保留距下关节的跟骨截骨术治疗跟骨骨折畸形愈合

摘要

目的 探讨采用保留或重建距下关节的跟骨截骨术治疗跟骨骨折畸形愈合的疗效.方法 从2014年1月至2016年2月共收治符合保留距下关节的跟骨骨折畸形愈合患者20例(21足),伤后时间3～11个月,平均(5±2.5)个月.采用跟骨体部斜形截骨保留距下关节,通过移动截骨端矫正畸形以及新的关节内截骨术重建距下关节治疗,利用凿除的外侧壁行骨移植术.术口一期闭合20足,行皮瓣覆盖创面1足.19例(19足)患者获得12～18个月随访,(11±1.5)个月的随访,1例患者(双跟骨陈旧性骨折)随访3个月后失访,采用临床及影像学指标来评价治疗效果.结果 术口发生延迟愈合4例(21.1％),无深部感染,骨折均在10～12周愈合,有6例(32.6％)患者遗留不同程度疼痛不适.术后的Maryland评分较术前有明显提高,两者比较差异具有统计学意义.术后跟骨B(o)hler角、Gissane角、距骨倾斜角、跟距骨的高度、跟骨宽度较术前均有明显改善,差异具有统计学意义.结论 对于距下关节面完整或大部分完整的跟骨畸形愈合患者,采用跟骨截骨保留或重建距下关节面能恢复跟骨的外形和生物力学机制,并在临床上取得较好的效果.%Objective To discuss results of treating calcaneal fracture malunion by reserving or restoring the subtalar joint with calcaneal osteotomy.Methods From January 2014 to February 2016,20 patients(21 feet) with the mean time from initial injury to reconstructive operation of 3 ～ 11 (5 ± 2.5) months were treated by oblique osteotomy at the calcaneal body which gained the correction by traslation of calcaneal tuber,and a new the intra-articular osteotomy to restor subtalar joint using excisinal lateral wall grafting.The incisions were closed at one stage in 20 cases,and the flap was used to cover the wound in 1 case.19 feet in 19 patients were follow-up for (11±1.5)months(12～18 months)except for 1 patients losing follow-up after 3 months after operation.The clinical effect were evaluated by clinical outcomes and radiographical result.Results Four(21.1％) of nineteen feet had delayed wound healing with no deep infection.All of patients achieved initial union at 10～12 weeks,in which 6 cases had different degrees of residual pain at the lateral aspect of the ankle.The postoperative Maryland foot score was significantly higher and the B6hler's angle,Gissane's angle,talus declination angle,and width and height of calcaneus were improved greatly than the preoperative assessment and the difference was statistically significant.Conclusion Reserving or restoring the subtalar joint with calcaneal osteotomy can regain the calcaneal shape and biomechanical mechanism,and achive good clinical effect in treating calcaneal malunion with normal or most normal articular cartilage in the subtalar joint.