小切口复位钢板内固定治疗跟骨关节内骨折21例初步报告

[目的]探讨小切口复位钢板内固定治疗跟骨关节内骨折治疗方法和疗效。[方法]自2004年5月～2007年10月，对22侧跟骨关节内骨折行跟骨外侧小切口复位钢板内固定治疗。[结果]所有患者术后获6～18个月随访（平均10个月）。按Creighton-Nebraska跟骨骨折疗效评定标准：优15侧，良5侧，可2侧，优良率90．9％。[结论]小切口复位钢板内固定治疗跟骨关节内骨折可获得满意的临床疗效。     

小切口复位植骨空心钉内固定治疗部分跟骨关节内骨折

目的：探讨小切口复位植骨空心钉内固定治疗部分跟骨关节内骨折的方法和疗效。方法：自2006年1月至2009年1月,对27例32足部分塌陷移位的跟骨关节内骨折（Sanders分型为Ⅱ-Ⅲ型）采用距下关节外侧小切口入路、复位距下关节面、同种异体骨移植,中空钉内固定。术后患者均石膏托外固定4周。结果：所有患者术后获6-48个月（平均22．9个月）随访,骨折全部愈合。按Maryland足部评分标准评价手术效果：优22足,良7足,可3足,优良率91％。无一例发生切口皮缘坏死及螺钉断裂。结论：有移位的Ⅱ、Ⅲ型跟骨关节内骨折,采用小切口切开复位植骨空心钉内固定治疗可获得满意疗效,能避免切口缘浅表坏死等并发症的发生。     

外侧切口钢板固定治疗跟骨关节内骨折

目的探讨改良外侧切口复位植骨钢板内固定治疗跟骨关节内骨折的方法和疗效。方法自2006年9月至2008年7月,对35足跟骨关节内骨折行改良外侧切口复位植骨钢板内固定治疗。结果所有患者术后获5～16个月随访（平均10个月）。按Maryland跟骨骨折疗效评定标准：优21足,良9足,一般3足,差2足,优良率85．7％。结论改良外侧切口复位植骨钢板内固定治疗跟骨关节内骨折创伤小,恢复快,能早期进行功能锻炼,可获得满意的临床疗效。     

小切口复位植骨空心钉内固定治疗部分跟骨关节内骨折的短期疗效分析

背景:手术治疗是跟骨关节内骨折有效的治疗方法,如何减少手术创伤,提高手术疗效,是临床研究的难题。目的:探讨小切口复位植骨空心钉内固定治疗部分跟骨关节内骨折的短期疗效。方法:2006年1月至2010年1月,对27例(32足)部分塌陷移位的跟骨关节内骨折(Sanders分型为Ⅱ~Ⅲ型)采用距下关节外侧小切口入路、复位距下关节面、同种异体骨移植,中空钉内固定进行治疗。术后患者均石膏托外固定4周。结果:所有患者术后获得6～48个月(平均22.9个月)随访,骨折全部愈合。按Maryland足部评分标准评价手术效果:优22足,良7足,可3足,优良率91%。无一例发生切口皮缘坏死及螺钉断裂。结论:有移位的Ⅱ、Ⅲ型跟骨关节内骨折,采用小切口切开复位植骨空心钉内固定治疗可获得满意疗效,能避免切口缘浅表坏死等并发症的发生,短期疗效可靠。     

手术治疗跟骨关节内骨折

目的探讨应用跟骨钢板治疗跟骨关节内骨折的手术方法和临床疗效。方法对44例(48足)跟骨关节内骨折采用足外侧入路行关节面复位,钢板内固定治疗,评价临床疗效。结果44例获12~36个月随访,参照M aryland的评分系统,优30足,良14足,可4足。结论应用跟骨钢板治疗跟骨关节内骨折有较好的效果,应重视术后处理,减少切口感染和皮肤坏死的发生。     

手术治疗波及关节面的跟骨骨折

目的探讨应用跟骨解剖钢板治疗跟骨关节内骨折的手术方法和临床疗效。方法对18例（19足）波及距下关节面跟骨骨折采用足外侧入路行关节面复位,解剖钢板内固定治疗,评价临床疗效。结果18例获7—14个月随访,参照Maryland的评分系统,优10足,良8足,可1足。结论应用跟骨解剖钢板治疗跟骨关节内骨折有较好的效果,应重视围手术期处理,减少切口感染和皮肤坏死的发生。     

