全关节镜下微创复位固定术治疗SandersⅡ、Ⅲ型跟骨关节内骨折的疗效分析

doi:10.3760/cma.j.cn101202-20220126-00028

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摘要目的探讨全关节镜下微创复位固定术治疗SandersⅡ、Ⅲ型跟骨关节内骨折的临床疗效。方法前瞻性随机对照研究。纳入2017年3月—2020年12月徐州仁慈医院足踝外科Sanders Ⅱ、Ⅲ型跟骨骨折患者40例,其中男36例、女4例,年龄18~58（39.6±10.8）岁,左侧22例、右侧18例,Sanders Ⅱ型16例、Ⅲ型24例。40例患者数字表法随机分为关节镜组（采用关节镜下跟骨关节内骨折微创复位、经皮螺钉固定术治疗）、大“L”形切口组（采用传统的大“L”形切口跟骨骨折复位钢板内固定术治疗）,每组20例。观察指标：（1）比较2组患者性别、年龄、体质量指数（BMI）、骨折类型、术前美国足踝外科学协会（AOFAS）踝-后足功能评分等基线资料差异;（2）比较2组患者手术切口长度、手术时间、术中出血量、住院时间、术后切口愈合情况等围术期资料差异;（3）术后观察局部有无麻木感、是否钢板外露、切口皮肤坏死、术后1年是否有创伤性关节炎等手术并发症情况;（4）对比分析2组患者末次随访时AOFAS踝-后足功能评分、Gissnae角和Bohler角。结果（1）2组患者性别、年龄、BMI、骨折类型、术前AOFAS踝-后足功能评分等基线资料比较,差异均无统计学意义（P值均>0.05）。（2）关节镜组患者的切口长度（0.94±0.08）cm、术中出血量（7.20±1.98）mL、手术时间（41.45±9.96）min、住院时间（8.45±2.01）d,大“L”形切口组患者的切口长度（14.35±1.63）cm、术中出血量（27.35±10.35）mL、手术时间（90.65±12.08）min、住院时间（17.15±6.72）d,关节镜组优于大“L”形切口组,差异均有统计学意义（t=-36.70、-8.54、-14.04、-5.54,P值均<0.001）。（3）术后平均随访12.3个月。术后关节镜组切口均甲级愈合,无创伤性关节炎、足背皮肤麻木。大“L”形切口组20例中,18例患者切口甲级愈合,2例患者切口皮缘坏死、钢板外露,予腓肠神经营养逆行岛状皮瓣修复后伤口愈合;有4例患者术后感足背外侧麻木,经治疗分别于术后8~14个月痊愈。（4）末次随访时AOFAS踝-后足功能评分关节镜组为（92.10±3.16）分、大“L”形切口组为（91.3±2.45）分,术后2组患者跟骨的Gissnae角和Bohler角均在正常范围内,组间比较差异均无统计学意义（P值均>0.05）。结论与传统的切开复位内固定术相比较,全关节镜下微创手术治疗Sanders Ⅱ、Ⅲ型跟骨关节内骨折,具有手术切口小、手术时间短、内固定牢固、切口愈合好、疗程短、术后瘢痕不明显、功能恢复快等优势。

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	周祥国
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关键词 ：跟骨, 跟骨关节内骨折, 关节镜检查, 外科手术,微创性

