跖背动脉皮支皮瓣

跖背动脉皮支皮瓣崔延才，周琳，隋永强，姜舒光我们在尸体解剖的基础上，应用跖背动脉皮支皮瓣修复足部软组织损伤５例，均获成功，为足部创面修复提供了一种新皮瓣。１临床资料本组５例，男４例，女１例，年龄１８～５８岁。急诊修复左趾背部皮肤缺损２例，左足第２跖背...     

踝关节骨折合并同侧跖跗关节损伤的诊治

2017年3月～2018年9月,我科收治13例踝关节骨折合并同侧跖跗关节损伤患者,现将诊治方法及体会报道如下. 1 材料与方法 1.1 病例资料 本组13 例,男8 例,女5例,年龄24～50岁.患者均为踝关节骨折合并同侧跖跗关节损伤,右侧9例,左侧4例.8例跖跗关节损伤并移位;5例入院时未发现跖跗关节损伤及移位,入院...     

背屈外翻试验诊断踝管综合征

踝管足小腿深筋膜在内踝关节处局部增厚．并张于跟骨内侧与内踝之间．与跟骨共同构成的软组织通道1962年Keck将胫神经在内蹑处受压所引起的临床症状和体征定义为踝管综合征。踝管综合征的典型临床表现为足底疼痛、     

踝关节骨折

1踝关节局部解剖 1．1骨性结构 踝关节的骨性结构由胫骨远端关节面穹窿部、内外踩与距骨组成。主要包括距骨体马鞍形顶与胫骨远端关节面所构成的关节和下胫腓间的关节,另外距骨体两侧的关节面还与相应的内、外踝构成关节。胫骨远端关节面外侧宽,内侧略窄,后侧比前侧略低。外侧面为凹面,与腓骨相关节,有前后结节,前结节为下胫腓前韧带止点,后结节为下胫腓后韧带止点。胫骨远端内侧面向内下方延伸至内踝,内踝由前后丘组成,前丘较大,后丘较小,且该处有向内下走行的斜沟,内有胫后肌腱。距骨体几乎均被软骨覆盖,前宽后窄,外侧前后径比内侧长,容纳于内外踝所形成的踝穴中。踝关节背伸活动时,距骨体外旋,其前部进入踝穴,同时,腓骨外旋、后外侧移动以适应距骨的运动。而在踝关节跖屈活动时,距骨体内旋后部进入踝穴。     

背阔肌皮瓣移位重建屈肘功能12例

自１９９１年３月￣１９９３年１０月，利用背阔肌移位重建臂丛神经损伤的屈肘功能１２例，随访６个月￣２年半，疗效满意。优点为：①不可逆性臂丛神经损伤肢体多为“皮包骨”，采用肌皮瓣移位，增大了肢体周径，减少了皮肤张力，有利于移位后肌肉滑行，改善了外观，同时也便于术后血运观察。②部分臂丛根性损伤，背阔肌多已萎缩无功能，利用神经移位重建胸背神经而恢复的背阔肌功能，再移位重建屈肘功能，证明是有效可行的。分析讨     

神经电生理检查对足趾背屈功能障碍的诊断价值

目的 探讨神经电生理检查对无明确外伤史足趾背屈功能障碍的诊断价值.方法 对66例(77侧)无明确外伤史且以足趾背屈功能障碍为主诉的患者行神经电生理检测,内容包括:腓肠神经、腓总神经感觉神经传导速度(sensory nerve conduction velocity,SNCV),胫神经、腓总神经运动神经传导速度(motor nerve conduction velocity,MNCV),胫神经、腓总神经、闭孔神经、臀上神经、臀下神经支配肌及椎旁肌的肌电图(electromyogram,EMG).结果 66例中30例(30侧)腓骨小头处腓总神经卡压,2例(2侧)梨状肌出口处坐骨神经卡压,18例(18侧)神经根处受到腰椎间盘压迫,6例(11侧)累及前角运动神经元病变,6例(10侧)为糖尿病引起的周围神经病变,4例(6侧)所检测指标均在正常范围.神经电生理检测所得结果阳性率为93.9%.结论 神经电生理检查可以为无明确外伤史引起的足趾背屈功能障碍提供客观的检测指标,对该病的病因诊断具有重要的参考价值.     

