跟骨牵引与外固定架临时固定分步延期治疗C型Pilon骨折的病例对照研究

Case-control study on calcaneal traction and external fixator fixation of fractional delayed surgery for type C Pilon fracture

目的:比较Ⅰ期跟骨牵引与外固定支架临时固定分步延期切开复位内固定治疗C型Pilon骨折的临床疗效。方法:回顾性分析2012年1月至2017年12月收治的45例Pilon骨折患者的临床资料。其中牵引组24例,男16例,女8例;年龄21~57(38.6±10.5)岁;高处坠落伤18例,车祸伤6例;左侧15例,右侧9例;AO/OTA分型C1型3例,C2型9例,C3型12例;采用Ⅰ期跟骨牵引,Ⅱ期切开复位钢板内固定治疗。外固定组21例,男15例,女6例;年龄19~58(37.8±11.2)岁;高处坠落伤17例,车祸伤4例;左侧11例,右侧10例;AO/OTA分型C1型2例,C2型8例,C3型11例;采用Ⅰ期外固定支架固定,Ⅱ期切开复位内固定治疗。所有患者为闭合性骨折。比较两组患者术前等待时间、住院时间、手术时间、术后并发症、骨折复位情况、骨折愈合时间等,采用VAS评分评价Ⅱ期内固定术前疼痛缓解情况,采用Burwell-Charnley影像学评价标准对内固定术后Pilon骨折复位情况进行评价,采用美国矫形足踝协会(AOFAS)踝-后足评分系统评价踝关节功能恢复情况。结果:两组患者手术时间、随访时间、骨折愈合时间比较差异无统计学意义。内固定术前跟骨牵引组VAS评分为(3.73±0.87)分,外固定组为(2.67±0.69)分,两组比较差异有统计学意义。牵引组术前等待时间、住院时间分别为(9.20±1.40) d、(12.30±3.60) d,外固定组分别为(7.60±1.50) d、(10.80±2.60) d,两组比较差异有统计学意义。两组并发症例数比较差异无统计学意义。根据Burwell-Charnley影像学评价标准,牵引组解剖复位20例,一般复位4例;外固定组解剖复位18例,一般复位3例;两组比较差异无统计学意义。两组AOFAS评分及疗效评价比较差异无统计学意义。结论:对于C型Pilon骨折,Ⅰ期跟骨牵引或临时外固定支架固定都能起到临时稳定作用,为Ⅱ期内固定手术创造较好的软组织条件,内固定术后能够获得较好的踝关节功能。跟骨牵引操作简单,外固定支架固定虽然会增加手术次数,但有更好的制动效果,在减轻术前疼痛、缩短术前等待时间和住院时间等方面较跟骨牵引更有优势。

Objective:To compare clinical effects of calcaneal traction and external fixator fixation of fractional delayed surgery in treating type C Pilon fractures.Methods:From January 2012 to December 2017,clinical data of 45 patients with tibial Pilon fractures were respectively analyzed.There were 24 patients in traction group,including 16 males and 8 females,aged from 21 to 57 years old with an average age of(38.6±10.5) years old;18 patients caused by falling down,6 patients caused by traffic accident;15 patients on the left side and 9 patients on the right side;according to AO/OTA classification.3 patients classified type C1,9 patients classified type C2 and 12 patients classified type C3;treated by calcaneal traction on the first stage,and open reduction and internal fixation on the second stage.There were 21 patients in external fixation group,including 15 males and 6 females,aged from 19 to 58 years old with an average age of(37.8±11.2) years old;17 patients caused by falling down,4 patients caused by traffic accident;11 patients on the left side and 10 patients on the right side;according to AO/OTA classification,2 patients classified type Cl,8 patients classified type C2 and 11 patients classified type C3;treated by external fixator on the first stage,and open reduction and internal fixation on the second stage.All patients were closed fracture.Preoperative waiting time,hospital stays,operative time,postoperative complications,fracture reduction and healing time between two groups were compared,VAS score was used to evaluate relief of pain before internal fixation on the second stage,Burwell-Charnley radiological evaluation criteria was applied to evaluate fracture reduction after internal fixation,A OF AS score was used to evaluate recovery of ankle joint function.Results:There were no statistical difference in operative time,following-up time and fracture healing time between two groups.VAS score before internal fixation in traction group was 3.73±0.87,while in external fixation group was 2.67±0.69,there was statistical difference between two groups.Preoperative waiting time,and hospital stays in traction group were(9.20±1.40) d,(12.30±3.60) d;while in external fixation group were(7.60±1.50) d,(10.80±2.60) d;and had significant difference between two groups.There was no difference in complications between two groups.According to Burwell-Charnley radiological evaluation criteria,20 patients obtained anatomical reduction,and 4 patients received normal reduction in traction group;18 patients obtained anatomical reduction,and 3 patients received normal reduction in external fixation group;while without difference between two groups.There was no difference between two groups in AOFAS score.Conclusion:For type C Pilon fractures,one-stage calcaneus traction or temporary external fixation also could achieve temporary fixation and provide better soft tissue conditions for the second stage internal fixation,and could receive better ankle joint function after internal fixation.The operation of calcaneus traction is simple,while external fixation may be increase the number of operation times,but external fixation has more advantages in reducing preoperative pain,shortening preoperative waiting days and hospitalization time than traction.