羅偉國(guó)
·論 著·
解剖鎖定鋼板內(nèi)固定治療跟骨骨折的臨床研究
羅偉國(guó)
目的 探討解剖鎖定鋼板內(nèi)固定(anatomical locking plate internal fixation,ALPIF)治療跟骨骨折(calcaneal fracture,CF)的臨床療效。方法 選取2013年1月~2015年12月治療的CF患者86例,男性58例,女性28例;年齡20~57(38.53±4.28)歲。依照隨機(jī)數(shù)字表法分為ALPIF組(n=44)與傳統(tǒng)鋼板內(nèi)固定(ordinary steel plate internal fixation,OSPIF)組(n=42)。ALPIF組行ALPIF治療,OSPIF組行OSPIF治療。觀察兩組手術(shù)時(shí)間、術(shù)后拔管時(shí)間、術(shù)后拆線時(shí)間、負(fù)重鍛煉時(shí)間、骨折愈合時(shí)間等手術(shù)相關(guān)時(shí)間指標(biāo),術(shù)前及術(shù)后1年跟骨寬度、跟骨高度、Gissane角、Bohlers角等指標(biāo)。結(jié)果 兩組手術(shù)時(shí)間、術(shù)后拔管時(shí)間、術(shù)后拆線時(shí)間差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。ALPIF組術(shù)后負(fù)重鍛煉時(shí)間、骨折愈合時(shí)間早于OSPIF組,有統(tǒng)計(jì)學(xué)意義(P<0.05)。術(shù)后1年,兩組跟骨寬度較術(shù)前減小,跟骨高度、Gissane角、Bohlers角較術(shù)前顯著增加,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。術(shù)后1年,ALPIF組跟骨寬度較OSPIF組低,跟骨高度、Gissane角、Bohlers角較OSPIF組高,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。ALPIF組術(shù)后1年優(yōu)良率(90.91%)高于OSPIF組(73.81%),差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。所有患者均一期愈合,未見(jiàn)骨折不愈合及其他術(shù)后并發(fā)癥發(fā)生。結(jié)論 ALPIF治療CF內(nèi)固定牢靠,術(shù)后1年優(yōu)良率高,值得應(yīng)用于臨床。
跟骨骨折; 鋼板; 內(nèi)固定
跟骨骨折(calcaneal fracture,CF)為跗骨骨折中重要的類別,約占跗骨骨折的3/5[1]。資料顯示,CF主要是高能量損傷引發(fā),特別是Sanders Ⅲ型、Ⅳ型CF(下稱Ⅲ、Ⅳ型CF),由于骨折導(dǎo)致關(guān)節(jié)面塌陷嚴(yán)重,若治療不當(dāng)??蓪?dǎo)致關(guān)節(jié)面不平整以及跟骨寬度、Gissane角、Bohlers角非正?;謴?fù),引發(fā)跟部疼痛、創(chuàng)傷性關(guān)節(jié)炎等并發(fā)癥,嚴(yán)重者甚至導(dǎo)致患者踝關(guān)節(jié)功能障礙,影響患者的正常行走[2]。在Ⅲ、Ⅳ型CF的治療上,傳統(tǒng)上多行普通鋼板內(nèi)固定(ordinary steel plate internal fixation,OSPIF)[3]。OSPIF治療Ⅲ、Ⅳ型CF盡管療效較顯著,但是由于設(shè)計(jì)上的缺陷,鋼板和螺釘之間可以微動(dòng),在應(yīng)力作用下固定角度常易丟失[4]。為提高Ⅲ、Ⅳ型CF的臨床療效,筆者于2013年1月~2015年12月將解剖鎖定鋼板內(nèi)固定(anatomical locking plate internal fixation,ALPIF)應(yīng)用于Ⅲ、Ⅳ型CF的臨床治療,其療效較滿意,現(xiàn)總結(jié)如下。
1 一般資料
本組CF患者86例,男性58例(67.44%),女性28例(32.56%);年齡20~57歲,平均(38.53±4.28)歲。左足42例(48.84%),右足36例(41.86%),雙足8例(9.30%);墜落傷51例(59.30%),道路交通傷35例(40.70%)。Sanders Ⅲ型51例(59.30%)、Ⅳ型35例(40.70%)。所有患者均經(jīng)跟骨X線、CT檢查確診為CF。納入標(biāo)準(zhǔn):閉合性骨折;骨折7~10d以內(nèi);后關(guān)節(jié)面塌陷或移位>2mm;Gissane角、Bohlers角減小;可耐受手術(shù);知情同意。排除標(biāo)準(zhǔn):開(kāi)放性骨折、陳舊性骨折、伴有其他部位骨折、神經(jīng)血管?chē)?yán)重?fù)p傷、凝血功能障礙、特征人群(孕期、哺乳期女性)、合并重大臟器疾病。將86例依照隨機(jī)數(shù)字表法分為ALPIF組(n=44)與OSPIF組(n=42),兩組一般資料差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),見(jiàn)表1。
