A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.     

Die Rekonstruktion von langstreckigen Achillessehnendefekten durch einen Transfer des Musculus flexor hallucis longus

Objective

The aim of flexor hallucis longus (FHL) transfer is to bridge long defects of the Achilles tendon. In addition to the substitution of the Achilles tendon by the tendon graft, the flexor hallucis longus muscle changes its function to plantar flexion of the ankle. A part of the muscle belly is placed into the paratendon sheath which supports healing even in patients with critical soft tissue injuries.

Indications

Extended Achilles tendon defects, extended degenerative disease of the Achilles tendon, and reruptures, especially in patients with significant soft tissue injuries.

Contraindications

Ruptures of the Achilles tendon which can be treated by direct reconstruction.

Surgical technique

The patient is placed in a prone position. After a central longitudinal approach to the Achilles tendon and debridement of the diseased tendon material, the deep fascia is split. After identification of the flexor hallucis longus tendon, the tendon is retracted with a plantiflexed hallux and dissected at the entrance point to the tarsal tunnel. The tendon is fixed to the calcaneus via a 6?mm drill hole using an interference screw in the press-fit technique.

Postoperative management

A lower limb orthosis is used for the first 8?weeks: the first 4?weeks plantar flexion of 30° with partial weight bearing of 20?kg, then full weight bearing for 2?weeks with 15° plantar flexion, and another 2?weeks with neutral position of the ankle. After removal of the orthosis, a heel lift of 1.5?cm (e.g., silicon heel cushion) is recommended for 3?months. Running activities are restricted for 6?months.

Results

In a series of 25 consecutive patients (15?men, 10?women) with an average age of 61?years (range 37?C79?years), it was possible in all cases to reconstruct the Achilles tendon function. The AOFAS Hindfoot Score improved from 62 to 89 points. Especially in the category pain, the patients reached 38?of a maximum of 40?points. Compared to the healthy leg, a limitation in maximum strength in plantar flexion was found (42?of a maximum of 50?points).     

Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report

Purpose

The aims of this anatomical study were to evaluate the feasibility of minimally invasive plate osteosynthesis (MIPO) using a posterolateral approach in distal tibial fractures and to study the relationship between neurovascular structures and the plate.

Methods

Two separate incisions, one proximal and one distal, were made on the posterolateral aspect of ten cadaveric legs in the prone position. A 14-hole contralateral anterolateral distal tibial locking plate was inserted into the submuscular tunnel using a posterolateral approach, and one screw was fixed on each side of the proximal and distal tibia. The MIPO tunnel was then explored to identify the relationship between neurovascular bundles and plate.

Results

For the proximal incision, retraction of the flexor hallucis longus and the tibialis posterior muscles medially was very important because it could protect the posterior tibial artery and the tibial nerve during plating. The sural nerve and lesser saphenous vein were easily identified and retracted in the superficial layer of the distal incision. In addition, we achieved satisfactory outcomes after using this MIPO technique in one patient.

Conclusion

Based on the results of our study, it seems that using the MIPO technique through a posterolateral approach should be a reasonable and safe treatment option for distal tibial fractures, especially when the anterior soft tissue is compromised. However, studies with a higher level of evidence should be done in more patients to confirm the clinical safety of using this technique.     

Adjacent tissue involvement of acute inflammatory ankle arthritis on magnetic resonance imaging findings

Purpose

The ankle joint and surrounding subtalar joint have several tendons in close proximity. This study was performed to investigate the concurrent adjacent tissue involvement on MRI findings when the surgical treatment is considered for an acute inflammatory arthritis of the ankle joint.

Methods

Consecutive patients with acute inflammatory ankle arthritis who visited the emergency room and underwent MRI were included. After interobserver reliability testing of MRI findings, adjacent tissue involvement in the acute inflammatory ankle arthritis were evaluated including flexor hallucis longus (FHL), flexor digitorum longus (FDL), tibialis posterior (TP), peroneus longus (PL), peroneus brevis (PB), extensor digitorum longus (EDL), tibialis anterior (Tib Ant), extensor hallucis longus (EHL), subtalar joint, talus, tibia, and calcaneus.

Results

Twenty-five patients (mean age 57.8 years; 16 males and nine females) were included. Of the 25 patients, 23 showed FHL involvement, 21 FDL, 21 TP, 15 PL, 15 PB, three EDL, 21 subtalar joint, six talus, six tibia, and five calcaneus on MR images. No Tib Ant or EHL involvement was observed on MR findings in acute inflammatory ankle arthritis.