小切口钢板螺栓加压内固定治疗跟骨骨折

目的探讨切开复位内固定治疗跟骨关节内骨折的新方法及其临床疗效。方法2004年8月～2005年8月,利用跟骨外侧小切口,用自行研制的跟骨解剖钢板及螺栓内固定治疗跟骨关节内骨折44例(54侧)。术前根据跟骨X线片及CT扫描结果进行分型,其中SandersⅡ型12侧,Ⅲ型32侧,Ⅳ型10侧。结果所有患者术后获2～12个月(平均8.3个月)随访。术后X线片显示跟骨高度、宽度、长度及Blhers角和Gissanes角均恢复,无一例切口感染。根据美国足踝外科协会跟骨骨折的评分标准:优26侧,良24侧,可4侧,优良率为92.6%。结论小切口跟骨解剖钢板螺栓内固定治疗跟骨关节内骨折可获得满意的临床疗效。     

改良外侧L切口加植骨锁定钢板内固定治疗跟骨关节内骨折

目的探讨改良外侧L切口加植骨锁定钢板内固定治疗跟骨关节内骨折的疗效。方法对44例(52足)跟骨骨折行改良外侧L切口加植骨结合锁定钢板治疗。结果随访8~39个月,术后Maryland足部评分系统评分优31例,良9例,一般4例,优良率90.9%,无皮瓣坏死。结论改良外侧L切口加植骨锁定钢板内固定是治疗跟骨关节内骨折的有效方法。     

经“八”字切口微创固定治疗跟骨关节内骨折

目的探讨经跟骨外侧"八"字切口、Y型解剖板微创固定治疗跟骨关节内骨折的疗效。方法对46例闭合跟骨关节内骨折采用跟骨外侧"八"字切口、Y型解剖板微创固定治疗。结果 46例均获得随访,时间12~30个月。患者骨折均愈合,无一例发生切口深部感染、皮肤坏死及骨髓炎等严重并发症。按AOFAS评分标准评价:优30足,良14足,可3足,差2足,优良率为89.8%。结论经跟骨外侧"八"字切口、Y型解剖板微创固定治疗跟骨关节内骨折,术中直视下复位跟骨后关节面,固定可靠,可早期活动。     

手术治疗有移位的跟骨关节内骨折

目的评价手术开放复位、钢板和螺钉内固定治疗跟骨关节内骨折的疗效.方法63例71侧有移位的跟骨关节内骨折,其中SandersⅡ型18侧(25.4%),Ⅲ型26侧(36.6%),Ⅳ型27侧(38.0%).采用外侧可延伸的"L"型切口入路,开放复位、钢板和螺钉内固定.部分Ⅳ型骨折采用骨移植且术后予以石膏短期外固定.结果63例均获随访,时间6～26个月,平均15.9个月.按AOFAS标准评价功能,优29侧,良26侧,可11侧,差5侧,优良率77.6%.结论有移位的跟骨关节内骨折,切开复位,钢板、螺钉内固定治疗可获得满意的效果,但Ⅳ型跟骨关节内骨折的治疗效果较Ⅱ、Ⅲ型差.     

跟骨关节内骨折内固定手术临床报告

目的通过对跟骨关节内骨折内固定手术和并发症研究,探讨跟骨关节内骨折内固定手术方法和治疗效果,防治并发症。方法 2004年2月至2010年10月我科采用外侧＂L＂型切口、可塑形跟骨解剖钢板进行开放复位内固定,手术治疗Sanders分型～型跟骨骨折42例45足,必要时行植骨。根据Sanders分型,型3足,型20足,型17足,型5足。术中侧位X线片透视观察Bhler角和Gissane角,Broden位透视观察后关节面的恢复情况。结果术后切口坏死感染3例,腓肠神经损伤1足。采用X轴、侧位摄片和病例随访,Maryland足部评分标准评价手术效果。随访时间2～36个月,平均18个月。本组优27足,良12足,可4足,差2足,优良率86.7%。结论经跟骨外侧＂L＂型切口切开复位内固定治疗跟骨关节内粉碎性骨折,能够获得满意的解剖皮肤复位和临床效果,固定可靠,是治疗跟骨关节内粉碎性骨折的有效方法。术中必须仔细保护切口皮瓣,防治术后切口皮肤坏死、感染等并发症。     

