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Is non-operative management of childhood neurologic cavovarus foot effective?
±Û¾´ÀÌ : °ü¸®ÀÚ ³¯Â¥ : 2017-03-15 (¼ö) 05:43 Á¶È¸ : 4215
Is non-operative management of childhood neurologic cavovarus foot effective.pdf (1.2M), Down : 0, 2017-03-18 07:36:54

Is non-operative management of childhood neurologic cavovarus foot effective?

 

Introduction

¿äÁ·¿¡ ´ëÇÑ Ä¡·á´Â ¼­·Î ´Ù¸¥ ¸¹Àº ÀÇ°ßµéÀÌ Ãæµ¹ÇÑ´Ù. ¿äÁ·ÀÇ ÀÚ¿¬Àû ÁøÇàÀº ¾Æµ¿ÀÇ ¼ºÀå°ú ¿äÁ·À» ÁøÇà½ÃÅ°´Â ½Å°æÇÐÀû º´ÀÎÀ¸·Î ÀÎÇÏ¿© ÁÁÁö ¾ÊÀº °á°ú¸¦ ÃÊ·¡ÇÏ´Â °æ¿ì°¡ ¸¹´Ù. ¿äÁ·À¸·Î ÀÎÇÑ º¯ÇüÀº ´ÙÀ½°ú °°Àº ±â´ÉÀûÀÎ Áõ»óÀ» À¯¹ßÇϴµ¥, ¹ß¸ñ°ú ¹ß¹Ù´ÚÀÇ ÅëÁõ°ú 5¹ø° ÁßÁ·°ñÀÇ ±âÀúºÎºÐ°ú ù¹ø° ÁßÁ·°ñÀÇ °ñµÎ¿¡ ±»Àº»ìÀÌ Àß »ý±ä´Ù.

º¯ÇüÀÌ ´õ ÁøÇàµÇ¸é ÀüÁ·ºÎÀÇ È¸³» ȤÀº ¿Ü¹Ý°ú ÈÄÁ·ºÎÀÇ È¸¿Ü ȤÀº ³»¹ÝÀÌ ÀϾ¼­ Á¾Á·ºÎ ´ÜÀ§(calcaneopedal unit)ÀÇ ºñƲ¸²ÀÌ À¯¹ßµÈ´Ù. ÀüÅëÀûÀÎ ¿äÁ·ÀÇ º´ÀÎÀº Àü°æ°ñ±Ù°ú ´Üºñ°ñ±ÙÀÇ ±â´ÉÀÌ»óÀ̸ç ÀÌÂ÷ÀûÀ¸·Î ³»Àç±Ù(intrinsic muscle)ÀÇ ±â´ÉÀúÇÏÀÌ´Ù. ÀÌ¿¡ ´ëÇÑ ´ëÇ¥ÀûÀÎ Áúº´Àº »þÄÚ-¸¶¸®¿¡-Åõ½º (Charcot-Marie-Tooth disease)·Î ¾Ë·ÁÁ® ÀÖ´Ù.

¿äÁ·ÀÇ ÁøÇà°úÁ¤¿¡¼­ ³»Àç±ÙÀÇ À§¾àÀ¸·Î ÀÎÇÑ ÁßÁ·Áö°üÀýÀÇ ºÒ¾ÈÁ¤È­°¡ ¹ß»ýÇÏ°í ±æÇ×±ÙÀÎ ÀåÁ·Áö½Å±Ù°ú À幫Áö½Å±ÙÀº È°¼ºµÇ¾î ÁßÁ·Áö°üÀýÀÇ °ú½ÅÀüÀ» À¯¹ßÇÑ´Ù. À̴ ù¹ø° ¹ß°¡¶ôÀÇ Á·Àú°Ç¸·(plantar aponeurosis)ÀÇ Àå·ÂÀ» Áõ°¡½ÃÄÑ Á·Àú±Ã(plantar arch)ÀÇ ³ôÀ̸¦ Áõ°¡½ÃŲ´Ù.     

¿äÁ·ÀÇ ÁøÇà°úÁ¤¿¡¼­ ÈÄÁ·ºÎÀÇ º¯ÇüÀº Ãʱ⿡´Â À¯¿¬ÇÑ ³»¹Ý º¯ÇüÀ» ³ªÅ¸³»Áö¸¸ ¼ºÀå¿¡ µû¶ó Á¡Â÷·Î ±»¾îÁø´Ù. ¿äÁ·ÀÇ È¯¿ø¼º¿¡ ´ëÇÑ °Ë»ç´Â ÀüÁ·ºÎÀÇ ¿µÇâÀ» ¹èÁ¦ÇÏ°í °Å°ñ³»¹ÝÀ» ±³Á¤ÇØ º¸´Â Coleman and Chesnut¡¯s block °Ë»ç°¡ ÀÖ´Ù. Á¤¸®ÇÏ¸é ¿äÁ·(cavovarus)´Â ÀüÁ·ºÎÀÇ º¯ÇüÀÌ ¸ÕÀú ÀϾ°í ÀÌ¿¡ µû¶ó ÈÄÁ·ºÎ°¡ º¯ÇüµÇ´Â °ÍÀÌ´Ù.

