足部截肢的假肢处理方式.pptx

Prosthetic Treatment for Partial Foot Amputation 足部截肢的假肢处理方式,Christian Schlierf Prosthetist/Orthotist,Guangzhou, China November 2011,Foot bone structures（足部骨骼结构）,The 27 bones of the foot skeleton（足部27块骨骼）,Forefoot（前足）,Rear foot（后足）,Digiti pedis (toes)脚趾部,Metatarsus (middle foot)中足,Tarsus (foot root)足跟,Levels of Foot Amputations（足部截肢平面）,If amputation in the area of toes is needed, no middle or basic parts of bones should remain because they tend to deviate to wrong positions. （如果必须足趾截肢的话，中部骨骼或骨骼的根部没有必要留下，因为它们将会偏离到错误位置） The disarticulation is optimal in this case as it ensures unproblematic prosthetic treatment. （假如能确保假肢安装没问题的话，跖趾离断是最佳选择） An exception is the big toe. If only the hallux is amputated, only a stiff sole and an appropriate roll-over edge would be an adequate prosthetic treatment. The shoe should have a flat sole in order to avoid too much strain on the stump. Where toes II-V are amputated, an insole with some compensation of the shape would be appropriate. （大脚趾是个例外。如果大拇趾被截肢，具有滚动边的硬鞋垫就是合理的假肢处理方式。应该穿平底鞋，避免残趾处应力集中。第二至第五足趾截肢，残缺部补好形状的的鞋垫就可以。）,Disarticulation of Toes（跖趾关节离断）,International name: Trans-metatarsal peripheral amp. （国际通用名:经跖骨远端截肢） Clinical sign: Amputation according to Sharp（临床名：Sharp截肢) Here the amputation line goes through the heads of the metatarsus bones, therefore through the spongious bone areas. Amputations at the diaphysis level are very unfavorable because the bones thin down and become very pointed, thus making the prosthetic treatment very complicated. (截肢线经过跖骨头部，因此经过跖骨髁部。经跖骨干截肢不好，因为此处骨变小而且很尖，安装假肢将很复杂。） The ends of the bones cut by amputation must be well curved on the plantar side. The scar should be positioned on the cranial side of the foot so that the skin of the foot sole can be pulled over the ends of the cut bones. （被截肢骨末端的足底面应该圆滑修整，伤疤应该安置在足背面，因此，足底皮肤可以被拉上来覆盖截骨末端。）,Transmetatarsal Amputation: Long Stump（经跖骨截肢:长残肢）,Levels of Foot Amputations （足部截肢平面）,International sign: Trans-metatarsal proximal amp. （国际通用名:经跖骨远端截肢） Clinical sign: Amputation according to Sharp-Jger（临床名：Sharp-Jger 截肢） If the metatarsus cannot be preserved, amputation line will go through the basis of the metatarsus bones. Prosthetic device is indicated here, but an orthopedic-technical shoe treatment is recommended especially for elderly patients.（如果跖骨不能保留，截肢线应经过跖骨基底。此处可以安装假肢，但要配符合矫形技术的鞋，尤其对老年人来说。）,Transmetatarsal Amputation: Short Stump （经跖骨截肢:短残肢）,Levels of Foot Amputations （足部截肢平面）,Disarticulation of toes 跖趾关节离断,Transmetatarsal peripheral 跖骨远端,Transmetatarsal proximal 跖骨近端,Levels of Foot Amputations （足部截肢平面）,Clinical name: Amputation according to Lisfranc （临床名：Lisfranc 截肢） Disarticulation in the Lisfranc line cannot be treated without prosthetic problems because the bones of tarsus are of different length and the stump end is uneven. 经Lisfranc（线离断截肢不处理的，安置假肢会有问题，因为跗骨长短不一、残端不平整。） If the lengths of the tarsus bones are adjusted through operation they show good functional results (according to Baumgartner). 如果跗骨长度通过手术处理的话，会有很好的功能效果（ 据Baumgartner） For this type of amputation, shoe-technical possibilities are no longer enough, therefore there is a clear indication for prosthetic treatment. 这种类型截肢，矫形鞋技术已经不够，因此，需要安置假肢处理。,Amputation in the Tarsus Area: Long Stump（跗骨部截肢：远端）,Levels of Foot Amputations （足部截肢平面）,Clinical name: Amputation according to Bona-Jger（临床名：Bona-Jger 截肢） Line of distal bones of tarsus is removed and the os cuboideum is cut. Stump end is round. 跗骨远端切除和骰骨切开，残端变圆滑。 With the amputation line moving more proximally, the tendency of the foot to move to plantarflexion increases. Moreover, the back part of the foot tends to move to supination position. 