中西医结合治疗拇趾外翻生物力学机制的有限元分析
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摘要
1.研究背景
拇外翻是常见足部畸形,发病率约为10%,占足踝门诊病人数量一半以上。主要表现为足部红肿疼痛、行走困难,严重影响生活质量。目前拇外翻治疗已有200多种术式,存在损伤大、并发症多、疗效差的缺点。中西医结合微创技术治疗拇趾外翻畸形具有操作简单、患者痛苦小、合并症少、疗效确定等优点。十多年来经过导师的不断完善、创新与发展,已经形成了规范化的诊疗体系。目前该方法已治疗2万多例拇外翻患者,其优良率达98.5%。2002年获得国家科技进步二等奖。该方法技术要点为：①微创技术在中医足踝外科的应用；②采用第1跖骨头颈斜行截骨矫正畸形；③中医正骨手法纠正畸形及关节脱位；④依据小夹板纸夹垫原理及“筋束骨”理论,采用“8”字绷带固定截骨端。摒弃西医传统的钢板螺钉内固定和石膏外固定方法,术后患者即能下地负重。此方法一经提出,就受到了部分西医骨科学者的质疑。现代医学认为截骨的愈合需要截骨端间的稳定,截骨复位后必须保持相对稳定才能达到最佳愈合。人体在负重时足部负荷增大,尤其是在第1跖骨处压力较大。一些骨科医生认为在此处截骨不做内固定,又不制动,会影响截骨端稳定,可能会出现截骨端的延迟愈合,甚至不愈合。但事实是中西医结合治疗拇趾外翻方法,通过十多年的临床应用,并未出现截骨不愈合现象,而且术后发生转移性跖骨痛的患者也少。如何分析中西医结合治疗拇趾外翻疗法的科学之处,从生物力学角度研究中西医结合治疗拇趾外翻的机理,证实小夹板纸压垫原理、“筋束骨”理论的科学内涵,对中医骨伤科治疗骨折理论的发扬光大具有重大意义。
拇外翻第1跖骨在何部位以何角度截骨最科学?截骨后根据小夹板纸压垫原理和“筋束骨”理论而采用“8”字绷带外固定是否稳定?第1跖骨截骨对前足的生物力学会产生什么影响?这些问题尚需做深入的研究。因此,十分必要对中西医结合治疗拇外翻相关生物力学机制进行研究。有限元分析为我们研究足部正常和病理状态下的生物力学情况提供十分有用的工具,它使我们能够全面了解足在不同状态下的应力分布,以及各种治疗措施对足部影响。目前,对拇外翻足进行有限元分析研究的报导很少,对第1跖骨截骨部位、截骨端稳定性及截骨愈合后足部生物力学变化情况等方面的研究未见报道。研究中西医结合治疗拇趾外翻截骨部位、截骨角度、“8”字绷带外固定的生物力学机制,阐述本疗法作用机理,进一步证实其科学性,已成当务之急。
2.研究目的
本研究拟通过建立拇外翻足有限元模型,分析中西医结合治疗拇外翻不同截骨角度截骨端位移和应力变化,明确最佳截骨角度。探讨“8”字绷带外固定方式对截骨端稳定和愈合的影响及其作用机理。提高对中西医结合治疗拇外翻科学内涵认识,为中西结合治疗拇外翻理论和方法的不断完善和发展提供实验依据。
3.研究内容
3.1拇外翻足的有限元模型建立与验证
3.1.1材料与方法
3.1.1.1足部相关组织材料参数测量
45岁女性左小腿-足新鲜标本1具,解剖出拇长屈肌及其肌腱、拇短屈肌内外侧头、拇长伸肌及其肌腱、拇收肌横头及斜头、拇展肌,分别做成试样。测试前将试样进行预加载拉伸,消除试样的载荷蠕变。每个试样重复测量4次,加载速率设为0.0835cm/min。采集强度极限、最大载荷等数据以及载荷-位移曲线。将载荷-位移曲线转换为力-变形曲线,用力除以横截面积,位移除以试件长度,得到应力-应变曲线,拟合曲线中间直线段,得到其弹性模量(E)。
3.1.1.2有限元图像数据的获得和存储
选取拇趾外翻志愿者,青年女性,年龄28岁,身高168cm,体质量62 kg,其右足HAV角为24°,IM角为13°。足部无其它畸形,无跖骨头下痛性胼胝体,无足部手术和外伤史,无其他系统疾病引起的足部畸形。采用螺旋CT对患足进行扫描,层厚1mm,间隔1mm,扫描从足尖至足后跟,共获得512×512像素CT图像542张,图片以DCIOM格式输出并存储。
3.1.1.3拇外翻有限元模型建立
利用软件对足部CT图像进行分割和轮廓数据提取处理,辨别软组织、骨皮质、髓腔的界限,获得骨骼边缘轮廓曲线的矢量数据。根据自由曲面实体的建模规则,进行足部骨骼曲面重构,获得足部骨骼的三维实体模型并进行装配。出于简化模型减少计算量考虑,模型中仅考虑骨骼、软骨、肌腱、足内在肌四种组织材料。把足部三维模型输入有限元软件ANSYS12.0,定义材料特性并对材料参数赋值,进行网格划分,获得有限元模型。
3.1.1.4模型载荷的加载和边界约束
模拟一个体质量62kg拇外翻患者在双足平衡站立时,足部的受力情况；以及足跟在抬起趾背伸30°和70°时,第1跖骨应力分布和变化情况。设足底压力、跟腱力和足底摩擦力为作用载荷。支撑结构上表面和足底表面的相互作用定义为接触关系,摩擦系数为0.6。根据载荷和地面反作用力等效互换原理,以集中力向上通过支撑结构面施加在压力中心处,距骨上表面完全约束,踝关节处在平衡站立时的中立位。
3.1.1.5拇外翻足的Foot scan足底压力测试
采用比利时RSscan公司生产的Foot scan USB21米平板式足底压力测试系统,对同一患者进行测试。测试前根据受试者的体重对测力板进行校准。分别在静态和动态下测量受试者足底受力情况,观察足底6个区域的静态压力(P)以及动态最大压力(MP)。将测量数值与有限元分析结果对比,寻找两者之间的关系,检验有限元模型的可靠性。
3.1.2结果
1)通过测量和计算共获得了9个样本的相关数据,主要包括：长度、宽度、厚度、横截面积、最大载荷、强度极限和弹性模量。为足部有限元建模,提供较为确切的材料参数。
2)建立了拇外翻足站立和步态周期站立相不同位置(0°、30°、45°和70°)三维有限元模型7个,模型重建了骨骼、软骨、肌腱、内在肌、皮肤等组织,共有67239个节点,69189个单元。
3)有限元模型静态足底应力与Foot scan力板测量对比,两者压力集中部位大体一致,压力在第2、3、5跖骨头部位的数值非常接近。有限元模拟步态周期前足足底最大应力换算值与相应部位力板最大压力测量值比较,变化趋势相似。
3.1.3结论
本研究建立了包括骨骼、肌腱、内在肌和皮肤等组织在内的拇外翻足有限元模型,并对部分材料参数进行了实测,获得了相关数据。通过Foot scan力板测试对有限元模型进行了可靠性检验,证实有限元模型可靠,基本反映了拇外翻足的实际情况。
3.2第1跖骨头颈部不同方向截骨截骨端稳定性的有限元分析
3.2.1材料与方法
3.2.1.1研究材料
建立拇外翻有限元截骨模型,分别模拟截骨线与第1跖骨轴线在矢状面上成300、450、60°、75°、90°、105°、120°角7个截骨方向,共7种工况。
3.2.1.2测试方法
模拟体质量为62kg拇外翻患者第1跖骨截骨后,拇趾尽量跖屈站立时,不同截骨角度截骨端的应力和位移情况。截骨近端设为固定端,远端设为自由端,断端间设为肉芽组织填充。其它部位的约束同前。单足约承受310N的体重载荷,仅考虑屈拇长肌和屈拇短肌对截骨端的影响,肌力以载荷表示,约为319N,设肌力载荷与第1跖骨长轴平行。截骨端摩擦系数设为0.6。
3.2.1.3观测项目
观察在相同条件的负荷加载下,7种工况截骨断端边缘节点的最大M应力值(VonMises)和总位移量V值,并进行比较。
3.2.2结果
1)截骨端总位移从30°逐渐变小,至60°达到最小值,后逐渐增大,截骨角度超过90°后,位移有明显加大的趋势。最大位移发生在120°时,为0.6486mm；最小位移发生在60°时,为0.2833mm。
2)截骨端Von Mises应力从30°逐渐增加,至75°达到第一个峰值,后应力走平并有逐渐减小趋势,至105°应力迅速增大。截骨端最大应力出现在120°时,为0.986Mpa；最小应力出现在30°时,为0.212Mpa。
3.2.3结论
通过有限元模型对第1跖骨矢状面不同角度截骨的模拟和计算,发现60°左右时截骨端最稳定。保持矢状面上从远端背侧到近端跖侧截骨线方向,截骨端才能维持稳定。矢状面上的最佳截骨角度要根据患者的不同情况适当调整,截骨不应采取固定的截骨角度。
3.3中西医结合治疗拇外翻外固定方法对第1跖骨截骨端固定作用有限元分析
3.3.1材料与方法
3.3.1.1研究材料
建立拇外翻足第1跖骨颈部截骨三维有限元模型,截骨线在矢状面与跖骨轴线的垂线成10°,水平面与跖骨轴线的垂线成15°,模拟第1、2趾蹼间放置分趾垫“8”字绷带包扎外固定站立时工况。模型各部分的材料特性和材料参数详见前两部分。
