解剖钢板和加压螺栓微创治疗跟骨关节内骨折的相关基础与临床研究
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摘要
跟骨骨折是常见的跗骨骨折,其中大约75%的成人跟骨骨折是涉及距下关节的关节内移位骨折。随着对跟骨骨折损伤认识的不断深入,治疗目的已经由19世纪和20世纪防止发生致命性的感染,发展为最大程度的恢复患足的功能,同时减少跟骨疼痛、侧方撞击综合征和距下关节炎等长期并发症。尽管有关跟骨骨折的最佳治疗策略依然存在争议,但随着新的手术技术的应用、术中高质量的影像学方法的运用以及采取有效的术前软组织处理办法,跟骨关节内骨折行手术治疗逐渐得到大多数学者的认可,并在过去的20年中得到了极大的发展。最近,大量临床研究表明,手术治疗跟骨关节内骨折能够获得比保守治疗更好的功能结果并降低距下关节炎的发生率。
跟骨骨折手术治疗可以通过外侧扩展切口、内侧切口、有限切口和经皮技术等显露和复位骨折。目前最常用的是外侧扩展的L形切口进行切开复位内固定,此入路的优点是能够直观显露距下关节,便于复位骨折片,同时侧方钢板和螺钉固定能够提供足够的强度。但是,跟骨关节内骨折行手术治疗的目的除了重建距下关节面、恢复跟骨的宽度和后足的力线、应用坚强固定以维持复位之外,还应当考虑治疗措施是否能够减少伤口并发症,尤其是伤口愈合并发症。而采用外侧扩展的L形切口进行切开复位内固定时,需要进行外侧壁广泛切开,剥离软组织范围较大,手术时间较长,增加了术后并发症发生风险。因此,为减少在跟骨骨折治疗中的软组织相关并发症,并提高骨折治疗的临床效果,各种闭合复位和微创治疗的手术方法以及不同设计的内固定器械被用于治疗跟骨骨折。
跟骨骨折分类系统为临床提供重要指导作用的关键在于该分类系统能否提供患者的预后信息、是否具有观察者之间的可靠性和观察者自身的可重复性。目前,涉及治疗决策制定和治疗效果评价的跟骨骨折分类系统仍不完善,成为跟骨骨折治疗争论的重点。既往临床医师主要根据X线平片进行骨折分类,近年来,随着CT影像技术的不断应用,根据骨折关节内损伤的要素进行分类的观点逐渐被认可并接受。但是,由于X线分型不能准确反映关节内骨折情况,而CT扫描分型不能获得跟骨整体的损伤情况。因此,张英泽教授根据跟骨严重粉碎骨折时,周围软组织完整但手术困难、不能解剖复位和预后差等临床特点,将跟骨严重粉碎骨折定义为跟骨骨性毁损伤,提出了跟骨骨性毁损伤的概念。
我院提出的解剖钢板和加压螺栓微创治疗技术,利用小切口、经皮撬拨复位以减少伤口愈合并发症。同时,采用加压螺栓代替拉力螺钉,以弥补螺钉不能有效复位跟骨内侧壁进而跟骨宽度恢复差的不足。本研究旨在分析比较解剖钢板和加压螺栓微创治疗技术与传统应用解剖钢板和螺钉切开复位内固定技术固定跟骨关节内骨折的生物力学稳定性,回顾性研究解剖钢板和加压螺栓与传统切开复位内固定治疗移位的跟骨关节内骨折的临床疗效,首次提出跟骨骨性毁损伤的概念及此类损伤经解剖钢板和加压螺栓治疗的临床效果。
第一部分解剖钢板和加压螺栓与传统解剖钢板和螺钉固定跟骨关节内骨折的生物力学比较
目的：在尸体标本上制作跟骨关节内骨折模型(Sander Ⅲ型),比较应用解剖钢板和加压螺栓固定与传统解剖钢板和螺钉固定跟骨关节内骨折的生物力学稳定性。
方法：新鲜冷冻下肢尸体融解后,使用摆锯在跟骨内侧载距突下1.5cm和2.5cm向距下关节纵行截骨,然后通过跟骨结节和跟骨后关节面中间冠状位截骨,制作可复制的跟骨关节内骨折模型(SandersⅢ型)。随机应用解剖钢板和加压螺栓固定或传统解剖钢板和螺钉固定跟骨骨折模型。固定完成后,通过X线摄片分别对骨折复位情况进行评估。每一个跟骨骨折模型分别通过距骨先后加载20-200N和20-700N的轴向载荷,两次加载的轴向载荷均循环1000个循环,频率为1赫兹,分别代表肢体部分负重和完全负重情况下跟骨所承受的压力,然后对样本加压至骨折固定失败。记录生物力学机上的数据并通过配对符号秩和检验来检验结果的差异。
结果：在20-200N的循环实验中,经传统解剖钢板和螺钉固定技术和解剖钢板和加压螺栓固定技术固定后,两组样本在轴向循环载荷下的骨折位移未发现明显统计学差异(P=0.06),而解剖钢板和加压螺栓固定的骨折模型在20-700N的循环载荷中发生的不可逆形变比传统解剖钢板和螺钉的更低(P=0.008)。两组固定结构能承受的使骨折固定失败的最大载荷明显不同(P=0.008)：解剖钢板和加压螺栓组为3839.6±152.4N,解剖钢板和螺钉组为3087.3±58.9N,而在最终载荷下两种固定结构的骨折最终位移没有显著差别(P=0.767)。
结论：在轴向循环载荷下,解剖钢板和加压螺栓固定技术能够提供比传统钢板和螺钉固定技术更好的生物力学稳定性。本研究从生物力学角度支持了解剖钢板和加压螺栓固定治疗跟骨关节内骨折的临床实用性。
第二部分解剖钢板和加压螺栓与传统解剖钢板和螺钉治疗跟骨关节内骨折的临床疗效比较
目的：随着手术技术的发展和术中影像学的成功运用,手术治疗跟骨关节内骨折已经逐渐为大家所接受。本文的研究目的是通过与传统的经标准外侧L切口AO解剖钢板和螺钉固定结果的比较,分析我院应用小切口微创解剖钢板和加压螺栓治疗跟骨关节内骨折的临床效果。
方法：对我院自2007年1月至2010年4月收治的106例(118足)跟骨关节内骨折患者的资料进行回顾性分析。其中男83例,女23例,年龄18-68岁,平均年龄44.57岁。左侧41例,右侧53例,双侧12例。根据sanders分型,Ⅱ型77例,Ⅲ型38例,Ⅳ型3例。其中,64例患者(71足)经小切口微创解剖钢板和加压螺栓治疗(加压螺栓组),42例患者(47足)经标准的外侧L形切口AO解剖钢板和螺钉治疗(传统AO组),伤后入院至手术时间1-16天,平均5.4天。收集并分析两组患者的年龄、性别、骨折的损伤原因、基础疾病情况、合并损伤、Sanders骨折分型、住院时间等情况。比较两组患者的围手术时间、手术时间、术后并发症、内固定情况、骨折愈合情况、Bohler角恢复程度。通过美国足与踝关节协会踝与后足功能评分来评估患者的疼痛及功能情况。如果患者需进行距下关节融合和早期植入物移除则进行相应的手术干预和处理。所有的患者常规随访1年后进行固定物移除。
