足底蚓状肌的形态学观察

[目的]观察足底蚓状肌的形态学结构.[方法]取20例经甲醛固定的足,行系统解剖,记录蚓状肌的起止点及其走行.[结果]4条蚓状肌起自趾长屈肌腱各趾腱的内侧相对缘,各终止腱分别沿跖骨深横韧带的跖面绕过第2~5趾的第1节趾骨基底部附于内侧跖趾关节.[结论]蚓状肌的主要功能是屈跖趾间关节,具有防止跖趾间关节近节趾骨过伸及维护跖趾间关节稳定的作用.     

锤状趾和爪形趾的治疗

目的锤状趾畸形主要发生在矢状面.近节趾骨背屈,中节趾骨跖屈,远节趾骨可能背屈,也可能跖屈,跖骨头突向跖侧.近侧趾间关节背面受鞋面压迫、摩擦而形成胼胝,跖骨头下方及趾尖亦可形成胼胝.这些病损可造成局部疼痛,或继发滑囊炎使症状加重.锤状趾多影响单个足趾,常见于第二至三趾.病因包括:第二趾过长,鞋子过紧,拇趾外翻等.目的:讨论锤状趾和爪形趾的治疗.方法根据患者的临床表现结合检查结果进行诊断并治疗.结论年轻人或轻度畸形者可试用保守治疗,但疗效不甚满意.严重畸形需要手术矫正,包括:胼胝切除、肌腱平衡手术、各种截骨术、关节成形术及关节固定术.     

第一跖列负重变化对(足母)趾形态影响的有限元分析

目的建立正常足的三维有限元模型，并以此模型为工具，分析正常足负重后第一跖列的空间位置变化与[足母]趾外展外翻的关系。方法螺旋CT以层厚1．2mm，间隔1．2mm扫描正常成年男性右足，根据获得的CT图像，以Metlab，Surface、ANSYS软件为工具，在电脑工作站建立正常足三维有限元模型，予以一定量加载，分析第一跖列的形态学变化。结果结得到正常足的三维有限元模型，加载后可见第一跖列向内侧、跖侧移位并伴有内侧纵弓变长塌陷。近节[足母]趾相对于第一跖骨有外展趋势。结论有限元足部模型是分析足部生物力学的良好工具。负重后，第一跖列内收、跖屈，内侧纵弓塌陷，[足母]趾相对于第一跖骨有外展，反复负重的应力可能是导致[足母]趾外展外翻的因素之一。     

游离第2足趾或关节移植术后供足X线改变

游离第2足趾或关节移植术是最主要的拇、手指再造方法之一。作者采用双足标准正位及负重侧位X线拍片，对27例术后病人平均随访5．66年，按手术截趾平面及随访时间不同行自身对照分层分析。结果：①第1跖骨和其近节趾骨长轴夹角比非手术测平均增大3．75°，原有足拇外翻畸形的病人，术后供足畸形加重。②跖骨截骨组41．67％随访病人供足外侧纵弓平均增大3°。③术后供足1～3趾间距平均比非手术侧小9．13mm。④术后供足最大宽度变小。⑤跖骨截骨组41．67％的病人出现残留跖骨密度降低，本组只有少数病人稍感供足不适，但均不需治疗。     

拇外翻的手术治疗进展

拇外翻是临床的一种常见病,发病率很高,特别是女性,在有些国家可高达50%.桂鉴超等[1]认为拇外翻主要是指第一序列的异常(足部第一序列是指跖楔关节、第一跖骨、跖趾关节、近远节趾骨以及趾间关节),而不仅仅表现为跖趾关节的异常.     