3.3.1.2测试方法
模拟体质量62kg拇外翻患者按要求截骨和固定后,拇趾尽量跖屈站立时,截骨端的应力和位移情况。将截骨近端设为固定端,远端为自由端,断端间设为肉芽组织填充。其它部位的约束同前。分趾垫和“8”字绷带的外固定力,经实验测量为24.84N,将其分解为与趾骨垂直和与第1跖骨平行的两个力,在分析时以载荷的方式表示。其它载荷和设置与前模型相同。
3.3.1.3观测项目
观测和计算截骨端的最大M应力值(VonMises)和总位移及X、Y、Z轴三个方向的位移情况。
3.3.2结果
1)截骨端位移情况：X轴上位移为0.261mm；Y轴位移为0.078mm；Z轴位移为-0.167mm；截骨端总位移为0.293mm。截骨端位移主要发生在X轴方向上,其它两个方向位移很小。
2)截骨端Von Mises应力值为0.712Mpa,应力主要分布在截骨端的外侧边缘部位。
3.3.3结论
通过有限元法对中西医结合微创技术治疗拇外翻术后“8”字绷带弹性固定的模拟与计算,发现该固定方式可有效减小截骨端位移,应力适中,能促进截骨端以软骨成骨的方式愈合。
4.总结
1)本研究建立了拇外翻足有限元模型,通过Foot scan力板测试证实有限元模型可靠。
2)第1跖骨矢状面截骨角度在60°左右时截骨端最稳定；截骨线方向从远端背侧到近端跖侧截骨端才能维持稳定;最佳截骨角度要根据患者的不同情况适当调整。
3)中西医结合微创技术治疗拇外翻术后“8”字绷带弹性固定可有效减小截骨端位移,应力适中,截骨端以软骨成骨的方式愈合。
该研究通过有限元法分析中西医结合治疗拇外翻截骨角度的选择和固定方式对截骨端稳定和愈合的影响,从生物力学角度阐释了截骨角度的确定方法,分析了分趾垫“8”字绷带外固定的作用机理,同时对“筋束骨”理论在拇外翻治疗中的作用作了深入的探讨。加深和提高了对中西医结合治疗拇外翻机理的认识,并证实了其科学内涵,对中西结合治疗拇趾外翻理论和方法的不断完善和发展产生深远的影响。
5.创新点
1)建立拇趾外翻足不同方向截骨及“8”字绷带外固定三维有限元模型,为拇外翻手术方法的评价及预后研究开辟新的思路。
2)模拟中西医结合治疗拇趾外翻截骨和固定方法,对截骨端应力、位移变化进行有限元分析,从生物力学机制方面证明中西医结合治疗拇趾外翻的科学性。
1. Background
Integrated Traditional Chinese and Western medicine combined minimally invasive treatment of hallux valgus deformity has many good points such as simple operation, the patient less pain, fewer complications, and efficacy to determine and so on. More than 30 years after two generations of continuous improvement, innovation and development, it has formed a standardized system for the diagnosis and treatment. At present this method has been treated more than 2 million cases of hallux valgus patients, the excellent rate reaches to 98.5%. The main technique points of the method are 1) the application minimally invasive techniques in Traditional Chinese Medicine foot and ankle surgery.2) An oblique osteotomy is used at the first metatarsal head and neck to correct the deformity.3) Chinese bone-setting techniques to correct deformities and joint dislocation and 4) based on a small plywood and paper pad clip principles and the "muscle bundle bone" theory, a "8"-shaped bandage fixed osteotomy end. Abandon the Western tradition methods such as plate and screws internal fixation and plaster external fixation. Patients are able to weight-bearing after operation. As soon as this method has been made, some Western orthopedics experts questioned it. It was believed by modern medicine that the healing of osteotomy need for stability between the sides of osteotomy. In order to achieve optimal healing, the sides of osteotomy must remain relatively stable after reset. When the human body in the weight-bearing the feet load increased, especially in the first metatarsal. Some orthopedic surgeons believe that the osteotomy is not fixed in this part will affect the stability of osteotomy-side. The osteotomy may appear delayed healing or even nonunion. Nevertheless the fact is Integrated Traditional Chinese and Western medicine treatment of hallux valgus method, through 30 years of clinical applications, the phenomenon of osteotomy non-union does not occur. Moreover the patients with metastatic metatarsalgia postoperative are also less. How to analyze the science mechanism of Integrated Traditional Chinese and Western medicine treatment of hallux valgus, to study the mechanism of Integrated Traditional Chinese and Western medicine treatment of hallux valgus from the biomechanics, to confirm the scientific content of the small plywood and paper pad clip principles and the "muscle bundle bone" theory would have great significance for the development of Chinese medicine orthopedic treatment to bone fractures theory.
