本文選題：跟骨骨折 + 流行病學(xué)調(diào)查��； 參考：《河北醫(yī)科大學(xué)》2015年博士論文

【摘要】：跟骨是人體最大的跗骨,周圍有重要軟組織結(jié)構(gòu)包裹,能提供獨(dú)特的承重功能。跟骨骨折在跗骨骨折中最常見(jiàn),占全身骨折的1%~2%,且其中75%涉及跟距關(guān)節(jié)面。早在1843年,Malgaigne等第一次報(bào)道了骨折線累及關(guān)節(jié)面的跟骨骨折。跟骨關(guān)節(jié)內(nèi)骨折是非常復(fù)雜的損傷,如果診治不當(dāng),常造成不良預(yù)后,甚至災(zāi)難性的后果。我國(guó)幅員遼闊,各地區(qū)自然條件、經(jīng)濟(jì)和社會(huì)發(fā)展各異,跟骨骨折致傷原因不同。隨著我國(guó)建筑、交通、加工、機(jī)械制造等行業(yè)的迅猛發(fā)展,高處墜落傷、擠壓傷以及交通傷等高能量暴力導(dǎo)致的跟骨骨折也日益增多,致傷原因的改變會(huì)導(dǎo)致跟骨骨折損傷類型及各類型構(gòu)成比改變。為了更好地了解我國(guó)跟骨骨折損傷特征,明確跟骨骨折各類型構(gòu)成比,有必要進(jìn)行全國(guó)范圍內(nèi)跟骨骨折流行病學(xué)調(diào)查。高能量暴力導(dǎo)致的跟骨關(guān)節(jié)內(nèi)骨折,尤其是嚴(yán)重粉碎的跟骨骨折,發(fā)生率逐漸增高,這類損傷診斷和治療十分棘手。跟骨關(guān)節(jié)內(nèi)骨折如不能準(zhǔn)確評(píng)估、有效治療,其預(yù)后欠佳,影響患者傷后生活和工作,對(duì)社會(huì)經(jīng)濟(jì)的發(fā)展也將有一定影響。診斷跟骨骨折最常用的影像檢查手段是X線攝像,跟骨骨折AO分型既是據(jù)此進(jìn)行評(píng)估、分型。除通過(guò)判斷跟骨骨折損傷類型評(píng)估其損傷嚴(yán)重程度外,還可以在跟骨X線片上測(cè)量B?hler’s角、Gissan’s角、跟骨寬度和長(zhǎng)度等指標(biāo)來(lái)輔助評(píng)估損傷嚴(yán)重程度。但是,關(guān)于B?hler’s角評(píng)價(jià)跟骨關(guān)節(jié)內(nèi)骨折損傷嚴(yán)重程度的作用、預(yù)測(cè)跟骨切開(kāi)復(fù)位內(nèi)固定治療后患足功能恢復(fù)情況中所起的作用,以及B?hler’s角在跟骨手術(shù)中的指導(dǎo)作用則長(zhǎng)期存在著很多爭(zhēng)論。大量研究表明B?hler’s角和跟骨關(guān)節(jié)內(nèi)移位骨折的功能恢復(fù)具有關(guān)聯(lián)性,但是二者的關(guān)聯(lián)性尚未明確。合并有有移位的跟骨關(guān)節(jié)內(nèi)骨折的損傷類型,其嚴(yán)重程度多與患者術(shù)前B?hler’s角的角度存在密切的相關(guān)。我們發(fā)現(xiàn)關(guān)節(jié)面尤其是后距下關(guān)節(jié)面的解剖復(fù)位,恢復(fù)跟骨高度,長(zhǎng)度,和寬度在跟骨骨折中顯得尤為重要,因此B?hler’s角可以作為一個(gè)高度靈敏的術(shù)中和術(shù)后評(píng)估預(yù)測(cè)指標(biāo),但相應(yīng)的恢復(fù)角度仍有待研究。因此本研究集中于解答下面的幾個(gè)相關(guān)問(wèn)題:1、B?hler’s角與較嚴(yán)重的有移位的跟骨關(guān)節(jié)內(nèi)骨折之間是否存在相互關(guān)系;2、B?hler’s角的手術(shù)復(fù)位與術(shù)后功能預(yù)后情況是否存在關(guān)聯(lián)性;3、如果存在關(guān)聯(lián)性,為獲得滿意的預(yù)后結(jié)果,B?hler’s角應(yīng)該手術(shù)恢復(fù)到什么程度。B?hler’s角的度數(shù)(手術(shù)后的測(cè)量值)對(duì)判斷患足的功能預(yù)后結(jié)果是否具有重要的參考價(jià)值。跟骨骨折行CT掃描可以更準(zhǔn)確地評(píng)估損傷嚴(yán)重程度。Sanders分型是臨床廣泛應(yīng)用的跟骨骨折CT分型,其根據(jù)冠狀面CT掃描圖像上骨折線的位置劃分骨折類型。在冠狀面圖像上選擇跟骨后距下關(guān)節(jié)面最寬處,從外向內(nèi)標(biāo)記A、B、C三條骨折線,可將骨折塊分為三部分關(guān)節(jié)面骨折塊和二部分載距突骨折塊。Sanders分型I型是指所有無(wú)移位骨折;Sanders分型Ⅱ型根據(jù)骨折線位置分為Ⅱa、Ⅱb、Ⅱc骨折;Sanders分型Ⅲ型是三部分骨折,根據(jù)骨折位置又為Ⅲab、Ⅲbc、Ⅲac骨折,其典型骨折有一中央壓縮骨塊;Ⅳ型包含3-4原發(fā)骨折線,超過(guò)2mm的關(guān)節(jié)面內(nèi)移位,并且嚴(yán)重粉碎性骨折。Sanders等許多學(xué)者認(rèn)為,即使對(duì)具有豐富經(jīng)驗(yàn)的外科醫(yī)生來(lái)說(shuō),治療跟骨關(guān)節(jié)內(nèi)移位骨折也是一個(gè)嚴(yán)峻的挑戰(zhàn)。距下關(guān)節(jié)復(fù)位不良是影響跟骨關(guān)節(jié)內(nèi)移位骨折預(yù)后的主要因素之一。然而,在臨床上由于跟骨關(guān)節(jié)內(nèi)移位骨折損傷嚴(yán)重、跟骨特殊的解剖結(jié)構(gòu)以及醫(yī)生手術(shù)經(jīng)驗(yàn)和使用復(fù)位工具及固定物的限制,部分跟骨關(guān)節(jié)內(nèi)移位骨折不能完全解剖復(fù)位關(guān)節(jié)面并有效固定。有學(xué)者報(bào)道跟骨骨折患者術(shù)后距下關(guān)節(jié)移位超過(guò)1mm即可能導(dǎo)致創(chuàng)傷性關(guān)節(jié)炎,影響患者患足功能,部分癥狀嚴(yán)重的患者需行距下關(guān)節(jié)融合等手術(shù)治療。根據(jù)本課題組前期研究,術(shù)后早期活動(dòng)患足、早期負(fù)重鍛煉的患者功能恢復(fù)更好,在隨訪時(shí)行患側(cè)跟骨CT檢查,可以觀察到術(shù)后殘留的移位有減小趨勢(shì)。術(shù)后早期功能鍛煉、磨造距下關(guān)節(jié)是否對(duì)跟骨骨折內(nèi)固定術(shù)后殘留移位具有二次復(fù)位作用,是否有助于改善患者預(yù)后,尚缺乏定量研究。