外侧小切口空心螺钉内固定治疗关节面移位的跟骨骨折

目的:观察外侧小切口复位内固定治疗关节面移位的跟骨骨折的疗效.方法:自2006年1月至2009年9月30例(31足)关节面移位的跟骨骨折,其中男23例,女7例;年龄18～60岁,平均36.5岁.SandersⅡ型21足,Ⅲ型8足,Ⅳ型2足.采用腓骨尖至第4足跖骨基底的外侧直切口显露,复位后空心螺钉内固定.结果:30例31足全部获得随访,时间3～24个月,平均14个月.31足术后无切口感染、皮肤坏死或切口愈合不良、腓肠神经损伤等软组织并发症.25足术后X线片示关节面复位良好、跟骨外形恢复满意,6足关节面、跟骨外形基本恢复正常.据Maryland评分标准,优6足,良20足,可5足.结论:跟骨外侧微创小切口空心钉内固定对软组织损伤小,并发症少,关节面显露清晰,适用于SandersⅡ、Ⅲ型,是治疗关节面移位的跟骨骨折一种较好选择.     

跟骨关节内移位骨折微创手术治疗临床疗效分析

目的探讨微创手术治疗跟骨关节内移位骨折的临床疗效。方法自2009-03－2010-10,采用小切口置入跟骨解剖钢板加压螺栓内固定治疗106例（131足）跟骨关节内骨折,其中SandersⅡ型59足,Ⅲ型57足,Ⅳ型15足。术后根据X线片和CT评估骨折复位质量,应用AOFAS评分标准评估患足功能恢复。116足经后足外侧纵形入路治疗,14足行跗骨窦入路。1例SandersⅣ型骨折同时行外侧纵形人路和跗骨窦人路治疗。结果本组手术时间平均83（60～135）min。Bohler角术前平均-1．7°,术后平均29°。骨折复位质量良好者达96．2％。术后24个月84例（95足）获得随访,患足功能恢复优34足,良47足,可11足,差3足,优良率85．3％。结论应用解剖接骨板加压螺栓系统微创内固定治疗跟骨关节内骨折可获得满意疗效。     

Management of displaced intra-articular calcaneal fractures using the limited open sinus tarsi approach and fixation by screws only technique

Purpose

Evaluation of management of the displaced intra-articular calcaneal fractures (DIACF) Sanders types II and III by using minimally invasive sinus tarsi approach and fixation by screws only technique.

Methods

Open reduction using the limited lateral approach and internal fixation using screws only was studied in 33 patients with unilateral isolated simple DIACF with a mean age of 35 years (15 type II patients and 18 type III patients). All patients were evaluated both clinically and radiologically.

Results

With a mean follow-up period of 28.8 months (range 12–53 months), no cases of failure of reduction or displacement of hardware were detected. The mean AOFAS was 91.73 points while the mean MFS was 95.09 points. Twenty-eight patients were able to resume their pre-injury level of work while the remaining five refrained to sedentary jobs. The mean pre-operative Bohlers’ angle was 2.8° (range from -38º to 24º) while postoperatively it was 19.4° (range 5º to 49º). There was no statistically significant difference when comparing the results (AOFAS p-value 1.00, MFS p-value 0.81) between Sanders’ type II and III fractures. One patient had postoperative superficial wound infection. Seven patients complained of prominent screw heads. Complex regional pain syndrome occurred in seven patients and was treated successfully at six months duration.

Conclusion

The limited open sinus tarsi approach can be used successfully to treat displaced Sanders type II and III fractures. It allows for adequate visualization and reduction. Fixation by screws only is also sufficient. It also clearly avoids the major wound complication problems.     

纵行及跗骨窦入路治疗跟骨关节内骨折的比较研究

 目的 比较纵行及跗骨窦微创入路治疗跟骨关节内骨折的临床疗效。方法 回顾性分析2010年4月至2010年9月分别使用纵行及跗骨窦微创入路治疗并获随访的93例跟骨关节内骨折患者资料。按手术入路将患者分为两组：纵行微创入路组(A组)50例(51足),男47例,女3例;平均年龄38.22岁;Sanders Ⅱ型27足,Ⅲ型18足,Ⅳ型6足;术前B?hler角平均-1.1°。跗骨窦微创入路组(B组)43例(45足),男42例,女1例;平均年龄41.40岁;Sanders Ⅱ型23足,Ⅲ型17足,Ⅳ型5足;术前B?hler角平均2.6°。两组患者在年龄、性别、Sanders分型等方面无统计学差异。比较两组患者手术时间、并发症和美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分差异。结果 A、B两组患者随访时间分别为平均28.2个月和27.6个月。A组平均手术时间、切口相关并发症发生率及AOFAS踝与后足评分分别为40.78 min、3.92%(2/51)、85.96分,B组分别为60.67 min、8.89%(4/45)、88.60分。A组手术时间较B组更短,两组切口相关并发症发生率及术后AOFAS评分无差异。结论 纵行微创入路与跗骨窦微创入路治疗跟骨关节内骨折疗效无明显差异,但纵行微创入路手术时间更短、并发症少,是治疗跟骨骨折的良好选择。     

Percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures: Systematic review and surgical technique

BackgroundThe aim of this study was to systematically evaluate the available literature on technique and outcomes of percutaneous arthroscopic calcaneal osteosynthesis for displaced intra-articular calcaneal fractures.MethodsA systematic review of the literature available in MEDLINE, EMBASE, and the Cochrane Library database was performed, including studies from January 1985 to august 2018. The literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. The surgical technique and perioperative management, clinical outcomes scores, radiographic outcomes and complication rate were evaluated.ResultsOf 66 reviewed articles, 8 studies met the inclusion criteria. The included studies reported on the results of 152 patients. At last follow up the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot was ranging from 72.1 to 94.1. The complication rate was low, including only one superficial infection.ConclusionsThe studies included were of too little level of evidence to allow for data pooling or meta-analysis. However, the percutaneous arthroscopic calcaneal osteosynthesis seems to be a good option for displaced intra-articular calcaneal fractures with a low complication rate. Appropriately powered randomized controlled trials with long-term follow up are needed to confirm the efficacy of this technique.Level of evidenceLevel III, systematic review of Level III studies.     

微创锁定板内固定治疗跟骨关节内骨折

目的 总结和评价采用跗骨窦有限切口切开复位锁定板内固定治疗跟骨关节内骨折的技术及临床效果. 方法 2010年2月至2011年2月共微创治疗16例跟骨关节内骨折患者,男10例,女6例;年龄24～56岁,平均40.3岁.术前常规摄片、CT扫描确定骨折类型和关节面受累情况.于伤后平均4 d(3～6 d)行经跗骨窦有限切口切开复位结合锁定板及经皮螺钉固定.术后患者定期复查X线片,测量B(o)hler角和Gissane角,并采用疼痛视觉模拟量表(VAS)、美国足踝外科协会(AOFAS)踝与后足评分系统及简明健康状况调查表(SF-36)综合评估治疗效果,同时记录相关并发症的发生情况. 结果 13例患者术后获12 ～24个月(平均18个月)随访.获随访患者术后均无切口感染、内固定失败等并发症发生.X线片显示平均术后10周(8～12周)骨折获愈合.末次随访时B(o)hler角从术前平均13.4°±3 4°改善至26.5°±4.5°,差异有统计学意义(t=9.781,P＜0.001);Gissane角从术前平均88.1°±7.6°善至116.2°±7.5°,差异有统计学意义(t=12.934,P＜0.001).末次随访时13例患者平均疼痛VAS评分为(1.5±1.7)分,平均AOFAS踝与后足评分为(84.2±5.9)分,平均SF-36评分为(79.5±8.1)分.所有患者随访期间未出现创伤性关节炎. 结论 经跗骨窦有限切口切开复位锁定板微创内固定治疗相对简单的跟骨关节内骨折,在获得关节面直接复位及稳定固定的同时,还可避免和减少软组织并发症,是一种安全、可靠的技术.     

后关节面移位的跟骨骨折的手术治疗

目的探讨后关节面移位的跟骨骨折手术治疗的相关问题。方法2003年1月～2006年1月，26例33足后关节面移位的跟骨骨折，经可延长的外侧“L”形入路行切开复位异形钢板内固定治疗。Essex—Lopresti分类：舌形骨折18足，关节压缩骨折15足；Sanders分类：Ⅱ型骨折21足，Ⅲ型骨折12足。13例合并身体其他部位骨折。骨折后平均8．3d（4～15d）接受手术。结果所有患者获得8～44个月（平均24．3个月）随访，切口均愈合良好，无皮瓣坏死及局部感染，骨折复位满意。按Maryland足部评分标准评价手术效果：优18足，良10足，中4足，差1足，优良率84．8％。结论经跟骨外侧“L”形入路的切开复位内固定技术是一种值得信赖的治疗移位跟骨骨折的方法。     

An introduction to the minimally invasive osteosynthesis of intra-articular calcaneal fractures

