Management of chronic calcaneal osteomyelitis with pull-through abductor hallucis muscle flap -a report of three cases

Three patients who had chronic osteomyelitis of the calcaneus were treated with radical debridement of all involved soft tissue and bone and obliteration of dead space with a pull-through abductor hallucis brevis muscle flap. Two patients had calcaneal osteomyelitis without soft tissue loss resulting from previous comminuted calcaneal fractures while a third patient had a large soft tissue defect and calcaneal osteomyelitis resulting from a destructive infection. All of the patients had undergone several surgical procedures for treatment of the osteomyelitis with histories ranging 18 months to 30 months. Following treatment with the pull-through muscle flap there has been no recurrence over the longterm (>two years). We believe that radical removal of all contaminated tissue and immediately coverage with a muscle flap provides an effective single stage treatment of chronic calcaneal osteomyelitis.     

Abductor hallucis release in congenital metatarsus varus

Summary Adduction of the forefoot diagnosed in the young child generally corrects spontaneously. Resistant forefoot adduction is usually combined with a degree of supination of the forefoot and described as congenital metatarsus varus.In true congenital metatarsus varus there is a contraction or shortening of the abductor hallucis muscle and tendon which is considered to be the primary deforming factor.In the early severe or resistant deformity correction can be achieved by either division of the tendon with release of its capsular attachment, or, in the more severe deformity, by complete release of the abductor hallucis muscle from its extensive attachment to bone and soft tissues.

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Résumé L'adduction de l'avant-pied découverte chez l'enfant jeune se corrige spontanément en règle générale. Dans le cas contraire, elle s'associe habituellement à un certain degré de supination de l'avant-pied et elle est alors décrite comme metatarsus varus congénital.Dans le véritable metatarsus varus congénital il existe une rétraction ou une brièveté du tendon et du muscle abducteur du 1 ^er orteil que l'on considère comme le facteur déterminant de la déformation.Dans les cas de déformation d'emblée sévère ou persistante, la correction peut être obtenue soit par section du tendon et de son insertion sur la capsule, soit, dans les cas les plus graves, par désinsertion complète du muscle abducteur du 1 ^er orteil, tant au niveau de l'os que des parties molles.

     

吻合血管神经的(足母)展肌移植修复晚期面瘫

目的:探讨和研究治疗晚期面瘫的手术治疗,总结应用以足底内侧动静脉为蒂的(足母)展肌游离移植一期修复晚期面瘫40例效果和经验.方法:选取(足母)展肌为供肌,以足底内侧动静脉及其延续的胫后动静脉为血管蒂,以支配(足母)展肌神经及其延续的足底内侧神经和胫神经为神经蒂.(足母)展肌移植于患侧面部皮下,肌近断固定于口角,远端固定于耳前颧弓,血管神经蒂通过上唇皮下隧道与健侧面动静脉和面神经颊支吻合.结果:经随访一年以上,23例恢复了面部静态对称和理想的下面部随意和不随意运动;8例恢复了面部静态对称和部分下面部随意和不随意运动;9例仅恢复了面部静态对称.结论:(足母)展肌游离移植一期修复晚期面瘫具有疗效好、手术操作简便、肌肉大小适中、血管神经蒂走行位置恒定紧密伴行、血管神经蒂可切取较长、变跨面神经移植和肌肉移植的两期移植为一期移植等优点;而且,神经是血管化移植.     

Differential effects of vecuronium on the thumb and the big toe muscles evaluated by acceleration measurement

To clarify the differential effects of vecuronium on the thumb and on the big toe, train-of-four (TOF) stimuli were applied to the ulnar nerve at the wrist and the tibial nerve at the ankle in anesthetized patients using two acceleration transducers. Ten adult patients, aged 21–55 years, were studied. Anesthesia was induced by an intravenous injection of thiopental, and vecuronium 0.1 mg·kg⁻¹ was used for paralysis. Anesthesia was maintained with nitrous oxide (66%)-oxygen-sevoflurane (1 MAC). The duration of time to the maximal twitch depression on the thumb and the big toe was 136.5±32.5 s and 183.0±40.1 s (P<0.05), respectively. The time to 25% recovery of the twitch height on the thumb and the big toe was 48.1±17.3 min and 39.1±11.6 min, respectively; the time to 50% recovery of twitch height on the thumb and the big toe was 54.1±16.1 min and 40.0±9.2 min (P<0.05), respectively. When paralysis was reversed at 25% of TOF ratio on the thumb, the value of the TOF ratio on the big toe was 58.5±18.2% (P<0.01).     

