超声引导腘窝上坐骨神经联合隐神经阻滞在拇外翻合并跖趾关节脱位手术的临床观察

目的 :探讨超声引导腘窝上坐骨神经联合隐神经阻滞在前足矫形手术中的临床疗效。方法 :自2017年1月至2017年10月,将60例拇外翻合并跖趾关节脱位需要手术治疗的患者,采用随机数字表法分为试验组和对照组。试验组30例采用超声引导腘窝上坐骨神经联合隐神经阻滞,其中男13例,女17例,年龄31～76(59.23±10.07)岁;体重指数为21～30(24.57±1.85) kg/m~2;ASA分级:Ⅰ级12例,Ⅱ级18例。对照组30例采用单次腰麻,其中男12例,女18例,年龄20～74(54.20±15.87)岁;体重指数为20～29(24.43±3.15) kg/m~2;ASA分级:Ⅰ级11例,Ⅱ级19例。观察两组患者麻醉的阻滞时间、感觉神经阻滞起效时间、运动神经阻滞起效时间、运动神经经阻滞失效时间、感觉神经阻滞失效时间;比较阻滞前(T_0),阻滞后15 min(T_1),阻滞后30 min(T_2),手术开始时(T_3),手术开始后30 min(T_4),术毕(T_5)的血流动力学变化,观察患者的不良反应情况及主观满意度。结果:两种麻醉方案均获得满意的临床效果。试验组的麻醉阻滞时间、感觉神经阻滞起效时间、运动神经阻滞失效时间、感觉神经阻滞失效时间长于对照组,差异有统计学意义(P0.001);两组的运动神经阻滞起效时间相比,差异无统计学意义(P0.05)。试验组麻醉后各时间点的收缩压(SBP)、舒张压(DBP)和心率(HR)与阻滞前(T_0)相比,差异无统计学意义(P0.05);对照组麻醉后各时间点的收缩压(SBP)、舒张压(DBP)与阻滞前(T_0)相比,差异有统计学意义(P0.05);心率(HR)与阻滞前(T_0)相比,差异无统计学意义(P0.05)。结论:超声引导腘窝上坐骨神经联合隐神经阻滞能够满足拇外翻及前足疾病手术的需求,维持血流动力学平稳,同时可有效延长术后镇痛时间,并且膝关节以上部位可以自由活动,提高了患者的整体舒适度及安全性。     

第1跖趾关节融合结合外侧足趾旋转Weil截骨治疗重度跖内收型拇外翻

目的：探讨第1跖趾关节融合结合外侧足趾旋转Weil截骨治疗重度跖内收型拇外翻临床疗效。方法：回顾性分析自2017年3月至2021年8月接受第1跖趾关节融合结合旋转Weil截骨治疗的重度跖内收型拇外翻患者37例（69足）,男8例（11足）,女29例（58足）;年龄67～83(70.03±2.87)岁;左侧3例,右侧2例,双侧32例。分别于术前、术后6周及末次随访时,采用疼痛视觉模拟评分（visual analogue scale,VAS）进行疼痛缓解程度评价。术前及末次随访时采用美国骨科足踝外科学会（American Orthopaedic Foot and Ankle Surgery,AOFAS）前足评分对患足功能进行评价。并测量手术前及末次随访时拇外翻角（hallux valgus angle,HVA）,第1、2跖间角（intermetatarsal angle,IMA）的变化情况。结果：37例（69足）患者获得随访,时间12～48 (22.8±0.6)个月。术后7～10(8.00±1.21)周第1跖趾关节处达到骨愈合,无延迟愈合及不愈合发生。术前HVA (44.30±2.84)°与...     

