外踝后穿支皮瓣修复足跟区皮肤缺损的疗效观察

目的观察外踝后穿支皮瓣修复足跟区皮肤缺损的临床应用效果。方法 2014年5月—2016年10月周口手外科医院收治跟外侧、后侧、足底、或跨区皮肤缺损者17例,其中男性12例,女性5例;年龄15~57岁,平均33.5岁。创伤所致皮肤跨区缺损14例、跟骨骨折切开复位内固定术后皮肤坏死致钢板外露3例,皮肤缺损范围2cm×4cm~7cm×10cm。合并跟骨骨折11例,其中跟骨骨质缺损6例,跟腱止点部位损伤5例;创面均采用外踝后穿支皮瓣修复,其中急诊修复9例,二期手术8例,对于伴有跟骨骨质缺损者通过取髂骨植骨方式修复、跟腱止点断裂损伤者重建修复。结果 16例皮瓣完全成活,1例皮瓣下血肿形成,未及时清除导致血循环障碍,皮瓣边缘局部皮肤坏死,经拆线引流等对症治疗后创缘愈合。17例经术后6个月~2年随访,皮瓣外形满意,跟骨愈合及跟腱抗应力性能良好。根据Marti后足(hindfoot)评分标准与Mackinnon感觉功能标准进行评定,行走功能及感觉恢复良好。结论应用外踝后上穿支皮瓣修复跟区皮肤组织缺损,临床效果满意。     

第一掌背动脉皮瓣Ⅰ期修复拇指皮肤缺损合并神经缺损

目的 探讨第一掌背动脉皮瓣携带指神经背侧支Ⅰ期修复拇指皮肤缺损合并神经缺损的手术方法和临床效果. 方法 对14例拇指皮肤缺损伴一侧或双侧神经断裂缺损患者,应用携带示指固有神经背侧支的第一掌背动脉岛状皮瓣修复,重建手指感觉.皮肤缺损最大面积为52 mm×32 mm,最小为10 mm×8 mm.神经缺损长度9～22 mm....     

应用内踝上逆行皮瓣修复足踝部皮肤软组织缺损

目的 观察应用内踝上逆行皮瓣修复足踝部皮肤软组织缺损并骨外露或跟腱外露的效果.方法 自2000年来应用内踝上逆行皮瓣27例,转移修复由车祸外伤、肿瘤等所致的足踝部皮肤软组织缺损并骨外露或跟腱外露.修复皮肤软组织缺损最大面积6cm×14cm,跟骨外露最大面积5cm×10cm.结果 共切取内踝上逆行皮瓣27块,其中血管蒂逆行皮瓣9例,筋膜血管蒂逆行皮瓣12例,带部分皮肤的筋膜血管蒂逆行皮瓣6例.其中1例皮瓣术后坏死,行游离背阔肌肌皮瓣移植修复愈合,其余逆行皮瓣及供瓣区所植皮片均完全成活,术后随访6个月～4年,效果满意.结论 内踝上逆行皮瓣移植是修复足踝部皮肤软组织缺损并骨外露或跟腱外露的理想方法之一.     

腕掌侧桡动脉掌浅支游离皮瓣修复手指皮肤缺损并桥接手指动脉

目的：探讨采用腕掌侧桡动脉掌浅支游离皮瓣修复手指皮肤缺损并桥接手指动脉的临床疗效。方法2012年1月～2013年11月对18例手指皮肤缺损合并血运障碍患者,缺损面积为1cm ×2cm～1.5cm ×2.5cm,采用腕掌侧桡动脉掌浅支游离皮瓣修复手指皮肤缺损并桥接指动脉。6例合并指固有神经缺损移植正中神经掌皮支桥接,腕部供区直接缝合。结果18例皮瓣全部成活。术后随访皮瓣质地好,外形及功能满意。无需二次手术皮瓣整形。结论桡动脉掌浅支游离皮瓣是修复手指皮肤缺损合并指动脉断裂缺损的良好方法。     

