足趾和/或(足母)甲瓣移植再造手指

目的总结120例164指足趾和/或甲瓣移植再造手指全部获得成活的临床经验.方法自1989年以来,共采用足趾和/或甲瓣移植再造手指120例164指,单个拇指再造58例,双拇指再造5例,2～4指单指再造24例,多指再造33例.其中2指再造28例,3指再造4例,4指再造1例.结果3例术后发生血管危象,经及时处理均得以纠正,所有手术全部一期完成并全部获得存活.结论1.明确趾蹼分型,尤其是明确第一跖骨背动脉和第一趾底动脉在趾蹼的交通情况,是确定采用第一跖骨背动脉系统,还是采用跖底动脉系统或其他第二套供血系统的首要依据.并将趾蹼间血管按交通支情况分为3型：Ⅰ型：交通支口径＞0.5mm;Ⅱ型交通支口径＜0.5mm;Ⅲ型：无交通支.2.以第一跖骨底动脉系统作为第二套供血系统更安全.3.在条件允许的情况下采用趾-指动脉吻合是避免第一跖骨背动脉或趾蹼血管解剖变异风险的最好选择.     

足趾移植中的血管分型及其临床意义

目的 分析３０４例足趾移植病例的血管形态，并提出其分型标准及临床意义。方法 对３０４例足趾移植中第一跖骨背动脉的解剖位置，口径及其在趾蹼部的分支情况进行分类。对２００例足趾移植中趾背静脉的回流情况。进行分类。结果（１）第一跖骨背动脉的分型；Ａ，按解剖位置分；①浅表型５８例，占１９．０８％；②肌内型１７２例，占５６．５８；③肌下型７４例，占２４．３４％；④缺如型１６例，占总数的５％。Ｂ．按口径分；９     

第一跖骨背动脉变异的第二足趾游离移植

目的　提出一种解决足趾游离移植中血管变异的新术式。方法　术中发现第一跖骨背动脉有变异。该动脉虽为浅表型 ,中点处口径大于 1mm,属中型 ;但在趾蹼处进入第二趾时 ,其动脉口径纤细 (细支型 )。这种解剖变异属顾玉东分型中的 M/ F型。由于进入趾的动脉在趾蹼远端有一口径较粗的分支进入第二趾 ,术中在该分支以远将趾蹼处皮下组织与动脉周围结缔组织缝合固定 ,切取趾蹼背侧半 ,必要时可将趾腓侧与趾蹼和第一跖骨背动脉分支相连的皮下组织 ,连同第二趾一并游离移植至受区。结果　共作 2例 ,术后移植足趾血循环良好 ,经过顺利 ,全部成活。结论　顾玉东分类法对此类血管变异者 ,在临床上有重要的指导意义。对该种变异采用部分趾蹼连同周围皮下组织移植的方法 ,处理简便、安全而有效。     

第一趾蹼间结构层次与血管的关系及其临床意义

目的探讨第一趾蹼间血管神经与第一跖骨深横韧带、伸肌扩张部的关系。方法在４２侧成人下肢尸体标本上，观测第一跖骨深横韧带、伸肌扩张部的起止形态，以及与第一跖背动脉、第一跖底动脉的关系。结果第一跖骨深横韧带分为跖层和背层。Ⅰ、Ⅱ型第一跖背动脉的远端段位于伸肌扩张部的浅面，第一跖底动脉远端段恒定地位于第一跖骨深横韧带跖层的深面。结论寻找第一跖背动脉远端段时，应在伸肌扩张部的浅面解剖；寻找第一跖底动脉远端段时，应在第一跖骨深横韧带跖层的深面解剖。     

