循原骨折线截骨矫正跟骨骨折畸形愈合

Reconstructive osteotomy of calcaneus for malunited calcaneal fractures

目的探讨循原骨折线截骨矫正跟骨骨折畸形愈合方法的可行性。方法2004年8月至2007年5月，跟骨骨折畸形愈合患者25例28足，男23例26足，女2例2足；年龄22~56岁，平均31岁；受伤至手术时间1．5～12个月，平均4．6个月。采用循原骨折线截骨术进行治疗。按照Zwipp和Rammeh跟骨骨折畸形愈合的分类方法进行分类，其中Ⅲ型11例12足，Ⅳ型14例16足。术前均摄双足跟骨侧位、轴位X线片及行CT检查，12例患者（14足）行三维CT重建。根据Sander及Essex-Lopresti分类，参考原始x线片对不同骨折类型制定截骨线，重现原始骨折。根据CT轴位载距突及外侧骨块所带关节面的宽度和轴位骨折线的斜度从前外上到后内下斜行截骨，恢复跟骨的高度，将后关节骨折块向后上撬起，使塌陷的后关节面骨块复位。骨缺损处，用劈下的跟骨外侧壁填塞植骨，或取自体髂骨植骨，最后用钢板螺钉固定。结果24例26足获得随访，随访时间10-16个月，平均12个月。骨折愈合时间10-14周，平均12周。2例发生伤口感染，经抗生素治疗后10周取出钢板伤口愈合。无一例发生钢板螺钉断裂和骨折再移位。按照Maryland足部评分标准，优10足，良12足，可4足，优良率84％。结论循原骨折线截骨重现原始骨折，可恢复跟骨的骨性结构，能更好地矫正跟骨各方位畸形，同时保留距下关节，减少了手术对足踝功能的影响，近期疗效满意。

Objective To investigate the feasibility of reconstructive osteotomy of calcaneus for malunited calcaneal fractures. Methods From August 2004 to May 2007, 25 cases with 28 calcaneal malunion for 1.5 to 12 months（average 4.6 months） were treated by reconstructive osteotomy of calcaneus. According to Zwipp and Rammelt classification for malunited calcaneal fractures, 12 calcaneal were type Ⅲ,16 type Ⅳ. All patients underwent radiography including axial, lateral views and CT imaging for calcaneus, and three-dimensional CT imaging reconstruction for 12 cases. According to Essex-Lopresti and Sander classification, and combining with primary X-ray film, reconstructive osteotomy was performed through the primary fracture line. According to widening of the sustentaculum of talus and pitch of fracture, the osteotomy line was from superior anterolateral to inferior posteromedial. The posterior subtalar facet was reduced by elevating the fragment of the posterior subtalar facet upwards and backwards. The defect of calcaneus was filled with the bone graft resected from the extruding lateral wall of caicaneus, or iliac crest bone autografts. The calcaneus was fixed with plate and screw. Results Twenty-four cases with 26 feet were followed up for an average of 12 months （range, 10-16 months）. Wound infection happened in 2 cases, which healed after the interfixed plate was removed. There were no screw breakage and displacement of the fracture. The average time for bone healing was 12 weeks（range, 10-14 weeks）. The postoperatively functional evaluation by Maryland score system revealed excellent result in 10 feet, good in 12, fair in 4. The rate of excellent and good results was 84%. Conclusion Reconstructive osteotomy recreating the primary fracture could facile restore the posterior facet and correct the varus and valgus deformity. Remained subtalar joint could reduce the influence of operation for the function of the foot and ankle joint. The results were satisfactory in recently.