余 斌, 劉德印, 杜曉龍, 童 興

·臨床論著·

跗骨竇入路結(jié)合空心螺釘固定植骨治療SandersⅡ、Ⅲ型跟骨骨折

余 斌, 劉德印, 杜曉龍, 童 興

目的評(píng)估跗骨竇入路結(jié)合空心螺釘固定植骨治療SandersⅡ、Ⅲ型跟骨骨折的臨床療效。方法對33例SandersⅡ、Ⅲ型跟骨閉合性骨折采用跗骨竇入路結(jié)合空心螺釘固定植骨治療。測量手術(shù)前后B?hler角及Gissane角,按照AOFAS踝-后足評(píng)分系統(tǒng)進(jìn)行功能評(píng)價(jià)。結(jié)果29例獲得隨訪,時(shí)間12～14個(gè)月;4例失訪。隨訪患者均骨性愈合,時(shí)間為2～4個(gè)月。B?hler角及Gissane角:術(shù)后及術(shù)后12個(gè)月與術(shù)前比較差異均有統(tǒng)計(jì)學(xué)意義(P<0.01);術(shù)后12個(gè)月與術(shù)后比較差異均無統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后12個(gè)月時(shí)AOFAS踝-后足評(píng)分為64～96分,其中優(yōu)19例,良7例,一般2例,差1例,優(yōu)良率為89.66%(26/29)。結(jié)論跗骨竇入路結(jié)合空心螺釘固定植骨治療SandersⅡ、Ⅲ型跟骨骨折療效可靠,且具有切口并發(fā)癥發(fā)生率低、手術(shù)時(shí)間短、軟組織損傷小等優(yōu)勢。

跟骨骨折;骨折固定術(shù),內(nèi);跗骨竇入路；空心螺釘固定

在跟骨骨折手術(shù)治療中,傳統(tǒng)外側(cè)L形入路術(shù)后切口感染、裂開、皮緣壞死等并發(fā)癥是困擾臨床醫(yī)師的難題。近年有不少學(xué)者[1-5]報(bào)道采用閉合復(fù)位經(jīng)皮螺釘固定、跗骨竇入路復(fù)位固定等微創(chuàng)手術(shù)可減少切口并發(fā)癥。但是,閉合復(fù)位經(jīng)皮螺釘固定被認(rèn)為不能提供滿意的復(fù)位及穩(wěn)定的固定;跗骨竇入路雖然減少了對局部皮膚血供的影響,但需要特殊設(shè)計(jì)的鋼板,且尚未經(jīng)過生物力學(xué)測試。為了有效支撐關(guān)節(jié)內(nèi)骨折塊及盡可能降低切口并發(fā)癥,2015年2月～2016年4月,我們采用跗骨竇入路結(jié)合空心螺釘固定植骨治療33例SandersⅡ、Ⅲ型跟骨骨折患者(35足),取得了較好的臨床效果,報(bào)道如下。

1 材料與方法

1.1病例資料本組33例(35足),男26例 (28足) ,女7例 (7足),年齡26～64歲。致傷原因:交通意外傷3例,高處墜落傷30例。均為閉合骨折。合并腰椎壓縮性骨折5例。骨折Sanders分型: Ⅱ型22足,Ⅲ型13足。術(shù)前傷足短腿支具臨時(shí)固定并抬高,局部冷敷48 h。待傷足出現(xiàn)皮紋后安排手術(shù),傷后至手術(shù)時(shí)間3～8 d。

1.2手術(shù)方法一般采用神經(jīng)阻滯麻醉,個(gè)別年齡偏大者結(jié)合全身麻醉(便于術(shù)中管理)。單側(cè)取健側(cè)臥位,雙側(cè)依次側(cè)臥位。術(shù)前用標(biāo)記筆標(biāo)出跟骨后緣、外踝、第5跖骨等骨性標(biāo)志。手術(shù)在氣壓止血帶下進(jìn)行。取跗骨竇入路:在外踝尖下稍偏后向第5跖骨方向做一長30～40 mm平行于足底的切口,依次切開皮膚及筋膜后,將趾短伸肌向近側(cè)牽開,腓骨長短肌腱牽向足底側(cè)以暴露骨折斷端,注意保護(hù)腓腸神經(jīng)。可用克氏針釘在周圍跗骨上以充分暴露骨折斷端,減少拉鉤反復(fù)牽拉對皮瓣的刺激。待骨折斷端清理完畢后,可用骨膜剝離子小心抬起塌陷的關(guān)節(jié)面。當(dāng)矢狀面劈裂的兩側(cè)關(guān)節(jié)面復(fù)位后用克氏針臨時(shí)固定,之后用2～3枚3.5 mm或4.0 mm半螺紋空心螺釘緊貼關(guān)節(jié)面固定(有時(shí)克氏針可當(dāng)空心螺釘導(dǎo)針用)。背伸踝關(guān)節(jié),雙手?jǐn)D壓跟骨體兩側(cè),以跟腱附著點(diǎn)略偏下之內(nèi)外側(cè)為進(jìn)針點(diǎn),也可選取一上一下方式。進(jìn)針方向瞄準(zhǔn)Gissane角頂點(diǎn),與足底成50°～70°角,鉆入6.5 mm空心螺釘專用導(dǎo)針,向遠(yuǎn)端不穿透跟骰關(guān)節(jié)為宜。C臂機(jī)透視側(cè)位及軸位,見導(dǎo)針位置滿意后,測量空心釘長度,配套空心鉆鉆孔,一般進(jìn)入10 mm左右即可,之后擰入相應(yīng)長度的空心螺釘。再次C臂機(jī)透視側(cè)位及軸位,見螺釘長度及位置合適后,在塌陷的關(guān)節(jié)面被抬起后遺留下的空腔內(nèi)植入同種異體骨。沖洗傷口,逐層縫合。

