| 四点垂直进针针刀术式治疗踝管综合征的临床解剖学研究 |
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投稿时间：2021-04-20
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| 作者 | Author | 单位 | Address | E-Mail |
| 孙小洁 |
SUN Xiao-jie |
中日友好医院针灸科, 北京 100029
北京中医药大学, 北京 100029 |
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| 石翀 |
SHI Chong |
中日友好医院针灸科, 北京 100029
北京中医药大学, 北京 100029 |
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| 李蕴楠 |
LI Yun-nan |
中日友好医院针灸科, 北京 100029
北京中医药大学, 北京 100029 |
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| 蓝扬敬 |
LAN Yang-jing |
中日友好医院针灸科, 北京 100029
北京中医药大学, 北京 100029 |
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| 王建伟 |
WANG Jian-wei |
北京大学基础医学院人体解剖教研室, 北京 100191 |
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| 张卫光 |
ZHANG Wei-guang |
北京大学基础医学院人体解剖教研室, 北京 100191 |
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| 李石良 |
LI Shi-liang |
中日友好医院针灸科, 北京 100029
北京中医药大学, 北京 100029 |
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zrlishiliang@163.com |
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| 期刊信息：《中国骨伤》2022年，第35卷，第6期，第543-547页 |
| DOI：10.12200/j.issn.1003-0034.2022.06.008 |
| 基金项目: |
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中文摘要:
目的:探讨四点垂直进针针刀术式治疗踝管综合征的安全性及准确性,为临床操作术式选择及后续进一步优化提供解剖参考依据。
方法:自2020年9月至2020年10月选取10%甲醛防腐固定的成人标本29具,男15具,女14具;年龄47~98(81.10±11.14)岁;左侧29例,右侧29例。在人体标本上模拟针刀松解踝管屈肌支持带操作,使标本双下肢蛙位摆放,内踝向上。在踝管屈肌支持带附近(取内踝前、后缘连成的曲线、跟骨结节内侧突前方的沟状曲线与屈肌支持带宽度的两条定义线之间的交点)选取4个不同位置进针,使针身与皮肤垂直,刃口方向与屈肌支持带走行方向垂直。针刀穿过皮肤缓慢探索,达到屈肌支持带时针下可有针尖触碰坚韧组织的感觉,此时切割松解4次。针刀松解操作完毕后,在皮肤表面沿针刀方向做横向切口,打开暴露屈肌支持带区域,逐层解剖,观察并记录针刀及其周边解剖结构。通过电子游标卡尺测量屈肌支持带的针刀切割痕迹长度,并通过肉眼观察并统计针刀损伤肌腱、神经等踝管内容物的数量及程度,以此评估针刀松解踝管屈肌支持带的安全性及准确性。安全性,即统计针刀损伤踝管内容物的例数;损伤率,即(损伤踝例数/总例数)×100%;准确性,即以松解长度L ≥ W/2(W为屈肌支持带宽度,定义为20 mm)为准确有效松解。
结果:安全性结果,在58例标本中,未见针刀损伤神经、血管,26例损伤了胫骨后肌腱,其中17例透刺肌腱,损伤严重;12例损伤了趾长屈肌腱,其中4例透刺肌腱,损伤程度为严重损伤,总损伤率为32.14%。c3,c4进针点未见神经血管损伤。准确性结果,58例标本全部松解成功,针刀松解痕迹的总长度Lc为(10.40±1.36) mm,长度6.38~12.88 mm,其中37例松解痕迹总长度范围≥ 10 mm,长度松解均成功。踝管屈肌支持带分层结构:屈肌支持带发出的纤维隔向内将踝管内容物分成不同的腔室,近内踝尖与跟骨结节连线中点处(即在神经血管走行的上方)纤维隔在此汇合成完整的屈肌支持带。
结论:四点垂直进针针刀术式松解屈肌支持带由于是在屈肌支持带两端骨面附着处进行操作,较易损伤肌腱,但不易损伤神经血管,其中在跟骨侧进针较为安全,但总体安全性不高;从松解长度来说,松解较为彻底,但由于屈肌支持带的分层结构,四点垂直进针针刀术式从骨缘垂直进针,仅能松解其中表层,无法做到全层彻底松解,因而临床上是否能到达理想的疗效仍有待观察。 |
| 【关键词】针刀疗法|解剖学|进针法|踝关节 |
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| Clinical anatomical study on the treatment of tarsal tunnel syndrome with four-point vertical acupotomy |
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ABSTRACT
Objective: To explore safety and accuracy of four-point acupotomy for the treatment of tarsal tunnel syndrome regarding release of ankle tunnel flexor retinaculum to provide an anatomical basis of clinical treatment.
