经皮微创跖骨远端截骨治疗拇外翻疗效观察

拇外翻是中老年人常见的后天性畸形，以女性多见，有家族性，时常合并扁平足。它是由拇跖外翻和跖骨内翻构成的三角形畸形，第一跖骨头肥大，内侧多形成滑囊，压痛明显，足前部增宽，足横弓塌陷，行走困难。传统的拇外翻手术方法有130余种，多数医生根据患者拇外翻角，跖骨间角，第一跖骨长度，内收程度等决定手术方式。我院白2006年1月～2007年4月采用经皮微创跖骨远端截骨方法治疗跖外翻16例27足取得了较好疗效，报告如下。[第一段]     

足韧带的解剖学研究及其临床意义

目的:研究足韧带的解剖学特点,探讨其临床意义。方法:30侧成人足标本解剖观测各韧带起至、走行和比邻,分析其作用。结果:距舟背侧韧带分为内、外两束。楔舟背侧韧带分为内、中、外、斜4束。足横弓和纵弓交汇处为足底最凹点,足底长短韧带、腓骨长肌腱、胫骨后肌腱为"外三角",楔舟足底韧带、楔骰足底韧带、跟舟足底韧带为"内三角",维系该凹点。跟舟足底韧带承托距骨头部,是将踝压力分向第1跖骨头和足跟的首要韧带。各楔骨、楔骰骨间韧矢状面上都位于关节前侧,不规则形,质地强韧,维系足横弓。结论:足部韧带分为足背、足底和骨间3个系统,结构复杂,其功能及其在创伤外科中的意义有待深入研究。     

第1跖趾关节相关生物力学研究进展

第1跖趾关节既参与前足横弓的构成,又是足内侧纵弓的重要组成部分,在维持足弓牛物力学稳定方面起着举足轻重的作用,其稳定性的破坏会引起前足生物力学的改变从而严苇影响足部负重和行走功能的有效行使,临床上(足)外翻、前跖痛等许多足部疾病的发生发展均与第1跖趾火节稳定性的破坏有关,本文主要就第1跖趾关节相关牛物力学的研究进展作一综述.     

(足母)长伸肌腱移位治疗(足母)外翻的应用解剖学

目的:探讨(足母)长伸肌腱移位治疗(足母)外翻的解剖学入路及手术的要点.方法:(1)100例正常足及100例(足母)外翻足,测量(足母)长伸屈肌腱的位置;(2)对20具尸体40足解剖,观察(足母)长伸肌腱、(足母)长屈肌腱、(足母)短伸肌腱、腓浅神经、腓深神经、隐神经及周围血管走行特点,并测量上述结构与解剖标志的相对位置.结果:正常(足母)长伸肌腱的位置在踝横纹处位于胫骨前肌外侧(9.44±4.26)mm,在跖附关节中点外侧(2.00±2.22)mm,跖趾关节中点外侧(1.32±1.46)mm,止点位于末节趾骨基底中点(2.22±2.42)mm范围内,(足母)长屈肌腱在跖趾关节中点外侧(0.44±2.42)mm.在(足母)外翻的患(足母)者中,(足母)长伸肌腱在踝横纹处位于胫骨前肌外侧(9.32±3.46)mm,在跗跖关节中点外侧(3.00±2.22)mm,跖趾关节中点外侧(4.22±2.26)mm,止点位于末节趾骨基底中点(2.02±2.32)mm范围内,(足母)长屈肌腱在跖趾关节中点外侧(3.24±2.32)mm.(足母)趾背侧皮肤由隐神经、腓浅及腓深神经支配.结论:(1)正常与(足母)外翻足的比较中,伸肌腱的位置在足横纹及止点处无明显的差异,在跖附关节及跖趾关节处,外翻足的伸肌腱明显外移(P＜0.05).(足母)长屈肌腱也明显外移(P＜0.05).(2)手术中隐神经终末支易受损伤.(3)伸肌腱内移并止点重建可矫正(足母)外翻.     

