成人获得性平足症的相关研究及进展

目的 总结成人获得性平足症的研究进展,为临床成人获得性平足症的诊断、治疗、预防提供理论依据。方法 分别以“成人获得性平足症”为关键词在万方数据库和以“acquired adult flatfoot”为关键词在PubMed数据库检索1985年1月—2017年1月与成人获得性平足症的解剖因素、发病原因及手术治疗相关文献并对其分析总结。结果 成人获得性平足症主要表现为足部骨性结构和软组织因素共同导致的足纵弓的塌陷或消失,胫后肌腱功能不全为其最常见的发病原因。若经保守治疗病情未缓解,需外科手术阻止病情进一步发展。结论 成人获得性平足症的诊治需结合发病原因、疾病分期等相关因素,对不同的患者制定个体化治疗方案。     

有限元建模分析牵开成形治疗踝关节骨性关节炎的生物力学响应

背景：目前踝关节骨性关节炎的手术方式包括关节置换和关节融合,但2种方式均存在一定问题,因此保踝治疗成为踝关节骨性关节炎初期治疗的首选方式。牵开成形是一种重要的保踝治疗术式,有利于缓解踝关节疼痛和改善功能,有助于关节软骨的自我修复,但现在仍缺乏确切的生物力学证据。目的：通过有限元建模探究踝关节牵开成形治疗早中期无明显力线改变的踝关节骨性关节炎的力学因素,为临床治疗提供力学证据。方法：将1名27岁志愿者足踝CT扫描数据DICOM文件导入有限元软件中,进行三维重建及曲面拟合,再进行网格划分,建立含有骨骼、韧带、肌腱和软骨的精细足踝有限元模型,对比踝骨关节炎组、外固定架组分别在中立0°、跖屈20°、背屈20°3种不同工况下的胫距关节面应力、距骨应力及距骨应变的生物力学响应。结果与结论：（1）经过有限元仿真计算发现,从踝关节整体受力来说,两组模型在中立位0°时最小,从中立位逐渐跖屈或背屈时,随着踝关节活动发生变化,应力值也逐渐增加,且在同等屈曲的条件下,背屈要比跖屈的整体应力增幅明显;（2）从胫距关节的应力峰值来说,踝骨关节炎组的胫距关节面应力峰值较正常组增幅明显,外固定架组的胫距关节面应力峰值...     

髋关节置换髋臼骨缺损的评估与重建选择

髋臼骨缺损的发病率逐年升高,病因多种多样,最常见于人工全髋关节置换术后。其治疗手段虽然在不断变化、更新,但成人髋臼骨缺损导致髋关节局部解剖变异及生物力学和继发性骨性关节炎的异常使手术难度增高,其手术处理一直是临床骨科医师面临的重大挑战。成人髋臼骨缺损修复重建成功的关键在于术前对缺损髋臼进行精准评估、选择合适的手术方式和正确的缺损重建假体。本文就髋臼骨缺损的病因、术前准备和计划、分型及重建手术方式进行综述。     

副舟骨源性平足症发病特点分析

目的分析副舟骨源性平足症发病特点。方法回顾性分析2006~2014年副舟骨源性平足症患者的临床资料,分析副舟骨源性平足症的发病特点。结果 66例82足副舟骨源性平足患者,男24例,女42例,年龄15~90岁,平均(37.15±16.76)岁;单侧50例,双侧16例,其中64例为II型副舟骨,2例为I型副舟骨,由于副舟骨存在,胫后肌腱解剖异常而功能受损。根据平足症分期,I期17例,II期26例,III期15例,IV期8例,柔韧性平足47例,僵硬性平足19例。结论副舟骨源性平足症临床较为常见,为胫后肌腱功能障碍性平足症,各个年龄段均可能出现,其中女性、II型副舟骨发病率高。副舟骨异常存在导致胫后功能失调为副舟骨源性平足原因。     

用髌骨重建胫骨平台关节面缺损的生物力学研究

目的研究用髌骨重建胫骨平台关节面缺损的生物力学特征，为临床手术提供理论依据。方法建立髌骨重建胫骨内侧髁或外侧髁上关节面缺损的实验装置，用实验应力分析方法测量重建后股胫关节的生物力学特征，并与理论相比较。结果实验组载荷-应变曲线、载荷-位移曲线和应力等与对照组无显著性差异(P＞0.05)。结论重建后的股胫关节能恢复正常生物力学特性。     