伸肌扩张部寻找第一跖背动脉在手指再造中的应用

目的确定第一趾蹼间结构层次与血管的关系,并应用于足趾再造手指中。方法对42侧成人下肢标本进行解剖学研究,观察第一跖背动脉和第一跖骨深横韧带、伸肌扩张部的关系。在临床上对36例拇指缺损的病人,在伸肌扩张部寻找第一跖背动脉切取足趾再造拇指。结果Ⅰ、Ⅱ型第一跖背动脉的远侧段位于伸肌扩张部的浅面。切取足趾时由过去的平均1h30min缩短为50min。再造手指全部成活。结论第一跖背动脉的远侧段位于伸肌扩张部的浅面恒定,在伸肌扩张部寻找第一跖背动脉,采用“顺逆行结合法”解剖第一跖背动脉,对绝大部分Ⅰ、Ⅱ型病例,可以较易找到第一跖背动脉的远侧段。     

正常人足部动脉彩色多普勒血流显像及临床意义

目的 探讨应用彩色多普勒超声显像方法对正常人足部动脉的解剖结构进行无损伤检测的可行性。方法 应用彩色多普勒检测对正常32人64足的足背、跖背、跖底动脉行径、来源与口径进行探测。结果 64足中16只检测到足背动脉弓，出现率为25％，36足检测到第二跖背动脉，出现率为56．2％，37足检测到第二跖底动脉，出现率为57.8％；1例足背动脉缺如，占1．6％，其第一跖背动脉来源于腓动脉。59足检测到第一跖背动脉，出现率为92．2％，其中，顾玉东I型，占28．1％，Ⅱ型，占46．9％(30例)，6足为Ⅲs型，占9．4％，正常人足部动脉彩超结果表明，5足为Ⅵ型，占7．8％。结论 应用彩色多普勒超声显像的方法可以对足部动脉的解剖结构进行无损伤的检测；以足背动脉为共同血管蒂，第一、二跖背(底)为动脉蒂共干同时移植拇趾皮甲瓣和第二足趾(或二、三足趾)，扩大再造手的虎口，改进现有单足供趾再造手技术的方法是可行的。     

第一跖背动脉逆行岛状皮瓣修复趾创面

趾在足部具有附着、防止滑跌,负重,辅助足的推进、弹跳、背伸、跖屈及内翻,维持足的内侧纵弓等作用,修复趾创面最大限度保留其功能具有重要意义。自1995年1月始,我们采用第一跖背动脉逆行岛状皮瓣修复趾,临床应用6例,全部成功,效果良好,报道如下。手术要点以第1趾蹼背根部相当于第一跖背动脉与第一跖底动脉的交通支处定为皮瓣的“旋转轴”点,此点至第一跖骨间隙近端足底深支发出点的连线为皮瓣的“轴心线”。先纵行切开第一趾蹼,分离出交通支并逆行向上分离至皮瓣远端,血管蒂两侧各带1cm宽的深筋膜并携带浅表的第一跖背静脉以利回流。…     

九种游离足部皮瓣及复合皮瓣在手外科的应用

从１９８７年以来，临床应用９种吻合血管的足部游离皮瓣或复俣皮瓣治疗２２例手外伤，包括：（１）带趾长伸肌腱的足背，趾蹼，趾腹，趾背复合皮瓣（２）第二跖趾关节复合皮瓣；（３）拇甲瓣；（４）第一趾蹼皮瓣；（５）只吻合动脉，神经的拇趾腓侧趾腹皮瓣；（６）带足背皮瓣的拇甲瓣；（７）带足背皮瓣的第二足趾；（８）带腓浅神经的足背皮瓣；（９）带第二跖骨的第一趾蹼皮瓣。     

九种游离足部皮瓣及复合皮瓣在手外科的应用

从１９８７年以来，临床应用９种吻合血管的足部游离皮瓣或复合皮瓣治疗２２例手外伤，包括：①带趾长伸肌腱的足背、趾蹼、趾腹、趾背复合皮瓣；②第二跖趾关节复合皮瓣；③甲瓣；④第一趾蹼皮瓣；⑤只吻合动脉、神经的趾腓侧趾腹皮瓣；⑥带足背皮瓣的甲瓣；⑦带足背皮瓣的第二足趾；⑧带腓浅神经的足背皮瓣；⑨带第二跖骨的第一趾蹼皮瓣。均获满意效果。就足部皮瓣的选择原则、应用指征、优缺点及手术注意事项等进行了讨论     