 

±×·¯¹Ç·Î ¿ì¸®´Â ºñ¼ö¼úÀûÀÎ Ä¡·á°¡ À¯³â±â¿¡ ¿äÁ·ÀÇ ±³Á¤À» ÃæºÐÈ÷ ÇÒ ¼ö ÀÖ´Ù´Â °¡Á¤ÇÏ¿¡ Untwisting nocturnal splint ¿Í Untwisting walking cast ¸¦ °³¹ßÇÏ¿© Àû¿ëÇØ º¸¾ÒÀ¸¸ç, ¼¼ºÎÀûÀ¸·Î Splint ÀÌÀü¿¡ Cast ¸¦ Àû¿ëÇÏ´Â °ÍÀÌ Ä¡·á¿¡ ´õ È¿°úÀûÀÏ °ÍÀ̶ó°í »ý°¢ÇÏ¿´´Ù.

 

Material and Method

2002³âºÎÅÍ 2010³â±îÁö 8³âµ¿¾È 23¸í, 35Á·À» ´ë»óÀ¸·Î ¿¬±¸¸¦ ÁøÇàÇÏ¿´´Ù. ¿äÁ·ÀÇ ¿øÀÎÀº »þÄÚ-¸¶¸®¿¡-Åõ½º(15¸í,22Á·), ³ú¿¬È­Áõ(3¸í,5Á·), ³ú¼º¸¶ºñ(2¸í, 3Á·), ô¼ö¿­°³(1¸í, 1Á·), ¿°»öüÀÌ»ó(1¸í,2Á·)À̾ú´Ù. Ä¡·á¸¦ ½ÃÀÛÇÒ ¶§ Æò±Õ ³ªÀÌ´Â 8.8¼¼(5-15¼¼) ¿´À¸¸ç, Ä¡·á ½ÃÀÛ ´ç½Ã ÈÄÁ·ºÎ °íÁ¤»óÅ¿¡¼­ üÁßÁöÁö Ãø¸é Á·ºÎ X-ray ¿Í Meary angle(°Å°ñ-Á¦1ÁßÁ·°ñÀÇ °¢µµ) µµ ÇÔ²² ÃøÁ¤ÇÏ¿´À¸¸ç Æò±Õ 16µµ¿´´Ù. Ä¡·á ¹æ¹ýÀº 3ÁÖ°£ ù¹ø° Cast ¸¦ Àû¿ë ÈÄ ±³Á¤À» À§ÇØ µÎ¹ø° Cast ¸¦ ´Ù½Ã Á¦ÀÛÇÏ¿© 3ÁÖ°£ Àû¿ëÇÏ°í, ÀÌÈÄ Splint ¸¦ Àû¿ëÇÏ´Â ¼ø¼­·Î ÁøÇàÇÑ ±ºÀÌ 13Á·(37)À̾úÀ¸¸ç, ¼Ò¾ÆÀÇ ºÎ¸ð°¡ cast ¸¦ °ÅºÎ ÇÏ¿© Splint ¸¸ Àû¿ëÇÑ ±ºÀÌ 22Á·(63%) À̾ú´Ù. Splint ´Â ¼ºÀå Á¾·á½Ã±îÁö Àû¿ëÇÏ¿´´Ù. Ä¡·á Á¾·á ½ÃÁ¡¿¡¼­ Wicart-Seringe Grades(Table 3)¸¦ Àû¿ëÇÏ¿© °á°ú¸¦ ºñ±³ÇÏ°í, Mann-Whitney test ·Î ºÐ¼®ÇÏ¿´´Ù. °æ°ú°¡ ÁÁÁö ¾Ê¾Æ ¼ö¼úÀ» ÇÑ °æ¿ì´Â ¸ðµÎ Poor Grade ·Î ºÐ·ùÇÏ¿´´Ù.

 

 

 

Untwisting walkinig cast (Table1, Fig.1.)

