中国骨与关节外科
中國骨與關節外科
중국골여관절외과
CHINESE BONE AND JOINT SURGERY
2014年
4期
280-284,304
,共6页
葛晨%徐向阳%王亚梓%刘津浩%朱渊
葛晨%徐嚮暘%王亞梓%劉津浩%硃淵
갈신%서향양%왕아재%류진호%주연
撬拨复位技术%外侧“L”形切口%外侧小切口%跟骨骨折%疗效
撬撥複位技術%外側“L”形切口%外側小切口%跟骨骨摺%療效
효발복위기술%외측“L”형절구%외측소절구%근골골절%료효
Percutaneous reduction%L-shaped lateral approach%Small sinus tarsi approach%Calcaneus fracture
背景:跟骨骨折是一种常见的复杂的足部骨折,多由高处坠落引起。移位及复杂的跟骨骨折仍需依靠手术治疗。但是术后伤口感染、疼痛等并发症发生率高,使得手术方式及入路仍存争议。本文就传统撬拨复位技术、经典外侧延长切口以及外侧小切口做一对比研究。目的:比较不同手术方式在跟骨关节内骨折治疗中的手术效果和优缺点。方法:回顾分析1990年2月至2010年9月,在我院行手术治疗的跟骨关节内骨折患者的病例资料。获得随访患者173例(195足)。其中采用撬拨复位技术44例,6例为双侧;标准外侧“L”形切口61例,9例为双侧;外侧小切口68例,7例为双侧。均为新鲜跟骨闭合性骨折,Sanders分型:Ⅱ型95例,Ⅲ型78例。患者年龄22~62岁,平均43岁。比较三组治疗期间的各项参数指标。结果:所有入组患者随访12~70个月,平均39个月。末次随访时,“L”形切口组和小切口组的B?hler角和Gissane角显著大于撬拨组(Q<0.05),而“L”形切口组与小切口组无明显统计学差异(Q>0.05)。撬拨组伤口未出现感染,“L”形切口组和小切口组的伤口感染率分别为22.86%和5.33%。撬拨组、“L”形切口组和小切口组的手术时间分别为(37±8.18)min、(83±12.83)min、(61±9.97)min,组间比较有显著统计学差异。撬拨组与小切口组的住院时间无明显统计学差异,分别为(7.36±0.61)d和(10.87±2.72)d,而“L”形切口组相对较长[(17.60±4.56)d],与前两组有显著统计学差异。内固定材料费用上,三组之间有统计学差异:撬拨组(1780.32±40.21)元,“L”形切口组(33060.49±72.73)元,小切口组(21451.83±745.91)元。撬拨组、“L”形切口组和小切口组受伤至手术的时间分别为(103.68±6.20)h、(257.73±11.80)h、(176.40±9.19)h,组间比较有显著统计学差异。末次随访时撬拨组的AOFAS评分显著低于另两组(Q<0.05),但“L”形切口组与小切口组之间无明显统计学差异(Q>0.05)。三组的SF36评分无明显统计学差异。再次手术发生率分别为撬拨组12.00%,“L”形切口组15.71%,小切口组2.67%,三组间有统计学差异。结论:对于骨折块较完整、单纯跟距关节面塌陷骨折,撬拨复位手术时间短、损伤小、无伤口愈合问题,存在部分复位丢失,发生距下关节炎后常需行距下关节融合。“L”形切口与小切口疗效相当,但小切口直接暴露距下关节面,便于复位;内固定物少;医源性软组织损伤小。小切口是一种有效的治疗跟骨关节内骨折的方法;术后并发症及再次手术发生率明显低于其他两种方法。
揹景:跟骨骨摺是一種常見的複雜的足部骨摺,多由高處墜落引起。移位及複雜的跟骨骨摺仍需依靠手術治療。但是術後傷口感染、疼痛等併髮癥髮生率高,使得手術方式及入路仍存爭議。本文就傳統撬撥複位技術、經典外側延長切口以及外側小切口做一對比研究。目的:比較不同手術方式在跟骨關節內骨摺治療中的手術效果和優缺點。方法:迴顧分析1990年2月至2010年9月,在我院行手術治療的跟骨關節內骨摺患者的病例資料。穫得隨訪患者173例(195足)。其中採用撬撥複位技術44例,6例為雙側;標準外側“L”形切口61例,9例為雙側;外側小切口68例,7例為雙側。均為新鮮跟骨閉閤性骨摺,Sanders分型:Ⅱ型95例,Ⅲ型78例。患者年齡22~62歲,平均43歲。比較三組治療期間的各項參數指標。結果:所有入組患者隨訪12~70箇月,平均39箇月。末次隨訪時,“L”形切口組和小切口組的B?hler角和Gissane角顯著大于撬撥組(Q<0.05),而“L”形切口組與小切口組無明顯統計學差異(Q>0.05)。撬撥組傷口未齣現感染,“L”形切口組和小切口組的傷口感染率分彆為22.86%和5.33%。撬撥組、“L”形切口組和小切口組的手術時間分彆為(37±8.18)min、(83±12.83)min、(61±9.97)min,組間比較有顯著統計學差異。撬撥組與小切口組的住院時間無明顯統計學差異,分彆為(7.36±0.61)d和(10.87±2.72)d,而“L”形切口組相對較長[(17.60±4.56)d],與前兩組有顯著統計學差異。內固定材料費用上,三組之間有統計學差異:撬撥組(1780.32±40.21)元,“L”形切口組(33060.49±72.73)元,小切口組(21451.83±745.91)元。撬撥組、“L”形切口組和小切口組受傷至手術的時間分彆為(103.68±6.20)h、(257.73±11.80)h、(176.40±9.19)h,組間比較有顯著統計學差異。末次隨訪時撬撥組的AOFAS評分顯著低于另兩組(Q<0.05),但“L”形切口組與小切口組之間無明顯統計學差異(Q>0.05)。三組的SF36評分無明顯統計學差異。再次手術髮生率分彆為撬撥組12.00%,“L”形切口組15.71%,小切口組2.67%,三組間有統計學差異。結論:對于骨摺塊較完整、單純跟距關節麵塌陷骨摺,撬撥複位手術時間短、損傷小、無傷口愈閤問題,存在部分複位丟失,髮生距下關節炎後常需行距下關節融閤。“L”形切口與小切口療效相噹,但小切口直接暴露距下關節麵,便于複位;內固定物少;醫源性軟組織損傷小。小切口是一種有效的治療跟骨關節內骨摺的方法;術後併髮癥及再次手術髮生率明顯低于其他兩種方法。