表1 兩組一般資料比較
2 方法
2.1 ALPIF組 ALPIF組行ALPIF(大博醫(yī)療科技股份有限公司產(chǎn)品)治療。患者全麻或連續(xù)硬麻,雙側(cè)CF取俯臥位,單側(cè)CF取側(cè)臥位,氣囊止血帶患側(cè)近端止血。于患肢踝上約3cm、跟腱前緣與腓骨后緣連線1/3位做切口,延長(zhǎng)切口至足底、足背皮膚。將跟骨外側(cè)骨膜及軟組織掀起,暴露骨折端,取3枚克氏針(2mm),分別鉆入距骨外側(cè)突、外踝及骰骨,充分暴露骨折端關(guān)節(jié)面,行骨折復(fù)位。預(yù)彎跟骨鎖定鋼板,取2枚皮質(zhì)骨螺釘(3.5mm)分別固定于后關(guān)節(jié)面及結(jié)節(jié)部,確保鋼板與外側(cè)皮質(zhì)吻合良好。C型臂X線下觀察Gissane角、Bohlers角恢復(fù)情況,復(fù)位滿意后,則以3枚鎖定螺釘多點(diǎn)牢固固定骨折位,常規(guī)放置引流管后關(guān)閉切口。術(shù)后常規(guī)抗感染治療。
2.2 OSPIF組 OSPIF組行OSPIF(大博醫(yī)療科技股份有限公司產(chǎn)品)治療。骨折復(fù)位前操作同ALPIF組,復(fù)位滿意后,以普通鋼板固定,按照跟骨外側(cè)形狀塑性,確保鋼板與外側(cè)皮質(zhì)吻合良好,分別于結(jié)節(jié)部、丘部、前突螺釘(每處至少2枚)固定,常規(guī)放置引流管后關(guān)閉切口。
3 觀察指標(biāo)
觀察兩組手術(shù)時(shí)間、術(shù)后拔管時(shí)間、術(shù)后拆線時(shí)間、負(fù)重鍛煉時(shí)間、骨折愈合時(shí)間等手術(shù)相關(guān)時(shí)間指標(biāo);術(shù)前及術(shù)后1年跟骨寬度、跟骨高度、Gissane角、Bohlers角。
4 療效評(píng)價(jià)標(biāo)準(zhǔn)
療效評(píng)價(jià)依據(jù)Maryland標(biāo)準(zhǔn)[5]制定。優(yōu):90~100分,患者行走正常,行走時(shí)無(wú)疼痛,工作恢復(fù)正常;良:75~89分,患者行走基本正常,行走時(shí)有輕微疼痛,工作基本恢復(fù)正常;中:50~74分,跟骨畸形,足底存在損傷嚴(yán)重足墊及骨贅,行走疼痛明顯或(和)輕微跛行,原來(lái)的工作難以完成,需改變工種;差:<50分,術(shù)后感染,關(guān)節(jié)僵直,骨缺損,殘疾,無(wú)法從事正常工作。療效評(píng)價(jià)術(shù)后1年進(jìn)行。
5 統(tǒng)計(jì)學(xué)處理
1 兩組手術(shù)相關(guān)時(shí)間指標(biāo)比較
兩組手術(shù)時(shí)間、術(shù)后拔管時(shí)間、術(shù)后拆線時(shí)間差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。ALPIF組術(shù)后負(fù)重鍛煉時(shí)間、骨折愈合時(shí)間早于OSPIF組,有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表2。
2 兩組術(shù)前及術(shù)后1年跟骨寬度、跟骨高度、Gissane角、Bohlers角比較
術(shù)前,兩組跟骨寬度、跟骨高度、Gissane角、Bohlers角差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);術(shù)后1年,兩組跟骨寬度較術(shù)前減小,跟骨高度、Gissane角、Bohlers角較術(shù)前顯著增加,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);術(shù)后1年ALPIF組跟骨寬度較OSPIF組低,跟骨高度、Gissane角、Bohlers角較OSPIF組高,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表3。
3 兩組臨床療效比較
ALPIF組術(shù)后1年優(yōu)良率為90.91%,OSPIF組術(shù)后1年優(yōu)良率為73.81%,組間比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表4。
表2 兩組手術(shù)相關(guān)時(shí)間指標(biāo)比較±s)
表3 兩組術(shù)前及術(shù)后1年跟骨寬度、跟骨高度、Gissane角、Bohlers角比較
