距下关节后侧入路关节镜辅助下微创治疗跟骨骨折

Minimally invasive treatment of calcaneal fractures by subtalar arthroscopy with posterior approach

目的评价距下关节后侧入路关节镜辅助下闭合复位经皮空心螺钉内固定治疗Essex-Lopresti舌型及SandersⅡA、ⅡB、ⅢAB型跟骨骨折的临床效果。方法 2012年6月—2015年6月,收治单侧跟骨骨折16例。男13例,女3例;年龄18~65岁,平均37.8岁。致伤原因:高处坠落伤10例,交通事故伤6例。Essex-Lopresti舌型骨折4例,SandersⅡA型5例、ⅡB型4例、ⅢAB型3例。受伤至手术时间4~8 d,平均5.94 d。均采用距下关节后外侧、后内侧入路关节镜辅助下闭合复位经皮空心螺钉内固定治疗。手术前后测量B?hler角、Gissane角、跟骨宽度,术后12个月根据美国矫形足踝协会(AOFAS)踝-后足评分评价踝关节功能。结果术后切口Ⅰ期愈合,无坏死感染、骨筋膜室综合征等并发症发生。术后患者均获随访,随访时间12~15个月,平均13.63个月。术后6个月X线片示骨折线消失,局部无明显压痛及纵向叩击痛,无内固定物断裂及退出,跟骨外侧壁无明显突出,跟骨结节无明显内翻,足弓形态良好,无距下关节融合及腓骨肌腱压迫症状。术后2例发生跟腱激惹,取出内固定物后症状消失;2例发生创伤性关节炎,其中1例症状明显者取出内固定物并行距下关节清理后症状缓解,另1例取钉时未予以关节清理,术后口服塞来昔布症状缓解。术后3 d及6个月B?hler角、Gissane角、跟骨宽度均较术前明显改善(P<0.05);术后6个月各指标均较术后3 d轻度丢失,但差异无统计学意义(P>0.05)。术后12个月根据AOFAS踝-后足评分评价踝关节功能,获优11例,良3例,中2例,优良率87.5%。结论距下关节后侧入路关节镜辅助下闭合复位经皮空心螺钉固定可有效治疗Essex-Lopresti舌型及SandersⅡA、ⅡB、ⅢAB型跟骨骨折,创伤小、并发症少、功能恢复优良,发挥了微创手术的优势。

Objective To evaluate the results of arthroscopically-assisted closed reduction and percutaneous screw fixation by posterior approach to subtalar joint for calcaneal fractures of Essex-Lopresti tongue type, Sanders IIA, IIB, and IIIAB. Methods Sixteen patients with unilateral calcaneal fracture were treated with arthroscopically-assisted closed reduction and percutaneous screw fixation by posterior approach to subtalar joint between June 2012 and June 2015. There were 13 males and 3 females with an average age of 37.8 years （range, 18-65 years）. The injury causes included falling from height in 10 cases and traffic accident in 6 cases. Of 16 cases, 4 were classified as Essex-Lopresti tongue type, 5 as Sanders IIA, 4 as Sanders liB, and 3 as Sanders IIIAB. The interval of injury and operation was 4-8 days （mean, 5.94 days）. The B6hler angle, Gissane angle, and width of calcaneus were measured before and after operation. American Orthopaedic Foot and Ankle Society （AOFAS） score was used to evaluate the ankle function at 12 months after operation. Results Primary healing of incision was obtained in all cases, and no complications of infection, necrosis, and osseousfascia compartment syndrome occurred. The patients were followed up 12-15 months （mean, 13.63 months）. The X-ray films showed that fracture line disappeared at 6 months after operation; the patients had no tenderness or percussion pain, no breakage or loosening of internal fixation, no varus calcaneus tuberosity, no subtalar joint fusion, and no compression symptoms of peroneal tendons. Achilles tendon irritation occurred in 2 cases, and disappeared after removal of internal fixation; traumatic arthritis occurred in 2 cases, and was relieved after removal of internal fixation. The Bohler angle, Gissane angle, and calcaneal width were significantly improved at 3 days and 6 months after operation when compared with preoperative ones （P〈0.05）. The loss of the above indexes was observed at 6 months, showing no significant difference between at 3 days and 6 months （P〉0.05）. The AOFAS score results were excellent in 11 cases, good in 3 cases, and fair in 2 cases, and the excellent and good rate was 87.5%. Conclusion It has the advantages of little trauma, less complication, and good function recovery to use arthroscopically-assited closed reduction and percutaneous screw fixation by posterior approach to subtalar joint for calcaneal fractures of Essex-Lopresti tongue type, Sanders IIA, Sanders IIB, and Sanders IIIAB.