距骨骨折骨不连和畸形愈合的原因及处理

Causes and management of nonunion or malunion after talus fractures

目的探讨距骨骨折后发生骨不连或畸形愈合的原因及处理方法。方法回顾性分析2015年7月至2023年3月南方医科大学南方医院收治的距骨骨折后骨不连或畸形愈合病例10例,均存在后足疼痛及畸形情况,按照Zwipp距骨畸形分型,Ⅰ型1例、Ⅱ型6例、Ⅱ型2例、Ⅳ型1例。Ⅰ型采用截骨切开复位内固定,Ⅱ型采用植骨内固定重建术,Ⅲ采用型切开复位植骨重建术,Ⅳ采用型自体骨移植关节融合术相应处理,分析发生畸形的原因,并观察翻修重建术前后的疗效及并发症发生情况。结果距骨骨折后畸形发生的原因包括骨折漏诊、复位不良、切口选择不正确、内置物安放不合理及保守治疗等。10例患者均获得随访,随访时间6~24个月,所有病例均无伤口并发症。美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝-后足评分术前(36.7±14.3)分、术后(87.3±11.0)分(P<0.001),Maryland评分术前(36.7±14.3)分、术后(85.8±16.0)分(P<0.001),健康调查简表(the MOS item short from health survey,SF-36)评分术前(38.8±10.7)分、术后(87.8±6.7)分(P<0.001)。2例Ⅲ型患者中1例未发生距骨头缺血性坏死进展,1例距骨塌陷;Ⅳ型患者行后足融合术后取得了满意效果。结论距骨骨折术后发生骨不连或畸形愈合的原因多样,距骨解剖形态复杂,应防止漏诊。手术应注意解剖修复重建距骨形态及充分保护血运,根据生物力学需求合理放置内置物,对开放性损伤注重清创及分期治疗。距骨骨折术后畸形根据不同分型个性化处理后疗效满意。

Objective To analyze the causes and management of bone nonunion or malunion after talus fractures.Methods A retrospective analysis was conducted on 10 cases of bone nonunion or malunion after talus fractures treated in Nanfang Hospital,Southern Medical University from July 2015 to March 2023.All patients experienced hindfoot pain and deformity.According to the Zwipp and Rammelt classification of talar deformities,there were 1 TypeⅠ,6 TypeⅡ,2 TypeⅢ,and 1 TypeⅣcases.Based on the classification,the treatments included osteotomy and internal fixation for TypeⅠ,bone grafting and internal fixation reconstruction for TypeⅡ,open reduction and bone grafting reconstruction for TypeⅢ,and autologous bone grafting with joint fusion for TypeⅣ.The causes of deformity were analyzed,and the outcomes and complications of revision reconstruction surgery were observed.Results The causes of deformities after talus fractures include missed diagnosis,poor reduction,incorrect incision selection,improper placement of implants,and conservative treatment.All 10 patients were followed up for 6~24 months,and none of them had wound complications.The American Orthopaedic Foot and Ankle Society(AOFAS)scores preoperative(36.7±14.3)points and postoperative(87.3±11.0)points ankle posterior foot scores(P<0.001),Maryland scores preoperative(36.7±14.3)points and postoperative(85.8±16.0)points(P<0.001),and the MOS item short from health survey(SF-36)scores preoperative(38.8±10.7)points and postoperative(87.8±6.7)points(P<0.001).Among the 2 typeⅢpatients,1 did not develop avascular necrosis of avascular necrosis of the talus progression,and 1 had talus collapse;Satisfactory results were achieved in typeⅣpatients after posterior foot fusion surgery.Conclusion The causes of bone nonunion or malunion after talus fractures are varied,attributed to the complex anatomy of the talus.Preventing missed diagnoses,ensuring anatomical restoration during surgery,and adequately protecting blood supply are crucial.Appropriate placement of implants according to biomechanical needs and thorough debridement and staged treatment of open injuries are essential.Personalized treatment based on different classifications of talar deformities results in satisfactory outcomes.