踇长屈肌移植治疗慢性跟腱病的解剖和临床应用

The anatomy and clinical applications of flexor haHucis longns tendon transfer in treatment of chronic

目的探讨不同手术切取长屈肌腱（FHLT）转移修复慢性跟腱病的临床效果。方法取64侧足标本，观测Henry结节处FHLT和趾长屈肌腱（FDLT）之间腱束联合并进行分型。测量单切口、双切口和小切口技术切取FHLT的长度。2012年1月至2015年6月，临床上应用双切口技术切取FHLT转移修复慢性跟腱病10例。根据美国矫形足踝协会（AOFAS）踝与后足疗效评价标准评分为（63.04 ±7.75）分。临床上应用双切口切取FHLT，做跟骨隧道反折后与跟腱编织缝合。 结果Henry结节处发现两种不同腱束联合。I型：腱束起于近端FHLT止于远端FDLT占96.9%（62/64），II型：一侧腱束起于近端FHLT止于远端FDLT，另外一侧腱束起于近端FDLT止于远端FHLT占3.1%（2/64）。单切口切取FHLT的平均长度为（5.08±1.09）cm；双切口切取FHLT的平均长度为（6.72 ± 1.02）cm；小切口切取FHLT的平均长度为（17.49 ± 1.80）cm，3种术式统计学分析差异有统计学意义（P〈0.01）。所有患者都获得随访，随访时间12~36个月，平均13.7个月。术后12个月根据AOFAS踝与后足疗效评价标准评分为（93.28 ± 3.72）分，与术前[（63.04±7.75）分]比较有统计学意义；其中优6例，良3例，可1例。随访期间均未见胫神经、腓肠神经和足底内、外侧神经损伤。结论超过96%的标本腱束联合从FHLT发出至FDLT，切取FHLT后残端不与FDLT腱缝合将丧失趾跖屈功能。切取FDLT腱后残端不做腱固定，余趾仍能保留跖屈功能；双切口切取FHLT转移修复慢性跟腱病具有肌腱固定强度高、保留趾跖屈功能以及并发症少的优点。

ObjectiveTo evaluate the effectiveness of flexor hallucis longus tendon transfer in treatment of chronic Achilles tendinopathy using different technique.MethodsSixty-four embalmed feet of 32 cadavers were analyzed and classified anatomically with respect to the individual cross links in the Henry＇s knot. These three techniques were then combined to determine the total potential tendon graft length obtainable using single incision, double incision and minimally invasive incision. From January, 2012 to June, 2015, 10 patients （10 feet） with chronic Achilles tendinopathy were treated with double incision technique. The score was 63.04 ±7.75 according to American Orthopedic Foot and Ankle Society （AOFAS） ankle and hindfoot score system.ResultsOnly two different configurations were found. Type 1, a tendinous slip branched from the FHLT to the FDLT was 96.9% （62 of 64 feet） . Type 2, a slip branched from the FHLT to the FDLT and another slip from the FDLT to FHLT was 3.1% （2 of 64） . The average length of the FHLT graft available from a single incision measured （5.08±1.09） cm, double incision technique measured （6.72 ± 1.02） cm, and minimally invasive incision measured （17.49 ± 1.80） cm. The difference between the lengths obtained from these three techniques was statistically significant. Ten patients were followed-up 12-36 months （mean, 13.7 months） . At 12 months after operation, the AOFAS ankle and hindfoot score was 93.28 ± 3.72, showing significant difference when compared with that before operation. The results were excellent in 6 cases, good in 3 cases, and fair in 1 case with an excellent and good rate of 90%. No sural nerve injury, posterior tibial nerve injury, medial plantar nerve injury, and lateral plantar nerve injury occurred.ConclusionIn over 96% of the feet, a proximal to distal connection from the FHLT to the FDLT was found, which might contribute to the residual function of the lesser toes after FDLT transfer. The distal stump of the FHLT tendon should be sutured onto the FDLT tendon under tension to enable a co-activation of the great toe, preserved hallux plantar flexion. Chronic Achilles tendinopathy reconstruction with flexor hallucis longus tendon harvested using double incision technique offers a desirable outcome in operative recovery, tendon fixation, preserved hallux plantar flexion and less complications.