足踝有限元模型的建立与初步临床应用

建立足踝部有限元模型，研究胫后肌腱功能不全（DPTT）、躅外翻与第一跖列不稳的静态生物力学变化。以螺旋CT扫描正常足部图像为资源，Matlab、Surfacer、ANSYS软件为工具，建立足部有限元模型，模拟静态直立时加载，分别分析跟骨应力应变、胫后肌腱功能不全与第一跖列失稳时的内侧纵弓关节应力应变、骨骼空间位置的的变化。静态直立负重时，跟骨与第一跖骨跖侧应力最大，其中跟骨内侧最大；胫后肌腱功能不全时，可以导致第一跖列的稳定性丧失，进而发生内侧纵弓各个关节之间应力分布、大小发生变化，第一跖骨内收、跖屈，躅趾相对于第一跖骨外展趋势增大。足踝有限元模型是分析足踝生物力学的有力工具；跟痛症的发生与应力反复作用有关；DPPT可以导致第一跖列失稳，进而引起第一跖骨内收、趾外展，与反复应力作用下的躅外翻发生发展有一定关系。     

Evans截骨跟骨外侧柱延长副舟骨切除胫后肌腱重建治疗副舟骨源性平足症的临床疗效观察

目的探讨Evans截骨联合胫后肌腱止点重建治疗伴前足外展副舟骨源性平足症的方法及临床疗效。方法 2013年9月~2016年9月,对20例(25足)经半年以上保守治疗疗效欠佳的伴前足外展副舟骨源性平足症患者采用Evans截骨联合胫后肌腱止点重建治疗。应用美国矫形足踝协会(AOFAS)评分标准及VAS疼痛评分评估治疗效果,同时对比术前和终末随访的足弓高度、跟骨倾斜角、前后位跟距角、侧位跟距角、前后位距骨-第1跖骨角、侧位距骨-第1跖骨角、距舟覆盖角等X片评价指标。结果术后患者切口均Ⅰ期愈合,无相关并发症发生。跟骨外侧柱延长植骨愈合。术后20例(25足)患者获随访,随访时间6~20个月,平均12个月。末次随访时中足功能AOFAS评分、VAS疼痛评分、足弓高度、跟骨倾斜角、侧位跟距角、前后位跟距角、侧位距骨-第1跖骨角、前后位距骨-第1跖骨角、距舟覆盖角等X片评价指标与术前比较,差异均有统计学意义(P0.05)。结论采用Evans截骨联合胫后肌腱止点重建治疗伴前足外展副舟骨源性平足症可有效纠正畸形,减轻疼痛,恢复功能。     

踝关节内侧韧带损伤肌腱重建的三维有限元分析

背景：踝关节内侧三角韧带损伤的重建方法很多,但是目前还没有研究对这些方法进行对比。 目的：三维有限元法对比Wiltberger、Deland、Kitaoka和Hintermann 4种修复方法重建踝关节内侧韧带损伤肌腱后的效果。 方法：建立踝关节三维有限元模型,模型中包括踝周的6块骨性结构、软骨和主要韧带。对模型进行验证试验后,在其基础上建立三角韧带损伤、Wiltberger、Deland、Kitaoka和Hintermann重建模型。在踝关节不同屈曲角度上对模型施加外翻及外旋应力,比较重建后的踝关节生物力学。 结果与结论：4种重建方法均不能使踝关节生物力学完全恢复正常,其中Kitaoka法在恢复踝关节外旋稳定性上最有效,Deland法在恢复踝关节外翻稳定性上最有效。提示4种内侧韧带肌腱重建术式中,Kitaoka和Deland法较其他方法能够相对有效的恢复踝关节旋转稳定性。     

前交叉韧带重建的研究进展

前交叉韧带(ACL)损伤是常见的运动损伤.随着我国经济的发展,热衷运动人群的增多,该病的发病率有逐年增高的趋势.由于ACL损伤后可引起膝关节不稳定,有导致骨性关节炎的可能[1].同时它缺乏自我愈合的能力,所以这种疾病的治疗方法以手术移植物重建为主[2].目前手术重建所采用的韧带移植物可大致分为自体肌腱,异体肌腱和人工肌腱或组织工程肌腱三种[3].     

