盧明峰 曹學(xué)偉

. 病例報(bào)告 Case report .

成人先天性巨趾畸形兩例報(bào)告

盧明峰 曹學(xué)偉

趾；先天畸形；趾

先天性巨趾畸形是一種非常罕見(jiàn)的先天性畸形[1]，目前病因尚未明確，該病無(wú)明顯的遺傳因素，染色體研究也尚未發(fā)現(xiàn)異常，2015 年 2 月至 2016 年 4 月我院收治成人先天性巨趾畸形 2 例?，F(xiàn)報(bào)告如下。

臨床資料

例 2，患者，男，19 歲。左足趾巨大畸形 19 年來(lái)我院就診?；颊叱錾蠹胰怂彀l(fā)現(xiàn)其左足第 1、2 趾變大畸形，隨著年齡增長(zhǎng)，左足第 1、2 趾不斷長(zhǎng)大畸形，無(wú)伴足趾疼痛，現(xiàn)影響美觀及日常生活。專(zhuān)科檢查：左足第1、2 趾巨大畸形，第 1 趾長(zhǎng)約 7 cm，周長(zhǎng) 25 cm，第 2 趾長(zhǎng)約 5 cm，周長(zhǎng) 12 cm，局部無(wú)紅腫，無(wú)壓痛，無(wú)胼胝體形成；足趾關(guān)節(jié)活動(dòng)無(wú)明顯受限，趾端感覺(jué)和血運(yùn)良好。患者無(wú)先天畸形家族史。左足 X 線片 ( 圖 4 ) 提示左足第1 跖骨增大，第 1、2 趾骨軟組織影稍增厚，診斷為先天性巨趾 ( 左足第 1、2 趾 )。2015 年 6 月 15 日在腰麻下行左趾先天性巨趾畸形遠(yuǎn)節(jié)趾骨截骨術(shù)＋左長(zhǎng)屈伸肌腱止點(diǎn)重建術(shù)＋左足第 2 趾近端趾間關(guān)節(jié)融合術(shù)，術(shù)后復(fù)查左足 X 線片 ( 圖 5 ) 左足趾截除遠(yuǎn)節(jié)趾骨，第 1 跖骨較前片縮小，第 2 趾近段趾間關(guān)節(jié)行小關(guān)節(jié)融合，術(shù)后患趾血運(yùn)感覺(jué)和活動(dòng)較好。術(shù)后隨訪 9 個(gè)月肢端血運(yùn)感覺(jué)良好，外觀及功能明顯改善，無(wú)復(fù)發(fā)病例。

圖1 術(shù)前右足正位片：右足趾改變，符合先天性巨趾畸形Fig.1 The preoperative anterioposterior film of the right foot: The form of the right hallux was abnormal.Congenital gigantism of the foot was conformed

圖2 足部螺旋 CT 平掃片：右足第 1 跖趾骨粗大，關(guān)節(jié)增生肥大及周?chē)浗M織增生，符合先天性巨趾畸形并創(chuàng)傷性關(guān)節(jié)炎，第1 跖趾關(guān)節(jié)半脫位Fig.2 The CT scan of the right foot: The first plantar phalanges of the right foot became large, with the joint and surrounding soft tissue hyperplasia.Congenital gigantism of the foot with traumatic arthritis was conformed

圖3 術(shù)后復(fù)查片：與前片相比，右足?趾截除遠(yuǎn)節(jié)趾骨，第1 跖骨較前片縮小，患者足趾功能及外觀很好地改善，右足?趾關(guān)節(jié)對(duì)位正常，形態(tài)良好，呈術(shù)后改變Fig.3 The postoperative film: The distal phalange of the right hallux was cut.The first metatarsal of the left foot shrank.The function and appearance of the 2 patients’ toes were improved after the surgery.The hallux of the right foot joint was normal.The shape was well after the surgery