拇外翻200例矫形术后的随访分析

拇外翻是拇趾近节趾骨自第1跖趾关节处外翻、内旋,第1跖骨内翻及第1跖骨头内侧骨赘形成,拇外翻患者第1跖趾关节疼痛、肿胀和拇囊炎及足底部胼胝形成。我院自1990年至2002年共收治拇外翻200例(219足),拇趾外翻角均>20°,现将其跟踪随访结果报道如下。1临床资料200例拇外翻患者,5例为男性,195例为女性。年龄18~55岁,平均年龄38.5岁。病程8个月~12年。临床表现有拇囊炎160例,第2、3跖骨头跖面胼胝形成29例,82例主诉有第1跖趾关节疼痛。200例中152例有穿高跟鞋习惯,150例有骑自行车经历。根据刘忠歧等〔1〕的分度,轻度采用M asride法术式,重度…     

12例糖尿病足的X线分析

目的 提高糖尿病足患者X线表现的认识.方法 对12例阳性糖尿病足患者X线平片进行回顾性分析,观察骨质、关节及软组织病变特点,以确定诊断价值的征象.结果 X线表现异常征象为足部骨质疏松,跖趾骨及趾间、跖趾关节骨质吸收,"笔尖"样吸收或伴骨膜增生,病理性骨折,趾间、跖趾关节脱位或半脱位,软组织肿胀和钙化等.结论 足部骨质疏松,趾跖骨及趾间、跖趾关节的骨质破坏,局部软组织肿胀是糖尿病足的主要X线表现.病变部位与足着力点有密切关系,"笔尖"样骨质吸收或伴骨膜增生是糖尿病足的重要征象.     

外翻发病因素的研究进展

外翻(hallux valgus, HV)主要表现为第1序列(指跖楔关节、第1跖骨、跖趾关节、近远节趾骨及趾间关节)的异常[1].19世纪外翻被认为是第1跖趾关节肿大[2],直到德国外科医生Carl Hueter (1838~1882)首次用"hallux abducto valgus"来描述"外翻",该畸形才被准确地描述为"发生在跖趾关节的第1跖骨横向偏移"[3].关于外翻发病的内因与外因的重要性问题争论了一个世纪仍未得到解决.20世纪50年代,Sim-Fook和Hodgson对比了穿鞋和不穿鞋的人群,发现穿鞋人群外翻发病率显著升高[4].但该研究并未探究外翻与从未穿过鞋或窄头鞋人群的关系,显然外翻的发病因素并不单一,而是涉及各个方面,本文就相关研究进展做一综述.     

痛风结节1例

1　患者 ,男 ,5 3岁 ,井下采煤工人。双手掌指关节及双足跖趾关节红肿、疼痛多年 ,2年前右足第五趾外长出一肿物 ,逐渐增大。Ｘ线检查 :右第五趾骨有虫蚀状改变。实验室检查 :血尿酸 (ＵＡ) 5 80 μｍｏｌ/Ｌ。临床诊断 :右足第五趾肿物性质待查。手术所见 :肿物始于跖趾关节内 ,约 5 .0ｃｍ× 3.0ｃｍ× 3.0ｃｍ大小。首次手术切除肿物及第五趾和部分跖骨。病理检查 :灰黄色肿物 ,7.0ｃｍ× 3.0ｃｍ× 2 .8ｃｍ大小 ,表面呈颗粒状 ,不规则椭圆形 ,包膜完整 ,切面实性 ,白色 ,呈地图形。显微镜下 :常规ＨＥ染色 ,见黄褐色放射状、针形排列的…     

足趾、跖骨缺血性坏死的X线表现

<正>跖骨头缺血坏死系Freiberg(1914年)首次报道,故又称Freiberg病,主要发生在第二跖骨头,偶有相连的近节趾骨和第三跖骨,第四跖骨也受侵犯[1]。由于Freiberg病是一种跖趾关节退行性疾病,除患者感觉脚掌脚背疼痛外,无其它典型临床症状,临床诊断较为困难[2]。近几年来,我院共确诊趾跖骨缺血性坏死27例,现将其X线表现报道如下,以探寻X线在诊断Freiberg病中的临床价值。     

