目的 探讨三关节截骨矫形融合术治疗成人僵硬性高弓足的临床效果.方法 回顾性分析2018年1月至2020年1月应用三关节融合(距下关节、跟骰关节、距舟关节)治疗10例成人僵硬性高弓足患者;患者行三关节融合术的同时联合跟腱Z行延长及跖筋膜松解作为辅助术式改善足部功能,同时保证术后踝关节的功能位,采用美国足踝外科协会(AOFAS)踝-后足评分、视觉模拟疼痛评分(VAS)及患者术前术后的主观满意度,末次随访时通过影像学分析对比跟骨倾斜角(Pitch角)、距骨第一跖骨角(Meary角)等.结果 术后10例患者全部获得随访,随访时间为15～36个月,平均23.4个月,患者均未出现手术切口感染,且术后患者的外观、症状、步态等方面均有明显的提高,末次随访时满意度评价:非常满意7例,满意2例,一般1例,不满意0例.术后AOFAS评分高于术前,VAS评分低于术前,Meary角、Pitch角及第一跖楔关节高度较术前明显改善,差异有统计学意义(P<0.05).结论 三关节截骨矫形融合治疗成人僵硬性高弓足可以显著纠正关节畸形,解除足部疼痛,提高患者的生活质量,但三关节融合术主要应用后足僵硬型高弓足,因其限制了足部部分功能,故应严格把握手术适应证.

目的 评估体外冲击波治疗(extracorporeal shock wave therapy,ESWT)糖尿病合并肩周炎的临床效果与安全性.方法 选择2017年1月起至2018年6月的53例糖尿病合并肩周炎患者参与此项研究.其中体外冲击波组(观察组,27例患者27肩)给予冲击波治疗6周,对照组(26例患者26肩)为单纯传统治疗组.治疗后对2组患者均随访12周,采用Constant-Murley评分表评估肩关节功能状态,VAS(视觉模拟评分)评估肩关节治疗前后的疼痛情况,时间节点分别为:治疗前、治疗后2周、6周和12周.采用Student-t检验评估治疗前后以及各时间节点2组肩关节功能评分的差异.结果 同治疗前相比,2组肩关节功能评分在治疗结束后的各时间节点均有明显改善,差异有统计学意义(P<0.05).相较于传统治疗组,体外冲击波治疗组肩关节功能评分在治疗后的各时间节点均较好,差异有统计学意义(P<0.05).在治疗过程中,2组均未发生任何并发症以及患者主观不适.结论 在治疗糖尿病合并肩周炎时,体外冲击波治疗具有良好的安全性和临床效应,可以考虑其作为治疗此类疾病的常规治疗方法.

目的 探讨趾长伸肌腱转位治疗小趾非僵硬型爪形趾的临床效果.方法 采用趾长伸肌腱转位治疗小趾非僵硬型爪形趾,根据美国足踝外科协会(AOFAS)踝-后足评分、视觉模拟评分(VAS)、患者主观满意度评估其疗效.结果 术后平均随访(15±3)个月,所有患者畸形矫正满意.AOFAS评分:术前平均(63.27±5.69)分,术后平均(94.45±3.93)分,差异具有统计学意义(P＜0.01).VAS评分:术前(6.64±1.67)分,术后平均(0.27±0.47)分,差异具有统计学意义(P＜0.01).患者主观满意率为90.91％.结论 趾长伸肌腱转位治疗小趾非僵硬型爪形趾,临床效果满意,畸形无复发,是治疗小趾非僵硬型爪形趾的有效方法.

