切开复位内固定结合植骨治疗SandersⅢ、Ⅳ型跟骨骨折

Open reduction and internal fixation plus artificial bone graft for treatment of Sanders type Ⅲ and Ⅳ calcaneal fractures

目的探讨切开复位内固定（ORIF）结合硫酸钙骨粉移植治疗SandersⅢ、Ⅳ型跟骨骨折的疗效。方法采用回顾性病例对照研究分析2012年1月-2015年12月收治的30例SandersⅢ、Ⅳ型跟骨骨折患者临床资料。根据治疗方法分为ORIF＋硫酸钙骨粉移植组（植骨组）和ORIF组（对照组）。植骨组17例，其中男12例，女5例；年龄19～62岁[（41．6±12．9）岁]；SandersⅢ型12例，Ⅳ型5例。对照组13例，其中男8例，女5例；年龄20～59岁[（39．4±11．8）岁]；SandersⅢ型10例，Ⅳ型3例。术后1，2，3，6，12个月随访记录并发症情况。观察术前、术后2d、术后12个月跟骨Bohler角和Gissan角变化。末次随访时以美国足踝外科协会（AOFAS）踝-后足评分评价两组患者功能改善情况。结果植骨组3例发生切口皮缘坏死，软组织浅表感染2例；对照组发生皮缘坏死2例，软组织浅表感染1例。两组患者术后Bohler角、Gissan角均有明显改善，术后早期组间比较，BShler角、Gissan角差异无统计学意义（P〉0．05）。术后12个月，植骨组与对照组Bohler角分别为（23．2±9．0）°、（19．5±11．1）°，角度丢失分别为（3．6-4-2．7）°、（6．9±3．1）°，两组角度丢失差异有统计学意义（P〈0．05）；而Gissan角分别为（123．4±9．4）°、（122．2±9．0）°，角度改变分别（2．8±1．8）°、（3．8±2．3）°（P〉0．05）。末次随访时所有患者均达骨性愈合，AOFAS评分差异无统计学意义（P〉0．05）。结论SandersⅢ、Ⅳ型跟骨骨折进行切开复位内固定时，植骨与否均能达到良好的治疗效果，但植骨可能对骨折块的稳定、跟距关节面的早期支撑起到良好的作用。

Objective To investigate the effects of open reduction and internal fixation plus calcium sulfate artificial bone graft for the treatment of Sanders type Ⅲ and Ⅳ calcaneal fractures. Methods The clinical data of patients with Sanders type Ⅲ and Ⅳ calcaneal fractures treated from January 2012 to December 2015 were retrospectively reviewed by case-control study. The patients were divided into two groups as bone graft group （open reduction and internal fixation combined with artificial bone graft） and control group （ open reduction and internal fixation）. The bone graft group was composed of 17 cases, among which there were 12 males and five females with age range of 19-62 years [ （41.6 ± 12.9） years]. In bone graft group, there were 12 cases of Sanders Ⅲ and five cases of Sanders Ⅳ. The control group was composed of 13 eases, among which there were eight males and five females with age range of 20-59 years [ （39.4 ±11.8） years ]. In control group, there were ten cases of Sanders Ⅲ and three cases of Sanders IV. The follow-up visits were done at 1, 2, 3, 6, and 12 months after surgery with record of complication occurrence. The changes of Bohler＇s angle and Gissan＇s angle were observed preoperatively as well as at 2 days and 12 months after surgery. The function recovery was evaluated by the American Orthopaedic Foot and Ankle Society （AOFAS） score at final follow-up visit. Results Five cases of marginal necrosis of the incision and two cases of superficial soft tissue infection were seen in bone graft group, while there were two cases of marginal necrosis of the incision and one cases of superficial soft tissue infection in control group. In early postoperative comparison between two groups, the variation of Bohler＇s angle and Gissan＇s angle had no significant difference （P 〉 0.05 ）. At 12 months after surgery, Bohler＇s angle of bone graft and control groups were （23.2 ± 9.0）° and （ 19.5± 11.1 ） °, respectively. The losses of Bohler＇s angle were （ 3.6± 2.7 ） ° and （ 6.9 ± 3. 1 ）°, respectively. The difference in the losses of angle in two groups had statistical significance （ P 〈 0.05 ）. Gissan＇s angle of bone graft and control groups were （ 123.4 ±9.4）° and （ 122.2±9.0） °, respectively. The losses of Gissan＇s angle were （ 2.8± 1.8 ）° and （ 3.8 ±2.3 ） °, respectively （ P 〉 0.05 ）. At the final follow-up, bone union was found in all cases, and there was no significant difference in AOFAS score between the two groups （ P 〉 0.05 ）. Conclusions Open reduction and internal fixation can attain good treatment results for Sanders type Ⅲ and Ⅳcalcaneal fractures, no matter whether bone graft is carried out. However, artificial bone graft may have good effects to sustain the stability of fracture fragments and provide early mechanical support for the subtalar joint.