1.3術(shù)后處理適當(dāng)加壓包扎并抬高患肢,冰敷48 h。術(shù)后第2天即可進(jìn)行足趾及踝關(guān)節(jié)適度屈伸活動(dòng)。仍將患足置于術(shù)前所用的足托支具內(nèi),進(jìn)行功能鍛煉時(shí)可取下,每日鍛煉3～5次,每次10～20 min。支具一般佩戴4～6周。反復(fù)向患者交代在骨折線消失之前禁止負(fù)重,必須遵醫(yī)囑才可負(fù)重,定期門診復(fù)查。需影像學(xué)證實(shí)骨折愈合后才可由部分負(fù)重，逐步過渡到完全負(fù)重。

1.4療效評(píng)價(jià)測量術(shù)前、術(shù)后及術(shù)后12個(gè)月B?hler角及Gissane角;按照AOFAS踝-后足評(píng)分系統(tǒng)對患足疼痛、功能、對線進(jìn)行功能評(píng)價(jià),90～100分為優(yōu), 80～89分為良,70～79分為可,<70分為差。

2 結(jié)果

29例獲得隨訪,時(shí)間12～14個(gè)月;4例失訪。隨訪期間未見傷口感染、皮瓣壞死等并發(fā)癥。隨訪患者影像學(xué)檢查提示均骨性愈合,骨折愈合時(shí)間為2～4個(gè)月。1例Sanders Ⅲ型骨折患者術(shù)后3個(gè)月攝X線片復(fù)查時(shí)發(fā)現(xiàn)B?hler角及Gissane角部分丟失,行走時(shí)有疼痛感;2例穿皮鞋時(shí)跟骨結(jié)節(jié)部有摩擦不適感,無皮膚破潰。未見退釘、斷釘?shù)绕渌惓Ｇ闆r。

患者B?hler角及Gissane角:術(shù)后及術(shù)后12個(gè)月均較術(shù)前明顯改善,差異均有統(tǒng)計(jì)學(xué)意義(P<0.01);術(shù)后12個(gè)月與術(shù)后比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表1。術(shù)后12個(gè)月按照AOFAS功能評(píng)分系統(tǒng)評(píng)價(jià)療效:評(píng)分為64～96分,其中優(yōu)19例,良7例,一般2例,差1例,優(yōu)良率為89.66%(26/29)。

典型病例見圖1。

表1 患者手術(shù)前后B?hler角及Gissane角比較

與術(shù)前比較:**P<0.01

3 討論

3.1入路選擇跟骨Sanders Ⅱ、Ⅲ型骨折可引起永久性功能損害,治療目的就是要重建跟骨解剖形態(tài),消除疼痛,減少并發(fā)癥,盡快恢復(fù)患者的行走能力。跗骨竇入路被認(rèn)為可以減少傳統(tǒng)入路的切口并發(fā)癥,但其是否可充分暴露骨折斷端尚無一致意見。一些隨機(jī)臨床對照研究及隊(duì)列研究試圖回答這一問題,但結(jié)論并不一致[4, 6-8]。Yao et al[9]對跗骨竇入路和外側(cè)延長入路治療跟骨關(guān)節(jié)內(nèi)骨折進(jìn)行Meta分析,認(rèn)為與傳統(tǒng)入路相比較,跗骨竇入路不僅能減少切口并發(fā)癥,而且能夠取得骨折的充分復(fù)位,達(dá)到與傳統(tǒng)入路同樣的功能結(jié)果。我們認(rèn)為,跟骨關(guān)節(jié)內(nèi)骨折重在關(guān)節(jié)面的解剖重建,跗骨竇入路能夠有效暴露關(guān)節(jié)面,并能在直視下恢復(fù)后關(guān)節(jié)面的解剖對位。

圖1 患者,女,61歲,因不慎踩空墜落致右足跟腫痛，活動(dòng)受限6 d入院A.術(shù)前X線片,顯示右足跟骨骨折,關(guān)節(jié)面塌陷,B?hler角及Gissane角減小;B.跗骨竇入路;C.術(shù)中透視;D.術(shù)后X線片,顯示塌陷關(guān)節(jié)面已復(fù)位,B?hler角及Gissane角恢復(fù),內(nèi)固定位置合適