Where the osteotomy was performed at the 1st metatarsal bone of the hallux valgus? Which angle of osteotomy is the most scientific? Wether or not the "8 "-shaped bandage for non-invasive biological fixation after the osteotomy according to the small plywood and paper pad clip principles and the "muscle bundle bone" theory is stable? What the effects to the biomechanics of forefoot effects after the 1st metatarsal osteotomy healed? These issues still need to do in-depth studies to answer. So, it is necessary to study the mechanism of Integrated Traditional Chinese and Western medicine treatment of hallux valgus. Finite element analysis provides a useful tool for studying normal and pathological state of foot biomechanics. It enables us to have a fully understand the stress distribution of foot under different conditions, as well as the impact of various therapeutic measures on the foot. At present, the reports on finite element analysis of hallux valgus foot are very few. There is no related research on the site the first metatarsal osteotomy, the stability of osteotomy and the biomechanical changes in the foot after the osteotomy healing. The purpose of this study is to establish finite element model of the hallux valgus foot including bone, part of the tendon and intrinsic muscles, to analyze the effects on the osteotomy side and forefoot stress change of Integrated Traditional Chinese and Western medicine treatment of hallux valgus osteotomy site selection and fixation methods. The study results will improve understanding of the treatment of hallux valgus. It will have a far-reaching impact in improving and perfecting Integrated Traditional Chinese and Western medicine treatment of hallux valgus. The research methods for the modernization of traditional Chinese medicine orthopedic research opened a new way.
2. Purposes
To Study of Integrated Traditional Chinese and Western medicine Treatment of hallux valgus osteotomy surgery site, osteotomy angle, biological fixation and postoperative biomechanical mechanism of plantar stress to explain the mechanism of this therapy, further confirm the scientific.
3. Contents of study
3.1 The establishment of finite element model of hallux valgus foot
3.1.1 Materials and methods
3.1.1.1 Measurement of material parameters of foot-related organizations
A left calf-foot of fresh specimen of a 45-year-old woman was acquired. The flexor hallux longus muscle and it's tendon, internal and external side head of flexor hallux brevis, musculus extensor hallux longus and it's tendon, cross-head and oblique head of musculus adductor hallux, musculus abductor hallux were thumb abductor were dissected. And all the musles and tedon were made into samples. In order to removing the load creep deformation of the samples they were pre-loaded and stretched before testing. Repeated measurements for each sample 4 times, loading rate set 0.0835cm/min. Collection intensity limit, the maximum load load-displacement curve and other data. The load-displacement curve was transformed into force-deformation curve. The force divided by the cross sectional area, the displacement divided by specimen length, and the stress-strain curve was acquired. Fit the line segment of the curve and obtain the elastic modulus (E).
3.1.1.2 Image data acquisition and storage
A young women volunteer with hallux valgus was selected, aged 28 years old, height 168 cm, weight 62 kg. The HAV angle was 24°, IM angle was13°of her right foot. There no other foot deformity, no metatarsalgia under the metatarsal head, no history of foot surgery and trauma, no other foot deformity caused by other system diseases. Using spiral CT to scan the affected foot, slice thickness lmm, interval 1mm, scanned from toe to heel, which obtained 512×512 pixel CT image 542 pages. The pictures were outputted and storage in DCIOM format.
3.1.1.3 The establishment of finite element model of hallux valgus
Using the relative software to segment foot CT image and extract the contour data, to distinguish soft tissue, bone cortex, medullar cavity of the boundaries, and access to the edge of bone contour vector data. According to free-form surface entity modeling rule, to reconstruct surface of foot bone, obtain three-dimensional solid model of foot bone and assemble. In order to simplify the model reduce calculating amount, the model only took into account bone, cartilage, tendon, foot intrinsic muscles four kinds of organizational materials. Three-dimensional model of the foot was entered the finite element software ANSYS12.0, to definite material properties and assign material parameters, to carry out meshing, obtain finite element model.
3.1.1.4 Load and boundary constraints of model
Simulated the foot force conditions of a 62kg person standing balance in feet., and the 1st metatarsal stress distribution and variation when the heel in lift, toe dorsiflexion 30°and 70°. Set foot pressure, plantar tendon force and the foot friction was load. The interaction between the the surface of support structure and the plantar surface is defined as contact. The friction coefficient is 0.6. According the principle of loading and ground reaction force equivalent exchange, through the support structure surface a concentration force was exerted up to the pressure center. The upper surface of the talus was fully bound. The ankle joint is considered in the middle position.
3.1.1.5 Foot scan plantar pressure test of hallux valgus
A Foot scan USB21 meter flat plantar pressure measurement system was used, which produced by Belgian RSscan company. The same patient was tested. According to the patient body weight adjust the force plate before the test. The static and dynamic loading situations of foot were measured respectively. The static pressure (P) and the maximum dynamic pressure (MP) were observed in six regions of foot. Compare the measured value and finite element analysis results, to find the relationship between them and test the reliability of finite element model.