支架外固定联合局部转移皮瓣修复伴皮肤软组织缺损胫腓骨开放骨折

目的：分析支架外固定联合局部转移皮瓣在修复伴皮肤缺损胫腓骨开放骨折中的应用。方法：选择胫骨或胫腓骨开放骨折伴皮肤缺损患者61例,分为观察组42例,对照组19例。观察组急诊清创、支架外固定骨折,一期或二期局部转移皮瓣修复皮肤缺损。对照组急诊清创、骨折内固定后直接缝合撕裂的皮肤。结果：观察组39例骨折达到临床愈合标准,2例瘢痕愈合,1例出现感染。对照组11例骨折达到临床愈合标准,8例发生皮肤及软组织缺血、坏死。结论：支架外固定联合局部转移皮瓣手术修复胫腓骨开放骨折伴皮肤软组织缺损疗效确切,值得临床推广。     

切口内筋膜血管丛下结合锚钉治疗新鲜闭合性跟腱断裂方法的探讨

目的探讨切口内筋膜血管丛下结合铆钉治疗新鲜闭合性跟腱断裂方法的临床疗效。方法对48例闭合性跟腱断裂患者行跟腱内侧切口,术中显露胫后动脉穿支,游离并保护其筋膜血管丛,形成连接切口两端皮肤筋膜血管蒂桥,结合铆钉编织缝合;6周去除外固定后,进行伸展及等长收缩等训练。结果术后48例均获得随访,随访时间9个月~2年,平均12.92个月,术后按照美国足踝外科协会(American Orthopaedic FootAnkle Society,AOFAS)踝与后足功能评价功能评分标准,其中优40例,良5例,可3例,优良率为93.75%(45/48)。无一例发生腓肠神经及胫神经损伤、跖部痛性瘢痕、足底内外侧神经损伤、伤口感染、裂开。结论采用跟腱内旁切口,保护筋膜血管丛,结合铆钉修复跟腱断裂手术方法治疗新鲜闭合性跟腱断裂,手术操作简便,吻合方法可靠,创伤小,皮肤坏死率低,功能恢复佳,适用于基层医院开展。     

臀部皮瓣修复儿童足跟部皮肤缺损的临床应用

臀部皮瓣修复儿童足跟部皮肤缺损的临床应用温术民儿童足跟部皮肤缺损修复难度较大。近年来，笔者试用臀部皮瓣修复，取得了较好的效果。临床资料本组共６例，男４例，女２例；年龄６～１４岁。足跟部软组织缺损致跟骨外露２例，足跟部软组织缺损，跟骨外露合并跟腱外露４...     

腓肠神经营养血管皮瓣逆行修复儿童跟腱部轮辐伤

目的探讨儿童跟腱部轮辐伤的临床特点及腓肠神经营养血管皮瓣的运用。方法我院2007年3月～2010年6月收治因摩托车轮致跟腱部轮辐伤患儿15例,软组织缺损范围2cm×2cm～7cm×5.5cm,根据朱跃良标准分型:Ⅰ型1例,Ⅱ12例,Ⅲ型2例。跟腱及骨骺早期清创后带线锚钉或可吸收线修复,跟腱缺损者选择跟腱翻转筋膜条重建,并采用腓肠神经营养血管皮瓣修复创面,皮瓣切取范围4.5cm×4.0cm～10.5cm×7.5cm,供区中厚皮片游离植皮治疗。结果术后14例皮瓣存活。1例出现皮瓣远端部分坏死,经换药植皮后治愈;2例术后早期创缘渗出,经换药后愈合;后期1例出现供区上缘麻胀感。15例获随访12～15个月,平均13个月。皮瓣质地柔软,外观良好,踝关节功能恢复良好。1例皮瓣臃肿,经Ⅱ期修整削薄后外观改善。结论摩托车轮致儿童跟腱部轮辐伤大多污染严重,同时存在跟腱、跟骨骨骺损伤及足跟部皮肤缺损,尽可能早期手术修复,可达到良好的临床效果。     

