CAJ | 학술논문

目的总结分析合并内侧伤口开放性跟骨骨折分阶段治疗的策略及疗效. 方法 2007年2月至2010年7月收治且获得随访的GustiloⅡ型及ⅢA型合并内侧伤口的开放性跟骨骨折患者23例,男16例,女7例；年龄39 ～56岁,平均43.3岁；左足9例,右足14例.骨折按Sanders分型:Ⅱ型9例,Ⅲ型12例,Ⅳ型2例.开放性损伤按Gustilo分型:Ⅱ型11例,ⅢA型12例.患者行急诊一期清创,同时通过内侧伤口复位跟骨内侧柱,恢复跟骨的高度、长度及轴线,克氏针临时固定,对不稳定伤口使用负压封闭引流敷料覆盖,使用抗生素预防性治疗和反复清创.待内侧伤口稳定后,二期行外侧扩大切口复位钢板内固定.末次随访时采用美国足踝外科协会踝-后足评分进行评定. 结果伤后至初次清创时间为3 ～36 h,平均6.8h；清创次数1～4次,平均2.6次；行最终内固定手术时间为伤后5～21 d,平均10.9d.23例患者术后获19 ～32个月(平均23.6个月)随访.所有患者外侧手术切口无感染、坏死发生,21例患者内侧伤口均获愈合,2例患者内侧伤口发生浅表感染,经换药延迟愈合.但所有患者距下关节活动度与健侧相比均有不同程度受限. 结论合并内侧伤口开放性跟骨骨折是一种特殊类型的开放性跟骨骨折,如果没有软组织缺损,通过分阶段的贯序治疗,其疗效可媲美闭合性骨折.急诊处理应注意彻底清创,同时通过复位及临时固定恢复跟骨的高度及长度.
목적 총결분석합병내측상구개방성근골골절분계단치료적책략급료효. 방법 2007년2월지2010년7월수치차획득수방적GustiloⅡ형급ⅢA형합병내측상구적개방성근골골절환자23례,남16례,녀7례；년령39 ～56세,평균43.3세；좌족9례,우족14례.골절안Sanders분형:Ⅱ형9례,Ⅲ형12례,Ⅳ형2례.개방성손상안Gustilo분형:Ⅱ형11례,ⅢA형12례.환자행급진일기청창,동시통과내측상구복위근골내측주,회복근골적고도、장도급축선,극씨침림시고정,대불은정상구사용부압봉폐인류부료복개,사용항생소예방성치료화반복청창.대내측상구은정후,이기행외측확대절구복위강판내고정.말차수방시채용미국족과외과협회과-후족평분진행평정. 결과 상후지초차청창시간위3 ～36 h,평균6.8h；청창차수1～4차,평균2.6차；행최종내고정수술시간위상후5～21 d,평균10.9d.23례환자술후획19 ～32개월(평균23.6개월)수방.소유환자외측수술절구무감염、배사발생,21례환자내측상구균획유합,2례환자내측상구발생천표감염,경환약연지유합.단소유환자거하관절활동도여건측상비균유불동정도수한. 결론 합병내측상구개방성근골골절시일충특수류형적개방성근골골절,여과몰유연조직결손,통과분계단적관서치료,기료효가비미폐합성골절.급진처리응주의철저청창,동시통과복위급림시고정회복근골적고도급장도.
Objective To evaluate clinical outcomes of staged treatment of open calcaneal fractures with medial wounds.Methods Between February 2007 and July 2010,23 patients with open calcaneal fractures with medial wound (Gustilo type Ⅱ and Ⅲ A) were treated and fully followed up in our department.They were 16 men and 7 women,aged from 39 to 56 years (average,43.3 years).The left foot was affected in 9 cases and the right in 14.By the Sanders classification,there were 11 cases of type Ⅱ and 12 ones of type Ⅲ.By the Gustilo's classification,the open wounds were type Ⅱ in 11 cases and type ⅢA in 12 ones.The patients were treated in a staged fashion.Emergent debridement,irrigation and antibiotic prophylaxis were carried out as soon as possible.During the debridement,the height,length and axial alignment of the calcaneus were restored through the medial wound before temporary fixation with percutaneous Kirschner wires.Unstable wounds of Gustilo type ⅢA were covered with vacuum sealed drainage and managed with antibiotic prophylaxis and repeated debridement until the wounds grew stable.At the second stage,definitive open reduction and internal fixation were performed through the extensile lateral approach when soft tissues were amenable for surgery.The patients were followed up regularly with clinical and radiological examinations.The American Orthopaedic Foot and Ankle Society (AOFAS) score for hindfoot was recorded at the final follow-up for every patient.Results On average,the primary debridement was conducted at 6.8 hours (from 3 to 36 hours) after the injury.The necessary debridements averaged 2.6 times (from 1 to 4 times).The definitiveopen reduction and internal fixation were performed at an average of 10.9 days (from 7 to 21 days) after the injury.The mean follow-up was 23.6 months (from 19 to 32 months).All the wounds healed without infection or necrosis except for 2 wounds that were healed later after change of dressing for superficial infection.The final AOFAS score for hindfoot averaged 82.1 points (from 77 to 89 points),indicating the range of motion of the affected subtalar joint was somewhat limited compared with the healthy side in all the patients.Conclusions For open calcaneal fracture with medial wound,fairly good clinical outcomes can result from staged treatment if there is no obvious soft tissue defect.The emergency management should include not only thorough debridement but also reduction and provisional fixation of the fracture to restore the height,length and axial alignment of the calcaneus.