脑瘫足下垂畸形改良手术治疗效果观察

肢体痉挛性瘫痪是脑瘫中最常见的一种类型，其中足部畸形以足下垂多见，以往多采用单纯跟腱延长术治疗，但术后复发率较高。1985年1月-1992年12月，我们采用跟腱延长加部分胫神经肌支切断术治疗脑瘫足下垂畸形，与同期单纯跟腱延长术比较，步态明显改善，复发率明显降低。     

医源性腓总神经损伤16例分析

腓总神经在膝部外侧绕腓骨颈前方下行、位于皮下,保护组织薄弱极易损伤,在医源性损伤中比重较大,仅次于桡神经损伤。2002年4月-2010年10月,我们共收治因医疗活动而发生的腓总神经损伤16例。现分析报告如下。     

高位腓总神经损伤7例报告

坐骨神经自梨状肌出口处于大腿后方中下1/3交界处发出,由于胫神经与腓总神经未完全分支或分支后距离很近,外伤后单纯腓总神经损伤而胫神经无改变的病变并不多见,本科自 1993年～1998年共收治上述病例7例,诊断明确,治疗结果满意。     

自体压迫性腓总神经损伤1例

周围神经损伤无论平时或战时都很常见,尤其是腓总神经由于解剖位置表浅、固定,临床上多见于膝部外伤,也见于窝内肿物压迫或体位不当等,而由于体位不当引起的腓总神经损伤又称为自体压迫性腓总神经损伤,临床上较少见,我院曾收治1例,经治疗后恢复良好,现报告如下。1临床资料患者,男,22岁。因右小腿、足背外侧麻木,右踝及足趾背伸乏力1个月余入院。自诉训练后第2日晨起时无明显诱因感右小腿、足背外侧麻木,右踝及足趾背伸乏力,患者无明显暴力外伤史,曾在当地医院予以保守治疗后效果欠佳,转入我院。入院查体:跨阈步态,右膝及右小腿无畸形及明显…     

用改良跟腱瘢痕瓣治疗瘢痕挛缩性足下垂11例

目的总结烧伤后瘢痕挛缩性足下垂的临床治疗经验。方法对跟腱瘢痕瓣进行改良设计,不切开内侧瓣内缘切口,内侧瘢痕瓣不游离,借助辅助横切口,将踝关节复位,同时观察早期烧伤创面的不同处理方法和伤后至手术时间的长短对功能复位的影响。结果改良跟腱瘢痕瓣同样能达到踝关节复位至功能位的要求,并且内侧瓣不易坏死;早期切痂者较削痂和自愈者瘢痕瓣坏死率高,病程在2年以上患者复位后效果较病程在0.5~2年患者的差。结论改良跟腱瘢痕瓣血供丰富,挛缩的跟腱易于松解,安全性高;对烧伤早期切痂者手术时应慎重,手术时机最好在伤后1年左右。     

足后内侧松解胫前肌外移治疗小儿先天性马蹄内翻足

作者以足后内侧松解胫前肌外移术治疗小儿先天性马蹄内翻足31例53只足。随访4年9例17只足,随访6年16例26只足,外形满意,踝关节和足的各项活动基本正常,足能放平走路,检查患儿鞋底磨损与正常儿童鞋底磨损无明显差别。总优良率93％。     

腰椎间盘突出症术后迟发性足下垂1例

<正>1临床资料患者女性,47岁。于2014年11月28日因"腰痛伴右下肢放射痛2年,症状加重5 d"入院,患者于两年前开始无明显诱因,出现下腰背酸痛,伴右下肢放射痛,行走时右大腿后侧及小腿外侧酸痛麻木,咳嗽时症状加重,卧床休息后可缓解。行不规则腰椎牵引、腰背部理疗及口服药物消炎止痛治疗,症状时好时坏,但无法完全缓解。入院5 d前上述腰腿痛症状突然加重,无法行走,口服药物消炎止痛治疗无效果,     

