足部截肢的假肢處理方式

足部截肢的假肢處理方式第1頁/共46頁Footbonestructures（足部骨骼結(jié)構(gòu)）The27bonesofthefootskeleton（足部27塊骨骼）Forefoot（前足）Rearfoot（后足）Digitipedis(toes)腳趾部Metatarsus(middlefoot)中足Tarsus(footroot)足跟第2頁/共46頁LevelsofFootAmputations（足部截肢平面）Ifamputationintheareaoftoesisneeded,nomiddleorbasicpartsofbonesshouldremainbecausetheytendtodeviatetowrongpositions.（如果必須足趾截肢的話，中部骨骼或骨骼的根部沒有必要留下，因為它們將會偏離到錯誤位置）Thedisarticulationisoptimalinthiscaseasitensuresunproblematicprosthetictreatment.（假如能確保假肢安裝沒問題的話，跖趾離斷是最佳選擇）Anexceptionisthebigtoe.Ifonlythehalluxisamputated,onlyastiffsoleandanappropriateroll-overedgewouldbeanadequateprosthetictreatment.Theshoeshouldhaveaflatsoleinordertoavoidtoomuchstrainonthestump.WheretoesII-Vareamputated,aninsolewithsomecompensationoftheshapewouldbeappropriate.（大腳趾是個例外。如果大拇趾被截肢，具有滾動邊的硬鞋墊就是合理的假肢處理方式。應(yīng)該穿平底鞋，避免殘趾處應(yīng)力集中。第二至第五足趾截肢，殘缺部補好形狀的的鞋墊就可以。）DisarticulationofToes（跖趾關(guān)節(jié)離斷）第3頁/共46頁Internationalname:Trans-metatarsalperipheralamp.（國際通用名:經(jīng)跖骨遠端截肢）Clinicalsign:AmputationaccordingtoSharp（臨床名：Sharp截肢)Heretheamputationlinegoesthroughtheheadsofthemetatarsusbones,thereforethroughthespongiousboneareas.Amputationsatthediaphysislevelareveryunfavorablebecausethebonesthindownandbecomeverypointed,thusmakingtheprosthetictreatmentverycomplicated.(截肢線經(jīng)過跖骨頭部，因此經(jīng)過跖骨髁部。經(jīng)跖骨干截肢不好，因為此處骨變小而且很尖，安裝假肢將很復(fù)雜。）Theendsofthebonescutbyamputationmustbewellcurvedontheplantarside.Thescarshouldbepositionedonthecranialsideofthefootsothattheskinofthefootsolecanbepulledovertheendsofthecutbones.（被截肢骨末端的足底面應(yīng)該圓滑修整，傷疤應(yīng)該安置在足背面，因此，足底皮膚可以被拉上來覆蓋截骨末端。）TransmetatarsalAmputation:LongStump（經(jīng)跖骨截肢:長殘肢）LevelsofFootAmputations（足部截肢平面）第4頁/共46頁Internationalsign:

Trans-metatarsalproximalamp.

（國際通用名:經(jīng)跖骨遠端截肢）Clinicalsign:

AmputationaccordingtoSharp-J?ger（臨床名：Sharp-J?ger截肢）Ifthemetatarsuscannotbepreserved,amputationlinewillgothroughthebasisofthemetatarsusbones.Prostheticdeviceisindicatedhere,butanorthopedic-technicalshoetreatmentisrecommended

especiallyforelderlypatients.（如果跖骨不能保留，截肢線應(yīng)經(jīng)過跖骨基底。此處可以安裝假肢，但要配符合矯形技術(shù)的鞋，尤其對老年人來說。）TransmetatarsalAmputation:Short

Stump（經(jīng)跖骨截肢:短殘肢）LevelsofFootAmputations（足部截肢平面）第5頁/共46頁Disarticulationoftoes

跖趾關(guān)節(jié)離斷Transmetatarsalperipheral跖骨遠端Transmetatarsalproximal

跖骨近端LevelsofFootAmputations（足部截肢平面）第6頁/共46頁Clinicalname:AmputationaccordingtoLisfranc（臨床名：Lisfranc截肢）DisarticulationintheLisfranclinecannotbetreatedwithoutprostheticproblemsbecausethebonesoftarsusareofdifferentlengthandthestumpendisuneven.經(jīng)Lisfranc（線離斷截肢不處理的，安置假肢會有問題，因為跗骨長短不一、殘端不平整。）Ifthelengthsofthetarsusbonesareadjustedthroughoperation

theyshowgoodfunctionalresults(accordingtoBaumgartner).如果跗骨長度通過手術(shù)處理的話，會有很好的功能效果（

