锁定钢板及锁定螺钉内固定治疗SandersⅢ型跟骨骨折:改良“L”型切口植骨与“L”型切口非植骨1年随访比较
|
摘要
背景:目前临床上跟骨复杂关节内骨折以切开复位内固定为主要治疗方案,但传统"L"型切口相关并发症仍较高,术中植骨与否仍存在较大争议,因此选择合适的修复方案提高临床疗效的同时降低术后并发症一直是国内外学者研究的热点。目的:探讨改良"L"型切口植骨内固定治疗SandersⅢ型跟骨骨折的临床效果。方法:回顾性分析进行手术治疗获得1年以上随访的单侧新鲜SandersⅢ型跟骨骨折患者82例,分为2组,改良"L"型切口植骨组42例(A组),"L"型切口非植骨组40例(B组)。比较2组患者手术时间、切口愈合时间、住院时间、负重时间、足部功能、并发症发生率及手术前后影像学参数。结果与结论:(1)A组患者的手术时间、切口愈合时间、住院时间及负重时间均短于B组(P <0.05);(2)术后2组跟骨B?hler角、Gissane角、跟骨宽度、高度恢复差异无显著性意义(P> 0.05);(3)术后1年随访时,2组Gissane角、跟骨宽度差异无显著性意义(P>0.05);但B?hler角及跟骨高度差异有显著性意义,A组大于B组(P <0.05);且2组均出现B?hler角丢失现象,A组B?hler角丢失值明显低于B组(P <0.05);(4)A组Maryland足功能评分及优良率均优于B组,差异有显著性意义(P <0.05);(5)A组切口并发症发生率明显低于B组(12%vs. 30%),差异有显著性意义(P <0.05);(6)提示改良"L"型切口植骨内固定治疗SandersⅢ型跟骨骨折可获得良好的复位,术后切口并发症少,植骨可减少术后Bohler角丢失,获得满意的临床疗效。
BACKGROUND: Open reduction and internal fixation is the main treatment method for complex intra-articular fractures of the calcaneus, but the traditional "L" type incision related complications are still high, and there is still much controversy about intraoperative bone grafting. Therefore, choosing appropriate surgery is a hot topic for scholars at home and abroad to improve the clinical efficacy and reduce postoperative complications. OBJECTIVE: To investigate the clinical outcomes of modified "L-shape" incision and internal fixation with bone graft in the treatment of the Sanders III calcaneal fractures. METHODS: Data of 82 patients of fresh unilateral Sanders III type calcaneal fractures followed up for more than 1 year were retrospectively analyzed. The patients were divided into two groups: There were 42 cases in group of modified "L-shape" incision with bone graft(group A) and 40 cases in group of "L-shape" incision with non-bone graft(group B). The operation time, incision healing time, hospitalization time, weight-bearing time, foot function, complication rate and imaging parameters before and after operation were compared between two groups. RESULTS AND CONCLUSION:(1) Operation time, wound healing time, hospitalization time and weight bearing time were shorter in the group A than in the group B(P < 0.05).(2) There was no significant difference while comparing the two group's B?hler's angle, Gissane's angle, calcaneal width and calcaneal height, on the first day after operation(P > 0.05).(3) At 1-year follow-up, there was no significant difference in the Gissane's angle and calcaneal width between the two groups(P > 0.05), and there was a significant difference in B?hler's angle and calcaneal height(P < 0.05), and the B?hler's angle was lost in both groups(P < 0.05).(4) The Maryland Foot Score and excellent rate at the 1-year follow-up visit, with the differences being significant(P < 0.05).(5) The incidence of incision complications in group A was significantly lower than that in group B(12% vs. 30%), and this difference was significant(P < 0.05).(6) The modified "L-shape" incision with bone graft and internal fixation in treatment of the Sanders III type calcaneal fractures can obtain good reduction, lower postoperative incision complications. The bone grafting reduces B?hler's angle loss and can obtain satisfactory clinical results.