Abstract Information on surgical site infection (SSI) after surgical treatment of ankle fracture is limited and remains controversial. The purpose of the present study was to determine the incidence and risk factors for SSI after open reduction and internal fixation (ORIF) of ankle fracture. Patients who underwent ORIF for ankle fracture at 3 centers between January 2015 and December 2016 were included. The potential risk factors for SSI included demographic variables, including age, sex, body mass index (BMI), hypertension, diabetes mellitus, heart disease, smoking, and excessive alcohol intake; blood test variables including preoperative white blood cell count, neutrophil count, red blood cell count, hemoglobin, total protein, albumin and globulin; injury- and surgery-related variables, including duration of operation (minutes), intraoperative blood loss, surgeon level, fracture site, accompanied dislocation, use of a drainage tube, and antibiotic use. Factors related with SSI occurrence were investigated by univariate analysis, and then by multivariate analysis. During hospitalization, 4.37% (66/1511) of patients developed SSI, which was deep in 1.32% (20/1510) and superficial in 3.05% (46/1510). The most common causative agent was polymicrobial (causing approximately half of all SSIs), followed by methicillin-resistant Staphylococcus aureus (MRSA). Multivariate analysis revealed that the significant risk factors for SSI occurrence were open injury, advanced age, incision cleanliness II – IV, high-energy injury, more experienced surgeon level, greater BMI, chronic heart disease, history of allergy, and preoperative neutrophil count > 75%. Preoperative preventative measures should be taken in patients with these conditions to lower the incidence of SSI after ORIF of ankle fracture. LEVEL OF EVIDENCE: Level III - Retrospective Comparative Study.

This study aimed to report our institution's experience in the diagnosis and treatment of chronic lateral ankle instability (CLAI) with ligamentum bifurcatum (LB) injury.This retrospective study included 218 consecutive patients with CLAI who underwent surgery from January 2012 to December 2015. The 218 patients received tendon allograft reconstruction of the lateral ligament. CLAI was combined with LB injury in 51.4% (112/218) of patients. The 112 patients with concurrent LB injury had this treated simultaneously; 36 patients underwent excision of the anterior process of the calcaneus, 68 underwent LB repair, and 8 underwent LB reconstruction. Patients returned for a clinical and radiologic follow-up evaluation at an average of 31 (range, 24-35) months postoperatively. Outcomes were assessed by comparison of pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale pain scores, Karlsson scores, and radiographic assessment.Of the patients with concurrent LB injury, 82.1% (92/112) returned for final evaluation. Postoperatively, most patients recovered very well. However, the outcome was not ideal in those who underwent excision of the anterior process of the calcaneus; there were significant postoperative decreases in talar tilt (P<.05) and anterior drawer (P<.05), but there was no significant postoperative improvement in visual analog scale pain score and AOFAS score. Patients who underwent LB repair or reconstruction had an excellent or good outcome regarding patient subjective self-assessment, pain scores, Karlsson scores, and AOFAS scores at final follow-up.Patients with CLAI often have concurrent LB injury. The diagnosis of LB injury can be missed or delayed. Clinicians should closely examine the LB in cases of CLAI, and should surgically repair or reconstruct the LB when necessary.

Background: The aim of this study was to assess the prevalence of cervical Modic change (MC) in patients with cervical spondylosis and to develop a better understanding of the possible risk factors for the prevalence of MC. Methods: Between January 2014 and April 2017, patients with cervical spondylosis were included in our study. All patients underwent magnetic resonance imaging (MRI) to evaluate the presence of MC. The MC was classified into three types according to the Modic classification. Potential risk factors were collected from demographic data, lifestyle variables, laboratory tests, and radiographic images. Both univariate and multivariate analysis were used to detect factors associated with MC. We further compared several variables related to fat metabolism between patients with Type 1 and Type 2 MC. Results: The prevalence of MC in patients with cervical spondylosis was 9.24%. The MC was most frequent at C5-6, followed by C6-7, C4-5, and C3-4. The proportion of Type 1 MC in patients with neck pain was significantly higher than that in patients without neck pain (46.2% vs 13.6%, P=0.027). However, none of the variables associated with fat metabolism showed a significant difference between Type 1 and Type 2 MC. Multivariate logistic analysis showed that age >= 55 years (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.22-2.98) and body mass index (BMI) >= 25 kg/m(2) (OR, 2.41; 95% CI, 1.62-3.59) were two significant independent factors that are associated with cervical MC in patients with cervical spondylosis (P<0.05). Conclusion: It appears that advanced age and high BMI were two factors that may be responsible for cervical MC. Type 1 MC is associated with the prevalence of neck pain. However, we cannot confirm that Type 2 MC is correlated with fat metabolism.

