【作者】 魏书田；

【导师】 张奉琪；

【作者基本信息】 河北医科大学 ， 外科学， 2010， 硕士

【摘要】 目的:通过研究第一跖骨远端截骨手术前后拇外翻足的影像学及前足底的生物力学变化,探讨拇外翻术后并发转移性跖骨痛的相关性因素,找出术后并发转移性跖骨痛的危险因素,为预防转移性跖骨的发生痛提供理论依据。方法:1、在临床上选取行第一跖骨远端截骨术的拇外翻患者91例161足,女79例,左74足,右6 8足;男12例左9足,右10足。在术前及术后3个月拍摄患足负重正、侧位X线片。测量包括拇外翻角(HVA)、第一、二跖间角(IMA1～2)、第一、二跖骨长度、第一、二跖骨相对突出及前足宽度指标,并采用美国骨科足外科协会拇趾-跖趾关节评分标准(AOFAS)进行临床评估评分,分析外翻角、第一、二跖间角与前足宽度的相关性。2、将所有患者进行分组:术前伴跖骨头下疼痛与术前不伴跖骨头下疼痛足两组;术前伴跖骨头下疼痛而术后不伴跖骨头下疼痛患足两组;术前伴跖骨头下疼痛而术后伴跖骨头下疼痛两组;术后不伴跖骨头下疼痛和术后伴跖骨头下疼痛两组,对两组患足的各指标进行比较。3、选取术前伴有前足底疼痛拇外翻患者24例48足,行第一跖骨远端截骨术,手术前及术后门诊随访时,分别采用Footscan足底压力系统进行动态测试,将前足底五个跖骨头分别作为研究,比较手术前后前足第1～5跖骨头下的区域峰压强(PP)和压强时间积分(PTI)的平时行走状态下的变化,前足第1～5跖骨头下所占的比重变化及手术各跖骨下应力的变化。结果:1、通过对负重正位X线片进行测量,术后与术前相比,HVA平均由33.71°±8.44°减至9.58°±5.07°,IMA由12.65°±2.94°减至7.52°±1.95°,第1跖骨平均长度由57.10mm±4.90mm短缩至54.04mm±5.97mm,平均短缩3.05mm,前足平均宽度由87.28mm±6.70mm缩窄至70.93mm±8.06mm,以上各指标比较差异均有统计学意义。HVA和IMA恢复至正常范围内。随访拇外翻足术后进行疗效评价, 144足为优, 12为足良,5足为差,AOFAS评分由57.8上升至82.4分。2、术前伴跖骨头下疼痛组与术前不伴跖骨头下疼痛组的比较, HVA之间的比较差异有统计学意义(T=2.977 P=0.03),IMA、足宽、第一、二跖骨长度、第一、二跖骨相对突出度间的比较差异无统计学意义。术前伴跖骨头下疼痛组与术后不伴跖骨头下疼痛患足的比较,HVA(T=20.16 P=0.00)、IMA(T=12.59 P=0.00)、足宽(T=19.22 P=0.00)、第一跖骨长度(T=-5.62 P=0.00)、第一、二跖骨相对突出度(T=-3.36 P=0.01)之间的比较差异有统计学意义。术前伴跖骨头下疼痛组与术后伴跖骨头下疼痛组的比较, HVA(T=9.33 P=0.011)、足宽(T=6.98 P=0.02)、第一、二跖骨相对突度间(T=9.72 P=0.01)之间的比较有统计学意义,IMA(T=4.00 P=0.057)、第一跖骨长度(T=-2.14 P=0.166)间比较差异无统计学意义。术后不伴跖骨头下疼痛组与术后伴跖骨头下疼痛组的比较,术前足宽(T=-3.07 P=0.02)、第一跖骨长度(T=-2.89 P=0.04)和第二跖骨长度(T=-5.65 P=0.00)之间的比较差异有统计学意义,HVA、IMA及第一、二跖骨相对短缩度之间差异无统计学意义。前足宽度与拇外翻角、第一、二跖间角间的存在相关性。3、拇外翻足的峰压强与压强时间积分最大值位于第二或三跖骨头下,截骨手术后第二、三、四跖骨头下峰压强与压强时间积分较术前减小,而第一、五跖骨头下压力大于术前。第一至三跖骨头的峰压强变化有统计学意义,第四、五跖骨无统计学意义;第一至三、五跖骨头的压强时间积分变化有统计学意义,第四跖骨变化无统计学意义。且前足的应力变化以第二、三跖骨头最大。结论:1、跖骨头下疼痛与外翻角、前足足宽与第一跖骨相对短缩有关。外翻角越大,越容易跖骨头下疼痛;前足越宽,越容易跖骨头下疼痛;第一跖骨相对短缩越大,第一跖骨相对短缩。2、拇外翻第一跖骨远端截骨术后,第一跖骨过度短缩可引起转移性跖骨痛。3、对第一跖骨相对短缩明显的拇外翻患者,应避免行截骨术,其余,可行跖骨截骨术。更多还原