針對(duì)上述問(wèn)題,我們開(kāi)展了全國(guó)跟骨骨折流行病學(xué)調(diào)查和骨折類型分析,回顧性分析了大樣本跟骨骨折患者術(shù)前、術(shù)后B?hler’s角、骨折類型及功能恢復(fù)(AOFAS評(píng)分)之間的相關(guān)關(guān)系,探討了早期鍛煉對(duì)內(nèi)固定術(shù)后跟骨關(guān)節(jié)內(nèi)移位骨折殘留移位二次復(fù)位的作用�，F(xiàn)報(bào)道如下:第一部分跟骨骨折的流行病學(xué)調(diào)查目的:跟骨骨折是一種常見(jiàn)骨折,這種骨折常常會(huì)遺留長(zhǎng)期嚴(yán)重的殘疾,因此給社會(huì)和患者家庭帶來(lái)極大的經(jīng)濟(jì)負(fù)擔(dān)。本文旨在回顧性研究跟骨骨折的流行病學(xué)特征及其在中國(guó)中東西部的地域特征。方法:我們從課題組建立的一個(gè)數(shù)據(jù)庫(kù)中抽取資料,此數(shù)據(jù)庫(kù)回顧性分析了2010年1月至2011年12月間我國(guó)83所醫(yī)院的431822例骨折資料。分析在此期間納入本研究的多個(gè)創(chuàng)傷中心的跟骨骨折患者,將這些患者的人口統(tǒng)計(jì)學(xué)詳細(xì)資料及X線片均行回顧性評(píng)價(jià)。所有患者(含門診患者)的跟骨骨折的影像學(xué)資料都依據(jù)AO分型進(jìn)行分型,進(jìn)而進(jìn)行數(shù)據(jù)分析。跟骨骨折包含在本次研究中,除此之外,這些骨折按醫(yī)院所在地分為中部地區(qū)、西部地區(qū)、東部地區(qū)三個(gè)類型。通過(guò)這三組的對(duì)比,分析這三組之間患者的年齡、性別及骨折類型的地域差異。結(jié)果:本次研究期間,共計(jì)11530名(12242例)跟骨骨折患者在我國(guó)的83所醫(yī)院中進(jìn)行治療。本次研究中患者的平均年齡為38.95歲(區(qū)間為1-93歲);收治兒童跟骨骨折522例(占全部總數(shù)的4.26%),成人跟骨骨折11720例(占全部總數(shù)的95.74%);男女比為5.13:1。男患者高發(fā)的年齡組為36~40歲,女患者高發(fā)的年齡組為36~40歲和46~50歲。中國(guó)最常見(jiàn)的類型為82-C型,此類型占成人跟骨骨折的57.95%。東部地區(qū)發(fā)生跟骨骨折的平均年齡比西部高(P0.05),中部比西部高(P0.05)。82-C型跟骨骨折在東部、中部和西部的構(gòu)成比分別為58.15%、55.44%、62.00%,統(tǒng)計(jì)學(xué)有顯著差異(P0.001)。結(jié)論:本次研究旨在調(diào)查我國(guó)跟骨骨折的地域性和流行病學(xué)特征。男性高發(fā)年齡組為36~40歲,而女性為36~40歲和46~50歲。我國(guó)最常見(jiàn)的跟骨骨折類型為82-C型(AO分型)。第二部分B?hler’s角評(píng)估跟骨關(guān)節(jié)內(nèi)骨折損傷嚴(yán)重程度及預(yù)測(cè)內(nèi)固定術(shù)后功能恢復(fù)情況的效度的分析目的:關(guān)于B?hler’s角用于評(píng)價(jià)有移位的跟骨關(guān)節(jié)內(nèi)骨折損傷的嚴(yán)重程度作用,以及預(yù)測(cè)跟骨切開(kāi)復(fù)位內(nèi)固定治療后的患足功能恢復(fù)情況中所起的作用。B?hler’s的作用在跟骨手術(shù)中長(zhǎng)期存在著很多爭(zhēng)論。據(jù)此本實(shí)驗(yàn)旨在研究B?hler’s角與損傷程度,手術(shù)改善B?hler’s角與功能恢復(fù)之間的相互關(guān)系是否是存在的。方法:研究對(duì)象為在河北醫(yī)科大學(xué)第三醫(yī)院行手術(shù)治療的,時(shí)間在2004年1月1日到2008年3月31日期間的,主要臨床癥狀表現(xiàn)為閉合性的、單純性的有移位的跟骨關(guān)節(jié)內(nèi)骨折患者。手術(shù)之前應(yīng)測(cè)量患者雙側(cè)跟骨的B?hler’s角,并以正常側(cè)的跟骨B?hler’s角作為對(duì)照組。分別記錄手術(shù)前、手術(shù)后,所有患者傷側(cè)和健側(cè)的B?hler’s角數(shù)值。通過(guò)對(duì)比雙側(cè)跟骨B?hler’s角的常規(guī)角度,通過(guò)計(jì)算得出傷側(cè)B?hler’s角的改變值。依據(jù)Sander分型來(lái)評(píng)價(jià)跟骨骨折損傷的嚴(yán)重程度,應(yīng)用AOFAS踝-后足評(píng)分系統(tǒng)來(lái)評(píng)價(jià)跟骨骨折術(shù)后的功能恢復(fù)結(jié)果。分析評(píng)價(jià)B?hler’s角與AOFAS踝-后足評(píng)分系統(tǒng)、B?hler’s角與Sander分型以及AOFAS踝至后足評(píng)分系統(tǒng)與Sander分型的相互關(guān)系。結(jié)果:本實(shí)驗(yàn)共計(jì)納入274名患者,平均隨訪時(shí)間超過(guò)71個(gè)月,根據(jù)Sander分型分類,其中包含Ⅳ型骨折共計(jì)48例,Ⅲ型骨折共計(jì)121例和Ⅱ型骨折共計(jì)105例。嚴(yán)格遵照AOFAS踝-后足的評(píng)分系統(tǒng)行分類,差11例、可27例、優(yōu)104例、良132例。對(duì)這三項(xiàng)數(shù)據(jù)的手術(shù)結(jié)束后的統(tǒng)計(jì)分析發(fā)現(xiàn):術(shù)前的B?hler’s角、雙側(cè)跟骨的B?hler’s角的差值以及B?hler’s角的變化率均與Sande分型有關(guān)聯(lián)(rs=-0.178,P=0.003;rs=-0.174,P=0.004;rs=-0.172,P=0.005),但與跟骨骨折術(shù)后的功能恢復(fù)結(jié)果沒(méi)有關(guān)聯(lián)性。術(shù)前的B?hler’s角、雙側(cè)跟骨的B?hler’s角的差值以及B?hler’s角的變化率與AOFAS踝-后足評(píng)分有明顯相關(guān)(rs=0.223,P0.001;rs=0.224,P0.001;rs=0.220,P0.001,但是關(guān)聯(lián)性較弱)。結(jié)論:僅發(fā)現(xiàn)手術(shù)之后的B?hler’s角與行跟骨骨折手術(shù)之后患者的功能恢復(fù)效果之間存在著相互的關(guān)聯(lián)性,術(shù)前患者B?hler’s角與患者的有移位的跟骨關(guān)節(jié)內(nèi)骨折的嚴(yán)重程度相關(guān)。