距骨开放性骨折1期内固定手术治疗策略

The Surgical Treatment Strategies of Talar open Fracture Using Internal Fixation in One- stage Treatment

目的：探讨急诊1期手术内固定治疗距骨开放性骨折的疗效及注意事项。方法：2007年4月～2014年7月，急诊1期内固定手术治疗距骨开放性骨折患者58例，男38例，女20例；年龄15-61岁，平均31．7岁；左侧35例，右侧23例。致伤原因：高处坠落伤28例，交通事故伤20例，重物砸伤10例。开放伤12部位；外侧横行伤1210例，后外侧伤口5例，前内侧伤129例，内后侧12例，经内踝骨折横行伤口15例．前侧斜行伤1：76例，损伤到手术的平均时间伤后5．3小时。手术入路：原开放伤12扩大显露30例，原伤12联合前外侧入路20例，原伤口联合前内侧切口3例，58例患者中，15例采用拉力螺钉固定；9例采用可吸收螺钉固定；34例采用空心拉力螺钉固定，其中4例辅以全螺纹松质骨螺钉＋自体髂骨移植固定。结果：58例患者获得随访，随访时间24～84个月，平均47．5个月。骨折均愈合，愈合时间为17—41周，平均22周。美国足与踝关节协会（AOFAS）功能评分为43～100分，平均78．3分；优28例，良17例，可10例，差3例。优良率为77．5％。距骨缺血性坏死发生率13．7％（8／58）；创伤性关节炎发生率43．1％（25／58）。伤口感染发生率8．6％（5／58）。伤口延期愈合发生率22．4％（13／58）。结论：急诊1期手术内固定治疗距骨开放性骨折可提高临床治疗效果。根据骨折类型和软组织损伤的具体情况，术中应注意选择适宜的手术入路，保护血供，精确复位。术后给予足够长的免负重时间和早期功能锻炼可降低并发症发生率。

Objective： TO discuss effects and Precautions of open fractures of talar using internal fixation in one - stage emergency surgery. Methods： 58 patients with talar open fractures who had been treated with internal fixation in one - stage emergency surgery from April 2007 to July 2014 at our hospital, including 38 males and 20 females; their ages ranged from 15 to 61 years old, average age is about 31.7 years old;35 patients had their talar open fracture in the left side and 23 patients in the right side. The causes of injury： 28 cases falling from height, 20 cases injured by traffic accident trauma, 10 cases injured by heavy objects. Wound site ： 10 cases with lateral transverse wounds, 5 cases with posterolateral wounds,9 cases with anterior medial wounds, 12 cases with internal -posterior wounds, 15 cases wounds through the medial malleolus fracture, 6 cases with front skewed wounds. Average time from injury to surgery is about 5. 3h. Surgical approach： 30 cases expanded the original open wounds,20 cases through Anterolateral approach combined with original wounds, 3cases through anterior medial incision combined with original wounds. Among 58 patients, 15 cases were treated with lag screw, 9 cases were treated with absorbable screws;34 cases using cannulated screws, including 4 cases combined with fully threaded cancellous bone screws and autogenous iliac bone graft. Results： 58 patients were followed up for 24 -84 months, with an average follow - up time of 47.5 months. All fractures healed, the healing time was 17 -41 weeks, and an average was 22 weeks . The function grades of AOFAS was in a region from 43 to 100, which generated a mean of 78.3 and the Good rate was 77.5 % , including 28 cases excellent, 17 cases good, 10 cases poor,3 cases bad. The function scores of AOFAS was in a region from 43 to 100, which generated a mean of 78. 3. The Good rate was 77.5% , including 28 cases excellent, 17 cases good, 10 cases poor,3 cases bad. The incidence rate of talar ischemic necrosis was 13.7 % （ 8/58 ）. The incidence of traumatic arthritis was 43.1% （ 25/58 ）. Wound infection rate was 8.6% （5/58）. The incidence of delayed wound healing was 22.4% （ 13/58 ）. Conclusions： One - stage treatment of talar open fracture using internal fixation can improve clinical outcomes. According to the type of fracture and soft tissue injury, surgery should pay attention to the surgical approach, accurately reseting fractures and protection blood supply. Long enough free load time and early exercise can reduce the incidence of complications.