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微创技术与开放手术治疗SandersⅡ、Ⅲ型跟骨骨折的疗效比较

Comparison of the efficacy of minimally invasive technique and open surgery in the treatment of Sanders Ⅱ and Ⅲ calcaneal fractures

摘要:

目的:探讨跗骨窦小切口结合空心拉力螺钉或小钢板内固定治疗SandersⅡ型、Ⅲ型跟骨骨折的临床疗效。方法:回顾性分析2015年09月至2017年04月收治并获得随访的50例闭合性跟骨骨折(sander Ⅱ、Ⅲ型)患者的相关资料。根据手术方式不同分为两组,采用跗骨窦小切口结合空心拉力螺钉或小钢板内固定术者为微创组;采用传统外侧"L"型入路结合传统钢板内固定术者为开放组。微创组30例,男20例,女10例;年龄(44.53±13.74)岁(范围,19~78岁)。开放组20例,男13例,女7例;年龄(45.35±12.93)岁(范围,19~70岁)。两组患者采用不同的方式进行手术治疗,术中均纠正跟骨内翻及恢复跟骨长度、宽度和高度,但以不同方式进行骨折端固定。术前及术后均行X线及CT检查,评价骨折类型及复位、骨折愈合情况。末次随访时测量Bohler角、Gissane角,并记录术后并发症,采用Maryland足部评分系统评价临床疗效。结果:两组患者一般资料的差异无统计学意义,具有可比性。微创组中7例行异体骨植骨,17例采用微型钢板、13例采用空心拉力螺钉固定;开放组中5例行异体骨植骨,均采用常规跟骨外侧钢板固定。微创组手术时间为(48.23±5.56) min,开放组为(54.25±5.09) min;微创组术中出血量为(53.10±8.5) ml,开放组为(61.75±7.13) ml,两组差异均有统计学意义( t=3.75, t=3.87,均 P<0.01)。微创组骨折愈合时间为(9.60±1.52)周,开放组为(11.05±2.33)周,两组差异有统计学意义( t=2.67, P< 0.05)。末次随访时微创组Maryland评分优良率为80.00%,开放组为50%。术后影像学显示两组患者跟骨术后关节面塌陷复位,跟骨高度、宽度和长度恢复,跟骨轴线得到纠正。微创组Bohler角术前为15.50°±4.18°,术后改善为31.03°±3.35°( t=15.88, P<0.001),微创组Gissan角术前为101.87°±9.94°,术后改善为129.17°±4.85°( t=13.52, P<0.001);开放组Bohler角术前为15.00°±4.22°,术后改善为30.75°±3.39°( t=13.02, P<0.001),开放组Gissan角术前为104.75°±11.02°,术后改善为128.60°±4.56( t=8.95, P<0.001)。两组患者术后Gissan角( t=0.414, P=0.68)和Bohler角( t=0.292, P=0.77)的差异均无统计学意义。微创组并发症发生率为6.67%,开放组为35.00%,两组的差异有统计学意义( P=0.021)。 结论:采用跗骨窦小切口结合空心拉力螺钉或小钢板内固定术治疗跟骨骨折,具有创伤小、直视下复位、固定可靠、并发症发生率低等优点,适用于SandersⅡ、Ⅲ型跟骨骨折。

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abstracts:

Objective:To investigate the clinical effect of small incision in the sinus tarsal combined with internal fixation with hollow nails or small plates in the treatment of Sanders type II and III calcaneal fractures.Methods:A retrospective analysis of the relevant data of 50 patients with closed calcaneal fractures (sander II, III) were admitted and followed up from September 2015 to April 2017. According to different surgical methods, they were divided into two groups. Those who used a small incision of the sinus tarsal combined with hollow nail or small plate internal fixation were the minimally invasive group; those who used the traditional lateral "L" approach combined with the traditional plate internal fixation were the open group. There were 30 cases in the minimally invasive group, 20 males and 10 females; age 44.53±13.74 years (19 to 78 years); 20 cases in the open group, 13 males and 7 females; age 45.35±12.93 years (19 to 70 years old). The two groups of patients were treated with different methods for surgical treatment. During the operation, the calcaneal varus was corrected and the length, width, and height of the calcaneus were restored, but the fracture end was fixed in different ways. X-ray and CT examinations were performed before and after the operation to evaluate the type of fracture, reduction and fracture healing, the Bohler angle and Gissane angle at the last follow-up were measured, and postoperative complications were recorded. The Maryland foot scoring system was used to evaluate the clinical efficacy.Results:The difference in general information between the two groups of patients was not statistically significant and comparable. Patients in both groups were followed up for 16 months to 36 months, with an average of 21 months. In the minimally invasive group, 7 cases received allogeneic bone grafts, 17 cases were fixed with microplates, and 13 cases were fixed with hollow lag screws; 5 cases in the open group received allogeneic bone grafts, all of which were fixed with conventional lateral calcaneal plates. The intraoperative blood loss during operation in the minimally invasive group was 48.23±5.56 min, the open group was 54.25±5.09 min; the minimally invasive group was 53.10±8.5 ml, and the open group was 61.75±7.13 ml. The differences were statistically significant ( t=3.75 and 3.87, P<0.01). The fracture healing time of the minimally invasive group was 9.6±1.52 weeks, and that of the open group was (11.05±2.33) weeks. The difference between the two groups was statistically significant ( t=2.67, P<0.05). According to the Maryland score at the last follow-up, the excellent and good rate was 80.00% in the minimally invasive group and 50% in the open group. Postoperative imaging showed that the articular surface of the two groups after calcaneal surgery was collapsed and reset, the height, width and length of the calcaneus were restored, and the axis of the calcaneus was corrected. The Gissane angle and Bohler angle were significantly different from those before the operation (both P<0.001) , while Bohler angle in minimally invasive group (15.50°±4.18° vs 31.03°±3.35°, t=15.88), Gissane angle in minimally invasive group (101.87°±9.94° vs 129.17°±4.85°, t=13.52); Bohler angle in open group (15.00°±4.22° vs 30.75°±3.39°, t=13.02), and Gissane angle (104.75°±11.02° vs 128.6°±4.56°, t=8.95). There was no significant difference in the Gissane angle ( t=0.414, P=0.68) and Bohler angle ( t=0.292, P=0.77) between the two groups of patients. In the minimally invasive group, there was 1 case of traumatic arthritis and 1 case of superficial skin border infection, with a complication rate of 6.67%. In the open group, there was 2 cases of skin border necrosis secondary to deep infection, 3 cases of superficial skin border, 2 cases of infection and traumatic arthritis, and the complication rate was 35%. The difference in the overall complication rate between the two groups was statistically significant ( P=0.021). Conclusion:The treatment of calcaneal fractures with sinus tarsal incision plate or hollow screw internal fixation has the advantages of less trauma, reduction under direct vision, reliable reduction and fixation, and low complications. It is suitable for Sanders type II and III calcaneal fractures.

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作者: 马超 [1] 王成伟 [1] 唐国柱 [1]
期刊: 《中华骨科杂志》2020年40卷21期 1443-1452页 ISTICPKUCSCDCA
栏目名称: 临床论著
DOI: 10.3760/cma.j.cn121113-20200628-00409
发布时间: 2020-11-09
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