據(jù)Baumgartner）Forthistypeofamputation,shoe-technicalpossibilitiesarenolongerenough,thereforethereisaclearindicationforprosthetictreatment.這種類型截肢，矯形鞋技術(shù)已經(jīng)不夠，因此，需要安置假肢處理。AmputationintheTarsusArea:LongStump（跗骨部截肢：遠端）LevelsofFootAmputations（足部截肢平面）第7頁/共46頁Clinicalname:AmputationaccordingtoBona-J?ger（臨床名：Bona-J?ger截肢）Lineofdistalbonesoftarsusisremovedandtheoscuboideumiscut.Stumpendisround.跗骨遠端切除和骰骨切開，殘端變圓滑。Withtheamputationlinemovingmoreproximally,thetendencyofthefoottomovetoplantarflexionincreases.Moreover,thebackpartofthefoottendstomovetosupinationposition.由于這種截肢太接近近端，足傾向于跖屈狀態(tài)，而且，足背部傾向于反掌運動。Throughtendoncausedforcessingletarsusbonesarelikelytomovetoamorelateral/medialandplantarpositions.由于跟腱產(chǎn)生的l力作用于單一的跗骨上，使這一跗骨可能移位在更外/內(nèi)側(cè)和跖屈位上Amputationinthetarsusarea-short

stump（跗骨部截肢：近端）LevelsofFootAmputations（足部截肢平面）第8頁/共46頁Clinicalsign:DisarticulationaccordingtoChopart（臨床名：Chopart離斷）HeretheamputationgoesthroughChopartline.Toimprovetheloadingabilitiesofthestump,lowerfrontedgeofcalcaneusshouldberounded.Withthisamputationloadingmaybepainfulbecausethejointscanmovefreely.Topreventthatsomesurgeonsshiftthetendonofthem.

tibialisanteriorespeciallyinyoungerpatients.經(jīng)Chopart線截肢，為了提高殘端的負重能力，跟骨下前沿應(yīng)該修整圓滑。這種截肢承重會造成疼痛，因為關(guān)節(jié)可以自由活動。為防止這種情況，可通過手術(shù)移位脛前肌，尤其對年輕的患者。Withtotallossofmovementsinthejointsofthestumpincorrectedplantar-flexedandsupinatedposition,arthrodesisispossible.由于殘端關(guān)節(jié)總體運動功能喪失并處于不正確的跖屈和反掌位，故關(guān)節(jié)融合術(shù)是可能的。Amputationinthetarsusarea（跗骨部截肢）LevelsofFootAmputations（足部截肢平面）第9頁/共46頁Lisfrancamputation

Lisfranc截肢Bona-J?ger

amputationBona-J?ger截肢Chopart

amputationChopart截肢LevelsofFootAmputations（足部截肢平面）第10頁/共46頁Inthistypeofamputation,thedorsalpartofthecutcalcaneusisoverturnedandputoncutendoftibia.這種類型截肢，是把切開的跟骨背部倒轉(zhuǎn)地安置在被切除的脛骨末端。Onepartoftheskinisexposedtohighpressureduringloadingandtherefore

todamageinthelongterm.負重時，一部份皮膚被暴露于高壓區(qū)，長遠來講，易于損傷。Pirogow-amputation(calcaneo-tibialarthrodesis)皮羅果夫截肢（跟骨—脛骨融合術(shù)）LevelsofFootAmputations（足部截肢平面）第11頁/共46頁ThestumpaccordingtoSymeislittleshorterthanaPirogowstumpbutitalsoshowsexcellentweightbearingcapacitiesbecausetheamputationlinegoesthroughbonesspongiosis.塞姆截肢比皮羅果夫截肢稍微短些，具有良好的承重能力，因為截肢線經(jīng)過骨髁部位。Syme-amputation(supra-malleloaramputation)塞姆截肢（踝上截肢）LevelsofFootAmputations（足部截肢平面）第12頁/共46頁PirogowAmputation皮羅果夫截肢Achillis(tendocalcaneus)跟腱Tibia脛骨Syme

Amputation塞姆截肢Talus距骨Osnaviculare

足舟骨Calcaneus跟骨LevelsofFootAmputations（足部截肢平面）第13頁/共46頁Biomechanicalaspects（生物力學(xué)方面分析）