Effect of the manual stretching maneuver for hallux valgus

BackgroundHallux valgus (HV), which is one of the most common musculoskeletal abnormalities of the foot, is defined as the medial deviation of the first metatarsophalangeal (MTP) joint and the lateral deviation of the great toe.ObjectsThis study aimed to investigate the immediate effects of a manual stretching maneuver (MSM) in subjects with HV.MethodsTwenty-five subjects with a total of 25 feet with mild HV participated in the study. The MSM, consisting of global stretching of the foot and toes, traction of the hallux, local stretching for hallux, and mobilization of the MTP joint of the hallux. The HV angle between the line of the first metatarsal bone and the proximal phalanx were measured using a goniometer. The cross-sectional area (CSA) of the AbdH was measured using ultrasonography. Zebris FDM was used to measure the static plantar pressure and the movement of the center of pressure (COP) standing on one foot. The dependent variables before and after treatment were compared using paired t-tests. The significance level was set at .05.ResultsThe HV angle significantly decreased from 20.25° to 16.96°. The CSA of the AbdH significantly increased from 14.00 mm² to 16.11 mm². The peak pressure on the hallux and 1st, 2nd and 3rd metatarsals increased significantly. The contact area and total pressure on the hallux significantly increased. The sway of the COP on the length of the minor axis and velocity significantly decreased.ConclusionThis study suggests that the MSM can be effective in decreasing the HV angle in subjects with mild HV. However, further longitudinal clinical studies are required to investigate the long-term effects of the MSM in subjects with HV.     

A new and simplified functional tendon transfer for a dropped hallux

A case of fracture of the right tibia proximal 1/3rd extending up to diaphysis after a road traffic accident along with a dropped hallux is being reported. The extensor digitorum longus (EDL) was intact. Patient was taken up for surgery for the fracture tibia with conservative management for his dropped hallux for initial six weeks. After six weeks when no improvement was seen surgical intervention was planned for the dropped hallux. The subsequent management of this patient is being described.     

动静结合的面神经瘫痪综合治疗

目的 探讨静态和动态结合综合治疗面神经瘫痪的方法。方法 1993年10月～2005年11月治疗了面神经瘫痪93例，男26例，女67例；年龄9～69岁。病程6个月～24年。不明原因发病48例，有颅内及耳手术史32例，外伤13例；其中全面神经瘫82例，向神经分支瘫11例。针对面神经瘫痪的不同情况（全瘫和分支瘫）采用了不同的修复方式，动态修复术包括手术和生物化学去神经足雌短伸肌、趾短伸肌游离移植联合颍肌筋膜瓣悬吊面瘫矫治；静态修复包括颧颊部组织上提联合颞肌筋膜瓣矫治眼闭合不全，埋设导引缝合眉上提术（单纯颞支损伤可单独应用），下颌缘支损伤采用肉毒毒素注射及健侧下颌缘支离断的两侧肌力调节。对于静态修复者，疗效的评价标准主要足面部的对称性检查，而动态修复者是联合面部对称性检查及House-Brackmann面神经功能国际评分。结果 手术和化学去神经足拇、趾短伸肌游离移植联合颞肌筋膜瓣悬吊面瘫矫治82例，面部基本对称77例，改善5例；Ⅱ级75例，Ⅲ级7例。颧颊部组织上提联合颞肌筋膜瓣矫治眼闭合不全3例，面部基本对称。埋设导引缝线眉上提术治疗15例，面部基本对称13例、悬吊脱落2例。下颌缘支损伤肉毒毒素注射及健侧下颌缘支离断的两侧肌力调节4例面部基本对称。术后随访3个月～10年，取得了较好的效果，按疗效评价标准：满意者75例，基本满意者13例，不满意者5例。采用小肌肉游离移植，短暂去神经肌肉移植后利于周围神经的长入，手术切口隐蔽，肉毒毒素的应用减少了创伤；动态和静态结合的个性化面神经瘫痪治疗，面部的改观较明显。结论 面瘫治疗需要根据面神经瘫痪不同的情况采取不同的治疗方法。     