结果：106例患者术后获12-50个月(平均26个月)随访。两组患者的年龄、性别、损伤原因、Sanders骨折分型、基础疾病、住院时间等临床基本特征比较,均无统计学差异。加压螺栓组与传统AO组围手术期时间分别为5.62±2.7天和5.20±3.11天,差别无统计学意义,但加压螺栓组固定的手术时间明显低于传统AO组,分别为84±21分钟和104±25分钟,差异具有统计学意义。传统AO组和加压螺栓组术后Bohler角均明显改善恢复,两组术后平均Bohler角分别恢复为28.1±7.8度和26.6±5.6度,差别无统计学意义。术后随访,所有骨折均愈合,加压螺栓组患者平均术后4.66周早期部分负重,而传统AO组患者平均部分负重时间为术后9.60周,两组差异具有统计学意义。加压螺栓组7例患者发生术后伤口相关并发症,发生率为7/71(9.86%),但未发生深部感染。传统AO组12例患者发生软组织并发症,其中2例发展为深部感染,1例伤口皮缘坏死较重,由于并发症不得不将内固定物移除,但没有骨髓炎的表现。加压螺栓组9例患者存在距下关节炎的影像学表现,其中6例患者存在轻度疼痛,2例患者存在中度疼痛,而1例患者虽疼痛严重但拒绝进行距下关节融合治疗。传统AO组7例患者存在距下关节炎的影像学表现,其中3例患者存在轻度疼痛,2例伴有中度疼痛,2例有严重疼痛而进行了距下关节融合治疗。经美国足踝矫形协会AOFAS评分,加压螺拴组和传统AO组AOFAS平均评分分别为85.75±9.36分和84.29±9.51分,差异无统计学意义。
结论：解剖钢板和加压螺栓小切口微创治疗跟骨关节内骨折能够减少手术相关并发症,坚强的内固定有助于患者早期负重活动,能够获得良好的治疗效果。解剖钢板和加压螺栓固定技术是治疗跟骨关节内骨折的不错选择。
第三部分跟骨骨性毁损伤概念的提出及经微创解剖钢板和加压螺栓固定治疗
目的：提出跟骨骨性毁损伤的概念,观察应用解剖钢板及加压螺栓微创固定并结合早期功能锻炼治疗跟骨骨性毁损伤的临床效果。
方法：对2004年4月至2006年10月收治的12例单侧跟骨关节内严重粉碎骨折的患者进行回顾性分析,所有患者均在软组织肿胀消退后,利用经皮撬拨复位及侧方挤压、采取小切口微创入路,解剖钢板及加压螺栓进行加压内固定治疗。术后48小时即进行主动功能锻炼,4周逐渐负重活动以磨造距下关节面。利用美国足踝矫形外科AOFAS评分标准进行评定患者术后的功能恢复情况。
结果：12例患者中,男10例,女2例,年龄24-56岁,平均年龄39岁。所有患者根据Sander分型均为Ⅳ型。患者损伤后平均7.6天(6-11天)进行手术,平均时间78分钟(56-93分钟)。术后,X线检查显示跟骨的高度、长度、宽度及跟骨的外形和后足的力线轴基本得到恢复,Bohler角恢复至24.5±3.7度。其中,7例复位后关节面移位小于3mm,其余5例移位大于3mm。另外,12例患者中仅1例发生伤口浅表感染。同时,术后所有患者均获得随访,平均随访76个月(66-87个月)。随访的结果显示：经2公里徒步行走后,2例存在轻度疼痛,1例存在中度疼痛,但所有患者均没有行距下关节融合术要求。经美国足踝矫形外科AOFAS评分标准进行评估,平均82分(65-94分),4例功能恢复优,5例恢复良,2例效果中,1例效果差。
结论：首次提出跟骨骨性毁损伤的概念。跟骨骨性毁损伤不是距下关节融合的绝对适应症。应用小切口微创,解剖钢板及加压螺栓进行加压固定、进行早期功能锻炼治疗跟骨骨性毁损伤是一个合理、有效的治疗选择。
Calcaneal fractures are the most frequent tarsal bone fracture and represent2%of all adult fractures. About75%of all calcaneal fractures in adults are displaced intra-articular fractures involving the subtalar joint. There have been dramatic changes in management protocols as our understanding of the fracture has evolved. The primary goal of fracture treatment has changed from the prevention of life-threatening infections which is frequently through partial or total calcanectomy during the18th and19th centuries into restoration of the functional outcomes as far as possible and reducing the long-term complications such as heel pain, lateral impingement syndrome and subtalar joint arthritis. Despite controversy related to optimal management of intraarticular fractures still persists, surgery treatment of the fractures has been accepted by most surgeons and has been improved greatly over the past20years because of the improvement of surgical techniques, the use of high-quality intraoperative imaging modalities to assess the quality of reduction, and effective preoperative management of soft tissue. Currently, numerous studies with large patient cohorts have demonstrated that surgery treatment predict higher functional outcomes and a lower incidence of posttraumatic subtalar arthritis.