小切口复位空心钉内固定治疗跟骨骨折

目的探讨经距下关节小切口撬拨复位植骨结合经皮空心钉内固定治疗SandersⅡ、Ⅲ型跟骨关节内骨折的疗效。方法采用跟骨外侧距下关节小切口撬拨复位后植入同种异体骨+经皮空心螺钉内固定治疗35例SandersⅡ、Ⅲ型跟骨骨折患者。测量术前术后Bhler角和Gissane角的变化,根据角度变化数值观察关节面恢复情况。结果 35例均获随访,时间10～32(14±3.5)个月,患者骨折均愈合。未出现切口感染、皮瓣坏死、腓肠神经损伤等并发症。按Maryland足部评分标准评价手术效果:优23例,良9例,可2例,差1例,优良率达91.4%。结论距下关节小切口复位、植骨、经皮空心螺钉内固定治疗SandersⅡ、Ⅲ型跟骨骨折,软组织损伤少、关节面复位好,疗效满意。     

植骨在手术治疗跟骨关节内骨折中的作用

目的通过前瞻性随机研究,观察植骨在切开复位内固定治疗关节内跟骨骨折中是否有益。方法2001年1月至2005年12月收治需要手术治疗的闭合性关节内跟骨骨折110例,随机分为植骨组和非植骨组。采用“L”形外侧延长切口,直视下显露整个跟骨外侧壁、距下关节后关节面及跟骰关节,给予跟骨骨折复位。对于植骨组采用自体髂骨植骨填充复位后的骨缺损,而非植骨组则不进行植骨。随后将塑形良好的跟骨解剖重建板放置于跟骨外侧壁以固定跟骨骨折。手术前后摄片测量Bohler角,术后采用美国矫形足踝协会踝后足评分标准进行患者的功能评价。结果手术前后植骨组和非植骨组的Bohler角增加没有统计学差异,术后6个月Bohler角的丢失也没有统计学差异,术后6个月、1年及2年的足功能评价也没有差异。结论在手术治疗关节内跟骨骨折中植骨并不具有优势。     

跟骨骨折手术治疗及早期并发症预防

目的探讨跟骨骨折切开复位内固定治疗及早期并发症预防对策。方法对我院35例（39足）跟骨骨折患者采用跟骨外侧入路行钢板内固定,术后皮瓣下放置引流以防止术后血肿形成。结果35例39足中,35足愈合优良,2足切口交角处皮瓣缘皮肤坏死,2足切口内血肿形成,均经换药痊愈。结论跟骨骨折内固定早期手术并发症与切口血供特点有关。选择适当的手术时机,熟悉切口解剖,采用全厚皮瓣并避免过分牵拉,术后充分引流并抬高患肢可有效减少并发症发生。     

Calcaneal fractures: indirect reduction and external fixation

BACKGROUND: The current treatment of displaced intra-articular calcaneal fractures has been surgical fixation. The objective of this study was to evaluate the use of indirect reduction with Ilizarov external fixation as a viable alternative in the surgical treatment of certain calcaneal fractures. METHODS: Thirty-one patients with 33 fractures of the calcaneus (Sanders types II, III, and IV) were treated using small wire circular external fixation. A limited percutaneous plantar skin incision was used to improve reduction of the posterior facet. Fractures were evaluated by preoperative CT scans and classified by an independent observer. Patients were evaluated by physical examination as well as by the AOFAS hindfoot score questionnaire. Followup ranged from 6 months to 4 years. RESULTS: The average AOFAS score for 18 patients available for examination was 66 (42 to 92). The average score increased to 74 for patients with more than 10 months followup and to 77 for patients with isolated calcaneal fractures. Open fractures also had early debridement and soft-tissue coverage; no deep infections were seen in this subgroup. There were 11 complications, including nine superficial pin track infections, one superficial skin necrosis under an area of fracture blister, and one deep infection in a diabetic smoker with severe hemorrhagic fracture blisters. All superficial infections responded to local pin or wound care and oral antibiotics. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. All open fractures healed and maintained soft-tissue coverage. CONCLUSIONS: Indirect reduction and external fixation is a viable surgical alternative for intra-articular calcaneal fractures. Particularly favorable results were obtained in open fractures when soft-tissue reconstruction also was done. Advantages include shorter time to surgery, immediate weightbearing, minimal invasiveness, few serious wound problems, and no residual hardware. Disadvantages include technical difficulty, incomplete reduction of fracture fragments, and the need for secondary surgery (fixator removal).     