恒河猴去神经骨骼肌游离移植的研究

目的为临床行去神经肌肉游离移植提供理论依据。方法将恒河猴的双足(足母)、趾短伸肌8块分2组去神经后游离移植于骶棘肌内,定期活检行光镜(HE 染色、银染色、酶染色)及电镜观察肌纤维及神经纤维。结果去神经后肌肉的代谢降低;移植到有正常神经支配的肌肉内12周后有神经长入。结论去神经后促进移植肌肉在缺氧环境下存活、再生,同时与受区正常肌肉接触后,有神经长入或再生神经长入并支配移植肌。本实验去神经肌肉游离移植后的存活为临床手术方法提供理论依据。     

Anatomical Study of the Accessory Tendon of the Extensor Hallucis Longus Muscle and Its Clinical Application

BackgroudThe accessory tendon of the extensor hallucis longus (ATEHL) muscle is a common abnormal structure, and its clinical significance remains debatable. In this study, we provide the incidence of the ATEHL and characterize its morphological types in Asian cadavers and investigate its clinical applications.MethodsThe tendons from 50 adult cadaveric feet, fixed in 10% formalin, were analyzed. We measured the length and width of both the ATEHL and the extensor hallucis brevis (EHB).ResultsAll dissected specimens had an ATEHL. The first metatarsophalangeal joint was surrounded by an accessory tendon that inserted onto the joint capsule and the dorsal base of the proximal phalanx. We classified the ATEHL into 3 types based on their directions. Differences in ATEHL type based on sex were not statistically significant.ConclusionsWe found an ATEHL in all cadaveric specimens in this study. We surmise that the ATEHL acts as an antagonist with the EHB when the toe is extending, which might help prevent the occurrence of hallux valgus deformity.     

拇短展肌肌力定量测定在腕管综合征诊断中作用

目的探讨临床客观、量化的拇短展肌肌力评判方法。方法应用计算机化微型便携式肌力测定仪对101例(162只手)腕管综合征患者进行测定。其中女77例、男24例。年龄20～59岁。所有患者均于术前进行了肌力测定,其中62只手在术后6周再次测定。结果44%的患者具有拇短展肌肌力减弱,其不同性别间的差异具有极显著意义(P<0.001)。部分年龄组别间差异有显著性意义(P<0.05)。术前术后差异具极显著意义(P<0.001)。结论拇短展肌肌力定量测定是判断腕管综合征严重程度、评定疗效的一个良好的客观指标。     

Utility of the central motor conduction time recorded from the abductor pollicis brevis and the abductor digiti minimi muscles in patients with C6–7 myelopathy

Objective: Central motor conduction time (CMCT) recorded from the abductor pollicis brevis (CMCT-APB) and abductor digiti minimi (CMCT-ADM) muscles may enable the evaluation of patients with C6–7 myelopathy. CMCT is more useful for the evaluation of the function of spinal cord than magnetic resonance imaging (MRI) findings. CMCT may be associated with age and height. However, there are few reports regarding CMCT-APB in normal subjects. This study aimed to investigate the relationships between age, height, and conduction parameters in normal subjects to assess the effectiveness of using CMCT-APB and CMCT-ADM for the evaluation of patients with C6–7 and C7–T1 myelopathy.

Design: Retrospective study.

Methods: Fifteen patients with cervical compressive myelopathy at C6–7 (11 patients) or C7-T1 (4 patients) level were enrolled. The control group consisted of 150 normal subjects (mean age 45.8±17.0 years; mean height 163.6±8.9?cm). Motor evoked potentials induced by transcranial magnetic stimulation and F-waves were used to determine CMCT.

Outcome measures: CMCT-APB, CMCT-ADM.

Results: The normative values of CMCT-APB and CMCT-ADM were 5.3±0.7?ms and 5.2±0.8?ms, respectively. CMCT-APB was significantly longer than CMCT-ADM for patients with C6–7 myelopathy (P < 0.05). Neither of the CMCTs for those with C7–T1 myelopathy were significantly different from those of controls, but CMCT-APB was more prolonged than CMCT-ADM in patients with C6–C7 myelopathy.

Conclusions: CMCTs improve the accuracy of the diagnosis of myelopathy by pinpointing the lesion in combination with MRI imaging. Selective CMCT-APB prolongation may be seen in patients with C6–7 myelopathy but not C7-T1 myelopathy.     