目的 探讨跟腱滑囊炎的诊断性分型及其指导临床治疗的意义.方法 回顾性分析自2012-01-2016-01诊治的196例跟腱滑囊炎,根据患者的临床表现和影像学资料自行设计诊断性分型.Ⅰ型,跟骨后结节增生不明显,长时间行走或站立有轻度疼痛;Ⅱ型,中度跟骨后结节增生,不伴有跟腱止点钙化,行走时出现疼痛;Ⅲ型,重度跟骨后结节增生伴跟腱钙化,行走时出现疼痛;Ⅳ型,重度跟骨后结节增生,长期病变造成跟腱断裂.本组Ⅰ型42例,Ⅱ型68例,Ⅲ型62例,Ⅳ型24例.Ⅰ型患者行非手术治疗,Ⅱ～Ⅳ型患者行手术治疗.结果 178例获得随访,随访时间平均3.4(1.8～5.3)年.5例Ⅰ型患者非手术治疗无效,1年后手术切除跟骨后结节.2例Ⅳ型患者踝关节背伸活动度稍差.171例恢复正常生活,未诉特殊不适.末次随访时疼痛VAS评分平均0.8(0～2)分,AOFAS评分平均91.7(88～96)分.结论 跟腱滑囊炎诊断性分型对于指导临床治疗具有重要意义,可针对不同患者合理选择正确的治疗方法,以获得满意的疗效.

重度(足母)外翻是指(足母)趾外偏挤压第2趾形成骑跨趾,(足母)趾有中重度旋前畸形,HAA＞40°,IMA通常＞16°,第2趾跖骨头下形成转移性跖骨痛,胫侧籽骨脱位于跖骨头腓侧缘外.绝大多数重度(足母)外翻患者保守治疗无效,需进行手术治疗.本例为河北医科大学第三医院足外科收治的1例重度(足母)外翻患者.

To analyze the effect of zhanjin huoxue san on the treatment of acute soft tissue injury of ankle.Methods:Sixty cases of patients with acute soft tissue injury of ankle in our hospital from June 2016 to February 2017 were randomly divided into the treatment group and the control group,thirty cases in each group.The patients in the treatment group were treated with zhanjin huoxue san while patients in the control group were treated with ibuprofen sustained-release capsules.Two weeks later the clinical effects of the two groups were observed and the pain scores swelling scores,tenderness scores, and disability scores before and after treatment were com-pared.Also,the imaging index of swelling attenuation T2 were observed and compared.Results:After two weeks of treatment,the clini-cal effective rate of treatment group reached 90.0%while the total efficiency of the control group was 53.3%.There was significant differ-ence between the treatment group and the control group(P<0.05).After treatment,the pain scores,swelling scores,tenderness scores, and disability scores of the two groups were both significantly lower(P<0.05).However, except the swelling scores and tenderness scores,the analgesic efficacy between the two groups was the same.Thus,it showed no statistical significance(P>0.05).The MRI ex-amination T2 values before and after the treatment were obviously different, which showed statistical significance(P<0.05).Further-more,the treatment group changed more, statistically proving the differences between the treatment group and the control group(P<0.05).Conclusion:Zhanjin huoxue san can significantly relief the clinical symptoms of acute soft tissue injury in the ankle,and signifi-cantly improve the swelling imaging indexes,which should be clinically expanded.