延长的外侧入路治疗跟骨关节内骨折

目的：评估延长的外侧入路治疗有移位的跟骨关节内骨折的临床疗效。方法：对34例跟骨关节内骨折,按Sanders分类法进行骨折分类。采用延长的外侧入路进行切开复位内固定。随访时间6－28个月,平均12．5个月。结果：按“跟骨关节内骨折评分标准”对患足功能进行评分。本组优17侧,良19侧,可2侧,差1侧。优良率为92．3％。结论：采用延长的外侧入路治疗有移位的跟骨关节内骨折能获得满意的临床疗效。     

Vascularity of the lateral calcaneal flap: a cadaveric injection study

OBJECTIVE: To describe the arterial blood supply of the subcutaneous tissues of the lateral hindfoot and define the relationships between these arteries and the lateral extensile incision used for open reduction and internal fixation of calcaneal fractures. DESIGN: Human cadaveric lower extremity specimens, doubly injected with India ink and latex, were used to demonstrate the location of the arteries of the subcutaneous tissues of the lateral hindfoot. SETTING: Anatomy laboratory. PATIENTS/PARTICIPANTS: Twenty-four randomly obtained, cadaveric elderly lower extremity specimens. INTERVENTION: India ink and then latex were injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system. Transtibial amputation specimens were manually debrided of the skin and chemically debrided of subcutaneous tissues with sodium hypochlorite to demonstrate the arterial supply to the soft tissues of the lateral hindfoot. MEAN OUTCOME MEASUREMENTS: The location of the three major arteries was determined relative to the lateral malleolus. The proximity of these vessels to the typical extensile lateral incision was determined radiographically with vascular clips applied along each artery and skin staples placed along the path of the typical skin incision. RESULTS: Three arteries, the lateral calcaneal artery, the lateral malleolar artery, and the lateral tarsal artery, were consistently found along the lateral aspect of the hindfoot. The lateral calcaneal artery appeared to be responsible for the majority of the blood supply to the corner of the flap and, because of its proximity to the vertical portion of the typical incision, it appeared most likely to be injured from inaccurate placement of the incision. CONCLUSIONS: The development of wound complications following open reduction and internal fixation of the calcaneus is multifactorial. Disruption of the blood supply to the surgically created flap may play a larger role in the development of wound complications than previously thought. An understanding of the local vascular anatomy may decrease the rate of wound complications during the operative treatment of intraarticular calcaneal fractures.     

Radial forearm free flap for coverage of postoperative lateral heel wounds after open reduction and internal fixation of the calcaneus

For intraarticular calcaneus fractures, open reduction and internal fixation has become commonplace for the reduction of morbidity of postinjury arthritis. Despite adequate surgical results, there are often associated postoperative wound complications. The purpose of this study was to describe a unique application of the radial forearm free flap for coverage of lateral postoperative heel defects seen after calcaneal fixation. Seven lateral heel wounds after open reduction of calcaneal fractures in 6 patients were covered with radial forearm free flaps. The technique used involved passage of the pedicle of the laterally placed flap anteriorly to the Achilles tendon so that it can be anastomosed to the posterior tibial artery. Flap application was 100% successful, with good functional and cosmetic results in all patients. The radial forearm free flap provides a quick, reliable, and easily harvested source of coverage for lateral heel wounds seen after open reduction and internal fixation of the calcaneus. Tunneling of the flap pedicle anterior to the Achilles tendon is simple and provides the additional advantages of access to reliable vessels, reduced scarring, and avoidance of further wound problems often seen with incisions used to access the anterior tibial artery.