指背腱膜中央束重建矫治钮孔畸形

自１９８４年以来，共行指背腱膜中央束重建治疗钮孔畸形３３例，其中Ｙ—Ｖ成形１７例，侧束切断交叉成形指背腱膜中央束８例，两侧束并拢合成中央束４例，游离腱移植重建中央束４例，均取得了较好效果。介绍了指背腱膜的解剖特点及生理功能，并分析了畸形发生机制，以及各种术式的优缺点。     

中央束侧束联合体治疗钮孔畸形

指伸肌腱中央束损伤,侧束向掌侧滑移形成手指钮孔畸形,其二期修复是指背伸腱装置中最为困难的一种.1997年2月-2006年1月,我们采用中央束与侧束缝合形成中央束侧束联合体的方法治疗钮孔畸形,术中患者主动伸、屈指以调整肌腱最佳的合并长度,取得了良好的效果.     

伸肌装置解剖及滑动的初步研究

对伸肌装置主要结构的解剖和滑动进行初步研究。方法：对１０只正常成人尸体手行大体解剖，测量实体标本肌腱的滑动范围及主要腱束间的角度，并做相应的组织学检查。结果：各指的伸腱装置虽相似，但内侧束的组成，内，外侧束形成的夹角不等；掌指关节矢状束的纵向运动和近似指间关节侧束的横向运动在伸指过程中起重要的作用。     

腱片移植治疗陈旧性锤状指

通过对手指伸腱装置的解剖与功能观察,设计了以掌长肌腱片或指背腱膜自身腱片移植修复伸指肌腱终腱手术,治疗陈旧性锤状指。1987年间试用3例,经2～3年随访,疗效满意。     

Y—V成形治疗指背腱膜中央腱束断伤

作者借鉴白求恩医大三院的经验,从1990～1994年用Y—V成形术治疗指背腱膜中央健束断伤13例,取得较好的效果,现报告如下.1 临床资料1.1 一般资料 本组13例全部为门诊手术病人.男9例,女4例;年龄多为10～40岁之间,受伤距手术时间:20～30天5例,30～60天6例,4年以上2例;损伤部位和程度:全部是中央腱束在近侧指间关节背侧部位的断伤;局部体征:患指全部呈典型的纽扣畸形,治疗方法:全部行指背腱膜中央腱束Y-V成形术.随访结果;通过1～3年的随访,除损伤4年以上的2例效果较差外,其余11例患指近侧指间关节屈伸功能在90～170°之间.     

爪形手畸形晚期功能重建及矫正

尺神经损伤,导致手指呈爪形畸形,其原因是骨间肌及蚓状肌麻痹,控制掌指关节屈曲、伸直手指力量丧失。指伸总肌失去侧腱束的抗衡而使掌指关节过伸;在掌指关节过伸时,指伸肌有效滑动也弱并消耗在掌指关节的过伸中,使伸指间关节的作用丧失,指屈肌作用于指间关节的力量相对加强,从而使指间关节过度屈曲,形成爪形指畸形。在低位尺神经损伤中,由于环、小指指深屈肌功能正常,而爪形指畸形更明显。     

手指中节远端毁损伤术后屈曲畸形的预防

手指中节远端毁损伤，常规残端缝合术后，常可因指浅屈肌键与伸肌键中央束肌力不平衡，导致近指间关节屈曲畸形，影响手的正常功能。我们自1997年1月-2000年1月，行伸肌腱加强及克氏针内固定术21例，预防近指间关节屈曲畸形，均取得满意效果，现报道如下。     

指背腱膜血供和微血管构筑的解剖学研究

目的研究指背腱膜的血供特点和配布规律，为临床应用提供依据。方法用乳胶灌注３０只成人陈旧尸手，在４倍放大镜下观察１～５指指背腱膜的外在动脉；另取２只新鲜成人尸手，经甲醛碳素墨汁灌注后将标本制成厚、薄两种切片，在光镜及Ｌｕｚｅｘ－Ｆ型显微图像分析仪下测定其内在动脉的分支、数量和密度。结果共观察到外在动脉１１０６支，拇指２９７支，近端外径２．６４±０．２１ｍｍ（ｘ±ｓｘ，下同）；２～５指指背腱膜中均存在优势动脉。内在动脉走行于腱束结缔组织内，逐级分支并相互吻合，腱束内无血管。拇、示指指背腱膜内毛细血管数量和密度优于其它３指。结论指背腱膜损伤修复时，定要将腱旁组织与腱膜一起缝合有利于腱组织的愈合。     