【Abstract】 Objectives: The aims of this study were to investigate the radiological change and the distribution of plantar pressure after distal osteotomy of the first metatarsal ,to discuss correlative factors of transfer metatarsalgia postoperatively and to find dangerous factors of transfer metatarsalgia, which will be some basis for treating and providing for transfer metatarsalgia.Methods:1. 91cases of hallux valgus (including 79 female,74 left feet,68 right feet; 12men,9 left feet,10 right feet) have undergone distal osteotomy of the first metatarsal were examined by X-ray on weightbearing and lateral position before and after operation. Several parameters,including HVA,IMA ,the wideth of forefoot, Peak Pressure and Pressure Time Integral,were measured and AOFAS score was carried out.2. Several parametes above are analysed between all patients preoperatively and postoperatively. Such as were between patients with metatarsalgia preoperatively and patients without metatarsalgia preoperatively, between patients with metatarsalgia preoperatively and postoperatively, between patients with metatarsalgia preoperatively and without metatarsalgia postoperatively, between patients with metatarsalgia postoperatively and patients without metatarsalgia postoperatively.3. The total of 24 cases of hallux valgus with 48 feet were choosed at random. Forefoot plantar pressure were measured during waking by Footscan system preoperatively and postoperatively.The forefoot was divided five regions according to the five metatarsals. Peak Pressure and Pressure Time Integral of the five regions and Percentage of Peak Pressure and Pressure Time Integral of the every region were compared preoperatively and postoperatively to evaluate the plantar pressure changes while walking. Results:1. Compared with preoperatively and postoperatively weighbearing X-ray measurement ,HVA was reduced to 9.58°±5.07°,form 33.71°±8.44°.IMA was 7.52°±1.95°,form 12.65°±2.94°.The length of the first metatarsal was 54.04mm±5.97mm form 57.10mm±4.90mm .The width of forefoot was 70.93mm±8.06mm form 87.28mm±6.70mm.The parameters are statistical significance. HVA and IMA was close to the normal value. when the therapeutic effect of the 161 feet were evaluated , 144 feet were excellent, 12 were good and 5 poor. AOFAS score was 82.4 while 57.8 preoperatively.There were Correlation among HVA ,IMA and the width of forefoot.2. Comparing patients with metatarsalgia preoperatively and patients without metatarsalgia preoperatively, HVA had statistical significant differences,IMA ,the width of forefoot,the length of the first and second metatarsal and the relative metatarsal protrusion between the first and second metatarsal had no statistical significant differences. Comparing patients with metatarsalgia preoperatively and without metatarsalgia postoperatively,HVA,IMA ,the width of forefoot,the length of the first metatarsal and the relative metatarsal protrusion between the first and second metatarsal had had statistical significant differences. Comparing patients with metatarsalgia preoperatively and postoperatively,HVA, the width of forefoot and the relative metatarsal protrusion between the first and second metatarsal had statistical significant differences,IMA and the length of the first metatarsal had no statistical significant differences. Comparing patients with metatarsalgia postoperatively and patients without metatarsalgia postoperatively, the width of forefoot, the length of the first and second metatarsal had statistical significant differences,HVA,IMA and the relative metatarsal protrusion between the first and second metatarsal had no statistical significant differences.3. Pressure Time Integral and Peak Pressure among five regions are maxium under the second or third metatarsal preoperatively. PTI and PP of under the second , third and fourth metatarsal reduced postoperatively. PTI and PP of under the first and fifth metatarsal increased. Peak Pressure under the first, second and third metatarsal was statistical significance preoperatively and postoperatively. There was no statistically significant differences under the fourth and fifth metatarsal. Pressure Time Integral under the first,second,third and fifth metatarsal was statistical significance preoperatively and postoperatively , There was no statistically significant differences under the fourth metatarsal.Conclusion:1. There was correlation between metatarsalgia and HVA, The relative metatarsal protruion of between the first and second metatasal, The width of the forefoot. More larger is HVA, More come into being metatarsalgia; More larger is The relative metatarsal protruion of between the first and second metatasal, More come into being metatarsalgia; More widther is the forefoot, More come into being metatarsalgia.2. Excessive shortening of the first metatarsal may result in transfer metatarsalgia after distal osteotomy of the first metatarsal.3. If Hallux valgus was the relative shortening of the first metatarsal ,we should be avoid osteotomy; another ,we can adopt osteotomy.更多还原