B.K.Foster,D.C.Paterson,et al.Long-term results of early release in clubfeet[J]. J Bone and Jiont Surg,1985;67-B(5):791-799.
George W, Simons M.D, Milwaukee, et al. Complete subtalar release in clubfeet: PartⅡ-comparison with less extensive procedures[J]. J Bone and Jiont Surg. 1985; 67-A(7):1056-1065.
Ulunay Kanatli M.D, Haluk Yetkin M.D, Erdal Cila M.D. Footprint and radiographic analysis of clubfeet[J]. J Pediatr orthop,2001;21(2):225-228.
Victoria-Diaz A,Victoria-Diaz J. Pathogenesis of idiopathic clubfoot[J]. Clin Orthop1984;185:14-24.
Nordin M, V.H Frankel, 过邦辅。临床骨科生物力学基础[M]。上海远东出版社。1993；1：225-236。
吉士俊，潘少川，王继孟. 小儿骨科学[M].山东: 山东科学技术出版社，2000.1：2-4.
C.B.Howard,F.R.C.S.,M.K.D. Benson,et al.Clubfoot:its pathological anatomy[J]. J Pediatr orthop,1993;13(5):654-658.
Reek J,Felten N, McCormack AP, et al. support of the talus;a biomechanical investigation of the contributions of the talonavicular and talocalcaneal joints,and the superomedial calcaneonavicular ligament[J]. Foot Ankle Int [J] 1998; 19(10): 674-82.
Luor SI, Huang SC, Cheng PY, et al. Calcaneocuboid joints deformity in clubfoot [J]. J Formos Med Assoc 1992;91(3): 304-8.
Baryluk M, Baryluk A, Lopata P. Residual clubfoot correction by means of lateral cuboid resection[J].Chir Narzadow Ruchu Ortop Pol 2001;66(3): 269-73.
Calhoun JH, Li F,Ledbetter BR,et al.A comprehesive study of pressure distribution in the ankle joints with inversion and eversion[J].Foot Ankle Int 1994;15(3):125-33.
Lakin RC, DeGnore LT, Pienkowski D. Ccontract mechanics of normal tarsometatasal joints[J]. J Bone and Jiont(Am) 2001;83-A(4):520-8.
王军，刘金祥，黄跃添。先天性马蹄内翻足足底压应力的动态视频图像测试与分析[J]。中华物理医学杂志， 1997；19（1）：24-26。
Simons. Deformity of calcaneocuboid joints in patiens who have talipes equinovarus[J]. J Bone and Jiont Surg Am 1993; 75(2): 190-5.
Simons. calcaneocuboid joint deformity in talipes equinovarus: an overview and update[J]. J Pediatr orthop B 1995; 4(1): 25-35.
何荣，张德文，王来喜。先天性马蹄内翻足足骨发育异常X表现研究[J]。中华小儿外科杂志，2004；25（2）：124-126。
张成普、吉士俊、周永德等。先天性马蹄内翻足小腿肌肉运动神经支配的组织学观察[J]。中华骨科杂志，1995；15（7）：443-445。
吉士俊，潘少川，王继孟. 小儿骨科学[M].山东: 山东科学技术出版社2000.177-179.
Sering R. Congenital equinovarus clubfoot[J]. Acta Orthop Belg, 1999,5(2): 127-53.
Greider MD, Siff SJ, Gerson P, et al. Arteriography in clubfoot[J]. J Bone Surg Am 1982; 64:57-62.
Hanan W, Tiberias, Israel. Congenital clubfoot[J]. J Bone and Jiont Surg; 55(4): 796-801.
Settle GW, The anatomy of congenital talipes equinovarus: sixteen dissected specimens[J]. J Bone and Jiont Surg[Am]; 1963;45:1341-54.
Shapiro F,Glimcher MJ. Gross and histological abnormalities of the talus in clubfoot[J]. J Bone and Jiont Surg[Am]; 1979;61:522-30.
Turco V.J. surgical correction of the resistant clubfoot. One-stage posteromedial release with internal fixation: A prelimilary report[J]. J Bone and Jiont Surg 1971;53-A: 477-497.
McKay D.W. New concept of and approach to clubfoot treatmeamt: sectionⅡ-correction of the clubfoot[J].J Pediat orthop 1983; 3:10-21.
George W, Simons MD, Milwaukee, et al. Complete subtalar release in clubfeet[J]. 1985; 67-A:1044-1055.
