经跗骨窦小切口入路和跟骨外侧“L”形切口入路治疗跟骨关节内骨折对患者功能恢复的影响

Effects of small sacral sinus incision approach and lateral calcaneal L-shaped incision approach on calcaneal intra-articular fractures in patients with functional recovery

目的探讨经跗骨窦小切口入路和跟骨外侧“L”形切口入路治疗跟骨关节内骨折对患者功能恢复的影响。方法采用前瞻性研究方法,选取2016年4月至2017年12月四川大学华西医院收治的跟骨关节内骨折患者94例,采用简单随机化方法将其分为两组:对照组和观察组,每组各47例。对照组患者采用跟骨外侧“L”形切口入路,观察组患者采用经跗骨窦小切口入路。比较两组患者的一般手术情况、跟骨宽度、Bolher角、跟骨长度、Gissane角、疼痛应激[P物质(SP)、神经肽Y(NPY)]和炎症应激[白细胞介素-1β(IL-1β)、肿瘤坏死因子-α(TNF-α)]指标水平、并发症、术后2年足功能。结果观察组患者的手术时间、下床时间、住院时间、切口愈合时间、切口长度分别为(41.03±6.85)min、(5.78±1.26)d、(12.55±3.93)d、(10.05±2.76)d、(4.25±0.82)mm,均短于对照组的(68.54±15.27)min、(7.85±2.40)d、(24.24±4.56)d、(16.29±5.34)d、(15.74±1.59)mm,术中失血量为(45.49±15.03)ml,低于对照组的(86.97±22.16)ml,差异均具有统计学意义(P<0.05);术后观察组患者的跟骨宽度为(27.59±2.46)mm,低于对照组的(30.11±2.23)mm,Bolher角、跟骨长度、Gissane角分别为(34.04±5.19)°、(74.08±6.40)mm、(119.44±8.01)°,高于对照组的(31.25±4.08)°、(71.11±5.06)mm、(112.37±6.28)°,差异均具有统计学意义(P<0.05);术后1 d,观察组患者的SP、NPY、IL-1β、TNF-α分别为(5.65±0.86)μg/ml、(169.87±15.03)pg/ml、(4.39±0.25)μg/L、(10.02±0.87)pg/ml,均低于对照组的(7.14±1.29)μg/ml、(185.49±13.35)pg/ml、(5.57±0.34)μg/L、(13.49±0.68)pg/ml,差异具有统计学意义(P<0.05);观察组患者的并发症发生率(2.13%,1/47)与对照组(8.51%,4/47)比较,差异无统计学意义(P>0.05);术后2年,观察组患者的足功能优良率(95.45%,42/44)与对照组(97.62%,41/42)比较,差异无统计学意义(P>0.05)。结论与跟骨外侧“L”形切口入路相比,经跗骨窦小切口入路治疗跟骨关节内骨折,能缩短手术时间,减少术中失血量,加快切口愈合和术后恢复,减轻围手术期疼痛和应激反应。

Objective To investigate the effect of small sacral sinus incision approach and lateral calcaneal L-shaped incision approach on intra-articular calcaneal fractures in patients with functional recovery.Methods A total of 94 patients with intra-articular calcaneal fractures admitted in West China Hospital,Sichuan University from April 2016 to December 2017 were selected for a prospective study,and they were divided into two groups using a simple randomization method:control group and observation group,with 47 cases in each group.The control group used an lateral L-shaped incision approach to the lateral calcaneus,and the observation group used a small iliac sinus approach.The general surgical conditions,calcaneal width,Bolher angle,calcaneal length,Gissane angle,pain stress[substance P(SP),neuropeptide Y(NPY)],inflammatory stress[interleukin-1β(IL-1β),tumor necrosis factor-α(TNF-α)]index levels,complications,and foot function at 2 years after operation were compared between the two groups.Results The operation time,getting out of bed,hospitalization time,incision healing time and incision length of observation group were(41.03±6.85)min,(5.78±1.26)d,(12.55±3.93)d,(10.05±2.76)d,(4.25±0.82)mm,all were shorter than(68.54±15.27)min,(7.85±2.40)d,(24.24±4.56)d,(16.29±5.34)d,(15.74±1.59)mm of the control group,the intraoperative blood loss was(45.49±15.03)ml,which was lower than that of the control group(86.97±22.16)ml,the differences were statistically significant(P<0.05).The calcaneus width of the postoperative observation group was(27.59±2.46)mm,which was lower than that of the control group(30.11±2.23)mm,Bolher angle,calcaneus length,and Gissane angle were(34.04±5.19)°,(74.08±6.40)mm,(119.44±8.01)°,which were higher than those of the control group(31.25±4.08)°,(71.11±5.06)mm,(112.37±6.28)°,the differences were statistically significant(P<0.05).One day after operation,the SP,NPY,IL-1βand TNF-αof the observation group were(5.65±0.86)μg/ml,(169.87±15.03)pg/ml,(4.39±0.25)μg/L,(10.02±0.87)pg/ml,lower than that of the control group(7.14±1.29)μg/ml,(185.49±13.35)pg/ml,(5.57±0.34)μg/L,(13.49±0.68)pg/ml,the difference was statistically significant(P<0.05).Compared with the control group(8.51%,4/47),the incidence of complications in the observation group(2.13%,1/47)was not statistically significant(P>0.05);two years after surgery,the excellent rate of foot function(95.45%,42/44)in the observation group was compared with the control group(97.62%,41/42),and the difference was not statistically significant(P>0.05).Conclusion Compared with the lateral calcaneal L-shaped incision approach,the transtarsal sinus incision approach to treat intra-articular fractures of the calcaneus can shorten the operation time and reduce blood loss during the operation,accelerate the incision healing and postoperative recovery,and reduce the perioperative pain and stress response.