The goal of operative treatment of calcaneal fractures is to obtain the best possible reduction of the articular surfaces, to restoration of heel height and length, restoration of mechanical axis of the hindfoot, and to hold the reduction with stable internal fixation. These goals must be balanced with the need to minimize the operative risks, especially the risk of wound healing complications. Operative management can consist of reduction through an extended open incision, lateral and medial approaches, limited incision or percutaneous techniques. The extended lateral approach with L-shaped incision has been the most frequently used operative technique as better visualization and reduction of fracture fragments. Besides, laterally based plate is commonly accepted to give the most rigid fixation. However,the prolonged operating time and extensive surgical wound exposure will significantly increase the incidence of wound complications. Folk reported25%of wound complications in his study, of which21%required surgical intervention. Therefore, a number of authors have proposed closed reduction, minimally invasive fixation, and various internal fixation devices to minimize soft tissue problems in the treatment of calcaneal fractures.
One controversial issue involving management decisions and outcome evaluation has been the inadequate classification systems available. For a fracture classification to be useful it must provide prognostic significance, interobserver reliability, and intraobserver reproducibility. Many classification systems have been advocated in the past, however, most studies have found reliability and reproducibility to be poor for fracture classification schemes. Many of these classifications are based on X ray-based evaluations of the fracture patterns, have given a poor exposure of the subtalar joints. With the introduction and development of the CT scan technique, classification methods based on the status of the intra-articular elements are now the most accepted. But, the CT scan cannot provide the overall condition of the calcaneal fracture. Thus, Professor Zhang Yingze proposed the concept of calcaneal bony destructive injuries according to the clinical features of the calcaneus which was so severely destroyed that it is impossible to reduce anatomically with surrounding soft tissue intact.
Our minimally invasive technique was proposed including small lateral incision, percutanous leverage, fixation using anatomic plate and compression bolts. Small lateral incision and percutanous leverage can minimize the soft tissue associated complications, fixation using anatomic plate and compression bolts can avoid the inadequate reduction of the medical wall and the poor restoration of the hell width. The study were to compare the biomechanical stability obtained using our technique and the conventional with an anatomic plate and cancellous screws in the fixation of cadavers calcaneal fractures, to compare the clinical outcomes of our surgical technique with traditional open reduction and internal fixation with anatomical plate and screws for displaced intra-articular calcaneal fractures, and a new concept of calcaneal bony destructive injuries was proposed and the preliminary outcomes of such injuries treated by an anatomic plate and compression bolts was present.
Part1A biomechanical comparison of conventional versus an anatomic plate and compression bolts for the fixation of intra-articular calcaneal fractures
Objective:The purpose of this study was to compare the biomechanical stability obtained using our technique featured an anatomical plate and compression bolts and the conventional with an anatomic plate and cancellous screws in the fixation of intraarticular calcaneal fractures.
Methods:Eighteen fresh frozen lower limbs cadavers were used to created a reproductive Sanders type-Ⅲ calcaneal fracture pattern with osteotomy. The calcaneus fractures were randomly selected to be fixed either using our anatomical plate and compression bolts or conventional anatomic plate and cancellous screws. Reduction of fracture was evaluated through X radiographs. Each calcaneus was successively loaded at a frequency of1HZ for1000cycles through the talus using an increasing axial force20N to200N and20N to700N, representing the partial weightbearing and full weightbearing respectively, and then the specimens were loaded to failure. Data extracted from the mechanical testing machine were recorded and used to test for difference in the results with the Wilcoxon signed rank test.
Results:No significant difference was detected between our fixation technique and conventional technique in displacement during20-200N cyclic loading (p=0.06), while the anatomical plate and compression bolts showed a great lower irreversible deformation during20-700N cyclic loading (p=0.008). The load achieved at loss of fixation of the constructs for the two groups were significant different:anatomic plate and compression bolts at3839.6±152.4N and anatomic plate and cancellous screws at3087.3±58.9N (p=0.008). The difference between the ultimate displacements was not significant (p=0.767).