踝关节扭伤是最常见的肌肉骨骼损伤,特别是在经常活动的人群中,占所有运动相关损伤的20%[1].踝关节扭伤后会使患者踝关节肿胀、疼痛,根据最初治疗方法及所涉及韧带的数目,有高达40%的患者由于外侧副韧带损伤最终逐渐成为慢性踝关节不稳,严重影响患者的生活质量[2].其中腓骨短肌肌腱重建外侧副韧带治疗踝关节不稳为常用的手术方法,但术后并发症较多.

高弓足是一种复合性畸形,既有严重的软组织挛缩或肌力不平衡,也有足部骨骼解剖的异常 [1].儿童高弓足多采用软组织松解治疗,但软组织松解对术者的要求较高,否则不仅不能矫正畸形,而且复发率很高 [2].软组织松解术的一种严重并发症为畸形矫正过度,导致后足外翻、前足外展即扁平足 [3,4].本病例选取河北医科大学第三医院足外科收治的 1 例高弓足术后扁平足的患者进行分析.现报道如下.

Patients with apparent symptoms of cervical spondylotic myelopathy (CSM) may only show a mild compressive lesion in ordinary magnetic resonance imaging (MRI). The aim of this study was to investigate the characteristics of CSM patients with "hidden" lesions on kinetic MRI and to determine an effective treatment.Thirty-one patients with obvious spinal cord compression only on kinetic MRI were included in our study. A variety of parameters were calculated from MRI of the cervical spine at different postures. The anterior cervical decompression and fusion (ACDF) procedure were used for treatment of CSM. To evaluate the effect of surgery, a further 31 age-and gender-matched ordinary CSM patients that received ACDF procedures were enrolled as the control group.The diameter of the cervical cord at the narrowest level in extension was significantly lower than that in the neutral posture (P<.01). The percentage of spinal cord compression was 34.6%. The diameter of the cervical canal at the narrowest level in the extension posture was significantly lower than that in the neutral posture (P<.01). The percentage of cervical canal stenosis was 43.6%. The anteroposterior diameter of the cervical canal in the case group was significantly lower than that in the control group (P<.01). However, the recovery rate of the Japanese Orthopaedic Association score at final follow-up was comparable between the case group and the control group (P=.53).Kinetic MRI is useful for the diagnosis of CSM with hidden lesions. ACDF is an effective procedure for treatment of CSM.

Background: This study aimed to report our institution's experience in the treatment of chronic lateral ankle instability using the anterior half of the peroneus longus tendon (AHPLT) to reconstruct the lateral ligament. Methods: This retrospective study included 32 consecutive patients with chronic lateral ankle instability who underwent surgery from January 2013 to December 2014. All patients had failed to resolve with conservative treatment. A total of 32 ankles underwent AHPLT transfer. Patients returned for a clinical and radiologic follow-up evaluation at an average of 28 (range, 24-35) months postoperatively. Outcomes were assessed by comparison of pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale pain scores, and Karlsson scores, and the radiographic assessment including talar tilt and anterior talar translation. Results: Thirty-two patients (32 ankles) (100%) returned for final evaluation. All patients had an excellent or good outcome on patient subjective self-assessment, pain scores, AOFAS scores, and Karlsson scores at final follow-up. Ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was significantly reduced from a preoperative mean of 14.1 +/- 4.2 degrees to 3.4 +/- 1.3 degrees postoperatively (P <.001), and the anterior drawer was significantly reduced from a preoperative mean of 13.8 +/- 3.4 mm to 3.6 +/- 1.5 mm after lateral ankle ligamentous reconstruction (P < .001). Conclusions: AHPLT transfer to reconstruct the lateral ligament resulted in a high percentage of successful results, with excellent ankle stability and not affected of ankle motion. (C) 2017 European Foot and Ankle Society. Published by Elsevier Ltd.All rights reserved.

平足症的发病原因很多,包括先天性和后天性.在后天获得性平足患者中,胫后肌腱功能不全是最常见的发病原因.先天性因素包括距跟骨桥、副舟骨、先天性垂直距骨等 [1].本研究对河北医科大学第三医院足外科收治的垂直距骨导致僵硬性平足患者 1 例进行了分析,现报道如下.