Conclusions

Patients with acute inflammatory ankle arthritis showed frequent concomitant surrounding tissue involvement on MRI, which included FHL, FDL, TP, and subtalar joint. This needs to be considered when surgical drainage is planned for acute inflammatory ankle arthritis.     

Combined peroneal and proximal tibial nerve palsies

Combined compression of both the common peroneal nerve and the proximal tibial nerve at the level of the popliteal fossa is rare. Recently, an anatomic site of compression of the proximal tibial nerve at the soleal sling (originating arch for the soleus muscle) has been described in cadavers. The present report includes three patients who had a combined compression of the common peroneal nerve at the fibular neck (fibular tunnel syndrome) and compression of the proximal tibial nerve at the soleal sling (soleal sling syndrome). In each case, blunt trauma was the precipitating event. Neurolysis of both nerves resulted in restoration of motor and sensory function in each ofthese three patients. This is the first clinical report illustrating combined neurolysis of the common peroneal at the knee and the proximal tibial nerve in the soleal sling. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Complications following palmar plate fixation of distal radius fractures: a review of 665 cases

Introduction

Palmar plate fixation of unstable distal radial fractures is quickly becoming the standard treatment for this common injury. The literature reporting complications consists mainly of isolated case reports or small case series.

Method

Between February 2004 and December 2009 palmar plate fixation was performed in 665 cases. The overall complication rate was 11.3 % (75 complications). Revision surgery was necessary in 10 % (65 procedures).

Results

The reasons for revision surgery were: postoperative median nerve compression (22 patients) and secondary dislocation (9 patients). An ulna shortening osteotomy for ulnar impingement syndrome was necessary in eight cases. Intraarticular screw placement occurred in three patients. There were two flexor pollicis longus, one finger flexor and three extensor pollicis longus tendon ruptures. Posttraumatic compartment syndrome of the forearm requiring fasciotomy occurred in four cases. There were three cases of infection. Nonoperative treatment was necessary in nine patients, who developed a complex regional pain syndrome. Hardware failure occurred in three cases. Hardware removal was performed in 232 (34 %) cases.

Conclusion

Palmar plate fixation of distal radius fractures is a safe and effective procedure. Nevertheless, complications necessitating a second intervention are relatively common. A proportion of these complications is iatrogenic and can be avoided by improving the surgical technique.     

Comparative outcomes of ulnar nerve transposition versus neurolysis in patients with entrapment neuropathy at the cubital tunnel: a 20-year analysis

Background

Entrapment neuropathy of the ulnar nerve at the level of the elbow is the shared domain of multiple surgical specialties. A wide variety of operative methods for its surgical management have been reported. Our hospital utilizes neurolysis (NL) and subcutaneous transposition (AST). The aim of this paper was to compare the clinical outcomes in patients treated by ulnar nerve transposition versus neurolysis over a 20-year period.

Methods

We included patients who underwent either neurolysis or an ulnar nerve transposition. A retrospective analysis was performed which included 480 patients at our institution between January 1992 and December 2012. In total, physical and electronic records for 480 patients were reviewed. Three-hundred and one underwent ulnar nerve transposition and 179 underwent ulnar nerve neurolysis .

Results

In the AST group 201/301 patients suffered from parasthesiae pre-operatively and 156/301 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 99/301 patients. At the 3-month follow-up appointment, 187/201 patients with parasthesiae and 113/156 patients with local pain had resolution of their symptoms. In the NL group 151/179 patients had parasthesiae pre-operatively and 126/179 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 56/179 patients. At the 3-month follow-up appointment, 141/151 patients with parasthesiae and 117/126 patients with local pain had resolution of their symptoms.

Conclusions

In cases of ulnar nerve compression at the cubital tunnel, both neurolysis and transposition are effective in improving clinical outcome. The only statistically significant advantage of neurolysis over transposition seems to be relief of localized elbow pain. We recommend neurolysis as the preferred procedure.     

Acute tarsal tunnel syndrome following partial avulsion of the flexor hallucis longus muscle: a case report.

An acute posterior tibial nerve compression from a partially ruptured flexor hallucis longus (FHL) muscle is reported. This etiology for acute tarsal tunnel syndrome has not been previously described. A 17-year-old male sustained multiple injuries in a motor vehicle accident, including a tibial shaft fracture and a posterior medial right ankle laceration of the same limb. The injured limb had no sensation on the plantar aspect of the foot and heel, decreased active great toe flexion, and associated leg pain. Exploration of the posterior tibial nerve for presumed laceration revealed the nerve to be intact, but compressed in a tense tarsal tunnel from a retracted partially ruptured flexor hallucis longus tendon. Decompression of the tunnel and resection of the devascularized muscle resulted in complete neurologic recovery.     