Great toe metatarsophalangeal arthrodesis for hallux valgus deformity in ambulatory adolescents with spastic cerebral palsy

Background  Hallux valgus deformity is a common sequel of spastic cerebral palsy. Methods  Twenty ambulatory patients (24 feet) suffering hallux valgus deformity, with painful forefoot and restricted footwear, secondary to spastic cerebral palsy acquired perinatally, were treated with great toe metatarsophalangeal (MTP) arthrodesis using percutaneous K-wires for fixation. The mean age at the time of surgery was 16.2 years (range 14–18 years). They were retrospectively evaluated for the results after arthrodesis at a mean interval of 3 years and 4 months (range 3–4 years) by physical examination and radiographs. Results  All patients had a stable painless aligned great toe, with <10° valgus, <20° dorsiflexion and neutral rotation after arthrodesis, evidenced by improvement in pain, cosmesis, functional activity, footwear, callosities and hygiene, as well as by significant improvement in the measures of the MTP and the intermetatarsal angles (IMA) by postoperative radiographs. Neither non-union (pseudoarthrosis) nor recurrence of the deformity developed. Complications included superficial wound slough in a single case. Using the modified American Orthopaedic Foot Ankle Society (AOFAS) Hallux Metatarsophalangeal–Interphalangeal Scale, 18 feet (75%) were classified as excellent and six feet (25%) as good. Neither fair nor poor cases were recorded. Conclusion  Hallux valgus deformity in adolescents with spastic cerebral palsy is best treated by great toe MTP arthrodesis to improve segmental foot malalignment and dynamic foot deviation.     

The first metatarsophalangeal joint meniscus and its relation to hallux valgus deformity—An anatomical and clinical study

Background

This study describes the anatomy and incidence of the metatarsophalangeal (MTP) joint meniscus, a structure not mentioned before in literature.

Methods

An anatomical cadaver study on 102 feet was performed with special attention to the first MTP joint anatomy. These results were compared with the per-operative findings in a clinical prospective study on 100 consecutive hallux valgus surgeries.

Results

On cadavers this meniscus is more common in patients with hallux valgus. Clinically, in patients with a mild hallux valgus the meniscus is found in more than half of cases during surgery, while it is seldom found in patients with moderate or severe deformities.

Conclusions

The presence of this structure seems to stabilize the MTP joint preventing progression of the hallux valgus deformity and may explain the pain, which is often seen in mild bunions in younger, patients. Once the rotational deformity increases the meniscus tears and slips into the joint. In the more advanced hallux valgus deformity this meniscus plays little function and seems to disappear, leading to arthrosis.     

Quantitative relationship of first metatarsophalangeal head morphology to hallux rigidus and hallux valgus

Background

Previous qualitative studies have linked first metatarsal head morphology with hallux valgus (HV) and hallux rigidus (HR). This study used a quantitative measurement of 1st MT radius of curvature to assess if HR MT heads were flatter than HV heads.

Hallux sesamoid bones. Anatomical observations with special reference to osteoarthritis and hallux valgus

Summary The normal characteristics of the hallux sesamoid bones were studied in 200 toes (100 dissections and 100 radiographs from patients with hallux valgus), and pathological changes were recorded. Normally each sesamoid articulated with a separate groove on the plantar surface of the first metatarsal head. A bony ridge on the head separated these grooves.Bipartite sesamoids were found in 4% of the toes. Osteoarthritic changes manifested by deformity, irregularity, lipping, cysts in the sesamoids and in the heads of the first metatarsal and erosions in the articular surfaces were present in 32% of the dissected toes. Fusion of the sesamoids was found in 6%. Ankylosis between the sesamoids and the head of the metatarsal was observed in 4%.In the toes affected by hallux valgus the sesamoids, together with the plantar pad and the tendon of the flexor hallucis brevis, were displaced laterally to a variable degree. In severe deformities the lateral sesamoid was dislocated lateral to the first metatarsal head and the medial sesamoid occupied the groove originally corresponding to the lateral sesamoid, while the metatarsal ridge separating the two sesamoids tended to disappear. Osteoarthritis of the metatarsophalangeal joint frequently accompanied hallux valgus.     

