顶压手法结合多针撬拨复位内固定治疗跟骨骨折临床疗效和安全性的比较研究

Comparative study on effect and safty of treating on calcaneus fractures with manipulative reduction with percutaneous K-wire fixation

目的:探讨顶压手法结合钢针微创撬拨复位治疗不同类型跟骨骨折的疗效和安全性,分析微创撬拨复位的治疗指征。方法:2008年12月至2011年12月采用随机分组、平行对照的方法,前瞻性对135例闭合性跟骨骨折患者分别应用撬拨复位内固定和切开复位内固定进行治疗。撬拨组69例(82足),男60例,女9例;年龄18～64岁,平均(43.29±10.46)岁;左足30例,右足26例,双足13例;Essex-Lopresti分型舌状骨折54足,关节压缩骨折28足;SandersⅡ型33足,Ⅲ型49足。钢板组66例(75足),男58例,女8例;年龄21～63岁,平均(46.00±2.42)岁;左足31例,右足26例,双足9例;Essex-Lopresti分型舌状骨折48足,关节压缩骨折27足;SandersⅡ型28足,Ⅲ型47足。根据Kerr评分标准评价基于Sanders分型和Essex-Lopresti分型结合应用下的疗效,并观察术后并发症情况。结果:135例患者术后24周获随访,所有骨折在8～12周愈合,平均愈合时间10.2周。撬拨组中,针道感染2例,退针5例,无发生神经血管损伤;钢板组中,术后切口皮缘坏死18例,腓肠神经损伤5例,两组差异有统计学意义(P<0.05)。术后24周疗效观察,在SandersⅡ型骨折中,撬拨组和钢板组的舌状骨折和关节压缩骨折治疗优良率均在70%以上,差异无统计学意义(P>0.05);SandersⅢ型骨折中,撬拨组和钢板组对舌状骨折的疗效相近,差异无统计学意义(P>0.05),而对关节压缩骨折,钢板组疗效优于撬拨组(P<0.01)。撬拨复位对SandersⅡ、Ⅲ型舌状骨折在疼痛评分、行走能力评分和Kerr总分比较等方面优于关节压缩骨折(P<0.05,P<0.01);SandersⅢ型关节压缩骨折使用钢板内固定较撬拨方法在工作能力评分、行走能力评分上更好(P<0.05)。结论:顶压手法结合多针撬拨复位内固定对SandersⅡ型中的舌状骨折、关节压缩骨折、SandersⅢ型中的舌状骨折具有微创操作、并发症少等优点。SandersⅢ型中的关节压缩骨折应该采用切开复位内固定治疗。

Objective ： To explore the clinical effects and safty of manipulative reduction with percutaneous poking Kwire fixation for the treatment of the calcaneus fractures and analyze the indication of the minimal invasion. Methods： From Decem ber 2008 to December 2011,135 closed calcaneal fractures cases were divided randomly into poking group and plate group, treated respectively by percutaneous poking reduction and operative reduction. In poking group, there were 69 cases （82 feet） including 60 males and 9 females, with an average age of （43.29-10.46） years ranging from 18 to 64 years ;30 cases of left, 26 cases of right and 13 cases of double;54 feet of EssexLopresti classification tongue form, 28 feet of joint compression;33 feet of Sanders type 11,49 of type In plate group, there were 66 cases （75 feet） including 58 males and 8 females, with an av erage age of （46.00±2.42） years ranging from 21 to 63 years; 31 cases of left, 26 cases of right and 9 cases of double ;48 feet of EssexLopresti classification tongue form, 27 feet of joint compression ;28 feet of Sanders type I1 , 47 of type HI. According to Kerr scoring standard, clinical effects and complications were evaluated combining with Sanders and EssexLopresti classifica tion. Results：All 135 cases were followed up after 24 weeks. Fractures were recoveried in 8 tO 12 weeks （means 10.2 weeks）. In poking group ,there were 2 cases of infection, 5 cases of wire movement ; in plate group, 18 cases of wound local skin necro sis, 5 cases of calf intestines nerve injured; there were statistical significant （P〈0.05）. Postoperative evaluation of Sanders typeⅡ after 24 weeks, the proportion of excellent results was above 70%, and there were no significant differences on effects of tongue form and compressing form of calcaneus fractures with percutaneous poking and operative redution （P〉0.05）. In thecaes of Sanders type m ,there were no significant differences on effects of tongue form fractures with percutaneous poking and operative reduction （P〉0.05）. There were significant differences on effects and complications of compressing form fractures （P〈O.O1）, operative reduction better than percutaneous poking. Pain, walking, Kerr scoring of tongue form fractures of Sanders Ⅱ, Ⅲ with poking reduction were better than compression fractures. In compression fractures of Sanders m ,plate internal fix ation was better than poking redution in working and walking function, there were significant difference （P〈0.05）. Conclusion： For tongue form or compressing form of Sanders type and tongue form of Sanders type Ⅲ, manipulative reduction with per cutaneous poking Kwire fixation has advantages of minimal invasion, minimized complications. Compressing form of Sanders type Ⅲfracture should be treated with operative redution.