跟骨骨折

跟骨骨折是最常见的跗骨骨折，多因从高处跌下所致。其合适的骨折分型、治疗选择、手术指征、手术入路和术后处理仍存在争议。跟骨骨折分为关节外骨折和关节内骨折。sanders的分型方法对跟骨骨折治疗方法的选择及预后的判断有重要意义。跟骨骨折的治疗具有挑战性，目前尚无理想的治疗方法，有待于进一步深入研究。保守治疗适合于移位小的骨折，对于移位大或粉碎的骨折可应用手术治疗。跟骨骨折的并发症有张力性水疱，筋膜间隙综合征，伤口裂开，伤口感染，疼痛，距跟关节炎等。本文对跟骨骨折的损伤机制、分型、评分、治疗方法及并发症等作一综述。     

跟骨骨折治疗进展

跟骨骨折是最为常见的跗骨骨折。非手术治疗主要用于无移位或移位较小的跟骨骨折及一些有手术禁忌证患者，关节融合术主要用于SandersⅥ型或粉碎性跟骨骨折，切开复位内固定术应用最为广泛，主要用于移位较大的关节外骨折和SandersⅡ、Ⅲ型及部分Ⅵ型骨折。手术疗效得到肯定的同时，软组织并发症问题备受关注。近年微创手术如外固定术、撬拔复位内固定术、经皮螺钉内固定术、关节镜手术及跟骨成形术等，均已取得较好的临床疗效。该文就跟骨骨折治疗研究进展作一综述。     

跟骨关节内骨折分型与治疗进展

跟骨关节内骨折是较复杂的骨折之一,其分型和治疗方法存在争议.目前临床常采用Sanders分型,对无明显移位者及全身情况较差而不能耐受手术者采用保守治疗,对有移位或粉碎性关节内骨折者大多采用手术治疗.手术治疗易发生切口边缘坏死、感染等并发症.微创技术已得到初步发展.     

跟骨关节内骨折的诊断与治疗

跟骨骨折是跗骨中最常见的骨折,约75%的跟骨骨折为关节内骨折。虽然跟骨骨折的治疗经验日益增多,但对其诊断和处理仍存在争论,包括最合适的分类方法、治疗方法的选择、手术治疗的指征、手术入路及术后处理等。本文对跟骨关节内骨折的诊断和治疗进行综述。对于有移位的跟骨关节内骨折,手术疗效优于保守治疗。     

移位的关节内粉碎跟骨骨折的内固定治疗

目的探讨移位的关节内跟骨骨折的内固定治疗方法。方法对1997年2月-2004年2月通过手术治疗有移位的关节内跟骨骨折43例53足进行分析。按Sanders分型对移位的关节内跟骨骨折切开复位，AO跟骨钢板内固定。结果43例患者全部获得随访，平均随访18．3(2—41)个月，按Maryland Foot Score进行评分，优11足(20．8％)，良35足(66％)，可4足(7．5％)，不满意3足(5．7％)。结论通过手术治疗有移位的关节内跟骨骨折，能最大限度地恢复跟骨的解剖形态、关节面的平整，恢复跟骨Boehler角，矫正跟骨宽度及内翻畸形。术后辅助合理的功能锻炼，能使足的功能得到良好的恢复。     

跟骨钢板治疗复杂跟骨骨折疗效分析

目的探讨波及跟距关节等复杂跟骨骨折手术治疗的方法和疗效。方法采用经外侧入路跟骨钢板治疗跟骨骨折24例(28足),观察术后切口愈合情况及随访术后患者关节功能恢复情况。结果 24例患者均获得7～24个月随访,maryland足部评分标准评价:优17足,良8足,可3足,优良率89.2%。结论对于波及距下关节的移位跟骨骨折,选择合适的手术时机,积极的手术治疗可以获得满意的治疗效果。     

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.     

AO跟骨钢板在跟骨关节内骨折中的应用

目的探讨应用AO跟骨钢板治疗跟骨关节内骨折的疗效以及分析手术并发症发生的原因及对策。方法对46例54足累及距下关节的跟骨骨折采用切开复位AO跟骨钢板内固定伴必要时自体髂骨植骨治疗。结果42例经8~38个月随访,患者均获得骨性愈合。采用Maryland足部评分标准评价手术效果,优良率达86%。结论AO跟骨钢板结合自体髂骨植骨治疗跟骨关节内骨折固定可靠,可早期功能锻炼,是目前一种治疗有移位跟骨关节内骨折的较好方法。通过选择适当的手术时机,术中注意操作细节,解剖复位以及植骨钢板内固定等措施可减少手术并发症的发生。     

切开复位内固定结合羟基磷灰石人工骨植入术治疗跟骨关节内骨折移位

粉碎性跟骨骨折的治疗仍然是一个难题，非手术治疗的结果常令人不满意。一些作者报道了切开复位、AO钢板内固定治疗跟骨骨折关节内骨折并移位取得成功，然而，对Sanders Ⅳ型骨折是否采用切开复位有争议，同时，对切开复位内固定术是否采用植骨术也存在不同意见，自2001年3月～2004年3月，共收治12例跟骨骨折并行手术治疗，本文旨在进一步探讨跟骨关节内骨折并移位的手术治疗及植骨术的适应证。     

移位跟骨关节内骨折的手术治疗

涉及跟距关节的移位跟骨骨折的治疗,目前仍是创伤骨科的一个棘手问题,若治疗不当,常遗留足的畸形和距下关节炎等严重后遗症,而影响正常的行走.近年来,随着对跟骨骨折的解剖特点、生物力学和损伤机制的深入研究,以及内固定材料的发展和手术技能的提高,对移位的跟骨关节内骨折目前国内外学者多主张积极的手术治疗以减少后期并发症[1].笔者自1998年3月至2002年1月,采取切开复位内固定治疗有移位的跟骨关节内骨折26例,疗效满意.现报告如下.     

