撬拨复位结合Ilizarov技术治疗跟骨关节内骨折

Treatment of intraarticular calcaneai fractures using poking reduction combined with Ilizarov method

目的介绍撬拨复位结合Ilizarov技术治疗足跟皮肤软组织条件不良的跟骨关节内骨折的方法。方法自2007年9月至2009年9月，应用该方法治疗足跟皮肤软组织条件不良的跟骨关节内骨折11例，男10例，女1例；年龄21～50岁，平均33．6岁。左4例，右7例。骨折采用Sanders分型：Ⅱ型7例，Ⅲ型3例，Ⅳ型1例。软组织损伤采用AO闭合软组织损伤分型：IC2型3例，IC3型6例，IC5型1例及皮肤开放撕脱伤1例。术前BShler角0°～12°，平均8°；Gissane角70°～95°，平均80°。手术方法：跟骨结节外侧插入骨圆针撬拨复位后关节面骨块，再利用打人的橄榄针的拉张纠正跟骨内、外侧骨块的移位，并用Ilizarov环形支架固定。结果11例患者全部获得随访，时间6～20个月，平均13．3个月。骨折全部愈合，愈合时间7～10周，平均8．1周。术后BShler角20°～45°，平均33°；Gissane角100°～118°，平均107°。对按Maryland足部评分系统评价术后功能，优7例，良3例，可1例，优良率为91％。结论撬拨复位结合Ilizarov技术可以恢复并维持跟骨正常的解剖形态，减少伤口感染等术后并发症的发生；尤其适用于SandersⅡ、Ⅲ型伴软组织损伤严重的闭合骨折或开放骨折；掌握好手术适应证及操作要点可以取得满意的临床疗效。

Objective To introduce the treatment of intraarticular ealcaneal fractures with poor soft tissue using poking reduction combined with Ilizarov methods. Methods From September 2007 to September 2009, 11 patients with the intraarticular calcaneal fractures were treated with poking reduction combined with Ilizarov methods, including 10 males and 1 female at average age of 33.6 years （ range, 21-50 years）. Four patients had the left calcaneal fractures and seven with the right ones. According to Sander classification, there were seven patients with type II fractures, three with type III fractures and one with type IV fracture. The various extents of heel soft tissue injury were emerged in all the patients. Before operation, Bshler angle was 0°-12°（average 8°） and Gissane angle 70°-95° （average 80°）. According to AO classification of close soft tissue injury, there were three patients with type IC2, six with type IC3, one with type IC5 and one with open soft tissue injury. The collapse of the articular surface was recovered by Steinmann pin which passed through the lateral calcaneal tubercle. The medial and lateral fracture fragments were cmxected by using the tensed olive wires. The height and width were maintained by using the Ilizarov external fixation. Results The mean duration of follow-up was 13.3 months （range, 6-20 months）. All fractures were healed after mean duration for 8. 1 weeks （range, 7-10 weeks）. The postoperative BShler angle was 20°-45° （ average 33°） and Gissane angle 100°-118°（average 107°）. According to Maryland Foot Score system, the result of postoperative function was excellent in seven patients, good in three and fair in one, with excellence rate of 91%. Conclusions For the intraarticular calcaueal fractures, the poking reduction combined with Ilizarov method is able to recover and maintain the normal calcaneal height and width and reduce postoperative wound infections and many other complications, specially for Sanders II or III with severe soil tissue injury, in the open or closed calcaneal fractures. Master of surgical indications and operating points can attain satisfactory clinical efficacy.