基于三维CT解剖重建距下关节撑开植骨融合术治疗陈旧性跟骨骨折畸形愈合临床观察

Clinical observation of subtalar joint expansion and bone graft fusion based on three-dimensional CT anatomical reconstruction for the treatment of old calcaneal fracture malunion

目的探讨基于三维CT解剖重建距下关节撑开植骨融合术治疗陈旧性跟骨骨折畸形愈合的临床效果。方法选择陈旧性跟骨骨折畸形愈合患者86例,随机分为观察组、对照组各43例。观察组予基于三维CT解剖重建距下关节撑开植骨融合术治疗,对照组予3D打印辅助下矫形术。比较两组手术一般情况,包括手术时间、术中出血量、术后下床时间、住院时间;术前和术后12、24 h疼痛创伤应激相关指标[β-内啡肽(β-EP)、P物质、前列腺素E2(PGE2)]和氧化应激相关指标[丙二醛(MDA)、总抗氧化能力(TAC)、脂质过氧化物(LPO)、羟基自由基(OH)、谷胱甘肽过氧化物酶(GSH-Px)];术前和术后3、6个月跟距影像学参数、美国足踝外科协会(AOFAS)Maryland评分、足部功能优良率,其中跟距影像学参数包括距骨倾斜角、Peries角、Gissane角、B(o)hler角、跟骨丘部高度、跟骨水平长度、跟骨轴长度、跟骨宽度。术后随访6个月,统计随访期间两组并发症情况。结果观察组手术时间长于对照组(P<0.05),两组术中出血量、术后下床时间和住院时间比较差异均无统计学意义(P均>0.05)。两组术后12 hβ-EP、P物质、PGE2、MDA、LPO、OH均高于术前,TAC、GSH-Px均低于术前(P均<0.05);两组术后同期上述指标比较差异均有统计学意义(P均<0.05)。观察组术后24 hβ-EP、P物质、PGE2、MDA、LPO、OH均低于术后12 h,TAC、GSH-Px均高于术后12 h(P均<0.05);但两组术后同期上述指标比较差异均无统计学意义(P均>0.05)。两组术后3、6个月距骨倾斜角、跟骨丘部高度、跟骨水平长度、跟骨轴长度、Peries角、Gissane角、B(o)hler角均高于术前,跟骨宽度均低于术前,且术后6个月变化更明显(P均<0.05);而两组同期上述指标比较差异均无统计学意义(P均>0.05)。两组术后3、6个月AOFAS Maryland评分均高于术前,以术后6个月变化更明显(P均<0.05);但两组同期AOFAS Maryland评分比较差异均无统计学意义(P均>0.05)。两组术后3、6个月足部功能优良率比较差异均无统计学意义(P均>0.05)。随访期间,两组术后并发症发生率比较差异无统计学意义(P>0.05)。结论基于三维CT解剖重建距下关节撑开植骨融合术治疗陈旧性跟骨骨折畸形愈合安全有效,有望成为治疗陈旧性跟骨骨折畸形愈合的理想术式。

Objective To investigate the clinical effect of subtalar joint expansion and bone graft fusion based on three-dimensional CT anatomical reconstruction in the treatment of old calcaneal fractures.Methods A total of 86 patients with old calcaneal fracture deformity were selected and randomly divided into the observation group and control group,with 43 cases in each group.The patients in the observation group were treated with subtalar joint expansion and fusion based on 3D CT anatomical reconstruction,and the control group with 3D printing assisted orthopedics.The general operation conditions of the two groups were compared,including operation time,intraoperative blood loss,time to get out of bed after operation,and hospital stay;related indexes of pain and trauma stress[β-endorphin(β-EP),substance P,prostaglandin E2(PGE2)]and oxidative stress related indexes[malondialdehyde(MDA),total antioxidant capacity(TAC),lipid peroxide(LPO),hydroxyl radical(OH),glutathione peroxidase(GSH-Px)]before operation and 12 and 24 h after operation;the imaging parameters of the heel distance,and the American Association of American Orthopaedic Foot&Ankle Society(AOFAS)Maryland score,and the excellent and good rate of foot function before and after 3 and 6 months;among them,the radiographic parameters of the heel distance included the inclination angle of the talus,the angle of Peries,the angle of Gissane,the B(o)hler angle,the height of the calcaneus,the horizontal length of the calcaneus,the length of the calcaneus axis,and the width of the calcaneus.The follow-up period was 6 months,and the complications of the two groups during the follow-up period were calculated.Results The operation time of the observation group was longer than that of the control group(P<0.05).No significant differences were found in the intraoperative blood loss,postoperative time to get out of bed or hospital stay between these two groups(all P>0.05).At 12 h after operation,β-EP,substance P,PGE2,MDA,LPO,and OH were higher than those before operation,and TAC and GSH-Px were lower than those before operation(all P<0.05).Significant differences were found in the above indicators between the two groups over the same period(all P<0.05).In the observation group,β-EP,substance P,PGE2,MDA,LPO,and OH were all lower than those at 12 h after operation,and TAC and GSH-Px were all higher than those at 12 h after operation(all P<0.05).However,no significant differences were found in the above indicators between the two groups over the same period(all P>0.05).The inclination angle of the talus,the height of the calcaneus,the horizontal length of the calcaneus,the length of the calcaneus axis,the Peries angle,the Gissane angle,and the B(o)hler angle of the two groups were higher than those before the operation,and the width of the calcaneus was lower than that before the operation,and the changes were more obvious at 6 months after the operation(P<0.05);significant differences were found in the above indicators between the two groups at the same time(all P>0.05).The AOFAS Maryland scores in the two groups were higher than those before the operation,and the changes were more significant at 6 months after operation(P<0.05).However,no significant difference was found in the AOFAS Maryland score between the two groups during the same period(P>0.05),as well as the comparison in the excellent and good rates of foot function between the two groups at 3 and 6 months after operation,and the incidence of postoperative complications between the two groups during the follow-up period(all P>0.05).Conclusion Subtalar joint distraction bone graft fusion based on three-dimensional CT anatomical reconstruction in the treatment of old calcaneal fracture malunion is safe and effective,and it is expected to become an ideal surgical procedure for the treatment of old calcaneal fracture malunion.