The approach to the treatment of intra-articular calcaneal fractures has often been the subject of discussion. The results achieved with both operative and non-operative management remain to some extent unpredictable. Minimally invasive osteosynthesis offers an alternative approach, especially in those cases in which open reduction would be hazardous and non-operative treatment inadequate. This technique requires minimal dissection and preserves subtalar motion almost completely. The authors believe that displaced intra-articular calcaneal fractures are best treated through operative intervention. Restoration of articular congruity is an integral, though not necessarily sufficient, component of a successful long-term outcome following calcaneal fracture. The extra-articular dimensions of the calcaneus must be restored in order to tolerate standard shoe-wear, maintain a functional range of talocalcaneal motion and avoid subsequent tibiotalar arthrosis. However, in certain circumstances open reduction may be associated with an unacceptably high complication rate. In these cases, the authors have found a "minimally invasive" osteosynthesis technique useful in dealing with competing goals. In our experience, this technique can, when used appropriately, result in a functional recovery of the patient suffering a calcaneal fracture.     

Percutaneous treatment of displaced intra-articular calcaneal fractures

Background The outcome after displaced intra-articular calcaneal fractures is influenced by the condition of the surrounding soft tissues. To avoid secondary soft tissue complications after surgical treatment, several less-invasive procedures for reduction and fixation have been introduced. The percutaneous technique according to Forgon and Zadravecz is suitable for all types of displaced intra-articular calcaneal fractures and was therefore introduced in our clinic. The aim of this study was to evaluate the long-term outcome of percutaneous treatment according to Forgon and Zadravecz in patients with displaced intra-articular calcaneal fractures. Methods A cohort of patients with displaced intra-articular calcaneal fractures treated with percutaneous surgery was retrospectively defined. Clinical outcome was evaluated by standardized physical examination, radiographs, three published outcome scores, and a visual analogue scale of patient satisfaction. Results Fifty patients with 61 calcaneal fractures were included. After a mean follow-up period of 35 months, the mean values of the Maryland foot score, the Creighton-Nebraska score, and the American Orthopaedic Foot and Ankle Society score were 79, 76, and 83 points out of 100, respectively. The average visual analogue scale was 7.2 points out of 10. The average range of motion of the ankle joint was 90% of normal and subtalar joint movements were almost 70% compared with the healthy side or normal values. Superficial wound complications occurred in seven cases (11%) and deep infections in two (3%). A secondary arthrodesis of the subtalar joint was performed in five patients and was scheduled in four patients (15%). Conclusions Compared with the outcome of historic controls from randomized trials and meta-analyses, this study indicates favorable results for the percutaneous technique compared with the open technique. Despite similar rates of postoperative infection and secondary arthrodesis, the total outcome scores and preserved subtalar motion are overall good to excellent.     

切开复位内固定治疗移位的跟骨关节内骨折

目的探讨切开复位可塑跟骨钢板内固定治疗移位的跟骨关节内骨折的疗效。方法对76例（82足）复杂跟骨关节内骨折行切开复位可塑跟骨钢板内固定治疗,其中39足予自体髂骨植骨。结果76例均获随访,时间12-35（22.3±3.7）个月。B hler角术前9.3°±3.2°,术后恢复到26.7°±6.8°;Gissane角术前101.6°±13.3°,术后恢复到120.1°±14.2°。根据Maryland足部评分系统：优39足,良31足,可8足,差4足。结论切开复位可塑跟骨钢板内固定治疗复杂的跟骨关节内骨折,固定牢固,能早期功能锻炼,可减少并发症。     

切开复位内固定治疗移位的跟骨关节内骨折的疗效分析

目的 评定切开复位内固定治疗移位的跟骨关节内骨折的疗效,并分析其影响因素.方法 回顾性分析2004年3月至2006年7月收治的采用切开复位内固定治疗的移位跟骨关节内骨折40例(46足).按照Sanders分型:Ⅱ型16足,Ⅲ型19足,Ⅳ型11足,总结评定其临床疗效并分析影响疗效的相关因素. 结果 所有患者均得到随访,平均随访18个月(13～28个月).根据Maryland足部评分系统评价术后疗效:优21足,良16足,可6足,差3足,优良率82.6%.优良率在不同骨折类型中分别为:Ⅱ型93.8%(15/16),Ⅲ型84.2%(16/19),1V型54.5%(6/11);伤后至手术时间≤14 d组和＞14d组分别为87.2%(34/38)和42.9%(3/8);在术后B0hler角＜15°组和≥15°组分别为37.5%(2/9)和89.5%(35/37);关节面复位质量≤2 mm组和＞2 mm组分别为91.2%(32/33)和45.5%(5/13).对各因素的优良率比较,差异有统计学意义(P＜0.05). 结论 切开复位内固定治疗移位的跟骨关节内骨折,治疗效果好.骨折类型、伤后至手术时间、术后Bohler角的恢复程度、关节内骨折的复位质量为影响其术后疗效的重要因素.     

