基于解剖测量设计的3D打印导板在单纯Lisfranc韧带损伤治疗中的应用

目的 探讨以解剖学为依据的3D打印导板在单纯Lisfranc韧带损伤治疗中的应用价值。方法 选取2015年9月—2016年4月中国医科大学第一附属医院诊治的10例下肢肿瘤患者截肢后的残足进行应用解剖学观察。其中男6例,女4例;年龄37~78岁;左足5例,右足5例。从残足标本中分离出Lisfranc韧带及其连接的骨组织,观察韧带的外观和走行,测量韧带及其周围结构的解剖参数。回顾性分析2016年1月—2017年2月中国医科大学第一附属医院收治的16例单纯Lisfranc韧带损伤患者的临床资料。其中男10例,女6例;年龄15～57岁;左足7例,右足9例;Myerson损伤分型A型7例,B1型3例,B2型6例。按治疗方式不同分为2组:利用3D打印导板辅助治疗的8例患者为导板组,采用导向器定位治疗的8例患者为对照组。记录对比2组患者手术时间、透视次数、止血带时间,术后1、3、9个月分别采用疼痛视觉模拟评分(VAS)、美国足踝外科协会(AOFAS)踝-中足评分、36项健康调查简表评分(SF-36)评定足部功能。结果 10例残足标本的Lisfranc韧带均由2束构成,外观呈白色,质地坚韧,有弹性,周围无脂肪组织包绕;起自内侧楔骨的外侧面,走行方向略向背外侧倾斜,止于第二跖骨基底部,与骨组织紧密连接。解剖测量结果:Lisfranc韧带长度(7.74±1.25)mm,宽度(7.04±1.42)mm,厚度(4.92±0.38)mm;韧带起点附着于距内侧楔骨的跖楔关节面中心(9.10±0.85)mm处,韧带止点附着于距第二跖骨的跖楔关节面远端(4.86±1.32)mm处;内侧楔骨内侧面长度(27.66±1.83)mm,高度(39.00±2.51)mm;从内侧楔骨沿韧带走行打入克氏针并穿过韧带,通过进针点分别作平行于内侧楔骨长和高所在径线且均垂直于内侧楔骨内侧面的平面a和b。韧带与平面a夹角17.5°±1.8°,与平面b夹角18.5°±2.4°;进针点到第二跖骨基底出针点的距离(34.52±3.72)mm。16例患者均顺利完成手术。导板组手术时间、止血带使用时间及透视次数分别为(42.3±5.2)min、(30.1±4.8)min、(2.9±0.8)次,均明显少于对照组的(56.7±8.4)min、(45.4±5.3)min、(6.0±1.6)次,差异均有统计学意义(t=-4.122、-4.889、-6.052, P值均＜0.01)。16例均获随访,随访时间9～12个月,平均10.2个月。术后1个月导板组AOFAS踝-中足评分(78±5)分、SF-36评分(68±2)分,均明显高于对照组的(72±6)分、(63±3)分,VAS(3.3±0.3)分,低于对照组的(3.7±0.4)分,差异均有统计学意义(t=2.173、3.922、-2.667, P值均＜0.05);而术后3、9个月,AOFAS踝-中足评分、VAS及SF-36评分两组间比较差异均无统计学意义(P值均＞0.05)。结论 通过对标本中Lisfranc韧带及相关结构的解剖和测量,可以为3D打印导板的设计提供数据支持。在临床中,利用Lisfranc韧带的解剖数据,应用计算机辅助设计及3D打印技术打印导板,不仅可以实现螺钉的精确置入,还能减少手术时间及患者、手术操作人员的射线暴露风险,患者术后恢复快,效果良好。

Application of 3D printed guide plate based on anatomic measurement in simple Lisfranc ligament injury