Swanson人工跖趾关节置换术治疗第2~5跖趾关节疾病的疗效评价

目的: 探讨使用Swanson双柄硅胶假体行跖趾关节置换治疗骨性关节炎、类风湿关节炎等引起的第2~5跖趾关节病变的中长期临床疗效。方法: 2010年1月至2015年10月应用Swanson双柄硅胶假体实施第2~5跖趾关节置换术21例,成功随访16例,其中,男性2例,女性14例,平均年龄(66.7±5.5)岁,类风湿关节炎9例,严重骨性关节炎5例,跖骨头骨软骨病2例。采用美国足踝外科协会Maryland足部评分系统、视觉模拟评分(visual analogue score, VAS)和影像学检查等方法对手术前后行走及跖趾关节活动度、疼痛程度等进行临床评价。结果: 随访时间17个月至5年,平均3.2年。Maryland足部评分:术前为(60.69±6.12)分,术后末次随访时为(88.13±5.84)分。术前跖趾关节活动度:背伸5.4°±3.1°,跖屈4.4°±2.7°;术后:背伸15.7°±4.5°,跖屈12.2°±4.3°,术后跖趾关节活动度较术前有明显改善,数据对比差异有统计学意义(P<0.01)。VAS评分:术前评分为(6.8±0.9)分,术后末次随访为(2.3±0.8)分,术后跖趾关节疼痛症状得到明显改善。根据美国足踝外科协会Maryland足部评分系统,术后评分较术前评分有显著性提高(P<0.01),优良率达到81.3%。结论: Swanson双柄硅胶假体跖趾关节置换术能够较好地缓解疼痛, 增加关节活动范围及稳定性,维持前足正常的行走能力,是重建第2~5跖趾关节结构、恢复关节功能的有效方法,但仍存在一些不良反应的发生概率,需要进一步改进。     

Swanson人工跖趾关节置换术治疗第2~5跖趾关节疾病的疗效评价

目的: 探讨使用Swanson双柄硅胶假体行跖趾关节置换治疗骨性关节炎、类风湿关节炎等引起的第2~5跖趾关节病变的中长期临床疗效。方法: 2010年1月至2015年10月应用Swanson双柄硅胶假体实施第2~5跖趾关节置换术21例,成功随访16例,其中,男性2例,女性14例,平均年龄(66.7±5.5)岁,类风湿关节炎9例,严重骨性关节炎5例,跖骨头骨软骨病2例。采用美国足踝外科协会Maryland足部评分系统、视觉模拟评分(visual analogue score, VAS)和影像学检查等方法对手术前后行走及跖趾关节活动度、疼痛程度等进行临床评价。结果: 随访时间17个月至5年,平均3.2年。Maryland足部评分:术前为(60.69±6.12)分,术后末次随访时为(88.13±5.84)分。术前跖趾关节活动度:背伸5.4°±3.1°,跖屈4.4°±2.7°;术后:背伸15.7°±4.5°,跖屈12.2°±4.3°,术后跖趾关节活动度较术前有明显改善,数据对比差异有统计学意义(P<0.01)。VAS评分:术前评分为(6.8±0.9)分,术后末次随访为(2.3±0.8)分,术后跖趾关节疼痛症状得到明显改善。根据美国足踝外科协会Maryland足部评分系统,术后评分较术前评分有显著性提高(P<0.01),优良率达到81.3%。结论: Swanson双柄硅胶假体跖趾关节置换术能够较好地缓解疼痛, 增加关节活动范围及稳定性,维持前足正常的行走能力,是重建第2~5跖趾关节结构、恢复关节功能的有效方法,但仍存在一些不良反应的发生概率,需要进一步改进。     

Plantar pressure and joint motion after the Youngswick procedure for hallux limitus

The effects of the Youngswick osteotomy on plantar peak pressure distribution in the forefoot are presented for 17 patients (23 feet) with mild-to-moderate hallux limitus deformity and 23 control subjects (23 feet). During 2 years of follow-up, the operation produced a significant increase in the range of dorsiflexion of the first metatarsophalangeal joint in these patients, reaching near-normal values. Preoperative and postoperative measurements, using a pressure-distribution measurement system, show that peak pressure beneath the hallux and the first metatarsal head remained unchanged. However, peak pressure was significantly increased beneath the second metatarsal head and decreased beneath the fifth metatarsal head. These findings suggest that the foot functioned in a less inverted manner postoperatively. Compared with normal feet, hallux limitus feet demonstrated significantly higher peak pressure beneath the fourth metatarsal head preoperatively and postoperatively.     

