目的 探讨踝关节腔内注射富含血小板血浆(platelet-rich plasma,PRP)治疗慢性踝关节骨性关节炎的疗效及安全性.方法 选取2018年1月至2020年3月于本院治疗的43例慢性踝关节骨性关节炎病人纳入本研究.病人采集自体静脉血制备PRP,均匀注入4 mL PRP至患踝关节.所有病人在首次注射后6周接受第二次注射,共给药两次.观察病人两次注射药物后的不良反应,记录病人治疗前后的疼痛视觉模拟量表(visual analogue scale,VAS)、美国足踝外科医师协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足功能评分系统、足踝能力评分(foot and ankle ability measure,FAAM),评价病人足踝部疼痛及功能改善情况.结果 与治疗前相比,病人治疗3个月、6个月、9个月后的VAS评分均明显下降(P<0.05);治疗3个月、6个月后的FAAM评分和AOFAS评分均明显上升(P<0.05),治疗后9个月与治疗前比较,差异无统计学意义(P>0.05).注射PRP后病人未出现严重不良反应.结论 踝关节腔内两次注射PRP,6个月内可有效缓解慢性踝关节炎病人疼痛及运动功能,但是9个月时效果减退,整个治疗过程安全,无严重不良反应.

复杂区域性疼痛综合征(complex regional pain syn-drome,CRPS)常发生在骨折和外科手术后,是骨科临床常见的并发症,一旦发生,处理较困难.该病是以肢体疼痛为主要症状,继发于组织损伤之后,关节、骨骼、皮肤和肌肉等组织均可涉及,且与血管运动因素有关的综合征.

目的 通过传统影像学检查难以准确判断外翻是否存在真正籽骨脱位,引入负重CT分析,对外翻假性籽骨脱位的患足进行分析.方法 选择2017年10月至2018年12月在首都医科大学附属北京同仁医院治疗的有症状的外翻患者的负重CT及负重CT扫描完成后系统软件生成的足负重正位片,记录年龄和外翻相关测量参数.以足正位X线胫侧籽骨位置(tibial sesamoid position,TSP)≥3度和冠状面胫侧籽骨分度(tibial sesamoid coronal grading,TSCG)为0度定义为假性籽骨脱位.根据数据正态性和类型相应进行t检验、Wilcoxon轶和检验或卡方检验.通过多因素logistic回归分析找到引发籽骨脱位的影响因素.通过ROC分析找到引发籽骨脱位可能的临界值.结果 最终入组患者119例(214)足,存在假性籽骨脱位有23例(10.7％).这一组患者与籽骨脱位的患者相比,存在较小的年龄、第1～2跖骨间角、外翻角、远端关节面固有角,差异有显著性.影响籽骨脱位的因素主要是年龄和外翻角.年龄界值是55.5岁(灵敏度63.4％,特异度78.3％),外翻角的界值是31.5°(灵敏度58.6％,特异度87.0％).结论 假性籽骨脱位在外翻患者中所占比例较小,假性脱位出现与受患者年龄以及外翻角大小的影响,主要应纠正第1跖骨旋转.

目的 探讨跗骨窦有限切口跟骨结合型解剖钢板内固定手术治疗SandersⅡ型、Ⅲ型跟骨关节内骨折的疗效.方法 回顾性分析南阳市骨科医院2018年5月至2019年12月采用跗骨窦有限切口跟骨结合型解剖钢板内固定治疗的39例跟骨关节内骨折病人的临床资料(40足),男21例,女18例,年龄为(38.3±5.2)岁,其中SandersⅡ型22足,SandersⅢ型18足,受伤至手术时间为(6.9±2.6)d.比较病人术前、术后首次及末次随访时Gissane角与B?hler角的变化,采用美国足踝医师协会(American Orthope-dic Foot and Ankle Society,AOFAS)踝与后足评分标准对患足功能进行评价.结果 病人随访时间为5～7个月,2例患足因切口渗出延期愈合,其余患足切口愈合良好,无内固定物并发症.术后首次及末次随访患足Gissane角、B?hler角与术前比较,差异均有统计学意义(P均<0.05).末次随访时患足AOFAS评分优良率为92.5％.结论 跗骨窦有限切口跟骨结合型解剖钢板内固定手术治疗SandersⅡ型、Ⅲ型跟骨关节内骨折,治疗效果满意.

