基于跟骨前部外侧壁和载距突解剖分区的载距突精准置钉技术的应用研究

An applied research on precise sustentacular screw placement based on anatomical division of the anterior lateral wall of calcaneus and the sustentaculum tali

目的评价基于跟骨前部外侧壁和载距突解剖分区的载距突精准置钉应用于SandersⅡ、Ⅲ型跟骨骨折治疗的效果。方法按"四分法"把跟骨前部外侧壁分为前上区(S1)、前下区(S2)、后上区(S3)和后下区(S4),用于标定进钉点;"三段法"把载距突分为前段、中段和后段,用以标定置钉靶点。标本做CT扫描和Mimics建模,在3D虚拟模型上从跟骨前部外侧壁每个区分别向载距突组配1枚螺钉,其中S1和S2靶点是载距突内侧前段与中段交点P1,S3和S4靶点是中段与后段交点P2,观察螺钉是否位于骨性通道内。回顾性分析2017年1月至2021年1月徐州医科大学附属宿迁医院收治的72例SandersⅡ、Ⅲ型跟骨骨折患者资料,根据不同的载距突置钉法把患者分为解剖分区组和3D打印组。解剖分区组32例,男25例,女7例;年龄24~60岁,基于解剖分区法置钉。3D打印组40例,男31例,女9例;年龄25~58岁,采用3D打印辅助置钉。比较解剖分区组置钉参数与实际值的差异,比较两组间置钉总数、平均置钉数、螺钉分布和置钉准确率。结果在标本上从S1和S2向P1、S3和S4向P2虚拟置钉,螺钉均在骨性通道内,未见穿破跗骨窦。两组患者术前一般资料比较差异均无统计学意义(P>0.05),具有比性。解剖分区组载距突置钉总数52枚,(1.63±0.48)枚/例,其中20例置钉2枚,置钉准确率为92.3%(48/52)。解剖分区组的各个置钉参数和实际值比较差异均无统计学意义(P>0.05)。3D打印组载距突置钉总数63枚,(1.58±0.49)枚/例,其中23例置钉2枚,准确置钉率为93.7%(59/63),以上指标与解剖分区组比较,差异均无统计学意义(P>0.05)。结论基于跟骨前部外侧壁和载距突解剖分区的载距突置钉技术应用于SandersⅡ、Ⅲ型跟骨骨折手术治疗,可以收到与3D打印辅助置钉相近的效果。

Objective To evaluate our novel path based on anatomical division of the anterior lateral wall of calcaneus and the sustentaculum tali for precise sustentacular screw placement in the surgical treatment of calcaneal fractures of Sanders typesⅡandⅢ.Methods The anterior lateral wall of the calcaneus was divided into the anterior-superior zone S1,the anterior-inferior zone S2,the posterior-superior zone S3 and the posterior-inferior zone S4 for demarcation of the screw insertion points by our method of Four Zones,and into the front,middle and rear sections by our method of Three Sections for demarcation of the screw target points.The specimens were scanned by CT and modeled by Mimics.On the 3D virtual model of the calcaneus,one screw was placed from each zone of the anterior lateral wall of the calcaneus to the sustentaculum tali body.The screw placement target for S1 and S2 was the medial intersection point P1 of the front and middle sections of the sustentaculum tali,and that for S3 and S4 was the medial intersection point P2 of the middle and rear sections of the sustentaculum tali.It was observed whether the screws were placed in the bone channel.A total of 72 patients were included who had been admitted to Department of Orthopaedics,Suqian Hospital Affiliated to Xuzhou Medical University for calcaneal fractures of Sanders typesⅡandⅢfrom January 2017 to January 2021.They were divided into an anatomical division group and a 3D printing group according to their screw placement method for the sustentaculum tali.In the anatomical division group of 32 patients subjected to screw placement based on our anatomical division,there were 25 males and 7 females,aged from 24 to 60 years;in the 3D printing group of 40 patients subjected to screw placement assisted by 3D printing,there were 31 males and 9 females,aged from 25 to 58 years.The disparities between the parameters of sustentacular screw placement and the actual values were compared in the anatomical division group,and the total number of screws,screws on average,distribution of screws,and accuracy of screw placement were compared between the 2 groups.Results All the screws which were virtually placed in the specimens of the calcaneus from S1 and S2 to P1 and from S3 and S4 to P2 passed through the bony channel,with no perforation into the tarsal sinus.There was no significant difference in the general date between the anatomical division group and the 3D printing group,showing they were comparable(P>0.05).In the anatomical division group,a total of 52 screws were placed to the sustentaculum tali with an average of(1.63±0.48)screws per patient,and 2 screws were placed in 20 patients,yielding an accuracy rate of screw placement of 92.3%(48/52).There were no statistically significant differences between the parameters and the actual values of screw placement in the anatomical division group(P>0.05).In the 3D printing group,a total of 63 screws were placed to the sustentaculum tali with an average of(1.58±0.49)screws per patient,and 2 screws were placed in 23 patients,yielding an accuracy rate of screw placement of 93.7%(59/63).There were no significant differences in the above comparisons between the anatomical division group and the 3D printing group(P>0.05).Conclusion In the surgical treatment of calcaneal fractures of Sanders typesⅡandⅢ,the sustentacular screw placement based on our anatomical division of the anterior lateral wall of the calcaneus and the sustentaculum tali can lead to similar clinical accuracy as 3D printing-assisted screw placement does.