跟骨骨折畸形愈合踝关节及距下关节僵硬的相关基础及临床研究
发布时间：2018-08-22 20:46
【摘要】：跟骨是人体最大的跗骨,其在支撑体重及行走过程中起着重要的作用。跟骨骨折在临床上比较常见,而且多为高能量损伤,其中关节内骨折占70%以上。骨折后治疗不当会导致畸形愈合,出现踝关节及距下关节僵硬等多种并发症,影响患者的工作及生活。目前对于跟骨骨折后畸形愈合没有统一、有效的治疗方法,主要采用手术治疗,而且大多行关节融合术。对患者足的功能影响较大,随着人们生活水平的提高、对跟骨骨折治疗重视程度的增加,以及影像学、内固定等治疗技术的进步,临床上严重的跟骨骨折畸形愈合越来越少。跟骨骨折后踝关节及距下关节僵硬逐渐引起人们的重视,但目前对于踝关节及距下关节僵硬的病理机制及治疗的报道较少,治疗效果也有较大差异。本研究针对跟骨骨折后踝关节及距下关节僵硬的病例,通过Stephens和Sanders CT分型,对于Ⅰ型及Ⅱ型畸形愈合引起的踝关节及距下关节僵硬的患者,采用保留距下关节的手术治疗,进行研究随访确定手术效果,为踝关节及距下关节僵硬找到合适的治疗方法。目的:根据跟骨骨折畸形愈合Sanders CT分型,对于Ⅰ型及Ⅱ型患者,采用腓骨肌腱延长或松解及距下关节松解术,治疗跟骨骨折后踝关节及距下关节僵硬,通过比较术前及术后跟骨内翻、外翻角度,踝关节跖屈、背伸角度,后足AOFAS功能评分及运动疼痛模拟评分(VAS),随访观察术后疗效,为跟骨骨折后踝关节及距下关节僵硬的病理机制及治疗提供理论基础。方法:选取2012年2月—2014年10月在河北医科大学第三医院就诊治疗的跟骨骨折后踝关节及距下关节僵硬的患者42例60足。男34例52足,年龄18-55岁,平均30岁;女8例8足,年龄20-46岁,平均35岁。受伤原因:高处坠落伤36足,车祸伤14足,砸伤10足。骨折后保守治疗(手法复位石膏固定、卧床休息)38足;手术治疗(外侧钢板、空心螺钉固定)22足。伤后负重时间2-4个月,平均3.3个月;骨折到本次住院手术时间6-37个月,平均15月。所有病例根据入选标准及排除标准选定,每足术前行X线片、CT扫描,测量跟骨内翻、外翻角度,踝关节跖屈、背伸角度,并进行后足AOFAS功能评分,应用疼痛模拟评分(VAS)系统让患者自行评分。对跟骨骨折畸形愈合采用Stephens和Sanders CT分型,Ⅰ型及Ⅱ型患者,手术选择跟骨外侧切口,行腓骨肌腱延长或松解及距下关节松解术,术中行手法松解,进一步增加活动度;术后6个月、12个月随访测量跟骨内翻、外翻角度,踝关节跖屈、背伸角度,并进行后足AOFAS功能评分及疼痛模拟评分(VAS),对上述手术前与手术后6个月,手术后6个月与手术后12个月指标,运用spss 21.0进行统计学数据分析比较,资料采用t检验,评价手术的临床疗效。P0.05为差异具有显著性意义。结果:本组病例共42例60足,随访13~27个月(平均随访16个月)。术后1足出现切口积血,皮缘局部坏死,早期给予拆除部分缝线,充分引流,切口愈合良好;1足切口皮缘坏死,切痂后软组织外露,行负压封闭引流技术(VSD)治疗,愈合良好。1例患者术后随访跟骨运动及疼痛程度较术前减轻不明显,加强功能锻炼后,较之前好转。其余患者跟骨内外翻活动度增加,疼痛缓解。所有病例没有发生跟骨二次骨折等并发症,能从事正常工作及生活。统计学分析比较术前及术后6个月足的观察指标,内翻活动度t=-34.790,P0.001,外翻活动度t=-19.363,P0.001、踝关节跖屈角度t=-1.973,P=0.0.0530.05,背伸运动角度t=-1.918,P=0.0600.05,运动时疼痛采用视觉模拟评分(visual analogue scale,VAS)比较t=28.796,P㩳0.001,美国足踝外科协会(American orthopaedic Foot and Ankle Society,AOFAS)足部功能评分t=-42.249,P0.001,术前可4足,差56足。术后6个月优11足,良46足,可3足,优良率95.0%。统计学分析比较术后6个月与术后12个月足的观察指标,内翻活动度t=-0.753,P=0.454,外翻活动度t=0.055,P=0.956、踝关节跖屈角度t=-0.406,P=0.686,背伸运动角度t=0.335,P=0.739,运动时疼痛采用视觉模拟评分(visual analogue scale,VAS)比较t=1.926,P=0.059,美国足踝外科协会(American orthopaedic Foot and Ankle Society,AOFAS)足部功能评分t=0.947,P=0.347。结论:1术前与术后6个月跟骨内翻及外翻角度、AOFAS足功能评分、疼痛视觉模拟评分(VAS)有统计学差异;术前与术后踝关节屈伸运动无统计学差异。术后6个月与术后12个月各项指标无统计学差异。2踝关节及距下关节僵硬有多种因素共同影响:腓骨肌痉挛、腓骨肌腱粘连、跟骨外侧壁外膨、距下关节关节间隙变窄,关节面不平整或关节面未完全恢复,关节“咬合”度减低。Ⅰ、Ⅱ型跟骨骨折畸形愈合对于踝关节僵硬的影响较小。3腓骨肌腱延长或松解,距下关节松解手术可有效治疗Ⅰ、Ⅱ型跟骨骨折畸形愈合引起的踝关节及距下关节僵硬,能减轻疼痛,而且保留关节活动度,提高患者的生活质量。要根据患者的病情,结合术前影响检查、患者的症状及对足功能的要求,选择保留距下关节的功能的手术治疗。
[Abstract]:The calcaneus is the largest tarsal bone in the human body and plays an important role in supporting body weight and walking process. Calcaneal fractures are common in clinic, and most of them are high-energy injuries, in which intra-articular fractures account for more than 70%. Improper treatment after fractures can lead to malunion, ankle and subtalar joint stiffness and other complications, affecting patients. At present, there is no unified and effective treatment for malunion after calcaneal fracture, mainly using surgical treatment, and mostly joint fusion. It has a great impact on the function of the foot. With the improvement of people's living standards, the treatment of calcaneal fracture attaches more importance to, and imaging, internal fixation and other treatment techniques. The malunion of calcaneal fractures is becoming less and less serious. The ankle and subtalar joint stiffness after calcaneal fractures has gradually attracted people's attention, but there are few reports on the pathological mechanism and treatment of ankle and subtalar joint stiffness. Subtalar joint stiffness was classified by Stephens and Saanders CT. The patients with ankle and subtalar joint stiffness caused by type I and type II malunion were treated with