应用跗骨窦有限切口克氏针内固定加植骨治疗儿童跟骨关节内骨折

Surgical treatment of displaced intraarticular calcaneal fractures in children

目的 回顾性评估应用跗骨窦有限切口克氏针内固定加植骨治疗儿童跟骨关节内骨折的疗效.方法 回顾性分析2010年6月至2014年2月,26例27足儿童跟骨关节内骨折行跗骨窦有限切口切开复位克氏针内固定加植骨术治疗的临床资料.26例均为男孩,年龄2～15岁,平均9.6岁;术前通过X线片及CT加三维重建检查对骨折情况进行评估和分型,骨折按Sanders分型分组：Ⅱ型组6足（Ⅱa型4足、Ⅱb型2足）、Ⅲ型组14足（Ⅲab型6足、Ⅲac型5足、Ⅲbc型3足）、Ⅳ型7足.术后临床评估使用改良AOFAS评分.结果 全部患儿均获8～30个月随访,平均21个月.骨折临床愈合时间均为术后4周.Ⅱ型组术前及术后B（o）hler角分别为16.8°±12.9°和36.8°±7.5°,术前及术后Gissane角分别为104.8°±12.8°和124.3°±9.6°,手术前后比较,差异均有统计学意义（P＜0.05）.Ⅲ型组术前及术后B（o）hler角分别为15.4°±14.1°和34.4°±9.1°,术前及术后Gissane角分别为100.6°±10.1°和119.8°±11.7°,手术前后比较,差异均有统计学意义（P＜0.000 1和P＜0.05）.Ⅳ型组手术前、后B（o）hler角分别为8.6°±10.5°和34.7°±5.3°,手术前、后Gissane角分别为105.4°±4.0°和121.4°±8.9°,手术前后比较,差异均有统计学意义（P＜0.05）.Ⅱ型组、Ⅲ型组和Ⅳ型组术后改良AOFAS评分分别平均为65.2±2.5、67.0±1.6和65.0±2.8,3组间评分差异无统计学意义（P＞0.05）.有1足出现克氏针针眼感染,无切口感染、软组织坏死、骨髓炎、创伤性骨关节炎等并发症发生.结论 应用跗骨窦有限切口切开复位克氏针内固定加植骨术治疗儿童跟骨关节内骨折,可以满意复位及稳固固定,可以获得满意的临床疗效,可以避免切口感染、软组织坏死、骨髓炎、创伤性骨关节炎等并发症.

Objective To retrospectively evaluate the surgical outcomes of displaced intraarticular calcaneal fractures in children after open reduction,internal fixation with Kirschner wire and bone grafting via limited tarsal sinus incision.Methods The clinical data of 26 boys （77 sides） with displaced intraarticular calcaneal fractures from June 2010 to February 2014 were collected for respective analyses.Limited open reduction,internal fixation and bone grafting via limited tarsal sinus incision with k-wire were performed.Their average age was 9.6 （2-15） years.Preoperative radiographs and computed tomographic scans were used to classify the fractures.According to the Sanders classification,there were 6 feet of type Ⅱ （4 type Ⅱa,2 type Ⅱb）,14 feet of type Ⅲ （6 type Ⅲab,5 type Ⅲac ＆ 3 type Ⅲbc） and 7 feet of type Ⅳ.The functional outcomes were assessed by the modified American Orthopedic Foot ＆ Ankle Society （AOFAS） ankle and hindfoot score.Results The mean follow-up period was 21 （8-30） months.All fractures healed clinically after 4 weeks postoperation.In patients with type Ⅱ fractures,B hler angle was restored from 16.8 ± 12.9 to 36.8 ±7.5 （P＜0.05）and Gissane angle from 104.8°± 12.8° to 124.3°± 9.6°（P＜0.05）; In type Ⅲ fractures,B？ hler angle improved from 15.4°± 14.1° to 34.4°± 9.1°（P＜0.000 1） and Gissane angle from 100.6° ± 10.1° to 119.8° ± 11.7°（P＜0.05） ; In type Ⅳ fractures,B？ hler angle was restored from 8.6° ± 10.5° to 34.7° ± 5.3°（P＜0.05） and Gissane angle from 105.4° ± 4.0° to 121.4° ± 8.9°（P＜0.05）.The mean modified AOFAS scores were 65.2 ± 2.5,67.0 ± 1.6 and 65.0 ± 2.8 in patients with type Ⅱ,type Ⅲ and type Ⅳ respectively.The differences of AOFAS scores were not statistically significant among three groups （P＜0.05）.Pin hole infection occurred in one foot.There was on onset of wound infection,tissue necrosis,osteomyelitis or traumatic arthritis.Conclusions Limited open reduction,internal fixation and bone grafting via small lateral incision with Kirschner wire is both safe and efficacious for displaced intraarticular calcaneal fractures in children.It has the advantages of satisfactory reduction of articular surface and solid fixation.Also such complications as infection,tissue necrosis,osteomyelitis and traumatic arthritis combe avoided.