背景:外翻畸形存在关节匹配与不匹配两种情况.目的:通过负重CT回顾性研究关节匹配度在外翻畸形中的影响,分析关节匹配度丧失后关节的变化特征.方法:选取2019年1月至2020年1月门诊连续就诊的外翻患者纳入本研究,进行站立位负重CT检查.测量第1-2跖骨间角(IMA)、外翻角(HVA)、跖内收角(MAA)、第1跖骨关节面外翻角(DMAA)、第1跖骨旋转α角、正位籽骨分度与冠状位籽骨分度.测量结果通过SPSS进行分析.结果:纳入117例(211足)患者,全部女性,其中23例为单足,94例为双足.年龄19～84岁,平均(55.0±12.6)岁,211足的IMA平均14.1°±3.0°,HVA平均33.1°±10.5°,DMAA平均18.7°±7.9°,MAA平均15.7°±5.3°,第1跖骨旋转α角平均23.2°±7.2°.匹配组和不匹配组IMA、HVA、MAA、DMAA差异有统计学意义(P<0.05),而两组的旋转α角差异无统计学意义(P>0.05).Spearman相关分析发现在两组中,IMA、HVA、DMAA与正位籽骨分度呈正相关.结论:外翻跖趾关节不匹配预示着更为严重的畸形和更严重的籽骨脱位.匹配与不匹配不影响第1跖骨旋前程度.DMAA角受第1跖骨旋转、IMA的影响.正位籽骨分度是判断第1跖骨内收和旋转三维改变的有效指标.

Objective:To explore the risk factors influencing the intersesamoidal crista erosion infemale patients with hallux valgus.Methods:Symptomatic female hallux valgus patients who underwent a weightbearing CT scan were reviewed from October 2017 to June 2018. A total of 144 patients (237 feet) aged 19-84 years (53.79±13.04) were included in the study. Two groups were identified by whether or not the inersesamoidal crista eroded. Parameters about hallux valgus included age, inter-metatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), tibial sesamoid grading on dorsoplantar view, coronal plane sesamoid grading, first metatarsal rotation angle (α angle), and first metatarsal bottom rotation angle (β angle). The two groups of data were compared by Student's t-test, Wilcoxon rank test, or chi-square test according to data type and distribution. Parameters that had significant differences were included in the logistic regression by the forward model, and risk factors of intersesamoidal crista erosion were calculated. Receiver operating characteristic (ROC) analysis was then used to determine the cut-off values. Results:The 144 (237 feet) patients showed an IMA of 13.85°±3.15°, an HVA 31.52°±11.23°, a DMAA of 18.10°±8.08°, an α angle of 22.78°±6.89°, and a β angle of 15.01°±6.45°. Only the β angle had no statistical difference ( Z=-1.171, P>0.05), and all other parameters were statistically significant (all P values<0.05). Logistic regression results showed that age [( OR(95% CI): 1.05(1.02-1.09), P<0.01)] and coronal plane sesamoid grading [( OR(95% CI): 4.41(2.90-6.70), P<0.01)] were the risk factors for intersesamoidal crista erosion. ROC calculation showed that the cut-off value of age was 53.5 years old (sensitivity 85.1%, specificity 56.6%), and that of coronal plane sesamoid grading was 1.5 (sensitivity 90.4%, specificity 67.8%). Conclusions:The intersesamoidal crista erosion in female patients with hallux valgus is affected by age and coronal plane sesamoid grading but not by IMA, HVA, DMAA, sesamoid grading on the dorsoplantar plane and first metatarsal rotation angle.

