内侧入路切开复位内固定治疗跟骨单纯载距突骨折

 目的　探讨内侧入路切开复位内固定治疗跟骨载距突骨折的临床疗效。方法　回顾性分析2006年9月至2011年3月采用内侧入路切开复位空心拉力螺钉或克氏针内固定治疗23例跟骨单纯载距突骨折患者资料,男19例,女4例;年龄17～41岁,平均26.3岁;右侧14例,左侧9例。伴随损伤：合并距骨骨折4例,跖骨骨折4例,骰骨骨折3例。其中17例载距突骨块移位 ＞1 mm,6例骨折线累及中距下关节面。采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分标准对手术前后足部功能进行评估。结果　跟骨载距突骨折均固定可靠,骨折临床愈合时间8～10周,平均8.5周。15例患者获得随访,随访时间10～56个月,平均20.5个月。末次随访时AOFAS踝与后足评分80～100分,其中优2例,良13例,优良率为100%(15/15)。3例患者恢复行走时有轻微一过性疼痛症状出现,经热敷等理疗后症状消失;无一例患者发生伤口感染、骨不连、长屈肌腱腱鞘炎、跗管综合征等严重并发症。结论　采用内侧入路切开复位内固定治疗移位超过1 mm或骨折线累及中距下关节面的单纯跟骨载距突骨折术后疗效满意。     

载距突的解剖学研究及其在跟骨关节内移位骨折手术中的应用

目的 通过研究跟骨载距突本身及其与周围组织的解剖学关系来设计内固定的最佳位置和角度. 方法①测量正常跟骨的以下指标:载距突的前倾角、跟骨后关节面前部的前倾角、跟骨中部最大宽度、载距突基底部厚度,②观察跟骨内部结构,⑧研究载距突及其周围结构解剖学,④观察跟骨中部螺钉模拟内固定及测量相关角度,⑤随访观察27例经外侧入路切开复位内固定治疗的跟骨关节内移位骨折患者的效果. 结果载距突的前倾角、跟骨后关节面前部的前倾角、跟骨中部最大宽度、载距突基底部最大及最小厚度分别是50°±5°、69°±5°、(41.75±1.76)mm、(12.14±1.60)mm、(4.81±1.07)mm;载距突中关节面下方的骨小梁结构致密,并且与跟骨后关节面下方的致密骨小梁相连续;载距突与走行于其内侧的肌腱血管关系密切;在冠状面上测量自后关节面到载距突的三个进针点打入克氏针的最佳进针方向分别是:最低点向上25°±5°、最高点向下3°±3°、中点向上13°±3°;根据以上测量值进行手术,无患者出现复位或内固定失败的情况,疗效按照美国足踝外科协会后足评分系统评分,优良率为88.9%. 结论载距突是跟骨关节内移位骨折手术时螺钉置入的理想位置,应根据跟骨中部的横径选择螺钉的长度,根据载距突基底部的最小径选择螺钉的直径,根据载距突与后关节面的相互关系决定螺钉的进钉方向,可以获得满意的临床疗效.     

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。     

跗骨窦入路空心钉固定术治疗SandersⅡ型跟骨骨折

背景:微创治疗跟骨骨折渐成趋势,通过跗骨窦入路空心螺钉内固定治疗SandersⅡ型跟骨骨折的方法和疗效值得探讨。目的:探讨跗骨窦入路空心螺钉内固定治疗跟骨SandersⅡ型骨折的手术方法和临床疗效。方法:采用跗骨窦入路经载距突空心螺钉内固定治疗35例跟骨骨折患者,男21例,女14例;年龄23~58岁,平均(45.4±6.9)岁;左侧23例,右侧12例;骨折按Sanders分型:ⅡA型17例,ⅡB型18例。测量记录患者术前术后B?hler角和Gissane角,观察关节面的恢复情况。按照美国足踝外科协会Maryland足部评分标准评价足部功能恢复效果。结果:本组患者均获得随访,随访时间6~12个月,平均(9.5±1.9)个月。骨折均愈合,愈合时间8~12周,平均(9.8±1.5)周。无切口并发症发生。B?hler角术前平均15.2°±2.6°,术后平均30.7°±3.2°;Gissane角术前平均95.9°±4.0°,术后平均125.2°±11.6°,手术前后比较差异均有统计学意义(P<0.05)。按Maryland足部评分系统进行功能评定:优24例,良9例,可2例,优良率为94.3%。结论:跗骨窦入路经载距突空心螺钉内固定治疗跟骨SandersⅡ型骨折,组织剥离少,可以很好地恢复跟距关节面平整,跟骨的宽度、B?hler角及Gissane角均得到良好的恢复,值得临床推广应用。     