Conclusion:Our technique featured anatomical plate and compression bolts for calcaneus fracture fixation was demonstrated to provide biomechanical stability as good as or better than the conventional with anatomic plate and cancellous screws under the axial loading. The study supports the mechanical viability of using our plate and compression bolts for the fixation of calcaneal fracture.
Part2A minimally invasive approach featured an anatomic plate and compression bolts to treat displaced intra-articular calcaneal fractures
Objective:Because of improvements in preoperative evaluation, the use of intraoperative imaging to verify the quality of reduction, and advancements in surgical techniques that include specialized hardware and soft tissue management, operative intervention has been shown to be effective at treating fractures of the calcaneus. The purpose of this paper was to compare the outcomes of our surgical technique featured an anatomic plate and compression bolts with traditional open reduction and internal fixation with AO plate and screws for displaced intra-articular calcaneal fractures
Methods:We retrospectively analyzed106patients (118feet,23female and83male) in our hospital for displaced intra-articular calcaneal fractures from January2007to April2010. Of them,64patients(71feet) were treated with an anatomic plate and multiple compression bolts through a small lateral incision (the compression group);42patients(47feet) were treated with traditional open reduction and internal fixation, which involved using AO anatomic plate and screws through standard L-shaped extended lateral approach (the tradition AO group). The operations were performed usually at5.4days (range, from1to16days) after the injury. The age, gender, mechanism of injury, pre-existing comorbidities, associated injuries, the Sanders type of fracture, and the length of stay were collected and analyzed. The average time of surgery, the Bohler angel, the quality of operation, and any postoperative complications were also analyzed and compared between the two groups. During following-up, radiographs of the calcaneus were made to assess whether the fixation had failed and whether the fracture had healed. The condition of the subtalar joint, pain and functional result were evaluated by using the American Orthopaedic Foot&Ankle Society (AOFAS) scores. Subsequent subtalar arthrodesis and early implant removal were performed if indicated. Routine hardware removal was scheduled for all patients at1year follow-up.
Results:all the patients were followed for an average of26months (range, twelve to fifty months). No significant differences between the two groups were detected with regard to the age at the time of the injury, gender, mechanism of injury, pre-existing comorbidities, associated injuries, the Sanders type of fracture, and the length of stay (p>0.05for all). There was no difference in the mean interval from the initial injury to definitive intervention between the two groups, but the operative time in the compression group was much shorter than the tradition AO groups (84±21.09mins versus104.26+25.33mins, p<0.05). Although the Bohler angels were improved greatly in both groups, no significant differences were detected between the compression group and the tradition AO group (26.6±5.6°versus28.1±+7.8°, p>0.05). Wound associated complications were7/71(9.86%) in the compression group, without deep infections, while12patients in the tradition AO group had wound associated complications and3cases had the hardware removed earlier due to deep infection. The average time after surgery to start weight-bearing exercise is4.66weeks in compression group and9.60weeks in tradition group (p<0.05). Posttraumatic arthritis was indentified in9patients of the compression group and7patients of the tradition AO group(p>0.05). The mean AOFAS score is higher in the compression group than in the tradition AO group, but the difference is not statistically significant (85.75±9.36versus84.29±9.51, p>0.05).
Conclusion:The study results suggest that the minimally invasive approach featured an anatomic plate and compression bolts to treat displaced intra-articular calcaneal fracture can equivalent functional outcome with, if not better than the open reduction and internal fixation with trational L-shaped lateral approach. It can reduce the soft tissue associated complications and specifically the rigid internal fixtion allows early weight-bearing exercise, which will improve the therapeutic effect. It is a good alternative to treat displaced intra-articular calcaneal fractures.
Part3Introduction of the concept of calcaneal bony destructive injuries and its treatment algorism with an anatomic plate and compression bolts
Objective:The purpose of this study is to introduce the concept of calcaneal bony destructive injuries, and present the preliminary results of such injuries treated by an anatomic plate and compression bolts, following by early exercise.
Methods:From April2004to October2006,12patients with calcaneal bony destructive injuries were identified and treated in our department. When the soft tissue swelling subsided, the patients were treated by internal fixation with an anatomic plate and three or four compression bolts. The reduction was achieved by percutaneous distraction and leverage. Postoperative radiographs were taken to assess the reduction. Supervised functional exercise began48hours after the operation. Progressively earlier weight-bearing commenced4weeks after surgery to mould the subtalar joint. Postoperative complications were collected. During following-up, the functional recovery was evaluated by using the American Orthopaedic Foot and Ankle Society (AOFAS) scores.
Results:Ten male and two female with an average of39years (range, from24to56years) were included in the study. According to Sander's classification, all patients were categorized as Type Ⅳ. There was an average of7.6days (range, from6to11days) before the operations were performed. The average operating time was78mins (range,56to93mins). The restoration of the height, length, width, normal outline of the calcaneus and the mechanical axis of the hindfoot were demonstrated on the radiographs. The postoperative Bohler angle of the affected calcaneus was24.5±3.7degrees. The reduction of the posterior facet was regarded as anatomical(less than3 mm displacement) in seven patients and more than3mm displacement was noted in the other five patients. Postoperative superficial infections occurred in one patient. All patients were followed up for an average of76months (range,66to87months). At the latest follow up, there was mild pain in two cases and moderate pain in one case after two-kilometer walking. However, no subtalar arthrodesis was required until the last follow up. The mean AOFAS score was82(range,65to94), and there were four of feet with excellent results, five with good results, two with fair results and one with poor result.