Deformity

Action by surgeon

Action by assistant


Cavus and equines

Adduction of

calcaneopedal unit

Talar varus

Forefoot pronation

Ankle at 90

Lateral rotation (abduction) of foot

Mediolateral pressure on heel

Forefoot supination,

Maintaining mediolateral pressure on heel

Pressure on knee

Medial rotation of leg

Lateromedial pressure on leg

No specitic action

 

 

Untwisting nocturnal splint (Table2, Fig.2.)

Effect of splint

Deformity component coreected


Ankle at 90

Forefoot supination

Hindfoot valgus

Dorsolateral strap

Cavus and equines

Forefoot pronation

Hindfoot varus

Cavus, dorsal hump and hindfoot varus

 

Table 3. Wicart-Seringe grades

Results

Functional signs

Clinical position of heel and Méary angle

Very good

None

VG, and 0◦ ¡Â Méary angle ¡Â 15Or N or VR, and 0◦ ¡Â Méary angle ¡Â 5

Good

None

VG, and 15< Méary angle ¡Â 20Or N, and 5< Méary angle ¡Â 20Or VR, and 5< Méary angle ¡Â 15Or 15 ¡Â Méary angle < 0 (minor hypercorrection)

Moderate

None

VG or N, and Méary angle > 20Or VR, and Méary angle > 15Or Méary angle < 15(major hypercorrection)

Poor

Pain and/or instability

VR, and Méary angle > 20Or cavus surgery

VG: talar valgus; N: heel in neutral position; VR: talar varus

 

Result  (Table4)

 

ÀÓ»óÀûÀ¸·Î 65%¿¡¼­ Very Good ¶Ç´Â Good Grade ¸¦ º¸¿´°í, ±â´ÉÀûÀ¸·Î 79% ¿¡¼­ È£ÀüµÇ¾ú´Ù.

ÈÄÁ·ºÎ ³»¹ÝÀº 25Á·(69%) ¿¡¼­ ±³Á¤µÇ¾ú´Ù. Meary Angle Àº Ä¡·áÀû Æò±Õ 16µµ¿¡¼­ Ä¡·á Á¾·á ÈÄ

Æò±Õ 7.5µµ·Î °¨¼ÒÇÏ¿´´Ù. ±×¸² 3°ú 4´Â ÀÓ»óÀû, ¹æ»ç¼±ÀûÀ¸·Î ÁÁÀº °á°úÀÇ ¿¹¸¦ º¸¿©ÁØ´Ù

 

Table 4 Results according to Wicart-Seringe grade

CMT: Charcot-Marie-Tooth disease; C + S: casts + splint; S: splint.

 

Whole series

(n = 35) (%)

CMT

(n = 22) (%)

Other etiologies

(n = 13) (%)

C + S

(n = 13) (%)

S

(n = 22) (%)

Very good result

Good result

Moderate result

Poor result

15(42)

8(23)

1(3)

11(32)

11(50)

5(23)

1(4)

5(23)

5(38)

2(16)

1(8)

5(38)

7(54)

4(31)

 

2(15)

8(36)

1(5)

3(14)

10(45)

 












Fig. 3. Clinical result in a 10-year-old girl with Charcot-Marie-Tooth disease. A and B. Initial aspect of foot: indication for surgical correction (POWOC) in left foot (moresevere) and cast + splint in right foot. C and D. Result at 16 years: very good

 


Fig. 4. Radiologic result in an 11-year-old girl with Charcot-Marie-Tooth disease. A. Pre-treatment weight-bearing radiograph: maximal cavus (Méary angle = 33). B. Pre-treatment weight-bearing radiograph: above (without block): Méary angle underestimated (15); below (with block): true Méary angle of 29. Cavus lessened in weight-bearing. Transverse defects not completely reducible. C. Untwisting walking cast: incomplete correction of cavus (Méary angle = 17) but complete correction of transversedefects. D. Result at 18 years: complete correction of cavus and transverse defects.

 

Discussion

 

ÀÌ ¿¬±¸ÀÇ Á¦ÇÑÁ¡Àº ÇÇÇèÀÚ ¼ö°¡ Àû°í, ºñÁøÇ༺ ¹× ÁøÇ༺ Á·ºÎ¸¦ ¸ðµÎ Æ÷ÇÔÇÏ°í ÀÖÀ¸¸ç, Ä¡·á ½ÃÀÛ Àü¿¡ ¿äÁ·ÀÇ Á¤µµ¸¦ Æò°¡ÇÏÁö ¾Ê¾Ò´Ù´Â °ÍÀÌ´Ù.