经皮空心钉内固定治疗距骨颈骨折

目的 探讨经皮空心钉内固定治疗距骨颈骨折的疗效.方法 对2005年5月至2009年5月收治的12例距骨颈骨折患者资料进行回顾性分析,其中男7例,女5例;年龄26～48岁,平均37岁;骨折根据Hawkins分型:Ⅰ型5例,Ⅱ型5例,Ⅲ型2例.均予直径为3.5 mm空心钉经距骨后路行经皮内固定术. 结果 所有患者术后获14 ～37个月(平均20.5个月)随访.骨折临床愈合时间10 ～ 22个月,平均16个月.无退钉、断钉现象,无畸形愈合和骨不连发生.根据美国足踝外科协会(AOFAS)踝-后足评分系统评定:优7例,良4例,一般l例.结论 经皮空心钉内固定治疗距骨颈骨折,既保护了距骨的血运,同时也达到了牢固固定的目的,不失为一种较好的治疗措施.     

关节镜辅助下钢板内固定治疗关节内跟骨骨折

[目的]探讨分析关节镜辅助下钢板内固定治疗关节内跟骨骨折的方法和疗效;[方法]对78位患者，86例累及关节面的跟骨骨折在关节镜辅助下行切开复位钢板内固定术，术后平均随访18个月（12～30个月），通过比较术前术后X线片和踝足功能的AOFAS评分对治疗效果作分析评价．[结果]86例关节内跟骨骨折术后X线示复位满意．与术前存在显著性差异（P〈0．01），AOFAS评分优良率91．86％．[结论]对于关节内跟骨骨折，采用关节镜辅助钢板内固定更加接近解剖复位，足部功能恢复满意且并发症少     

自制骨科导向复位钳在载距突螺钉置入应用

[目的]介绍跟骨关节内骨折手术治疗时使用自制骨科导向复位钳辅助载距突螺钉手术技术的初步疗效。[方法] 2016年1月～2019年8月开放复位内固定治疗跟骨关节内骨折41例(43足)。所有手术均采用跗骨窦与跟骨后外侧联合切口,术中使用自制骨科导向复位钳辅助置入跟骨载距突螺钉。[结果] 41例患者均顺利手术,切口均I期愈合,无感染和皮缘坏死及不愈合发生。末次随访时Maryland足功能评分(89.09±5.37)分,术后CT扫描显示2枚载距突螺钉部分螺纹自距下关节中关节面穿出;1例自载距突前侧穿出,准确率为93.02%(40/43)。与术前相比,术后CT间隙显著减少,而贝氏角和盖氏角显著增加(P0.05)。[结论]骨科导向复位钳能辅助术者准确完成载距突螺钉置钉,并可减少冠状面骨折间隙。     

内侧入路微型钢板固定治疗单纯跟骨载距突骨折

目的:探讨内侧入路微型钢板固定治疗单纯跟骨载距突骨折的手术方法及疗效。方法:采用跟骨内侧入路切开复位微型钢板固定治疗单纯跟骨载距突骨折7例,术后随访根据并发症、骨折愈合时间、内固定情况及AOFAS踝与后足评分进行疗效评价。结果:本组7例切口均一期愈合,无皮肤坏死。未并发深部感染及血管神经损伤。术后随访12~47个月,平均21.3个月;骨折临床愈合时间8~12周,平均9.5周;末次随访AOFAS踝与后足评分(89.5±4.6),其中优4例,良3例;未见骨折复位丢失及内固定松动、断裂。结论:应用跟骨内侧入路切开复位微型钢板固定治疗跟骨载距突骨折,具有复位操作简单、内固定可靠、并发症低等优点,是治疗单纯跟骨载距突骨折的理想手术方式。     

载距突螺钉固定术治疗Sanders Ⅱ型和Ⅲ型跟骨骨折

目的:探讨载距突螺钉固定术治疗SandersⅡ、Ⅲ型跟骨骨折的临床疗效.方法:2010年1月至2012年10月行切开复位内固定治疗跟骨骨折38例38足.根据Sanders分类,Ⅱ型15足,Ⅲ型23足.按固定方式不同分为两组:载距突固定组18例,男13例,女5例,年龄25～55岁,平均(38.56±8.03)岁,每例均有1枚螺钉拧入载距突;载距突未固定组20例,男16例,女4例,年龄29～53岁,平均(42.35±8.29)岁,螺钉未拧入载距突.通过两组术前、术后影像学指标的变化及术后Maryland足评分、VAS评分比较疗效.结果:38例均获随访,时间12～20个月,平均14个月.两组术后均恢复了B(o)hler角,重建了距下关节.术后1年Maryland足评分,载距突固定组平均88.61±7.59,载距突未固定组平均82.40±9.24,载距突固定组评分高于未固定组,足功能恢复更好.术后1年VAS评分,载距突固定组平均13.39±11.47,载距突未固定组平均22.50±13.10,载距突固定组术后VAS评分更低,足痛更少.结论:使用载距突螺钉固定术治疗SandersⅡ、Ⅲ型跟骨骨折,固定强度大,稳定性高,术后疼痛少,功能恢复更好.     