Conclusion:The concept of calcaneal bony destructive injuries was first proposed. The calcaneal bony destructive injuries are not an absolute indication of primary arthrodesis. Anatomic plate and compression bolts for the treatment of calcaneal bony destructive injuries in combination with early exercise to mould the subtalar joint is a reasonable treatment alternative.
跟骨骨折手术治疗可以通过外侧扩展切口、内侧切口、有限切口和经皮技术等显露和复位骨折。目前最常用的是外侧扩展的L形切口进行切开复位内固定,此入路的优点是能够直观显露距下关节,便于复位骨折片,同时侧方钢板和螺钉固定能够提供足够的强度。但是,跟骨关节内骨折行手术治疗的目的除了重建距下关节面、恢复跟骨的宽度和后足的力线、应用坚强固定以维持复位之外,还应当考虑治疗措施是否能够减少伤口并发症,尤其是伤口愈合并发症。而采用外侧扩展的L形切口进行切开复位内固定时,需要进行外侧壁广泛切开,剥离软组织范围较大,手术时间较长,增加了术后并发症发生风险。因此,为减少在跟骨骨折治疗中的软组织相关并发症,并提高骨折治疗的临床效果,各种闭合复位和微创治疗的手术方法以及不同设计的内固定器械被用于治疗跟骨骨折。
跟骨骨折分类系统为临床提供重要指导作用的关键在于该分类系统能否提供患者的预后信息、是否具有观察者之间的可靠性和观察者自身的可重复性。目前,涉及治疗决策制定和治疗效果评价的跟骨骨折分类系统仍不完善,成为跟骨骨折治疗争论的重点。既往临床医师主要根据X线平片进行骨折分类,近年来,随着CT影像技术的不断应用,根据骨折关节内损伤的要素进行分类的观点逐渐被认可并接受。但是,由于X线分型不能准确反映关节内骨折情况,而CT扫描分型不能获得跟骨整体的损伤情况。因此,张英泽教授根据跟骨严重粉碎骨折时,周围软组织完整但手术困难、不能解剖复位和预后差等临床特点,将跟骨严重粉碎骨折定义为跟骨骨性毁损伤,提出了跟骨骨性毁损伤的概念。
我院提出的解剖钢板和加压螺栓微创治疗技术,利用小切口、经皮撬拨复位以减少伤口愈合并发症。同时,采用加压螺栓代替拉力螺钉,以弥补螺钉不能有效复位跟骨内侧壁进而跟骨宽度恢复差的不足。本研究旨在分析比较解剖钢板和加压螺栓微创治疗技术与传统应用解剖钢板和螺钉切开复位内固定技术固定跟骨关节内骨折的生物力学稳定性,回顾性研究解剖钢板和加压螺栓与传统切开复位内固定治疗移位的跟骨关节内骨折的临床疗效,首次提出跟骨骨性毁损伤的概念及此类损伤经解剖钢板和加压螺栓治疗的临床效果。
第一部分解剖钢板和加压螺栓与传统解剖钢板和螺钉固定跟骨关节内骨折的生物力学比较
目的：在尸体标本上制作跟骨关节内骨折模型(Sander Ⅲ型),比较应用解剖钢板和加压螺栓固定与传统解剖钢板和螺钉固定跟骨关节内骨折的生物力学稳定性。
方法：新鲜冷冻下肢尸体融解后,使用摆锯在跟骨内侧载距突下1.5cm和2.5cm向距下关节纵行截骨,然后通过跟骨结节和跟骨后关节面中间冠状位截骨,制作可复制的跟骨关节内骨折模型(SandersⅢ型)。随机应用解剖钢板和加压螺栓固定或传统解剖钢板和螺钉固定跟骨骨折模型。固定完成后,通过X线摄片分别对骨折复位情况进行评估。每一个跟骨骨折模型分别通过距骨先后加载20-200N和20-700N的轴向载荷,两次加载的轴向载荷均循环1000个循环,频率为1赫兹,分别代表肢体部分负重和完全负重情况下跟骨所承受的压力,然后对样本加压至骨折固定失败。记录生物力学机上的数据并通过配对符号秩和检验来检验结果的差异。
结果：在20-200N的循环实验中,经传统解剖钢板和螺钉固定技术和解剖钢板和加压螺栓固定技术固定后,两组样本在轴向循环载荷下的骨折位移未发现明显统计学差异(P=0.06),而解剖钢板和加压螺栓固定的骨折模型在20-700N的循环载荷中发生的不可逆形变比传统解剖钢板和螺钉的更低(P=0.008)。两组固定结构能承受的使骨折固定失败的最大载荷明显不同(P=0.008)：解剖钢板和加压螺栓组为3839.6±152.4N,解剖钢板和螺钉组为3087.3±58.9N,而在最终载荷下两种固定结构的骨折最终位移没有显著差别(P=0.767)。
结论：在轴向循环载荷下,解剖钢板和加压螺栓固定技术能够提供比传统钢板和螺钉固定技术更好的生物力学稳定性。本研究从生物力学角度支持了解剖钢板和加压螺栓固定治疗跟骨关节内骨折的临床实用性。
第二部分解剖钢板和加压螺栓与传统解剖钢板和螺钉治疗跟骨关节内骨折的临床疗效比较
目的：随着手术技术的发展和术中影像学的成功运用,手术治疗跟骨关节内骨折已经逐渐为大家所接受。本文的研究目的是通过与传统的经标准外侧L切口AO解剖钢板和螺钉固定结果的比较,分析我院应用小切口微创解剖钢板和加压螺栓治疗跟骨关节内骨折的临床效果。
方法：对我院自2007年1月至2010年4月收治的106例(118足)跟骨关节内骨折患者的资料进行回顾性分析。其中男83例,女23例,年龄18-68岁,平均年龄44.57岁。左侧41例,右侧53例,双侧12例。根据sanders分型,Ⅱ型77例,Ⅲ型38例,Ⅳ型3例。其中,64例患者(71足)经小切口微创解剖钢板和加压螺栓治疗(加压螺栓组),42例患者(47足)经标准的外侧L形切口AO解剖钢板和螺钉治疗(传统AO组),伤后入院至手术时间1-16天,平均5.4天。收集并分析两组患者的年龄、性别、骨折的损伤原因、基础疾病情况、合并损伤、Sanders骨折分型、住院时间等情况。比较两组患者的围手术时间、手术时间、术后并发症、内固定情况、骨折愈合情况、Bohler角恢复程度。通过美国足与踝关节协会踝与后足功能评分来评估患者的疼痛及功能情况。如果患者需进行距下关节融合和早期植入物移除则进行相应的手术干预和处理。所有的患者常规随访1年后进行固定物移除。
