三通道全内距下关节镜排钉技术在SandersⅡ、Ⅲ型跟骨骨折治疗中的应用

All-inside subtalar arthroscopy through three portals combined with rafting screws technique for the treatment of the calcaneal fractures of Sanders Ⅱ and Ⅲ

目的探讨三通道全内距下关节镜排钉技术治疗SandersⅡ、Ⅲ型跟骨骨折的临床效果。方法回顾性分析2017年3月至2019年3月于徐州市中心医院骨科采用三通道全内距下关节镜排钉技术治疗的33例(33足)SandersⅡ、Ⅲ型跟骨骨折的患者资料。其中男性19例,女性14例,年龄(32.6±11.3)岁(范围:20~55岁)。Sanders分型Ⅱ型12例,Ⅲ型21例。受伤至手术时间(101.2±32.1)h(范围:6~140 h)。术前患者疼痛视觉模拟评分(VAS)为(6.4±2.9)分(范围:4~8分);美国骨科足踝外科协会(AOFAS)踝与后足评分为(63.3±11.8)分(范围:50~75分);SF-36生活质量评分为(94.8±9.1)分(范围:70~105分)。所有患者均使用三通道全内距下关节镜联合排钉技术进行固定,记录患者术后切口愈合情况、骨折复位情况及骨折愈合情况,采用VAS、AOFAS踝与后足评分、SF-36生活质量评分评估患肢疼痛和功能。手术前后评分的比较采用重复测量方差分析。结果所有患者均顺利完成手术,手术时间为(69.7±10.4)min(范围:40~110 min),患者均未行植骨术。所有患者术后第1天跟骨影像学评估满意,术后切口均获得一期愈合,未出现皮肤感觉异常及腓骨肌损伤并发症。所有患者均获得24个月随访,术后跟骨影像学指标(跟骨长度、跟骨宽度、跟骨高度、Bohler角、Gissane角)较术前明显改善(P值均<0.01);术后第1天、术后1年、术后2年的跟骨影像学指标的差异无统计学意义(P值均>0.05),提示骨折复位无丢失(P值均>0.05)。术后VAS、AOFAS踝与后足评分及SF-36生活质量评分较术前明显改善(P值均<0.01)。末次随访时,患者后足力线及功能恢复满意,跟骨外观及外侧壁外形恢复满意,AOFAS踝与后足评分为优27例,良4例,中2例,优良率为94.0%。结论三通道全内距下关节镜排钉技术,复位精准,固定可靠,功能效果满意,并发症少,是治疗SandersⅡ、Ⅲ型跟骨骨折可供选择的有效方法。

Objective To investigate the surgical technology and clinical efficacy of using the all-inside subtalar arthroscopy through three portals combined with rafting screws technique for the treatment of the calcaneal fractures of SandersⅡandⅢ.Methods The clinical data of 33 patients(33 feet)with intra-articular displaced calcaneal fractures treated by modified all-inside arthroscopic from March 2017 to March 2019 at Department of Orthopedics,Xuzhou Central Hospital were retrospectively analyzed.There were 19 male patients,and 14 female patients,aged(32.6±11.3)years(range:20 to 55 years).According to the Sanders classification,there were 12 cases of typeⅡand 21 cases of typeⅢ.The duration from injury to surgery was(101.2±32.1)hours(range:6 to 140 hours).The preoperative visual analogue scale(VAS)was 6.4±2.9(range:4 to 8);The preoperative American Orthopaedic Foot&Ankle Society(AOFAS)ankle-hindfoot scale and the SF-36 score was 63.3±11.8(range:50 to 75)and 94.8±9.1(range:70 to 105)respectively.All the patients were managed with the all-side subtalar arthroscopy through three portals combined with rafting screws technique.The incision healing,reduction of fracture,and fracture healing were recorded.The VAS,AOFAS ankle-hindfoot scale,and SF-36 score were used to assess the pain and functional outcomes.Repeated-measurement was used to compare the scores before and after surgery.Results The time of operation was(69.7±10.4)minutes(range:40 to 110 minutes).All patients did not undergo bone grafting.The incision healed in one stage without complications of skin sensory and peroneal tendon injury.All patients were followed up for 24 months.At the last follow-up,all the patients were satisfied with the hindfoot alignment,function,and hindfoot appearance.Postoperative calcaneal imaging indicators(calcaneal length,calcaneal width,calcaneal height,Bohler angle and Gissane angle)were significantly improved compared with those before surgery(P<0.01).There was no statistically significant difference in the imaging indexes of calcaneus at 1 day,1 year and 2 years after surgery,indicating no loss of fracture reduction(all P>0.05).The VAS,AOFAS ankle-hindfoot scale,and SF-36 score were 1.5±0.4(range:0 to 2),94.0±6.5(range:90 to 100),and 119.1±7.2(range:105 to 130),respectively,which were better than those before surgery(all P>0.05).According to the AOFAS scoring system,27 cases were excellent,4 cases were good,2 cases were fair,and the excellent and good rate was 94.0%.Conclusion All-inside subtalar arthroscopy through three portals combined with rafting screws technique for the treatment of the calcaneal fractures of SandersⅡandⅢprovides precise reduction,reliable fixation,satisfactory function and limited complications,which is an alternative method.