第三部分早期功能鍛煉對(duì)跟骨骨折術(shù)后二次復(fù)位作用的影像學(xué)研究目的:本文旨在探討經(jīng)皮撬撥復(fù)位、應(yīng)用跟骨解剖接骨板-加壓骨栓微創(chuàng)固定治療跟骨關(guān)節(jié)內(nèi)移位骨折術(shù)后早期功能鍛煉對(duì)跟骨關(guān)節(jié)面的二期復(fù)位作用以及對(duì)足部功能恢復(fù)的影響。方法:將我院2012年12月后收治的單側(cè)跟骨關(guān)節(jié)內(nèi)移位骨折患者納入本研究,所有患者均行經(jīng)皮撬撥復(fù)位、應(yīng)用跟骨解剖接骨板-加壓骨栓微創(chuàng)固定治療。根據(jù)術(shù)后是否早期鍛煉及負(fù)重隨機(jī)分配為實(shí)驗(yàn)組和對(duì)照組。實(shí)驗(yàn)組患者術(shù)后早期進(jìn)行功能鍛煉,術(shù)后2~3天行足底研磨瓶子,術(shù)后3周部分負(fù)重,12周完全負(fù)重;對(duì)照組按照常規(guī)進(jìn)行康復(fù)鍛煉,術(shù)后6周部分負(fù)重,骨折愈合后完全負(fù)重。術(shù)后隨訪患者,術(shù)后第1天、4周、8周、12周行CT掃描,在矢狀位、水平位和冠狀位圖像上測(cè)量骨折最大移位。術(shù)后12個(gè)月根據(jù)AOFAS評(píng)分對(duì)患足功能進(jìn)行評(píng)估,在足側(cè)位X線片上測(cè)量B?hler’s角和Gissane角,統(tǒng)計(jì)學(xué)分析評(píng)估術(shù)后早期功能鍛煉對(duì)距下關(guān)節(jié)殘留移位是否具有二次復(fù)位作用以及改善后足功能的作用。結(jié)果:實(shí)驗(yàn)組和對(duì)照組患者在年齡、性別和骨折類型等方面差異無(wú)統(tǒng)計(jì)學(xué)意義。術(shù)后第1天、4周、8周、12周在CT矢狀位、水平位和冠狀位圖像上測(cè)量骨折最大移位,并進(jìn)行重復(fù)測(cè)量設(shè)計(jì)的方差分析顯示實(shí)驗(yàn)組和對(duì)照組組間差異有統(tǒng)計(jì)學(xué)意義,組別與時(shí)間點(diǎn)間存在交互作用,各時(shí)間點(diǎn)除第一時(shí)間點(diǎn)外兩組差別均有統(tǒng)計(jì)學(xué)意義;實(shí)驗(yàn)組在各時(shí)間點(diǎn)間差異均有統(tǒng)計(jì)學(xué)意義。術(shù)后12個(gè)月AOFAS評(píng)分與術(shù)后12周CT矢狀位、水平位和冠狀位重建圖像上測(cè)量的骨折最大移位具有顯著相關(guān)性,與AOFAS相關(guān)性由大到小依次為矢狀位移位、冠狀位移位和水平位移位。B?hler’s角、Gissan角與AOFAS的相關(guān)系數(shù)比較差異均無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論:跟骨關(guān)節(jié)內(nèi)移位骨折微創(chuàng)復(fù)位堅(jiān)強(qiáng)內(nèi)固定治療后建議早期行康復(fù)鍛煉,早期行功能鍛煉及負(fù)重可以模造距下關(guān)節(jié),減小關(guān)節(jié)面殘留移位,改善足部功能恢復(fù)。
[Abstract]:Calcaneus is the largest tarsal bone, surrounded by an important soft tissue structure, which provides unique bearing function. Calcaneus fracture is the most common fracture of the tarsal bone, which accounts for 1%~2% of the whole body fracture, and 75% of them involve the heel articular surface. As early as 1843, Malgaigne was the first time to report the fracture of the calcaneus with the fracture of the articular surface. Folding is a very complicated injury. If the diagnosis and treatment are unsuitable, it often causes bad prognosis and even disastrous consequences. China has a vast territory, natural conditions, economic and social development in various regions, and the causes of calcaneus fracture are different. The calcaneus fracture, which is caused by high energy violence such as injury, is also increasing. The change of the cause of the injury will lead to the type of calcaneal fracture and the change of the type of constitution. In order to understand the characteristics of the calcaneus fracture in our country and the ratio of all types of calcaneus fracture, it is necessary to carry out an epidemiological investigation of calcaneus fracture throughout the country. The incidence of intra-articular fractures of calcaneus, especially severe comminuted calcaneal fractures, is increasing. The diagnosis and treatment of these types of injuries is very difficult. The intra-articular fractures of the calcaneus can not be accurately