结果：106例患者术后获12-50个月(平均26个月)随访。两组患者的年龄、性别、损伤原因、Sanders骨折分型、基础疾病、住院时间等临床基本特征比较,均无统计学差异。加压螺栓组与传统AO组围手术期时间分别为5.62±2.7天和5.20±3.11天,差别无统计学意义,但加压螺栓组固定的手术时间明显低于传统AO组,分别为84±21分钟和104±25分钟,差异具有统计学意义。传统AO组和加压螺栓组术后Bohler角均明显改善恢复,两组术后平均Bohler角分别恢复为28.1±7.8度和26.6±5.6度,差别无统计学意义。术后随访,所有骨折均愈合,加压螺栓组患者平均术后4.66周早期部分负重,而传统AO组患者平均部分负重时间为术后9.60周,两组差异具有统计学意义。加压螺栓组7例患者发生术后伤口相关并发症,发生率为7/71(9.86%),但未发生深部感染。传统AO组12例患者发生软组织并发症,其中2例发展为深部感染,1例伤口皮缘坏死较重,由于并发症不得不将内固定物移除,但没有骨髓炎的表现。加压螺栓组9例患者存在距下关节炎的影像学表现,其中6例患者存在轻度疼痛,2例患者存在中度疼痛,而1例患者虽疼痛严重但拒绝进行距下关节融合治疗。传统AO组7例患者存在距下关节炎的影像学表现,其中3例患者存在轻度疼痛,2例伴有中度疼痛,2例有严重疼痛而进行了距下关节融合治疗。经美国足踝矫形协会AOFAS评分,加压螺拴组和传统AO组AOFAS平均评分分别为85.75±9.36分和84.29±9.51分,差异无统计学意义。
结论：解剖钢板和加压螺栓小切口微创治疗跟骨关节内骨折能够减少手术相关并发症,坚强的内固定有助于患者早期负重活动,能够获得良好的治疗效果。解剖钢板和加压螺栓固定技术是治疗跟骨关节内骨折的不错选择。
第三部分跟骨骨性毁损伤概念的提出及经微创解剖钢板和加压螺栓固定治疗
目的：提出跟骨骨性毁损伤的概念,观察应用解剖钢板及加压螺栓微创固定并结合早期功能锻炼治疗跟骨骨性毁损伤的临床效果。
方法：对2004年4月至2006年10月收治的12例单侧跟骨关节内严重粉碎骨折的患者进行回顾性分析,所有患者均在软组织肿胀消退后,利用经皮撬拨复位及侧方挤压、采取小切口微创入路,解剖钢板及加压螺栓进行加压内固定治疗。术后48小时即进行主动功能锻炼,4周逐渐负重活动以磨造距下关节面。利用美国足踝矫形外科AOFAS评分标准进行评定患者术后的功能恢复情况。
结果：12例患者中,男10例,女2例,年龄24-56岁,平均年龄39岁。所有患者根据Sander分型均为Ⅳ型。患者损伤后平均7.6天(6-11天)进行手术,平均时间78分钟(56-93分钟)。术后,X线检查显示跟骨的高度、长度、宽度及跟骨的外形和后足的力线轴基本得到恢复,Bohler角恢复至24.5±3.7度。其中,7例复位后关节面移位小于3mm,其余5例移位大于3mm。另外,12例患者中仅1例发生伤口浅表感染。同时,术后所有患者均获得随访,平均随访76个月(66-87个月)。随访的结果显示：经2公里徒步行走后,2例存在轻度疼痛,1例存在中度疼痛,但所有患者均没有行距下关节融合术要求。经美国足踝矫形外科AOFAS评分标准进行评估,平均82分(65-94分),4例功能恢复优,5例恢复良,2例效果中,1例效果差。
结论：首次提出跟骨骨性毁损伤的概念。跟骨骨性毁损伤不是距下关节融合的绝对适应症。应用小切口微创,解剖钢板及加压螺栓进行加压固定、进行早期功能锻炼治疗跟骨骨性毁损伤是一个合理、有效的治疗选择。
Calcaneal fractures are the most frequent tarsal bone fracture and represent2%of all adult fractures. About75%of all calcaneal fractures in adults are displaced intra-articular fractures involving the subtalar joint. There have been dramatic changes in management protocols as our understanding of the fracture has evolved. The primary goal of fracture treatment has changed from the prevention of life-threatening infections which is frequently through partial or total calcanectomy during the18th and19th centuries into restoration of the functional outcomes as far as possible and reducing the long-term complications such as heel pain, lateral impingement syndrome and subtalar joint arthritis. Despite controversy related to optimal management of intraarticular fractures still persists, surgery treatment of the fractures has been accepted by most surgeons and has been improved greatly over the past20years because of the improvement of surgical techniques, the use of high-quality intraoperative imaging modalities to assess the quality of reduction, and effective preoperative management of soft tissue. Currently, numerous studies with large patient cohorts have demonstrated that surgery treatment predict higher functional outcomes and a lower incidence of posttraumatic subtalar arthritis.