The effect of gender in hallux valgus surgery. A propensity score matched study

BackgroundMales and females who undergo hallux valgus (HV) surgery have different expectations.MethodsData from 439 patients, with 26 males, were prospectively collected between 2007–2015. Propensity score matching (PSM) of one male to two females was performed using logistic regression of six variables to minimize selection bias. Hallux visual analogue scale (VAS) scores, AOFAS scores, SF-36, satisfaction and expectation scores were analysed at two years.ResultsThere were no significant differences in patient demographics after PSM. At two years, males and females attained similar VAS and AOFAS scores but males had significantly lower SF-36 general health score (males 68.7, females 79.3). 26.9% of males and 21.2% of females were not satisfied after surgery. Higher proportion of males did not have their expectations fulfilled (males 19.2%, females 5.8%) although this was not statistically significant.ConclusionsBoth genders attain similar outcome at two years. There is a trend towards lower expectation fulfilment in males after surgery.     

Ludloff截骨+跖趾关节置换治疗重度拇外翻的临床研究

目的 探讨Ludloff截骨+跖趾关节置换治疗伴有跖趾关节骨性关节病的重度拇外翻的临床效果.方法 选取首都医科大学附属北京友谊医院2013年4月-2015年8月的病例,共120例,术前通过足部负重正位片,测量踇外翻角、跖骨间角、近端关节面固有角,并进行Maryland评分评价患者足部情况,组间进行t检验,两组间术前资料差异无统计学意义,具有可比性.两组诊断均是伴有跖趾关节骨性关节病的重度拇外翻患者进行研究,按照入院顺序随机分为试验组和对照组,每组各60足.试验组采用Ludloff截骨+跖趾关节置换治疗,对照组采取Ludloff截骨+Akin截骨的手术方法治疗.采用视觉模拟评分量表评价患者的疼痛,采用生活质量核心量表以及Maryland足功能评分对两组患者手术前后的疼痛、跖趾关节活动、外观及稳定情况、日常生活质量及体育活动情况,进行统计分析,组间比较采用t检验,手术前后比较采用配对t检验,采用Fisher确切概率法分析两组间并发症的差异.结果 试验组总优良率(91.7％)高于对照组的总优良率(75.0％),差异具有统计学意义(P＜0.05);试验组不良反应发病率(1.7％)低于对照组不良反应发病率(8.3％),但是差异无统计学意义(P＞0.05);试验组治疗后生活质量各维度评分明显高于对照组,差异有统计学意义(P＜0.05);术后试验组的VAS疼痛评分(1.61±0.12)明显低于术后对照组(3.68±0.58),差异有统计学意义(P＜0.05).结论 采用Ludloff截骨+跖趾关节置换治疗伴有跖趾关节骨性关节病的重度拇外翻的临床效果较好、安全性强、创伤小、患者恢复快,有一定的推广和使用价值.     

Degenerative osteoarthrosis of tarsometatarsal joints in hallux valgus: a radiographic study

To clarify the pathogenesis of degenerative osteoarthrosis of the tarsometatarsal joints in hallux valgus, we evaluated dorsoplantar and lateral radiographs during weight-bearing in 16 patients (25 feet) with hallux valgus accompanied by degenerative osteoarthrosis of the tarsometatarsal joints and 25 controls (25 feet) with hallux valgus alone. The proximal second metatarsal articular angle (a parameter we devised), the hallux valgus angle, intermetatarsal angle, metatarsal length, sesamoid displacement, calcaneal pitch, and foot length were measured and then evaluation using a mapping system was performed. There were no significant differences in the hallux valgus angle, intermetatarsal angle, sesamoid displacement, calcaneal pitch, or foot length. In the presence of degenerative osteoarthrosis of the tarsometatarsal joints, the second, third, and fourth metatarsals were long, and a large inclination of the proximal articular surface of the second metatarsal and adduction of the first to fourth metatarsals were observed. These findings appeared to be involved in the development of this disorder.     

