目的:探讨四点针刀治疗下踝管屈支持带松解术的安全性和准确性,为临床治疗提供解剖学依据。
方法:29个成人标本(15个男性和14个女性)用10%福尔马林固定,年龄在47至98岁之间,平均年龄为(81.10±11.14)岁,29在右侧,29在左侧,从2020年9月至2020年10月入选研究。模拟用针刀在人体标本上松开屈肌视网膜的操作,并将标本放置在下肢的青蛙位置,内踝向上,以确定内踝的中心。选择屈肌支持带附近的4个不同位置插入针头,使针体垂直于皮肤,切边方向垂直于屈肌支持带的运行方向。针刀穿透皮肤,慢慢探索。当屈肌支持带到达时,针尖可能会接触到坚韧的组织。此时,将切割松开4次。针刀松解术完成后,沿着针刀方向在皮肤表面做一个横向切口,打开暴露的屈肌支持带区域,逐层解剖,观察并记录针刀及其周围解剖结构。用电子游标卡尺测量屈指支持带针刀切割痕迹的长度。通过观察针刀损伤踝管内容物如肌腱和神经的数量和程度,评价踝管屈肌支持带针刀松解的安全性和准确性。安全性是计算针刀损伤踝管内容物的例数,计算受伤率,也就是说,伤害例数/总例数×100%。有效释放定义为释放长度L≥W/2(W为屈肌支持带的宽度,定义为20毫米)。
结果:为了安全,58例无针刀神经血管损伤,胫骨后肌腱损伤26例,其中肌腱损伤17例,肌腱被穿透严重受伤,12例手指长屈肌腱损伤。在这些案例中,4例肌腱被穿透并严重受伤,总损伤率为32.14%。c3和c4点无神经血管损伤。为了准确,58个标本被成功释放。针刀松痕长度Lc为(10.40±1.36)cm,和长度范围6.38至12.88厘米。在所有案件中,37例释放痕迹长度≥10mm。整体发布成功率为100.00%。踝管屈肌支持带的层状结构:屈肌支持带的纤维隔膜将踝管内容物向内分成不同的腔室,和纤维隔膜在这里相遇,在内踝尖端和跟骨结节之间的线的中点(在神经血管的上方)合成完整的屈肌支持带。
结论:四点针刀松解屈肌支持带的方法是在屈肌支持带两端的附着处进行治疗。肌腱,但不是神经和血管,很容易损坏。在跟骨侧面插入针头是安全的。释放的程度比较完整,但是由于屈肌支持带的“分层”结构,经典的手术技术只能在将针头插入骨骼边缘时释放一层屈肌支持带,并且无法完全释放屈肌的全部厚度。因此,临床上能否达到预期效果尚待确定。
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).
CONCLUSIONS: 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.