Operative Nervendekompression an der unteren Extremit?t bei diabetischer Polyneuropathie

Objective

Surgical decompression of nerves of the lower leg should facilitate swelling-related pressure in diabetic polyneuropathic similar to carpal and cubital tunnel syndrome. Pain reduction, reduced need for pain medication, improved pedal sensitivity, improved balance and proprioception, and potential prevention of ulcerations and amputations are the objectives of the operation.

Indications

Diabetic polyneuropathy with positive Hoffmann-Tinel sign over the tarsal tunnel and an ankle-brachial index?>0.7

Contraindications

No Hoffmann-Tinel sign over the tarsal tunnel, no pain, no sensibility disorders, ankle-brachial index?<0.7, body weight?>140?kg. Relative contraindication: venous stasis and postthromobitic syndrome.

Surgical technique

Under general or spinal anesthesia, tourniquet, decompression of nerves of the lower leg in three locations: (1) common peroneal nerve at the fibula head with incision of the peroneus longus muscle, (2) tarsal tunnel with its four tunnels: (a) tibial nerve in the tarsal tunnel, (b) medial plantar nerve in the medial plantar tunnel, (c) lateral plantar nerve in the lateral plantar tunnel, (d) Rr. calcaneare in the calcaneal tunnel, (3) dorsum of the foot with decompression of the peroneus profundus nerve with excision of the extensor hallucis brevis muscle.

Postoperative management

No weight bearing for up to 3?weeks, suture removal after 3?weeks, water aerobics starting postoperative week?4.

Results

A total of 12?patients (64±9?years) were operated and were followed up for 12±6?months. Procedure time was 83±27?min. Pain reduction on a visual analogue scale improved from 7.1±1.2 preoperatively to 3.3±2.4 postoperatively. Balance improved on a Likert scale (1=best, 6=worst) from 5±1 to 2±1, while sensory impairment improved from 5±2 to 3±1. There were no ulcerations or amputations. Two secondary wound healing problems at the ankle and one lower leg venous thrombosis 2?weeks following discharge were managed conservatively.     

Eine spezielle Weichteilplastik am Gro?zehengrundgelenk bei Hallux-valgus-Operationen

Objective

Maintaining the corrected position of the first metatasophalangeal axis. Reducing postoperative stiffness by forgoing a medial capsular shift.

Indications

Hallux valgus deformities or recurrent hallux valgus deformities.

Contraindications

Existing osteoarthritis, joint stiffness, large bone defects, osteonecrosis. General medical contraindications to surgical interventions and anesthesiological procedures.

Surgical technique

Operation under regional anesthesia (foot block) or general anesthesia. Tourniquet. Longitudinal skin incision medial over the pseudexostosis of the first metatarsal bone. Preparing the tendon of the Musculus abductor hallucis. Detaching the tendon from the capsule. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle in an L-wise manner. Osteotomy of the first metatarsal bone. Lax sutures of the capsule in correct position and reattachment of the Musculus abductor hallucis tendon shifted toward distal and dorsal, regarding the rotation of the hallux.

Postoperative management

Postoperative elevation of the operated foot. Analgesia with nonsteroidal antiinflammatory drugs. Postoperative weight-bearing according to the osteotomy. Passive mobilization of the metatarsophalangeal joint. Dressing for 4?weeks postoperatively in the corrected position. Radiologic control after 6?weeks. Hallux valgus orthosis at night and a toe spreader for a further 6?weeks.

Results

A total of 30 isolated hallux valgus deformities with a mean preoperative intermetatarsal (IMA) angle of 12.9°?(range 11?C15°) were operated with a chevron osteotomy. The mean follow-up was 14.4 (range 8?C17)?months. The mean dorsiflexion at the last follow-up was 44° (range 20?C60°). Only 2?patients had a dorsiflexion <40°. The mean reduction of the IM angle was 5.6° (range 3?C7°). One patient required wound revision. There was no infection or avascular necrosis of the metatarsal head observed in the patients. At follow-up, 20?(67%) patients were completely satisfied, 9?(30%) satisfied, and 1?(3%) was not satisfied.     