目的 探讨踝关节融合术治疗成人高弓足的疗效分析.方法 回顾性研究2010年1月至2015年9月应用踝关节融合术治疗成人高弓足65例.男29例,女36例.年龄35～67岁,平均49岁.所有患者的踝关节均存在严重的骨关节炎,患者行踝关节融合术的同时跟腱延长及跖筋膜松解作为辅助术式以纠正足部的跖屈畸形,保证踝关节为功能位;其中26例患者合并距下关节炎,踝关节融合的同时行距下关节融合.踝关节融合主要改善足的负重及行走的功能,采用美国足踝外科协会(AOFAS)踝-后足评分、Maryland足部评分及视觉模拟评分(VAS)、患者主观满意度评价术前及末次随访时足踝关节功能,比较术前术后X线测量角度的结果.结果 术后58例患者获得随访,随访时间为23～63个月,平均29个月.所有患者踝关节切口均愈合,未诉明显不适,其中1例术后6个月出现骨不愈合,冲击波治疗6个月后踝关节融合;所有患者均未出现术后感染.末次随访时,AOFAS踝-后足评分为(83.6±4.1)分,Maryland足部评分为(86.4±3.1)分,VAS评分为(1.9±0.9)分,并且患者术后步态稳定,效果满意,差异均有统计学意义(P<0.05).术后Meary角、跟骨倾斜角均有不同程度的改善;患者主观满意度评价:极好42踝,良12踝,一般3踝,差1踝,满意度为93.1％.结论 踝关节融合治疗成人高弓足可以纠正关节畸形、缓解疼痛与重建功能,但踝关节融合术对于畸形明显或者严重内翻的患者矫正能力有限,仅适用于轻度的高弓足畸形.只要适应证选择恰当,即可以获得良好的治疗效果.

Employing a drain or not always put surgeons in a dilemma. Few studies have evaluated the associated factors of surgical drains after lumbar posterior decompression and instrumented fusion. The aim of this study was to record the characteristics of postoperative drain output, and tried to identify possible risk factors that are independently associated with it. From January 2014 to March 2017, patients undergoing posterior lumbar interbody fusion were included in our study. All patients underwent single-or multiple-level transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF). The volume of drain output was measured. Variable were collected from demographic data, lab test and surgical information. Both univariate and multivariate analysis were used to detect factors associated with greater drain output. Besides, correlations between the potential variables and volume of drain output were also analyzed. A total of 429 patients were included in this study. Patients with drain output greater than 240 ml drain output were ascribed to case group, and other patients were in control group. The operative time was not correlated with volume of drain output (r = 0.471; P = 0.29), but age was positively correlated with postoperative drain output (r = 0.269; P < 0.001). Multivariate logistic analysis showed that age >= 55 years (odds ratio [OR], 2.860; 95% confidence interval [CI], 1.164-6.847) and multiple levels fused (OR, 1.359; 95% CI, 1.680-6.432) were two significant independent factors that are associated with greater drain output after lumbar spine surgery (P < 0.05). The present analysis demonstrated that age and number of levels are two factors that are associated with volume of postoperative drain output. Patients with these factors should be informed of the possibility of increased drain output, and routine blood test should be performed after surgery in case of the incidence of low hemoglobin.

1 病例介绍 患者男性,13岁,学生.主因左足第二趾根部肿痛伴活动受限1年,于2016年7月26日入院.患者于1年前无明显诱因出现左足第2趾根部肿痛,休息时疼痛缓解,行走时疼痛加重,当时尚能忍受,近日,左足第2趾疼痛明显加重,影响到学习和生活.近1年来,患者在外院贴膏药治疗,症状无缓解,为进一步明确诊治,患者来河北医科大学第三医院就诊.患者既往体健,否认左足外伤史.查体:生命体征正常,心肺腹未见异常.左足第2趾根部略肿胀,压痛明显,屈伸活动受限,感觉无增强及减退,末梢循环好.入院诊断:“左足第2跖骨头坏死”.入院后完善常规检查:血白细胞4.68×109/L,红细胞4.81×109/L,血小板185.7×109/L,C-反应蛋白0.20 mg/L,血糖5.5 mmol/L;左足影像学检查见图1、2.