Abstract：Objective This study investigated the clinical efficacy of minimally invasive reduction and fixation for Sanders types Ⅱ and Ⅲ intra-articular calcaneal fractures under total arthroscopy. Methods Prospective randomized controlled study was conducted, using the clinical data of 40 patients admitted to Xuzhou Renci Hospital Foot and Ankle Surgery from March 2017 to December 2020 because of Sanders types Ⅱ and Ⅲ calcaneal fractures. The patients were composed of 36 males and 4 females aged 18-58 (39.6±10.8) years. Sanders classification type Ⅱ was found in 16 cases; and type Ⅲ, in 24 cases. Then, 40 patients were randomly divided into arthroscopic group (using arthroscopic minimally invasive reduction and percutaneous screw fixation for intra-articular calcaneal fractures), large "L" incision group (traditional large "L" incision calcaneus fracture reduction and plate internal fixation), 20 cases in each group. Observation indicators: (1) the gender, age, body mass index (BMI), fracture type, preoperative American Orthopedics Foot and Ankle Score (AOFAS) score, and operation timing (surgery days after injury) of the two groups were compared and analyzed between groups; (2) the two groups were compared by length of incision, operation time, and intraoperative bleeding; (3) Perioperative data, such as volume, hospital stay, postoperative incision healing, local numbness, exposed steel plate, incision skin necrosis, and postoperative complications, including traumatic arthritis 1 year after surgery, were compared. (4) Regular follow-up after operation was conducted. AOFAS was used in evaluating the recovery of ankle function at the last follow-up. The Gissnae and Bohler angles of the two groups were compared and analyzed. Results (1) No significant differences in baseline data including gender, age, BMI, fracture type, and AOFAS score before surgery were found between the two groups (all P values >0.05). (2) The incision length of the patients in the arthroscopy group was (0.94±0.08)cm, the intraoperative blood loss was (7.20±1.98)mL, the operation time was (41.45±9.96)min, and the length of hospital stay was (8.45±2.01)days. The incision length of the patients in large "L" incision group was (14.35±1.63)cm, the intraoperative blood loss was (27.35±10.35)mL, the operation time was (90.65±12.08)min, and the hospitalization time was (17.15±6.72)days. The arthroscopy group were better than the large "L" shaped incision group, and the difference were statistically significant (t=-36.70, -8.54, -14.04, -5.54, all P values <0.05). (3) All patients were followed up for an average of 12.3 months. In the calcaneal arthroscopy group, all incisions healed in grade A, and no traumatic arthritis and dorsal skin numbness occurred. In the large "L" incision group, two of the 20 patients discharged from the hospital had grade B wound healing, and 18 patients had grade A wound healing. Two patients had wound skin edge necrosis and exposed steel plate, and the wound healed after repair with sural nerve nutrition retrograde island flap. Numbness gradually disappeared after a month. (4) The AOFAS ankle-hindfoot function score was used at the last follow-up. The AOFAS score in the arthroscopic group was 92.10±3.16, whereas that in the large "L" incision group was 91.3±2.45. No significant difference was found (P>0.05). The Gissnae and Bohler angles of the calcaneus in the two groups after operation were within the normal range, and the difference was not statistically significant (P>0.05). Conclusion Compared with traditional open reduction and internal fixation, total arthroscopic minimally invasive surgery for Sanders types Ⅱ and Ⅲ intra-articular calcaneal fractures has the advantages of small surgical incision, short operation time, firm internal fixation, good incision healing, and long course of treatment. It is worthy of further clinical application because of its advantages of short duration, reduced postoperative scar, and accelerated functional recovery.

Key words： Calcaneus Intra-articular fracture of calcaneus Arthroscopy Surgical procedures,minimally invasive

收稿日期: 2022-01-26

通讯作者: 徐明亮,Email：357296104@qq.com

引用本文:

周祥国, 魏笛, 娄理想, 徐明亮. 全关节镜下微创复位固定术治疗SandersⅡ、Ⅲ型跟骨关节内骨折的疗效分析[J]. 中华解剖与临床杂志, 2022, 27(10): 702-708.
Zhou Xiangguo, Wei Di, Lou Lixiang, Xu Mingliang. Observation on the effect of minimally invasive reduction and fixation of Sanders types Ⅱ and Ⅲ intra-articular calcaneal fractures under full arthroscopy. Chinese Journal of Anatomy and Clinics, 2022, 27(10): 702-708.

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http://www.cjac.com.cn/CN/10.3760/cma.j.cn101202-20220126-00028 或 http://www.cjac.com.cn/CN/Y2022/V27/I10/702

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