3.1.2 Results
i. By measuring and calculating 9 samples data were obtained, including:length, width, thickness, cross-sectional area, maximum load, ultimate strength and elastic modulus. Providerelative precise material parameters for the foot finite element model construct,
ii. Established 7 three-dimensional finite element modeles of the hallux valgus foot standing and gait cycle standing phase with different positions (0°,30°,45°and 70°). The bone, cartilage, tendon, intrinsic muscles and skin of the Modeles were reconstruced, which include 67,239 nodes,69,189 units.
iii. Compared the static plantar stress between finite element model and Foot scan foot force plate the two stress concentration was broadly consistent. Pressure values in the parts of the 2nd,3rd,5th metatarsal head were very close. Compared the maximum stress conversion value of Finite element in sole, which simulated a gait cycle with the maximum stress value of Foot scan force plate measured in corresponding parts, the trend of the maximum pressure was similar.
3.1.3 Conclusions
Finite element models of hallux valgus were established in this study, including bone, tendon, intrinsic muscles, and skin and so on. Parts of the material parameters were measured and some relevant data were obtained. The reliability of the finite element model was tested by Foot scan force plate. The results proved finite element models reliable and they basically reflected the actual situation of hallux valgus.
3.2 The finite element analysis on the osteotomy end stability of 1st metatarsal in different directions osteotomy
3.2.1 Materials and methods
3.2.1.1 Research Materials
Established finite element osteotomy models of hallux valgus and 7 kinds of working conditions were simulated which the osteotomy line and 1st metatarsal axis were angulated in 30°,45°,60°,75°,90°,105°,120°in sagittal plane.
3.2.1.2 Test Methods
Simulated a body weight 62kg hallux valgus patient who suffered from 1st metatarsal osteotomy stood toe plantar flexion as far as possible the osteotomy end conditions of the stress and displacement in different angle osteotomy. Set the proximal osteotomy end the fixed end and distal end the free end. Set the ends filled with granulation tissue.The constraints of other parts were similar with the former. One foot was beared about 310N weight load. Considered the effects of the flexor hallux longus muscle and flexor hallux brevis muscle only on the osteotomy end. Muscle strength was expressed with load. That was about 319N. Muscle load wre supposed parallel with the 1st metatarsal long axis. The friction coefficient in osteotomy faces was set to 0.6.
3.2.1.3 Observation Project
Observed the maximum Von Mises stress and the total value of the displacement in osteotomy ends of the seven kinds of conditions under the same load conditions, and compared.
3.2.2 Results
i. The total displacement of osteotomy end diminished gradually from 30°, reched to the minimum at 60°, and then gradually increased. The displacement increased significantly as osteotomy angle exceeds 90°. The maximum displacement occurred at 120°, which was 0.6486mm; the minimum displacement occurs at 60°, which was 0.2833mm.
ii. The Von Mises stress of the osteotomy end gradually increased from 30°, reached to the first peak at 75°, and then flattened and reduced gradually. The stress increased rapidly at 105°. The maximum stress occurred at 120°, which was 0.986Mpa; the minimum stress occurred at 30°, which was 0.212Mpa.
3.2.3 Conclusions
Through simulation and calculation to the osteotomy in different angles of 1st metatarsal in the sagittal plane by finite element model it had found the osteotomy end was the most stable at about 60°. Only Maintain osteotomy line direction from the dorsal distal to plantar proximal lateral in the sagittal plane could the osteotomy ends maintain stability. According to factors that influencing the osteotomy stability, the best osteotomy angle in the sagittal plane should adjust appropriately according to the patients different situations. Osteotomy should not be taken fixed angle.
3.3 The finite element analysis on the fixed action of Integrated Traditional Chinese and Western medicine treatment of hallux valgus external fixation methods in 1st metatarsal osteotomy end
3.3.1 Materials and methods
3.3.1.1 Research Materials
Established finite element model of hallux valgus with osteotomy at 1st metatarsal neck. The osteotomy line was angled with the vertical of 1st metatarsal axis into 10°in the sagittal plane, with the vertical of 1st metatarsal axis into 15°in the horizontal plane. Simulated standing conditions with a pad in 1st toe web and "8"-shaped bandage fixation. The material properties and material parameters of parts of the Model could be found in the first two parts.
3.3.1.2 Test Methods
Simulated a body weight 62kg hallux valgus patient who suffered from 1st metatarsal osteotomy and fixation stood toe plantar flexion as far as possible the osteotomy end conditions of the stress and displacement. Set the proximal osteotomy end the fixed end and distal end the free end. Set the ends filled with granulation tissue.The constraints of other parts were similar with the former. The force of the sub-toe pad and the "8"-shaped bandage external fixation was 24.84N by the experimental measurement. It cuold be divided into two powers; one was vertical with hallux the other parallel with 1st metatarsal. They were expressed with load in analysis. Other load and settings were same as the previous model.
3.3.13 Observation Project
Observed the maximum Von Mises stress and the total value of the displacement in osteotomy end and the displacements of X, Y, Z axises.
3.3.2 Results
i. Displacement of the osteotomy end:it was 0.261mm in X axis,0.078mm in Y axis,-0.167mm in Z axis. The total displacement in osteotomy end was 0.293mm. The main displacement occurred in X axis. The other two were very small.
ii. The Von Mises stress of the osteotomy end was 0.712Mpa. The stress was mainly located in the lateral edge of the osteotomy end.
3.3.3 Conclusions
Through simulation and calculation to the "8"-shaped bandage external fixation of Integrated Traditional Chinese and Western medicine treatment of hallux valgus it had found the fixation can effectively reduce the displacement of the osteotomy end. The stress was moderate. It could promote osteotomy to healing in an approach of endochondral ossification.
4. Summary
The study analyzed the choice of osteotomy angles and effects of the fixation methods on the stability and healing of osteotomy by finite element in Integrated Traditional Chinese and Western medicine treatment of hallux valgus. It explained how to determin the osteotomy angles from the biomechanical viewpoint. It analyzed the mechanism of sub-toe pad and "8"-shaped bandage external fixation. At the same time a deep study had done on the role of "muscle bundle bone" theory in the treatment of hallux valgus. The understandings of the mechanism in Integrated Traditional Chinese and Western medicine treatment of hallux valgus were deepened and improved, and confirmed its scientific content. It will have a far-reaching impact on the constant improvement and development of the theories and methods in Integrated Traditional Chinese and Western medicine treatment of hallux valgus.
5. Innovations
i. The establishment of dimensional finite element model on hallux valgus osteotomy in different directions, and "8 "-shaped bandage external fixation open up a new way for evaluation of hallux valgus surgical methods and prognosis of the feasibility.
ii. The finite element analyses were performed on stress and displacement of osteotomy ends by simulating osteotomy and fixation methods of Integrated Traditional Chinese and Western medicine treatment of hallux valgus, and proved the scientificity of Integrated Traditional Chinese and Western medicine treatment of hallux valgus from the biomechanical mechanisms.
