【作者】 吴昊；

【导师】 贾堂宏；

【作者基本信息】 山东大学 ， 骨外科学， 2011， 博士

【摘要】 背景：足是人体最直接的负重器官,足的主要功能是负重与行走,相应的,足的各个部位的结构也均以此为目的演化。足部的骨结构及软组织扮演着吸收能量和减低负荷的角色。以往,人们的研究目光主要集中在足的重要功能区一足跟、足弓、前跖部等上面,对于在负重及行走中均起辅助作用的足趾观注不多。足趾损伤在临床上很常见,当足趾受到比较严重的创伤或疾患时,人们则更容易舍弃“不重要”的足趾以换取临床上所谓的“治愈”,最常用的治疗方式是将其直接截除。在手部外伤修复时也常用足趾或足趾皮肤作为供区,而且是“缺一个补一个,缺多少补多少”的原则,对足部供区的修复则基本上也是行残端缝合。随着显微外科技术的普及,利用皮瓣等技术来保留足趾已不再是什么困难,但是人们已习惯于忽视足趾的作用,是否有必要耗费精力去保留足趾的长度不同的医生有不同的认识。国内外对足趾损伤对足功能影响的研究主要集中在医源性损伤——手指再造领域。由于不同学者对手指再造术式及供区修复术式的选择往往有其自身的倾向性,因此临床上手指再造导致的足趾缺损对供足功能影响的研究多为某种特定术式的报告,缺乏综合性比较性研究。虽然在手指再造领域,人们对供足功能的改变已日渐重视,但是相同的创面,不同的修复方式愈后结果也会有所差别。患足功能的状况除了受到足趾缺损数量及骨性缺损长短的影响之外,局部软组织条件对其影响也占有相当的比例,尽可能排除局部皮肤条件、疼性瘢痕等因素的干扰,才能更加客观的反映足趾缺损对足功能的影响,更合理的指导我们对患足修复时足趾长短的取舍,选择相对更为妥当的术式。在研究足趾缺损对足功能的影响时,我们首先要筛选出干扰较大的局部软组织覆盖不良的病例,对趾端均有良好皮肤条件覆盖的不同类型足趾缺损患者进行了随访研究,了解不同缺损平面对足功能的影响,以期在足趾外伤的修复及手指再造时的术式的选择上能够提供帮助。本研究从主客观两方面对患足的功能进行评价：主观方面包括主观疼痛程度与运动障碍评分,并通过这些量化的评分来比较分析。客观指标是利用Footscan足底压力分析仪进行步态分析,观测步态周期,足底触地区域压力、冲量等方面的变化,来了解足趾缺损对患足功能的影响。为了保证采集数据具有可比性,我们首先收集了不同时期健康人的足底压力数据加以对比分析,以了解正常人足底压力有无变化及规律可寻,对病理性足底的压力变化可能出现的合理偏差加以纠正。第一部分足趾缺损对足功能影响的远期随访目的以问卷形式调查不同类型的足趾缺损时患者的主观感受及患足功能。方法对2003年1月至2009年12月收治的各种足趾外伤患者进行分组随访,A组为拇趾远节部分缺损、B组为拇趾远节皮肤缺损行皮瓣修复、C组为拇趾趾间关节平面以近缺损、D组为二趾近节缺损、E组为3、4单趾缺损、F组为2-5多趾缺损,G组为中间单趾列缺损伴足横弓损伤。以足功能指数-5分口述评分(FFI-5ppt)为参考,对患足进行疼痛及功能方面的评分。评分结果采用x±s表示,用Mann-Whitney检验,对各组进行两两比较,以α=0.05为检验水准,P<0.05为有统计学意义。结果157例患者获得随访,随访时间24-90个月,平均37个月。疼痛评分A组1.08±1.1分,B组1.09±1.2分,C组0.9±1.2分,D组1.05±1.2分,E组0.73±0.9分,F组1.4±1.1分,G组1.94±1.4分。行动障碍评分A组为0.33±0.9分,B组0.93±1.02分,C组1.55±1.1分,D组0.61±0.8分,E组0.33±0.5分,F组1.9±1.0分,G组1.37±0.9分。足功能障碍评分：A组为1.50±1.8分,B组2.02±2.1分,C组2.45±2.0分,D组1.65±1.7分,E组0.93±1.2分,F组3.30±1.5分,G组3.31±2.1分。经组间两两比较各组评分,差异有统计学意义视为可行大小排序,足趾缺损对足功能的主观影响按大小排序G组最大、依次为F组、C组、B组、D组、A组,E组对足功能影响最小。结论不同类型的足趾损伤对足功能的影响不同,拇趾远节部分残修与3、4趾的缺损,拇趾远节皮肤缺损经皮瓣修复与第二足趾缺损对患足的影响基本相同,趾列的缺损伤及足横弓对足功能的影响比拇指末远节缺损更大。第二部分应用步态分析系统研究正常人足底压力分布目的应用Footscan步态分析系统研究正常济南人的足底压力分布及不同时间足底压力的改变。方法用Footscan步态分析系统测量50例正常济南人双足的足底压力,将左右足采集数据合并统计,50例计100足。每人相隔3月以上再测试1次,每次测试结果归为一组,分为A、B两组,以Mann-Whitney检验,对各组进行两两比较,以α=0.05为检验水准,P<0.05为有统计学意义。结果个体足底压力分布存在着较大差异,综合分析足底压力冲量分布从大到小依次为足跟区、第2、3跖骨头区、第4跖骨头、中足、第1跖骨头、拇趾、第5跖骨头、第2-5趾；压强冲量分布大小依次为第2、3跖骨头区、足跟区、第4跖骨头、拇趾、第1跖骨头、第5跖骨头、中足、第25趾。相同测试人群不同测试时间足底压力会发生改变,左右足改变相同。结论不同时间足底压力分布情况存在变化,总体上足跟压力最大,前跖中部压强最大,压力改变时左右足变化同步,可互为参照。第三部分应用步态分析评价足趾缺损对足功能的影响目的用步态分析的方法研究不同类型的足趾损伤对足功能的影响。方法随访拇趾远节部分缺损、拇趾远节缺损、二趾缺损、二趾列缺损共四组患者,采用自身健足对照,用Footscan足底压力分析系统行足底生物力学分析。结果拇趾远节部分缺损主要引起局部压力的改变,拇指远节缺损引起重心后移及前足蹬离期的缩短,二趾缺损可引起足底压力的外移,跖骨头缺损引起整个前足压力显著升高。结论各类足趾缺损均会对足底步态产生不同影响,拇趾远节及第二跖骨头缺损对足底压力分布影响较大,应尽力予以保留。更多还原

【Abstract】 Background:The foot is the most intimate weight loading organ. Its main function is weight loading and walking. Therefore, the structure of the foot is all involved according to this. The role of the bone and parenchyma in foot is to absorb energy and reduce loading. Formerly, the study is concentrated on the significant domain of foot, for example, heel, instep, the former metatarsus, etc. The focus is not on the assistant toe. Toe damage can be seen often in clinic. The people are easy to give up the "unimportant" toe to exchange "the clinical" cure when the toe injured severely or be pedopath. The general therapia is to amputate it directly. Using the toe or the skin of toe as the donor site in the repairing of hand surgical trauma is commonly. Furthermore, the principle is "reconstruction as possible as you can". The method of repairing the foot donor site is apical stitch. Along with the pervasion of the microsurgical technique, it is not difficult to retain the toe by the technique of flap. But the people accustomed to ignore the function of toe. Whether retaining the length of toe is necessary, or