由于这种截肢太接近近端，足倾向于跖屈状态，而且，足背部倾向于反掌运动。 Through tendon caused forces single tarsus bones are likely to move to a more lateral/medial and plantar positions.由于跟腱产生的l力作用于单一的跗骨上，使这一跗骨可能移位在更外/内侧和跖屈位上,Amputation in the tarsus area - short stump （跗骨部截肢：近端）,Levels of Foot Amputations （足部截肢平面）,Clinical sign: Disarticulation according to Chopart（临床名：Chopart离断） Here the amputation goes through Chopart line. To improve the loading abilities of the stump, lower front edge of calcaneus should be rounded. With this amputation loading may be painful because the joints can move freely. To prevent that some surgeons shift the tendon of the m. tibialis anterior especially in younger patients. 经Chopart线截肢，为了提高残端的负重能力，跟骨下前沿应该修整圆滑。这种截肢承重会造成疼痛，因为关节可以自由活动。为防止这种情况，可通过手术移位胫前肌，尤其对年轻的患者。 With total loss of movements in the joints of the stump in corrected plantar-flexed and supinated position, arthrodesis is possible.由于残端关节总体运动功能丧失并处于不正确的跖屈和反掌位，故关节融合术是可能的。,Amputation in the tarsus area（跗骨部截肢）,Levels of Foot Amputations （足部截肢平面）,Lisfranc amputation Lisfranc截肢,Bona-Jger amputation Bona-Jger截肢,Chopart amputation Chopart截肢,Levels of Foot Amputations （足部截肢平面）,In this type of amputation, the dorsal part of the cut calcaneus is overturned and put on cut end of tibia. 这种类型截肢，是把切开的跟骨背部倒转地安置在被切除的胫骨末端。 One part of the skin is exposed to high pressure during loading and therefore to damage in the long term. 负重时，一部份皮肤被暴露于高压区，长远来讲，易于损伤。,Pirogow-amputation (calcaneo-tibial arthrodesis) 皮罗果夫截肢（跟骨胫骨融合术）,Levels of Foot Amputations （足部截肢平面）,The stump according to Syme is little shorter than a Pirogow stump but it also shows excellent weight bearing capacities because the amputation line goes through bones spongiosis. 塞姆截肢比皮罗果夫截肢稍微短些，具有良好的承重能力，因为截肢线经过骨髁部位。,Syme-amputation (supra-malleloar amputation) 塞姆截肢（踝上截肢）,Levels of Foot Amputations （足部截肢平面）,Pirogow Amputation 皮罗果夫截肢,Achillis (tendo calcaneus) 跟腱,Tibia胫骨,Syme Amputation 塞姆截肢,Talus距骨,Os naviculare 足舟骨,Calcaneus 跟骨,Levels of Foot Amputations （足部截肢平面）,Biomechanical aspects（生物力学方面分析）,“Touch sense“ (proprioception) of the foot sole 足垫的”触觉感受器”（本体感觉）,A heel is marked as the eye of the foot because the brain receives information over the receptors of the ankles, muscles and nerves about where the foot is, which position it has and what the ground is made of. The sole of the foot has a touch sense that should stay preserved within after amputation. 足跟被认为是足的眼睛，因为大脑通过踝、肌肉、神经这些感受器接受信息：足的位置以及地面的形成。在截肢后，足垫应该具有“触觉感受器”的功能来反馈信息。,Biomechanical aspects（生物力学方面分析）,Maleolus axis,Biomechanical aspects （生物力学方面分析）,Position and posture of the end of the cut bone （残骨的位置和姿势）,Mal-position of the foot-stump as a result of muscle imbalance must be distinguished from the different functional mal-positions: 肌力不平衡导致的残肢异常位必须和不同的功能位异常区分出来： Through the loss of the front part of the foot, the back part of the foot stands in an increased plantar flexed position (see picture) that must be compensated through appropriate containment in the prosthesis by positioning the remaining foot bones in a “relative dorsal extension. 由于前足的缺失，后足处于跖屈状态（如图），所以必须通过假肢的合适的包容来补偿，使残肢处于相对的背伸状态。,Only within a normal physiological position an appropriate scope of movement and force development for adequate plantar flexion is guaranteed. 保证正常的生理位置、合适的运动范围以及充分跖屈力的实施。,Biomechanical aspects （生物力学方面分析）,Position and posture of the end of the cut bone（残骨的位置和姿势）,In the frontal area occurs a similar picture with an apparent supination of the foot (see picture) without real participation of the calcaneus.