第2足趾重塑后再造拇指的临床研究

目的探讨重塑第2趾后再造拇指的新术式。方法对12例再造手指,利用第2跖背动脉或第2趾底总动脉在第3足趾发出的分支的血管,设计局部转移皮瓣,将其嵌入第2足趾中节的腓侧,以增加第2足趾的周径;利用趾背动脉之间、趾背与趾足底动脉之间、趾足底动脉之间存在的吻合,设计趾腹皮瓣,将其嵌入第2足趾跖侧,消除再造手指狭细的形态;将第2足趾整形后,再移植于手部,再造拇指。结果 12例18指,32个局部转移皮瓣全部成活,供区第3足趾血运无影响,再造手指外形非常满意。结论以第2、3足趾局部转移皮瓣将第2足趾整形,再进行拇指再造,此法是改善再造手指外形的良好方法 。     

足背动脉和跖背动脉走行变异1例

足背动脉走行变异和跖背动脉解剖变异有文献报道 ,我们在游离第二足趾移植再造手指手术中 ,遇到一例足背动脉和跖背动脉走行变异的特殊病例 ,报道如下。病人男性 ,16岁。因右手示、中指外伤性缺如入院。 2 0 0 3年 3月 16日行游离双足第二足趾移植再造右手示、中指手术。切取右足第二足趾时见足背动脉走行于足背的正常位置 ,第一跖背动脉近端走行于骨间肌的深层 ,向远端走行逐渐浅出 ,在跖骨头横韧带的浅层分出趾和第二足趾的趾背动脉。切取解剖左足第二足趾时 ,首先在跖骨间隙和趾蹼处解剖显露跖背动脉 ,发现第一跖背动脉缺如 ,在跖骨头…     

足背动脉移植手指再造与其解剖变异

背景:以足背动脉为血供的第二足趾和拇甲瓣移植再造手指在临床有广泛的应用,但有的患者足背动脉出现解剖变异,给手术过程带来了困难,第2套供血系统的发现——第一跖底动脉和第二趾背动脉解决了这一问题。目的:分析游离第二足趾移植拇甲瓣移植手指再造及其足背动脉变异的临床意义。方法:游离第二足趾及拇甲瓣再造拇指15例,术中运用第2套供血系统——第一跖底动脉和第二趾背动脉。功能评估参照中华医学会手外科学会拇手指再造功能评定试用标准(2005-3-25),由患者根据再造拇指长度、外形、功能及感觉的恢复情况进行评估。结果与结论:再造拇指全部成活,无移植并发症,随访5个月～2年,再造拇指功能恢复好,长度合适,感觉恢复好,按手外科学会再造指功能评定标准,优良率93%,外形满意,复查供趾足,外形尚好,步态平稳,步行无疼痛。提示充分做好移植前准备,术中无创操作,移植后仔细观察,熟悉足部解剖特别是足背动脉变异,以及第2套供血系统的解剖是确保拇指再造成功的关键。     

改形趾甲皮瓣与第2足趾联合移植再造拇指术的解剖学基础

目的为改形趾甲皮瓣与第2足趾联合移植再造拇指手术提供解剖学基础。方法对10例20侧红色乳胶灌注的成人足标本(其中新鲜足标本5例10侧)进行显微解剖,观测营养趾甲皮瓣、第2足趾骨皮瓣血供。结果趾甲皮瓣的血供为多源性,主要为趾腓侧趾底动脉和趾趾背动脉,二者外径分别为(1.5±0.3)mm、(0.9±0.2)mm;趾甲皮瓣静脉为大隐静脉-第一跖背静脉-趾腓侧趾背静脉;神经为趾腓侧固有神经和腓深神经。剔除第2足趾甲皮瓣的第2足趾骨皮瓣血供为第2足趾胫侧趾底、趾背动脉,外径分别为(0.7±0.1)mm、(0.3±0.1)mm;静脉为大隐静脉-第一跖背静脉-第2足趾胫侧趾背静脉;神经为第2足趾胫侧趾底固有神经。结论趾腓侧趾底动脉、趾趾背动脉及第2足趾胫侧趾底、趾背动脉起始、走行恒定,外径较粗,有较多皮肤穿支和恒定血供范围,可为改形趾甲皮瓣与第2足趾联合移植再造拇指手术提供理想的血供。     