拇外翻是常见足部畸形,发病率约为10%,占足踝门诊病人数量一半以上。主要表现为足部红肿疼痛、行走困难,严重影响生活质量。目前拇外翻治疗已有200多种术式,存在损伤大、并发症多、疗效差的缺点。中西医结合微创技术治疗拇趾外翻畸形具有操作简单、患者痛苦小、合并症少、疗效确定等优点。十多年来经过导师的不断完善、创新与发展,已经形成了规范化的诊疗体系。目前该方法已治疗2万多例拇外翻患者,其优良率达98.5%。2002年获得国家科技进步二等奖。该方法技术要点为：①微创技术在中医足踝外科的应用；②采用第1跖骨头颈斜行截骨矫正畸形；③中医正骨手法纠正畸形及关节脱位；④依据小夹板纸夹垫原理及“筋束骨”理论,采用“8”字绷带固定截骨端。摒弃西医传统的钢板螺钉内固定和石膏外固定方法,术后患者即能下地负重。此方法一经提出,就受到了部分西医骨科学者的质疑。现代医学认为截骨的愈合需要截骨端间的稳定,截骨复位后必须保持相对稳定才能达到最佳愈合。人体在负重时足部负荷增大,尤其是在第1跖骨处压力较大。一些骨科医生认为在此处截骨不做内固定,又不制动,会影响截骨端稳定,可能会出现截骨端的延迟愈合,甚至不愈合。但事实是中西医结合治疗拇趾外翻方法,通过十多年的临床应用,并未出现截骨不愈合现象,而且术后发生转移性跖骨痛的患者也少。如何分析中西医结合治疗拇趾外翻疗法的科学之处,从生物力学角度研究中西医结合治疗拇趾外翻的机理,证实小夹板纸压垫原理、“筋束骨”理论的科学内涵,对中医骨伤科治疗骨折理论的发扬光大具有重大意义。
拇外翻第1跖骨在何部位以何角度截骨最科学?截骨后根据小夹板纸压垫原理和“筋束骨”理论而采用“8”字绷带外固定是否稳定?第1跖骨截骨对前足的生物力学会产生什么影响?这些问题尚需做深入的研究。因此,十分必要对中西医结合治疗拇外翻相关生物力学机制进行研究。有限元分析为我们研究足部正常和病理状态下的生物力学情况提供十分有用的工具,它使我们能够全面了解足在不同状态下的应力分布,以及各种治疗措施对足部影响。目前,对拇外翻足进行有限元分析研究的报导很少,对第1跖骨截骨部位、截骨端稳定性及截骨愈合后足部生物力学变化情况等方面的研究未见报道。研究中西医结合治疗拇趾外翻截骨部位、截骨角度、“8”字绷带外固定的生物力学机制,阐述本疗法作用机理,进一步证实其科学性,已成当务之急。
2.研究目的
本研究拟通过建立拇外翻足有限元模型,分析中西医结合治疗拇外翻不同截骨角度截骨端位移和应力变化,明确最佳截骨角度。探讨“8”字绷带外固定方式对截骨端稳定和愈合的影响及其作用机理。提高对中西医结合治疗拇外翻科学内涵认识,为中西结合治疗拇外翻理论和方法的不断完善和发展提供实验依据。
3.研究内容
3.1拇外翻足的有限元模型建立与验证
3.1.1材料与方法
3.1.1.1足部相关组织材料参数测量
45岁女性左小腿-足新鲜标本1具,解剖出拇长屈肌及其肌腱、拇短屈肌内外侧头、拇长伸肌及其肌腱、拇收肌横头及斜头、拇展肌,分别做成试样。测试前将试样进行预加载拉伸,消除试样的载荷蠕变。每个试样重复测量4次,加载速率设为0.0835cm/min。采集强度极限、最大载荷等数据以及载荷-位移曲线。将载荷-位移曲线转换为力-变形曲线,用力除以横截面积,位移除以试件长度,得到应力-应变曲线,拟合曲线中间直线段,得到其弹性模量(E)。
3.1.1.2有限元图像数据的获得和存储
选取拇趾外翻志愿者,青年女性,年龄28岁,身高168cm,体质量62 kg,其右足HAV角为24°,IM角为13°。足部无其它畸形,无跖骨头下痛性胼胝体,无足部手术和外伤史,无其他系统疾病引起的足部畸形。采用螺旋CT对患足进行扫描,层厚1mm,间隔1mm,扫描从足尖至足后跟,共获得512×512像素CT图像542张,图片以DCIOM格式输出并存储。
3.1.1.3拇外翻有限元模型建立
利用软件对足部CT图像进行分割和轮廓数据提取处理,辨别软组织、骨皮质、髓腔的界限,获得骨骼边缘轮廓曲线的矢量数据。根据自由曲面实体的建模规则,进行足部骨骼曲面重构,获得足部骨骼的三维实体模型并进行装配。出于简化模型减少计算量考虑,模型中仅考虑骨骼、软骨、肌腱、足内在肌四种组织材料。把足部三维模型输入有限元软件ANSYS12.0,定义材料特性并对材料参数赋值,进行网格划分,获得有限元模型。
3.1.1.4模型载荷的加载和边界约束
模拟一个体质量62kg拇外翻患者在双足平衡站立时,足部的受力情况；以及足跟在抬起趾背伸30°和70°时,第1跖骨应力分布和变化情况。设足底压力、跟腱力和足底摩擦力为作用载荷。支撑结构上表面和足底表面的相互作用定义为接触关系,摩擦系数为0.6。根据载荷和地面反作用力等效互换原理,以集中力向上通过支撑结构面施加在压力中心处,距骨上表面完全约束,踝关节处在平衡站立时的中立位。
3.1.1.5拇外翻足的Foot scan足底压力测试
采用比利时RSscan公司生产的Foot scan USB21米平板式足底压力测试系统,对同一患者进行测试。测试前根据受试者的体重对测力板进行校准。分别在静态和动态下测量受试者足底受力情况,观察足底6个区域的静态压力(P)以及动态最大压力(MP)。将测量数值与有限元分析结果对比,寻找两者之间的关系,检验有限元模型的可靠性。
3.1.2结果
1)通过测量和计算共获得了9个样本的相关数据,主要包括：长度、宽度、厚度、横截面积、最大载荷、强度极限和弹性模量。为足部有限元建模,提供较为确切的材料参数。
2)建立了拇外翻足站立和步态周期站立相不同位置(0°、30°、45°和70°)三维有限元模型7个,模型重建了骨骼、软骨、肌腱、内在肌、皮肤等组织,共有67239个节点,69189个单元。
3)有限元模型静态足底应力与Foot scan力板测量对比,两者压力集中部位大体一致,压力在第2、3、5跖骨头部位的数值非常接近。有限元模拟步态周期前足足底最大应力换算值与相应部位力板最大压力测量值比较,变化趋势相似。
3.1.3结论
本研究建立了包括骨骼、肌腱、内在肌和皮肤等组织在内的拇外翻足有限元模型,并对部分材料参数进行了实测,获得了相关数据。通过Foot scan力板测试对有限元模型进行了可靠性检验,证实有限元模型可靠,基本反映了拇外翻足的实际情况。
3.2第1跖骨头颈部不同方向截骨截骨端稳定性的有限元分析
3.2.1材料与方法
3.2.1.1研究材料
建立拇外翻有限元截骨模型,分别模拟截骨线与第1跖骨轴线在矢状面上成300、450、60°、75°、90°、105°、120°角7个截骨方向,共7种工况。
3.2.1.2测试方法
模拟体质量为62kg拇外翻患者第1跖骨截骨后,拇趾尽量跖屈站立时,不同截骨角度截骨端的应力和位移情况。截骨近端设为固定端,远端设为自由端,断端间设为肉芽组织填充。其它部位的约束同前。单足约承受310N的体重载荷,仅考虑屈拇长肌和屈拇短肌对截骨端的影响,肌力以载荷表示,约为319N,设肌力载荷与第1跖骨长轴平行。截骨端摩擦系数设为0.6。
3.2.1.3观测项目
观察在相同条件的负荷加载下,7种工况截骨断端边缘节点的最大M应力值(VonMises)和总位移量V值,并进行比较。
3.2.2结果
1)截骨端总位移从30°逐渐变小,至60°达到最小值,后逐渐增大,截骨角度超过90°后,位移有明显加大的趋势。最大位移发生在120°时,为0.6486mm；最小位移发生在60°时,为0.2833mm。
2)截骨端Von Mises应力从30°逐渐增加,至75°达到第一个峰值,后应力走平并有逐渐减小趋势,至105°应力迅速增大。截骨端最大应力出现在120°时,为0.986Mpa；最小应力出现在30°时,为0.212Mpa。
3.2.3结论
通过有限元模型对第1跖骨矢状面不同角度截骨的模拟和计算,发现60°左右时截骨端最稳定。保持矢状面上从远端背侧到近端跖侧截骨线方向,截骨端才能维持稳定。矢状面上的最佳截骨角度要根据患者的不同情况适当调整,截骨不应采取固定的截骨角度。
3.3中西医结合治疗拇外翻外固定方法对第1跖骨截骨端固定作用有限元分析
3.3.1材料与方法
3.3.1.1研究材料
建立拇外翻足第1跖骨颈部截骨三维有限元模型,截骨线在矢状面与跖骨轴线的垂线成10°,水平面与跖骨轴线的垂线成15°,模拟第1、2趾蹼间放置分趾垫“8”字绷带包扎外固定站立时工况。模型各部分的材料特性和材料参数详见前两部分。