not, the different doctor has different cognition.The study of the influence of toe injury to the foot function is focused on the iatrogenic injury, for example, the finger reconstruction. Because of different doctor has personal proneness to select the method of finger reconstruction and the repairing of donor site. So the study of the influence on donor foot function resulted in the toe defect caused by the finger reconstruction are some kind of definite operation type. It is short of comprehensive and comparing study. Although, the people has thought highly of the change of donor foot day by day, but the consequence of recovery is different using different recovery method in identical wound surface. The condition of the injured foot can be impacted by the local condition of parenchyma, in addition to the amount of toe defect and the length of bone defect. As far as possible to eliminate the interference of local condition of skin, the painful cicatricle and so on, in order to objectively reflect the influence of the toe defect on foot function. Thereby, it can guide us to decide the level of amputation.To study the influence to the function of the foot with toe amputation, we should consider the defect and scar of soft tissue firstly. So all the patients we followed are all with good skin coverd in order to exclude the interference with the pain scarf. Thus we can find the influence to the function of the foot only caused by different level toe amputation. This study is to be expect it can do some help to the surgeon when face repairing the toe injury and finger reconstruction. We will evaluate the function of damaged foot from two parts:subjective and objective. The pain score and movement disorder score are all included in subjective evaluate. With analysis of these quantitative score, we can find the how the function of the foot lost. The objective evaluate is using Footscan gait pressure analysis, the gait cycle, pressure of the under foot, impulse such data should be comparative analysis. All the collected data are comparable. We collect somes of the health person as the pre-test to find whether it has some common change or law in those people. Thus, we can correct some the reasonable deviation when facing the pathological change in the pressure of the foot.Part One Long-term follow up the function of the foot with toes amputationObjectives To study the patient’s subjective reception and the injured foot function in different type of toe defect by questionnaire investigation.Medthods Patients who suffered toes injury between Jan 2003 and December 2009 were followed up. All the patients were divided into seven groups. Team A is partial amputation of the distal hallux. Team B is the skin defect of the distal hallux repaired with flap. Team C is the distal hallux amputation at the interphalangeal joint level. Team D is the second toe amputation. Team E is the single toe amputation range from 3rd to 5th. Team F includes multiple toes amputation range from 2nd to 5th toe. Team G is the middle line toe amputation accompany with arcus pedis transversalis damage. The foot were examined and photoed, meanwhile, Foot function index-verbal rating scales (FFI-5pt) were conducted to these patients. The score is represented with x±s. The outcomes were tested by Mann-Whitney test. Using the conventional definition with alpha=0.05, p-values less than 0.05 are considered as variation.Results One hundred and fifty seven patients were followed up postoperatively. With a mean period of 37 months (range 24-90 months). The painful score was 1.08±1.1 in team A,1.09±1.2 in team B,0.9±1.2 in team