subtalar joint preservation surgery. The follow-up study was conducted to determine the surgical effect and find the appropriate treatment for ankle and subtalar joint stiffness. Sanders CT classification of malunion of bone fracture. For type I and type II patients, fibular tendon lengthening or releasing and subtalar joint releasing were used to treat ankle and subtalar joint stiffness after calcaneal fracture. Calcaneal varus, valgus angle, ankle metatarsal flexion, dorsal extension angle, AOFAS functional score of hind foot and motor pain model were compared before and after operation. Methods: 42 cases (60 feet) with ankle and subtalar joint stiffness after calcaneal fracture were selected from February 2012 to October 2014 in the Third Hospital of Hebei Medical University. The age ranged from 18 to 55 years, with an average of 30 years; 8 females, aged 20 to 46, with an average of 35 years. Causes of injury: 36 high fall injuries, 14 traffic accidents, 10 smashed injuries; 38 conservative treatments (manual reduction, plaster fixation, bed rest) after fracture; 22 surgical treatments (lateral plate, hollow screw fixation); 2 to 4 months, with an average of 3.3 months after injury; All cases were selected according to the criteria of admission and exclusion. X-ray film, CT scan, calcaneal varus, valgus angle, ankle metatarsal flexion, dorsal extension angle were measured before each foot operation. AOFAS functional score of hind foot was performed. Pain analogue scale (VAS) system was used to score the calcaneal fracture. Malunion was classified by Stephens and Saanders CT. Patients of type I and type II were operated by lateral calcaneal incision, fibular tendon lengthening or release and subtalar joint release. Manual release was performed during the operation to further increase mobility. Calcaneal varus, valgus angle, ankle metatarsal flexion and dorsal extension angle were measured 6 months and 12 months after operation. AOFAS function score and pain analogue score (VAS) of hind foot were compared with those of 6 months before operation, 6 months after operation and 12 months after operation. The data were analyzed by SPSS 21.0. T test was used to evaluate the clinical effect of operation. P 0.05 was significant. Results: There were 42 cases with 60 feet in this group. The follow-up period ranged from 13 to 27 months (mean follow-up 16 months). One foot developed hematocele and local necrosis of the skin margin, and the incision healed well after early removal of sutures and adequate drainage. One foot had skin margin necrosis and soft tissue exposure after escharectomy, and was treated with vacuum sealing drainage (VSD). All the patients had no complications such as secondary fracture of calcaneus, so they could engage in normal work and life. 01, valgus activity t = - 19.363, P 0.001, ankle metatarsal flexion angle t = - 1.973, P = 0.0.0530.05, back extension angle t = - 1.918, P = 0.0600.05, movement pain using visual analogue scale (VAS) comparison t = 28.796, P? 0.001, American Foot and Ankle Society (AOFAS) Foot Function Assessment After 6 months, 11 feet were excellent, 46 feet were good, 3 feet were fair, and the excellent and good rate was 95.0%. Statistical analysis and comparison were made between 6 months after operation and 12 months after operation. The indexes of varus activity t = - 0.753, P = 0.454, valgus activity t = 0.055, P = 0.956, ankle metatarsal flexion t = - 0.406, P = 0.686, dorsal extension angle t = 0.335, P = 0.7, P = 0. 