鼻唇沟区域解剖学研究

目的 对颌面整形美容外科提供形态学依据。方法 对20例成人新鲜尸头行10％福尔马林血管灌注固定后，在手术放大镜下进行形态学观测。结果 ①首次对少数国人与鼻唇沟区域相关的各表情肌逐块进行长、宽、厚的显微解剖测量。②测得鼻唇沟内侧脂肪厚度为1．3mm，外侧为4．5mm。③鼻唇沟内侧真皮层有肌纤维附着，外侧也有稀少肌束附着。④面部有浅肌肉宰不但存在腱膜，还由筋膜、肌肉、腱膜共同构成一个立体网状结构。结论 进一步证实了有关SMAS中央腱的理论假说。     

鼻唇沟区域解剖学研究

目的对颌面整形美容外科提供形态学依据。方法对20侧成人新鲜尸头行10%福尔马林血管灌注固定后,在手术放大镜下进行形态学观测。结果①首次对少数国人与鼻唇沟区域相关的各表情肌逐块进行长、宽、厚的显微解剖测量。②测得鼻唇沟内侧脂肪厚度为1.3mm,外侧为4.5mm。③鼻唇沟内侧真皮层有肌纤维附着,外侧也有稀少肌束附着。④面部表浅肌肉之间不但存在腱膜,还由筋膜、肌肉、腱膜共同构成一个立体网状结构。结论进一步证实了有关SMAS 中央腱的理论假说。     

Segmental variation in microstructure, matrix synthesis and cell proliferation in rabbit flexor tendon

An experimental culture system was designed with the purpose of studying matrix synthesis and cell proliferation in the deep flexor tendon of the rabbit forepaw. Special attention was paid to differences between three consecutive defined segments of the tendon from the region of the tendon sheath. There were two fibrocartilaginous areas in the tendon, one in the dorsal part of the proximal segment and one in the volar part of the distal segment. The intermediate segment consisted of regular tendinous tissue. The dorsal aspect of the distal segment was further characterized by a cell rich area related to the entrance of the vinculum longum. Proteoglycan synthesis in vitro was higher in the proximal and distal segments than in the intermediate, while collagen synthesis was highest in the intermediate tendinous segment. Variations in collagen content were reflected in variations in collagen synthesis. The rate of cell proliferation was highest in the intermediate segment. Segmental biochemical characteristics correlated well with morphological variations of the deep flexor tendon. These variations may reflect an adaptation to different mechanical forces acting on the tendon. The segmental variations may also be relevant for the healing capacity of the flexor tendon.     

Tendon injuries of the hand

Tendon injuries are the second most common injuries of the hand and therefore an important topic in trauma and orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons, but less frequent injuries, e.g., damage to the functional system tendon sheath and pulley or dull avulsions, also need to be considered. After clinical examination, ultrasound and magnetic resonance imaging have proved to be important diagnostic tools. Tendon injuries mostly require surgical repair, dull avulsions of the distal phalanges extensor tendon can receive conservative therapy. Injuries of the flexor tendon sheath or single pulley injuries are treated conservatively and multiple pulley injuries receive surgical repair. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger an "intrinsic" tendon healing to guarantee a good outcome. Many substances were evaluated to see if they improved tendon healing; however, little evidence was found. Nevertheless, hyaluronic acid may improve intrinsic tendon healing.     

“指伸肌腱终腱-止点系统”与锤状指形成原因的探讨

目的：通过对指伸肌腱终腱止点及末节指骨的解剖学观测,以物理力学方法对锤状指的形成原因做进一步的探讨。方法在成人新鲜尸体手指标本上,通过模拟手术,对指伸肌腱终腱止点及末节指骨的结构特点进行应用解剖学观测,用物理力学原理对指伸肌腱终腱及末节指骨进行受力分析。结果指伸肌腱终腱止点呈浅帽状被覆于末节指骨基底背侧的“舌”形骨嵴顶端,远侧指间关节侧面观呈规则的圆弧形,末节指骨在屈伸肌腱的牵拉下围绕一个固定的轴心在中节指骨头表面做屈伸运动;终腱或舌形骨嵴在手指纵轴线处受力最大,在垂直于手指纵轴线处受力最小。结论“指伸肌腱终腱-止点系统”的命名利于对锤状指的形成原因作进一步解释,并为锤状指治疗方法的改进提供解剖学依据。     

Flexor tendon-tendon sheath interaction after tendon grafting: a biomechanical study in a human model in vitro.

A human cadaver tendon sheath model was used to study the differences in excursion resistance of tendons that might be considered as sources of clinical tendon grafts. The flexor digitorum profundus and superficialis tendons, the extensor indicis proprius tendon used in its normal proximal-distal orientation, the extensor indicis proprius tendon used in a reversed distal-proximal orientation, and the palmaris longus tendon were studied in 7 fingers. The intrasynovial tendons (the flexor digitorum profundus and superficialis tendons and the reversed extensor indicis proprius tendon) produced less excursion resistance (p < .05) than the extrasynovial tendons (the normally oriented extensor indicis proprius tendon and the palmaris longus tendon). In contrast to studies measuring resistance against a single pulley, resistance within a complete tendon sheath may be affected by contact with other structures, particularly in joint extension.     