3.2復(fù)位及固定方式跟骨關(guān)節(jié)內(nèi)骨折復(fù)位與固定方式對臨床功能結(jié)果也有一定的影響。Law et al[10]在關(guān)節(jié)鏡及透視輔助下復(fù)位經(jīng)皮固定,并進(jìn)行了5～8年的隨訪,取得了良好的功能結(jié)果。Tantavisut et al[11]采用經(jīng)皮復(fù)位僅用螺釘固定,進(jìn)行平均2.6年的隨訪后取得了良好的臨床效果。Takasaka et al[8]對L形入路3.5 mm系統(tǒng)雙H形鋼板固定、跗骨竇入路克氏針及螺釘固定、跗骨竇入路可調(diào)式單邊外固定架固定進(jìn)行了對比,發(fā)現(xiàn)跗骨竇入路有限內(nèi)固定并發(fā)癥更少,患者生活質(zhì)量更高。本研究結(jié)果與之相似。我們認(rèn)為,固定是維持復(fù)位的手段,在骨折愈合前要盡量避免患者負(fù)重以防復(fù)位丟失。有限切開復(fù)位植骨空心釘固定能夠有效維持骨折位置,并能保持一定的穩(wěn)定性,利于骨折順利愈合。

3.3植骨跟骨關(guān)節(jié)內(nèi)骨折復(fù)位后遺留的空腔是否需要植骨,目前仍有爭議。Duymus et al[12]對比植骨與不植骨后發(fā)現(xiàn),非植骨組術(shù)后B?hler角及Gissane角丟失更加顯著;盡管植骨組有著滿意的影像學(xué)表現(xiàn),但AOFAS評(píng)分兩組比較差異無統(tǒng)計(jì)學(xué)意義。我們認(rèn)為,植骨可以在一定程度上支撐塌陷的關(guān)節(jié)面,而且可以避免空腔內(nèi)血腫形成,預(yù)防感染;并且在骨折愈合及后期骨性骨痂改建時(shí)提供支架,有利于“爬行替代”。由于B?hler角及Gissane角與跟骨關(guān)節(jié)內(nèi)骨折愈合后功能之間的關(guān)系尚不明確,因此,加強(qiáng)這一方面的研究對改進(jìn)治療方法和提高功能結(jié)果有一定的臨床現(xiàn)實(shí)意義。

綜上所述,跗骨竇入路結(jié)合空心螺釘固定植骨治療SandersⅡ、Ⅲ型跟骨骨折方法簡單、效果滿意,且具有切口并發(fā)癥發(fā)生率低、手術(shù)時(shí)間短、軟組織損傷小等優(yōu)勢。

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ThetreatmentofSanderstypeⅡ, Ⅲcalcanealfractureswithsinustarsiapproachcombinedwithcannulatedscrewfixationandallograft

YUBin,LIUDe-yin,DUXiao-long,TONGXing

(DeptofOrthopaedics,HonghuiHospital,Xi′anJiaotongUniversity,Xi′an,Shaanxi710054,China)

ObjectiveTo evaluate the clinical curative effects of sinus tarsi approach combined with cannulated screw fixation and allograft for treatment of calcaneal fractures of Sanders type Ⅱ, Ⅲ.MethodsThe 33 cases of closed calcaneal fractures of Sanders type Ⅱ, Ⅲ were treated with sinus tarsi approach combined with cannulated screw fixation and allograft. The calcaneal B?hler angles and Gissane angles were measured pre- and postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) scoring system was used to assess clinical functional outcomes.ResultsThe 29 patients

follow-up of 12～14 months, 4 cases were lost to follow-up. The time to bone union ranged from 2 months to 4 months, and all 29 patients got bony union. The calcaneal B?hler angles and Gissane angles showed significant differences at postoperation and 12 months after surgery, compared with the preoperation (P<0.01), but no significant differences existed between postoperation and 12 months after surgery (P>0.05). At 12 months postoperatively, the AOFAS scoring system scores ranged from 64～96 points, excellent results were obtained in 19 patients, good in 7, fair in 2, and poor in 1, with excellent and good rate of 89.66% (26/29).ConclusionsSinus tarsi approach combined with cannulated screw fixation and allograft are a viable option for calcaneal fractures of Sanders type Ⅱ, Ⅲ, which have the advantages of less incisional complications, shorter operation time, as well as lower soft tissue damages.

calcaneus fractures; fractures fixation，internal; sinus tarsi approach；cannulated screw fixation

10.3969/j.issn.1008-0287.2017.06.039

西安交通大學(xué)醫(yī)學(xué)院附屬紅會(huì)醫(yī)院骨科, 陜西 西安 710054

余 斌,男,博士,副主任醫(yī)師,主要從事創(chuàng)傷骨科及骨關(guān)節(jié)退行性病變研究,E-mail: yubin3600@sina.com

R 683.42；R 687.32

A

1008-0287(2017)06-0746-04

(接收日期:2017-09-18)