3.3.1.2测试方法
模拟体质量62kg拇外翻患者按要求截骨和固定后,拇趾尽量跖屈站立时,截骨端的应力和位移情况。将截骨近端设为固定端,远端为自由端,断端间设为肉芽组织填充。其它部位的约束同前。分趾垫和“8”字绷带的外固定力,经实验测量为24.84N,将其分解为与趾骨垂直和与第1跖骨平行的两个力,在分析时以载荷的方式表示。其它载荷和设置与前模型相同。
3.3.1.3观测项目
观测和计算截骨端的最大M应力值(VonMises)和总位移及X、Y、Z轴三个方向的位移情况。
3.3.2结果
1)截骨端位移情况：X轴上位移为0.261mm；Y轴位移为0.078mm；Z轴位移为-0.167mm；截骨端总位移为0.293mm。截骨端位移主要发生在X轴方向上,其它两个方向位移很小。
2)截骨端Von Mises应力值为0.712Mpa,应力主要分布在截骨端的外侧边缘部位。
3.3.3结论
通过有限元法对中西医结合微创技术治疗拇外翻术后“8”字绷带弹性固定的模拟与计算,发现该固定方式可有效减小截骨端位移,应力适中,能促进截骨端以软骨成骨的方式愈合。
4.总结
1)本研究建立了拇外翻足有限元模型,通过Foot scan力板测试证实有限元模型可靠。
2)第1跖骨矢状面截骨角度在60°左右时截骨端最稳定；截骨线方向从远端背侧到近端跖侧截骨端才能维持稳定;最佳截骨角度要根据患者的不同情况适当调整。
3)中西医结合微创技术治疗拇外翻术后“8”字绷带弹性固定可有效减小截骨端位移,应力适中,截骨端以软骨成骨的方式愈合。
该研究通过有限元法分析中西医结合治疗拇外翻截骨角度的选择和固定方式对截骨端稳定和愈合的影响,从生物力学角度阐释了截骨角度的确定方法,分析了分趾垫“8”字绷带外固定的作用机理,同时对“筋束骨”理论在拇外翻治疗中的作用作了深入的探讨。加深和提高了对中西医结合治疗拇外翻机理的认识,并证实了其科学内涵,对中西结合治疗拇趾外翻理论和方法的不断完善和发展产生深远的影响。
5.创新点
1)建立拇趾外翻足不同方向截骨及“8”字绷带外固定三维有限元模型,为拇外翻手术方法的评价及预后研究开辟新的思路。
2)模拟中西医结合治疗拇趾外翻截骨和固定方法,对截骨端应力、位移变化进行有限元分析,从生物力学机制方面证明中西医结合治疗拇趾外翻的科学性。
1. Background
Integrated Traditional Chinese and Western medicine combined minimally invasive treatment of hallux valgus deformity has many good points such as simple operation, the patient less pain, fewer complications, and efficacy to determine and so on. More than 30 years after two generations of continuous improvement, innovation and development, it has formed a standardized system for the diagnosis and treatment. At present this method has been treated more than 2 million cases of hallux valgus patients, the excellent rate reaches to 98.5%. The main technique points of the method are 1) the application minimally invasive techniques in Traditional Chinese Medicine foot and ankle surgery.2) An oblique osteotomy is used at the first metatarsal head and neck to correct the deformity.3) Chinese bone-setting techniques to correct deformities and joint dislocation and 4) based on a small plywood and paper pad clip principles and the "muscle bundle bone" theory, a "8"-shaped bandage fixed osteotomy end. Abandon the Western tradition methods such as plate and screws internal fixation and plaster external fixation. Patients are able to weight-bearing after operation. As soon as this method has been made, some Western orthopedics experts questioned it. It was believed by modern medicine that the healing of osteotomy need for stability between the sides of osteotomy. In order to achieve optimal healing, the sides of osteotomy must remain relatively stable after reset. When the human body in the weight-bearing the feet load increased, especially in the first metatarsal. Some orthopedic surgeons believe that the osteotomy is not fixed in this part will affect the stability of osteotomy-side. The osteotomy may appear delayed healing or even nonunion. Nevertheless the fact is Integrated Traditional Chinese and Western medicine treatment of hallux valgus method, through 30 years of clinical applications, the phenomenon of osteotomy non-union does not occur. Moreover the patients with metastatic metatarsalgia postoperative are also less. How to analyze the science mechanism of Integrated Traditional Chinese and Western medicine treatment of hallux valgus, to study the mechanism of Integrated Traditional Chinese and Western medicine treatment of hallux valgus from the biomechanics, to confirm the scientific content of the small plywood and paper pad clip principles and the "muscle bundle bone" theory would have great significance for the development of Chinese medicine orthopedic treatment to bone fractures theory.
