三种手术方案治疗跟骨关节内骨折的临床疗效及对机体内环境的影响

Clinical efficacy and impact on internal environment of three surgical approaches in treatment of intra-articular calcaneal fractures

目的比较经皮撬拨复位空心螺钉、小切口结合微钢板内固定和微创跗骨窦入路内固定术治疗SandersⅡ、Ⅲ型跟骨关节内骨折的疗效及对机体内环境的影响。方法选择2017年9月至2019年6月在淮北市中医医院收治的90例SandersⅡ、Ⅲ型闭合性跟骨关节内骨折患者,其中男性72例,女性18例;年龄25~65岁,平均年龄41.62岁;左侧43例,右侧47例;高处坠落伤71例,车祸12例,其他原因7例。Sanders分型Ⅱ型47例,Ⅲ型43例;受伤至手术时间2~8 d,平均受伤至手术时间(3.50±0.34) d。按随机数字表法分为空心钉组、微钢板组、跗骨窦组,其中空心钉组给予经皮撬拨复位空心螺钉进行手术治疗;微钢板组给予小切口结合微钢板内固定;跗骨窦组给予微创跗骨窦入路内固定术。术后完成6个月随访,比较3组手术时间、术中出血量、骨折愈合时间和完全下地负重时间,术前、术后均测量B觟hler角和Gissane角,按美国足踝外科协会(AOFAS)足部评分系统评价疗效。采用免疫比浊仪法检测各组患者术前和术后1周血清中IgG、IgM、IgA水平。结果空心钉组术中出血量为(14.54±1.36) mL,均低于微钢板组[(29.35±3.20) mL]和跗骨窦组[(29.41±3.17) mL];空心钉组切口长度为(1.21±0.07) cm,均低于微钢板组[(4.36±0.35) cm]和跗骨窦组[(4.40±0.37) cm];而术中透视次数为(4.27±0.34)次,均高于微钢板组[(3.69±0.37)次]和跗骨窦组[(2.22±0.24)次],差异均具有统计学意义(P <0.05)。空心钉组术后1个月和6个月跟骨宽度为(32.25 cm±3.24 cm、32.44 cm±2.87 cm),分别高于微钢板组[(27.29±3.36) cm、(27.38±2.73) cm]和跗骨窦组[(27.36±3.35) cm、(27.29±2.66) cm];Gissane角为(34.48°±3.88°、35.16°±3.25°),均高于微钢板组(31.54°±3.93°、31.59°±3.36°)和跗骨窦组(31.37°±3.68°、31.33°±3.29°),而B觟hler角为(111.14°±8.33°、111.18°±8.39°),均低于微钢板组(115.21°±8.28°、115.60°±9.20°)和跗骨窦组(115.35°±8.31°、115.65°±9.21°),差异均具有统计学意义(P <0.05)。跗骨窦组AOFAS评分优良率高于其他两组(93.3%vs 80.0%、86.7%;P <0.05)。3组术前血清IgG、IgM、IgA水平无明显差异(P> 0.05);术后1周空心钉组IgM、IgA分别为(1.12±0.08) g/L、(0.87±0.07) g/L,均低于微钢板组[(1.24±0.11) g/L、(0.95±0.10) g/L]和跗骨窦组[(1.21±0.10) g/L、(0.99±0.11) g/L],差异均具有统计学意义(P <0.05)。结论横斜型小切口微钢板固定和跗骨窦切口固定均可获得较好的力学稳定性,降低损伤,减少术中透视次数,改善术后关节功能,是SandersⅡ、Ⅲ型跟骨骨折的首选治疗方案。

Objective To compare the efficacy and impact on internal environment of percutaneous poking reduction cannulate screw, small-incision with microplate internal fixation and minimally invasive tarsal sinus internal fixation for treatment of Sanders type Ⅱ and Ⅲ intra-articular calcaneal fractures. Methods From September 2017 to June 2019, 90 patients with Sanders type Ⅱ and Ⅲ closed intra-articular calcaneal fractures were enrolled, which included 72 males and 18 females,aged 25-65 years old with mean age of 41.62 years old;There were 43 cases on the left side and 47 cases on the right side;71 cases of high falling injury, 12 of car accidents and 7 of other causes. The Sanders was divided into 47 cases of type Ⅱand 43 of type Ⅲ. The time of injury to surgery was 2-8 days with mean time of(3.50 ± 0.34) days. According to random number method, all of them were divided into cannulate screw group(performed percutaneous poking reduction cannulate screw),microplate group(performed small-incision with microplate internal fixation) and tarsal sinus group(performed minimally invasive tarsal sinus internal fixation). All of them were followed-up 6-month post-surgery, the surgery time, intraoperative blood loss, fracture healing time and full weight-bearing time in 3 groups were compared. The B?hler angle and Gissane angle before and after surgery were measured. The efficacy was evaluated according to American Foot and Ankle Surgery Association(AOFAS) Foot Scoring System. The level of IgG, IgM and IgA in serum before and 1-week after surgery of 3 groups were measured by immunoturbidimetry. Results The intraoperative blood loss of cannulate screw group[(14.54 ± 1.36) mL] was lower than that of microplate group[(29.35 ± 3.20) mL] and tarsal sinus group[(29.41 ± 3.17) mL];The incision length of cannulate screw group[(1.21 ± 0.07) cm] was lower than that of microplate group[(4.36 ± 0.35) cm] and tarsal sinus group[(4.40 ± 0.37) cm].The intraoperative perspective times of cannulate screw group[(4.27 ± 0.34) times] were statistically significantly higher than that of microplate group[(3.69 ± 0.37) times] and tarsal sinus group[(2.22 ± 0.24) times](P < 0.05). One-month and 6-month after surgery, the calcaneus width of cannulate screw group(32.25 cm ± 3.24 cm, 32.44 cm ± 2.87 cm) were higher than those of microplate group[(27.29 ± 3.36) cm,(27.38 ± 2.73) cm] and tarsal sinus group [(27.36 ± 3.35) cm,(27.29 ± 2.66) cm].The Gissane angle of cannulate screw group(34.48° ± 3.88°, 35.16° ± 3.25°) were higher than those of microplate group(31.54° ± 3.93°, 31.59° ± 3.36°) and tarsal sinus group(31.37° ± 3.68°, 31.33° ± 3.29°). The B?hler angle of cannulate screw group(111.14° ± 8.33°, 111.18° ± 8.39°) were statistically significantly lower than those of microplate group(115.21 ° ±8.28°, 115.60° ± 9.20°) and tarsal sinus group(115.35° ± 8.31°, 115.65° ± 9.21°)(P < 0.05). The excellent rate of AOFAS score in tarsal sinus group was higher than that in other 2 groups(93.3 % vs 80.0 %, 86.7 %;P < 0.05). There was no significant difference in serum IgG, IgM and IgA levels before surgery in 3 groups(P > 0.05). The IgM and IgA 1-week post-surgery of cannulate screw group[(1.12 ± 0.08) g/L,(0.87 ± 0.07) g/L] were lower than those of microplate group[(1.24 ± 0.11) g/L,(0.95 ±0.10) g/L] and tarsal sinus group[(1.21 ± 0.10) g/L,(0.99 ± 0.11) g/L], the differences were statistically significant(P < 0.05).Conclusion It is demonstrated that transverse small incision microplate fixation and tarsal sinus incision fixation showed good mechanical stability with low injury, reduced perspective times and improved postoperative joint function, which are preferred treatment in Sanders type Ⅱ and Ⅲ calcaneal fractures.