长伸肌腱移位治疗外翻的应用解剖学

目的:探讨长伸肌腱移位治疗外翻的解剖学入路及手术的要点。方法:(1)100例正常足及100例外翻足,测量长伸屈肌腱的位置;(2)对20具尸体40足解剖,观察长伸肌腱、长屈肌腱、短伸肌腱、腓浅神经、腓深神经、隐神经及周围血管走行特点,并测量上述结构与解剖标志的相对位置。结果:正常长伸肌腱的位置在踝横纹处位于胫骨前肌外侧(9.44±4.26)m m,在跖附关节中点外侧(2.00±2.22)m m,跖趾关节中点外侧(1.32±1.46)m m,止点位于末节趾骨基底中点(2.22±2.42)m m范围内,长屈肌腱在跖趾关节中点外侧(0.44±2.42)m m。在外翻的患者中,长伸肌腱在踝横纹处位于胫骨前肌外侧(9.32±3.46)m m,在跗跖关节中点外侧(3.00±2.22)m m,跖趾关节中点外侧(4.22±2.26)m m,止点位于末节趾骨基底中点(2.02±2.32)m m范围内,长屈肌腱在跖趾关节中点外侧(3.24±2.32)m m。趾背侧皮肤由隐神经、腓浅及腓深神经支配。结论:(1)正常与外翻足的比较中,伸肌腱的位置在足横纹及止点处无明显的差异,在跖附关节及跖趾关节处,外翻足的伸肌腱明显外移(P<0.05)。长屈肌腱也明显外移(P<0.05)。(2)手术中隐神经终末支易受损伤。(3)伸肌腱内移并止点重建可矫正外翻。     

腹腔镜腹股沟疝修补术肌耻骨孔的活体解剖学观察及临床意义

目的　探讨腹膜前间隙的解剖学特点,为腹腔镜腹股沟疝修补术的提供手术解剖依据。 方法　对我院30例腹股沟疝患者行LIHR时进行术中解剖观察及术后回顾分析手术视频,通过解剖学绘图描述LIHR手术入路、解剖层次及技术要点。 结果　腹膜前间隙由Retzius间隙和Bogros间隙组成,其间有间隔分开。腹横筋膜由深浅两层结构组成,腹膜与腹横筋膜的深层之间为无血管区域。 腹横筋膜在腹股沟韧带深面增厚形成髂耻束,参与构成股管的内侧壁及腹股沟管的下壁,生殖股神经股支及股外侧皮神经在髂耻束下方通过。 结论　熟悉腹膜前间隙肌耻骨孔区域解剖标志点,是LIHR手术的前提,具有重要临床意义。     

跟骨内侧和下部神经的解剖学研究

由于存在因神经受压而引发的慢性足跟痛 ,促使我们对足跟的神经支配进行解剖学研究。解剖了 15只尸体足标本 ,对跟骨内侧神经以及跟骨下神经的起源、走行和分支进行研究。不管跟骨内侧神经起源于胫神经或足底外侧神经 ,其分支通常恒定分布于展肌浅层。跟骨内侧神经发出分支至展肌并支配足跟内侧面的后部 ,于足跟下部终止于足跟垫的浅层。我们的研究发现跟骨下神经通常起自足底外侧神经 ,它与展肌深筋膜及跟骨前结节之间的关系可以解释跟骨下神经压迫综合症。跟骨内侧和下部神经的解剖学研究     

足踝有限元模型的建立与初步临床应用

建立足踝部有限元模型，研究胫后肌腱功能不全（DPTT）、躅外翻与第一跖列不稳的静态生物力学变化。以螺旋CT扫描正常足部图像为资源，Matlab、Surfacer、ANSYS软件为工具，建立足部有限元模型，模拟静态直立时加载，分别分析跟骨应力应变、胫后肌腱功能不全与第一跖列失稳时的内侧纵弓关节应力应变、骨骼空间位置的的变化。静态直立负重时，跟骨与第一跖骨跖侧应力最大，其中跟骨内侧最大；胫后肌腱功能不全时，可以导致第一跖列的稳定性丧失，进而发生内侧纵弓各个关节之间应力分布、大小发生变化，第一跖骨内收、跖屈，躅趾相对于第一跖骨外展趋势增大。足踝有限元模型是分析足踝生物力学的有力工具；跟痛症的发生与应力反复作用有关；DPPT可以导致第一跖列失稳，进而引起第一跖骨内收、趾外展，与反复应力作用下的躅外翻发生发展有一定关系。     