BACKGROUND: Open reduction and internal fixation is the main treatment method for complex intra-articular fractures of the calcaneus, but the traditional "L" type incision related complications are still high, and there is still much controversy about intraoperative bone grafting. Therefore, choosing appropriate surgery is a hot topic for scholars at home and abroad to improve the clinical efficacy and reduce postoperative complications. OBJECTIVE: To investigate the clinical outcomes of modified "L-shape" incision and internal fixation with bone graft in the treatment of the Sanders III calcaneal fractures. METHODS: Data of 82 patients of fresh unilateral Sanders III type calcaneal fractures followed up for more than 1 year were retrospectively analyzed. The patients were divided into two groups: There were 42 cases in group of modified "L-shape" incision with bone graft(group A) and 40 cases in group of "L-shape" incision with non-bone graft(group B). The operation time, incision healing time, hospitalization time, weight-bearing time, foot function, complication rate and imaging parameters before and after operation were compared between two groups. RESULTS AND CONCLUSION:(1) Operation time, wound healing time, hospitalization time and weight bearing time were shorter in the group A than in the group B(P < 0.05).(2) There was no significant difference while comparing the two group's B?hler's angle, Gissane's angle, calcaneal width and calcaneal height, on the first day after operation(P > 0.05).(3) At 1-year follow-up, there was no significant difference in the Gissane's angle and calcaneal width between the two groups(P > 0.05), and there was a significant difference in B?hler's angle and calcaneal height(P < 0.05), and the B?hler's angle was lost in both groups(P < 0.05).(4) The Maryland Foot Score and excellent rate at the 1-year follow-up visit, with the differences being significant(P < 0.05).(5) The incidence of incision complications in group A was significantly lower than that in group B(12% vs. 30%), and this difference was significant(P < 0.05).(6) The modified "L-shape" incision with bone graft and internal fixation in treatment of the Sanders III type calcaneal fractures can obtain good reduction, lower postoperative incision complications. The bone grafting reduces B?hler's angle loss and can obtain satisfactory clinical results.
引文
[1]Wallin KJ,Cozzetto D,Russell L,et al.Evidence-based rationale for percutaneous fixation technique of displaced intra-articular calcaneal fractures:a systematic review of clinical outcome.J Foot Ankle Surg.2014;53(6):740-743.
[2]Epstein N,Chandran S,Chou L.Current concepts review:intraarticu-lar fractures of the calcaneus.Foot Ankle Int.2012;33(1):79-86.
[3]Buckley R,Tough S,McCormack R,et al.Operative compared with nonoperative treatment of displaced intra-articular fractures:a prospective,randomized,controlled multicenter trial.J Bone Joint Surg Am.2002;84:1733-1744.
[4]Sanders R.Displaced intra-articular fractures of the calcaneus.Bone Joint Surg(Am).2000;82:225-250.
[5]Barei DP,Bellabarba C,Sangeorzan BJ,et al.Fractures of the calcaneus.Orthop Clin North Am.2002;33(1):263 285.
[6]陈小亮,叶哲伟,刘建湘,等.开窗直视下联合复位内固定治疗跟骨骨折[J].临床骨科杂志,2014,17(5):583-586.
[7]杨振军,何新泽,孙勃,等.改良“L”型切口治疗跟骨骨折疗效及并发症相关因素研究[J].中国矫形外科杂志,2015,23(12):1123-1126.
[8]徐建民,于超.改良外侧“L”型切口与传统“L”型切口治疗跟骨骨折的比较研究[J].中国矫形外科杂志,2013,21(22):2313-2316.
[9]Burdeaux BD Jr.Fractures of the calcaneus:open reduction and internal fixation From the medial side-a 21-year prospective study.Foot Ankle Int.1997;18:685-692.
[10]Tennent TD,Calder PR,Salisbury RD,et al.The operative management of displaced intra-articular fractures of the calcaneum:a two-centre study using a defined protocol.Injury.2001;32(6):491-496.
[11]Allmacher D,Gallen KS,Marsh J.Intra-articular calcaneal fractures treated non-operation and followed sequentially for 2 decades.JOrthop Trauma.2006;20(7):464-469.
[12]朱炼.跟骨周围神经、血管的体表投影测量及其临床意义[D].石家庄:河北医科大学,2007.
[13]章鸣.异位保存离体足跟皮瓣再回植技术修复足跟软组织缺损的临床研究[D].苏州:苏州大学,2010.
[14]黄远清,杨福周,易远历,等.足背外侧血管神经的解剖及足背外侧逆行筋膜蒂皮瓣的临床应用研究[J].中国医学创新,2017,14(17):18-22.
[15]Shin TM,Bordaux JS.How suture technique affects the cosmetic outcome of cutaneous repairs.J Drugs Dermatol.2014;13(8):967-969.
[16]Cao H,Li YG,An Q,et al.Short-term outcomes of open reduction and internal fixation for sanders type iii calcaneal fractures with and without bone grafts.J Foot Ankle Surg.2018;57(1):7-14.
[17]顾世勤,方毅,萨晨琛,等.切开复位内固定植骨与不植骨治疗移位型跟骨关节内骨折的Meta分析[J].中国骨与关节损伤杂志,2017,32(12):1270-1274.
[18]Duymus TM,Mutlu S,Mutlu H,et al.Need for bone grafts in the surgical treatment of displaced intra-articular calcaneal fractures.J Foot Ankle Surg.2017;56(1):54-58.
[19]Liang J,Cao HB,Xin JY.Therapeutic efficacies of bone grafng for calcaneal intra-calcaneal fractures.Zhonghua Yi Xue Za Zhi.2012;92(3):197-199.
[20]许云,陈康.一期人工植骨内固定治疗关节内压缩性跟骨骨折的疗效观察[J].临床急诊杂志,2013,14(8):381-382.