V-Y肌腱瓣结合屈(足母)长肌腱转移治疗退变的跟腱断裂

目的 介绍V-Y肌腱瓣结合屈(足母)长肌腱转移治疗退变的跟腱断裂的术式、手术指征及疗效.方法 2003年10月至2006年5月对21例跟腱断裂采用V-Y肌腱瓣结合屈躅长肌腱转移治疗,其中采用铆钉17例,界面螺钉4例.介绍该手术方法,并根据文献和实践总结手术指征. 结果 本组所有患者获得12～18个月(平均14个月)随访.根据Arner-Lindholm疗效评价标准:优19例,良2例.术后伤口均一期愈合,随访期间跟腱无再次断裂,无伤口感染,无皮肤坏死,踝关节活动好,无僵直,无神经血管损伤.行走步态基本正常,对前足推进影响不大.该术式修复强度允许跟腱早期功能锻炼. 结论 采用V-Y肌腱瓣结合足屈(足母)长肌腱治疗跟腱断裂疗效好,该术式适用于跟腱组织退变、炎症和部分缺损(<3cm)患者,术中单纯V-Y肌腱瓣修补强度不够可采用屈(足母)长肌腱转移.     

Fractures of the sustentaculum tali

Objective

Anatomical reconstruction of displaced sustentaculum tali fractures via a direct medial approach.

Indications

Displaced fractures of the sustentaculum tali with incongruity or depression of the medial facet of the subtalar joint, entrapment of the flexor hallucis longus or flexor digitorum longus tendons, fracture line extending into the posterior facet of the subtalar joint.

Contraindications

Infected or grossly contaminated soft tissue, severely restricted vascular supply to the foot, high perioperative risk.

Surgical technique

Direct medial approach over the sustentaculum tali, retraction of the tendons, joint exploration, fracture reduction using the medial facet and cortical outline as guidelines, fracture fixation with two small fragment screws from medial to lateral directed slightly plantarly and posteriorly. Fractures with depression of the medial facet as a whole can alternatively be reduced and fixed percutaneously.

Postoperative management

Lower leg splint for 5–7 days, partial weight-bearing with 20 kg for 6–8 weeks (until radiographic signs of consolidation) in the patient’s own shoewear, early range of motion exercises of the ankle, subtalar and mid-tarsal joints.

Results

Over a course of 15 years, 31 patients were treated operatively for sustentacular fractures. In all, 27 patients (87?%) had additional fractures to the same foot and ankle. Eighteen patients with a mean age of 41 years treated at our institution with screw fixation for a unilateral fracture of the sustentaculum tali could be followed for a mean of 80 months (range 15–151 months). No wound healing problems or infections were seen with the medial approach. At the time of follow-up, 15 sustentaculum tali fractures had an average Foot Function Index of 21.6 and an average AOFAS Ankle–Hindfoot Score of 83.6. Patients with isolated fractures of the sustentaculum tali had significantly better scores than those with additional injuries. In 1 patient, an additional lateral process fracture of the talus required subtalar fusion due to persistent pain. Care must be taken not to overlook these atypical calcaneal fractures and accompanying injuries to the mid-tarsal joint and the lateral talar process as seen in 45% and 23%, respectively, in the present series.     

Axon counts of potential nerve transfer donors for peroneal nerve reconstruction

BACKGROUND:

The common peroneal nerve is the most commonly injured nerve in the lower limb. Nerve transfer using expendable donor nerves is emerging in the literature as an alternative surgical procedure to traditional treatments.

OBJECTIVE:

To identify potential donors of motor axons from the tibial nerve that can be transferred to the common peroneal nerve branches.

METHODS:

Using 10 human cadaveric lower extremities, all motor nerve branches of the tibial nerve were identified and biopsied. These were compared with the motor branches to tibialis anterior and extensor hallucis longus (branches of the deep peroneal nerve).

RESULTS:

The most suitable donor nerves with respect to cross-sectional area to tibialis anterior (cross sectional area [mean ± SD] 0.255±0.111 mm) was the motor branch to lateral gastrocnemius (0.256±0.105 mm). When comparing the total number of axons, the branch to the tibialis anterior had a mean of 3363±1997 axons. The branch to the popliteus was most similar, with 3317±1467 axons. The most suitable donor nerves for the motor branch to extensor hallucis longus (cross sectional area 0.197±0.302 mm) with respect to cross-sectional area was the motor branch to flexor hallucis longus (0.234±0.147 mm). When comparing the total number of axons, the branch to the extensor hallucis longus had an average of 2062±2314 axons. The branch to the lateral gastrocnemius was most similar with 2352±1249 axons and was a suitable donor.

