外侧扩大“L”形入路治疗移位关节内跟骨骨折的疗效评价

Extensile L-shaped lateral approach for displaced intra-articular calcaneal fractures

目的评价外侧扩大"L"形入路治疗移位关节内跟骨骨折(displaced intra-articular calcaneal fractures,DIACF)的效果。方法回顾性分析2015年1月—2016年12月收治的DIACF患者临床资料97例121足,其中男性89例,女性8例;年龄19~63岁,平均37.0岁;致伤原因:高处坠落伤70例,道路交通伤27例;骨折分型采用Sanders分型,Ⅱ型43足(35.5%),Ⅲ型54足(44.6%),Ⅳ型24足(19.8%);受伤至手术时间4~13d,平均7.3d。所有患者均采用外侧扩大"L"形入路手术治疗,术后记录切口愈合情况并对切口并发症危险因素进行Logistic回归分析,术后随访采用末次X线B9hler角,功能评价采用Maryland足部功能评分。结果术后有22足发生切口并发症,其中15足皮缘发黑,4足皮瓣坏死,3足切口感染,予抗感染、切口换药、负压封闭引流或抗生素骨水泥填塞后治愈。Logistic回归分析模型显示Sanders分型Ⅲ、Ⅳ型及手术时间≥1.5h为危险因素(OR值>1,P<0.05);术后随访时间10~18个月(平均12.7个月),术后B9hler角较术前改善(28.1°±4.1°vs.3.1°±4.5°,P=0.000),Maryland评分总优良率为79.3%,不同Sanders分型的术后功能优良率差异有统计学意义(χ~2=9.447,P=0.009)。结论外侧扩大"L"形入路治疗DIACF依然切实可行,有助于恢复跟骨的解剖结构,应尽量缩短手术时间。

Objective To investigate the effect of extensile L-shaped lateral surgical approach for displaced intra-articular calcaneal fractures（ DIACF）. Methods A retrospective review was made between Jan. 2015 to Dec. 2016. Ninety-seven patients（ 121 feet） with closed DIACF were included. Eighty-nine were males and 8 females,with age ranging from 19 to 63 years（ mean 37. 0 years）. The trauma causes included high fall injury in 70 cases,and traffic injury in 27 cases. Calcaneal fractures were classified according to the Sanders classification,43 feet were type Ⅱ,54 were type Ⅲ and 24 were type Ⅳ. Operations were performed 4-13 days after injury. All patients presented extensile L-shaped lateral approach surgery. Information about wound complications and risk factors was recorded. Postoperative clinical outcome was evaluated according to the analysis of B9 hler＇s angle at final followup,and functional assessment was conducted using the Maryland foot score（ MFS）. Results There were 22 heels of wound complications,including dark skin in heel margin in 15 cases,skin flap necrosis in 4 heels,and infection in3 heels. All incisions cured after antibiotics,wound dressing,or using vacuum sealing drainage,or filling antibioticimpregnated cement. Multivariate logistic regression analysis showed that Sanders fracture type Ⅲ,Ⅳ and surgical timing of more than 1. 5 h increased the wound complications incidence（ odds ratio value 1,P 0. 05）. The follow-up period was from 10 to 18 months（ mean 12. 7 months）. Radiological results were satisfying with postoperative B9 hler angle improved at follow-up（ P = 0. 000）. Based on the MFS,79. 3% of the patients had a good-to-excellent clinical result. Sanders fracture type had significant influence on the functional postoperative outcome in terms of MFS（ χ2= 9. 447,P = 0. 009）. Conclusion Extensile L-shaped lateral approach for DIACF continues to be practicable. The main objective of the operation is to restore anatomy of calcaneus,and try our best to shorten the operation time is important.