开放性跟骨骨折的手术治疗

Treatment of open calcaneal fractures

目的:通过回顾性病例系列研究,探讨开放性跟骨骨折的临床疗效和预后相关影响因素。方法:2004年至2009年10月,共收治跟骨骨折427例,其中开放性跟骨骨折22例,有15例15足获随访,男9例,女6例;年龄18～66岁,平均34.7岁。跟骨骨折按照Sanders分型,Ⅰ型2例,Ⅱ型3例,Ⅲ型6例,Ⅳ型4例;软组织损伤Gustilo分型,Ⅰ型1例,Ⅱ型4例,ⅢA型5例,ⅢB型5例。按照OCIS分型,ⅠA型1例,ⅡA型2例,ⅡB型7例,ⅢA型2例,ⅢB型3例。所有患者急诊行伤口清创,预防性抗生素应用,根据伤口情况I期闭合或临时覆盖,患肢临时固定,根据软组织损伤情况急诊或择期行跟骨骨折复位内固定。随访是通过临床检查、影像学评估和AOFAS踝与后足评分进行预后评估。结果:15例患者均获随访,时间8～31个月,平均16.4个月,AOFAS评分(74.6±10.4)分(58～94分),有4足需要筋膜瓣或皮瓣覆盖伤口。有5例发生浅表感染,其中有4例为GustiloⅢ型,2例深部感染和1例骨髓炎,无患者需要截肢治疗。结论:开放性跟骨骨折如果早期合理清创,认真评估软组织损伤情况,把握内固定的时机和手术指征,选择恰当的固定方法,可以有效降低术后深部感染和骨髓炎发生率。另外,对于GustiloⅢ型和OCISB型骨折,应避免早期切开复位内固定。

Objective：Review the series cases of open calcaneal fractures,to discuss the clinical outcome and evaluate the effective factors associated with the prognosis. Methods：Between 2004 and October 2009,427 calcaneal fractures were treated,22 of these fractures were open,15 feet of 15 patients were available for the follow up. There were 9 males and 6 females with a mean age of 34.7 years （range 18 to 66）. According to the Sanders classification,there were 2 typeⅠfractures,3 type Ⅱ,6 type Ⅲ and 4 type Ⅳ. According to the Gustilo classification,there were 1 of type I,4 of typeⅡ,5 of typeⅢA,and 5 of type ⅢB open fracture. According to the open calcaneal injury subtypes （OCIS）,there were 1 of type IA,2 of typeⅡA,7 of typeⅡB,2 of type ⅢA and 3 of typeⅢB. All patients were treated with intravenous antibiotics,immediate and repeat irrigation and debridement,temporary wound coverage,and initial stabilization of the limb. Clinical examination,radiographs and AO- FAS ankle hindfoot scores were used for outcome measurement. Results：The average follow up time was 16.4 months （8 to 31 months）. The mean AOFAS score was （74.6±10.4）（range 58 to 94）. There were 4 feet required tissue transfer for wound cov- erage. An infection developed at the sites of 5 fractures,4 of witch were Gustilo type Ⅲ,2 deep infections with osteomyelitis developing at the site of 1 patient,no patient required amputation. Conclusion：These findings do not reflect as high a deep infection and osteomyelitis rate for open calcaneal fractures as previously reported,if early and satisfying debridement,evaluate the soft tissue injury carefully,and choose the right time and indications for internal fixation. In addition,early internal fixation should be avoided for Gustilo type Ⅲ and OCIS type B calcaneal fractures.