创伤性浮肩的手术修复与重建

目的 探讨创伤性浮肩手术修复与重建的效果.方法 对16例浮肩损伤行切开复位重建钢板内固定术.其中锁骨横行骨折1例,斜行骨折6例,粉碎性骨折9例;肩胛骨骨折Ⅰ型1例,Ⅱ型3例,Ⅲ型4例,Ⅳ型6例,Ⅴ型2例.合并伤:肋骨骨折伴血气胸6例,创伤性湿肺2例,颅脑损伤2例,肝脾破裂2例,臂丛神经损伤1例.伤后至手术时间3～21 d,平均7 d.结果 随访15例,随访时间6～28个月,平均11个月.全部获得骨性愈合,无感染,无钢板及螺钉松动和断裂.根据Herscvici等功能评价标准,肩关节功能恢复优11例,良3例,可1例,优良率93%.结论 创伤性浮肩的手术修复与重建,最大限度地恢复了肩关节及周边的解剖结构和稳定性,缩短肩关节制动及固定时间,有利于肩关节功能恢复,减少并发症的发生.     

远端蒂大隐静脉筋膜皮瓣修复足跟皮肤缺损16例

足跟腱部较大面积皮肤缺损、腱组织外露创面的修复 ,难度较大。我们科自 1997年以来应用远端蒂逆行大隐静脉筋膜皮瓣修复大面积跟腱部皮肤缺损创面 16例 ,患部功能及外形恢复满意。1　临床资料1 1　资料　本组男 10例 ,女 6例 ,年龄 9岁～ 3 5岁。患部皮肤缺损原因 :车轮辗压伤 6例 ,感染致皮肤坏死 5例 ,瘢痕切除后创面 5例。缺损面积 2ｃｍ× 4ｃｍ～ 4 5ｃｍ× 8ｃｍ。合并内踝骨组织外露 3例。皮瓣大小 5ｃｍ× 12ｃｍ～ 8ｃｍ× 18ｃｍ ,长宽比 2～ 3∶1。1 2　手术方法　按创面形状设计皮瓣 ,以大隐静脉为中轴线 ,蒂宽 3～ 5ｃｍ。自…     

深低温冷冻保存同种异体肌腱移植修复陈旧性跟腱断裂研究

目的：探讨深低温冷冻保存同种异体肌腱移植修复陈旧性跟腱断裂的临床效果。方法2010年1月-2012年9月收治急性创伤所致跟腱断裂一期未行修复导致的陈旧性跟腱断裂患者共32例,缺损长度3-6（4.6±1.0）cm,手术所用肌腱为经过深低温处理的同种异体胫前肌肌腱。在跟腱远端和近端用2-0可吸收抗菌薇乔采用双束 Kessler 法端端吻合,术后常规跖屈20-30°位固定踝关节,足背肢具或石膏板固定4-6 w。3例合并皮肤缺损者,行腓肠神经营养皮瓣转移覆盖创面。术后采用美国足踝外科协会（ AOFAS）踝与后足评分行疗效评价。结果术后32例均获随访1年以上,平均随访（15.0±3.5）个月,其中29例切口Ⅰ期愈合,2例切口Ⅱ期愈合,1例因为排异反应取出移植肌腱由于疤痕愈合未行再次肌腱移植,目前可以正常行走。术后踝关节功能恢复良好,AOFAS 足踝评分从术前（50.5±5.5）分提高到术后（90.5±6.5）分。结论修复陈旧性跟腱断裂可用深低温冷冻保存同种异体肌腱,手术效果可,并可避免取自体腱造成二次损伤和并发症,患者更容易接受,移植物可长期保存,但长期效果仍需长期随访。     

Magnetic resonance imaging after operative repair of achilles tendon rupture

We performed a magnetic resonance imaging (MRI) study in 16 consecutive patients who had undergone open repair of a unilateral Achilles tendon rupture (ATR) at an average of 32.5 (SD 3.2) (range 29-36) months from the operation. We measured the widest antero-posterior diameter of the tendon, the longest distance between the insertion of the Achilles tendon on the calcaneum and the musculo-tendinous junction of the soleus muscle on the Achilles tendon, the distance between the insertion of the Achilles tendon on the calcaneum and the point of maximal width of the tendon. We also ascertained whether areas of altered signal were present in and around the tendon. The operated tendons were always significantly thicker than the non-operated ones. There was a non-significant trend for the other measurements to be greater in the operated tendons. In five patients, areas of dishomogeneous signal were present in the operated tendon. These areas were less than 25% of the antero-posterior diameter of the tendon, and were clinically silent. These findings probably represent normal features of long-term tendon healing following open repair of an ATR.     