关节镜下行(足母)外翻外侧松解背侧入路的研究

目的探讨关节镜下行躅外翻外侧松解背侧入路的可行性及方法。方法解剖研究采用10具新鲜保留踝关节的足部标本。在关节镜监视下,以钩刀松解外侧关节囊和躅内收肌斜头。观察各入路与周围神经血管、肌腱之间的关系,并统计松解范围。临床研究对5例躅外翻患者行关节镜下外侧松解加内侧软组织紧缩手术,患者均为女性,平均年龄30岁。术前躅外翻角为24^o-38^o,平均30^o,跖间角为9^o-11^o,平均10^o。结果解剖研究近侧切口与躅短伸肌腱非常接近,为0—3mm,平均1．5mm;与躅长伸肌腱相距为1—4mm,平均2．4mm。远侧切口与第一趾背动脉和趾背神经非常接近,为1～3mm,平均1、4mm,极易损伤。6例正常足中,1例松解跖籽骨韧带,1例作部分松解（70％）。在4例足母外翻足中,2例松解跖籽骨韧带,1例作了部分松解（50％）。临床研究5例患者平均随访时间9个月。最后一次随访时X线片示足母外翻角4^o-9^o,平均7^o,跖间角8^o～10^o,平均9^o。患者均恢复良好,对外形满意,未见肌腱损伤、麻木、感染、跖趾关节僵硬等并发症发生。结论背侧入路关节镜下外侧松解是可行的,其手术切口较小,镜下视野清晰,可以根据需要松解外侧结构的各个部分,由于不损伤血管,减少了跖骨头坏死的发生。     

外翻合并第二跖骨头下疼痛的生物力学定量研究

目的探讨跖骨头下压力变化与(足,母)外翻合并跖骨头下疼痛的关系,并对引起第二跖骨头下疼痛的跖骨头下压力进行定量分析.方法采用由中国中医研究院骨伤科研究所生物力学实验室研制的足底压力测试系统,对58名正常人(116足),32例(45足)(足,母)外翻单纯合并第二跖骨头下疼痛患者,56例(102足)(足,母)外翻无足底疼痛患者进行足底压力测试,将三组跖骨头下压力进行比较.采用病例-对照设计,研究压力与疼痛的关系,并对引起第二跖骨头下疼痛的压力进行定量分析.结果 (1)(足,母)外翻单纯合并第二跖骨头下疼痛组分别与(足,母)外翻无足底疼痛组及正常组比较,第二跖骨头下压力均明显增高(均P＜0.05);(2)第二跖骨头下压力高于正常组与第二跖骨头下压力不高于正常组比较,疼痛的发生率明显增加(P＜0.05,OR＞3,OR 95%CI＞1);(3)(足,母)外翻合并第二跖骨头下疼痛组第二跖骨头下压力占体重的5.20%～7.29%.结论跖骨头下压力异常增高是跖骨头下疼痛的危险因素,第二跖骨头下压力超过体重的5.20%,极易出现跖骨头下疼痛.     

(足,母)外翻合并第二跖骨头下疼痛的生物力学定量研究

目的探讨跖骨头下压力变化与蹰外翻合并跖骨头下疼痛的关系，并对引起第二跖骨头下疼痛的跖骨头下压力进行定量分析。方法采用由中国中医研究院骨伤科研究所生物力学实验室研制的足底压力测试系统，对58名正常人（116足），32例（45足）拇外翻单纯合并第二跖骨头下疼痛患者，56例（102足）拇外翻无足底疼痛患者进行足底压力测试，将三组跖骨头下压力进行比较。采用病例一对照设计，研究压力与疼痛的关系，并对引起第二跖骨头下疼痛的压力进行定量分析。结果（1）蹲外翻单纯合并第二跖骨头下疼痛组分别与拇外翻无足底疼痛组及正常组比较，第二跖骨头下压力均明显增高（均P〈0．05）；（2）第二跖骨头下压力高于正常组与第二跖骨头下压力不高于正常组比较，疼痛的发生率明显增加（P〈0．05，OR〉3，OR95％CI〉1）；（3）拇外翻合并第二跖骨头下疼痛组第二跖骨头下压力占体重的5．20％-7．29％。结论跖骨头下压力异常增高是跖骨头下疼痛的危险因素，第二跖骨头下压力超过体重的5．20％，极易出现跖骨头下疼痛。     