内侧柱稳定手术治疗Ⅱ期成人胫后肌腱功能不全性平足的三维有限元生物力学分析

文题释义：平足内侧柱稳定手术：是指通过实施融合固定手术即融合舟楔关节或者跖楔关节,或者两者均融合来稳定足的第一跖列,恢复内侧纵弓的高度,纠正前足的旋前。 背景：平足症是足踝外科的常见病,其中Ⅱ期成人获得性平足在临床上最多见,此期的治疗最为关键。然而Ⅱ期平足内侧柱存在着不稳定,这也是造成足弓塌陷的重要原因。内侧柱稳定手术可以相当程度地纠正畸形,但是目前尚缺乏详细的生物力学实验来全面判断内侧柱稳定后对于全足带来的影响。 目的：探讨单纯内侧柱稳定手术对Ⅱ期成人获得性平足足部生物力学的影响。 方法：首先建立Ⅱa期及Ⅱb期成人获得性平足三维有限元模型,通过Geomagic软件、Solidwork软件及Abaqus软件模拟内侧柱稳定手术(舟楔关节融合､跖楔关节融合､两者均融合),将术前和术后模型模拟单倍体质量负重,比较其足底、内外侧柱骨块、内侧韧带的最大应力值,并通过测量相关参数来进行综合对比。 结果与结论：①单纯内侧柱稳定术后模拟负重时足底应力最大值均出现在第一跖骨头下方,其中Ⅱa期模型行内侧柱稳定后足底应力最大值明显增加,Ⅱb期模型内侧柱稳定后足底应力变化不明显;②内侧柱融合后相应关节的应力有所减轻,但对于第一跖列的其他关节应力反而增加了;③内侧柱融合后对于内侧韧带及足底筋膜的应力均没有减轻作用;④结果表明,单纯内侧柱稳定手术并不能降低Ⅱ期成人获得性平足内侧柱的压力,它仅可以作为联合使用的手术来稳定过度活动的关节以及纠正前足旋后畸形。 ORCID: 0000-0002-8230-1151(刘付胜华) 中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

三维有限元方法构建足部健康骨骼与常见疾病模型及生物力学分析

文题释义： 有限元分析：利用数学近似的方法对真实物理系统进行模拟,还利用简单而又相互作用的元素,即单元,用有限数量的未知量去逼近无限未知量的真实系统。它将求解域看成是由许多称为有限元的小的互连子域组成,对每一单元假定一个合适的近似解,然后推导求解这个域总的满足条件,从而得到问题的解。由于大多数实际问题难以得到准确解,而有限元不仅计算精度高,而且能适应各种复杂形状,因而成为行之有效的工程分析手段。 DICOM：即医学数字成像和通信,是医学图像和相关信息的国际标准(ISO 12052)。它定义了能满足临床需要的可用于数据交换的医学图像格式。DICOM被广泛应用于放射医疗、心血管成像以及放射诊疗诊断设备(X射线、CT、核磁共振、超声等),并且在其他医学领域得到越来越深入广泛的应用。在数以万计的医学成像设备中,DICOM是部署最为广泛的医疗信息标准之一。当前大约有百亿级符合DICOM标准的医学图像用于临床使用。 背景：在创伤骨科方面,三维有限元分析不仅仅作为骨折内固定治疗过程中生物力学评估和内固定器材设计、优化的常规手段,近年来也为创伤骨科基础与临床研究开拓新的方向。 目的：对足部正常骨骼、扁平足、马蹄足、足部骨折病例进行三维建模及生物力学分析。 方法：选取健康受试者以及扁平足、马蹄足、足部骨折患者进行足部CT检查,根据检查数据利用计算机三维成像技术进行三维有限元建模及生物力学分析,根据分析结果得到足部健康骨骼、扁平足、马蹄足及足部骨折应力分布图以及应力值等数据,并对数据结果进行分析。该研究获得福建医科大学附属闽东医院伦理批准。 结果与结论：建立足部正常骨骼、扁平足、马蹄足、足部骨折模型并进行生物力学分析,扁平足患者跖骨、跗骨应力值较正常明显增加,马蹄内翻足的应力主要集中于踝关节周围,尤其是在距骨关节面。单纯跖骨骨折对于足跗骨区域应力变化影响较小,Lisfranc损伤患者的足跗骨区应力较正常足部增加较明显。该研究以足部三维有限元建模和生物力学分析将计算机技术与临床实际相结合,为人体足部生物力学研究提供参考,通过应力分析将多种足部情况的力学信息数值化,为足部的临床治疗提供了重要的力学依据。 ORCID: 0000-0002-7688-6990(何晓宇) 中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