第一跖背区皮瓣修复手指软组织缺损5例

我院自 1996年起 ,采用第一跖背动脉腓深神经皮瓣修复手指皮肤缺损取得了良好的效果 ,现报告如下。1　临床资料本组 5例 ,男 2例 ,女 3例 ,年龄 17～ 35岁。右手 3例 ,左手2例。急诊 2例。拇指掌侧皮肤缺损 2例 ,其中 1例桡侧指动脉、指神经损伤 ,屈指肌腱部分损伤 ;拇指背侧热压伤致皮肤坏死缺损 1例 ;食指掌侧皮肤缺损 1例 ,合并桡侧指神经、指动脉损伤 ,屈指肌腱鞘于 A3处部分损伤 ,末节指骨部分外露 ,指甲部分缺损 ;环指掌侧皮肤缺损 1例。缺损范围 2 .5～ 2 3.5 cm×4 .0～ 6 .0 cm。　　手术于第一跖背区根据受区情况设计皮瓣 ,于足…     

Kinematic analysis of ankle stiffness in subjects with and without flat foot

BackgroundAlthough the magnitude of ankle motion is influenced by joint congruence and ligament elasticity, there is a lack of understanding on ankle stiffness between subjects with and without flat foot.ObjectiveThis study investigated a quantified ankle stiffness difference between subjects with and without flat foot.MethodsThere were forty-five age- and gender-matched subjects who participated in the study. Each subject was seated upright with the tested foot held firmly onto a footplate that was attached to a torque sensor by the joint-driving device.ResultsThe flat foot group (mean ± standard deviation) demonstrated increased stiffness during ankle dorsiflexion (0.37 ± 0.16 for flat foot group, 0.28 ± 0.10 for control group; t = −2.11, p = 0.04). However, there was no significant group difference during plantar flexion (0.35 ± 0.15 for flat foot group, 0.33 ± 0.07 for control group; t = 0.64, p = 0.06).ConclusionThe results of this study indicated that the flat foot group demonstrated increased ankle stiffness during dorsiflexion regardless of demographic factors. This study highlights the need for kinematic analyses and joint stiffness measures during ankle dorsiflexion in subjects with flat foot.     

The effect of collateral ligament release on ankle dorsiflexion: An anatomical study

Background

Ankle stiffness is a common complication after ankle fracture, reconstructive surgery or total ankle replacement, and the usual limitation is in dorsiflexion. There are few articles in the literature concerning this frequent problem, and furthermore they are not recent and tend to be controversial. The purpose of this anatomical study was to evaluate and quantify the effect of ankle collateral ligament release on dorsiflexion, specifically the amount of increase in ankle dorsiflexion following section of the two ligaments most often implicated in ankle stiffness: the deep posterior tibiotalar ligament (dPTTaL, or posterior deep deltoid) and the posterior talofibular ligament (PTaFL).

Methods

We dissected 18 adult fresh cadaveric ankle joints, and with an electronic goniometer combined with an electronic dynamometer measured their mobility in dorsiflexion before and after transection of each ligament separately, and the two ligaments combined.

Results

The results showed a significant difference between the two groups of ankles with section of the dPTTaL resulting in a greater increase in ankle dorsiflexion than section of the PTaFL (mean 7.45° vs. 3.5°, respectively; p < 0.001). Combined section of both ligaments improved the gain in ankle dorsiflexion more than isolated section of each ligament, but was not statistically significant (p = 0.88).

Conclusion

If after gastrocnemius recession or Achilles tendon lengthening persistent restriction remains in ankle dorsiflexion, the results of our study demonstrate that the next step should be release of the dPTTaL.     

Corin ankle arthroplasty: Case-series

BackgroundTotal Ankle Arthroplasty (TAA) is complex and can bring a wide variety of complications. Implant revision rates can vary from 4% to 8% in 5 years. Recent publications have shown good results in the short and intermediate follow-up and high patient satisfaction. The pre- and postoperative evaluation of these patients should include physical examination and objective radiographic measurements, which may have predictive value for implant failures and survivorship. In this paper we will present the results obtained with 29 patients treated with the Zennith (Corin Group, UK) total ankle prosthesis in Brazil.MethodsThis paper presents the results obtained with 29 patients treated with the Corin-Zennith prosthesis in three tertiary hospitals in Brazil, with an average follow-up of 5 years. The patients were submitted to clinical and radiographic evaluation. There were seventeen women and twelve men, ranging in age from 35 to 76 years, who were submitted to surgical treatment between January 16, 2013 and May 5, 2017.ResultsSeven patients (24%) presented cysts, being 4 (13.7%) tibial cysts and 3 (10.3%) tibial and talar cysts. Six patients (20.6%) presented talar subsidence and 3 (10.3%) presented tibial subsidence. Three patients (10.3%) presented component wear. VAS reduced and AOFAS and ROM increased in the post-operative period. The development of Cysts was associated with the theta angle and the difference in LTS (between the post and preoperative period) was associated with tibial subsidence. The complications rate was 44.8%, the revision rate was 6.9% and the survivorship rate was 93.1%.ConclusionThe Corin-Zennith prosthesis demonstrated to be a safe implant for improving functional parameters. Functional outcomes were not influenced for most commonly measured radiographic parameters. Further studies are needed to better understand these associations.     