배경:근골골절시일충상견적복잡적족부골절,다유고처추락인기。이위급복잡적근골골절잉수의고수술치료。단시술후상구감염、동통등병발증발생솔고,사득수술방식급입로잉존쟁의。본문취전통효발복위기술、경전외측연장절구이급외측소절구주일대비연구。목적:비교불동수술방식재근골관절내골절치료중적수술효과화우결점。방법:회고분석1990년2월지2010년9월,재아원행수술치료적근골관절내골절환자적병례자료。획득수방환자173례(195족)。기중채용효발복위기술44례,6례위쌍측;표준외측“L”형절구61례,9례위쌍측;외측소절구68례,7례위쌍측。균위신선근골폐합성골절,Sanders분형:Ⅱ형95례,Ⅲ형78례。환자년령22~62세,평균43세。비교삼조치료기간적각항삼수지표。결과:소유입조환자수방12~70개월,평균39개월。말차수방시,“L”형절구조화소절구조적B?hler각화Gissane각현저대우효발조(Q<0.05),이“L”형절구조여소절구조무명현통계학차이(Q>0.05)。효발조상구미출현감염,“L”형절구조화소절구조적상구감염솔분별위22.86%화5.33%。효발조、“L”형절구조화소절구조적수술시간분별위(37±8.18)min、(83±12.83)min、(61±9.97)min,조간비교유현저통계학차이。효발조여소절구조적주원시간무명현통계학차이,분별위(7.36±0.61)d화(10.87±2.72)d,이“L”형절구조상대교장[(17.60±4.56)d],여전량조유현저통계학차이。내고정재료비용상,삼조지간유통계학차이:효발조(1780.32±40.21)원,“L”형절구조(33060.49±72.73)원,소절구조(21451.83±745.91)원。효발조、“L”형절구조화소절구조수상지수술적시간분별위(103.68±6.20)h、(257.73±11.80)h、(176.40±9.19)h,조간비교유현저통계학차이。말차수방시효발조적AOFAS평분현저저우령량조(Q<0.05),단“L”형절구조여소절구조지간무명현통계학차이(Q>0.05)。삼조적SF36평분무명현통계학차이。재차수술발생솔분별위효발조12.00%,“L”형절구조15.71%,소절구조2.67%,삼조간유통계학차이。결론:대우골절괴교완정、단순근거관절면탑함골절,효발복위수술시간단、손상소、무상구유합문제,존재부분복위주실,발생거하관절염후상수행거하관절융합。“L”형절구여소절구료효상당,단소절구직접폭로거하관절면,편우복위;내고정물소;의원성연조직손상소。소절구시일충유효적치료근골관절내골절적방법;술후병발증급재차수술발생솔명현저우기타량충방법。
Background:Fractures of calcaneus are complex injuries with a high incidence in feet and usually the result of a fall from a great height. Surgical techniques are the preferred methods for displaced and comminuted fractures. Due to the rising rate of complications after operation, such as wound infection and pain, controversies remain regarding treatment options and sur-gical approaches. In this article, we attempted to investigate clinical effects by three different surgical treatments. Objective:To compare the complications and outcomes of three operations to determine the better approach for the treat-ment of calcaneal intraarticular fracture. Methods:Between 1990 and 2010, 175 patients were admitted for 195 calcaneal fracture, including 50 feet with percutane-ous reduction by leverage, 70 feet with L-shaped lateral approach and 75 feet with small sinus tarsi approach. All fractures were fresh closed fractures of calcaneus. There were 95 cases of SandersⅡand 78 cases of SandersⅢ. The mean age of the patients was 43 years (range, 22-62 years). The measured parameters during treatment were compared between groups. Results: ALL the patients were followed up for 39 months on average (range, 12-70 months). At the last follow-up, the B?hler and Gissane angles and AOFAS score of percutaneous reduction group were significantly lower than those of the oth-er two groups (Q<0.05), but there was no significant difference between L-shaped lateral approach group and small sinus tarsi approach group (Q>0.05). Wound infection occurred in 20 feet (10.25%), including 16 feet in L-shaped lateral ap-proach group (22.86%) and 4 feet in small sinus tarsi approach group (5.33%). There was no complication in percutaneous reduction group. There were significant differences in terms of operative time, costs of internal fixation and reoperation rate between groups. The hospital stay in L-shaped lateral approach group was longer than that in the other two groups. Conclusions:Small sinus tarsi approach with better function after operation or percutaneous reduction approach with lower rate of complication, may be the better choice for calcaneal fracture than L-shaped lateral approach.