目的 探讨超声在足底跖筋膜炎诊断及鉴别中的应用价值.方法 回顾性分析2019年1月至2020年7月,我院203例临床诊断跟痛症病人的临床及超声影像学资料,并总结病因.对比分析跖筋膜炎病人的双侧跖筋膜及足底脂肪垫的超声参数.按身体质量指数(body mass index,BMI)是否大于24 kg/m2分为BMI>24 kg/m2组和BMI≤24 kg/m2组,对比两组上述参数,探讨超声诊断跖筋膜炎的价值.结果 跖筋膜炎是203例病人足跟痛的首要病因,占82.8％.其中跖筋膜炎病人患侧跖筋膜跟骨止点处的超声测量厚度大于健侧(0.50 cm vs.0.37 cm),而脂肪垫厚度小于健侧(0.55 cm vs.0.60 cm),差异均有统计学意义(P均<0.05),中段跖筋膜厚度的差异无统计学意义(P>0.05).BMI>24 kg/m2组与BMI≤24 kg/m2组病人右侧跟骨止点处跖筋膜厚度的差异无统计学意义(P>0.05),而BMI>24 kg/m2组左侧跖筋膜厚于BMI≤24 kg/m2组(0.46 cm vs.0.40 cm),差异有统计学意义(P<0.05).同时,BMI>24 kg/m2组右侧足底脂肪垫厚度较BMI≤24 kg/m2组增厚(0.59 cm vs.0.50 cm),差异有统计学意义(P<0.05).结论 超声可直接显示跖筋膜跟骨止点处增厚,可为足底跖筋膜炎临床诊断提供定量的参数指标,对于足跟痛的软组织因素分析和鉴别有重要临床价值.

背景:Lisfranc损伤治疗多采用切开复位内固定,也可以采用闭合复位内固定.目的:探讨闭合复位经皮内固定治疗低能量Lisfranc损伤的临床疗效及并发症情况.方法:回顾性分析2010年1月至2018年1月采用闭合复位经皮内固定治疗18例低能量Lisfranc损伤患者的临床资料,男12例,女6例;年龄22～83岁,平均(41.2±6.3)岁.患者受伤至手术时间为2～7 d,平均(3.7±1.6)d.使用3.5 mm实心螺钉固定内侧柱和中间柱,使用克氏针固定外侧柱.采用美国足踝外科协会(AOFAS)中足评分、患者简明健康量表(SF-36)评分和视觉模拟评分(VAS)评估临床疗效,随访观察临床结果和并发症情况.结果:18例的随访时间为18～48个月,平均(27.4±4.6)个月.术后切口均甲级愈合,无伤口并发症,无神经损伤和血管损伤.末次随访的AOFAS中足评分(80.3±5.9)分,VAS评分为(2.1±0.4)分,SF-36的生理功能评分为(82.4±6.8)分,SF-36的躯体疼痛评分为(85.7±7.9)分.末次随访时2例发生内固定物松动或断裂,均无症状,其中1例患者要求取出螺钉,1例未行处理;1例发生跖跗关节创伤性关节炎,但无症状,未行处理.结论:低能量Lisfranc损伤可以采用闭合复位经皮内固定进行治疗,临床疗效可靠.

目的 探讨IOFIX在第1跖楔关节融合的应用及短期临床效果.方法 对10例中重度且伴有跖楔关节松弛的外翻患者行第1跖楔关节融合手术,评价术前及最终随访时第1、2跖骨间夹角(IMA)、 外翻角(HAV)、 趾AOFAS评分和VAS评分.结果 所有患者术后第10周经X线及临床判断均显示第1跖楔关节骨性融合.最终随访时X线片显示融合位置良好,螺钉周围无钉痕.术前HAV平均36°,最终随访时HAV平均13°;术前IMA平均18°,最终随访时平均5°.术前VAS评分平均4.6分,最终随访时VAS评分平均1.2分;术前趾AOFAS评分平均56分,最终随访时趾AOFAS评分平均86分.结论 IOFIX用于足部关节融合术的短期临床效果良好,融合率高,同时可避免二次手术取出,但对重度骨质疏松患者慎用.