討 論

先天性巨趾畸形是非常少見(jiàn)的足部畸形，可以發(fā)生于單趾或者多個(gè)足趾[1]，尤其是第 2、3 趾的發(fā)生率最高，其次是趾，多見(jiàn)于單側(cè)發(fā)病。王海華等[2]報(bào)道多趾巨大畸形患者多于單趾畸形的患者，脛側(cè)足趾好發(fā)。本研究2 例患者巨趾畸形均是單側(cè)發(fā)病，第 1 例是趾?jiǎn)沃喊l(fā)病，第 2 例是多趾發(fā)病。巨趾癥在四肢先天性畸形疾病中的發(fā)病率非常低，約為 1 / 18 000[3]，男女的發(fā)病率無(wú)明顯的差異，并且也沒(méi)有明顯的遺傳傾向[4]。該病的發(fā)病原因目前尚不明確，最新觀點(diǎn)認(rèn)為由于生長(zhǎng)抑制因子缺乏或局部?jī)?nèi)因子表達(dá)，導(dǎo)致了足趾神經(jīng)損害和脂肪、纖維組織過(guò)度增殖蓄積而成[4-5]；一般來(lái)說(shuō)，患此病的嬰兒出生后即出現(xiàn)。對(duì)于出生時(shí)不明顯，隨年齡增長(zhǎng)患趾增粗變長(zhǎng)的患者較少見(jiàn)。而本次報(bào)告的病例 1 屬于上述情況。先天性巨趾以足趾軟組織和骨的過(guò)度生長(zhǎng)為主要特征，累及神經(jīng)較少[6]，常發(fā)生在側(cè)方或跖面，不對(duì)稱(chēng)的肥大足趾亦導(dǎo)致側(cè)彎，異常增大的腳趾常導(dǎo)致患者穿鞋困難和行走不便，從而導(dǎo)致患者前去醫(yī)院就診。臨床中，先天性巨趾畸形分兩種類(lèi)型：靜止型和進(jìn)展型；靜止型患者肥大的足趾出生時(shí)已伴有，但不會(huì)再發(fā)展，與其它足趾同等比例生長(zhǎng)，并且治療效果較好；進(jìn)展型的患者巨趾亦為出生伴有，然而肥厚增大的足趾的生長(zhǎng)速度遠(yuǎn)遠(yuǎn)超過(guò)正常足趾，而且往往影響其它足趾。

圖4 術(shù)前雙足正位片：左足第 1 跖骨增大，第 1、2 趾骨軟組織影稍增厚，診斷為先天性巨趾 ( 左足第 1、2 趾 )Fig.4 The preoperative anterioposterior film of the feet: The first metatarsal of the left foot was enlarged.The soft tissue shadows of the first and second phalanges were slightly thickened.Congenital gigantism of the foot was diagnosed

圖5 左趾先天性巨趾畸形遠(yuǎn)節(jié)趾骨截骨術(shù) + 左長(zhǎng)屈伸肌腱止點(diǎn)重建術(shù) + 左足第 2 趾近端趾間關(guān)節(jié)融合術(shù)后改變，左足趾截除遠(yuǎn)節(jié)趾骨，第 1 跖骨較前片縮小，形態(tài)大小基本正常，第2 趾近段趾間關(guān)節(jié)行小關(guān)節(jié)融合，術(shù)后發(fā)現(xiàn)患趾血運(yùn)感覺(jué)和活動(dòng)較好Fig.5 Osteotomy of the distal phalanges of the left hallux, the check point revascularization of the left long toe flexion tendons, the joint arthrodesis of the second left proximal interphalangeal joint were performed.The distal phalange of the left hallux was cut.The first metatarsal of the left foot shrank.The form and size were normal.The joint arthrodesis was performed on the second proximal interphalangeal joint.The blood supply, feelings and activities of the 2 patients’ toes were well after the surgery