电针胫骨前肌运动点治疗脑卒中后足下垂的临床疗效观察

目的：通过电针胫骨前肌运动点复合康复训练治疗脑卒中后足下垂,观察患者胫骨前肌肌力及下肢运动功能,验证电针运动点提高肌力方案的临床疗效,为临床治疗脑卒中后足下垂探索一种安全有效的新方案。方法随机将20例脑卒中后足下垂患者分为观察组和对照组,两组均进行常规康复治疗,观察组在此基础上采用电针胫骨前肌运动点治疗4周后,对患者进行患侧踝关节主动背屈关节活动度（AROM）测量,患侧胫骨前肌表面肌电积分（iEMG）测量,简式Fugl-Meyer量表（FMA）下肢运动功能评定。结果治疗前后两组患者踝关节主动背屈ROM变化无统计学意义（P﹥0.05）;治疗前后两组胫骨前肌iEMG变化、FMA评分有统计学意义（P﹤0.05）。结论电针胫骨前肌运动点可改善脑卒中后患者足下垂。在常规康复治疗基础上加用电针胫骨前肌运动点治疗可提高脑卒中患者下肢步行功能。     

膀胱截石位致腓总神经损伤2例分析

回顾性分析2例泌尿系腔镜手术腓总神经损伤患者的临床资料。膀胱截石位导致腓总神经损伤的主要原因是不正确的体位使膝关节长时间外旋、外展使神经损伤或局部受压。熟悉腓总神经的解剖特点,加强泌尿系腔镜手术患者围手术期的管理,提高手术医师的操作水平,可以避免损伤腓总神经。     

选择性胫神经显微切断术矫治中枢神经外伤后足痉挛畸形

目的　探讨选择性胫神经显微切断术 (SMTN)对中枢神经外伤后遗足痉挛的作用、适应证等。方法　对 2 3侧脑和脊髓外伤后遗足痉挛施行SMTN。手术在双极电刺激辅助下选定胫神经的痉挛责任支 ,显微外科技术部分切断。结果　随访 6～ 17个月 ,87%的马蹄足、90 %的足内翻、80 %的足趾强直屈曲和 73 %的踝阵挛获完全矫正 ;90 %以上患者的足自主运动能力和整体运动功能得到改善。结论　SMTN可解除足痉挛、矫正畸形 ;由于痉挛肌与其拮抗肌张力之间重新平衡及所谓“远程效应” ,术后整个患肢乃至全身运动功能均不同程度地改善 ;中枢神经外伤后遗痉挛限于足或明显以足痉挛为主者是SMTN的理想适应证。该术应在足痉挛演变成肌腱挛缩或关节强直之前施行。     

Surplus value of implanted peroneal functional electrical stimulation over ankle-foot orthosis for gait adaptability in people with foot drop after stroke

BackgroundImplanted peroneal functional electrical stimulation (FES) is an effective alternative treatment to ankle-foot orthosis (AFO) in people with drop foot after stroke. With FES no constraints on ankle mobility are imposed which might particularly be exploited in challenging walking environments that require adaptations of the gait pattern to environmental disturbances.Research questionIs gait adaptability, by means of the capacity to avoid sudden obstacles while walking on a treadmill, superior with implanted FES compared to AFO in people with drop foot after stroke?MethodsA 4-channel peroneal nerve stimulator (ActiGait®) was implanted in 22 persons with stroke (>6 months) who regularly used an AFO. Gait adaptability was tested with an obstacle avoidance task on an instrumented treadmill up to 26 weeks (n = 10) or 52 weeks (n = 12) after FES-system activation. At assessments, 30 trials, in which obstacles were suddenly dropped onto the treadmill in front of the paretic leg, were recorded with each device (FES / AFO). Trials were grouped by available response times (ART) and success rates were calculated. The effect of device, ART and follow up time on success rates was tested using generalized estimated equations. Nonparametric correlations were calculated to associate changes in success rates with clinimetrics.ResultsSuccess rates of obstacle avoidance were higher when participants used their FES system compared to AFO (Δ4.7%, p = 0.03), which effect was largest for longest ARTs (Δ15%, p = 0.03). Participants with greater motor impairment of the paretic leg showed greater benefit from FES (r_s=-0.49, p = 0.04).SignificanceFES has been found equally effective as AFO in improving walking speed of people with drop foot after stroke. We now present superior walking performance in a complex walking environment for implanted peroneal FES compared to AFO. These findings underline the importance of using gait assessments that require interplay with the environment, besides assessment of stationary walking, in community ambulators.     