evaluated, effective treatment, poor prognosis, the life and work of the patients after injury, and the development of the social and economic development will also have some influence. The most commonly used imaging method for calcaneal fracture is X ray photography. The AO subtype of calcaneal fracture is assessed and typed. In addition to judging the severity of calcaneal fracture damage by judging the type of calcaneal fracture damage, the B? Hler 's angle, Gissan' s angle, bone width and length can be measured on the calcaneus X-ray film to assist in assessing the severity of the injury. However, the role of B? Hler 's angle in evaluating the severity of intra-articular fracture of calcaneus, the role of predicting the recovery of foot function after open reduction and internal fixation for calcaneus, and the guiding role of B hler' s in calcaneus surgery have long been controversial. A large number of studies have shown B? Hler 's angle and calcaneus. The functional recovery of intra-articular displaced fractures is associated, but the association of the two is not clear. The type of fracture of the displaced intra-articular fracture of the calcaneus is closely related to the angle of the B? Hler 's angle before the operation. We found that the articular surface, especially the posterior lower part of the joint, is anatomic and restored to the calcaneus. Height, length, and width are particularly important in calcaneus fractures, so the B? Hler 's angle can be used as a highly sensitive and post-operative assessment of postoperative and postoperative assessment, but the corresponding recovery angle remains to be studied. Therefore, this study focuses on the following questions: 1, B? Hler' s angle and the more displaced calcaneus joint Is there a correlation between internal fractures; 2, whether there is a correlation between the surgical reduction of B? Hler 's angle and postoperative functional prognosis; 3, if there is a correlation, to obtain a satisfactory outcome, the degree of.B? Hler's s angle to the B? Hler' s angle (postoperative measurement value) is to determine the functional prognosis of the patient's foot. The CT scan of calcaneal fracture can be used to evaluate the severity of the injury more accurately,.Sanders typing is a clinically widely used CT type of calcaneal fracture, which divides the fracture type according to the position of the fracture line on the coronary CT scan image. The three fracture lines of A, B, and C can be divided into three parts of the articular fracture block and two part of the carrier fracture block.Sanders type I, which refers to all non displaced fractures; the Sanders type II type is divided into II A, II B, and II C fracture according to the position of the fracture line, and the Sanders type III type is three partial fractures, according to the fracture position III AB, B III B C, III AC fractures have a central compression bone in typical fractures; type IV contains 3-4 primary fracture