三种手术方法治疗SandersⅢ型跟骨骨折的疗效比较

Comparison among three surgical methods in the treatment of Sanders typeⅢcalcaneal fracture

目的探讨经皮撬剥复位、跗骨窦入路螺钉、扩大外侧入路钢板固定治疗SandersⅢ型跟骨骨折的临床疗效。方法回顾性分析2015年2月至2018年2月我院采用手术治疗的27例SandersⅢ型闭合跟骨骨折患者的临床资料。其中男18例,女9例;年龄22~48岁,平均38.5岁。致伤原因:交通伤10例,高坠伤17例。按手术方式将其随机双盲分为三组(n=9):A组采用经皮撬剥复位固定,B组采用跗骨窦入路螺钉固定,C组采用扩大外侧入路钢板固定。记录三组患者的受伤至手术时间、手术时间、失血量、复位质量和术后并发症发生情况等,术后3个月和末次随访采用美国矫形外科足踝协会(American orthopaedic foot&ankle society,AOFAS)评分评价后足功能。结果本组获10~16个月(平均11.4个月)随访。所有患者均获骨折愈合,无深静脉血栓形成等早期并发症的发生。A、B组的受伤至手术时间分别为(3.3±0.5)天、(4.0±0.8)天,手术时间为(35.4±3.17)min、(52.3±4.9)min,失血量为(28.9±10.5)ml、(65.0±12.5)ml均明显少于C组(11.1±1.2)天、(88.4±5.2)min、(95.0±13.5)ml,三组相比差异有统计学意义(P均<0.01)。术后B、C组骨折复位质量Bohler(26.8±2.0)°、(29.0±2.8)°均好于A组(19.1±1.8)°,三组比较差异有统计学意义(P均<0.01)。末次随访B、C组AOFAS评分(82.0±2.7)分、(85.0±4.7)分明显优于A组(74.2±4.5)分(P=0.002)。术后A组出现3例骨折复位部分丢失,C组出现1例部分切口皮缘坏死、延迟愈合。结论三种手术方式均可用于SandersⅢ型跟骨骨折的治疗。跗骨窦入路螺钉固定与扩大外侧入路钢板固定有相似的固定效果和功能恢复,但跗骨窦入路螺钉固定对软组织损伤小、操作简单;扩大外侧入路钢板固定显露更充分、放置内置物方便。经皮撬剥复位固定对软组织损伤最小,但难以解剖复位距下关节面、无法有效恢复跟骨宽度,术后存在复位丢失的风险。

Objective To investigate clinical effects of percutaneous reduction,tarsal sinus screw and expanded lateral approach plate fixation in the treatment of Sanders typeⅢcalcaneal fracture.Methods Clinical data of 27 patients with Sanders typeⅢclosed calcaneal fractures were retrospectively analyzed.All were treated surgically from February 2015 to February 2018.There were 18 males and 9 females with an average age of 38.5 years(range:22-48 years).Causes of injury:traffic injuries in 10 patients;high fall injuries in 17 patients.All patients were divided into 3 groups according to different operation methods:Group A(n=9),percutaneous prying reduction and fixation;Group B(n=9),tarsal sinus screw fixation;Group C(n=9),expanded lateral approach plate fixation.The time from injury to operation,operation time,blood loss,reduction quality and complications were recorded.The hind foot functions were evaluated by AOFAS score 3 months postoperatively and at the final follow-up.Results All patients were followed up for 10-16 months(average:11.4 months).Bone union was achieved in all patients without early complications such like deep venous thrombosis.The average time from injury to operation[(3.3±0.5)days;(4.0±0.8)days],operation time[(35.4±3.17)minutes;(52.3±4.9)minutes],blood loss[(28.9±10.5)ml;(65.0±12.5)ml]of Group A and B were significantly less than those of Group C[(11.1±1.2)days;(88.4±5.2)minutes;(95.0±13.5)ml]with statistical significance among 3 groups(P<0.01).The postoperative average Bohler angles of the fracture reduction quality of Group B(26.8±2.0)°and C(29.0±2.8)°were better than that of Group A(19.1±1.8)°with statistical significance among 3 groups(P<0.01).The AOFAS scores of Group B(82.0±2.7)and C(85.0±4.7)were significantly higher than that of Group A(74.2±4.5)(P=0.002).Partial loss of the fracture reduction was observed in 3 patients in Group A.Skin margin necrosis and delayed healing were noted in 1 patient of Group C.Conclusions All 3 surgical methods can be used in the treatment of Sanders typeⅢcalcaneal fracture.Screw fixation via tarsal sinus approach will achieve similar effects with less invasion and easier operation as the plate fixation via expanded lateral approach with better exposure for implants.Percutaneous prying restoration and fixation causes least damage to soft tissues,however,it is difficult to anatomically reposition the subtalar articular surface and restore calcaneal width effectively with a risk of reduction loss.