Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach

Purpose

Post-operative wound infections (PWI) following calcaneal fracture surgery can lead to prolonged hospital stay and additional treatment with antibiotics, surgical debridement or implant removal. Our aim was to determine the incidence of superficial and deep PWI and to identify risk factors (RF).

Methods

This study is a retrospective case series. All consecutive patients from 2000 to 2010 with a closed unilateral calcaneal fracture treated with open reduction and internal fixation (ORIF) by an extended lateral approach were included. Patient, fracture, trauma and peri-operative characteristics were collected, including RF such as smoking, diabetes mellitus, time to operation, pre-operative in- or outpatient management and wound closure technique. The primary end point was a PWI as defined by the US Centers for Disease Control and Prevention.

Results

A total of 191 patients were included of which 47 patients (24.6 %) had a PWI; 21 (11.0 %) and 26 (13.6 %) patients had a superficial and deep wound infection, respectively. American Society of Anesthesiologists (ASA) classification higher than ASA 1 was associated with an increased risk. Placement of a closed suction drain at the end of surgery was associated with less PWI (35 % vs 15 %, p = 0.002). In this study, none of the previously reported RF were associated with an increased risk for PWI.

Conclusions

ORIF of displaced calcaneal fractures is associated with a high rate of PWI of 25 %. Factors that were associated with an increased risk were ASA classification other than 1 and absence of a closed suction drain placement. A closed suction drain may be a protective measure to avoid wound complications.     

拉应力对体外培养人足跟皮肤成纤维细胞增殖影响的实验研究

目的：观察拉应力对人足跟外倒皮肤成纤维细胞增殖的影响,为预防跟骨骨折术后切口边缘皮肤坏死、切口不愈合提供一定的理论依据.方法：取40岁男性足跟外侧皮肤成纤维细胞培养及传代后,分Oh组、6h组、24 h组进行拉应力加载试验,检测培养液中TGF-β1、IL-6含量,使用透射电镜、光镜观察线粒体、细胞核的变化.结果：在10％的拉应力下,成纤维细胞随着承受应力的时间增加,线粒体逐渐减少,TGF-β1和IL-6的分泌受到抑制,细胞增殖逐渐受到抑制.结论：人足跟外侧皮肤长时间处于拉应力状态是跟骨骨折手术后切口边缘皮肤坏死、切口不愈合的重要原因.     

载距突螺钉导向器在跟骨载距突螺钉置钉中的应用

背景：跟骨关节内骨折手术治疗时准确置入载距突螺钉可获得最佳固定效果。但由于跟骨复杂的解剖特点和术中有限的X线透视效果,完成载距突螺钉的准确置钉工作难度极大。而准确置入载距突螺钉的方法仍存较大争议。目的：探讨跟骨关节内骨折手术治疗时使用跟骨载距突螺钉导向器辅助载距突螺钉的准确置钉效果。方法方法：回顾性分析2010年7月至2013年12月手术治疗的42例（48足）跟骨关节内骨折病例,男35例,女7例;年龄15-67岁,平均38.9岁。根据Sanders分型：Ⅱ型22足,Ⅲ型19足,Ⅳ型7足。所有手术均采用跟骨外侧入路,术中使用跟骨载距突螺钉导向器辅助置入跟骨载距突螺钉。术后复查X线与CT,验证螺钉置入载距突的准确性。结果：42例患者术后随访7-28个月,平均17.4个月。按美国足踝外科协会Maryland足部功能评分标准进行功能评定：优21足,良19足,可8足,差0足;术后Maryland足部评分平均为87.8分,优良率83.3%。共置入53枚载距突螺钉。1枚螺钉从跟骨后关节面内下方露出部分螺纹,1枚螺钉从载距突前方穿出,1枚螺钉穿出载距突关节面进入距跟中关节,1枚螺钉远端一半螺纹在载距突下方露出,余49枚螺钉位于载距突内;螺钉置入精确率为92.5%（49/53）。结论：跟骨载距突螺钉导向器能辅助术者从跟骨外侧入路准确完成载距突螺钉置钉。     

螺旋CT在跟骨关节内骨折各关节面受累诊断中的应用研究

目的：通过螺旋CT多平面及表面重建来探讨跟骨骨折的特征及其在跟骨各关节面骨折诊断中的临床应用价值。材料与方法：经CR或临床检查可疑或确诊跟骨骨折的患者，应用Light SpeedQ／iGE4层扫描机进行检查，对35例47侧跟骨关节内骨折行多平面及表面重建。对骨折进行分型，同时分析各关节面受累情况。结果：跟骨结节位扫描是显示各关节受累总数最多的一种方法（95／101），在准确显示后关节骨折（46／47）与轴位（39／47）间有统计学差别。冠状位重建是显示距下中（14／14）、后（47，47）关节面受累的较佳方法，但11侧（11／47）骨折后关节面压缩及旋转移位在冠状位上没有被准确的反映出来，而在矢状重建中则准确的被显示。约60％的患者未发现独立的前关节。跟骰关节的骨折在轴位（32／32）、结节位（32／32）得到较准确的显示。三维重建是观察骨折整体空间改变的一种方法。结论：螺旋CT重建在跟骨各关节面骨折诊断中具有很高的临床价值。     

益气温肾汤联合鲑降钙素注射液治疗跟骨骨折术后骨萎缩临床研究

目的 评价益气温肾汤联合鲑降钙素注射液治疗跟骨骨折患者术后骨萎缩的临床疗效.方法 将符合入选标准的120例跟骨骨折术后骨萎缩患者采用随机数字表法分为2组,每组60例.对照组在常规对症处理基础上皮下注射鲑降钙素注射液,联合组在对照组基础上加用益气温肾汤治疗.2组均连续治疗6周.采用双能X线骨密度检测仪检测患侧肢体局部骨密度值,采用踝与后足功能评分评价踝关节功能的恢复情况,观察并记录患者治疗前后临床症状、体征的变化,评价临床疗效.结果 治疗后,联合组疼痛[(2.8±1.1)分比(3.6±1.1)分,t=4.129]、压痛[(1.0±0.5)分比(1.4±0.7)分,t=3.297]、肤色改变[(1.5±0.8)分比(2.0±0.6)分,t=3.117]评分低于对照组(P<0.05),肿胀程度[(112.5±11.8)cm3比(122.5±13.6)cm3,t=3.816]低于对照组(P<0.05)、骨密度值[(0.762±0.020)g/cm2比(0.722±0.023)g/cm2,t=3.803]高于对照组(P<0.05).联合组愈显率为90.0%(54/60)、对照组为70.0%(42/60),2组比较差异有统计学意义(χ2=7.500,P=0.006).联合组踝关节功能优良率为83.3%(50/60)、对照组为70.0%(42/60),2组比较差异有统计学意义(χ2=4.444,P=0.035).结论 益气温肾汤联合皮下注射鲑降钙素注射液可缓解跟骨骨折术后骨萎缩患者的疼痛、肿胀等症状、改善骨密度、促进骨折愈合,有利于患者骨折康复及踝关节功能的恢复.