摘要
目的探讨内外侧联合入路治疗合并载距突骨折脱位的跟骨骨折的疗效。方法选取成人下肢防腐标本4具(8侧),其中2具(4侧)行跟骨内侧解剖,观察载距突毗邻结构及显露范围;另2具模拟内外侧联合入路复位固定跟骨骨折。回顾性分析临床应用内外侧联合入路切开复位内固定术治疗的合并载距突骨折脱位的SandersⅡ~Ⅳ型跟骨骨折患者9例(9足),男7例、女2例;年龄(49.9±11.3)岁(范围25~58岁)。术中先取内侧切口,临时复位并固定载距突于距骨;再取外侧切口,显露跟骨外侧,复位并固定骨折块;载距突以螺钉经外侧固定,其中2例经内侧辅以可吸收棒固定。同期采用单纯外侧入路手术的合并载距突骨折脱位的跟骨骨折6例(8足)作为对照。两组外侧均采用跟骨锁定接骨板固定,并以脱钙骨基质植入后关节面复位后的空腔。测量两组患者术后1年的Böhler角、Gissane角,并采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分系统评估功能。结果载距突-距骨关节面呈倒"V"形,分为前、后两部分。经胫后肌腱前方可显露载距突尖部,经胫后肌腱与趾长屈肌腱间隙可完整显露并复位固定载距突及跟骨体内侧。内外侧联合入路组术后切口引流量为(73.6±4.3)ml,大于单纯外侧入路组的(70.6±7.1)ml(t=2.18,P=0.045)。外侧切口均一期愈合,内外侧联合入路组1例内侧切口出现延迟愈合。内外侧联合入路组及单纯外侧入路组骨折均愈合,愈合时间分别为(12.2±2.1)周和(12.8±2.8)周,差异无统计学意义(t=0.50,P=0.622)。术后1年,内外侧联合入路组及单纯外侧入路组Böhler角分别为37.0°±5.7°、27.9°±4.0°,大于术前的4.7°±3.4°、3.9°±2.9°(P<0.05),组间比较差异有统计学意义(t=3.76,P=0.002);Gissane角分别为133.2°±9.8°、139.1°±9.4°,较术前的172°±7.3°、175.6°±5.6°减小(P<0.05),组间差异无统计学意义(t=1.26,P=0.226);内外侧联合入路组AOFAS评分为(93.6±4.0)分,大于外侧入路组的(84.3±8.2)分,差异有统计学意义(t=3.03,P=0.008)。结论跟骨关节内骨折合并较高概率的载距突骨折或脱位,采用内外侧联合入路及先内侧后外侧的手术顺序有利于恢复跟骨力线及解剖形态,尤其是跟骨内侧载距突与距骨下缘的对位关系,与采用单纯外侧入路比较可获得更好的早期临床疗效。
Objective To explore the clinical effects of combined medial and lateral approaches in treating of calcaneal fractures combined with sustentaculum tali fractures and/or dislocations of sustentaculum tali-talus joint.Methods Four adult cadaver specimens(8 feet)were selected,of which two(4 feet)were dissected on the medial side of the calcaneus to observe the adjacency and exposure range of sustentaculum tali.The other two specimens were simulated as medial and lateral approaches to reduce and fix calcaneal fractures.Retrospective analysis of 9 cases(9 feet)of Sanders II-IV type calcaneal fractures with combined medial and lateral approaches in the treatment of fractures and/or dislocations of sustentaculum tali-talus joint was performed.The average age was 49.9±11.3(25-58)years.During the operation,the medial incision was made first,and the sustentaculum tali fracture was temporarily reduced and fixed to the talus.Then the lateral incision was made to expose the lateral side of the calcaneus,and the fracture fragments were reduced and fixed;the sustentaculum tali was fixed laterally with screws,and 2 cases were additionally fixed medially with absorbable rods.At the same time,six cases(8 feet)of calcaneal fractures with sustentaculum tali fractures and/or dislocations of sustentaculum tali-talus were treated with lateral approach as a control group.The lateral sides of both groups were fixed with calcaneal locking plate and implanted with demineralized bone matrix into the cavity after articular surface reduction.The Böhler and Gissane angles of the two groups of patients were measured at 1 year after operation.The American Orthopaedic Foot and Ankle Society(AOFAS)scoring system was used to evaluate the clinical efficacy.Results The sustentaculum tali-talus joint had a shape of an inverted"V"with two divided parts.The tip of the sustentaculum tali was exposed through the front window of the posterior tibial tendon.The sustentaculum tali and the medial side of the calcaneal body was completely exposed and fixed through the window between the posterior tibial tendon and the flexor digitorum longus tendon.The postoperative incision blood loss in the combined medial and lateral approach group was 73.6±4.3 ml,which was greater than that in the lateral approach group(70.6±7.1 ml)(t=2.18,P=0.045).The lateral incision healed in both groups.The medial incision healed delayed in 1 patient in the combined medial and lateral approach group.The fractures in the combined medial-lateral approach group and the lateral approach group were both healed.The healing duration was 12.2±2.1 weeks and 12.8±2.8 weeks,respectively,without significant difference(t=0.50,P=0.622).The Böhler angles of the combined medial-lateral approach group and the lateral approach group were 37.0°±5.7°and 27.9°±4.0°at 1 year after operation,respectively.These values were greater than the preoperative values of 4.7°±3.4°and 3.9°±2.9°(P<0.05),with significant difference between groups(t=3.76,P=0.002).The Gissane angles were 133.2°±9.8°and 139.1°±9.4°respectively,which were lower than those of 172°±7.3°and 175.6°±5.6°before operation(P<0.05).There was no significant difference between the groups(t=1.26,P=0.226).The AOFAS score of the combined medial and lateral approach group was 93.6±4.0 points,which was higher than that of the lateral approach group(84.3±8.2 points)(t=3.03,P=0.008).Conclusion Intra-articular calcaneal fractures combined with a high probability of sustentaculum tali fractures and/or dislocations of sustentaculum tali-talus joint.Compared with the simple lateral approach,the use of the combined medial-lateral approach and the medial-lateral surgical sequence is beneficial to restore the calcaneal alignment and anatomic shape,especially the alignment relationship of the medial calcaneus and talus,so as to obstain better early clinical outcomes.
作者
陈晔
孙焕建
施凤超
朱文峰
刘璠
Chen Ye;Sun Huanjian;Shi Fengchao;Zhu Wenfeng;Liu Fan(Department of Orthopaedic Surgery,Nantong Haimen People's Hospital,Nantong 226199,China;Department of Orthopaedic Surgery,Affiliated Hospital 6 of Nantong University,Yancheng 224001,China;Department of Orthopaedic Surgery,Affiliated Hospital of Nantong University,Nantong 226001,China)
出处
《中华骨科杂志》
CAS
CSCD
北大核心
2022年第3期172-181,共10页
Chinese Journal of Orthopaedics
关键词
跟骨
骨折脱位
骨折固定术
内
Calcaneus
Fracture dislocation
Fracture fixation,internal