Where the osteotomy was performed at the 1st metatarsal bone of the hallux valgus? Which angle of osteotomy is the most scientific? Wether or not the "8 "-shaped bandage for non-invasive biological fixation after the osteotomy according to the small plywood and paper pad clip principles and the "muscle bundle bone" theory is stable? What the effects to the biomechanics of forefoot effects after the 1st metatarsal osteotomy healed? These issues still need to do in-depth studies to answer. So, it is necessary to study the mechanism of Integrated Traditional Chinese and Western medicine treatment of hallux valgus. Finite element analysis provides a useful tool for studying normal and pathological state of foot biomechanics. It enables us to have a fully understand the stress distribution of foot under different conditions, as well as the impact of various therapeutic measures on the foot. At present, the reports on finite element analysis of hallux valgus foot are very few. There is no related research on the site the first metatarsal osteotomy, the stability of osteotomy and the biomechanical changes in the foot after the osteotomy healing. The purpose of this study is to establish finite element model of the hallux valgus foot including bone, part of the tendon and intrinsic muscles, to analyze the effects on the osteotomy side and forefoot stress change of Integrated Traditional Chinese and Western medicine treatment of hallux valgus osteotomy site selection and fixation methods. The study results will improve understanding of the treatment of hallux valgus. It will have a far-reaching impact in improving and perfecting Integrated Traditional Chinese and Western medicine treatment of hallux valgus. The research methods for the modernization of traditional Chinese medicine orthopedic research opened a new way.
2. Purposes
To Study of Integrated Traditional Chinese and Western medicine Treatment of hallux valgus osteotomy surgery site, osteotomy angle, biological fixation and postoperative biomechanical mechanism of plantar stress to explain the mechanism of this therapy, further confirm the scientific.
3. Contents of study
3.1 The establishment of finite element model of hallux valgus foot
3.1.1 Materials and methods
3.1.1.1 Measurement of material parameters of foot-related organizations
A left calf-foot of fresh specimen of a 45-year-old woman was acquired. The flexor hallux longus muscle and it's tendon, internal and external side head of flexor hallux brevis, musculus extensor hallux longus and it's tendon, cross-head and oblique head of musculus adductor hallux, musculus abductor hallux were thumb abductor were dissected. And all the musles and tedon were made into samples. In order to removing the load creep deformation of the samples they were pre-loaded and stretched before testing. Repeated measurements for each sample 4 times, loading rate set 0.0835cm/min. Collection intensity limit, the maximum load load-displacement curve and other data. The load-displacement curve was transformed into force-deformation curve. The force divided by the cross sectional area, the displacement divided by specimen length, and the stress-strain curve was acquired. Fit the line segment of the curve and obtain the elastic modulus (E).
3.1.1.2 Image data acquisition and storage
A young women volunteer with hallux valgus was selected, aged 28 years old, height 168 cm, weight 62 kg. The HAV angle was 24°, IM angle was13°of her right foot. There no other foot deformity, no metatarsalgia under the metatarsal head, no history of foot surgery and trauma, no other foot deformity caused by other system diseases. Using spiral CT to scan the affected foot, slice thickness lmm, interval 1mm, scanned from toe to heel, which obtained 512×512 pixel CT image 542 pages. The pictures were outputted and storage in DCIOM format.
3.1.1.3 The establishment of finite element model of hallux valgus
Using the relative software to segment foot CT image and extract the contour data, to distinguish soft tissue, bone cortex, medullar cavity of the boundaries, and access to the edge of bone contour vector data. According to free-form surface entity modeling rule, to reconstruct surface of foot bone, obtain three-dimensional solid model of foot bone and assemble. In order to simplify the model reduce calculating amount, the model only took into account bone, cartilage, tendon, foot intrinsic muscles four kinds of organizational materials. Three-dimensional model of the foot was entered the finite element software ANSYS12.0, to definite material properties and assign material parameters, to carry out meshing, obtain finite element model.
3.1.1.4 Load and boundary constraints of model
Simulated the foot force conditions of a 62kg person standing balance in feet., and the 1st metatarsal stress distribution and variation when the heel in lift, toe dorsiflexion 30°and 70°. Set foot pressure, plantar tendon force and the foot friction was load. The interaction between the the surface of support structure and the plantar surface is defined as contact. The friction coefficient is 0.6. According the principle of loading and ground reaction force equivalent exchange, through the support structure surface a concentration force was exerted up to the pressure center. The upper surface of the talus was fully bound. The ankle joint is considered in the middle position.
3.1.1.5 Foot scan plantar pressure test of hallux valgus
A Foot scan USB21 meter flat plantar pressure measurement system was used, which produced by Belgian RSscan company. The same patient was tested. According to the patient body weight adjust the force plate before the test. The static and dynamic loading situations of foot were measured respectively. The static pressure (P) and the maximum dynamic pressure (MP) were observed in six regions of foot. Compare the measured value and finite element analysis results, to find the relationship between them and test the reliability of finite element model.