目的 探讨应用富含血小板血浆(platelet-rich plasma,PRP)注射治疗慢性跖筋膜炎的有效性和安全性.方法 选取2014年1月至2016年3月于本院治疗的慢性跖筋膜炎患者19例(21足)纳入本研究.每例患者均采集自体静脉血制备PRP,胫后神经阻滞后行跖筋膜穿刺,均匀注入2 ml PRP.记录患者注射后不良反应,采用视觉模拟评分法(visual analogue scale,VAS)、美国足踝外科学会(American Orthopaedic Foot&Ankle Society,AOFAS)踝-后足评分系统评价患者足踝部疼痛及功能改善情况,采用改良Roles and Maudsley评分系统评价患者治疗满意度.结果 与治疗前相比,患者治疗后6个月、12个月VAS评分均显著下降(P均<0.001),AOFAS踝-后足评分均显著上升(P均<0.001);治疗后12个月,患者治疗满意8例(42.1％),良好8例(42.1％),不满意3例(15.8％).注射PRP后患者未出现严重不良反应.结论 跖筋膜穿刺注射PRP治疗慢性跖筋膜炎安全有效,能有效改善患者足部疼痛及活动受限.

目的 观察富含血小板血浆(platelet-rich plasma,PRP)对距骨软骨内基质细胞衍生因子-1(stro-mal cell-derived factor-1,SDF-1)/CxC趋化因子受体4(CXC chemokine receptor4,CXCR4)信号通路及糖胺聚糖(glycosaminoglycan,GAG)、基质金属蛋白酶-13(matrix metalloproteinase-13,MMP13)表达的影响,探讨PRP治疗距骨软骨损伤的作用机制.方法 选择2017年9月至2018年11月首都医科大学附属北京同仁医院收治的距骨软骨损伤患者16例,先做踝关节镜检查并做病灶清理骨髓刺激术(微骨折)治疗,然后分别于术后第1d、术后第1、2个月抽取自体静脉血制备PRP后,每次于踝关节腔内注射PRP 3ml.比较关节镜术前及第3次注射PRP前抽取关节液样本中SDF-1及GAG水平;在关节镜术中取距骨病灶区软骨样本,经SDF-1预处理后,将距骨软骨细胞接种于培养板中,融合率达80％ ～90％时,将软骨细胞随机分为PRP治疗组及空白对照组,每组8个,分别经PRP及不含PRP的人血清处理3天后,比较两组细胞培养液中SDF-1、CX-CR4、MMP13及GAG水平.结果 患者第3次PRP注射前患者踝关节液中SDF-1蛋白浓度[(1250.07±376.72)ng/L]较术前[(1707.88±180.32)ng/L]明显降低,差异有显著性(t=4.385,P=0.000);第3次PRP注射前患者踝关节液中GAG浓度[(20.93±3.88)μg/L]较术前[(14.39±3.95)μg/L]明显增高,差异有显著性(t=-4.736,P=0.000).PRP治疗组SDF-1蛋白浓度[(1412.39±38.15)ng/L]较空白对照组[(1003.37±109.45)ng/L]显著增高,差异有显著性(t=9.981,P=0.000);PRP治疗组CXCR4蛋白浓度[(5.22±1.51)μg/L]较空白对照组[0.65±0.18)μg/L]显著增高,差异有显著性(t=2.285,P=0.013);PRP治疗组MMP13蛋白浓度[(2.42±0.36)μg/L]较空白对照组[(5.53±0.63)μg/L]显著降低,差异有显著性(P=0.000);PRP治疗组GAG浓度[(5.75±2.75)μg/L]较空白对照组[(17.99±3.96)μg/L]显著降低,差异有显著性(t=7.181,P=0.000).PRP处理后的距骨软骨细胞生长曲线及生长趋势平稳,空白对照组的软骨细胞存活率不佳,PRP治疗组与空白对照组软骨细胞生长差异有显著性(t=12.837,P=0.000).结论 距骨软骨损伤时,软骨细胞内SDF-1/CXCR4通路可能参与了软骨细胞蜕变及降解过程;PRP可能通过抑制该通路,抑制软骨细胞蜕变及降解,从而促进距骨软骨损伤的修复.