Minimally invasive hallux valgus surgery: a critical review of the evidence

This systematic review aims to illustrate the published results of “minimally invasive” procedures for correction of hallux valgus. Based on former systematic reviews on that topic, the literature search was organised by two independent investigators. MEDLINE was systematically searched for available studies. The keywords used were “hallux valgus”, “bunion”, “percutaneous surgery”, “minimally invasive surgery”, “arthroscopy”, “Bosch” and “SERI”. Studies were assessed using the level of evidence rating. A total of 21 papers were included in this review. These studies described a total of 1,750 patients with 2,195 instances of percutaneous, minimally invasive or arthroscopic hallux valgus surgery. Clinical reports of results after minimally invasive hallux valgus surgery at meetings are common. Published results in peer-reviewed journals are less common and the majority of papers are level IV studies according to the level of evidence ratings. We found one level II and three level III studies. Reported complications seem to be less than one may see in one’s own clinical practice. This possible bias may be related to the fact that most studies are published by centres performing primarily minimally invasive hallux valgus surgery.     

跖骨近端短缩跖趾关节复位术治疗跖痛症合并重度跖趾关节脱位临床疗效分析

目的探讨跖骨近端短缩跖趾关节复位术治疗跖痛症合并重度跖趾关节脱位的临床疗效。方法采用跖骨近端截骨短缩、跖趾关节复位术治疗的跖痛症合并重度跖趾关节脱位65例,共83个跖趾关节,其中第2跖趾关节68个,第3跖趾关节15个。患足均于手术前后拍摄负重正侧位X线片,测量相关指标,并采用ACFAS、VAS评分对手术前后进行临床评估。结果截骨后跖骨平均短缩长度为5.94 mm。术后跖趾骨夹角、跖骨切线角、跖趾关节间隙及跖趾关节活动度等指标较术前均有改善,差异有统计学意义(P<0.05)。ACFAS评分术前为(44.06±7.54)分,术后为(90.43±3.88)分;VAS评分术前为(8.14±0.97)分,术后为(1.14±0.73)分;各评分术后均较术前明显改善,差异有统计学意义(P<0.05)。结论跖骨近端短缩跖趾关节复位术治疗跖痛症合并重度跖趾关节脱位临床疗效确切。     

Lateral sesamoid position in hallux valgus: Correlation with the conventional radiological assessment

Background

We aimed to quantify the severity of the hallux valgus based on the lateral sesamoid position and to establish a correlation of our simple assessment method with the conventional radiological assessments.

Methods

We reviewed one hundred and twenty two dorso-plantar weight bearing radiographs of feet. The intermetatarsal and hallux valgus angles were measured by the conventional methods; and the position of lateral sesamoid in relation to first metatarsal neck was assessed by our new and simple method.

Results

Significant correlation was noted between intermetatarsal angle and lateral sesamoid position (Rho 0.74, p < 0.0001); lateral sesamoid position and hallux valgus angle (Rho 0.56, p < 0.0001). Similar trends were noted in different grades of severity of hallux valgus in all the three methods of assessment.

Conclusions

Our method of assessing hallux valgus deformity based on the lateral sesamoid position is simple, less time consuming and has statistically significant correlation with that of the established conventional radiological measurements.     