Objective To observe the efficacy of tendon allograft reconstruction of chronic lateral ankle instability (CLAI).Methods We retrospectively reviewed the 30 CLAI patients who had received tendon allograft reconstruction of lateral ligament between January 2013 and January 2014.They were 12 men and 18 women,aged from 23 to 45 years (average,35.3 years).Their American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score,Karlsson-Peterson score,Sefton articular stability scale,anterior talar translation and talar tilt angle were compared between preoperation and the last follow-up.Results Of this series,26 cases (26 ankles) were followed up for an average period of 20.3 months (from 15 to 27 months).Follow-up at 6 weeks after surgery showed they could complete non-weight-bearing walking and follow-up at 12 weeks observed that they achieved weight-bearing walking.X-ray films showed negative results of stress ankle varus test and anterior drawer test.At the last follow-up,all patients recovered normal life without obvious discomfort.Their AOFAS ankle and hindfoot score (87.1 ± 4.9),Karlsson-Peterson score (89.6 ± 4.5),Sefton articular stability scale (grade Ⅱ),anterior talar translation (3.5 ± 0.4 mm) and talar tilt angle (3.9 ° ± O.9°) at the last follow-up were significantly improved in comparison with the preoperative values (56.3 ± 11.0,51.1 ±7.5,grade Ⅳ,7.6 ±0.8 mm,14.3°±2.2°,respectively) (P ＜ 0.05).The follow-up showed 15 excellent,6 good and 5 poor ankles,yielding a patient satisfaction rate of 80.8％.Conclusions Anatomic reconstruction with tendon allograft is safe and effective for chronic lateral ankle instability.

1 病例介绍 患者女性,36岁,农民.主因右足(踇)趾疼痛9年,加重1年于2015年12月7日入院.患者于9年前无意中触及右足(踇)趾趾甲,自觉局部触痛明显,无红肿,未触及肿物,休息时疼痛缓解,行走后疼痛加重,当时尚能忍受.1年前,右足(踇)趾趾甲疼痛明显加重,为刺痛,呈持续性,休息、行走疼痛均明显,严重影响工作和生活.

目的 探讨联合截骨治疗青少年外翻畸形的疗效分析.方法 回顾性分析2008年1月至2015年1月河北医科大学第三医院收治的联合截骨治疗青少年外翻100例(185足)患者的临床资料,其中男48例(88足),女52例(97足),年龄11~19岁,平均(15.5±3.48)岁,随访时间为18~48个月,平均(28.5±6.8)个月.手术前后均摄双足负重正侧位X线影响检查,术前测量外翻角为35°~65°,平均(49.61±14.25)°,第1、2跖骨间角15°~27°,平均(21.03±6.73)°.手术方法采用第1跖骨基底或跖骨干加第1跖骨颈截骨钢板固定或近节趾骨基底截骨克氏针固定.根据不同患者外翻的症状矫正软组织平衡,必要时松解内收肌.采用AOFAS评分评价临床疗效.结果 85例(157足)获得随访,患者外翻角为(18.18±4.55)°,第1、2跖骨间夹角为(5.07±1.70)°,平均矫正30.54°和17.33°,术后,足部评分(84.8±7.6)分,与治疗前的(46.5±9.4)分相比,差异有统计学意义(P<0.05).结论 青少年外翻以遗传为主,外翻严重.采用联合截骨位治疗青少年外翻,可矫正第1跖骨内翻同时矫正远端关节固角,提高矫正效果,降低复发率.