撬拨复位空心钉内固定治疗SandersⅡ型跟骨骨折

目的:探讨采用平乐正骨筋骨互用平衡论指导撬拨复位空心钉内固定治疗SandersⅡ型跟骨骨折的临床疗效。方法:自2014年10月至2017年12月,采用平乐正骨筋骨互用平衡论指导撬拨复位空心钉内固定治疗SandersⅡ型跟骨骨折患者28例,均为单足,其中男20例,女8例;年龄24～55(37.2±3.9)岁。手术前后测量跟骨宽度、Bohler角、Gissane角的变化情况,术前及术后6个月采用Maryland足部评分对其功能进行评价。结果:28例患者获得随访,时间12～16(13.7±1.3)个月。所有骨折获得愈合,愈合时间9～12(10.2±1.3)周,术后无切口感染、皮缘坏死及骨髓炎发生。跟骨宽度由术前的(34.15±2.58) mm降至术后的(30.49±2.37) mm(P0.05),Bohler角由术前的(14.16±3.27)°增加至术后的(31.95±3.07)°(P0.05),Gissane角由术前的(128.45±9.04)。降至术后的(120.83±8.15)°(P0.05)。Maryland足部评分由术前的(15.68±4.73)分提高至术后6个月的(88.32±2.65)分,其中优19例,良6例,可2例,差1例。结论:平乐正骨筋骨互用平衡论指导撬拨复位空心钉内固定治疗SandersⅡ型跟骨骨折临床疗效确切,患者接受程度高,且对骨折周围软组织条件无特殊要求。但须注意避免选择粉碎严重的SandersⅢ、Ⅳ型跟骨骨折。     

Sanders Ⅱ型跟骨骨折螺钉微创治疗的有限元优化分析

目的:探讨Sanders Ⅱ型跟骨骨折微创治疗时螺钉不同固定方式后的生物力学特点.方法:将CT 扫描后的跟骨Dicom 数据输入Mimics 21.0 软件及Ansys 15.0 软件中构建跟骨三维有限元数字模型;将此模型导入UG NX 10.0 软件中,根据Sanders 分型切割跟骨,建立后关节面塌陷的Sander...     

Fractures of the sustentaculum tali

Objective

Anatomical reconstruction of displaced sustentaculum tali fractures via a direct medial approach.

Indications

Displaced fractures of the sustentaculum tali with incongruity or depression of the medial facet of the subtalar joint, entrapment of the flexor hallucis longus or flexor digitorum longus tendons, fracture line extending into the posterior facet of the subtalar joint.

Contraindications

Infected or grossly contaminated soft tissue, severely restricted vascular supply to the foot, high perioperative risk.

Surgical technique

Direct medial approach over the sustentaculum tali, retraction of the tendons, joint exploration, fracture reduction using the medial facet and cortical outline as guidelines, fracture fixation with two small fragment screws from medial to lateral directed slightly plantarly and posteriorly. Fractures with depression of the medial facet as a whole can alternatively be reduced and fixed percutaneously.

Postoperative management

Lower leg splint for 5–7 days, partial weight-bearing with 20 kg for 6–8 weeks (until radiographic signs of consolidation) in the patient’s own shoewear, early range of motion exercises of the ankle, subtalar and mid-tarsal joints.

Results

Over a course of 15 years, 31 patients were treated operatively for sustentacular fractures. In all, 27 patients (87?%) had additional fractures to the same foot and ankle. Eighteen patients with a mean age of 41 years treated at our institution with screw fixation for a unilateral fracture of the sustentaculum tali could be followed for a mean of 80 months (range 15–151 months). No wound healing problems or infections were seen with the medial approach. At the time of follow-up, 15 sustentaculum tali fractures had an average Foot Function Index of 21.6 and an average AOFAS Ankle–Hindfoot Score of 83.6. Patients with isolated fractures of the sustentaculum tali had significantly better scores than those with additional injuries. In 1 patient, an additional lateral process fracture of the talus required subtalar fusion due to persistent pain. Care must be taken not to overlook these atypical calcaneal fractures and accompanying injuries to the mid-tarsal joint and the lateral talar process as seen in 45% and 23%, respectively, in the present series.     