Vascular malformation within the flexor tendon sheath

We report an unusual location of a capillary vascular malformation found entirely within the flexor tendon sheath of an 8-year-old girl. Vascular malformations have been found in many locations throughout the hand but have, to our knowledge, not been reported to involve the vinculum of the flexor tendon sheath. The vascular malformation was contained completely within the sheath. Therapeutic management involved surgical excision of the vascular malformation.     

矫正拇掌指关节过伸畸形的新术式

目的为矫正拇掌关节过伸畸形寻求一种行之有效且操作简便的手术方式。方法采用近端切断拇短伸肌腱,保护止点周围的完整,在拇掌指关节掌侧拇长屈肌腱鞘浅面“8”字交叉,最后靠近拇内收肌止点与拇内收肌腱缝合。结果治疗34例拇掌指关节过伸畸形病人,其中类风湿病15例,掌板损伤10例,尺神经损伤9例,平均随访6年,所有过伸畸形完全矫正,未再复发。结论操作简便,疗效佳,有临床应用价值。     

Traumatische und degenerative Läsionen der Sehnen an der Hand

Tendon lesions are the second most common injury in the hand and therefore an important factor in orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons; nevertheless, also less frequent injuries such as damage to the functional system of tendon sheath and pulley or dull avulsions need to be considered. Besides the clinical examination, ultrasound and MRI have proven to be important diagnostic tools. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger "intrinsic" tendon healing to guarantee a good outcome.     

The extensor carpi radialis intermedius tendon

I examined 312 arms from 156 cadavers in the anatomy laboratory of Loma Linda University to find the incidence of the extensor carpi radialis intermedius tendon. I found 29 bodies (12%) that had a good extensor carpi radialis intermedius. In 17 of these 29 bodies, an extra tendon was found bilaterally. Thirty-two extensor carpi radialis intermedius tendons were suitable for transfer operations, and seven were unacceptable. One must be careful to differentiate between a true extensor carpi radialis intermedius tendon and accessory tendinous bands. The relatively high incidence rate and percentage of tendons suitable for transfer operations make this tendon potentially valuable in treating severe quadriplegia with tendon transfers. It can be used successfully for thumb opposition, to motor the flexor pollicis longus, or as a motor for the extensor pollicis longus of the thumb.     

Arthroscopic Release of First Metatarsophalangeal Arthrofibrosis

Various degrees of first metatarsophalangeal joint arthrofibrosis frequently occur in patients with bunion surgery or big toe trauma. In those patients with functional limitation who fail to respond to conservative treatment, surgery is indicated. We describe here an arthroscopic approach to first metatarsophalangeal release that is designed to improve functional results. Dorsomedial and dorsolateral portals are established at the medial and lateral sides of the extensor hallucis longus tendon. Through these 2 portals, the dorsal capsule is released and the medial and lateral joint gutters can be cleared up. The metatarsosesamoid compartment is approached through the straight medial portal and the working portal, the latter of which is located 4 cm proximal to the joint line between the abductor hallucis tendon and the medial head of the flexor hallucis brevis. Under visualization through the medial portal, adhesions around the sesamoid apparatus can be debrided with a shaver through the working portal. This completes the release of joint circumference and improves the motion range of the joint.     

Histology of the extensor retinaculum of the wrist and the ankle.

The extensor retinaculum of the wrist has been used for reconstruction of the annular pulleys of the flexor sheath. We examined the histologic structure of the extensor retinaculum and tendon sheath of the wrist and ankle in cadaveric specimens using hematoxylin-eosin and Verhoeff-van Gieson stains to detect elastin and alcian blue to detect hyaluronic acid, comparing the structure with that described previously for the annular pulleys. Three distinct layers are identified in the retinaculums of both the ankle and wrist: the inner gliding layer, with hyaluronic acid-secreting cells, shows isolated chondroid metaplasia; the thick middle layer contains collagen bundles, fibroblasts, and interspersed elastin fibers; and the outer layer consists of loose connective tissue containing vascular channels. This basic 3-layered histologic composition of the extensor retinaculum is carried in anatomic pulleys throughout the body and appears to represent an adaptive mechanism to provide both a smooth gliding surface as well as the mechanical strength to prevent tendon bowstringing. Given the same histologic structure as the annular pulleys, the extensor retinaculum is a reasonable biologic replacement for the reconstruction of deficient annular pulleys. Likewise, the extensor retinaculum of the ankle could be used to reconstruct a deficient retinaculum of the wrist.