腓骨肌痉挛性平足症是以各种原因引起的腓骨肌痉挛为主要发病机制的平足症.腓骨肌痉挛性平足症的病因包括跗骨联合、跗骨窦区病变和感染等因素.发病机制为中足解剖结构异常、腓神经刺激,临床表现为足部僵硬、疼痛、前足外展、后足外翻、腓骨肌痉挛.诊断主要依据为临床表现和影像学检查.治疗方法依据病因和病程的不同,包括神经阻滞、支具、肉毒毒素注射、序列石膏固定、跟骨截骨和关节融合.对腓骨肌痉挛性平足症的早期识别和准确诊断是防止继发性病变和取得良好预后的关键.

Objective To evaluate the short-term efficacy of Brostr(o)m-Gould repair combined with Internal Brace artificial ligament reinforcement under arthroscopy for anterior talofibular ligament injury in overweight and poor ligament quality population.Methods A total of 12 patients with anterior talofibular ligament injury treated by arthroscopy were enrolled from October 2017 to May 2018,involving 7 males and 5 females aged from 16 to 57 years old (mean 32.4 years).Patients were with ankle instability,and their BMI was 28.0-30.7 kg/m2 (average,28.8±0.91 kg/m2),among which there were 2 cases of poor ligament quality (Beighton score ≥-4).The anterior tibiofibular ligament injury and the quality of the ligament stump were intraoperatively evaluated under arthroscopy.A 4.75 mm diameter anchor with Internal Brace artificial ligament was inserted into the fibula insertion site,and non-absorbable suture was placed at the talus under total arthroscopy.Firstly,the non-absorbable line on the anchor was performed under the standard Brostr(o)m-Gould procedure to repair the anterior talofibular ligament,and the other end of the ligament was fixed near the distal end of the talus.The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and foot and ankle ability measure (FAAM) was compared before and after surgery.Results All the incisions were healed in the first stage after operation,and no operative complications such as infection occurred.All the 12 patients were followed up for 7 to 12 months (average 9.1 months).After 2 weeks,the patient began functional exercise and could walk with ankle braces.At the latest follow-up,the anterior drawer test was negative.The ankle-posterior foot score of AOFAS was increased from 61.3±7.9 (preoperative) to 85.0±6.0 (latest follow-up) (t=21.422,P＜ 0.01),and the FAAM score was increased from 57.5±10.1 (preoperative) to 86.3± 4.8 (latest follow-up) (t=15.032,P＜ 0.01).AOFAS score was excellent in 1 case and good in 11 cases.The excellent and good rate was 100％ (12/12).No complications such as infection and re-rupture occurred after operation.Conclusion For anterior talofibular ligament injury patients with overweight or poor quality of ligament,the Brostr(o)m-Gould procedure can be applied to strengthen under arthroscopic Internal Brace ligament without additional tendon reconstruction,which can also obtain good results.

踝关节创伤性关节炎是踝关节骨折、踝关节周围韧带损伤后引起的较常见并发症,主要临床表现为踝关节疼痛、肿胀,继发跛行进而影响患肢行走功能,其治疗方法可分为早期保守治疗及后期手术治疗,其中手术治疗又可分为保踝治疗及踝关节融合治疗,对于青少年患者的治疗尤为复杂.本文介绍北京同仁医院足踝外科矫形中心采用保守治疗的 1 例青少年踝关节创伤性关节炎,并对踝关节创伤性关节炎的保踝治疗做一文献回顾,现报告如下.