Real-time sonoelastography of the Achilles tendon: pattern description in healthy subjects and patients with surgically repaired complete ruptures

Objective

The purpose of this study is to describe the elastographic appearance of the Achilles tendon in healthy subjects and patients with surgically repaired complete ruptures.

Materials and methods

Nineteen Achilles tendons of 16 amateur footballers with surgically repaired complete ruptures and their contralateral asymptomatic Achilles tendons were assessed with ultrasound and real-time sonoelastography. Additionally, 40 asymptomatic Achilles tendons of 20 healthy amateur footballers were assessed. The Achilles tendons were divided into the distal, middle, and proximal thirds for elastographic image evaluation. Tendons were classified into three main types according to the elasticity features: type 1, blue (hardest tissue); type 2, blue/green (hard tissue); or type 3, green (intermediate tissue). In addition, three subtypes were determined: homogeneous, relatively homogeneous, and heterogeneous.

Results

Most of the Achilles tendons of the patients with surgically repaired complete ruptures were detected to have type 2 elasticity (64.9%), and the remaining had type 1 (35.1%). In contrast, most of the healthy tendons had type 2 (64.2%), and the remaining had either a type 3 (20.8%) or a type 1 (15%) elastographic pattern. All of the ruptured tendons had a heterogeneous structure, whereas all of the healthy Achilles tendons had a homogeneous or relatively homogeneous structure.

Conclusion

In sonoelastography, the recognition of normal tendon structure will be useful in assessing pathologies of the Achilles tendon. Additionally, in patients with excellent American Orthopedic Foot and Ankle Society (AOFAS) scores and surgically repaired complete ruptures, a hard and heterogeneous pattern of tendon structure may be a natural consequence of tendon healing.     

Repair of Achilles tendon ruptures with a polylactic acid implant: assessment with MR imaging

An investigational tendon repair device composed of a polymer of lactic acid (PLA) is currently undergoing multicenter clinical trials for use in repairing rupture of the Achilles tendon. The advantages of the PLA device include high tensile strength and the induction of a rapid proliferative tissue response resulting in a shorter rehabilitation period than with conventional surgical repair. We reviewed 16 MR examinations performed in 10 patients 3-35 months after repair to characterize the MR appearance. All 16 T1-weighted sagittal images revealed a thickened fusiform tendon with streaks of moderate signal within the tendon corresponding to the PLA device and its surrounding collagenogenic response. The double-echo T2-weighted axial images at the mid tendon level demonstrated progressive changes in the signal pattern of the central portion of the tendon that reflected the maturation of the healing tendon. All tendons repaired with PLA implants were uniformly hypertrophied relative to the contralateral normal side because of the induced proliferative collagenogenic ingrowth. Two follow-up MR examinations were performed in six patients and showed mean reductions in tendon caliber of 24% and 30% at the mid and inferior levels. MR imaging of the Achilles tendon repaired with PLA implants shows a diffusely thickened tendon with streaks of signal within the tendon that distinguish it from tendons repaired by conventional techniques.     

Sonographic incidence of tendon microtears in athletes with chronic Achilles tendinosis

OBJECTIVE: To assess the number and distribution of tendon microtears in asymptomatic controls and athletes with chronic Achilles tendinitis or partial thickness tears using high resolution ultrasound. METHODS: The mean number of microtears in three random tendon cross sections were recorded per tendon third in 19 asymptomatic volunteers, 16 athletes with symptomatic chronic Achilles tendinitis, and eight athletes with partial Achilles tendon rupture. RESULTS: Microtears were most numerous in the middle third section of the Achilles tendon. Some 67% of tendons in the control group had no microtears, and 28% showed a single microtear. Only 18% of the athletes with chronic Achilles tendinitis and none of the athletes with partial tendon rupture were without microtears in the middle third of their Achilles tendon. Of the tendons with chronic tendinitis, 13% had more than three microtears per section which increased to 87% in tendons exhibiting partial rupture. CONCLUSIONS: There appears to be an association between microtear formation and Achilles tendon rupture.     