虚拟中国人足底韧带结构失效后的足弓负荷机制研究

目的　建立虚拟中国人的足内侧纵弓与外侧纵弓的有限元模型,研究跖腱膜松解术或足底韧带损伤后足骨与内在肌群的生物力学特性,探讨骨性结构、足底韧带、足底腱膜、足底固有肌群之间的协调作用机制。方法　采用虚拟中国人“女性1号”CT图像和MRI图像;采用非线性有限元方法进行足弓术后或韧带损伤后的平衡直立负荷状态仿真;并应用足底固有肌群的3种被动张力（微弱、适度、强烈）模拟术后或韧带损伤后的肌肉状态。结果　建立了虚拟中国人“女性1号”足内侧纵弓第2跖列与外侧纵弓第5跖列的生物力学有限元模型,计算得到内侧纵弓和外侧纵弓在平衡直立时,韧带损伤时,固有肌群活动时的张应力矢量图、压应力矢量图和von Mises应力整体分布数据。结论　跖腱膜松解术和足底韧带损伤等增加了足纵弓von Mises应力峰值,改变了张应力与压应力的流向;而足底固有肌活动的被动张力能降低足纵弓von Mises应力集中程度,调节张应力、压应力矢量接近平衡状态,减小了并发骨折和腱炎的危险性。骨性结构、韧带、腱膜、固有肌群的内在应力具有定量的相互调节功能。     

拇展肌与拇收肌移位吻接术前、后黏弹性实验研究

研究了正常拇展肌、拇收肌拉伸黏弹性力学性质和模拟拇外翻拇展肌、拇收肌移位吻接术后拇展肌和拇收肌的拉伸黏弹性力学性质.取20个足标本,解剖后暴露拇展肌与拇收肌,得出拉伸应力松弛、蠕变等数据.对断裂后的拇收肌和拇展肌模拟临床手术进行移位吻接,对10个拇展肌和10个拇收肌标本做腱与腱吻接,另各取10个拇收肌、拇展肌标本做了腱与骨膜吻接.对吻接后的标本进行拉伸实验,得出了吻接术后各组拉伸应力松弛、蠕变曲线.以回归分析的方法处理实验数据,得出了归一化应力松弛、蠕变曲线及归一化应力松弛函数和归一换化蠕变函数.     

Insertion of the abductor hallucis muscle in feet with and without hallux valgus

Textbooks of human anatomy present different opinions on the insertion of the abductor hallucis muscle which is concerned in etiology as well as in therapy of hallux valgus. In plastic and reconstructive surgery the muscle is taken as a graft for flap-surgery. In this study 109 feet (58 right, 51 left) were examined, 18 of these with clinical hallux valgus. The tendon of the muscle may attach to the tendon of the medial head of the short flexor hallucis muscle where a subtendineous bursa can be found. At the head of the first metatarsal bone the joint capsule is reinforced by fibres arising from the medial sesamoid bone which may be called "medial sesamoidal ligament." The tendon passes the first metatarsophalangeal joint plantarily to its transverse axis. Three types of insertion could be distinguished: type A, insertion at the proximal phalanx (N = 42); type B, insertion at the medial sesamoid ligament and at the medial sesamoid bone (N = 65); type C, insertion at the medial sesamoid bone (N = 2). In all types superficial fibres of the tendon extended to the medial and plantar sides of the base of the proximal phalanx, running in a plantar to dorsal direction. Statistical analysis exposed neither significant differences between both sides nor significant difference between normal feet and feet with hallux valgus. Therefore, a specific pattern of insertion of the abductor hallucis muscle in hallux valgus cannot be stated.     

拇外翻术后拇外翻角和第1-2跖骨间角X射线测量方法评价

背景：拇外翻术后拇外翻角和第1-2跖骨间角的测量关键在于第1跖骨轴线的确定。第1跖骨轴线的不同确定方法,造成了这两个角度测量值的差异,使不同临床研究之间的数据不具有可比性。对于拇外翻术后角度测量,国内外尚未形成公认的标准方法。 目的：回顾不同拇外翻术后拇外翻角和第1-2跖骨间角的测量方法的研究进展,为拇外翻的术后测量与评价研究提供参考。 方法：由第一作者在2012年2月检索PubMed、中国期刊全文数据库以及万方数据库。其中,英文检索词为：“hallux valgus”、“angles”、“radiographic measurements”。中文检索词为“拇外翻”、“角度”、“X射线测量”。选取29 篇文献进行归纳总结。 结果与结论：最好的测量方法其标记点必须是易于确定,可重复性好,应尽量避免受到截骨部位及跖骨本身解剖变异的影响。拇外翻术后X射线测量方法目前多用头部中心/基底部中心测量方法。专业化的工具软件测量取代手工测量是未来拇外翻术后X射线测量的发展趋势。     