“Touchsense“(proprioception)ofthefootsole足墊的”觸覺感受器”（本體感覺）Aheelismarkedastheeyeofthefootbecausethebrainreceivesinformationoverthereceptorsoftheankles,musclesandnervesaboutwherethefootis,whichpositionithasandwhatthegroundismadeof.Thesoleofthefoothasa‘’touchsense’’thatshouldstaypreservedwithinafteramputation.足跟被認為是足的眼睛，因為大腦通過踝、肌肉、神經(jīng)這些感受器接受信息：足的位置以及地面的形成。在截肢后，足墊應(yīng)該具有“觸覺感受器”的功能來反饋信息。第14頁/共46頁Biomechanicalaspects（生物力學(xué)方面分析）

Maleolusaxis第15頁/共46頁Biomechanicalaspects（生物力學(xué)方面分析）

Positionandpostureoftheendofthecutbone

（殘骨的位置和姿勢）Mal-positionofthefoot-stumpasaresultofmuscleimbalancemustbedistinguishedfromthedifferentfunctionalmal-positions:肌力不平衡導(dǎo)致的殘肢異常位必須和不同的功能位異常區(qū)分出來：Throughthelossofthefrontpartofthefoot,thebackpartofthefootstandsinanincreasedplantarflexedposition(seepicture)thatmustbecompensatedthroughappropriatecontainmentintheprosthesisbypositioningtheremainingfootbonesina“relative’dorsalextension.由于前足的缺失，后足處于跖屈狀態(tài)（如圖），所以必須通過假肢的合適的包容來補償，使殘肢處于相對的背伸狀態(tài)。Onlywithinanormalphysiologicalpositionanappropriatescopeofmovementandforcedevelopmentforadequateplantarflexionisguaranteed.保證正常的生理位置、合適的運動范圍以及充分跖屈力的實施。第16頁/共46頁Biomechanicalaspects（生物力學(xué)方面分析）

Positionandpostureoftheendofthecutbone（殘骨的位置和姿勢）Inthefrontalareaoccursasimilarpicturewithanapparentsupinationofthefoot(seepicture)withoutrealparticipationofthecalcaneus.在沒有跟骨的參與下，前足區(qū)出現(xiàn)如圖所示的內(nèi)翻足。Theshorterthefrontpartofthefootthecloser

theamputationlineistothehighestpointofthelongitudinalarch,whichcreatestheimpressionofanincreasedsupination.前足越短，截肢線越接近縱弓最高點，越容易形成內(nèi)翻足。Theseanatomicalaswellasfunctionalaspectsmustbemetwithinanappropriatecontainmentandbearingoftheresiduallimb.解剖結(jié)構(gòu)和功能方面必須融合在適當(dāng)?shù)陌菪院蜌埗说某兄匦陨稀５?7頁/共46頁Biomechanicalaspects（生物力學(xué)方面分析）

Positionofthe‘mechanicalroll-overedge’力學(xué)滾動邊的位置

Withaprostheticdevice,notonlytheaestheticappearanceshouldberestoredbutalsohomologousmovementsandgaitpatternsshouldbeensured.一個假肢，不僅要恢復(fù)它的外觀而且要保證相應(yīng)的運動和步態(tài)模式。Animportantfactorhereisthepositionandthedirectionofthemetatarsal‘roll-overedge’.跖趾滾動邊的位置和方向是個重要的因素。Heretheproportionsofthehealthyfootshouldserveascriterion.下面是正常足比例分部，以此作為標(biāo)準(zhǔn)。第18頁/共46頁Biomechanicalaspects（生物力學(xué)方面分析）

Positionofthe‘mechanicalroll-overedge’力學(xué)滾動邊的位置

Footmidline

足中線10-15°Footlongitudinalaxis(lineofprogression)足縱軸（行徑線）Mechanicalrool-overedge力學(xué)滾動邊Mechanicalmaleolusaxis力學(xué)橫軸第19頁/共46頁Biomechanicalaspects（生物力學(xué)方面分析）

Lengthofstumpafteramputationinthetarsusarea跗骨部截肢的殘長Thepicturebelowshowsamputationsinthetarsusareawiththeirapproximatelengthdifferentiations.下圖顯示了跗骨部截肢的大概長度偏差。Chopart肖帕特Pirogow皮羅果夫Syme塞姆AccordingtoBaumgartner第20頁/共46頁Measurementsheet測量表