Isolierte Fraktur des Sustentaculum tali: ein Fallbericht

Case reportA 32 years old male patient slipped while going downhill and injured his right foot. The next day X-rays were taken in which no bony injury was seen. Because of persistent complaints additional diagnostic by MRI and CT were performed. These showed a displaced fracture of the sustentaculum tali. The sustentaculum tali was fixed with screws. The fracture healed with a congruent articular surface and good functional outcome.ConclusionFractures of the sustentaculum tali are rare and are overseen frequently because of overlapping structures on X-rays. Even low energy trauma can cause these fractures in young patients. In patients with persistent complaints of the foot an additional cross-sectional diagnostic is strongly recommended.     

载距突螺钉内固定治疗SandersⅡ型跟骨骨折的生物力学研究

 目的 探讨载距突螺钉内固定在SandersⅡ型跟骨骨折治疗中的作用及必要性。方法 将跟骨CT扫描后的Dicom数据输入Mimics 12.0软件及Ansys 13.0软件中构建跟骨三维有限元数字模型。而后,将此模型导入Solidworks 2010软件中,根据Sanders分型切割跟骨,建立SandersⅡ型跟骨骨折模型。将AO跟骨钢板及螺钉的几何参数输入Solidworks 2010软件中,在跟骨模型的基础上建立两种内固定模拟,一种为钢板放于跟骨外侧面,在钢板后关节面下方2枚螺钉孔、钢板后方2枚螺钉孔、钢板下方1枚螺钉孔、钢板前方2枚螺钉孔分别垂直跟骨打入松质骨螺钉;另一种为在前一种固定方式的基础上再在钢板后关节面最下方螺钉孔向载距突打入1枚皮质骨螺钉。在相同条件下分别对两种内固定模型加载,行非线性有限元分析,分别计算两种内固定模型的应力分布情况。结果 在相同条件的加载下两种内固定跟骨模型的最大主应力均集中于载距突皮质骨,载距突螺钉内固定模型在骨缝间位移值、跟骨最大主应力值、钢板螺钉内固定系统的最大主应力值方面均较无载距突螺钉内固定模型小,且应力更分散。结论 载距突螺钉内固定治疗跟骨骨折符合生物力学稳定性,可很好地用于临床。     

Morphology of sustentaculum tali: Biomechanical importance and correlation with angular dimensions of the talus

Summary of background data

The talus and the calcaneus share the bulk of load transmitted from the leg to the skeleton of the foot. The present study analyses the inter-relationship between the superior articular surface and the angular dimensions of the talus with the morphology of the sustentaculum tali.

Objective

Identification of possible relationships between different angular parameters of the talus morphology and the sustentaculum tali in context of load transmission through the foot.

Methods

One articular surface and three angular parameters at the junction of the head and the body were measured from dried human talar bones. Corresponding calcaneal samples were measured for four dimensions at the sustentaculum tali. Correlation and regression statistical values between parameters were worked out and analysed.

Results

Several parameters within the talus demonstrated significant correlations amongst themselves. The neck vertical angle showed a strong correlation with the articulating surface area below the head of the talus.

Conclusions

The inter-relationship between articular and angular parameters within the talus demonstrates strong correlation for certain parameters. Data presented in the study may be helpful to adjust calcaneal and talar screw placement techniques, prosthesis designing and bio-mechanical studies at this important region.     

Percutaneous reduction and screw fixation of fracture neck talus

BackgroundFracture neck talus is a rare fracture represents about 1% of all fractures and usually due to high energy trauma. These fractures are usually associated with compromised soft tissues, concomitant skeletal fractures, or life threatening injuries. Talus has a tenuous blood supply which is affected by fracture displacement. Urgent fracture reduction ± fracture fixation is mandatory. The associated injuries may make the conventional open reduction and internal fixation is impossible to be done in urgent base as it may impacts the already tenuous blood supply of talus increasing the risk of AVN and non union. Percutaneous fracture reduction and fixation can overcome this problem, and decrease complications associated with conventional open reduction and internal fixation.Materials and methodsBetween 2006 and 2008, 16 patients with talar neck fractures were operated on by percutaneous reduction of fracture and percutaneous fixation with 3.5 mm cannulated screws. Injuries were classified according to modified Hawkins classification system. Patients were followed up over an average of 48 months.Results87.5% of the patients were satisfied and resumed their preoperative activities. The mean AOFAS Hind Foot Scale was 89.25 points (range: 74–100) and no poor outcomes.ConclusionAlthough the number of patients in this study is small, the results showed that, percutaneous reduction and fixation is a good treatment modality in treatment of fracture neck talus, especially in cases with increased risk of soft tissue complications and open reduction should be resort only when percutaneous reduction was failed.     