Absence of the flexor digitorum longus tendon: An MRI study

Flexor digitorum longus (FDL) is the primary flexor of the lateral four toes. It is a reliable source of tendon for transfer surgery. We present a case whereby a patient who required a reconstruction for adult acquired flatfoot deformity using FDL as a dynamic structure for transfer was found to have an absent FDL tendon at the time of operation, necessitating the use of flexor hallucis longus (FHL) instead. This unusual finding prompted us to investigate the frequency of absence of the FDL tendon. We reviewed our hospital MRI database of foot and ankle images specifically looking for patients with absence of this tendon. After randomization, 756 images were reviewed independently by two surgeons and a consultant musculoskeletal radiologist. No instances of an absent FDL tendon were identified. In conclusion, the frequency of absence of the FDL tendon is less than 1 in 750. Surgeons who require FDL for tendon transfer surgery need not image the foot preoperatively to anticipate the need for the use of FHL as an alternative. Clin. Anat. 25:1062–1065, 2012. © 2012 Wiley Periodicals, Inc.     

Effects of Degree of Surgical Correction for Flatfoot Deformity in Patient-Specific Computational Models

A cohort of adult acquired flatfoot deformity rigid-body models was developed to investigate the effects of isolated tendon transfer with successive levels of medializing calcaneal osteotomy (MCO). Following IRB approval, six diagnosed flatfoot sufferers were subjected to magnetic resonance imaging (MRI) and their scans used to derive patient-specific models. Single-leg stance was modeled, constrained solely through physiologic joint contact, passive soft-tissue tension, extrinsic muscle force, body weight, and without assumptions of idealized mechanical joints. Surgical effect was quantified using simulated mediolateral (ML) and anteroposterior (AP) X-rays, pedobarography, soft-tissue strains, and joint contact force. Radiographic changes varied across states with the largest average improvements for the tendon transfer (TT) + 10 mm MCO state evidenced through ML and AP talo-1st metatarsal angles. Interestingly, 12 of 14 measures showed increased deformity following TT-only, though all increases disappeared with inclusion of MCO. Plantar force distributions showed medial forefoot offloading concomitant with increases laterally such that the most corrected state had 9.0% greater lateral load. Predicted alterations in spring, deltoid, and plantar fascia soft-tissue strain agreed with prior cadaveric and computational works suggesting decreased strain medially with successive surgical repair. Finally, joint contact force demonstrated consistent medial offloading concomitant with variable increases laterally. Rigid-body modeling thus offers novel advantages for the investigation of foot/ankle biomechanics not easily measured in vivo.     

Insertion of the tendon of the tibialis anterior muscle in feet with and without hallux valgus

The insertion of the tendon of the tibialis anterior muscle may be related to pathologic changes of the foot and, in particular, hallux valgus. Morphologic data should enable evaluation of such a relationship and perhaps offer a basis for improved therapy. One hundred fifty-six embalmed feet, including 27 with hallux valgus, were examined. The tendon of the tibialis anterior muscle was dissected and measurements were made, including the width of the insertion on the first metatarsal and medial cuneiform. Distal-superficial and proximal-deep slips of the tendon twisted around each other. Two specimens presented with an insertion only on the medial cuneiform; in two other cases the insertion was limited to the first metatarsal; in one case the tendon inserted into the navicular and the medial cuneiform; in all other cases, the tendon inserted into the medial cuneiform and first metatarsal. The insertion was mainly located along the plantar margin of the medial side of the foot; some of the proximal-deep fibers also passed onto the plantar surface. Fibers inserting on the first metatarsal bone can outwardly rotate the first ray, which is opposite to the inward rotation of the first ray in hallux valgus. In all feet with hallux valgus these fibers were present. Therefore, it is unlikely that this deformity develops because of a specific type of insertion of the tendon of the tibialis anterior muscle, and any therapeutic approach altering the attachment of the tibialis anterior tendon would cause no biomechanical improvement.     