双足第2趾皮瓣瓦合修复手指Ⅰ度脱套伤

目的 探索游离足第2趾甲背皮瓣联合对侧第2趾胫侧皮瓣瓦合修复单手指Ⅰ度脱套伤的临床效果.方法 2009年3月至2012年6月,我科采用游离足第2趾甲背皮瓣联合对侧第2趾胫侧皮瓣瓦合修复单手指Ⅰ度脱套伤13例13指,并进行了随访.结果 本组13例13指移植瓦合的皮瓣全部成活,经过6～24月随访,皮瓣颜色与正常手指相同,皮瓣无明显萎缩及色素沉着,除1例外形欠佳外,其余12例外形美观,13例指甲均生长良好,感觉恢复2-PD 6～10 mm,术后经理疗和功能锻炼,远指间关节伸屈活动良好,参照中华医学会手外科学分会拇、手指再造功能评定试用标准评定:优8指,良4指,可1指,优良率为92.3％,供区植皮全部成活,无瘢痕挛缩,无破溃,足趾无垂趾畸形,足部活动无影响.结论 游离足第2趾甲背皮瓣瓦合对侧足第2趾胫侧皮瓣是修复单手指Ⅰ°脱套伤的一种理想方法.     

𧿹趾腓侧皮瓣在1、2趾和2、3趾并趾分趾术中的应用

目的 探讨𧿹趾腓侧皮瓣应用于并趾分趾术的可行性及临床效果。方法 回顾性分析2014年6月—2017年6月山东大学第二医院手足外科收治的24例并趾畸形患者的临床资料。其中男14例,女10例;年龄6~47个月,中位年龄29.2个月。第1、2趾并趾畸形8例,第2、3趾并趾畸形16例。在分趾手术中均应用𧿹趾腓侧皮瓣修复趾蹼部皮肤缺损,所有病例无需植皮。结果 术后24例患儿并趾畸形均得到了矫正,皮瓣均完全成活,分趾后趾蹼的深度和弧度与正常趾蹼相似。术后22例随访3~36个月,平均8.2个月;皮瓣愈合后与周围皮肤无色差;所有患儿术后足趾功能良好,与健侧对比足趾功能无明显差别,术后无严重并发症出现。结论 𧿹趾腓侧皮瓣可用以修复第1、2趾和第2、3趾并趾分趾术中的软组织缺损,术中无需植皮,术后趾蹼外形满意,用于先天性并趾畸形分趾手术中安全而有效。     

带拇趾腓侧皮瓣第2足趾移植再造修复手拇指缺损

目的探讨用(足母)趾腓侧皮瓣修饰第2足趾移植再造拇指的新方法。方法对16例手拇指缺如病人,在切取第2足趾再造拇指时,携带足母趾腓侧皮瓣,并将其嵌入第2足趾跖侧,消除第2足趾中段狭细的形态。-结果16例再造的拇指及携带的皮瓣全部成活,再造拇指外形非常满意,感觉恢复良好。结论足母趾腓侧皮瓣嵌入第2足趾,使再造拇指外形更接近正常的拇指。     