在没有跟骨的参与下，前足区出现如图所示的内翻足。 The shorter the front part of the foot the closer the amputation line is to the highest point of the longitudinal arch, which creates the impression of an increased supination. 前足越短，截肢线越接近纵弓最高点，越容易形成内翻足。 These anatomical as well as functional aspects must be met within an appropriate containment and bearing of the residual limb.解剖结构和功能方面必须融合在适当的包容性和残端的承重性上。,Biomechanical aspects （生物力学方面分析）,Position of the mechanical roll-over edge 力学滚动边的位置,With a prosthetic device, not only the aesthetic appearance should be restored but also homologous movements and gait patterns should be ensured. 一个假肢，不仅要恢复它的外观而且要保证相应的运动和步态模式。 An important factor here is the position and the direction of the metatarsal roll-over edge. 跖趾滚动边的位置和方向是个重要的因素。 Here the proportions of the healthy foot should serve as criterion.下面是正常足比例分部，以此作为标准。,Biomechanical aspects （生物力学方面分析）,Position of the mechanical roll-over edge 力学滚动边的位置,Biomechanical aspects （生物力学方面分析）,Length of stump after amputation in the tarsus area 跗骨部截肢的残长,The picture below shows amputations in the tarsus area with their approximate length differentiations. 下图显示了跗骨部截肢的大概长度偏差。,Chopart 肖帕特,Pirogow 皮罗果夫,Syme 塞姆,According to Baumgartner,Measurement sheet测量表,Effective heel height 有效跟高,Remove uneven spots with a SURFORM rasp 用半圆锉修掉不平整的斑点。 Flatten the distal surface of the heel 把跟骨末端平面修平,Model technique,Add plaster 补石膏,Reduce plaster 修石膏,Work steps of measurement and modification technique （测量步骤和修型技术）,Type A: Rear-foot prosthesis (short foot root stump with ankle joint mobility) A型：足部假肢（短足残肢，踝关节可活动） If movements in the upper ankle joint are possible and if they should be used with the prosthesis then the frame construction according to Botta is to recommend.如果踝上活动可以而且需要使用假肢的话，这是结构是Botta 比较推荐的。 The frontal height should cover more than 2/3 of the lower leg in order to distribute the pressure of the prosthesis on the tibia flares as extensively as possible.为了尽量的分布假肢在胫骨面的压力，前缘高度应该超过小腿的三分之二。 The dorsal height should not reach higher than to the base of the m. gastrocnemius. 后侧高度不应超过腓肠肌起点。,Design of a Rear-foot prosthesis（足部假肢设计）,Type A: For Rear-foot prosthesis (short foot root stump with ankle joint mobility) A型：足部假肢（短足残肢，踝关节可活动）,Design of a Rear-foot prosthesis 一种足部假肢的设计,Rear-foot Prosthesis - Type A, frame construction A型框架,Edge of cut 切开边缘,Soft in-layer 软垫层,Soft in-layer 软垫层,Lock strap 搭扣带,Axis of the stump 残肢的轴线,Core made of wood or PU foam内芯由木头或聚氨酯泡沫橡胶制成。,PE foam or rubber聚乙烯泡沫板或橡胶,Pedilan sole Pedilan 垫,Type B: For Rear-foot prosthesis (amputation according to Pirogow and its modifications no ankle joint mobility) B型：足部假肢（适用踝骨限制活动的皮罗果夫截肢） For very sensitive and bulbous stumps, a rear-foot prosthesis with a dorsal flap door for easy donning of the prosthesis is recommended.因为这种残端比较敏感性和类似球状，比较推荐易于穿戴带后片的足部假肢,Design of a Rear-foot prosthesis足部截肢设计,Dorsal flap door 后片,Rear-foot Prosthesis - Type B, dorsal flap-door B型，带后片型,Tab扣环,Modular foot component标准足组件,Soft in-layer 软垫层,Dorsal Flap 后片,Locking pin 锁闩,Lamination cut edge 板材边缘,Type C: Rear-foot prosthesis (amputation according to Syme with a closed socket and soft-liner inlay no ankle joint mobility) C型：足部假肢（适用无关节活动的塞姆截肢，需要带内衬软板封闭的接受腔） Within muscular atrophy and a resulting bulbous stump end it can be better to insert a soft socket that will compensate the greatest circumference differences. 由于肌肉萎缩和球状的残端，软内衬接受腔可补偿最大围度的偏差，有利于穿戴。 The laminated container can be designed closed or with window openings. 外层可设计为封闭式或者开窗式,Design of a Rear-foot prosthesis足部截肢设计,Design of a Rear-foot prosthesis足部截肢设计,