39. Pain during exercise was compared with visual analogue scale (VAS) t = 1.926, P = 0.059. The foot function score of the American orthopaedic Foot and Ankle Society (AOFAS) t = 0.947, P = 0.347. Conclusion: 1 Calcaneal varus and valgus angle, AOFAS foot function score, visual analogue pain There was no significant difference in the indexes of ankle flexion and extension between preoperative and postoperative. 2 There were many factors affecting ankle and subtalar joint stiffness: fibular spasm, fibular tendon adhesion, calcaneal lateral wall ectasia, subtalar joint space narrowing, joint joint stiffness. The malunion of type I and II calcaneal fractures has little effect on ankle stiffness. 3 The fibular tendon is lengthened or loosened. Subtalar joint release surgery can effectively treat ankle and subtalar joint stiffness caused by malunion of type I and II calcaneal fractures. According to the patient's condition, the preoperative examination, the patient's symptoms and the requirement of foot function, we should choose the surgical treatment to preserve the function of subtalar joint.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3
本文编号：2198255
[Abstract]:The calcaneus is the largest tarsal bone in the human body and plays an important role in supporting body weight and walking process. Calcaneal fractures are common in clinic, and most of them are high-energy injuries, in which intra-articular fractures account for more than 70%. Improper treatment after fractures can lead to malunion, ankle and subtalar joint stiffness and other complications, affecting patients. At present, there is no unified and effective treatment for malunion after calcaneal fracture, mainly using surgical treatment, and mostly joint fusion. It has a great impact on the function of the foot. With the improvement of people's living standards, the treatment of calcaneal fracture attaches more importance to, and imaging, internal fixation and other treatment techniques. The malunion of calcaneal fractures is becoming less and less serious. The ankle and subtalar joint stiffness after calcaneal fractures has gradually attracted people's attention, but there are few reports on the pathological mechanism and treatment of ankle and subtalar joint stiffness. Subtalar joint stiffness was classified by Stephens and Saanders CT. The patients with ankle and subtalar joint stiffness caused by type I and type II malunion were treated with subtalar joint preservation surgery. The follow-up study was conducted to determine the surgical effect and find the appropriate treatment for ankle and subtalar joint stiffness. Sanders CT classification of malunion of bone fracture. For type I and type II patients, fibular tendon lengthening or releasing and subtalar joint releasing were used to treat ankle and subtalar joint stiffness after calcaneal fracture. Calcaneal varus, valgus angle, ankle metatarsal flexion, dorsal extension angle, AOFAS functional score of hind foot and motor pain model were compared before and after operation. Methods: 42 cases (60 feet) with ankle and subtalar joint stiffness after calcaneal fracture were selected from February 2012 to October 2014 in the Third Hospital of Hebei Medical University. The age ranged from 18 to 55 years, with an average of 30 years; 8 females, aged 20 to 46, with an average of 35 years. Causes of injury: 36 high fall injuries, 14 traffic accidents, 10 smashed injuries; 38 conservative treatments (manual reduction, plaster fixation, bed rest) after fracture; 22 surgical treatments (lateral plate, hollow screw fixation); 2 to 4 months, with