开放距骨骨折的手术疗效分析

Surgical treatment of open fractures of the talus

目的回顾性分析切开复位内固定手术治疗开放距骨骨折的手术效果及其相关因素。方法对手术治疗距骨颈、距骨体骨折16例随访资料完整病例进行回顾性分析。所有骨折均按Gustilo-Anderson 分型:type 1型3例,Ⅱ型8例,Ⅲ型 A 型2例,Ⅲ型 B 型2例,Ⅲ型 C 型1例;距骨颈骨折按照 Hawkins 分型:2型5例,3型3例,4型1例。全部患者均急诊行开放骨折清创、一期切开复位内固定手术。16例开放距骨骨折患者术后均接受随访,根据患者术后的主诉、X 线片、CT 片、AOFAS 评分结合术前的开放伤口情况、距骨骨折分型、术中复位情况等临床征象来分析临床疗效。结果病例的随访时间3～6年,平均4.7年。骨折的愈合率81%,13例患者骨折愈合,另3例发生骨髓炎,未愈合,骨折愈合时间平均为4.5个月。16例中的5例术后感染,感染的发生率31%;其中2例为浅表软组织感染,另3例发生骨髓炎,其中2例经过抗感染治疗成功,二期行 Blair 关节融合术2例,1例行小腿中下1/3水平截肢术。伤口的愈合情况,9例伤口一期愈合,7例经过伤口换药,其中4例延迟愈合、2例行二期游离植皮术、1例行局部皮瓣转移术覆盖伤口成功。13例继发创伤性关节炎。11例出现距骨坏死征象。AOFAS 后足评分45-78分,平均53.7分。结论正确掌握开放骨折的治疗原则,结合距骨骨折的损伤特点,进行一期清创、切开复位内固定是治疗的关键。

Objective To evaluate the long-term outcomes of surgical treatment of open fracture of talus. Methods Sixteen patients with displaced open fractures of the talus, including 3 cases of type 1, 8 of type 2, 2 of type 3A, 2 of type 3B, and 1 of type 3C according to the Gustilo-Anderson classification system, 15 males and 1 female, aged 37.5 （21 -48）, were treated with open reduction and stable internal fixation within 6 - 8 hours after injury, and followed up for 3.2 years （ 3 - 6 years）. There were 7 cases of pure displaced talar neck or body fracture and 9 cases of fractures associated with an ipsilateral pilon, ankle, and calcaneus totally that included 2 cases of type 2, 3 of type 3, and 1 of type 4 according to the Hawkins classification system modified by Canale. Results The union rate was 81% （13/16） with the average union time of 4.5 months. Three cases failed to heal and developed osteomyelitis, of which 2 were treated with late talectomy because of septic nonunion. One case underwent amputation below-the-knee because of instability and pain. Osteonecrosis developed after seven of the nineteen closed fractures, whereas posttraumatic arthritis developed after all nineteen. Osteonecrosis developed in 11 （68%） , and posttraumatic arthritis developed in 13 of the 16 cases（85% ）. The average American Orthopaedic Foot and Ankle Society score of these patients was 43.7 points. Conclusion Open fractures of the talus has a low union rate, a higher osteonecrosis rate, and substantially higher reoperation and infection rates. Posttraumatic arthritis is a more common complication than osteonecrosis following operative treatment. Open reduction and internal fixation are recommended for the treatment of open fractures of talus.