Objective To evaluate the value of applying surgical video combined with case discussion teaching in clinical practice of seven-year medical students, and to improve the clinical comprehensive level of medical students. Methods 42 medical students were selected from Capital Medical University. According to the random number table method, the students were divided into control group (n=21) and experimental group (n=21). The control group was taught by the traditional practice teaching method. The experimental group was supplemented with the video teaching and the case discussion on the basis of the control group. After 16 weeks, the effect of the two groups was evaluated. Results The subjective evaluation of the experimental group was significantly better than that of the control group, the difference was statistically significant (P < 0.01); the theoretical test score in experimental group was significantly better than that of the control group, the difference was statistically significant (P < 0.01). The skills score and scene simulation score in experimental group was significantly higher than that of the control group, the difference was statistically significant (P < 0.01). The results of the oral test in experimental group were slightly higher than the control group, but the difference was not statistically significant (P > 0.05). Conclusion Surgical video combined with case discussion teaching can improve the basic theory, basic skills and clinical thinking of medical students.

骨样骨瘤是一种良性肿瘤,30岁以下人群常发病,男性居多,占良性骨肿瘤的10%.骨样骨瘤常见于股骨颈和胫骨.足踝部骨样骨瘤发病率较低,文献报道主要是个案报道.本文结合3例我院收治的足踝部骨样骨瘤病例对相关文献进行复习,以供临床医师参考.

目的 探讨足趾甲下血管球瘤的临床特点、诊断要点及误诊原因. 方法 回顾性分析2015年7月-2016年12月北京同仁医院足踝外科收治的长期误诊的足趾甲下血管球瘤3例病例资料. 结果 3例均以长期患趾间歇性剧痛就诊,病史1例6年,2例20余年,均在多家医院多个专科就诊,误诊为甲沟炎等疾病,予相应治疗未见明显好转.来我院经查体,Hildreth试验、Love大头针试验阳性,诊断足趾甲下血管球瘤,手术切除甲下肿物,术后病理检查确诊为甲下血管球瘤.术后患者疼痛均缓解. 结论 足趾甲下血管球瘤容易误诊为甲沟炎等疾病,依据独有的三联征和Hildreth试验、Love大头针试验阳性可做出初步诊断,手术切除效果良好.

Scarf截骨常用于治疗第一二跖间角(IMA)<20°的有症状 外翻畸形,第一跖楔关节应该稳定无松弛. 趾近节趾骨Akin截骨可进一步矫正Scarf截骨后残留的趾骨外翻或旋转畸形.手术步骤如下: 1. 麻醉生效后,患者取仰卧位,可根据情况应用踝上或大腿根部止血带,常规消毒铺巾,清点器械及纱布无误并记录.

僵硬是第一跖趾关节退行性疾病,50岁以上的人发病率在2.5%.背侧骨赘和关节间隙变窄可导致疼痛、运动范围的受限.具体病因仍然存有争论.可通过临床症状、体格检查和影像学资料对疾病进行评估和分级.非手术治疗包括非甾体类抗炎药,关节腔内注射,鞋的改良,运动的调整和物理治疗,在所有僵硬患者中都应该先尝试保守治疗.手术的目的是为缓解疼痛,保持第一跖趾关节的稳定性,改善功能和生活质量.手术治疗可分为保留关节与非保留关节手术.僵硬早期阶段的治疗以保关节为主,主要是骨赘切除术和截骨术.融合术在僵硬晚期治疗中被认为是金标准.其他治疗方法例如关节成形术、关节置换术、关节镜技术,被证明早期是有效的.然而,还需要验证其长期疗效和安全性.手术方式的选择应根据关节的情况,患者的目标和期望以及外科医师的临床经验和技术水平.

足踝外科学是骨外科学重要的分支学科之一,我国骨科医师治疗足踝创伤性疾病已经有很长的历史,而足踝外科在我国却是一个比较新兴的专业,最近几年才得到人们的广泛重视,在国家医疗行政部门的支持和关怀下,开始进入了发展快车道,从事足踝外科专业的骨科医师也在逐年增加。全国各地的足踝外科学术组织如雨后春笋般蓬勃发展起来。在"中华医学会骨科学分会足踝外科学组"和"中华医学会骨科学分会足踝外科专业委员会"的带领下,国