Ⅲ、Ⅳ型CF主要是由剪切暴力導(dǎo)致的骨折[6]。在強(qiáng)大壓縮力的作用下,跟骨破裂為前內(nèi)側(cè)骨塊及后外側(cè)骨塊[7]。其中,前內(nèi)側(cè)骨塊主要包括后關(guān)節(jié)面內(nèi)側(cè)、載距突及跟骨前部等骨塊,后外側(cè)骨塊主要包括后關(guān)節(jié)面外側(cè)及其他跟骨骨塊[8]。在關(guān)節(jié)囊及韌帶的保護(hù)作用下,前外側(cè)骨塊移位多不明顯,后外側(cè)骨塊多成外側(cè)移位或內(nèi)翻位,并產(chǎn)生初級(jí)、次級(jí)骨折線[9]。研究發(fā)現(xiàn),在周?chē)馄式Y(jié)構(gòu)的保護(hù)作用下,載距突骨塊較為穩(wěn)定,移位多不明顯,故術(shù)中常將載距突作為固定點(diǎn)及CF復(fù)位的標(biāo)志[10]。
資料顯示,在CF的臨床治療上,不同內(nèi)固定物其固定牢固程度不同[11]。對(duì)于傷及距下關(guān)節(jié)的CF,復(fù)位后若以螺釘或(和)克氏針固定,常易松動(dòng),難以達(dá)到牢固內(nèi)固定的要求,故臨床常將螺釘、克氏針用于臨時(shí)內(nèi)固定[12]。普通鋼板可經(jīng)螺釘加壓固定骨塊,使固定相對(duì)穩(wěn)定[13]。但是,由于CF關(guān)節(jié)內(nèi)骨折較為復(fù)雜,且壓縮塌陷的松質(zhì)骨形成的骨缺損比較嚴(yán)重,或者軟骨之下的骨塊孤立或體積較小,從而導(dǎo)致普通螺釘把持不牢或失效,致使OSPIF失去作用[14]。而鎖定鋼板則具有較好的可塑性,能夠按照跟骨的生理特征塑性,使鋼板與跟骨吻合,增強(qiáng)CF內(nèi)固定的牢固性[15]。鎖定螺釘具有立體支撐能力及成角穩(wěn)定性,能夠與鋼板牢固固定,具有較強(qiáng)的支撐能力及內(nèi)支架功能,不但能夠?qū)⒐菈K牢固固定在接骨板上,還能保證術(shù)后塌陷骨折的穩(wěn)定性,避免其變形[16]。此外,ALPIF釘板間固定鉚合力及抵抗力較強(qiáng),能夠有效提高跟骨承載能力及其穩(wěn)定性[17]。鋼板與鎖定螺釘?shù)尼斘渤制剑捎行Ь徑鈩?chuàng)面間張力,避免發(fā)生感染及異物反應(yīng)[18]。
邢濤等[19]將ALPIF聯(lián)合植骨應(yīng)用于Ⅲ、Ⅳ型CF的臨床治療,其優(yōu)良率達(dá)87.5%,且術(shù)后未見(jiàn)螺釘固定不牢固,復(fù)位丟失、關(guān)節(jié)面塌陷等不良現(xiàn)象。游景揚(yáng)等[20]研究發(fā)現(xiàn),ALPIF可縮短術(shù)后跟骨骨折愈合時(shí)間,提高優(yōu)良率。張鵬舉[21]研究證明,ALPIF治療Ⅲ、Ⅳ型CF可有效避免復(fù)位后Gissane角、Bohlers角丟失,縮短骨折愈合及術(shù)后負(fù)重鍛煉時(shí)間。戚春潮和汪瑋[22]研究證實(shí),ALPIF可顯著改善CF患者跟骨寬度及高度、Gissane角、Bohler角,維持跟骨解剖結(jié)構(gòu)的穩(wěn)定性,且術(shù)后無(wú)不良反應(yīng)發(fā)生。在本研究中,ALPIF組術(shù)后負(fù)重鍛煉時(shí)間、骨折愈合時(shí)間早于OSPIF組,術(shù)后1年ALPIF組跟骨寬度低于OSPIF組,跟骨高度、Gissane角、Bohlers角及優(yōu)良率高于OSPIF組,且術(shù)后未見(jiàn)不良反應(yīng)發(fā)生,提示與OSPIF治療CF相比較,ALPIF的優(yōu)勢(shì)更加明顯。
總之,本研究結(jié)果證明,ALPIF治療Ⅲ、Ⅳ型CF可有效避免復(fù)位后Gissane角、Bohlers角丟失,改善CF患者跟骨寬度、高度,縮短骨折愈合及術(shù)后負(fù)重鍛煉時(shí)間,優(yōu)良率高,不良反應(yīng)發(fā)生率低,值得臨床推廣應(yīng)用。
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(本文編輯: 黃小英)
Clinical research on anatomical locking plate internal fixation in treating calcaneal fracture
LUOWei-guo
(Department of Orthopedics,the 187 Hospital of PLA,Haikou 571159,China)