CONCLUSION:

Nerve transfers should be included in the armamentarium for lower extremity reinnervation, as it is in the upper limb.     

Les vaisseaux perforants de l’artère tibiale postérieure : étude anatomique pour une meilleure planification préopératoire du lambeau adipofascial médial de la jambe

Introduction

Distal tissue losses to the leg and the foot with exposure of the bone still poses cover issues. The adipofascial flap of the anteromedial side of the leg, as described by Heymans, is based on perforator vessels of the posterior tibial artery. It provides a good alternative to free flaps and enables all the tissue loss to the leg to be covered, from the knee down to the ankle. The aim of this paper is to specify the exact location of the perforator vessels, mainly the most distal, with the aim of guiding the surgeon in their pre-operative planning of the repair and thus make surgical dissection easier when raising the flap.

Materials and methods

This is a study reporting on 10 lower limb dissections on 5 cadavers (4 fresh legs and 6 legs that had been embalmed with formaldehyde; 5 right and 5 left). The dissections comprised of raising the flap and were carried out according to the following steps: 1) skin incision going from the anterior tuberosity of the tibia to the medial malleolus, 1 cm behind the anterior border of the tibia; 2) subcutaneous separation and exposure of the fatty tissue, while saving the saphenous vein and the saphenous nerve; 3) incision of the fascia then careful separation of the flap, locating the perforator vessels and specifying their locations. A clinical case is also reported by the authors to complete the illustration of raising the flap.

Results

During the dissections, 3 to 5 perforator vessels were found. The perforator vessels were located between 6 and 30 cm from the anterior tibial tuberosity (ATT): 1) the proximal perforators: these were located 6 cm under the ATT and pass between the anterior border of the tibia and the gastrocnemius muscle; 2) the middle perforators: these are located 10 to 20 cm under the ATT and pass between the soleus muscle and the flexor hallucis longus muscle; 3) the distal perforators: these are located 3.5 to 7 cm above the medial malleolus (on average 5.5 cm) and pass under the flexor digitorum longus and the flexor hallucis longus muscles.

Discussion

From this cadaver study, the consistency, the variety and the staged character of the perforator pedicles used as adipose tissue for the anteromedial side of the leg are clear. The pedicle is chosen based on the location of the tissue loss on the leg. The flap can thus cover the tissue loss from various locations form the knee to the heel. The use of a distal pedicle flap enables the problem of tissue loss coverage to be resolved to the distal quarter of the leg and the ankle and is a good alternative to free, neurocutaneous, supramalleolar, medial plantar and semi-soleus flaps. The results from this study are compatible with data from the literature and the measures used during this work will help in the location of the perforators during raising of the flap. From this work it is also possible to conclude that keeping a distance of 7 to 8 cm above the medial malleolus ensures that the most distal perforators are not missed.

Conclusion

The adipose flap from the anteromedial side of the leg presents several advantages: easy and quick to carry out, consistent, staged and a variety of perforator pedicles enabling tissue loss to the leg to be covered, from the knee to the heel. This anatomical study could be a support to aid in the preliminary location of the preferable sites of perforators, in particular the most distal, thus guiding the surgeon during their pre-operative planning and surgical dissection.     

Die Arthrodese des Tarsometatarsal-I-Gelenks mit einer plantaren Zuggurtungsosteosynthese

Objective

Treatment of hallux valgus in patients with a pathology of the first metatarsocuneiform (MC) joint by a fusion of the first MC fixed by a plantar plate. The plantar plate has biomechanical advantages and has good soft tissue coverage by the M.?abductor hallucis.

Indications

Instability or degenerative arthritis of the first MC joint in patients with hallux valgus.

Contraindications

Short first metatarsal.

Surgical technique

Bone-saving resection of the first MC joint. Arthrodesis using a compression screw and a plantar interlocking plate. Distal soft tissue procedure and resection of the exostosis.

Postoperative management

For 6?weeks, a long sole, post-operative shoe with weight bearing as pain allows. Mobilization of the first metatarsophalangeal joint when the wound healing is assured. Full weight bearing after 6?C8?weeks in a normal shoe, when the bone healing is completed on the x-rays. No sports with high demands on the foot for 12?weeks. Orthotics only in cases with persisted pain or associated pathology.

Results

In a case control study including 72?patients, a significantly lower rate of nonunion and soft tissue problems, compared to dorsal or medial plate positioning, was observed.     

Die Musculus-peroneus-brevis-Lappenplastiken

Objective

Soft tissue defect reconstruction by transposition of well-vascularized muscle tissue with a muscle flap and as an osteomuscular flap together with a fibular bone segment for combined skeletal and soft tissue defects.

