3D打印辅助跟骨骨折畸形愈合手术重建的意义

Three-dimensional printing used in the treatment of calcaneal fracture malunion

背景:跟骨骨折畸形愈合,严重影响患者的生活质量,而手术难度及复杂性较大,术式选择困难。目的:探讨3D打印技术在跟骨骨折畸形愈合手术重建中的应用价值。方法:选择2016年5月至2018年8月收治的34例跟骨骨折畸形愈合患者,随机分成3D打印手术组(18例)和常规手术组(16例)两组;根据术前X线片、CT数据导入Mimics软件中进行骨折三维重建,数字化设计手术方案,3D打印手术组应用3D打印1∶1跟骨骨折实体模型,模拟手术方案;常规手术组根据X线片及CT设计手术方案;采用跟骨外侧L形切口,患者分别进行切开复位内固定、距下关节原位融合、距下关节撑开植骨融合及跟骨丘部和距下关节重建手术。随访测量跟骨形态学参数,并记录Maryland足部评分、美国足踝外科协会(AOFAS)、疼痛视觉模拟评分(VAS)及36项健康调查简表评分(SF-36)。结果:所有患者均获得随访,随访10~24个月,平均随访(18.5±2.8)个月。所有患者切口均甲级愈合,无感染、断钉等并发症。骨折愈合时间为12.6~16.8周,平均(15.5±3.6)周。末次随访时3D打印手术组患者B?hler角、Gissane角、跟骨宽度、丘部高度较术前明显改善,差异均有统计学意义(P<0.05);跟骨高度与术前比较差异无统计学意义;Maryland评分、AOFAS评分、疼痛VAS评分及SF-36评分均较术前明显改善,差异均有统计学意义(P<0.05);3D打印手术组优良率(88.9%)高于常规手术组(75.0%),且差异有统计学意义(P<0.05),而两组患者四种手术方案优良率差异均无统计学意义(P>0.05)。结论:采用3D打印技术有助于根据骨折畸形愈合的具体情况进行相应的术式选择,减少手术的盲目性,提高手术的准确性,制定更加精确、可靠、合理的个体化治疗方案,从而获得更好的预后效果。

Background: Calcaneal fracture malunion has a strong impact on patients′ quality of life. But It is difficult to select an appropriate operative method due to the difficulty and complexity of the operation. Objective: To investigate the value of 3D printing technology in the treatment of calcaneal fracture malunion. Methods: A total of 34 patients with calcaneal fracture malunion treated from May 2016 to August 2018 were randomly divided into 3D printing group(n=18) and routine operation group(n=16). The images of X ray and CT were uploaded into Mimics software for 3D reconstruction and digital surgical design. Real-size calcaneal models were produced using 3D printing technology for preshaping and surgical simulation in 3D printing group. Through the modified lateral L-shaped approach, 34 patients were treated by the open reduction and internal fixation, subtalar arthrodesis, calcaneal thalamus and subtalar reconstruction. Postoperative calcaneal morphological parameters were evaluated by the system of Maryland, AOFAS, VAS and SF-36. Regular follow-up was done. The postoperative function was evaluated according to the Maryland podiatric foot grading system. Results: The mean duration of follow-up was(18.5±2.8) months(range, 10-24 months) in all the patients. All the incisions healed well. No infection or screw breakage were observed. The mean bone healing time was(15.5±3.6) weeks(range, 12.6-16.8 weeks). B?hler angle, Gissane angle, calcaneal width and height of the calcaneal thalamus were improved greatly at the final follow-up(P<0.05). There was no significant difference between preoperative and postoperative calcaneal height(P>0.05). The scores of Maryland, AOFAS,VAS and SF-36 were improved greatly as compared with preoperative ones(P<0.05). According to Maryland foot score system, the total excellent and good rate of 3D printing group was significantly higher than routine operation(88.9% vs 75.0%,P<0.05). There was no significant difference in the excellent and good rate between four operation methods(P>0.05).Conclusions: 3D printing technology can be conductive to choose suitable operative methods according to real calcaneal fracture malunion. It can reduce operation blindness, improve the accuracy, make more precise, reliable and reasonable individual treatment plan.