游离足趾及关节移植术对供足功能的影响

对游离第二足趾移植、多趾移植及关节移植术后的病人，进行了详细的病史复习、体格检查、步态分析及双足负重位Ｘ线检查，并采用自身对照分层分析。极少数病人供足有轻度的蹬力减退，一般不引起病人注意。其中多趾移植及关节移植组术后供足问题相对较多，跖骨截骨的第二足趾移植组次之，跖趾关节离断组最少，但均不影响日常生活和工作。本组手术对双足步态无明显影响。术后供足内侧纵弓无影响，但有引起拇趾外翻的倾向，跖骨截骨组远期可出现足外侧纵弓下降现象。     

Use of a Kirschner wire for distraction and capsular flaps in the Keller interpositional arthroplasty

We describe a simplified capsular interpositional technique for the Keller bunionectomy that uses a Kirschner wire to interpose the capsule into the first metatarsophalangeal joint without requiring sutures. The capsule acts as a biologic spacer in the first metatarsophalangeal joint, allowing for fibrosis to fill the void created, with the Kirschner wire maintaining the distance between the metatarsal head and the stump of the proximal phalanx. This creation of a nonpainful pseudarthrosis prevents shortening of the hallux and retraction of the base of the proximal phalanx on the metatarsal head.     

扁平足第二跖纵弓疲劳损伤的生物力学机制

目的 研究扁平足和正常足的第二跖骨与足底腱膜的过劳性损伤生物力学机理,对比分析步态周期中扁平足与正常足疲劳损伤的危险性,为制定临床防治措施提供定量化理论依据。方法 采用生物力学实验和计算医学手段,通过有限元方法和疲劳损伤理论分析,开展了步态周期中扁平足和正常足疲劳行为的计算机定量模拟,并通过足骨应力集中部位测定及足弓变形X线片测量来验证模型的可靠性。结果 建立了扁平足弹性足弓有限元模型,计算得到步态周期各个阶段扁平足第二跖骨和足底腱膜的动态应力峰值分别约为28．77MPa和12．53MPa,扁平足的第二跖骨动态应力比正常足增加了8％～21％,扁平足的足底腱膜动态应力比正常足增加了21％～51％。足底腱膜发炎或部分切除后扁平足和正常足的张拉应力都发生了转移,最大相对量转移发生于足底长韧带,最大绝对量转移发生于第二跖骨底,但扁平足的最后应力始终超过正常足0．26～5．32MPa。结论 无论扁平足或正常足,其应力集中部位均发生于第二跖骨和足底腱膜,但扁平足的疲劳应力峰值始终高于正常足。足底各类软组织中,足底腱膜承受的张拉应力最大,足底腱膜发炎或外科部分切除导致腱膜张拉应力转移,加剧了足底固有肌和长韧带的劳损,同时也增加了第二跖骨疲劳骨折的危险性。扁平足的足踝内旋,足弓塌陷,以及mu囊炎引发的第二跖骨槌状畸变,均可增加过劳性损伤的发病率。     

Ⅱ型糖尿病患者前行和倒走时的足底压力变化

目的 探讨Ⅱ型糖尿病患者前行与倒走时的足底压力与足部知识及自护行为的情况,为临床寻求减少糖尿病足发生率的方法提供依据.方法 对医院收治的105例Ⅱ型糖尿病患者设为观察组,同期选择在医院进行健康体检的105名正常人为对照组,检测两组足底压力及压力中心轨迹变化,并对观察组进行足部知识自护问卷调查.结果 与对照组相比,观察组在第2～5趾、第2跖骨区的峰值压力显著降低,差异具有统计学差异（P＜0.05）,而在第3跖骨、第1跖骨、足跟内侧这三个区域双足底的压力均增大（P＜0.05）;与前行时相比,观察组患者倒走时在第1趾、第2～5趾、第1跖骨、足中部或足弓、足跟内侧、足跟外侧等各个区域的双足足底峰值压力均有不同程度的增加（P＜0.05）;但在第3跖骨区域倒走时双足压力却较前行时显著降低（P＜0.05）;观察组倒走时的足底压力中心轨迹在X轴上的位移相比于前行时显著增大（P＜0.05）,但在Y轴上的位移则明显减小（P＜0.05）,双足在位移上差异不大;Ⅱ型糖尿病患者问卷总分为（20.64±3.47）分.结论 糖尿病患者前行时足底压力分布与正常人存在差异;倒走时较前行时足底压力区域分布更为均匀,前足掌压力减轻,缓解了该区疲劳损伤,能起到预防糖尿病的作用;应加强对糖尿病患者足部保护知识及自护行为的教育指导,减少糖尿病足的发生率.     