The goal of operative treatment of calcaneal fractures is to obtain the best possible reduction of the articular surfaces, to restoration of heel height and length, restoration of mechanical axis of the hindfoot, and to hold the reduction with stable internal fixation. These goals must be balanced with the need to minimize the operative risks, especially the risk of wound healing complications. Operative management can consist of reduction through an extended open incision, lateral and medial approaches, limited incision or percutaneous techniques. The extended lateral approach with L-shaped incision has been the most frequently used operative technique as better visualization and reduction of fracture fragments. Besides, laterally based plate is commonly accepted to give the most rigid fixation. However,the prolonged operating time and extensive surgical wound exposure will significantly increase the incidence of wound complications. Folk reported25%of wound complications in his study, of which21%required surgical intervention. Therefore, a number of authors have proposed closed reduction, minimally invasive fixation, and various internal fixation devices to minimize soft tissue problems in the treatment of calcaneal fractures.
One controversial issue involving management decisions and outcome evaluation has been the inadequate classification systems available. For a fracture classification to be useful it must provide prognostic significance, interobserver reliability, and intraobserver reproducibility. Many classification systems have been advocated in the past, however, most studies have found reliability and reproducibility to be poor for fracture classification schemes. Many of these classifications are based on X ray-based evaluations of the fracture patterns, have given a poor exposure of the subtalar joints. With the introduction and development of the CT scan technique, classification methods based on the status of the intra-articular elements are now the most accepted. But, the CT scan cannot provide the overall condition of the calcaneal fracture. Thus, Professor Zhang Yingze proposed the concept of calcaneal bony destructive injuries according to the clinical features of the calcaneus which was so severely destroyed that it is impossible to reduce anatomically with surrounding soft tissue intact.
Our minimally invasive technique was proposed including small lateral incision, percutanous leverage, fixation using anatomic plate and compression bolts. Small lateral incision and percutanous leverage can minimize the soft tissue associated complications, fixation using anatomic plate and compression bolts can avoid the inadequate reduction of the medical wall and the poor restoration of the hell width. The study were to compare the biomechanical stability obtained using our technique and the conventional with an anatomic plate and cancellous screws in the fixation of cadavers calcaneal fractures, to compare the clinical outcomes of our surgical technique with traditional open reduction and internal fixation with anatomical plate and screws for displaced intra-articular calcaneal fractures, and a new concept of calcaneal bony destructive injuries was proposed and the preliminary outcomes of such injuries treated by an anatomic plate and compression bolts was present.
Part1A biomechanical comparison of conventional versus an anatomic plate and compression bolts for the fixation of intra-articular calcaneal fractures
Objective:The purpose of this study was to compare the biomechanical stability obtained using our technique featured an anatomical plate and compression bolts and the conventional with an anatomic plate and cancellous screws in the fixation of intraarticular calcaneal fractures.
Methods:Eighteen fresh frozen lower limbs cadavers were used to created a reproductive Sanders type-Ⅲ calcaneal fracture pattern with osteotomy. The calcaneus fractures were randomly selected to be fixed either using our anatomical plate and compression bolts or conventional anatomic plate and cancellous screws. Reduction of fracture was evaluated through X radiographs. Each calcaneus was successively loaded at a frequency of1HZ for1000cycles through the talus using an increasing axial force20N to200N and20N to700N, representing the partial weightbearing and full weightbearing respectively, and then the specimens were loaded to failure. Data extracted from the mechanical testing machine were recorded and used to test for difference in the results with the Wilcoxon signed rank test.
Results:No significant difference was detected between our fixation technique and conventional technique in displacement during20-200N cyclic loading (p=0.06), while the anatomical plate and compression bolts showed a great lower irreversible deformation during20-700N cyclic loading (p=0.008). The load achieved at loss of fixation of the constructs for the two groups were significant different:anatomic plate and compression bolts at3839.6±152.4N and anatomic plate and cancellous screws at3087.3±58.9N (p=0.008). The difference between the ultimate displacements was not significant (p=0.767).
Conclusion:Our technique featured anatomical plate and compression bolts for calcaneus fracture fixation was demonstrated to provide biomechanical stability as good as or better than the conventional with anatomic plate and cancellous screws under the axial loading. The study supports the mechanical viability of using our plate and compression bolts for the fixation of calcaneal fracture.