lines, more than 2mm in the articular surface, and severe comminuted fracture.Sanders, and many scholars believe that the treatment of intra-articular displaced fractures of the calcaneus is also a severe challenge for the experienced surgeon. Malposition is one of the major factors affecting the prognosis of intra-articular displaced fractures of the calcaneus. However, the displaced fractures in the calcaneus can not be completely dissected by displaced fractures in the calcaneus, due to the severe fracture of the calcaneus, the special anatomical structure of the calcaneus, the surgical experience of the calcaneus, and the use of the reduction tools and fixtures. Some scholars have reported that the dislocation of the subtalar joint after the calcaneus fracture is more than 1mm, which may lead to traumatic arthritis, affect the patient's foot function, and the patients with serious symptoms need surgical treatment of the subtalar joint fusion. Better recovery, CT examination of the calcaneus on the side of the patient during follow-up, it can be observed that the residual displacement has a decreasing trend. Early functional exercise after operation, whether or not the residual dislocation of the subtalar joint has two reposition effects after the internal fixation of calcaneus fracture, whether it is helpful to improve the patient's preview, is still lack of quantitative study. For the above problems, we The national calcaneus fracture epidemiological survey and fracture type analysis were carried out. The relationship between B? Hler 's angle, fracture type and function recovery (AOFAS score) was analyzed retrospectively. The two reposition of the residual displacement of the displaced fracture in the calcaneal joint after internal fixation was discussed. The present report is as follows: Part 1 epidemiological investigation of calcaneal fracture: calcaneus fracture is a common fracture, which often leads to long and severe disability, and therefore brings great economic burden to the society and the family. This article aims to review the epidemiological characteristics of calcaneal fracture and the Chinese things in China. Method: We extracted data from a database established by the group. This database reviewed 431822 cases of fracture data in 83 hospitals between January 2010 and December 2011. All patients (including outpatient) of the calcaneus fracture were classified according to the AO classification and then analyzed. The calcaneus fracture was included in this study. Apart from this, these fractures were divided into three types in the central region, the western region and the eastern region. A total of 11530 (12242) patients with calcaneus fractures were treated in 83 hospitals in our country during this study. The average age of the three patients in this study was 38.95 years (1-93 years of age), and 522 cases of calcaneal fractures in children were admitted to this study. (4.26% of the total number of total), 