對(duì)于成人巨趾畸形的治療，手術(shù)矯形是首選，其目的是使患足和健足能穿同樣的鞋，并且行走無(wú)痛，最后是美觀問(wèn)題。由于畸形的形式形態(tài)多種多樣，故對(duì)應(yīng)的手術(shù)方式也多種多樣，主要是在改善外形和功能的基礎(chǔ)上進(jìn)行。巨趾的常用手術(shù)治療方法有：軟組織切除術(shù)、骨骺遏止術(shù)、截骨術(shù)、趾列切除術(shù)等。王海華等[2]對(duì) 12 例患者進(jìn)行手術(shù)治療，術(shù)式包括軟組織縮容、截骨術(shù)等，效果都比較顯著；Kalen 等[7]和 Ishida 等[8]研究發(fā)現(xiàn)處于進(jìn)展型巨趾畸形復(fù)發(fā)率較高，采用截趾聯(lián)合縮容手術(shù)更為適合。本組 2 例均處于進(jìn)展期，嚴(yán)重影響美觀、功能和生活。為了保存患趾功能，選擇遠(yuǎn)節(jié)趾骨截骨矯形術(shù)外加肌腱止點(diǎn)重建術(shù)，能很好改善患者足趾功能及外觀，術(shù)后隨訪 2 例患趾血運(yùn)感覺(jué)和活動(dòng)較好。

[1] 張保付.先天性巨趾畸形2例.中醫(yī)正骨, 2015, 27(4):78-80.

[2] 王海華, 田光磊, 諸寅, 等.巨趾畸形12例臨床分析.中華外科雜志, 2008, 46(6):434-436.

[3] Kowtharapu DN, Thawrani D, Kumar SJ.Drennen’s the child’s foot and ankle.Ed2.Baltimore: Lippincot Williams and Wilkins, 2009: 443-449.

[4] 余慶雄, 盛玲玲.先天性巨(指)趾畸形的研究進(jìn)展.中國(guó)矯形外科雜志, 2013, 21(23):2371-2374.

[5] 姚棟, 蘇巍, 張邵軍, 等.巨趾癥1例報(bào)道及文獻(xiàn)復(fù)習(xí).山西醫(yī)科大學(xué)學(xué)報(bào), 2005, 36(4):520-521.

[6] 周禮祥, 袁長(zhǎng)深, 梅其杰, 等.巨趾癥1例報(bào)告.醫(yī)藥前沿, 2013, 14(14):329-329.

[7] Kalen V, Burwell DS, Omer GE.Macrodactyly of the hands and feet.J Pediatr Orthop, 1988, 8(3):311-315.

[8] Ishida O, Ikuta Y.Long -term results of surgical treatment for macrodactyly of the hand.Plast Reconstr Surg, 1998, 102(5): 1586-1590.

( 本文編輯：李貴存 )

Two cases of adult congenital macrodactylia

LU Ming-feng, CAO Xue-wei.
The second Clinical College, Guangzhou University of Traditional Chinese Medicine, Guangzhou, Guangdong, 510000, PRC

Objective To analyze and discuss the clinical therapy and treatment outcomes of congenital gigantism of the foot.Methods The clinical documents of 2 cases of congenital gigantism of the foot were retrospectively analyzed.The 2 patients’ average age was 20 years old.All the deformities were found at birth.The cases of multiple toes involved were more than that of single toe, and the cases of tibial toe involved were more than that of fibular toe.The forefoot was enlarged.All the phalanges involved and partial metatarsal bones were enlarged.Marked increase in subcutaneous fat was found in all the cases in the operation, which infiltrated the interossei and articular capsules.The appearance of the nerves and their branches in the foot were normal and fatty infiltration was not discovered.Corrective osteotomy and reconstruction of tendon check point were performed on the 2 patients, who were followed up for 1 year.The appearance and function of the limb were observed.Results The 2 patients were satisfactory with the postoperative function and appearance.Conclusions According to the age, clinical classification, degree of pathological changes and limb function, the 2 cases of the digital gigantism of the foot are in progress.To save the function, we choose corrective osteotomy and reconstruction of tendon check point.The function and appearance of the 2 patients’ toes get improved after the surgery.The blood supply, feelings and activities of the toes are well during the follow-up.

Toes; Congenital abnormalities; Hallux

10.3969/j.issn.2095-252X.2000.12.014

R684.2

510000 廣州中醫(yī)藥大學(xué)第二臨床醫(yī)學(xué)院研究生 ( 盧明峰 )；510000 廣東省中醫(yī)院骨三科 ( 曹學(xué)偉 )

曹學(xué)偉，Email: 1543896277@qq.com

2016-05-18 )