Part2A minimally invasive approach featured an anatomic plate and compression bolts to treat displaced intra-articular calcaneal fractures
Objective:Because of improvements in preoperative evaluation, the use of intraoperative imaging to verify the quality of reduction, and advancements in surgical techniques that include specialized hardware and soft tissue management, operative intervention has been shown to be effective at treating fractures of the calcaneus. The purpose of this paper was to compare the outcomes of our surgical technique featured an anatomic plate and compression bolts with traditional open reduction and internal fixation with AO plate and screws for displaced intra-articular calcaneal fractures
Methods:We retrospectively analyzed106patients (118feet,23female and83male) in our hospital for displaced intra-articular calcaneal fractures from January2007to April2010. Of them,64patients(71feet) were treated with an anatomic plate and multiple compression bolts through a small lateral incision (the compression group);42patients(47feet) were treated with traditional open reduction and internal fixation, which involved using AO anatomic plate and screws through standard L-shaped extended lateral approach (the tradition AO group). The operations were performed usually at5.4days (range, from1to16days) after the injury. The age, gender, mechanism of injury, pre-existing comorbidities, associated injuries, the Sanders type of fracture, and the length of stay were collected and analyzed. The average time of surgery, the Bohler angel, the quality of operation, and any postoperative complications were also analyzed and compared between the two groups. During following-up, radiographs of the calcaneus were made to assess whether the fixation had failed and whether the fracture had healed. The condition of the subtalar joint, pain and functional result were evaluated by using the American Orthopaedic Foot&Ankle Society (AOFAS) scores. Subsequent subtalar arthrodesis and early implant removal were performed if indicated. Routine hardware removal was scheduled for all patients at1year follow-up.
Results:all the patients were followed for an average of26months (range, twelve to fifty months). No significant differences between the two groups were detected with regard to the age at the time of the injury, gender, mechanism of injury, pre-existing comorbidities, associated injuries, the Sanders type of fracture, and the length of stay (p>0.05for all). There was no difference in the mean interval from the initial injury to definitive intervention between the two groups, but the operative time in the compression group was much shorter than the tradition AO groups (84±21.09mins versus104.26+25.33mins, p<0.05). Although the Bohler angels were improved greatly in both groups, no significant differences were detected between the compression group and the tradition AO group (26.6±5.6°versus28.1±+7.8°, p>0.05). Wound associated complications were7/71(9.86%) in the compression group, without deep infections, while12patients in the tradition AO group had wound associated complications and3cases had the hardware removed earlier due to deep infection. The average time after surgery to start weight-bearing exercise is4.66weeks in compression group and9.60weeks in tradition group (p<0.05). Posttraumatic arthritis was indentified in9patients of the compression group and7patients of the tradition AO group(p>0.05). The mean AOFAS score is higher in the compression group than in the tradition AO group, but the difference is not statistically significant (85.75±9.36versus84.29±9.51, p>0.05).
Conclusion:The study results suggest that the minimally invasive approach featured an anatomic plate and compression bolts to treat displaced intra-articular calcaneal fracture can equivalent functional outcome with, if not better than the open reduction and internal fixation with trational L-shaped lateral approach. It can reduce the soft tissue associated complications and specifically the rigid internal fixtion allows early weight-bearing exercise, which will improve the therapeutic effect. It is a good alternative to treat displaced intra-articular calcaneal fractures.
Part3Introduction of the concept of calcaneal bony destructive injuries and its treatment algorism with an anatomic plate and compression bolts
Objective:The purpose of this study is to introduce the concept of calcaneal bony destructive injuries, and present the preliminary results of such injuries treated by an anatomic plate and compression bolts, following by early exercise.
Methods:From April2004to October2006,12patients with calcaneal bony destructive injuries were identified and treated in our department. When the soft tissue swelling subsided, the patients were treated by internal fixation with an anatomic plate and three or four compression bolts. The reduction was achieved by percutaneous distraction and leverage. Postoperative radiographs were taken to assess the reduction. Supervised functional exercise began48hours after the operation. Progressively earlier weight-bearing commenced4weeks after surgery to mould the subtalar joint. Postoperative complications were collected. During following-up, the functional recovery was evaluated by using the American Orthopaedic Foot and Ankle Society (AOFAS) scores.
Results:Ten male and two female with an average of39years (range, from24to56years) were included in the study. According to Sander's classification, all patients were categorized as Type Ⅳ. There was an average of7.6days (range, from6to11days) before the operations were performed. The average operating time was78mins (range,56to93mins). The restoration of the height, length, width, normal outline of the calcaneus and the mechanical axis of the hindfoot were demonstrated on the radiographs. The postoperative Bohler angle of the affected calcaneus was24.5±3.7degrees. The reduction of the posterior facet was regarded as anatomical(less than3 mm displacement) in seven patients and more than3mm displacement was noted in the other five patients. Postoperative superficial infections occurred in one patient. All patients were followed up for an average of76months (range,66to87months). At the latest follow up, there was mild pain in two cases and moderate pain in one case after two-kilometer walking. However, no subtalar arthrodesis was required until the last follow up. The mean AOFAS score was82(range,65to94), and there were four of feet with excellent results, five with good results, two with fair results and one with poor result.
Conclusion:The concept of calcaneal bony destructive injuries was first proposed. The calcaneal bony destructive injuries are not an absolute indication of primary arthrodesis. Anatomic plate and compression bolts for the treatment of calcaneal bony destructive injuries in combination with early exercise to mould the subtalar joint is a reasonable treatment alternative.
引文
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