11720 cases of calcaneal fracture in adults (95.74% of the total number); the age group with high incidence of male and female compared to 5.13:1. men is 36~40 years old, and the age group of high incidence of female patients is 36~40 and 46~50. The most common type in China is 82-C type, which accounts for calcaneus fracture in the eastern region of the calcaneal fracture of the human body. The average age was higher than that in the West (P0.05), and the high (P0.05).82-C calcaneus fracture in the middle and western regions was in the East, the ratio of the middle and western regions was 58.15%, 55.44%, 62%, respectively (P0.001). Conclusion: This study was designed to investigate the regional and epidemiological characteristics of calcaneus fracture in China. The age group of male high incidence is 36~40 years old, and the female is at the age of 36~40. The most common type of calcaneal fracture in China is type 82-C (AO type). The second part of the B? Hler 's angle is used to evaluate the severity of intra-articular fracture in calcaneus and to predict the validity of functional recovery after internal fixation: the B? Hler' s angle is used to evaluate the severity of the displaced intra-articular fracture of the calcaneus. Degree action, and the role of.B? Hler 's in the recovery of foot function after calcaneus open reduction and internal fixation, there are many controversies in the calcaneus operation. This experiment aims to study the relationship between the B? Hler' s angle and the degree of injury, and the relationship between the s angle of B hler, and the functional recovery of the B? Hler. Methods: the study was performed at the Third Hospital of Hebei Medical University. The time was from January 1, 2004 to March 31, 2008. The main clinical symptoms were closed, simple and displaced intra-articular fractures of the calcaneus. The B? Hler 's angle of the bilateral calcaneus should be measured before the operation, and the normal side should be measured in the normal side. The B? Hler 's angle of the calcaneus was used as the control group. The B? Hler' s angle values of the injured side and the healthy side of all patients were recorded before and after the operation. The values of the B? Hler 's angle of the injured side were calculated by comparing the conventional angles of the B? Hler' s angle of the bilateral calcaneus. The posterior foot scoring system was used to evaluate the functional recovery of calcaneal fractures. Analysis and evaluation of the relationship between the B? Hler 's angle and the AOFAS ankle postfoot scoring system, B hler' s angle and Sander typing, and the AOFAS ankle to hind foot scoring system and the Sander classification. Results: this experiment included 274 patients with an average follow-up time of more than 71 months, according to Sa. Nder classification, including 48 cases of type IV fracture, 121 cases of type III fracture and 105 cases of type II fracture, strictly followed