第一趾蹼皮瓣游离移植重建口角的应用解剖

目的为第一趾蹼皮瓣移植修复重建颜面口角软组织缺损提供解剖学基础。方法解剖观测40侧成人下肢标本第一趾蹼皮肤软组织区域的血管和神经分布。结果该区由第一跖背动脉供血，第一跖背动脉为足背动脉的分支，其主干长为(4.6士0.6)cm，起始处外径为(1.6士0.3)mm，感觉神经来自腓深神经。结论第一趾蹼皮瓣与口角形态、厚薄近似，取材方便，吻合血管易于成活，是口角再造的理想组织瓣。     

The crossover toe and valgus toe deformity

Second toe problems are among the most common of all forefoot complaints. Its proximity to the hallux combined with limited motion at the second tarsometatarsal joint likely contributes to the second MTP joint being the most common to experience both pain and deformity. Many causes have been linked to this problem, which has lead to many surgical techniques to correct this deformity. Although many techniques have been described, a systematic approach relying first on soft tissue releases and plication followed by osteotomies as necessary has lead to satisfactory outcomes in the treatment of this difficult problem.     

Neuropathic toe ulcers treated with toe flexor tenotomies

BACKGROUND: Foot ulcers are common causes of hospital admissions for infection and amputation in patients with neuropathy. This retrospective study evaluates the results of treating plantar neuropathic toe ulcers with percutaneous flexor tenotomy. METHODS: From 1996 to 2003, 28 toe ulcers in 18 patients were treated with tenotomy of the toe flexors. RESULTS: Fourteen of 18 patients had diabetic neuropathy. No patients were lost to followup. Average followup for the 28 ulcers was 36 (range 20 to 65) months. All ulcers healed. None of the 11 lesser toe ulcers recurred. Three of 17 first toe ulcers recurred but two that had repeat tenotomy healed and did not recur. There were no toe amputations, infections, or other complications of tenotomy. One patient had unrelated transtibial amputation. CONCLUSIONS: No long-term results of treating toe ulcers with toe flexor tenotomy by other authors have been found. Toe flexor tenotomies appear to be effective and safe treatment for neuropathic toe ulcers.     

拇趾毁损伤的再造

目的介绍逆行足内、外侧双岛状瓦合皮瓣加髂骨植骨再造足拇趾外伤性缺损的临床经验。方法对拇趾及踌、第2趾毁损且跖趾关节完好者,采用以足背动脉跖底深支为蒂,以内踩前或跗内侧血管、外踝前或跗外侧血管为分支的足内、外侧分叶皮瓣瓦合加髂骨植骨再造足拇趾。结果术后皮瓣顺利成活,经6～18个月随访,再造足拇趾外形满意,皮瓣两点辨别觉6-8mm,X线示髂骨与残端趾骨骨性愈合,髂骨未见吸收征象．拇趾跖趾关节背伸达40°,屈曲达30°。结论采用逆行足内、外侧分叶瓦合皮瓣加髂骨植骨再造拇趾是一种简单有效的方法。     

Double toe transfers

Ten double toe transfers for mutilating hand injuries have been studied. In two patients with total loss of all digits, pincer pinch was restored by the transfer of two separate toes, one to each side of the stump. Seven patients had survival of the thumb and a three-point chuck pinch was provided by transfer of a second toe plus a wrap-around flap over a bone graft to create a third, but stiff digit. One patient required three fingers and was treated by one single toe transfer and one double toe transfer.     

The great toe

The biomechanics of the great toe and the pathologic anatomy of a hallux valgus deformity are presented. Patient evaluation is discussed. The section on decision making includes explanations of the Akin, chevron, and Mitchell procedures and instances for which the use of each is recommended.     

Lesser toe deformities

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.     

Mallet toe deformity

Mallet toe is one of the most common deformities encountered by orthopedic surgeons. Care needs to be taken to ascertain whether it is a primary condition or secondary to a systemic disease, especially if multiple deformities are present. There are numerous operative strategies available, but each has its specific indications. If the indications are followed, highly successful outcomes may be achieved.