两种切口开放复位内固定跟骨骨折的比较△

Comparison of two incisions for open reduction and internal fixation of calcaneus fractures

摘要:

［目的］探讨儿童肱骨髁上骨折闭合复位失败的处理与相关因素。［方法］回顾性分析本院 2019 年 6 月—2020 年 12 月治疗的儿童肱骨髁上骨折 375 例患者的临床资料。所有患者均行闭合复位，复位成功者行经皮交叉克氏针内固定术 （closed reduction）（CR 组），复位失败者改行切开复位+交叉克氏针固定（open reduction）（OR 组）。比较两组临床与影像资料。以 CR 是否成功分组比较和二元多因素逻辑回归分析术前资料，探讨 CR 失败的相关因素。［结果］ 375 例患者中，348 例 CR 成功， 占 92.80%；27 例 CR 失败改行 OR，占 7.20%。最终两组患儿均顺利完成骨折复位交叉克氏针固定。CR 组手术时间、术中透视次数、住院时间、早期并发症发生率、术后 1 d 的 VAS 评分均显著优于 OR 组 （P<0.05）。随访时间 14~46 个月，平均 （23.40±4.59） 个月。两组拆除石膏时间、恢复完全负重活动时间、末次随访时肘伸屈 ROM 和 Flynn 临床结果评级的差异均无统计学意义（P>0.05）。影像方面，两组术后均达到满意骨折复位，骨折愈合良好。末次随访时两组提携角和 Baumann 角的差异均无统计学意义 （P>0.05）。单因素比较，CR 组 BMI、骨折复杂程度、损伤至手术时间、损伤能量均显著低于 OR 组 （P< 0.05）。逻辑回归方面，骨折类型复杂 （OR=8.251，P=0.037）、损伤能量高 （OR=1.593，P=0.035）、损伤至手术时间长 （OR= 1.400，P=0.026）是儿童肱骨髁上骨折 CR 失败的独立危险因素。［结论］对儿童肱骨髁上骨折初次闭合复位失败者应及时更改为开放复位，仍可取得满意治疗效果。骨折类型复杂、损伤能量高和损伤至手术时间长是初次闭合复位失败的主要危险因素。

Abstract:

[Objective] To compare the clinical efficacy of two incisions for open reduction and internal fixation (ORIF) in the treat- ment of intraarticular calcaneus fractures. [Methods] From March 2016 to January 2020, a total of 35 patients received surgical treatment for calcaneal fractures in our department. The patients were divided into two groups by random number table method, and received ORIF. Of them, 16 patients in the minimally invasive group had ORIF performed through tarsal sinus incision, while the other 19 patients in the conventional group were through the conventional lateral L-shaped incision. The perioperative, follow-up and imaging data were compared between the two groups. [Results] The minimally invasive group proved significantly superior to the conventional group in terms of opera- tion time, blood loss, incision length, incision healing and hospital stay (P<0.05) , but the former had significantly greater number of intraop- erative fluoroscopy than the latter (P<0.05) . All the 35 patients were followed up for more than 12 months. There was no statistically signifi- cant difference in the time to return to full weight-bearing activity between the two groups (P>0.05) . The VAS scores decreased significant- ly (P<0.05) , whereas the AOFAS and Maryland scores increased significantly over time in both groups (P<0.05) . At any corresponding time points, there was no significant difference in the above scores between the two groups (P>0.05) . Radiographically, all patients in both groups got fracture healing well, with significant improvements of calcaneal width, height, and length as well as Gissane angle and Bohler angle at the latest follow-up compared with those preoperatively (P<0.05) . However, there was no significant difference in aforesaid imag- ing measures between the two groups at any matching time points (P>0.05) . [Conclusion] Both tarsal sinus incision and the conventional lateral L-shaped incision for ORIF of intra-articular calcaneal fractures achieve satisfactory clinical outcomes, by comparison, the tarsal si- nus incision has a benefit of minimizing iatrogenic trauma.