Indications

Small- and medium-sized defects of the hindfoot, around the ankle and the distal and middle third of the lower leg, skeletal reconstruction of underlying small- and medium-sized bone defects.

Contraindications

Lesions of the proximal anterior tibial artery (proximal pedicled flap), combined lesions of the distal peroneal artery including the communicating branch with the posterior tibial artery (distal pedicled flap); lesion or paralysis of the peroneus longus muscle in an intact ankle joint.

Surgical technique

Distally pedicled flap: blunt separation between the peroneus longus and brevis muscle, subperiosteal release with isolation on a distal septocutaneous branch of the peroneal artery. To increase perfusion, the proximally released branch of the anterior tibial artery may be re-anastomosed in the recipient site. Proximally pedicled flap: dissection of distal peroneus brevis muscle tendon and subperiosteal release in a proximal direction with ligation of the segmental peroneal artery branches until the flap is isolated on its proximal anterior tibial artery branch. For an osteomuscular flap, simultaneous harvest of a fibula segment underneath the muscle origin with preservation of the intimate periosteal relationship between muscle and bone.

Postoperative management

Complete immobilization and elevated leg position for 5 days, followed by successive orthostatic training for 10 days. Postoperative standardized compression garments for 6 months, eventually combined with silicone sheet scar therapy.

Results

Reliable, excellent functional and aesthetic results with very low donor site morbidity.     

腓骨骨折术后并发(足母)趾屈曲畸形的治疗

目的 探讨腓骨骨折切开复位内固定术后并发拇趾屈曲畸形的病因、临床表现、解剖学特征、诊断及治疗方法。方法 1996年10月至2004年3月，腓骨骨折术后并发拇趾屈曲畸形患者33例，男19例，女14例；年龄22-49岁，平均33．2岁。其中合并踝关节骨折24例，根据Lauge—Hansen分型：旋前-外旋型18例，旋后-外旋型4例，旋前-外翻型2例；胫腓骨远端1／3螺旋形骨折9例。腓骨骨折均行切开复位钢板螺钉内固定术。患者均于术后1-5个月，平均3个月出现拇趾屈曲畸形。其中单纯拇趾屈曲畸形19例，伴二、三趾屈曲畸形8例，伴二至五趾屈曲畸形6例。采用单纯肌腱粘连松解术、单纯拇长屈肌腱延长或合并趾长屈肌腱延长术矫正畸形。结果19例单纯拇趾屈曲畸形患者，7例行单纯拇长屈肌腱粘连松解术，12例行拇长屈肌腱延长术。14例合并其余足趾屈曲畸形患者，6例行单纯拇长屈肌腱延长术，8例行拇长屈肌腱合并趾长屈肌腱延长术。术后随访2-10个月，平均6个月，所有患者足趾畸形完全矫正，疼痛缓解，步态及穿鞋改善，无畸形复发。结论 腓骨骨折术后并发拇趾屈曲畸形，拇长屈肌腱与骨折处粘连是重要因素。在Henry结部位，拇长屈肌腱与趾长屈肌腱之间存在腱性连接的解剖变异，对于足部矫形手术具有特殊的临床意义。     

Anatomische Wiederherstellung des chronisch instabilen Lisfranc-Ligaments

Hintergrund

From June 2001 to May 2013 four selected patients with an isolated and old Lisfranc’s ligament rupture were treated at the Trauma Department of the University Hospital Carl Gustav Carus in Dresden with an anatomical repair of the ligament using half of the extensor hallucis longus tendon. This kind of graft 7 cm in length was used in three cases and in the fourth case the whole extensor hallucis brevis tendon was used. Of the four patients three were female with an average age of 28.6 years (range 15-39 years). The fourth patient was a 23-year-old male who was followed up for only 3 months due to emigration abroad. The three female patients were postoperatively followed up for a minimum of 1 year clinically and at the 1 year follow-up all three women had a stable Lisfranc’s joint, two were absolutely pain free and one was relatively pain free.

Results

The youngest of the three females was 15 years old at the time of surgery and in preparation for the Olympic Games as a gymnast. This gave rise to the idea for an anatomical repair to avoid partial fusion of the Lisfranc’s joint in this very young and an extremely competitive sportswoman. The Lisfranc’s joint was completely stable and pain free 2 years postoperatively and 10 years after surgery she qualified for the 2005 World Championships in Australia and the Olympic Games in Beijing in 2008.