Outcomes of management of displaced intra-articular calcaneal fractures

Despite the advances in operative management, displaced intra-articular calcaneal fractures (DIAFCs) are often associated with long term sequelae, permanent disability, a considerable reduction in quality of life, and a high socio-economic cost. Randomized controlled trials have shown that patient reported outcomes of surgery are no better than those of nonoperative management. Methodological flaws and selection bias may have influenced the results, however, and subgroup analysis showed that some patients could benefit from surgery, whilst patients’ preference can be the decisive factor in choosing a management modality. Fractures with significant lateral wall displacement predisposing to impingements often require surgery, and management has to be individualized and tailored to the patient. Surgery does not usually achieve excellent results, though it exposes the patient to potential risks and complications. Wound healing problems and infections affect around 20% of patients when the extensile lateral approach has been used. Sinus tarsi approach and minimally invasive surgery may be viable alternatives, offering similar results with fewer wound complications, but most of the available studies are of low to moderate quality. Late subtalar joint arthrodesis is often required: however, such procedure would be less technically difficult and could result in better foot function should the shape of the calcaneus have been anatomically restored with surgery in the acute phase.     

Surgical treatment of displaced intraarticular calcaneal fractures by a minimally invasive technique using a locking nail: A preliminary study

BackgroundThe aim of this retrospective study was to evaluate the outcome of patients with intra-articular calcaneal fractures treated using a minimally invasive locking nail (Calcanail^®).MethodsBetween January 2016 and April 2017, 15 patients (9 men and 6 women) with a calcaneal fracture were consecutively treated with Calcanail^®. The Böhler angle was recorded on standard X-rays pre- and post-operatively. The articular reduction of the posterior facet was evaluated with the Goldzak index in a CT scan 3 months post-operatively. The mean age of the patients was 53 years (range, 24–78). Mean final follow-up was 18 months (range, 12–24).ResultsSix fractures were classified as Sanders II, 7 as Sanders III and 2 as Sanders IV. In 13 out of the 15 patients treated, the post-operative Böhler angle was of more than 20°. Goldzak index was deemed as excellent in 73.5% of the cases (11 patients), good in 20% of cases (3 patients), and poor in 6.5% (1 patient). Post-operative mean AOFAS score was 85 (range, 60–96).ConclusionsThe Calcanail^® provides good restoration of the subtalar joint and the calcaneal angles with the advantages of a minimally invasive approach. It was effectively used in Sanders types II and III, even in the presence of poor cutaneous conditions.     

Timax钛合金跟骨钢板治疗移位的关节内跟骨骨折

目的 探讨切开复位、Timax钛合金跟骨钢板内固定治疗移位的关节内跟骨骨折的疗效.方法 对37例(45足)波及距下关节面的移位性跟骨骨折进行切开复位、Timax钛合金跟骨钢板内固定治疗.结果 37例获12～29(15.4±4.11)个月随访,术后3个月骨折均完全愈合,未发生伤口感染、钢板外露等并发症,3足出现表皮坏死.按照Maryland足部评分标准:优23足,良16足,中4足,差2足,优良率达86.7%.结论 波及距下关节的移位性跟骨骨折采用Timax钛合金跟骨钢板治疗,可有效恢复跟骨解剖位,显著减少手术并发症的发生率,降低病残率.     

Subjective results after surgical treatment for displaced intra-articular calcaneal fractures

We present a retrospective study investigating the results of the subjective assessment of displaced intra-articular calcaneal fractures in a selected cohort of 42 patients treated operatively, with a follow-up duration of at least 3 years. The adjusted American Orthopaedic Foot and Ankle Society questionnaire, Foot Function Index, and visual analog scale were used to quantify the subjective evaluations. Our hypothesis was that good subjective results could be predicted and obtained in patients with specific characteristics if anatomic reduction of the fracture was achieved. The results of the study confirmed our hypothesis. A number of specific subgroup analyses were undertaken. The study confirmed that Böhler angle restoration and the quality of reduction of the subtalar joint facet are important prognostic factors related to the outcome. In contrast, gender and Sanders type had less influence at the intermediate-term follow-up results. The main weaknesses of the present study included its retrospective nature, the lack of a control group managed nonoperatively for comparison, and the small sample size. Moreover, the operating surgeon performed the radiographic measurement and categorized the quality of the surgical reconstruction.     

