Gökmen DENİZ, HASAN BOMBACI, Hakan TUYGUN, Mücahit GÖRGEÇ, Özkan KÖSE, H.Serhat YANIK

Doğuştan çarpık ayak tedavisinde geniş cerrahi diseksiyonun uzun dönem sonuçları

Amaç: Doğuştan çarpık ayak nedeniyle geniş cerrahi diseksiyon ile tedavi edilen hastaların geç dönem fonksiyonel ve radyografik sonuçları değerlendirildi. Çalışma planı: Çalışmada, doğuştan çarpık ayak için geniş cerrahi diseksiyon uygulanan 30 çocuğun (6 kız, 24 erkek; ort. yaş 9.8 ay) 47 ayağı incelendi. On yedi hastanın her iki ayağında deformite vardı. Otuz beş ayağa komplet subtalar gevşetme (KSTG), 12’sine posteromedial gevşetme (PMG) uygulandı. Ameliyat sırasında ortalama yaş KSTG grubunda 9.6 ay (dağılım 6-23 ay), PMG grubunda 10.6 ay (dağılım 5-23 ay) idi. Hastalar Laaveg-Ponseti fonksiyon değerlendirme skoru, ayak bimalleolar açısı ve radyografik ölçümlerle değerlendirildi. Ortalama takip süresi 117.3 ay (KSTG grubunda 106.6 ay, PMG grubunda 150.6 ay) idi. Sonuçlar: Fonksiyon değerlendirmesinde, 47 ayağın 24’ünde mükemmel, 12’sinde iyi, altısında orta, beşinde kötü sonuç alındı. Kötü sonuç alınan beş ayağın hepsi KSTG grubunda idi. Bu ayakların ikisinde nüks gelişirken, iki ayakta kavus ve metatarsus adduktus deformiteleri, bir ayakta kavus deformitesi vardı. Ayak bimalleolar açısına göre değerlendirildiğinde, PMG uygulanan ayakların %83.4’ü, KSTG uygulananların %85.7’si tip 1-2 grubu içinde yer aldı. Ayak bimalleolar açısı, ön-arka ve yan grafilerde talus-birinci metatars açısı ve ön-arka grafide talokalkaneal açı ile ayak fonksiyon skoru arasında anlamlı ilişki saptandı (p0.05). Çıkarımlar: Geniş cerrahi diseksiyon deformitenin tüm bileşenlerinin bir seansta düzeltilmesini sağlayan, sonuçları erken dönemde olduğu gibi uzun dönemde de başarılı olan bir yöntemdir.

Anahtar Kelimeler:

Tedavi sonucu, Geriyedönük çalışma, Hastalık ciddiyet indeksi, Hareket açıklığı, eklem, Çarpık ayak, Ortopedik işlemler

Long-term results of extensive surgical dissection in the treatment of congenital clubfoot

Objectives: We evaluated the long-term functional and radiographic results of patients who underwent extensive soft tissue dissection for the treatment of congenital club foot. Methods: We retrospectively evaluated 47 feet of 30 patients (6 girls, 24 boys; mean age 9.8 months) who underwent extensive surgical dissection for congenital clubfoot. Involvement was bilateral in 17 patients. Surgical dissection included complete subtalar release (CSTR) in 35 feet, and posteromedial release (PMR) in 12 feet. The mean age was 9.6 months (range 6 to 23 months) in CSTR-, and 10.6 months (range 5 to 23 months) in PMR-treated patients. The patients were assessed with the Laaveg-Ponseti functional score, foot bimalleolar angle, and other radiographic measurements. The mean follow-up was 117.3 months (106.6 months in the CSTR, and 150.6 months in the PMR group). Results: Functional results were excellent in 24 feet, good in 12 feet, fair in six feet, and poor in five feet. All the poor results were seen in the CSTR group. Of these five feet, two developed recurrences, two had both pes cavus and metatarsus adductus deformities, and one had pes cavus deformity. Considering the foot bimalleolar angle, 83.4% of PMRtreated feet, and 85.7% of CSTR-treated feet were rated as type 1 or 2. Functional scores were significantly correlated with the foot bimalleolar angle, talus-first metatarsus angle on anteroposterior and lateral radiographs, and with the talocalcaneal angle on anteroposterior radiographs (p<0.05). There were no significant differences between the two surgical procedures with respect to functional scores and radiographic measurements (p>0.05). Conclusion: Extensive surgical dissection enables simultaneous correction of all components of deformity and provides satisfactory results not only in the short-term but also in the long-term follow-up.