Otremski I, Salarma R, Residual adduction of the forefoot: a review of the Turco procedure for congenital clubfoot[J]. J Bone and Jiont Surg(Br),1987;69:832-4.
R Jay C, Christopher J,Bsshore, et al. Avascular necrosis of the talus after McKay clubfoot release for idiopathic congenital clubfoot[J]. J Pediat orthop, 2001; 21(2):221-224.
Tuncay C, Erdem B, Tahir O,et al. Comparison of the soft-tissue release method in idiopathic clubfoot[J]. J Pediat orthop, 2000; 20: 648-651.
McKay D.W. New concept of and approach to clubfoot treatmeamt: sectionⅠ -principles and morbid anatomy[J]. J Pediatr orthop, 1982;2:347-356.
Kowalczyk B,Lejman T. Pathological anatomy of congenital clubfoot-review of the literature and personal observations[J]. Chir Naradow Ruchu Othop Pol 2002;11(2): 134-8.
Cauhuzac JP, Baunin C, Luu S.Assessment of hidfoot deformity by three-dimension MRI in infant clubfoot[J]. J Bone and Jiont Surg(Br), 1999;81(1):97-101.
Pirani S,Zeznik L,Hodeges D. Magnetic resonance imaging study of the congenital clubfoot treated with the Ponseti method[J]. J Pediatr orthop,2001;21(6):719-26.
George W, Simons, Settle,et al. Analytical radiography of clubfeet[J]. J Bone and Jiont Surg,1977;59-B(4):485-489.
P.M.Hutchins.B.K.Foster,D.C.Paterson,et al.Long-term results of early release in clubfeet[J]. J Bone and Jiont Surg,1985;67-B(5):791-799.
George W, Simons M.D, Milwaukee, et al. Complete subtalar release in clubfeet: PartⅡ-comparison with less extensive procedures[J]. J Bone and Jiont Surg. 1985; 67-A(7):1056-1065.
Ulunay Kanatli M.D, Haluk Yetkin M.D, Erdal Cila M.D. Footprint and radiographic analysis of clubfeet[J]. J Pediatr orthop,2001;21(2):225-228.
Victoria-Diaz A,Victoria-Diaz J. Pathogenesis of idiopathic clubfoot[J]. Clin Orthop1984;185:14-24.
Nordin M, V.H Frankel, 过邦辅。临床骨科生物力学基础[M]。上海远东出版社。1993；1：225-236。
吉士俊，潘少川，王继孟. 小儿骨科学[M].山东: 山东科学技术出版社，2000.1：2-4.
C.B.Howard,F.R.C.S.,M.K.D. Benson,et al.Clubfoot:its pathological anatomy[J]. J Pediatr orthop,1993;13(5):654-658.
Reek J,Felten N, McCormack AP, et al. support of the talus;a biomechanical investigation of the contributions of the talonavicular and talocalcaneal joints,and the superomedial calcaneonavicular ligament[J]. Foot Ankle Int [J] 1998; 19(10): 674-82.
Luor SI, Huang SC, Cheng PY, et al. Calcaneocuboid joints deformity in clubfoot [J]. J Formos Med Assoc 1992;91(3): 304-8.
Baryluk M, Baryluk A, Lopata P. Residual clubfoot correction by means of lateral cuboid resection[J].Chir Narzadow Ruchu Ortop Pol 2001;66(3): 269-73.
Calhoun JH, Li F,Ledbetter BR,et al.A comprehesive study of pressure distribution in the ankle joints with inversion and eversion[J].Foot Ankle Int 1994;15(3):125-33.
Lakin RC, DeGnore LT, Pienkowski D. Ccontract mechanics of normal tarsometatasal joints[J]. J Bone and Jiont(Am) 2001;83-A(4):520-8.
王军，刘金祥，黄跃添。先天性马蹄内翻足足底压应力的动态视频图像测试与分析[J]。中华物理医学杂志， 1997；19（1）：24-26。
Simons. Deformity of calcaneocuboid joints in patiens who have talipes equinovarus[J]. J Bone and Jiont Surg Am 1993; 75(2): 190-5.
Simons. calcaneocuboid joint deformity in talipes equinovarus: an overview and update[J]. J Pediatr orthop B 1995; 4(1): 25-35.
何荣，张德文，王来喜。先天性马蹄内翻足足骨发育异常X表现研究[J]。中华小儿外科杂志，2004；25（2）：124-126。
张成普、吉士俊、周永德等。先天性马蹄内翻足小腿肌肉运动神经支配的组织学观察[J]。中华骨科杂志，1995；15（7）：443-445。
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