陈旧性跟骨骨折畸形愈合的手术治疗:五种手术方式的疗效分析

Surgical treatments of the malunited calcaneal fractures: curative effects analysis of the five methods

目的探讨五种手术方式治疗不同类型陈旧性跟骨骨折畸形愈合的临床效果。方法回顾分析2003年1月至2017年7月郑州市骨科医院采用切复内固定术、跟骨丘部和后距下关节重建保留距下关节术、距下关节原位关节融合术、距下关节撑开植骨融合术、跟骨旋转截骨丘部重建距下关节融合术五种方法治疗各种陈旧性跟骨骨折畸形愈合60例72足,男49例60足,女11例12足;单侧52例52足,双侧10例20足。年龄10～68岁,平均(42.4±2.1)岁。采用切复内固定术10例14足、跟骨丘部和后距下关节重建保留距下关节术28例34足、距下关节原位关节融合术6例6足、距下关节撑开植骨融合术9例10足、跟骨旋转截骨丘部重建距下关节融合术7例8足。结果本组60例72足随访时间8～24个月,平均(11.0±1.6)个月。按Maryland足部评分系统评价术后功能,切复内固定组10例14足,优11足,良2足,可1足,差0足,优良率为92.9%;跟骨丘部和后距下关节重建保留距下关节组28例34足,优24足,良7足,可3足,差0足,优良率为91.2%;距下关节原位关节融合组6例6足,优3足,良2足,可1足,差0足,优良率为83.3%;距下关节撑开植骨融合组9例10足,优5足,良4足,可1足,差0足,优良率为90.0%;跟骨旋转截骨丘部重建距下关节融合组7例8足,优5足,良2足,可1足,差0足,优良率为87.5%。全组优48足,良17足,可7足,差0足,优良率为90.3%。术后切口感染、裂开7例,经换药、肉芽创面游离植皮逐渐愈合,螺钉松动1例,无跟骨内翻等并发症。骨折愈合时间10.5～16.2周,平均12.6周。结论伤后4个月以内的陈旧性跟骨骨折畸形愈合可以重现原始骨折线,采用切复内固定术可取得类似新鲜骨折的良好效果;对于伤后4个月至1年左右、术中跟距关节面接近正常者,采用重建跟骨丘部和后距下关节术具有矫正跟骨畸形、恢复后足外形及功能,同时保留距下关节的优点,是治疗严重陈旧性跟骨骨折畸形愈合的有效方法;对于伤后1年以上、术中跟距关节面尤其跟骨后关节面磨损严重者,可根据跟骨高度丢失情况及骨折类型,采用距下关节原位关节融合术、距下关节撑开植骨融合术及跟骨旋转截骨丘部重建距下关节融合术矫正陈旧性跟骨骨折后足畸形,恢复后足功能,有效缓解疼痛症状。

Objective To explore the curative effects of five surgical methods in treatment of different types of malunited calcaneal fractures.Methods From January2003to July2017,five kinds of surgical methods,such as open reduction and fixation,caleaneal cumulus and subtalar joint reconstruction,in situ subtalar arthrodesis,subtaler distraction bone-block arthrodesis and reconstructive osteotomy of the calcaneal with subtalar arthrodesis were performed in our hospital for calcaneal fracture malunion in60cases,72feet(49male60feet,11female12feet.Unilateral:52cases52feet, bilateral:10cases20feet).They were10to68years old,with an average of(42.4+2.1)years.Among them,re-open reduction and refixation was performed in10cases(14feet),caleaneal cumulus and subtalar joint reconstruction was performed in28cases(34feet),in situ subtalar arthrodesis was performed in6cases(6feet),subtaler distraction bone-block arthrodesis was performed in9cases(10feet),and reconstructive osteotomy of the calcaneal with subtalar arthrodesis was performed in7cases(8feet).Results A total of60cases were followed up for8to24months with an average of(11.0±1.6)months.According to the Maryland podiatric foot grading system,the postoperative function was evaluated in the group of10cases14feet with re-open reduction and fixation,11feet were excellent,2feet were good,1foot was fair,0foot was poor,and the superior rate was92.9%.Reconstruction of calcaneal dome and posterior subtalar joint reserved34feet in28cases,24feet were excellent,7feet were good,3feet were fair,0foot was poor,the superior rate was91.2%.In the in situ subtalar arthrodesis group,3feet were excellent,2feet were good,3feet were fair,0foot was poor,the superior rate was83.3%.In the subtaler distraction boneblockarthrodesis group,5feet were excellent,4feet were good,1foot was fair,0foot was poor,the superior rate was90.0%.In thereconstructive osteotomy of the calcaneal with subtalar arthrodesis group,5feet were excellent,2feet were good,1foot was fair,0footwas poor,the superior rate was87.5%.Totally,there were48feet excellent,17feet good,7feet fair,0foot poor,the total superior ratewas90.3%.There were7cases of wound infection and dehiscence after surgery,and1case with screw loosening was cured by dressingchange and skin graft on granulation wound,without complications such as heel varus.Fracture healing time ranged from10.5to16.2weeks,averaging12.6weeks.Conclusion For the malformation of calcaneal fractures within4months after injury,the original fractureline can be found.Good results similar to fresh fractures can be achieved by internal fixation.For those who have been injured between4months and1year,and the calcaneal joint surface is almost normal in operation,caleaneal cumulus and subtalar joint reconstructioncan be adopted,which can correct the calcaneal deformity,restore the shape and function of the hind foot,and retain subtalar joint.Forpatients injuried more than1year,with serious wear off the articular surface,especially the posterior articular surface of calcaneus,in situ subtalar arthrodesis,subtaler distraction bone-block arthrodesis and reconstructive osteotomy of the calcaneal with subtalararthrodesis can be chosen according to the height of calcaneus loss and fracture type,to correct foot deformity,restore hindfoot function,and relieve pain symptom effectively.