Anatomy and function of the thenar muscles

The four thenar muscles make up the intrinsic muscles of the thumb. They include the abductor pollicis, adductor pollicis, opponens pollicis, and flexor pollicis brevis. Thumb motion is facilitated through the coordination of these intrinsic muscles. The thumb musculature dynamically allows for precision pinching ad power gripping.     

Reprint: Sehnentransfers in der Vorfußchirurgie

The aim of the current forefoot surgery is to retain function or to restore lost function. In contrast, in the past resection arthroplasty or amputation of the lesser toes were common. Included in the repertoire of every specialist are different operation techniques especially the tendon surgery, in addition to experience in indication and rehabilitation. It is important, that the focus during history taking, clinical examination and choice of treatment should not only be on the forefoot but also on the axis of the leg and the hindfoot position and function. As an example, the recruitment of the extensor digitorum longus – meaning the excessive support by the toe extension for forefoot extension – over time results in hammer toes. In some cases this excessive recruitment is the result of the rupture of the tibialis anterior tendon. Therefore, one should address the cause and repair the tibialis anterior tendon by suture and/or augmentation and not operate on the hammer toes in isolation.     

后推、减张、缩咽综合手术修复腭裂

为修复腭裂畸形1992年1月以来,应用硬腭粘膜瓣后推,软腭鼻腔粘膜 Z 成形术,腭帆提肌吊带重建,颊肌粘膜瓣移转修复硬腭裂隙及腭部创面,选择性地施行去神经的(足母)短伸肌游离移植行腭咽环扎等综合手术,修复20例腭裂及腭裂术后腭咽闭合不全患者,效果满意。     

后推、减张、缩咽综合手术修复腭裂

为修复腭裂畸形１９９２年１月以来，应用硬腭粘膜瓣后推，软腭鼻腔粘膜Ｚ成形术，腭帆提肌吊带重建，颊肌粘膜瓣移转修复硬腭裂隙及腭部创面，选择性地施行去神经的　短伸肌游离移植行腭咽环扎等综合手术，修复２０例腭裂及腭裂术后腭咽闭合不全患者，效果满意。     

Riche-Cannieu吻合支再支配作用的初步研究

目的 了解Riche-Cannieu吻合支(尺神经深支与正中神经返支在手掌中的变异吻合支)在正中神经损伤时对拇短展肌是否存在再支配作用. 方法 收集病例共43例(男29例,女14例,年龄14 ～ 57岁,平均32.6岁),均符合以下条件:(1)前臂及前臂以下外伤所致的正中神经损伤(临床以及电生理检测证实).(2)神经电生理检测证实RCA存在,电位波幅小于1mV.(3)除外合并其他神经损伤或神经系统疾病及颈椎病、糖尿病.分别在损伤2～3周内、2～4个月内、1年之后进行患肢正中神经电生理检测,评估神经功能. 结果 43例正中神经中在临床与电生理方面均无明显恢复;8例拇指外展功能在3个月之内明显好转,相应Riche-Cannieu吻合支的CMAP波幅明显增高,相应拇短展肌的肌电图明显好转. 结论 在正中神经损伤合并存在RCA的情况下,失去正中神经支配的拇短展肌肌纤维有可能逐渐获得RCA纤维的再支配;这种再支配的速度大于一般受损神经的再生速度.     

Evaluation of twitch responses obtained from abductor hallucis muscle as a monitor of neuromuscular blockade: Comparison with the results from adductor pollicis muscle

The twitch responses evoked from the abductor hallucis muscle (AHM) and the adductor pollicis muscle (APM) were examined simultaneously in 20 anesthetized patients following a single bolus intravenous administration of 0.04 mg·kg⁻¹ of vecuronium bromide. The mean onset time of vecuronium-induced depression of AHM twitch responses was significantly slower than that of APM twitch responses (4.9±1.5 minvs 3.7±1.2 min, mean±SD,P<0.001), and when the clinical duration times of vecuronium were compared, AHM twitch responses recovered more quickly than APM twitch responses (15.3±4.1 minvs 19.6±6.7 min,P<0.01), although there was no statistically significant difference in the spontaneous recovery time between AHM and APM (9.8±2.9 minvs 10.0±3.6 min). It is concluded that the twitch responses of AHM may be a useful monitor of neuromuscular blockade in anesthetized patients in whom setting the blockade monitor on the patient's arms is difficult, although monitoring of twitch response of AHM is less sensitive than that of APM in case of vecuronium administration.