an average of 3.3 months after injury; All cases were selected according to the criteria of admission and exclusion. X-ray film, CT scan, calcaneal varus, valgus angle, ankle metatarsal flexion, dorsal extension angle were measured before each foot operation. AOFAS functional score of hind foot was performed. Pain analogue scale (VAS) system was used to score the calcaneal fracture. Malunion was classified by Stephens and Saanders CT. Patients of type I and type II were operated by lateral calcaneal incision, fibular tendon lengthening or release and subtalar joint release. Manual release was performed during the operation to further increase mobility. Calcaneal varus, valgus angle, ankle metatarsal flexion and dorsal extension angle were measured 6 months and 12 months after operation. AOFAS function score and pain analogue score (VAS) of hind foot were compared with those of 6 months before operation, 6 months after operation and 12 months after operation. The data were analyzed by SPSS 21.0. T test was used to evaluate the clinical effect of operation. P 0.05 was significant. Results: There were 42 cases with 60 feet in this group. The follow-up period ranged from 13 to 27 months (mean follow-up 16 months). One foot developed hematocele and local necrosis of the skin margin, and the incision healed well after early removal of sutures and adequate drainage. One foot had skin margin necrosis and soft tissue exposure after escharectomy, and was treated with vacuum sealing drainage (VSD). All the patients had no complications such as secondary fracture of calcaneus, so they could engage in normal work and life. 01, valgus activity t = - 19.363, P 0.001, ankle metatarsal flexion angle t = - 1.973, P = 0.0.0530.05, back extension angle t = - 1.918, P = 0.0600.05, movement pain using visual analogue scale (VAS) comparison t = 28.796, P? 0.001, American Foot and Ankle Society (AOFAS) Foot Function Assessment After 6 months, 11 feet were excellent, 46 feet were good, 3 feet were fair, and the excellent and good rate was 95.0%. Statistical analysis and comparison were made between 6 months after operation and 12 months after operation. The indexes of varus activity t = - 0.753, P = 0.454, valgus activity t = 0.055, P = 0.956, ankle metatarsal flexion t = - 0.406, P = 0.686, dorsal extension angle t = 0.335, P = 0.7, P = 0. 39. Pain during exercise was compared with visual analogue scale (VAS) t = 1.926, P = 0.059. The foot function score of the American orthopaedic Foot and Ankle Society (AOFAS) t = 0.947, P = 0.347. Conclusion: 1 Calcaneal varus and valgus angle, AOFAS foot function score, visual analogue pain There was no significant difference in the indexes of ankle flexion and extension between preoperative and postoperative. 2 There were many factors affecting ankle and subtalar joint stiffness: fibular spasm, fibular tendon adhesion, calcaneal lateral wall ectasia, subtalar joint space narrowing, joint joint stiffness. The malunion of type I and II calcaneal fractures has little effect on ankle stiffness. 3 The fibular tendon is lengthened or loosened. Subtalar joint release surgery can effectively treat ankle and subtalar joint stiffness caused by malunion of type I and II calcaneal fractures. According to the patient's condition, the preoperative examination, the patient's symptoms and the requirement of foot function, we should choose the surgical treatment to preserve the function of subtalar joint.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3
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