第二足趾第二套血供系统的探讨

在第二足趾移植时,所使用的血管蒂为第一跖背动脉,当第一跖背动脉出现变异时,往往造成足趾移植后血循危象及失败。据上海第一医学院附属华山医院200例足趾移植的经验,对足趾移植中血管变异处理时采用第二套血供系统取得良好效果。为此,本文用80只经动脉灌注红色乳胶的成人足标本,观测了第二跖背动脉,第一跖底动脉和第二跖底动脉的起源、行程、位置及第二跖背动脉与第二趾底总动脉在趾蹼处的分支吻合类型(外加13侧足部动脉铸型标本),对提供第二套血供系统作了解剖学的研究。提出第二套供血系统应首选第二跖背动脉。第一、二跖底动脉的位置深,在跖趾关节附近与周围结构紧密愈着,不易剥离,易遭损伤,作为第二套血供的血管蒂时,手术操作的难度较大。     

第一趾蹼逆行岛状皮瓣修复趾端损伤的解剖学基础

在35只经动脉灌注红色乳胶的成人足标本上和23只足血管铸型标本上,解剖观察了第一趾蹼皮瓣的血管分支分布和吻合。第一跖背动脉在趾蹼间隙处与第一跖底动脉或趾底动脉间有吻合支相连,吻合支外径平均0.7mm,有伴行静脉。以此吻合支为蒂,第一跖背动脉为轴,可设计第一趾蹼逆行岛状皮瓣修复趾背、趾底和足底远端组织缺损。文中对皮瓣的血供、静脉回流、皮瓣的设计等进行了讨论。     

吻合趾底动脉的足拇趾腓侧皮瓣修饰性修复手指指腹缺损

目的探讨应用吻合趾底动脉的足拇趾腓侧皮瓣修饰性修复手指指腹缺损的治疗方法和临床效果。方法自2014年3月至2019年3月,应用吻合趾底动脉的足拇趾腓侧皮瓣移植的方法,对东部战区总医院秦淮医疗区收治的21例手指指腹缺损患者进行修复。术后按功能活动度、再造指力量、感觉测定、手使用情况进行评定。结果20例皮瓣均一期成活。1例皮瓣出现血管危象,经手术探查,皮瓣成活。足拇趾供区或直接缝合或植皮修复。术后随访3~12个月,皮瓣质地良好,两点辨别觉为4~6 mm,手指外观及功能恢复满意,按中华医学会手外科学会上肢功能评定标准评价:优19例,良1例,可1例,优良率为95.2%。足拇趾外观良好,行走等不受影响。结论足拇趾腓侧皮瓣感觉恢复良好、外形逼真、带罗纹,达到修饰性修复目的,且对足部供区影响小,是修复手指指腹缺损的理想皮瓣。     