Keywords:

Treatment Outcome, Retrospective Studies, Severity of Illness Index, Range of Motion, Articular, Clubfoot, Orthopedic Procedures,

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1. Cummings RJ, Davidson RS, Armstrong PF, Lehman WB. Congenital clubfoot. J Bone Joint Surg [Am] 2002;84:290-308.
2. Kite JH. Nonoperative treatment of congenital clubfoot. Clin Orthop Relat Res 1972;(84):29-38.
3. Souchet P, Bensahel H, Themar-Noel C, Pennecot G, Csukonyi Z. Functional treatment of clubfoot: a new series of 350 idiopathic clubfeet with long-term follow-up. J Pediatr Orthop B 2004;13:189-96.
4. Herring JA. Disorders of the foot. In: Tachdjian’s pediatric orthopaedics. 3rd ed. Philadelphia: W. B. Saunders; 2002.p. 922-59.
5. McKay DW. New concept of and approach to clubfoot treatment: Section III - evaluation and results. J Pediatr Orthop 1983;3:141-8.
6. Simons GW. Complete subtalar release in club feet. Part II Comparison with less extensive procedures. J Bone Joint Surg [Am] 1985;67:1056-65.
7. Centel T, Bagatur AE, Ogut T, Aksu T. Comparison of the soft-tissue release methods in idiopathic clubfoot. J Pediatr Orthop 2000;20:648-51.
8. Magone JB, Torch MA, Clark RN, Kean JR. Comparative review of surgical treatment of the idiopathic clubfoot by three different procedures at Columbus Children’s Hospital. J Pediatr Orthop 1989;9:49-58.
9. Dobbs MB, Nunley R, Schoenecker PL. Long-term followup of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg [Am] 2006;88:986-96.
10. Simons GW. Complete subtalar release in club feet. Part I. A preliminary report. J Bone Joint Surg [Am] 1985;67:1044-55.
11. Siapkara A, Duncan R. Congenital talipes equinovarus: a review of current management. J Bone Joint Surg [Br] 2007;89:995-1000.
12. McKay DW. New concept of and approach to clubfoot treatment: section II - correction of the clubfoot. J Pediatr Orthop 1983;3:10-21.
13. Franke J, Hein G. Our experiences with the early operative treatment of congenital clubfoot. J Pediatr Orthop 1988;8:26-30.
14. Main BJ, Crider RJ, Polk M, Lloyd-Roberts GC, Swann M, Kamdar BA. The results of early operation in talipes quino-varus. A preliminary report. J Bone Joint Surg [Br]1977;59:337-41.
15. Turco VJ. Resistant congenital club foot-one-stage posteromedial release with internal fixation. A follow-up report of a fifteen-year experience. J Bone Joint Surg [Am] 1979;61:805-14.
16. Simons GW. The complete subtalar release in clubfeet. Orthop Clin North Am 1987;18:667-88.
17. DePuy J, Drennan JC. Correction of idiopathic clubfoot: a comparison of results of early versus delayed posteromedial release. J Pediatr Orthop 1989;9:44-8.
18. Crawford AH, Marxen JL, Osterfeld DL. The Cincinnati incision: a comprehensive approach for surgical procedures of the foot and ankle in childhood. J Bone Joint Surg [Am] 1982;64:1355-8.
19. Ferlic RJ, Breed AL, Mann DC, Cherney JJ. Partial wound closure after surgical correction of equinovarus foot deformity. J Pediatr Orthop 1997;17:486-9.
20. Rumyantsev NJ, Ezrohi VE. Complete subtalar release in resistant clubfeet: a critical analysis of results in 146 cases. J Pediatr Orthop 1997;17:490-5.
21. Kalenderer O, Aguş H, Ak M, Ozluk S. Correlation of clinical and radiologic results of complete subtalar release in congenital clubfoot. [Article in Turkish] Acta Orthop Traumatol Turc 2003;37:368-73.
22. Karakurt L, Yilmaz E, Inci M, Serin E, Ozturk M. Early results of complete subtalar release in congenital clubfoot deformity. [Article in Turkish] Acta Orthop Traumatol Turc 2003;37:53-62.
23. Rosselli P, Reyes R, Medina A, Cespedes LJ. Use of a soft tissue expander before surgical treatment of clubfoot in children and adolescents. J Pediatr Orthop 2005;25:353-6.
24. Lubicky JP, Altiok H. Regional fasciocutaneous flap closure for clubfoot surgery. J Pediatr Orthop 2001;21:50-4.
25. Uglow MG, Clarke NM. Relapse in staged surgery for congenital talipes equinovarus. J Bone Joint Surg [Br] 2000;82:739-43.
26. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg [Am] 1980;62:23-31.
27. Jain AK, Zulfiqar AM, Kumar S, Dhammi IK. Evaluation of foot bimalleolar angle in the management of congenital talipes equinovarus. J Pediatr Orthop 2001;21:55-9.
28. Drvaric DM, Kuivila TE, Roberts JM. Congenital clubfoot. Etiology, pathoanatomy, pathogenesis, and the changing spectrum of early management. Orthop Clin North Am 1989;20:641-7.
29. Carroll NC, McMurtry R, Leete SF. The pathoanatomy of congenital clubfoot. Orthop Clin North Am 1978;9:225-32.