Chevron截骨术对外翻足关节接触特征影响的生物力学研究

目的 探究Chevron截骨术截骨远端外侧位移距离对外翻足关节接触特征的影响,为临床上选择合适的位移距离提供参考依据。方法 测量踝关节中立位状态下正常足、外翻足及外翻足Chevron截骨术截骨远端分别向外侧位移2.0、4.0、6.0 mm后前足、中足和后足各关节接触力、峰值压强和接触面积,并对结果进行分析。结果 与正常足相比,外翻足第1跖楔关节（t=-3.33, P=0.02）、跟骰关节（t=-2.74, P=0.03）和距下关节（后关节面）（t=-2.89, P=0.03）的接触力显著增高;外翻足距舟关节（t=-2.73, P=0.03）与跟骰关节（t=-2.74, P=0.03）的峰值压强显著增高;行Chevron截骨术后,随着截骨远端向外侧位移距离的增加,外翻足第1跖楔关节和跟骰关节的接触力逐渐减小;外翻足距舟关节和跟骰关节的峰值压强逐渐减小。结论 中度外翻足行Chevron截骨术后,当第1跖骨截骨远端向外侧位移6 mm时能有效恢复部分关节间力的分布,且能缓解部分关节局部应力集中现象。     

Insertion of the tendon of the tibialis anterior muscle in feet with and without hallux valgus

The insertion of the tendon of the tibialis anterior muscle may be related to pathologic changes of the foot and, in particular, hallux valgus. Morphologic data should enable evaluation of such a relationship and perhaps offer a basis for improved therapy. One hundred fifty-six embalmed feet, including 27 with hallux valgus, were examined. The tendon of the tibialis anterior muscle was dissected and measurements were made, including the width of the insertion on the first metatarsal and medial cuneiform. Distal-superficial and proximal-deep slips of the tendon twisted around each other. Two specimens presented with an insertion only on the medial cuneiform; in two other cases the insertion was limited to the first metatarsal; in one case the tendon inserted into the navicular and the medial cuneiform; in all other cases, the tendon inserted into the medial cuneiform and first metatarsal. The insertion was mainly located along the plantar margin of the medial side of the foot; some of the proximal-deep fibers also passed onto the plantar surface. Fibers inserting on the first metatarsal bone can outwardly rotate the first ray, which is opposite to the inward rotation of the first ray in hallux valgus. In all feet with hallux valgus these fibers were present. Therefore, it is unlikely that this deformity develops because of a specific type of insertion of the tendon of the tibialis anterior muscle, and any therapeutic approach altering the attachment of the tibialis anterior tendon would cause no biomechanical improvement.     

The intersesamoidal ridge of the first metatarsal bone: anatomical basics and clinical considerations

The first metatarsal shows a ridge at the plantar side of the head, aligned nearly longitudinally. On 100 macerated first metatarsals (53 right, 47 left) the existence and alignment of this ridge was examined. On the basis of a regression formula, the specimens were assigned to the genders; accordingly, 29 bones were female, the remaining 71 bones male. The intersesamoidal ridge existed in 95 cases (50 right, 45 left); all 29 female bones showed this ridge, male ones in 66 cases. The ridge deviated on average 7.99 degrees from the longitudinal axis of the first metatarsal towards distal-lateral (from -3 degrees to 19 degrees ). Significant differences ( p=0.001) were found for side (left: 6.04 degrees, right: 9.74 degrees ) but not for gender (female: 8.14 degrees, male: 7.92 degrees ). Noticeable correlations with the length of the first metatarsal and the size of the head could not be determined. The mean values of the alignment of the intersesamoidal ridge seem also not to correlate with the metatarsophalangeal angle. The ridge separates the joint surfaces for the sesamoid bones, which are built-in to the tendons of the two heads of the flexor hallucis brevis muscle. Thus, from the alignment of the ridge, the functional direction of this muscle can be concluded. Since the alignment deviates from the longitudinal axis of the first metatarsal, an adduction, in addition to the flexion, can be concluded. Operative techniques for the correction of hallux valgus often change the alignment of the ridge, and therefore also the biomechanical properties of the flexor hallucis brevis muscle. This could explain failures in several surgical therapies.     