±×µ¿¾È ºñ¼ö¼úÀû ¿äÁ·ÀÇ Ä¡·á¸¦ ½ÃÇàÇÑ ÇÑ °ÇÀÇ ¿¬±¸¿¡¼­´Â ÁÁÁö ¾ÊÀº °á°ú¸¦ º¸°í ÇÏ¿´À¸³ª, 6ÁÖ¸¸ Splint ¸¦ Âø¿ëÇÏ¿´°í ¼ºÀÎÀ» ´ë»óÀ¸·Î ÇÏ¿© °ñÀÇ ÀçÇü¼º ±âȸ°¡ ¾ø¾ú´Ù´Â Á¡¿¡¼­ ÀÌ ¿¬±¸°ú´Â Â÷ÀÌ°¡ ÀÖ´Ù. º» ¿¬±¸¿¡¼­ ½ÃÇàÇÑ ±³Á¤Àº È¿°úÀûÀ̾úÀ¸¸ç, ¼ö¼úÀÇ À§Ç輺À» °¨¼Ò½ÃÄ×´Ù. ¶ÇÇÑ ¼ö¼úÀÌ ÇÊ¿äÇÑ °æ¿ì¿¡µµ Æò±Õ 4.5³âÀ» ¿¬Àå½ÃÄÑ ´ÜÀÏ ´Ü°èÀÇ ±³Á¤ÀÌ °¡´ÉÇϸç, ¹Ýº¹¼ö¼úÀ» ÇÏÁö ¾Ê°í ¼ö¼ú ÈÄÀÇ ÀÜ¿© ¼ºÀå¿¡¼­ ¹ß»ýÇÒ ¼ö ÀÖ´Â º¯ÇüÀ» ¿¹¹æÇÒ ¼ö ÀÖ´Â °ÍÀ¸·Î ¿©±âÁø´Ù. ¶ÇÇÑ Splint ¸¸ ÇÏ´Â °Íº¸´Ù Cast ÀÌÈÄ Splint ¸¦ Àû¿ëÇÏ´Â °ÍÀÌ ¼ö¼úÀÇ À§Ç輺À» °¨¼Ò½ÃÅ°Áö´Â ¾ÊÁö¸¸ Àû¾îµµ Meary Angle ±³Á¤¸é¿¡¼­´Â ´õ È¿°úÀûÀÓÀ» È®ÀÎÇÏ¿´´Ù.

 

Ä¡·á ½ÃÀÛ ´ç½Ã 10¼¼ ¹Ì¸¸ÀÇ ¾î¸° ³ªÀÌ¿¡¼­´Â ¿¹ÈÄ°¡ ÁÁÁö ¾Ê¾Ò´Ù. ÀÌ·¯ÇÑ ÀÌÀ¯´Â º¯ÇüÀÇ ÁøÇà°ú ¼ºÀåÀÌ ³¡³ª±â Àü Àç¹ßÀÌ ÀÖ¾ú±â ¶§¹®À̾ú´Ù. ¶ÇÇÑ Splinting¿¡ ´ëÇÑ ºÒ·®ÇÑ ¼øÀÀµµµµ ÁÁÁö ¾ÊÀº ¿¹ÈÄ ÀÎÀÚ¿´´Ù. ÀÌ ¿¬±¸¿¡¼­ Cast ¿Í Splint ¸¦ ¿¬¼ÓÀ¸·Î Àû¿ëÇÏ´Â °Í¿¡ ´ëÇÑ ÇÕº´ÁõÀº ¾ø¾úÁö¸¸ »þÄÚ-¸¶¸®¿¡-Åõ½º º´°ú °°Àº ¹Î°¨ÇÑ Áúº´ÀÇ È¯ÀÚ¿¡°Ô ij½ºÆ®¿Í ºÎ¸ñÀ» Àû¿ëÇÒ ¶§¿¡´Â ÁÖÀǸ¦ ±â¿ïÀÌ´Â °ÍÀÌ ¹Ù¶÷Á÷ÇÒ °ÍÀ¸·Î »ý°¢µÈ´Ù.

 

Conclusion

 

À̹ø ¿¬±¸´Â ¼Ò¾Æ¿¡¼­ ½Å°æÀμº ¿äÁ·ÀÇ ºñ¼ö¼úÀû Ä¡·áÀÇ È¿¿ë¼ºÀ» ÀÔÁõÇÏ¿´À¸¸ç ¼ö¼úÀ» ÇÇÇϰųª(¼ºÀå ¸»±â 50%¿¡¼­) Æò±Õ 4.5³âÀ» ¿¬±âÇÏ¿´´Ù. Meary Angle ÀÌ 15µµ°¡ µÇ¸é ¹Ù·Î Untwisting walking cast ÀÌÈÄ Untwisting nocturnal splint ¸¦ Àû¿ëÇÏ´Â °ÍÀ» ±ÇÀåÇÑ´Ù.

 


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