手术治疗中青年女性(足母)外翻畸形

目的矫正中青年女性(足母)外翻畸形。方法经过解剖学研究,提出跨外翻形成的内在因素是一种“绞盘式”挤压机制。为消除这一机制,将(足母)收肌与跨趾的联系彻底切断,并与经第1跖骨头横孔穿行的跨囊筋膜瓣中1/3吻合,以起到坚强固定,直接牵拉第Ⅰ跖骨头的作用。结果 20只足接受了本术式,18只做了0.5～4年随诊,优良率100％。结论 (足母)收肌与(足母)囊筋膜瓣吻合,能有效地紧缩前足,达到兼顾美观及解除疼痛的目的。     

(足母)外翻足内侧足纵弓的初步研究

目的观察     

Overview of randomised controlled trials in hallux valgus surgery (2,184 patients)

BackgroundThe aim of this study is to provide an overview of randomised controlled trials (RCTs) in hallux valgus correction surgery summarising the available high-quality evidence.MethodsFollowing PRISMA guidelines, we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE (1946 to 1 February 2020) and Embase (1980 to 1 February 2020). We excluded non-randomised trials, systematic reviews and case-series. We also excluded trials of MTPJ arthrodesis. Trials that met our inclusion criteria were assessed by two authors using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to intervention groups.Results32 RCTs met the inclusion criteria and were included. The total number of patients in those trials was 2,184. Only 4 RCTs (12.5%) reported significant differences between the intervention and the control groups. The remaining trials evaluated scarf or chevron osteotomies in 18 RCTs, and 10 RCTs compared other osteotomies or technical aspects of hallux valgus surgery using functional and radiological outcome measures with none reporting significant differences.ConclusionEvidence from RCTs of hallux valgus surgery suggest that scarf and chevron osteotomies are the most popular techniques and lead to similar clinical outcomes.     

拇外翻足并发第2跖骨头下疼痛的相关因素研究

目的:通过对拇外翻足足弓的X线指标与足底压力指标的检测,分析拇趾外翻角的变化与足弓X线测量指标变化及足底压力变化的相关性,探讨拇外翻足并发第2跖骨头下疼痛影响因素。方法:采用回顾性研究方法,观察自2012年1月至2013年6月治疗的254例(477足)拇外翻患者病历资料,记录患者第2跖骨头下疼痛及年龄的情况,把所有拇外翻足按并发第2跖骨头下疼痛的有无分为两组(疼痛组和无痛组),分别测量各组负重位拇外翻足拇趾外翻角(hallux abductor valgus angle,HAVA),第1、2跖骨间角(the inter-metatarsal angle between the first and second metatarsals,IMA1-2),第1、5跖骨间角(the inter-metatarsal angle between the first and fifth metatarsals,IMA1-5),内弓顶角、前弓顶角及第1、2跖骨头的相对长度,检测步态中第2跖骨头下峰压强、冲量、触地时间百分比等压力的情况。运用相关性分析及Logistic回归分析方法,探讨拇外翻足并发第2跖骨头下疼痛的影响因素。结果:Spearman相关性分析结果示HAVA分别与各测量指标的IMA1-2、IMA1-5、内弓顶角、前弓顶角、第2跖骨触地时间百分比呈相关性(P0.05,r=0.647、0.553、0.127、-0.165、0.158)。Logistic回归分析结果示并发第2跖骨头下疼痛的影响因素为HAVA、第2跖骨相对长度、第2跖骨头触地时间百分比(P0.05,ORj=1.030,1.069,1.060)。结论:拇外翻角的增大导致了拇外翻足足弓塌陷,使步态中第2跖骨头负重的时间延长,从而导致了第2跖头下疼痛的发生。     

Postural stability impairment in patients with bilateral hallux valgus: A case-control study using a stabilometer

BackgroundHallux valgus (HV) is an important risk factor for falls (in older people); however, the detailed relationship is less understood. We aimed to evaluate postural stability in bilateral HV patients.MethodsTwo groups of 20 female patients—an HV group and a C (i.e., non-HV) group—participated in this study. Evaluations were made using the Timed Up and Go (TUG) test, the Berg Balance Scale (BBS), the Falls Efficacy Scale (FES), track length (LNG), velocity (VEL), enveloped area (ENV), and root mean square area (RMS).ResultsTUG and FES scores were significantly higher and BBS scores were lower in the HV group than in the C group. LNG was significantly longer, VEL was higher, and ENV and RMS were wider in the HV group than in the C group.ConclusionsThe HV group exhibited impaired walking mobility, balance, and postural stability.