Toe Deformity of a Gilt-Bronze Pensive Bodhisattva Statue

I recently visited the National Museum of Korea, where I viewed two pensive Bodhisattvas in the Room of Quiet Contemplation. Among the two gilt-bronze statues, one was familiar to me since I previously wrote about Bodhisattvas’ face, which has a hint of a smile that exhibits a sense of serene concentration and gives the viewer the impression of an aura of deep thought.1 In Buddhism, any person who is on the path towards Buddhahood (the condition and rank of a Buddha, awakened one) is called a ‘Bodhisattva’. This time I focused on the cross-leg sitting and bare right foot, where I observed hyperextension of the first metatarsophalangeal joint and flexion of the interphalangeal joint of the pensive Bodhisattva (National Treasure 83, Fig. 1).Open in a separate windowFig. 1Pensive Bodhisattva (Korean National Treasure 83). Note the hyperextension of the first metatarsophalangeal joint and flexion of the interphalangeal joint of the hallux.It is well known that Siddhartha Gautama (Buddha, c. 6th to 5th century BC or c. 5th to 4th century BC) founded Buddhism. Before the expedition of Alexander the Great (356-323 BC) to the East, people in eastern Asia thought that transcendent beings like God could not be expressed as human figures. Thereafter, Buddhists did not make any statues of the Buddha; instead, they made stupas, which contained small crystals believed to be derived from Buddha’s cremated remains. There was an approximately 500-year period when the Buddha was not represented as a figure. Later, as the Greek culture was transmitted to the East, the first statue of Buddha appeared in the Gandhara region. The resulting statues were influenced by ancient Greeks’ pursuit of ideal beauty, which they perceived as arising from harmony and balance.Buddhism was transferred to China through the Silk Road in the 1^st century AD, and then to the Three Kingdoms of Korea in the 4^th to 6^th century AD. The above-described pensive Bodhisattva statue was produced in the late 6^th century in Shilla kingdom.This statue (National Treasure #83) of the pensive Bodhisattva differs from the classic contemplative pose with one leg perched up on the other knee and the fingers of one hand raised against the cheek. This pose is derived from the image of the young Indian Prince Siddhartha Gautama contemplating the nature of human life, which is quite common in Buddhist sculpture. In China, such pensive statues were most widespread in the 5^th and 6^th centuries, but in Korea they were most frequently produced in the 6^th and 7^th centuries.In both Korea and Japan, however, the pensive Bodhisattva is generally considered to depict the Maitreya Bodhisattva (known as the future Buddha). This iconography is thought to reflect the Sutra on the Descent of Maitreya, in which the Maitreya follows a similar path in life as that of Prince Siddhartha.Normally, it is impossible to hyperextend the first metatarsophalangeal joint and flex the first interphalangeal joint with the remaining toes in neutral position. In a close look, a shallow groove can be seen on the medial border of the big toe and metatarsophalangeal joint. The statue definitely shows a deformity of the right big toe, known as the hallux hammertoe (hallux malleus) or claw toe.A question then arises regarding why the artist who made this statue (600-650 AD) made a ‘deformed’ toe in a sacred statue of the future Buddha. A likely interpretation is that the model for the statue, who was believed to be a Buddhist nun or monk, had that deformity. Then, we may ask—why did that Buddhist nun or monk have a toe deformity?A recent article could provide an answer to this question. A cross-sectional survey was conducted in combination with foot and ankle examinations of monks living in northern Thailand. In the 208 monks who were included, common foot and ankle problems were callosity (70.8%), toe deformities (18.2%), plantar fasciitis (13.4%), metatarsalgia (3.8%), and numbness (2.9%). Commonly found toe deformities included hallux valgus and claw toe. Hallux valgus was found in 14.4% of Thai monks and claw toe in 4.3%. The reasons for monks’ foot deformities are as follows: 1) Thai monks usually walk without wearing shoes for long periods of time each day, causing increased pressure on the plantar surface of the foot. The push-off and heel-strike phases during barefoot walking create high pressure on the forefoot and heel, respectively; 2) Monks walk in rural areas that do not have smooth surfaces or on concrete or dirt roads. High contact pressure on the plantar aspect of the foot results in callosity; 3) Monks cease wearing shoes when they are ordained. Prior to that, their feet usually have not been accustomed to barefoot walking. Callosity and toe deformities were associated with prolonged barefoot walking over extended periods since ordainment (P < 0.05).2Based on this article, we infer that the early 7^th-century Buddhist monks, who practiced strict asceticism, walked barefoot like the Theravada monks in present-day Thailand (Fig. 2). Through the enigmatic smile, we also can conjecture that the Buddhist monks were happy and ‘awakened’ despite their foot deformity caused by their barefoot training.Open in a separate windowFig. 2Buddhist monks, who practiced strict asceticism, walked barefoot. This type of walking causes foot deformity (hallux hammertoe or claw toe).These deformities can now be improved by surgery. If the hallux hammertoe or claw toe is flexible, a tendon release may be helpful. If the deformity is rigid, joint fusion or arthroplasty may be needed to straighten the big toe.     