Objective To investigate the clinical efficacy of anatomical locking plate internal fixation(ALPIF)in the treatment of calcaneal fracture(CF). Methods Totally 86 patients [58 males and 28 females,mean age (38.53±4.28)(20-57) years] with CF treated in our hospital from Jan.2013 to Dec.2015 were selected and divided into ALPIF group(n=44) and OSPIF group(n=42) according to the random number table method. ALPIF group was given ALPIF treatment,and ordinary steel plate internal fixation(OSPIF) group was given OSPIF treatment. The operation time,postoperative extubation time,postoperative stitches removal time,loading exercise time,fracture healing time and other operation relevant time indicators of the two groups were observed.Besides,the width and height of calcaneus,the Gissane angle,the Bohlers angle and the clinical efficacy of the two groups before operation and at 1 year after operation were observed. Results The differences in operation time,postoperative extubation time,postoperative stitches removal time,postoperative loading exercise time,indicators of the two groups had no statistical significance(P> 0.05). The postoperative loaded exercise time and fracture healing time of the ALPIF group were shorter than those of the OSPIF group,and the differences were statistically significant(P<0.05). One year after the operation,the widths of calcaneus of the two groups were smaller than those before operation,while the heights of calcaneus,Gissane angles and Bohlers angles were significantly larger than those before operation,and the differences were statistically significant(P<0.05). One year after operation,the width of calcaneus of the ALPIF group was smaller than that of the OSPIF group,the height of calcaneus,the Gissane angle and Bohlers angle were larger than those of the OSPIF group,and the differences were statistically significant(P<0.05). The excellent and good rate of the ALPIF group (90.91%) one year after operation was higher than that of the OSPIF group (73.81%),and the difference was statistically significant(P<0.05). All of the patients were healed by first intention,and no ununion or other postoperative complications was found. Conclusion ALPIF in the treatment of CF has firm fixation,and the excellent and good rate at one year after operation is high. The therapy is worthy of clinical application.
calcaneal fracture; plate; internal fixation
1009-4237(2016)11-0671-04
571159 海南 ???,解放軍187醫(yī)院創(chuàng)傷骨科
R683.42
A 【DOI】 10.3969/j.issn.1009-4237.2016.11.009
2016-07-29;
2016-08-23)