Displaced intra-articular calcaneal fractures

BACKGROUND: Calcaneal fractures comprise 1 to 2 percent of all fractures. Approximately 75% of calcaneal fractures are intra-articular. The management of intra-articular calcaneal fractures remains controversial. Nonoperative treatment options include elevation, ice, early mobilization, and cyclic compression of the plantar arch. Operative treatment options include closed reduction and percutaneous pin fixation, open reduction and internal fixation, and arthrodesis. The effect of operative versus nonoperative treatment has been the focus of several comparative studies. OBJECTIVE: This study was designed to determine the effect of operative treatment compared with nonoperative treatment on the rate of union, complications, and functional outcome after intra-articular calcaneal fracture in adults.     

Kalkaneusfrakturen

The diagnosis and therapy of calcaneal fractures are reviewed with details of anatomy and biomechanics, fracture pathology, radiographic and computer tomographic evaluation, and the classification systems in current use. Operative and conservative treatment options are highlighted with reference to the indications for each and the techniques and postoperative therapy required, the possible complications, and the revision procedures for their correction.     

Calcaneal fractures: Where are we now?

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the “constant fragment” in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures?     

Managing the open calcaneal fracture: A systematic review

IntroductionOpen fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm.Material and methodsA literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions.ResultsA total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8 days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points.ConclusionThe complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database.     

Demographics of extra-articular calcaneal fractures: including a review of the literature on treatment and outcome

Introduction  Extra-articular calcaneal fractures represent 25–40% of all calcaneal fractures and an even higher percentage of up to 60% is seen in children. A disproportionately small part of the literature on calcaneal fractures involves the extra-articular type. The aim of this study was to investigate the incidence of extra-articular calcaneal fractures in a Level 1 trauma centre, define the distribution of the various types of fractures and compare patient demographics between extra- and intra-articular calcaneal fractures. In addition the literature was reviewed for the most common types of extra-articular calcaneal fractures with regard to incidence, treatment and clinical outcome. Methods  The radiological records between 2003 and 2005 were reviewed for intra- and extra-articular calcaneal fractures. Patient gender-distribution and age were compared. A literature search was conducted for the treatment of extra-articular calcaneal fractures. Results  In this 3-year study period a total of 49 patients with 50 extra-articular calcaneal fractures and 91 patients with 101 intra-articular fractures were identified. The median age for the first group was 32.7 years, and for the second group 40.3 years; P = 0.04. Male predominance was significantly less pronounced for extra-articular (63%) compared with intra-articular fractures (79%; P = 0.04). Conclusion  One-third of all calcaneal fractures are extra-articular. Significant differences exist between the intra- and extra-articular groups, in terms of lower age and male–female ratio. The literature study shows inconsistencies in treatment options, but most extra-articular fractures are well manageable conservatively.     

开放性跟骨骨折治疗效果评价

根据现有的六项病例报告评价开放性跟骨骨折的治疗效果证据不足.其中两项研究对随访2～10年的病例按Gustilo评分对创伤程度和功能恢复情况评价为一般或差,在这两项研究中,严重的软组织损伤处理后的并发症影响了骨折治疗.在所有研究中,感染是常见的并发症,即使大部分患者慢性感染最终得到了治愈,但是仍有部分患者接受了截肢术治疗.现有的研究证据不足以说明何种治疗方法最佳,因此,应通过大样本对照研究来分析何种治疗方法更合适该骨折.     

Avulsionsfraktur der Tuberositas calcanei bei Athleten

Avulsion fractures of the calcaneal tuberosity are rare injuries. Several surgical treatment options have been described. The size of the calcaneal fragment is the limiting factor in choosing the method for restoration. Finding the right type of fixation modality remains challenging in this rare kind of injury. In the case presented one Mitek Super Anchor was used to reattach the small fragment of the tuberosity to the calcaneus. Stable fixation with bony reunion and excellent functional outcome were achieved by this technique within 10 weeks. Therefore, we recommend the use of an anchor system for the treatment of small fragment calcaneal avulsion fractures.     

Grouping of intraarticular calcaneal fractures relative to treatment options

None of the classifications of intraarticular calcaneal fractures are comprehensive enough to accommodate all types of fractures. Of the 150 intraarticular calcaneal fractures, 37 could not be placed in the commonly used Sanders classification. These then were grouped according to where their primary fracture line was located in relation to the posterior calcaneal facet. Twenty-three fractures were anteromedial to the facet; 75% of these were of the tongue type and were amenable to being treated with the Essex-Lopresti method of reduction and placement of two screws. The joint depression type in this group required open reduction and internal fixation through the lateral approach. Eight fractures were located posterolateral to the facet. They were treated from the lateral or the medial approach. Six fractures crossed the facet transversely; these were treated percutaneously with placement of two lag screws. Clinically this grouping was helpful because it provided a guideline to appropriate treatment strategies for fractures that could not be accommodated in the Sanders classification.