正常人足趾甲襞微循环检测

目的:通过检测正常人足趾甲襞微血管,分析国人正常足趾甲襞微循环形态、流态和袢周状态的特点,为临床足趾甲襞微血管的评价提供依据。方法:用微循环检测仪及其图像分析系统,观测正常人双足趾甲襞微血管形态、流态、袢周指标。结果:正常人双足趾甲襞各项指标检查结果无明显差异,其中管袢数目和长度范围分别在4.33～5.67条/mm和70.94～155.92μm之间;输入支管径、输出支管径和袢顶直径范围分别在5.50～10.50μm、8.03～12.41μm和7.64～12.66μm之间。84.61%的正常人双足趾血流速度≥400μm/s,15.39%的血流速度在300～399μm/s之间;88.46%的正常人双足趾红细胞聚集和渗出为无或轻度,11.54%的红细胞聚集和渗出为中度;所有正常人双足趾的血管运动性为0～4次/min,乳头下静脉丛≤2排,皮肤乳头为波纹状或浅波纹状,且均未见白微栓和出血。结论:足趾是活体微循环观测的良好部位,其左、右足趾微血管形态、微血流流态、微血管袢周状态无明显差异。     

(足母)甲皮瓣术(足母)趾侧皮肤及创面植皮坏死原因的解剖学分析

在55只灌注红色乳胶足标本和13只塑料血管铸型足标本上,研究了(?)趾胫侧皮肤的血供来源。分析了施行(?)甲皮瓣术,破坏了大部分来自(?)趾跖侧和背侧的血供来源后,残留的(?)趾胫侧皮肤,主要靠第一跖骨头内侧血管网供养。本文依据解剖学基础,提出改变手术切口,扩大第一跖骨头内侧血管网血供来源的建议,可以减少该部的皮肤坏死。     

蓝趾综合征的诊治体会

目的 总结蓝趾综合征的临床诊断及治疗经验.方法 2004-01～2007-01我院共收治12例,分别依据临床特殊性表现,多功能周围血管检查仪.彩超确诊.均采取抗凝、溶栓,改善微循环药物治疗.结果 除1例因入院时趾端已坏疽,而行截趾术痊愈外.余11例经2～3周药物治疗后,临床症状明显好转.结论 蓝趾综合征的及时正确诊断,有效的药物治疗是取得良好临床治疗效果的关键.     

吻合血管腓骨及(足母)长屈肌移植的应用解剖学

在50具(100侧)成年人尸体标本上,对吻合血管的腓骨和(足母)长屈肌复合瓣移植的应用解剖学进行了研究。这个复合组织瓣以腓血管及其伴行的胫神经(足母)长屈肌支为吻接的血管神经蒂,腓动脉外径3.7mm,(足母)长屈肌神经支横径1.6mm。     

Biofeedback Training Effects on Minimum Toe Clearance Variability During Treadmill Walking

A number of variability analysis techniques, including Poincaré plots and detrended fluctuation analysis (DFA) were used to investigate minimum toe clearance (MTC) control during walking. Ten young adults walked on a treadmill for 10 min at preferred speed in three conditions: (i) no-intervention baseline, (ii) with biofeedback of MTC within a target range, and (iii) no-biofeedback retention. Mean, median, standard deviation (SD), and inter quartile range of MTC during biofeedback (45.57 ± 11.65, 44.98 ± 11.57, 7.08 ± 2.61, 8.58 ± 2.77 mm, respectively) and retention (56.95 ± 20.31, 56.69 ± 20.94, 10.68 ± 5.41, 15.38 ± 10.19 mm) were significantly greater than baseline (30.77 ± 9.49, 30.51 ± 9.49, 3.04 ± 0.77, 3.66 ± 0.91 mm). Relative to baseline, skewness was reduced in biofeedback and retention but only significantly for retention (0.88 ± 0.51, 0.63 ± 0.55, and 0.40 ± 0.40, respectively). Baseline Poincaré measures (SD1 = 0.25, SD2 = 0.34) and DFA (α1 = 0.72 and α2 = 0.64) were lower than biofeedback (SD1 = 0.58, SD2 = 0.83, DFA α1 = 0.76 and α2 = 0.92) with significantly greater variability in retention compared to biofeedback only in the long-term SD2 and α2 analyses. Increased DFA longer-term correlations α2 in retention confirm that a novel gait pattern was acquired with a longer-term variability structure. Short- and long-term variability analyses were both useful in quantifying gait adaptations with biofeedback. The findings provide evidence that MTC can be modified with feedback, suggesting future applications in gait training procedures for impaired populations designed to reduce tripping risk.     