Extrinsic foot muscle forces and joint contact forces in flexible flatfoot adult with foot orthosis: A parametric study of tibialis posterior muscle weakness

BackgroundThe posterior tibialis tendon dysfunction (PTTD) is typically associated with progressive flatfoot deformity, which could be alleviated with foot orthosis. However, the evaluation of tibialis posterior (TP) weakness on lower limb mechanics of flatfoot adults with foot orthoses is scarce and requires further investigation.Research questionThis study aimed to examine the effects of TP weakness on lower limb mechanics in flatfoot adults with foot orthosis through gait analysis and musculoskeletal modelling.MethodsFifteen young adults with flatfoot were recruited from University to perform a gait experiment with and without foot orthoses. Data collected from the motion capture system were used to drive the musculoskeletal modelling for the estimation of the joint force and extrinsic muscle forces of the lower limb. A parametric analysis was conducted by adjusting the TP muscle strength from 40 % to 100 %. Two-way repeated measures ANOVA was used to compare the peak extrinsic foot muscle forces and joint forces among different levels of TP weakness and insole conditions.ResultsTP weakness significantly increased ankle joint force superoinferiorly (F = 125.9, p < 0.001) and decreased anteroposteriorly (F = 125.9, p < 0.001), in addition to a significant increase in the muscle forces of flexor hallucis longus (p < 0.001) and flexor digitorum longus (p < 0.001). Besides, the foot orthosis significantly reduced most peak muscle forces whilst significantly reduced the second peak knee force and peak ankle force compared to the control condition (F = 8.79–30.9, p < 0.05).SignificanceThe increased extrinsic foot muscle forces (flexor hallucis longus and flexor digitorum longus) and ankle joint forces in the TP weakness condition indicated that TP weakness may induce compensatory muscle activation and attenuated joint load. The abnormal muscle and joint mechanics in flatfoot adults with TP weakness might be restored by the orthosis.     

Peroneal nerve palsy following knee dislocation: pathoanatomy and implications for treatment

Peroneal nerve palsy following knee dislocation is a serious problem, and neurolysis at the time of knee reconstruction does not always result in return of peroneal nerve function. We describe peroneal nerve pathoanatomy in three patients in whom late exploration of the peroneal nerve was performed because of ongoing absence of ankle dorsiflexion. We identified frank nerve rupture in two patients and a lengthy neuroma in continuity in one which extended far proximal to the fibular head and well above the previous surgical incision used for peroneal nerve neurolysis at the time of knee reconstruction. In light of the current state of microneural surgery and the potential to reconstruct nerve defects, we discuss how our findings impact on treatment, and provide recommendations which may improve recovery of peroneal nerve function in future cases. Received: 26 October 1999/Accepted: 5 January 2000     

Relationship between foot muscle morphology and severity of pronated foot deformity and foot kinematics during gait: A preliminary study

BackgroundThe morphology of foot muscles that support the medial longitudinal arch differs between normal and pronated feet. The degree to which the difference depends on the severity of the pronated foot deformity is unclear. In the clinical setting, however, to reduce the pronated deformity, muscle-strengthening exercises are performed.Research questionDoes a relationship exist between foot muscle morphology and severity of the pronated foot deformity and foot kinematics during gait?MethodsUsing the six-item foot posture index (FPI-6), 26 study participants were assessed for their foot posture and divided into two groups of 13 participants each based on the FPI-6 score: pronated foot group (with a score of 6–9) and highly pronated foot group (with a score of 10–12). Select foot muscles were scanned with ultrasonography, and muscle thicknesses were measured. The following were the muscles of interest: abductor hallucis, flexor hallucis brevis and longus, flexor digitorum brevis and longus, and peroneus longus. Foot kinematic data during gait was collected using a three-dimensional motion capture system as a dynamic navicular drop.ResultsNo between-group differences were noted for muscle thickness and dynamic navicular drop. However, the abductor hallucis and flexor hallucis brevis thicknesses were correlated with the dynamic navicular drop, but not with the severity of the pronated foot deformity.SignificanceIn individuals with pronated foot deformity, more developed abductor hallucis and flexor hallucis brevis muscles may reduce the dynamic navicular drop that represents the degree of medial longitudinal arch deformation during the stance phase of gait.     