Overtightening of the syndesmosis revisited and the effect of syndesmotic malreduction on ankle dorsiflexion

BackgroundAnkle syndesmotic injuries are a significant source of morbidity and require anatomic reduction to optimize outcomes. Although a previous study concluded that maximal dorsiflexion during syndesmotic fixation was not required, methodologic weaknesses existed and several studies have demonstrated improved ankle dorsiflexion after removal of syndesmotic screws.The purposes of the current investigation are: (1) To assess the effect of compressive syndesmotic screw fixation on ankle dorsiflexion utilizing a controlled load and instrumentation allowing for precise measurement of motion. (2) To assess the effect of anterior & posterior syndesmotic malreduction after compressive syndesmotic screw fixation on ankle dorsiflexion.Material and methodsFifteen lower limb cadaveric leg specimens were utilized for the study. Ankle dorsiflexion was measured utilizing a precise micro-sensor system after application of a consistent load in the (1) intact state, (2) after compression fixation with a syndesmotic screw and (3) after anterior & (4) posterior malreduction of the syndesmosis.ResultsFollowing screw compression of the nondisplaced syndesmosis, dorsiflexion ROM was 99.7 ± 0.87% (mean ± standard error) of baseline ankle ROM. Anterior and posterior malreduction of the syndesmosis resulted in dorsiflexion ROM that was 99.1 ± 1.75% and 98.6 ± 1.56% of baseline ankle ROM, respectively. One-way ANOVA was performed showing no statistical significance between groups (p-value = 0.88).Two-way ANOVA comparing the groups with respect to both the reduction condition (intact, anatomic reduction, anterior displacement, posterior displacement) and the displacement order (anterior first, posterior first) did not demonstrate a statistically significant effect (p-value = 0.99).ConclusionMaximal dorsiflexion of the ankle is not required prior to syndesmotic fixation as no loss of motion was seen with compressive fixation in our cadaver model. Anterior or posterior syndesmotic malreduction following syndesmotic screw fixation had no effect on ankle dorsiflexion. Poor patient outcomes after syndesmotic malreduction may be due to other factors and not loss of dorsiflexion motion.Level of Evidence: IV     

踝关节骨折脱位的治疗

踝关节骨折脱位为临床常见损伤之一，若处理不当，易并发创伤性关节炎。现将我科1996年3月～2001年10月住院治疗的53例患者的治疗方法及疗效进行总结。     

Increased flexor hallucis longus tension decreases ankle dorsiflexion

BackgroundRestricted excursion of the flexor hallucis longus (FHL) is associated with several clinical problems. An FHL excursion measurement device (EMD) was used to objectively assess differences between patients with clinically normal or tight FHL tendons.Methods188 patients (356 feet) were enrolled. The EMD measured maximum ankle dorsiflexion with the great toe in 15°, 30°, and 45° of dorsiflexion. All had clinical assessment of FHL tightness by their provider independently of the EMD measurement.ResultsIncreased hallux DF always caused decreased ankle DF. Patients with clinically tight FHLs demonstrated decreased ankle DF compared to normal subjects at all hallux positions (p < 0.01). The EMD measurement was not sensitive enough for detection of FHL tightness in individuals. A clinically tight FHL was seen in almost 50% of feet.ConclusionsTension in the FHL can limit ankle DF. Clinical tightness of the FHL is likely more common than currently recognized.     