Anomalous tibialis posterior muscle as an etiologic factor of hallux valgus

The role of an anomalous tibialis posterior (TP) tendon in the etiology of hallux valgus (HV) deformity was investigated in four stages: clinical, anatomical, neurological, and operative. In the clinical stage, the patients were instructed to planter flex and invert the foot to contract the TP tendon. Attempts to correct the deformity passively were not possible and resulted in, moderate pain in all patients (197 feet). When the foot was in dorsiflexion and everted (TP tendon was relaxed) the deformity was easily corrected without any pain in 196 feet (99.5%). In the second stage (anatomical), 10 cadavers (20 feet) with HV deformity and 10 cadavers (20 feet) without any foot deformity were dissected. An abnormal expansion of TP tendon into the oblique part of adductor hallucis was found consistently in all HV feet. The tendinous expansion was absent in all normal feet studied. Also when traction was applied to TP tendon, an increase in the metatarsophalangeal (MP) angle of the big toe was observed in all HV feet, but not in the control group. In the third group (neurological), faradic stimulation was applied to the TP muscle in 7 patients with HV deformity and 7 without deformity. The MP angle was increased in HV patients, but no change was observed in the control group. In the fourth stage, 11 patients (18 feet) surgically operated for HV deformity by proximal metatarsal osteotomy and excision of the band anchoring TP tendon to the oblique part of adductor hallucis. The results were excellent in 10 patients (17 feet) even after a minimum 2.5 year follow-up. Also, in two patients who were operated by different procedures with poor results, the TP tendon was lengthened by Z-plasty and they were completely pain free. Our data show the dynamic role of anomalous expansions of the TP tendon into the oblique part of adductor hallucis muscle in HV patients. We suggest this expansion be excised in addition to other operative procedures selected for the surgical treatment of HV patients. © 1994 Wiley-Liss, Inc.     

Endobutton悬吊钢板在拇外翻畸形中的新应用

背景:拇外翻是一种复杂的畸形,尚无治疗金标准,截骨治疗目前得到推崇,但并发症较多,能否进行不截骨矫正拇外翻是作者所在课题组进行的一项新尝试。目的:探讨Endobutton钢板悬吊固定治疗拇外翻畸形的效果。方法:2013年4月至2018年8月苏州大学附属常州肿瘤医院骨科采用Endobutton钢板悬吊固定治疗拇外翻26足,不截骨。所有患者对治疗方案均知情同意,且得到医院伦理委员会批准。术前、术后测量拇外翻角及第1,2跖骨间角,术后12个月评估美国足踝外科协会评分。结果与结论:①所有患者均获满意随访,随访周期8-38个月;②术后患者拇外翻角[(14.15±3.60)°vs.(28.95±4.12)°,P<0.01]及第1,2跖骨间角均显著小于术前[(7.88±0.90)°vs.(15.82±1.81)°,P<0.01]:③术后12个月患者美国足踝外科协会评分为(89.15±7.81)分,显著高于术前(62.08±7.10)分(P<0.01);④提示Endobutton钢板悬吊固定第1,2跖骨间是治疗拇外翻是一种可行的方案。     

迷你双螺纹空心钉结合截骨治疗拇外翻

背景：拇外翻畸形矫正方式多样,采用迷你双螺纹空心钉材料结合截骨矫形的方式损伤小,能够满足拇外翻矫形的目的,是临床上新型的微创生物型内固定材料。 目的：回顾性分析迷你双螺纹空心钉材料应用于截骨矫形拇外翻治疗中的临床疗效。 方法：选择拇外翻畸形患者30例,其中双侧矫形患者8例,单侧矫形患者22例。根据自愿均采用第一跖骨截骨矫形迷你双螺纹空心钉内固定,治疗前后拍摄X射线片测量外翻角、跖间角、籽骨位置,进行AOFAS评分,并计算第一跖骨短缩长度。 结果与结论：采用迷你双螺纹空心钉结合截骨矫形治疗后,拇外翻畸形患者的外翻角、跖间角、AOFAS评分及籽骨位置较治疗前明显改善,第一跖骨短缩在矫形可控范围内避免畸形复发及跖骨痛。     

足底内侧和外侧群肌的肌内神经整体分布模式及临床意义

目的 揭示足底内侧和外侧群肌的肌内神经整体分布模式,探讨其临床意义。 方法 24具成年尸体,完整取下足底内侧和外侧群肌,采用改良Sihler染色显示肌内神经分布模式。 结果 母收肌的神经支从肌止端的深面入肌,而 母展肌、母短屈肌、小趾展肌和小趾短屈肌的神经支常从肌起端的深面入肌。母展肌中有1个半月形和1个长方形的肌内神经密集区（INDR）;母收肌横头内有2个肾形INDRs,斜头内有1个肾形和1个长方形的INDR;母短屈肌、小趾展肌和小趾短屈肌内均有2个长方形的INDRs。这5块肌均可分为2个神经肌肉亚部,但各肌的INDR及其中心点在肌长上的百分位置不同。结论 上述结果可为外科手术免于神经损伤,肌移植的选材匹配,以及注射肉毒毒素A阻滞这些肌肉的痉挛提供形态学指导依据。