C,1.05±1.2 in team D, 0.73±0.9 in team E,1.4±1.1 in team F,1.94±1.4 in team G. The score of action disturbance was 0.33±0.9 in team A,0.93±1.02in team B,1.55±1.1 in team C, 0.61±0.8 in team D,0.33±0.5 in team E,1.9±1.0 in team F,1.37±0.9 in team G. The score of foot disturbance was 1.50±1.8 in team A,2.02±2.1 in team B,2.45±2.0 in team C,1.65±1.7 in team D,0.93±1.2 in team E,3.30±1.5 in team F,3.31±2.1in team G. The influence of toe defect on foot function sort by size was G, F, C, B, D, A, E. The maximum effect was G. The minimum effect was E.Conclusion Different type of the toe damage has different influence on the foot. The influence of the partial distal end of the hallux amputation is similar to the 3rd or 4th toe amputation. The influence of the skin defect of the distal hallux repaired with flap is similar to the second toe amputation. The influence of the toe amputation accompany with arcus pedis transversalis damage is larger than distal hallux amputation.Part Two To study the contribution of the foot pressure in health people with Footscan gait analyse systemObjectives To study the variation of distribution of foot pressure in different time in healthy Jinan people by using Footscan gait analyse system.Medthods To measure and analyse the bipedal pressure data in 50 cases of healthy Jinan people and the same time three months after by using Footscan gait analyse system. The results every time is included of one team. It concluded of two teams. The outcomes were tested by Mann-Whitney test, Using the conventional definition with alpha=0.05, p-values less than 0.05 are considered as variation.Results The distribution of the footplate pressure existed distinction individually. The pressure in different part of the foot lined from large to small is the heel, the 2nd metatarsal bone or the 3rd metatarsal bone, the 4th metatarsal bone, the bid toe, the 1st metatarsal bone, hallux, the 5th metatarsal bone, the 2-5 toes. The pressure-time integral in different part of the foot lined from large to small is the 2nd metatarsal bone, the 3rd metatarsal bone, the heel, the 4th metatarsal bone, hallux, the 1st metatarsal bone, the 5th metatarsal bone, the bid toe, the 2-5 toes. The foot pressure will change with time apart in the same tested people while the change is similar in a pair of foot.Conclusion Tthe foot pressure contribution changes when time apart. The maximum pressure are always observed in the heel and middle parts of the fore-metarsal. The pair the foot change synchronize with pressure changed. These two pair can be refer each other.Part Three Assessment of the function of the foot with toe defect by gait analysis.Objectives To study the influence to the function of the foot with different type of toe injury by the method of gait analysis.Medthods Four groups of patients with different type of toe amputation were followed up and the plantar biomechanical were analyzed by the Footscan plantar biomechanical machine. To use the good foot of the patient as the control.Results The partial amputation of the distal hallux cause the local pressure change. The whole distal hallux amputation can cause the center of gravity retrocession and forefoot push off phase short. The second toe amputation can cause the planta pressure shift outside. The head of metatarsal bone amputation will make the propodium’s pressure increase.Conclusion Each kind of the toe amputation may cause different influence to the kinematics of the foot. The amputation of distal hallux and the head of the second metatarsal bone bring significant change to planta pressure. We should attempt to save it.更多还原