软组织评估及干预策略对预防跟骨骨折术后伤口并发症的临床意义

Soft tissue assessment and intervention strategies to prevent postoperative wound complications inclosed calcaneai fractures

目的探讨软组织评估及干预策略在闭合性跟骨骨折治疗过程中的临床意义。方法前瞻性研究2005年2月至2011年7月收治的168例（207足）跟骨关节内移位骨折患者，男152例190足，女16例17足；年龄17-68岁，平均38．1岁。骨折按Sanders分型：Ⅱ型58足，Ⅲ型124足，Ⅳ型25足。采用自制的软组织评估标准进行评价，包括初始软组织评估和术前评估，并采取相应的临床干预措施。将所有患者随机分为3组，由资历相当的不同医生进行手术治疗，但术中及术后严格遵照上述特定的手术方式及流程进行处理。分析初始软组织评估严重程度与受伤至手术时间的相关性，受伤早期初始软组织评估、术前评估与伤口并发症的相关性，并比较3组患者术后伤口并发症的发生率。结果本组患者术后伤口并发症发生率为9．2％。初始软组织评估严重程度与受伤至手术时间成正相关（r=2．474，P=0．ooo），与骨折严重程度有密切关系（χ2=109．829，P=0．000），且初始评估软组织肿胀程度和皮肤创面条件均对伤口预后有影响（P〈0．05）。术前对软组织的3项评估（皱纹试验、毛细血管反应实验及经皮氧分压）对伤口并发症有明显影响（χ2=440．961，P=0．000）。3组患者伤口并发症发生率差异无统计学意义（P〉0．05）。结论重视软组织损伤、制定完善的围手术期软组织干预策略对闭合性跟骨骨折的治疗至关重要，可明显减少术后伤口并发症的发生。

Objective To evaluate the clinical significance of soft tissue assessment and intervention strategies to prevent postoperative wound complications in closed caleaneal fractures. Methods A prospective study over a 6-year period was conducted on 207 closed calcaneal fractures in 168 patients who had sought medical treatment in our department from February 2005 through July 2011 for closed ealcaneal fractures. There were 152 men with 190 feet involved and 16 women with 17 feet involved. They were aged from 17 to 68 years （average, 38.1 years）. By Sanders classification, 58 feet were of typeⅡ, 124 feet of type Ⅲ and 25 feet of type Ⅳ. A self-developed system of soft tissue assessment was adopted to evaluate the patients, including initial assessment and preoperative assessment, before clinical interventions were adopted accord- ingly. All patients were randomized into 3 groups who were taken care of by doctors with similar compe- tence according to the same specified protocol. The associations were analyzed between initial soft tissue assessment and time interval from injury to operation, and between initial and preoperative soft tissue as- sessments and wound complications as well. The postoperative wound complications were compared between groups. Results The incidence of wound complications was 9.2% in this series. The initial soft tissue assessment was positively correlated with the time interval from injury to operation （ r = 2, 474, P = 0, 000）, closely associated with the severity of the fracture （χ2 = 109. 829, P = 0. 000）, and significantly associated with the wound prognosis （P 〈 0.05）. Preoperative soft tissue assessment （including wrinkle test, capillary reaction test and percutaneous partial pressure of oxygen） had significant effects on the incidence of wound complications （χ2 = 440. 961, P = 0. 000） . There was no significant difference between the 3 groups in in- cidence of wound complications （ P 〉 0. 05） . Conclusion It is important to conduct perioperative soft tissue assessments and to take intervention strategies accordingly for closed calcaneal fractures, because they can obviously reduce the wound complications.