Effect of foot posture and inverted foot orthoses on hallux dorsiflexion

A pronated foot posture is considered to be a factor in limitation of dorsiflexion at the first metatarsophalangeal joint during weightbearing. Customized foot orthoses are widely used to increase dorsiflexion at the first metatarsophalangeal joint in people with pronated feet. However, the effect of foot posture and customized foot orthoses on maximum first metatarsophalangeal joint dorsiflexion has not been widely investigated. This study sought to determine 1) the relationship between foot posture and static maximum first metatarsophalangeal joint dorsiflexion and 2) the effect of customized foot orthoses on static maximum first metatarsophalangeal joint dorsiflexion in people with pronated feet. Foot posture was assessed using the Foot Posture Index. Static maximum first metatarsophalangeal joint dorsiflexion of the right foot was determined using a goniometer while participants stood relaxed with and without Blake-style inverted (30 degrees) foot orthoses positioned under their feet. There was a significant negative correlation between Foot Posture Index and static maximum first metatarsophalangeal joint dorsiflexion (r = -0.587). Inverted (30 degrees) foot orthoses increased the magnitude of static maximum first metatarsophalangeal joint dorsiflexion from 83.4 degrees to 85.3 degrees in participants with an excessively pronated foot posture. However, this difference was not statistically significant. People with pronated feet are more likely to exhibit limitation of dorsiflexion at the first metatarsophalangeal joint during gait, and inverted foot orthoses are unlikely to be effective in increasing dorsiflexion at the first metatarsophalangeal joint in these people.     

Lesser-metatarsal medial displacement osteotomy for the treatment of digital transverse plane deformities

We sought to evaluate the clinical and radiographic outcomes in patients treated with a medial displacement transverse osteotomy of the second metatarsal to correct transverse hammer toe deformities. Eighteen patients underwent 20 procedures in 3 years. Each patient had a transverse plane deformity of the second metatarsophalangeal joint. Evaluation consisted of clinical examination, radiographic examination, and self-reported pain and function parameters. Mean +/- SD follow-up was 2.5 +/- 1.0 years. Radiographic joint congruence improved from 20% before surgery to 95% after surgery. Clinical examination revealed a rectus digit in 85% of cases, a transverse plane deviation in 10%, and a residual hammer toe deformity in 5%. At follow-up, the mean +/- SD visual analog scale score for pain with activity was 2.2 +/- 2.8 and for pain at rest was 0.6 +/- 1.4. Ninety-five percent of the patients said that they would undergo the procedure again. Medial displacement osteotomy for transverse plane deformity of the second metatarsophalangeal joint is a reliable procedure, with substantial improvement in joint congruence and self-reported pain.     

CLINICAL CONCEPTION OF KELLER''''S OPERATION FOR HALLUX VALGUS DEFORMITY——A SURVEY OF 112 CASES

In a long-term follow-up study (average, 6.5 years) of 112 feet (90 pa-tients) subjected to Keller's operation for hallux valgus deformity, the author observed arelationship between Keller's operation and the metatarsalgia which was located beneaththe central metatarsal heads. The data showed that the metatarsalgia developed or was ag-gravated in 26 feet (23%), and was eliminated or alleviated in 23 feet (21%) afterKeller's operation. When more than one-third of the proximal phalanx of the big toe wasresected, the incidence of the metatarsalgia obviously increased following surgery. Theautho rpreferred a "Z" lengthening of the extensor hallucis longus tendon instead ofresecting excessive proximal phalanx. The total incidence of the metatarsalgia was 36%(40 feet) preoperatively and 38% (43 feet) postoperatively. This result indicated thatthere was no obvious difference in the incidence of the preoperative and postoperativemetatarsalgia. No more than one-third of the proximal phalanx of the big toe should beremoved. This seems to reduce the incidence of the metatarsalgia after Keller's operation.After operation, the three princepal symptoms of hallux valgus deformity, painful bunionand difficulty in shoe-wearing were improved for more than 95% in the 112 feet.Eighty one% of the patients were satisfied with the result of the operation. We considerthat this method is one of the effective operation for correcting the hallux valgusdeformity and it is also important to select suitable patients.