3.1.2 Results
i. By measuring and calculating 9 samples data were obtained, including:length, width, thickness, cross-sectional area, maximum load, ultimate strength and elastic modulus. Providerelative precise material parameters for the foot finite element model construct,
ii. Established 7 three-dimensional finite element modeles of the hallux valgus foot standing and gait cycle standing phase with different positions (0°,30°,45°and 70°). The bone, cartilage, tendon, intrinsic muscles and skin of the Modeles were reconstruced, which include 67,239 nodes,69,189 units.
iii. Compared the static plantar stress between finite element model and Foot scan foot force plate the two stress concentration was broadly consistent. Pressure values in the parts of the 2nd,3rd,5th metatarsal head were very close. Compared the maximum stress conversion value of Finite element in sole, which simulated a gait cycle with the maximum stress value of Foot scan force plate measured in corresponding parts, the trend of the maximum pressure was similar.
3.1.3 Conclusions
Finite element models of hallux valgus were established in this study, including bone, tendon, intrinsic muscles, and skin and so on. Parts of the material parameters were measured and some relevant data were obtained. The reliability of the finite element model was tested by Foot scan force plate. The results proved finite element models reliable and they basically reflected the actual situation of hallux valgus.
3.2 The finite element analysis on the osteotomy end stability of 1st metatarsal in different directions osteotomy
3.2.1 Materials and methods
3.2.1.1 Research Materials
Established finite element osteotomy models of hallux valgus and 7 kinds of working conditions were simulated which the osteotomy line and 1st metatarsal axis were angulated in 30°,45°,60°,75°,90°,105°,120°in sagittal plane.
3.2.1.2 Test Methods
Simulated a body weight 62kg hallux valgus patient who suffered from 1st metatarsal osteotomy stood toe plantar flexion as far as possible the osteotomy end conditions of the stress and displacement in different angle osteotomy. Set the proximal osteotomy end the fixed end and distal end the free end. Set the ends filled with granulation tissue.The constraints of other parts were similar with the former. One foot was beared about 310N weight load. Considered the effects of the flexor hallux longus muscle and flexor hallux brevis muscle only on the osteotomy end. Muscle strength was expressed with load. That was about 319N. Muscle load wre supposed parallel with the 1st metatarsal long axis. The friction coefficient in osteotomy faces was set to 0.6.
3.2.1.3 Observation Project
Observed the maximum Von Mises stress and the total value of the displacement in osteotomy ends of the seven kinds of conditions under the same load conditions, and compared.
3.2.2 Results
i. The total displacement of osteotomy end diminished gradually from 30°, reched to the minimum at 60°, and then gradually increased. The displacement increased significantly as osteotomy angle exceeds 90°. The maximum displacement occurred at 120°, which was 0.6486mm; the minimum displacement occurs at 60°, which was 0.2833mm.
ii. The Von Mises stress of the osteotomy end gradually increased from 30°, reached to the first peak at 75°, and then flattened and reduced gradually. The stress increased rapidly at 105°. The maximum stress occurred at 120°, which was 0.986Mpa; the minimum stress occurred at 30°, which was 0.212Mpa.
3.2.3 Conclusions
Through simulation and calculation to the osteotomy in different angles of 1st metatarsal in the sagittal plane by finite element model it had found the osteotomy end was the most stable at about 60°. Only Maintain osteotomy line direction from the dorsal distal to plantar proximal lateral in the sagittal plane could the osteotomy ends maintain stability. According to factors that influencing the osteotomy stability, the best osteotomy angle in the sagittal plane should adjust appropriately according to the patients different situations. Osteotomy should not be taken fixed angle.
3.3 The finite element analysis on the fixed action of Integrated Traditional Chinese and Western medicine treatment of hallux valgus external fixation methods in 1st metatarsal osteotomy end
3.3.1 Materials and methods
3.3.1.1 Research Materials
Established finite element model of hallux valgus with osteotomy at 1st metatarsal neck. The osteotomy line was angled with the vertical of 1st metatarsal axis into 10°in the sagittal plane, with the vertical of 1st metatarsal axis into 15°in the horizontal plane. Simulated standing conditions with a pad in 1st toe web and "8"-shaped bandage fixation. The material properties and material parameters of parts of the Model could be found in the first two parts.
3.3.1.2 Test Methods
Simulated a body weight 62kg hallux valgus patient who suffered from 1st metatarsal osteotomy and fixation stood toe plantar flexion as far as possible the osteotomy end conditions of the stress and displacement. Set the proximal osteotomy end the fixed end and distal end the free end. Set the ends filled with granulation tissue.The constraints of other parts were similar with the former. The force of the sub-toe pad and the "8"-shaped bandage external fixation was 24.84N by the experimental measurement. It cuold be divided into two powers; one was vertical with hallux the other parallel with 1st metatarsal. They were expressed with load in analysis. Other load and settings were same as the previous model.
3.3.13 Observation Project
Observed the maximum Von Mises stress and the total value of the displacement in osteotomy end and the displacements of X, Y, Z axises.
3.3.2 Results
i. Displacement of the osteotomy end:it was 0.261mm in X axis,0.078mm in Y axis,-0.167mm in Z axis. The total displacement in osteotomy end was 0.293mm. The main displacement occurred in X axis. The other two were very small.
ii. The Von Mises stress of the osteotomy end was 0.712Mpa. The stress was mainly located in the lateral edge of the osteotomy end.
3.3.3 Conclusions
Through simulation and calculation to the "8"-shaped bandage external fixation of Integrated Traditional Chinese and Western medicine treatment of hallux valgus it had found the fixation can effectively reduce the displacement of the osteotomy end. The stress was moderate. It could promote osteotomy to healing in an approach of endochondral ossification.
4. Summary
The study analyzed the choice of osteotomy angles and effects of the fixation methods on the stability and healing of osteotomy by finite element in Integrated Traditional Chinese and Western medicine treatment of hallux valgus. It explained how to determin the osteotomy angles from the biomechanical viewpoint. It analyzed the mechanism of sub-toe pad and "8"-shaped bandage external fixation. At the same time a deep study had done on the role of "muscle bundle bone" theory in the treatment of hallux valgus. The understandings of the mechanism in Integrated Traditional Chinese and Western medicine treatment of hallux valgus were deepened and improved, and confirmed its scientific content. It will have a far-reaching impact on the constant improvement and development of the theories and methods in Integrated Traditional Chinese and Western medicine treatment of hallux valgus.
5. Innovations
i. The establishment of dimensional finite element model on hallux valgus osteotomy in different directions, and "8 "-shaped bandage external fixation open up a new way for evaluation of hallux valgus surgical methods and prognosis of the feasibility.
ii. The finite element analyses were performed on stress and displacement of osteotomy ends by simulating osteotomy and fixation methods of Integrated Traditional Chinese and Western medicine treatment of hallux valgus, and proved the scientificity of Integrated Traditional Chinese and Western medicine treatment of hallux valgus from the biomechanical mechanisms.
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