Changes in muscle moment arms following split tendon transfer of tibialis anterior and tibialis posterior

Moment arms of tibialis anterior (TA) and tibialis posterior (TP) about the subtalar and talocrural joint axes were measured in anatomic specimens both before and after split tendon transfers. These procedures are commonly performed to correct hindfoot varus, a gait deformity that is often seen in patients with cerebral palsy, stroke, and brain injury. Split tendon transfer significantly reduced the inversion moment arms of tibialis anterior and tibialis posterior at all subtalar joint angles except for the most everted position in the case of TA. Changes in subtalar joint moment arms produced by split tendon transfer, especially those seen in TA, were variable, suggesting that the procedure may be susceptible to technical errors, especially related to balancing tensions in the medial and lateral tendon halves. Talocrural joint moment arms of both muscles were preserved following split tendon transfer. This study presents the first measurements of the moment arms of split transferred muscles. These characterizations of the mechanics of split tendon transfer will aid in the planning and assessment of these procedures.     

视神经损伤治疗和不全损伤再生研究的回顾

临床的视神经损伤可发生在从球后到颅内的各段。造成严重损伤必须具备足够的致伤力度。伤后无光感的预后差。视神经管减压手术效果不肯定。大剂量皮质类固醇治疗可能有帮助。视神经不完全损伤模型研究提示,视神经再生能力与损伤程度密切相关。不全损伤与完全损伤对于损伤的纤维其再生环境是不同的。在不全损伤时,不可逆损伤纤维可能有更强的再生能力。     

Ilizarov技术矫正儿童骨骺损伤后踝内翻畸形

儿童踝骨骺损伤后容易遗留踝内翻畸形,导致疼痛、肢体不等长、创伤性关节炎发生。通过微创截骨,根据旋转成角中心(CORA)原则使用Ilizarov环形外固定矫正,能够获得满意的力线和肢体长度,同时能处理其邻近骨、关节和软组织的病变,治疗后踝的外形和功能都非常满意。使用Ilizarov技术矫正此类畸形,可控性好、创伤小、并发症少。     

腓肠神经营养血管远端蒂皮瓣治疗足踝部软组织缺损

目的：探讨腓肠神经营养血管远端蒂皮瓣治疗足踝部软组织缺损的效果。方法：以小腿腓肠神经营养血管为蒂设计并切取皮瓣,逆行转移修复踝部、足跟部、足背及足内侧皮肤软组织缺损26例。结果：26例皮瓣中除1例修复前足内侧皮瓣远端发生脂肪液化外,余25例皮瓣全部成活。随访1~12个月,皮瓣色泽、质地、弹性良好,无破溃发生。结论：腓肠神经营养血管蒂皮瓣是修复踝部、足跟部、足背及足内侧皮肤软组织缺损的理想方法。     

腓肠神经营养血管皮瓣修复外伤性小腿及足部骨外露:15例临床报告

目的总结应用腓肠神经营养血管皮瓣修复小腿及足部骨外露的临床效果及经验。方法回顾性分析2010年10月至2015年10月中国医科大学附属第一医院整形外科收治的15例外伤性小腿及足部股外露患者的临床资料。其中,胫骨外露10例,足跟骨外露5例;软组织缺损面积为6 cm×9 cm~9 cm×12 cm。所有缺损均采用腓肠神经营养血管皮瓣修复。结果本组14例皮瓣完全成活,1例局部坏死,最终瘢痕愈合。术后随访6~12个月,供受区愈合良好,无明显的功能障碍,临床效果满意。结论腓肠神经营养血管皮瓣血供丰富,手术设计灵活,同时皮瓣内带有感觉神经,保证了皮瓣感觉,是修复小腿及足部骨外露的有效方法。     

76例骨间背侧神经损伤特点及手术治疗初探

 目的 总结骨间背侧神经损伤的特点及诊治经验和体会。方法 对1975年以来手术治疗并获随访的76例进行分析,按国际上通用的BMRC神经损伤修复综合评价标准进行疗效评价。结果 平均随访5a4个月。优49例,占64.47％;良22例,占28.95％;可5例,占6.58％;无差级病例。优良率93.42％。结论 骨间背侧神经损伤修复后效果良好。无法行神经修复者,采用神经肌肉植入或屈肌腱移位伸肌功能重建亦可取得满意疗效。