Objective To explore the value of the anatomical-based 3D printed guide plate in the treatment of simple Lisfranc ligament injury.Methods A prospective study of 10 cases of residual foot after amputation of lower extremity tumor patients was performed from September 2015 to April 2016 in the First Affiliated Hospital of China Medical University. There were 6 males and 4 females; aged 37-78 years; 5 cases of left foot and 5 cases of right foot. The Lisfranc ligament and its connected bone tissue were isolated from the stump specimen, the appearance and shape of the ligament were observed, and the detailed parameters of the ligament and its surrounding structure were measured. The clinical data of 16 patients with simple Lisfranc ligament injury from the First Hospital of China Medical University from January 2016 to February 2017 were retrospectively analyzed. There were 10 males and 6 females,aged 15 to 57 years old, 7 left foot and 9 right foot. According to Myerson injury classification: 7 patients of type A, 3 patients of type B1, and 6 patients of type B2. According to the different treatment methods, they were divided into two groups. Eight patients that were treated with 3D printed guide plates were the guide plate group, and 8 patients that were treated with positioning guidance devices were the control group. The operation time, number of perspectives and tourniquet time of the 2 groups of patients were recorded and compared. Foot function assessment was performed in the 1st,3rd and 9th month after surgery using Visual Analogue Score (VAS), Ankle-midfoot Score of American Orthopedic Foot and Ankle Society (AOFAS) and 36 items of MOS item short from health survey(SF-36).Results The Lisfranc ligaments of 10 residual specimens were composed of 2 bundles. The appearance was white, the texture was tough, elastic, surrounded by no fat tissue, starting from the outer side of the medial cuneiform, the direction of travel was slightly inclined to the lateral side, ending at the base of the second metatarsal, tightly connected to the bone tissue. Anatomical measurements: The length of the Lisfranc ligament was (7.74±1.25) mm, the total width was (7.04±1.42) mm, and the thickness was (4.92±0.38) mm. The distance between the attachment point of the ligament and the center of the medial wedge bone was (9.10±0.85) mm. The distance between the ligament stop point attachment point and the distal end of the second humerus wedge joint surface was (4.86±1.32) mm. The inner side of the medial wedge bone was (27.66±1.83) mm and the height was (39.00±2.51) mm. Along the ligament, the Kirschner wire was driven from the medial wedge and passes through it. Two planes A and B were made throught the needle point, which were parallel to the line of the length and height of the medial wedge bone, respectively, and were perpendicular to the inner side of the medial cuneiform. The angle between the ligament and the plane A was 17.5°±1.8°, and the angle with the plane B was 18.5°±2.4°. The distance from the needle insertion point to the needle point of the second metatarsal base was (34.52±3.72)mm. The patients' surgery was successfully pertormed. The operation time, tourniquet use time and fluoroscopy times of the guide plate group were (42.3±5.2) min, (30.1±4.8) min, (2.9±0.8) times, respectively, which were significantly less than the control group (56.7±8.4) min, (45.4±5.3)min、(6.0±1.6)times. The differences were statistically significant (t=-4.122, -4.889, -6.052, all P values＜0.01). All 16 patients were followed up for 9-12 months with an average of 10.2 months. The AOFAS ankle-middle foot score (78±5) and SF-36 score (68±2) in the guide group were significantly higher than those in the control group (72±6) and (63±3). The scores of VAS (3.3±0.3) were lower than those of the control group (3.7±0.4), and the differences were statistically significant (t=2.173, 3.922, -2.667, all P values＜0.05). At 3 and 9 months after operation, there was no significant difference in the AOFAS ankle-middle foot score, VAS and SF-36 scores (all P values＞0.05).Conclusions By anatomizing and measuring the Lisfranc ligament and related structures in the specimen, the data support can be provided for the design of the 3D printed guide. In the clinic, with the anatomical data of the Lisfranc ligament and computer-aided design,3D printing guide plate, it not only can the precise insertion of the screw, but also reduce the operation time and the risk of radiation exposure. The patients recover quickly after surgery and have good results.