前踝撞击征的关节镜下诊断与治疗

目的探讨前踝撞击征的关节镜下诊断与治疗。方法2000年1月至2006年1月，关节镜下治疗前踝撞击征患者28例，男18例，女10例；年龄18-51岁，平均32岁；左踝12例，右踝16例。17例有长期运动史，5例有踝关节背伸劳作史，6例有踝部骨折脱位史及反复损伤史；病史最短6个月，最长7年。踝关节检查时胫骨前缘或前内侧有固定压痛，背伸活动均不同程度受限，部分踝关节僵硬。根据Scranton和McDermott的放射学分级标准，Ⅰ级6例，Ⅱ级15例，Ⅲ级5例，Ⅳ级2例。术前采用McGuire踝关节评分系统进行评分，13例可（65-70分），15例差（〈65分）。最低41分，最高67分，平均52分。踝关节镜下用刨削器、磨钻、组织汽化仪等清理增生肥厚及炎性的滑膜、退变的软骨和骨赘等。结果所有患者均获随访，随访时间11-48个月，平均27个月。术后McGuire评分显示：Ⅰ级6例，均为优良。Ⅱ级15例，12例优良，3例可。Ⅲ级5例，2例优良，2例可，1例差；其中无间隙狭窄者2例，1例为优良，有间隙狭窄者3例，1例为优良。Ⅳ级2例，均为差。优良率为71．4％。术后最低59分，最高94分，平均76分，较术前平均提高24分。无一例发生并发症。1例Ⅳ级患者术后27个月复发。结论关节镜下治疗Ⅰ、Ⅱ级及部分无关节间隙狭窄的Ⅲ级前踝撞击征患者疗效肯定，而对于部分有关节间隙狭窄的Ⅲ级及Ⅳ级前踝撞击征患者疗效欠佳。     

Synovectomy of the ankle joint

Summary Between 1970 and 1979, 123 synovectomies of the ankle joint were performed on 99 patients. Sixty two of these patients (81 ankles) were followed up for an average period of four years. Using Steinbrocker's classification 10 ankles had Stage I disease, 34 had Stage II, 33 had Stage III and 4 had Stage IV. In more than 80% of the joints pain and swelling significantly decreased after operation, with improvement in te range of motion and of the gait pattern. However the procedure did not change the walking distance or dependency upon walking aids, probably because the ankle joint was rarely the only joint of the lower extremity affected by rheumatoid arthritis.

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Résumé De 1970 à 1979, 123 synovectomies de la tibio-tarsienne ont été réalisées sur 99 malades. Soixante-deux d'entre eux (81 articulations) ont été suivis pendant une duréemoyenne de 4 ans. Selon la classification de Steinbrocker, 10 chevilles étaient cotées degré I, 34 degré II, 33 degré III et 4 degré IV. Dans plus de 80% des cas la douleur et le gonflement ont diminué de façon notable après l'opération, avec amélioration de la mobilité et de la marche. Par contre l'intervention n'a pas modifié le périmètre de marche, ni la nécessité d'utiliser des cannes, probablement parce que la tibio-tarsienne était rarement la seule articulation atteinte par la polyarthrite rhumatoïde au niveau des membres inférieurs.

     

踝关节完全脱位的治疗

目的 探讨踝关节完全脱位的损伤机制与疗效.方法 2003年1月至2008年12月共收治39例踝关节完全脱位患者,男25例,女14例;年龄14～69岁,平均31.6岁.闭合性脱位10例,开放性脱位29例;伴踝关节骨折23例.按距骨移位方向分类:内侧脱位15例,外侧脱位10例,踝关节后脱位10例,旋转分离向上脱位4例.保守治疗7例,闭合复位短腿石膏固定6周;手术治疗32例,包括骨折脱位复位内固定22例,其中行外侧副韧带修复6例,三角韧带修复3例;单纯行三角韧带修复2例;单纯行外侧副韧带修复6例;内外侧韧带同时修复2例.下胫腓联合螺钉固定7例.因踝部皮肤缺损二期行皮瓣移植7例,二期小腿下端截肢2例.采用美国足踝外科协会(AOFAS)踝与后足评分系统评价术后疗效. 结果 35例患者术后获1～4年(平均26个月)随访.伴骨折者骨折愈合时间平均为14周(6～25周).术后随访发现踝关节不稳定5例,创伤性关节炎3例.术后AOFAS踝与后足评分平均为86.5分(48～96分). 结论 踝关节完全脱位早期应注意骨折脱位的复位固定和韧带的修复,防止后期关节不稳定和创伤性关节炎的发生.开放性脱位常伴有皮肤坏死,及时皮瓣移植对防止关节感染尤为重要.