[21]马腾,谭力,朱亮亮,等.闭合性SandersⅢ-Ⅳ型跟骨骨折植骨内固定手术的远期随访[J].中外医学研究,2013,11(31):25-27.
[22]Müller SA,Barg A,Vavken P,et al.Autograft versus sterilized allograft for lateral calcaneal lengthening osteotomies Comparison of 50patients.Medicine(Baltimore).2016;95(30):e4343.
[23]Devrier JG,Scharer B.Comparison and use of allograft bone morphogenetic protein versus other materials in ankle and hindfoot fusions.J Foot Ankle Surg.2018.S1067-2516(17)30704-4.
[2]Epstein N,Chandran S,Chou L.Current concepts review:intraarticu-lar fractures of the calcaneus.Foot Ankle Int.2012;33(1):79-86.
[3]Buckley R,Tough S,McCormack R,et al.Operative compared with nonoperative treatment of displaced intra-articular fractures:a prospective,randomized,controlled multicenter trial.J Bone Joint Surg Am.2002;84:1733-1744.
[4]Sanders R.Displaced intra-articular fractures of the calcaneus.Bone Joint Surg(Am).2000;82:225-250.
[5]Barei DP,Bellabarba C,Sangeorzan BJ,et al.Fractures of the calcaneus.Orthop Clin North Am.2002;33(1):263 285.
[6]陈小亮,叶哲伟,刘建湘,等.开窗直视下联合复位内固定治疗跟骨骨折[J].临床骨科杂志,2014,17(5):583-586.
[7]杨振军,何新泽,孙勃,等.改良“L”型切口治疗跟骨骨折疗效及并发症相关因素研究[J].中国矫形外科杂志,2015,23(12):1123-1126.
[8]徐建民,于超.改良外侧“L”型切口与传统“L”型切口治疗跟骨骨折的比较研究[J].中国矫形外科杂志,2013,21(22):2313-2316.
[9]Burdeaux BD Jr.Fractures of the calcaneus:open reduction and internal fixation From the medial side-a 21-year prospective study.Foot Ankle Int.1997;18:685-692.
[10]Tennent TD,Calder PR,Salisbury RD,et al.The operative management of displaced intra-articular fractures of the calcaneum:a two-centre study using a defined protocol.Injury.2001;32(6):491-496.
[11]Allmacher D,Gallen KS,Marsh J.Intra-articular calcaneal fractures treated non-operation and followed sequentially for 2 decades.JOrthop Trauma.2006;20(7):464-469.
[12]朱炼.跟骨周围神经、血管的体表投影测量及其临床意义[D].石家庄:河北医科大学,2007.
[13]章鸣.异位保存离体足跟皮瓣再回植技术修复足跟软组织缺损的临床研究[D].苏州:苏州大学,2010.
[14]黄远清,杨福周,易远历,等.足背外侧血管神经的解剖及足背外侧逆行筋膜蒂皮瓣的临床应用研究[J].中国医学创新,2017,14(17):18-22.
[15]Shin TM,Bordaux JS.How suture technique affects the cosmetic outcome of cutaneous repairs.J Drugs Dermatol.2014;13(8):967-969.
[16]Cao H,Li YG,An Q,et al.Short-term outcomes of open reduction and internal fixation for sanders type iii calcaneal fractures with and without bone grafts.J Foot Ankle Surg.2018;57(1):7-14.
[17]顾世勤,方毅,萨晨琛,等.切开复位内固定植骨与不植骨治疗移位型跟骨关节内骨折的Meta分析[J].中国骨与关节损伤杂志,2017,32(12):1270-1274.
[18]Duymus TM,Mutlu S,Mutlu H,et al.Need for bone grafts in the surgical treatment of displaced intra-articular calcaneal fractures.J Foot Ankle Surg.2017;56(1):54-58.
[19]Liang J,Cao HB,Xin JY.Therapeutic efficacies of bone grafng for calcaneal intra-calcaneal fractures.Zhonghua Yi Xue Za Zhi.2012;92(3):197-199.
[20]许云,陈康.一期人工植骨内固定治疗关节内压缩性跟骨骨折的疗效观察[J].临床急诊杂志,2013,14(8):381-382.
[21]马腾,谭力,朱亮亮,等.闭合性SandersⅢ-Ⅳ型跟骨骨折植骨内固定手术的远期随访[J].中外医学研究,2013,11(31):25-27.
[22]Müller SA,Barg A,Vavken P,et al.Autograft versus sterilized allograft for lateral calcaneal lengthening osteotomies Comparison of 50patients.Medicine(Baltimore).2016;95(30):e4343.
[23]Devrier JG,Scharer B.Comparison and use of allograft bone morphogenetic protein versus other materials in ankle and hindfoot fusions.J Foot Ankle Surg.2018.S1067-2516(17)30704-4.