移位跟骨关节内骨折手术方法的进展与选择

<正>跟骨骨折是临床较为常见的后足损伤,多为高处坠落所致,占全身骨折的1%～2%^[1],占足踝部骨折的60%,分为关节内骨折和关节外骨折,其中75%为关节内骨折^[2]。目前研究表明,移位的关节内骨折手术治疗是适当的,虽然文献中关于跟骨骨折的最佳治疗方法存在许多争议,但毫无疑问的是,成功的关节复位和重建正常的跟骨结构对良好的临床疗效至关重要^[3]。     

Outcome evaluation of minimally invasive surgery versus extensile lateral approach in management of displaced intra-articular calcaneal fractures: A randomised control trial

BackgroundMinimally invasive surgery has a significant and evolving role in the treatment of DIACFs, but there is limited literature on this topic.ObjectivesTo compare the clinico-radiological outcomes of DIACFs fixed with MIS technique with ORIF.MethodsThis randomised control trial (RCT) included 21 closed Sanders type 2 and 3 DIACFs which were selected from 70 who presented. Extensile lateral approach was used in the ORIF group; while MIS techniques included either percutaneous reduction or small incisions with indirect fragment manipulation.Main Outcome MeasurementAOFAS hindfoot score, pre-operative and postoperative radiology.ResultsThere were 9 fractures in the Extensile group and 12 in the MIS group, with both groups having comparable demography, fracture classification, surgery delay & initial radiology. Bohler′s angle improved after surgery by an average of 18.44 with ORIF and 14.67 with MIS (p = 0.28). Mean AOFAS in the MIS group was 82.58 (66.67% good and 33.33% fair) and was 89.56 (44.44% excellent, 55.56% good, 0 fair/poor) with ORIF (p = 0.034). Two patients who underwent ORIF had a major complication (one deep infection and Sural nerve injury each) while none in the MIS group.ConclusionsMIS methods minimized soft tissue complications and achieved comparable radiological reductions but clinical outcomes were poorer, with percutaneous methods having the worst outcomes.     

Prospective randomized trial comparing open reduction and internal fixation with minimally invasive reduction and percutaneous fixation in managing displaced intra-articular calcaneal fractures

Purpose

Managing displaced intra-articular calcaneal fractures remains controversial. A prospective randomised trial was undertaken to compare open reduction and internal fixation (ORIF) with minimally invasive reduction and percutaneous fixation (MIRPF).

Methods

Forty-five displaced intra-articular calcaneal fractures were randomised to undergo either ORIF (n?=?23) or MIRPF (n?=?22). Patients were followed up clinically and radiologically for a minimum of one year postoperatively. The primary outcome measure was wound-healing complication. Functional outcome was assessed using Creighton Nebraska Health Foundation (CNF) scale, and radiological outcome was assessed using plain radiographs and computed tomography (CT) scans.

Results

Of the 23 heels in the ORIF group, seven (30%) had wound-healing problems, compared with none in the MIRPF group (p?=?0.005). There was no statistically significant difference in radiological outcomes between groups, as measured by Böhler’s angle, Gissane’s angle and Score Analysis of Verona (SAVE). Median time to return to work was two weeks earlier (p?=?0.004), and the functional outcome score (CNF scale) at one year of follow-up was better (p?=?0.013) following MIRPF compared with ORIF.

Conclusion

MIRPF is associated with fewer wound-healing problems, better functional outcome and earlier return to work compared with ORIF.     

经跗骨窦入路跟骨锁定钢板外固定治疗跟骨关节内骨折

目的：探讨经跗骨窦入路、跟骨锁定钢板外固定治疗跟骨关节内骨折临床疗效。方法：自2011年7月至2012年8月,采用经跗骨窦入路小切口切开复位、跟骨锁定钢板置于皮外固定治疗跟骨关节内骨折12例（13足）,其中男10例,女2例;年龄25～48岁,平均35岁。骨折根据Sanders分型：Ⅱ型7足,Ⅲ型6足。比较手术前后跟骨Bohler角、Gissane角,并按照Maryland足部评分系统对疗效进行评价。结果：12例均获得随访,时间6-14个月,平均10个月。术后无切口皮肤并发症;骨折愈合时间3～6个月,平均4个月。BiJhler角由术前（11．19±5．69）°提高至术后（30．13±7．52）°：Gissane角由术前（108．31±10．35）°提高至术后（118．99±8．94）°。按照Maryland足部评分系统：优8足,良3足,可2足。结论：经跗骨窦入路、跟骨锁定钢板外固定治疗跟骨关节内骨折,复位效果确切,固定牢固,可早期手术,手术损伤小,并发症少,是治疗SandersII、III型跟骨关节内骨折的一种有效方法。