早期清创复位克氏针内固定与Ⅱ期钢板内固定治疗开放性跟骨骨折的病例对照研究

Case-control study on therapeutic effects between Kirschner wire fixation after early bebridement and staged plate fixation in the treatment of open calcaneal fractures

目的:比较早期清创骨折复位克氏针内固定(克氏针组)与Ⅱ期骨折复位钢板内固定(钢板组)治疗开放性跟骨骨折的临床疗效。方法:自2001年1月至2008年5月收治开放性跟骨骨折55例(58足),年龄19～65岁,平均36.8岁;伤后至就诊时间30min～7h,平均3h。克氏针组:男20例(20足),女9例(9足);软组织损伤Gustilo分型,Ⅰ型15足,Ⅱ型13足,ⅢA型1足;跟骨骨折Sanders分型,Ⅱ型9足,Ⅲ型18足,Ⅳ型2足;采用早期清创骨折复位克氏针固定治疗,软组织缺损采用VSD临时覆盖,Ⅱ期皮片或皮瓣移植术。钢板组:男18例(19足),女8例(10足);软组织损伤Gustilo分型,Ⅰ型13足,Ⅱ型14足,ⅢA型2足;跟骨骨折Sanders分型,Ⅱ型11足,Ⅲ型15足,Ⅳ型3足;采用早期清创,创面稳定后采用Ⅱ期骨折复位钢板内固定治疗。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:克氏针组15例(23足)和钢板组13例(22足)得到随访,随访时间10～36个月,平均24个月。2组患者最后一次随访时的X线片与术前比较,跟骨高度、宽度、B觟hler角和Gissane角均有改善。根据AOFAS踝-后足评价,克氏针组优11足,良8足,可3足,差1足,术后早期伤口局部皮肤坏死2足,经换药后治愈,1足出现大面积皮肤坏死并深部感染,1足出现慢性骨髓炎,后期均行关节融合术;钢板组优7足,良4足,可4足,差7足,清创早期轻度并发症2例,慢性骨髓炎1例,Ⅱ期术后切口并发症10例,其中皮肤坏死7例,浅表感染3例。2组放射学指标和AOFAS踝-后足评分比较,差异有统计学意义;而清创术后早期并发症比较,差异无统计学意义。结论:早期清创克氏针固定治疗开放性跟骨骨折早期并发症较少,是一种简单安全有效的治疗方法。

Objective：To compare therapeutic effects between Kirschner wire fixation after early debridement（Kirschner wire group） and staged plate fixation（plate group） in the treatment of open calcaneal fractures. Methods：From January 2001 to May 2008,55 patients （58 feet） with open calcaneal fractures were reviewed,the mean age was 36.8 years（ranged,19 to 65 years） and the average visit time was 3 hours（ranged,30 min to 7 h）. All the patients were divided into two groups：Kirschner wire group and plate group. There were 20 males（20 feet） and 9 females（9 feet） in Kirschner wire group,in which 15 feet were type I,13 feet were type Ⅱ,1 foot was type ⅢA according to Gustilo classification and 9 feet were type Ⅱ,18 feet were type Ⅲ,2 feet were type Ⅳ according to Sanders classification. The patients in Kirschner wire group were treated with early debridement,fracture reduction and Kirschner wire fixation,and the soft tissue defects were covered with VSD temporarily,and then were enveloped by skin or flap grafts at the second stage. There were 18 males（19 feet） and 8 females（10 feet） in the plate group,in which 13 feet were type I,14 feet were type Ⅱ,2 feet were type ⅢA according to Gustilo classification and 11 feet were type Ⅱ,15 feet were type Ⅲ,3 feet were typeⅣ according to Sanders classification. The patients in the plate group were treated with early debridement,and plate internal fixation with were performed when the wound became stabilization. Results：Twenty-three feet （15 patients） in the Kirschner wire group and 22 feet（13 patients） in the plate group were followed,the duration ranged from 10 to 36 months,with an average of 24 months. Compared with preoperative ones,the heel height,width,Bhler angle and Gissane angle of calcaneal got improvements. According to AOFAS ankle- foot evaluation system,11 feet got an excellent result,8 good in the Kirschner wire group;2 feet had wound local skin necrosis and cured by dressing;1 foot had a large area of skin necrosis and deep infection;1 foot had chronic osteomyelitis. All above 4 feet underwent arthrodesis later. As comparison,7 feet got an excellent result,4 good in the plate group;2 patients had mild complications of wounds;1 patient had chronic osteomyelitis after early debridement;10 patients had wound complications after internal fixation,including 7 patients with skin necrosis,superficial infection in 3 patients. There were statistical significant in radiological indicators and AOFAS ankle-foot scores between two groups. But there were no significant differences in early postoperative complications between the two groups. Conclusion：Early debridement and Kirschner wire fixation for the treatment of open calcaneal fractures has fewer early complications,which is a simple,safe and effective method.