Toe flexor muscle spindle discharge and stretch modulation during locomotor activity in the decerebrate cat

In order to investigate the nature (i.e. static or dynamic) of fusimotor drive to the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles during locomotion we recorded Ia and group II muscle spindle afferent responses to sinusoidal stretch (0.25 and 1 mm amplitude, respectively, 4–5 Hz) in a decerebrate cat preparation. FHL Ia and group II afferents generally had increased discharge rates and decreased modulation to stretch throughout the step cycle, compared to rest, suggesting raised static γ drive at all locomotor phases. Although the modulation of Ia afferents was reduced during locomotion, most (13 of 18) showed a clear increasing trend during homonymous muscle activity (extension). This was consistent with phasic dynamic γ drive to FHL spindles linked with α drive. In agreement with previous reports, FHL gave a single burst of EMG activity during the step cycle while FDL α drive had two components. One was related to extension while the other comprised a brief burst around the end of this phase. Typically FDL Ia and group II afferents also had elevated firing rates and reduced modulation at all locomotor phases, again implicating static γ drive. Half the afferents (seven Ia, three group II) showed increased discharge during extension, suggesting phasic static γ drive. There was no γ drive associated with the late FDL α burst. In conclusion, the γ drives to FHL and FDL differed during locomotion. FHL, which has the α drive of a classic extensor, received γ drive that closely resembled other extensors. The γ drive of FDL, which exhibits both extensor and flexor α synergies, did not match either muscle type. These observations are compatible with the view that fusimotor drive varies in different muscles during locomotion according to the prevailing sensorimotor requirements.     

跑者足部形态与足趾及跖趾关节屈肌力量的相关性

目的 探究坐姿及站姿下跑者足部形态与足趾屈曲力量和跖趾关节屈肌力量的相关性.方法 选取26名男性跑者,采用数显游标卡尺、跖趾关节屈肌力量测试仪、屈曲力量计测量足长、截脚长、足宽、足舟骨高度、50％足长处足背高度、跖趾关节屈肌力量、第1和其余四趾屈曲力量.使用偏相关分析足部形态与足部肌力的相关性.结果 校正年龄与身体质量...     

中西医结合三联疗法对股骨头缺血性坏死患者足甲襞微循环的影响

目的:观察中西医结合三联疗法对股骨头缺血性坏死(ANFH)患者足甲襞微循环的影响。方法:60例患者随机分为三组,每组20例。三联治疗组:运用腰交感神经毁损术(LS)、针刀和中药3法同时治疗;针药治疗组:运用针刀加中药同时治疗;中药治疗组:只运用中药治疗。比较三组的临床疗效,并比较治疗前、治疗1周末和治疗结束后患者足甲襞微循环变化。结果:三联治疗组疗效明显优于其它两组(P<0.05或P<0.01)。甲襞微循环比较:三组治疗前各项指标均显著高于正常对照组(P<0.01);治疗1周末三联治疗组微循环较治疗前有明显改善(P<0.05或P<0.01),且三联治疗组各项积分均明显优于其它两组(P<0.05或P<0.01);治疗结束后各组与治疗前相比均有显著性改善(P<0.05或P<0.01),针药治疗组改善幅度明显优于中药治疗组,而三联治疗组改善幅度又明显优于针药治疗组(P<0.05或P<0.01),并接近正常。结论:LS、针刀和中药联合治疗能快速而又持久地改善ANFH的微循环状况,取得更好的临床疗效,且明显优于针刀和中药的单独或联合作用。