the scoring system of AOFAS ankle foot, 11 cases, 27 cases, excellent 104 cases, 132 good cases. The statistical analysis of these three data after operation concluded that the preoperative B? Hler 's angle, B? Hler bilateral calcaneus, hler The difference in the s angle and the change rate of the B? Hler 's angle were all associated with the Sande typing (rs=-0.178, P=0.003; rs=-0.174, P=0.004; rs=-0.172, P=0.005), but had no correlation with the results of functional recovery after calcaneus fracture. The score has a significant correlation (rs=0.223, P0.001; rs=0.224, P0.001; rs=0.220, P0.001, but weakly associated). Conclusion: there is a mutual association between the s angle of B? Hler 'after operation and the functional recovery effect of the patients after the operation of calcaneus fracture, the B? Hler' s angle of the preoperative patients and the displaced intra-articular fracture of the calcaneus in patients. The third part of the early functional exercise for the two reduction of calcaneal fracture: the purpose of this study was to explore the two stage reduction of the calcaneal joint surface after the early functional exercise after the percutaneous pry reduction and the treatment of the calcaneus intra-articular displaced fracture with the calcaneus compression bone bolt minimally invasive fixation. Methods: the effects on the functional recovery of the foot. Methods: the patients with unilateral calcaneal displaced fractures admitted after December 2012 were included in the study. All patients were treated with percutaneous pry reduction and applied calcaneus anatomic plate compression bone thrombus minimally invasive fixation. In the control group, the patients in the experimental group were exercised early after operation, and the plantar lapping bottles were performed on 2~3 days after operation. The patients were weight-bearing 3 weeks after the operation and 12 weeks were completely weighed. The control group was rehabilitative after 12 weeks, 6 weeks after the operation and completely weighed after the fracture healing. After the operation, the patients were followed up for first days, 4 weeks, 8 weeks and 12 weeks after the operation, in the sagittal position and water. The maximum fracture displacement was measured on the horizontal and coronal images. 12 months after the operation, the foot function was evaluated according to the AOFAS score. The B? Hler 's angle and Gissane angle were measured on the foot lateral X ray. Statistical analysis was made to assess whether the early functional exercise had two reposition effects on the residual dislocation of the subtalar joint and the improvement of the function of the posterior foot. Results: there was no significant difference in age, sex and fracture type between the experimental group and the control group. After first days, 4 weeks, 8 weeks, 12
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R683.4

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