Bilateral Achilles tendon rupture: a report on two cases

Two cases of traumatic bilateral Achilles tendon rupture are reported. One of the patients was a healthy middle-aged man, who had been an active nationallevel gymnast 20 years earlier. He had not suffered any complaints of Achilles tendons before. The ruptures occurred when, after a sauna, he showed his guests a vault forwards, which he had been able to perform easily. This time the landing took place on the toes, causing a high peak stretch to the calf muscles and Achilles tendons. The total rupture of both Achilles tendons was treated surgically, with an excellent result 2 days after the trauma. End-to-end suturation and a fascial flap plasty were made on both sides. No macroscopic degeneration could be detected on the rupture sites. He was allowed to walk freely 6 weeks after the surgery. The second case was a 54-year-old woman, who had suffered from Achilles tendinitis and peritendinitis for 2 years. Both tendons had been surgically treated, and severe adhesions and local degenerative changes had been found. The tendon rupture occurred when she injured her left ankle while getting out of the car. Two days later she fell at home, because of the weakness of the left side, and consequently the right Achilles tendon was injured. She was treated conservatively for 10 days, before the surgery was performed. Both tendons were ruptured and an extensive degeneration of the area was observed. The right side suffered from a rerupture, which was again treated surgically. After surgery the recovery was slow, but the final result 3 years later was moderate. Neither of the patients had any systemic diseases.     

关节镜辅助下经皮Kessler缝合法修复新鲜闭合跟腱断裂

目的介绍并评价关节镜辅助下经皮Kessler缝合法修复新鲜闭合跟腱断裂的临床效果。方法本组26例均为闭合性新鲜跟腱断裂，关节镜证实均为跟腱完全断裂，首先在关节镜下清理跟腱断端间的瘢痕组织和凝血块，使跟腱断端对合整齐，然后在关节镜监视下采用由内向外的穿针技术，经皮Kessler缝合修复断裂的跟腱。所有患者均得到了随访，平均随访18个月（6-36个月）。随访包括常规的临床评价和MRI检查，并按Amer Lindholm评分标准进行术后疗效评定。结果按Amer Lindholm评分标准，本组优18例，良8例，优良率100％。全部患者无神经损伤，术后无感染，随访期内无跟腱再次断裂发生。MRI显示全部患者跟腱均得到了良好的修复且塑形好。结论关节镜辅助下经皮Kessler缝合法修复新鲜闭合跟腱断裂是一种较为理想的方法，具有术后疗效优良、功能恢复迅速、无明显术后并发症等优点。     

微量元素锌对跟腱创伤后修复过程的影响

本文分两部分对微量元素锌在跟腱断裂后修复过程中的作用进行研究。动物实验采用80只大白鼠为对象,按食物配方造成低锌、低蛋白补锌及手术后补锌的条件,观察跟腱断裂后愈合的状况,人体观察采用我所跟腱断裂手术的病例,观察血清锌在手术前后的变化。本实验结果表明在组织受创伤时,机体有调整体内锌分布的能力以保证组织愈合的需要。缺锌对跟腱修复有不良影响。机体在低蛋白状况时,单纯补锌的作用是极其有限的。     

急性跟腱撕裂的影像学诊断

目的探讨跟腱撕裂的X线平片和MRI诊断价值。方法分析21例有急性踝关节损伤病史、经手术证实为跟腱完全撕裂或部分撕裂患者的X线平片和MRI表现，并与手术结果对照。结果21例MRI均有异常表现，诊断跟腱完全撕裂7例，部分撕裂14例，MRI表现为跟腱增粗，腱内信号增高，腱束连续性完全中断或部分中断。X线片5例诊断跟腱撕裂，12例疑似撕裂，4例正常。手术结果完全撕裂9例，部分撕裂12例。结论MRI能准确显示跟腱撕裂的程度和部位，对临床治疗具有重要的指导意义；X线可作为跟腱撕裂初诊的辅助检查，但明确诊断还有赖于MRI。