Methods: Twenty-nine adult specimens (15 males and 14 females) fixed with 10% formalin,aged from 47 to 98 years old with an average age of (81.10±11.14) years old,29 on the right side and 29 on the left side,which were selected for the study from September 2020 to October 2020. Simulate the operation of loosening flexor retinaculumt with a needle knife on the human specimen,and place the specimen on the frog position of lower limbs with medial malleolus upward to determine the center of medial malleolus. Choose 4 different positions near the flexor retinaculum to insert the needle so that the needle body was perpendicular to skin and cutting edge direction was perpendicular to the running direction of the flexor retinaculum. The needle knife penetrates the skin and explores slowly. When the flexor retinaculum was reached,the needle tip may touch the tough tissue. At this time,the cutting is loosened for 4 times. After acupotomy release operation was completed,make a lateral incision on the skin surface along acupotomy direction,open the area of the exposed flexor retinaculum,dissecting layer by layer,observe and record the needle knife and its surrounding anatomical structure. The length of acupotomy cutting marks of flexor retinaculum was measured by electronic vernier caliper. The safety and accuracy of acupotomy loosening of ankle canal flexor retinaculum were evaluated by observing the number and degree of ankle canal contents such as tendons and nerves injured by needle knife. The safety is to count the number of cases of acupotomy injury to the contents of the ankle canal,and to calculate the injury rate,that is,the number of injury cases/total cases×100%. The effective release was defined as the release length L ≥ W/2(W is the width of the flexor retinaculum,defined as 20 mm).
Results: For safety,there were no acupotomy injuries to nerves or blood vessels in 58 cases,26 cases injuried to posterior tibial tendon which 17 of these tendon injury cases,the tendon was penetrated and severely injured,and flexor digitorum longus tendon was injured in 12 cases. Among these cases,tendon was penetrated and severely injured in 4 cases,and total injury rate was 32.14%. No nerve and vessel injury on c3 and c4 point. For accuracy,58 specimens were successfully released. The length Lc of releasing trace for acupotomy was (10.40±1.36) cm,and length range 6.38 to 12.88 cm. Among all cases,the length of releasing trace was ≥ 10 mm in 37 cases. The overall success rate of release was 100.00%. Layered structure of ankle tube flexor retinaculumt:fiber diaphragm from flexor retinaculum divides contents of ankle tube into different chambers inward,and fiber diaphragm meets here to synthesize a complete flexor retinaculum at the midpoint of the line between the medial malleolus tip and calcaneal tubercle(above the neurovascular course).
Conclusion: Four-point needle-knife method of releasing flexor retinaculum for the treatment of tarsal tunnel syndrome is performed at the attachment of the two ends of flexor retinaculum;the tendon,but not the nerves and blood vessels,is easily damaged. It is safe to insert needle on the side of calcaneus. The extent of release is relatively complete,but due to the "layered" structure of the flexor retinaculum,classic surgical technique could only release one layer of flexor retinaculum when a needle is inserted at the edge of the bone and cannot achieve complete release of the full thickness of the flexor. Therefore,it remains to be determined whether the desired effect can be achieved clinically. |
| KEY WORDS Acupotomy therapy|Anatomy|Method of needle insertion|Ankle joint |
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| 引用本文，请按以下格式著录参考文献： |
| 中文格式: | 孙小洁,石翀,李蕴楠,蓝扬敬,王建伟,张卫光,李石良.四点垂直进针针刀术式治疗踝管综合征的临床解剖学研究[J].中国骨伤,2022,35(6):543~547 |
| 英文格式: | SUN Xiao-jie,SHI Chong,LI Yun-nan,LAN Yang-jing,WANG Jian-wei,ZHANG Wei-guang,LI Shi-liang.Clinical anatomical study on the treatment of tarsal tunnel syndrome with four-point vertical acupotomy[J].zhongguo gu shang / China J Orthop Trauma ,2022,35(6):543~547 |
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