可吸收螺钉固定治疗移位的距骨颈骨折

目的 研究距骨颈骨折新的手术治疗方法。方法 1996年4月～2001年3月，采用足内侧途径加内踝截骨显露距骨颈骨折，利用可吸收螺钉对骨折行内固定治疗9例移位的距骨颈骨折。术后膝下石膏管型固定6～12周，骨折有明显愈合迹象后，患者每日定时在短石膏靴外进行一定范围内活动。结果 9例均获随访15～60个月，平均28个月，骨愈合时间20～42周。按AOFAS足部评分标准，功能优良率77．8％(7／9)。术后1例伤口表浅皮肤感染并皮缘部分坏死，为HawkinsⅢ型。术后随访2例并发距骨体缺血性坏死，1例为HawkinsⅡ型，系5周即扶拐负重，评分为中；1例HawkinsⅢ型，经保守治疗无效后行踝关节融合术，评分为差。结论 以足内侧途径为入路，应用可吸收拉力螺钉固定治疗；矩骨颈骨折是一种新手术方法，辅以严格的术后处理可获得良好的临床治疗效果，值得推广使用。     

Fractures of the sustentaculum tali of the calcaneus: a case report

BACKGROUND: Isolated fractures of the sustentaculum tali of the calcaneus are rare and often missed upon initial presentation. There are few papers in the literature that comment on the management of these fractures. MATERIALS AND METHODS: We reviewed four cases of fractures of the sustentaculum talus of the calcaneus treated with open reduction and internal fixation from one surgeon's 15-year practice. RESULTS: This is a case report that describes the presentation, management and outcome of these four cases. CONCLUSIONS: In this small series of cases, operative treatment appears to have been appropriate. Direct anatomic approach with accurate open reduction and internal fixation has been relatively successful in these patients.     

四种手术方式行距下关节融合术治疗陈旧性跟骨骨折的疗效观察

目的 :观察采用4种手术方式行距下关节融合内固定术治疗陈旧性跟骨骨折的临床疗效。方法 :自2014年3月至2017年11月,采用4种手术方式行距下关节融合术治疗陈旧性跟骨骨折25例(26足),年龄23～70(36.7±5.8)岁,病程3～35(9.5±5.1)个月,距下关节原位融合术2例(2足),距下关节撑开植骨融合术6例(7足),跟骨"V"形截骨距下关节融合术6例(6足),跟骨体斜行截骨联合距下关节植骨融合术11例(11足)。观察患者手术并发症情况;比较术前及术后12个月距骨倾斜角、跟骨B觟hler角、Gissane角、跟距高度,术后12个月时采用视觉模拟评分(visual analogue score,VAS)及美国足踝外科协会(American Orthopedic Foot and Ankle Society,AOFAS)踝与后足评分评估手术疗效。结果:21例(21足)患者获得随访,时间13～34 (20.1±3.7)个月,4例(5足)失访。术后2例手术切口裂开,1例骨折不愈合,其余病例未发生骨折不愈合及内固定松动或断裂等并发症。术前与术后12个月距骨倾斜角[(5.3±2.4)°vs (11.2±4.6)°,t=7.24,P0.05],跟骨B觟hler角[(5.4±2.7)°vs (25.5±5.3)°,t=11.2,P0.05],Gissane角[(89.4±9.6)°vs (122.0±5.2)°,t=8.13,P0.05],跟距高度[(28.5±5.1) mm vs (47.1±3.7) mm,t=6.45,P0.05]比较差异有统计学意义。术后12个月VAS评分1.6±0.7,较术前5.2±1.0明显改善(t=5.12,P0.05);术后12个月AOFAS评分86.2±5.2,较术前52.4±6.4明显提高(t=6.41,P0.05);其中优14足,良4足,可2足,差1足。结论:距下关节原位融合术、距下关节撑开植骨融合术、跟骨"V"形截骨距下关节融合术、跟骨体斜行截骨联合距下关节植骨融合术均为治疗陈旧性跟骨骨折的有效手术方式,具有缓解疼痛、纠正跟骨畸形、改善足部功能等优点,严格掌握各种手术方式的适应证是保证手术疗效的关键。