Anomalous tibialis posterior muscle as an etiologic factor of hallux valgus

The role of an anomalous tibialis posterior (TP) tendon in the etiology of hallux valgus (HV) deformity was investigated in four stages: clinical, anatomical, neurological, and operative. In the clinical stage, the patients were instructed to planter flex and invert the foot to contract the TP tendon. Attempts to correct the deformity passively were not possible and resulted in, moderate pain in all patients (197 feet). When the foot was in dorsiflexion and everted (TP tendon was relaxed) the deformity was easily corrected without any pain in 196 feet (99.5%). In the second stage (anatomical), 10 cadavers (20 feet) with HV deformity and 10 cadavers (20 feet) without any foot deformity were dissected. An abnormal expansion of TP tendon into the oblique part of adductor hallucis was found consistently in all HV feet. The tendinous expansion was absent in all normal feet studied. Also when traction was applied to TP tendon, an increase in the metatarsophalangeal (MP) angle of the big toe was observed in all HV feet, but not in the control group. In the third group (neurological), faradic stimulation was applied to the TP muscle in 7 patients with HV deformity and 7 without deformity. The MP angle was increased in HV patients, but no change was observed in the control group. In the fourth stage, 11 patients (18 feet) surgically operated for HV deformity by proximal metatarsal osteotomy and excision of the band anchoring TP tendon to the oblique part of adductor hallucis. The results were excellent in 10 patients (17 feet) even after a minimum 2.5 year follow-up. Also, in two patients who were operated by different procedures with poor results, the TP tendon was lengthened by Z-plasty and they were completely pain free. Our data show the dynamic role of anomalous expansions of the TP tendon into the oblique part of adductor hallucis muscle in HV patients. We suggest this expansion be excised in addition to other operative procedures selected for the surgical treatment of HV patients. © 1994 Wiley-Liss, Inc.     

足部三维有限元建模方法及其生物力学应用

目的探讨建立足部三维有限元模型的方法,应用模型模拟分析研究鞋垫设计参数,不同软组织刚度和受力情况下对足部的生物力学影响。方法建立基于解剖结构,包括软组织,韧带和腱膜,考虑材料的非线性和关节接触的足部三维有限元模型。有限元模型的可靠性利用模拟足踝关节在不同病理、手术和鞋垫矫治情况下的生物力学反应来验证。结果有限元分析结果表明,定制型鞋垫的形状比鞋垫材料的刚度对减少足底最大压力有更重要影响。软组织刚度的增加引起足底接触面积的减小,从而会导致足底跖骨区最大压力增加。部分和完全松解足底腱膜都会降低足弓高度,并增加足底韧带的张力和增加中足和跖骨的应力。体重增加和跟腱拉力增加都将成倍足底筋膜的拉力。结论所建足部有限元模型能预测足底压力分布和足内部骨骼软组织应力、应变情况,可以成为设计鞋垫和研究足部各种临床状况提供有力的分析工具。     

Use of allograft in skeletally immature patients for calcaneal neck lengthening osteotomy

PURPOSE: To date, there have been no studies evaluating the usefulness of allograft as a substitute for autograft in calcaneal neck lengthening osteotomy. This retrospective study examined the results of calcaneal neck lengthening osteotomy using allograft for pathologic flatfoot deformity in children and adolescents with various neuromuscular diseases. MATERIALS AND METHODS: 118 feet in 79 children treated surgically between Mar 2000 and July 2005 were reviewed. The mean age at the time of the operation was 9+3 years (range, 3-17 years) and follow-up averaged 15.4 months (range, 13-21 months) postoperatively. Talo-1st metatarsal angle, talo-calcaneal angle, calcaneal pitch were measured before and after operation and bony union was estimated. RESULTS: Bony union was noted at the latest follow-up and there were no postoperative complications such as reduction loss, infection, nonunion, delayed union or graft loss during the follow-up period in all but one foot. All radiographic indices were improved postoperatively in all cases. CONCLUSION: Our results indicate that use of allograft in calcaneal neck lengthening osteotomy is a useful option for correction of the planovalgus deformity in skeletally immature patients whose enough autobone can not be obtained.     

3D打印技术在骨科矫形器中的应用

随着计算机科学和技术的快速发展,数字医学概念应运而生,数字化技术在骨科的研究和应用日趋普及。 有限元分析是一种强大且高效的模拟真实实验的数值方法,常用于研究医学中涉及的生物力学、生物材料性能以及手术模拟等问题,尤其是近几年在足踝领域的应用也越来越多。 目前,基于足踝有限元模型的生物力学分析已被广泛应用于糖尿病足、足底筋膜疾病、足踝骨折及骨性关节炎等的机制分析、假体设计、手术模拟、鞋和鞋垫设计等方向,极大提高了临床医生对足踝生物力学的认知,为足踝相关疾病的研究与诊断提供新思路。 然而,利用有限元法分析拇外翻畸形的研究相对有限。 本文概述拇外翻及继发的扁平足、跖骨痛等病变的生物力学分析和建模方法,以及该方法在临床实际应用的现状,总结其优缺点并进行展望。