距下关节截骨缓慢延长治疗陈旧性跟骨骨折

External fixation and gradual limb lengthening for complicated delayed calcaneal fractures:report of 12 cases

目的伴有距下关节损伤的陈旧性跟骨骨折,目前主要是采用距下关节原位融合术和距下关节牵伸骨块植入融合术治疗,在此介绍一种新手术方式,距下关节截骨外固定支架缓慢延长手术,并评估其疗效。方法 12例15足（单足9例,双足3例）陈旧性跟距关节骨折脱位,年龄16-53岁,平均33.6岁。闭合性7例（10足）,开放型性5例（5足）。开放性损伤中3例严重多发伤病人手术时伤口已愈合2个月以上,2例伤口仍未愈合。均采用距下关节截骨牵伸融合新方法治疗,术中行内、外侧骨突切除、距下关节截骨与植骨、Orthofix外固定支架固定,术后7-10天延长,至距下关节间隙牵开1-2 cm、跟骨高度和Bohler角基本恢复正常时结束延长,2-3个月后距下关节骨性融合后取出外固定支架开始负重行走。结果 12例（15足）得到了6-50个月的随访,伤口均愈合,无皮肤坏死。距下关节在3-6个月（平均3.7个月）得到骨性融合。采用美国骨科足踝外科学会（AOFAS）评分标准,平均由术前的24.2分提高到术后随访时的76.8分。结论距下关节截骨缓慢延长治疗陈旧性跟骨骨折是一种新的有效治疗方法;无皮肤坏死、无需植骨和内固定;用于开放性陈旧性跟骨骨折的治疗可明显缩短疗程。

Objective For delayed calcaneal fractures accompanied by subtalar joint injury,the most common treatment is the use of in situ subtalar arthrodesis and subtalar distraction bone-block arthrodesis.In this study,we introduced a novel surgical treatment,subtalar osteotomy with external fixation and limb lengthening,and assessed its efficacy.Methods Totally 12 cases（15 feet）of delayed calcaneal fractures accompanied by severe subtalar joint injury were treated with this method.The patients ranged in age from 16 to 54 years,with an average age of 33.6 years.And seven cases were closed injury,others were opened injury.The protruding lateral calcaneus was surgically removed and subtalar osteotomy was performed.An external fixator was used to fix the bone for 7 to 10 days,followed by lengthening of the subtalar joint by gradual pulling.The lengthening procedure was stopped when the calcaneal height was essentially restored.The external fixator was removed after the patient＇s subtalar joint achieved bone fusion.Results For all 12 cases（3 cases of both feet）,the postoperative wound healed by first intention.After 6 to 50 months of follow-up,subtalar joint bone fusion was completed between 4 to 6 months after the operation,with an average fusion time of 3.7 months.The average preoperative American Orthopedic Foot and Ankle Society（AOFAS） hindfoot score for the eight feet was 24.2 and the average of the postoperative AOFAS score was 76.8.Conclusion Subtalar osteotomy with external fixation and limb lengthening is a novel,effective method for the treatment of delayed calcaneal fractures accompanied by severe subtalar joint injury.