跗骨窦入路锁定钢板内固定治疗跟骨骨折

Sinus tarsi approach combined with locking plate internal fixation in treatment of calcaneal fracture

目的探讨跗骨窦入路经皮斯氏针撬拨复位锁定钢板内固定治疗跟骨骨折的临床疗效。方法回顾性分析福建省立医院创伤外科2015年12月—2018年12月收治的92例跟骨骨折患者的临床资料,男性63例,女性29例;年龄24~72岁,平均41.9岁。均为闭合性骨折,按Sanders分型:Ⅱ型57例,Ⅲ型35例。受伤至手术时间4~14d,平均6.2d。行经跗骨窦入路复位锁定钢板内固定治疗47例(跗骨窦组),SandersⅡ型32例,Ⅲ型15例;行经外侧入路“L”形切开复位锁定钢板内固定治疗45例(外侧组),SandersⅡ型25例,Ⅲ型20例。比较两组切口总长度、手术时间、术中出血量、住院时间、术前及术后Bohler及Gissane角(组内对比)、术后6个月骨折愈合情况、术后12个月美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝-后足评分和并发症情况。结果术后随访12~24个月,平均17.2个月。跗骨窦组和外侧组切口总长度分别为(5.7±1.2)cm和(10.4±1.5)cm(P<0.05),手术时间分别为(70.9±10.4)min和(69.6±11.9)min(P>0.05),术中出血量分别为(46.5±14.6)mL和(57.1±18.8)mL(P<0.05),住院时间分别为(13.7±2.7)d和(17.2±4.4)d(P<0.05)。跗骨窦组术前及术后Bohler角分别为(17.3±2.3)°和(26.1±3.2)°(P<0.05),Gissane角分别为(105.5±4.8)°和(121.5±15.9)°(P<0.05);外侧组术前及术后Bohler角分别为(17.4±2.2)°和(28.9±2.0)°(P<0.05),Gissane角分别为(105.7±4.1)°和(120.5±16.9)°(P<0.05)。术后6个月所有患者骨折愈合良好。术后12个月跗骨窦组AOFAS评分:优36例,良7例,中3例,差1例,优良率91.5%;外侧组:优30例,良10例,中4例,差1例,优良率88.9%(P>0.05)。术后并发症:跗骨窦组1例(患足疼痛感),外侧组6例(3例切口皮缘坏死、2例切口感染、1例关节僵硬),差异有统计学意义(2.1%vs.13.3%,P<0.05),两组均无足内翻畸形。结论对于SandersⅡ、Ⅲ型跟骨骨折,跗骨窦入路经皮斯氏针撬拨复位内固定较外侧入路“L”形切开复位内固定切口更小、并发症更少、功能恢复更好,是一种微创且可靠的治疗方法。

Objective To investigate the clinical efficacy of sinus tarsi approach with percutaneous pry reduction and locking plate internal fixation with calcaneal locking plate for calcaneal fracture.Methods A retrospective case-control study was conducted to analyze the complete medical records of 92 patients with calcaneal fracture admitted to the Department of Traumatic Surgery,Fujian Provincial Hospital from Dec.2015 to Dec.2018.There were 63 males and 29 females,aged from 24 to 72 years(average,41.9 years).All patients were closed fractures.According to Sanders classification,there were 57 cases of typeⅡand 35 cases of typeⅢ.The duration from injury to operation ranged from 4 to 14 days(average,6.2 days).Forty-seven cases received sinus tarsi approach with reduction and locking plate internal fixation(minimally invasive group),including 32 cases of typeⅡand 15 cases of typeⅢ.Forty-five cases received the lateral approach L-shaped incision with reduction and locking plate internal fixation(conventional group),including 25 cases of typeⅡand 20 cases of typeⅢ.The total length of incision,operation time,intraoperative blood loss,hospitalization time,the Bohler and Gissane angles with X-ray before and after operation(intra-group comparison),and the fracture healing at 6 months after operation,the Ankle-Hindfoot Score(American Orthopaedic Foot and Ankle Society,AOFAS)at 12 months after operation and complications were compared.Results All patients were followed up for 12 to 24 months(average,17.2 months).In the minimally invasive group and the conventional group,the total length of incision was(5.7±1.2)cm and(10.4±1.5)cm(P<0.01),the operation time was(70.9±10.4)minutes and(69.6±11.9)minutes(P>0.05),the intraoperative blood loss was(46.5±14.6)mL and(57.1±18.8)mL(P<0.01),the hospitalization time was(13.7±2.7)days and(17.2±4.4)days(P<0.05).In the minimally invasive group the Bohler angle before and after surgery was(17.3±2.3)°and(26.1±3.2)°(P<0.01),and the Gissane angle before and after surgery was(105.5±4.8)°and(121.5±15.9)°(P<0.01).In the conventional group,the Bohler angle before and after operation was(17.4±2.2)°and(28.9±2.0)°(P<0.01),and the Gissane angle before and after operation was(105.7±4.1)°and(120.5±16.9)°(P<0.01).All 92 patients obtained good bone healing at 6 months after operation.After 12 months,the AOFAS score in the minimally invasive group was excellent in 36 cases,good in 7 cases,fair in 3 cases,and poor in 1 case,with an excellent and good rate of 91.5%.For the conventional group,the score was excellent in 30 cases,good in 10 cases,fair in 4 cases,and poor in 1 case,with an excellent and good rate of 88.9%(P<0.05).One case(2.1%)felt foot pain after operation in minimally invasive group,while 6 cases(13.3%)occurred complications in conventional group(including 3 cases of incision flap necrosis,2 cases of incision infection,1 case of foot joint stiffnes).Neither group had varus deformity.Conclusion For the Sanders typeⅡorⅢof calcaneal fractures,compared with the lateral approach L-shaped incision,the sinus tarsi approach with percutaneous pry reduction and locking plate internal fixation has the advantages of smaller incision,less complications,and better functional recovery,which is minimally invasive and reliable.