Effectiveheelheight

有效跟高第21頁/共46頁第22頁/共46頁RemoveunevenspotswithaSURFORMrasp

用半圓銼修掉不平整的斑點。Flattenthedistalsurfaceoftheheel把跟骨末端平面修平ModeltechniqueAddplaster

補石膏Reduceplaster

修石膏Workstepsofmeasurementandmodificationtechnique（測量步驟和修型技術(shù)）第23頁/共46頁TypeA: Rear-footprosthesis

(shortfootrootstumpwithanklejointmobility)A型：足部假肢（短足殘肢，踝關(guān)節(jié)可活動）IfmovementsintheupperanklejointarepossibleandiftheyshouldbeusedwiththeprosthesisthentheframeconstructionaccordingtoBottaistorecommend.如果踝上活動可以而且需要使用假肢的話，這是結(jié)構(gòu)是Botta比較推薦的。Thefrontalheightshouldcovermorethan2/3ofthelowerleginordertodistributethepressureoftheprosthesisonthetibiaflaresasextensivelyaspossible.為了盡量的分布假肢在脛骨面的壓力，前緣高度應(yīng)該超過小腿的三分之二。Thedorsalheightshouldnotreachhigherthantothebaseofthem.gastrocnemius.后側(cè)高度不應(yīng)超過腓腸肌起點。DesignofaRear-footprosthesis（足部假肢設(shè)計）第24頁/共46頁TypeA: ForRear-footprosthesis (shortfootrootstumpwithankle jointmobility)A型：足部假肢（短足殘肢，踝關(guān)節(jié)可活動）

DesignofaRear-footprosthesis一種足部假肢的設(shè)計第25頁/共46頁Rear-footProsthesis-TypeA,frameconstructionA型框架

Edgeofcut切開邊緣Softin-layer

軟墊層Softin-layer

軟墊層

Lockstrap

搭扣帶Axisofthe

stump

殘肢的軸線CoremadeofwoodorPUfoam內(nèi)芯由木頭或聚氨酯泡沫橡膠制成。PEfoamorrubber聚乙烯泡沫板或橡膠Pedilansole

Pedilan墊第26頁/共46頁TypeB:ForRear-footprosthesis(amputationaccordingtoPirogowanditsmodifications–noanklejointmobility)B型：足部假肢（適用踝骨限制活動的皮羅果夫截肢）Forverysensitiveandbulbousstumps,arear-footprosthesis

withadorsalflapdoorforeasydonningoftheprosthesisisrecommended.因為這種殘端比較敏感性和類似球狀，比較推薦易于穿戴帶后片的足部假肢DesignofaRear-footprosthesis足部截肢設(shè)計Dorsalflap

door后片第27頁/共46頁Rear-footProsthesis-TypeB,dorsalflap-door

B型，帶后片型Tab扣環(huán)Modularfootcomponent標(biāo)準(zhǔn)足組件Softin-layer

軟墊層DorsalFlap

后片Lockingpin

鎖閂

Laminationcutedge板材邊緣第28頁/共46頁TypeC:Rear-footprosthesis(amputationaccordingtoSymewithaclosedsocketandsoft-linerinlay

–

noanklejointmobility)C型：足部假肢（適用無關(guān)節(jié)活動的塞姆截肢，需要帶內(nèi)襯軟板封閉的接受腔）Withinmuscularatrophyandaresultingbulbousstumpenditcanbebettertoinsertasoftsocketthatwillcompensatethegreatestcircumferencedifferences.由于肌肉萎縮和球狀的殘端，軟內(nèi)襯接受腔可補償最大圍度的偏差，有利于穿戴。Thelaminatedcontainercanbedesignedclosedorwithwindowopenings.外層可設(shè)計為封閉式或者開窗式DesignofaRear-footprosthesis足部截肢設(shè)計第29頁/共46頁DesignofaRear-footprosthesis足部截肢設(shè)計Softinlinercompensatingundercutareas軟板材補償凹陷處Modularfootcomponent標(biāo)準(zhǔn)節(jié)組件Windowedhardsocketdesign外層開窗式設(shè)計第30頁/共46頁Rear-footProsthesis-TypeC,withsoftsocketinlayC型，帶內(nèi)襯套接受腔Laminationcutedge

外層邊緣Softsocketinlay

軟內(nèi)襯套Slitinthesoftsocketinlay內(nèi)襯套切開處Adapter連接器Modularfootcomponent標(biāo)準(zhǔn)足組件第31頁/共46頁ExampleofPr