跟骨骨折畸形愈合踝關(guān)節(jié)及距下關(guān)節(jié)僵硬的相關(guān)基礎(chǔ)及臨床研究
發(fā)布時間：2018-08-22 20:46
【摘要】：跟骨是人體最大的跗骨,其在支撐體重及行走過程中起著重要的作用。跟骨骨折在臨床上比較常見,而且多為高能量損傷,其中關(guān)節(jié)內(nèi)骨折占70%以上。骨折后治療不當(dāng)會導(dǎo)致畸形愈合,出現(xiàn)踝關(guān)節(jié)及距下關(guān)節(jié)僵硬等多種并發(fā)癥,影響患者的工作及生活。目前對于跟骨骨折后畸形愈合沒有統(tǒng)一、有效的治療方法,主要采用手術(shù)治療,而且大多行關(guān)節(jié)融合術(shù)。對患者足的功能影響較大,隨著人們生活水平的提高、對跟骨骨折治療重視程度的增加,以及影像學(xué)、內(nèi)固定等治療技術(shù)的進(jìn)步,臨床上嚴(yán)重的跟骨骨折畸形愈合越來越少。跟骨骨折后踝關(guān)節(jié)及距下關(guān)節(jié)僵硬逐漸引起人們的重視,但目前對于踝關(guān)節(jié)及距下關(guān)節(jié)僵硬的病理機(jī)制及治療的報道較少,治療效果也有較大差異。本研究針對跟骨骨折后踝關(guān)節(jié)及距下關(guān)節(jié)僵硬的病例,通過Stephens和Sanders CT分型,對于Ⅰ型及Ⅱ型畸形愈合引起的踝關(guān)節(jié)及距下關(guān)節(jié)僵硬的患者,采用保留距下關(guān)節(jié)的手術(shù)治療,進(jìn)行研究隨訪確定手術(shù)效果,為踝關(guān)節(jié)及距下關(guān)節(jié)僵硬找到合適的治療方法。目的:根據(jù)跟骨骨折畸形愈合Sanders CT分型,對于Ⅰ型及Ⅱ型患者,采用腓骨肌腱延長或松解及距下關(guān)節(jié)松解術(shù),治療跟骨骨折后踝關(guān)節(jié)及距下關(guān)節(jié)僵硬,通過比較術(shù)前及術(shù)后跟骨內(nèi)翻、外翻角度,踝關(guān)節(jié)跖屈、背伸角度,后足AOFAS功能評分及運動疼痛模擬評分(VAS),隨訪觀察術(shù)后療效,為跟骨骨折后踝關(guān)節(jié)及距下關(guān)節(jié)僵硬的病理機(jī)制及治療提供理論基礎(chǔ)。方法:選取2012年2月—2014年10月在河北醫(yī)科大學(xué)第三醫(yī)院就診治療的跟骨骨折后踝關(guān)節(jié)及距下關(guān)節(jié)僵硬的患者42例60足。男34例52足,年齡18-55歲,平均30歲;女8例8足,年齡20-46歲,平均35歲。受傷原因:高處墜落傷36足,車禍傷14足,砸傷10足。骨折后保守治療(手法復(fù)位石膏固定、臥床休息)38足;手術(shù)治療(外側(cè)鋼板、空心螺釘固定)22足。傷后負(fù)重時間2-4個月,平均3.3個月;骨折到本次住院手術(shù)時間6-37個月,平均15月。所有病例根據(jù)入選標(biāo)準(zhǔn)及排除標(biāo)準(zhǔn)選定,每足術(shù)前行X線片、CT掃描,測量跟骨內(nèi)翻、外翻角度,踝關(guān)節(jié)跖屈、背伸角度,并進(jìn)行后足AOFAS功能評分,應(yīng)用疼痛模擬評分(VAS)系統(tǒng)讓患者自行評分。對跟骨骨折畸形愈合采用Stephens和Sanders CT分型,Ⅰ型及Ⅱ型患者,手術(shù)選擇跟骨外側(cè)切口,行腓骨肌腱延長或松解及距下關(guān)節(jié)松解術(shù),術(shù)中行手法松解,進(jìn)一步增加活動度;術(shù)后6個月、12個月隨訪測量跟骨內(nèi)翻、外翻角度,踝關(guān)節(jié)跖屈、背伸角度,并進(jìn)行后足AOFAS功能評分及疼痛模擬評分(VAS),對上述手術(shù)前與手術(shù)后6個月,手術(shù)后6個月與手術(shù)后12個月指標(biāo),運用spss 21.0進(jìn)行統(tǒng)計學(xué)數(shù)據(jù)分析比較,資料采用t檢驗,評價手術(shù)的臨床療效。P0.05為差異具有顯著性意義。結(jié)果:本組病例共42例60足,隨訪13~27個月(平均隨訪16個月)。術(shù)后1足出現(xiàn)切口積血,皮緣局部壞死,早期給予拆除部分縫線,充分引流,切口愈合良好;1足切口皮緣壞死,切痂后軟組織外露,行負(fù)壓封閉引流技術(shù)(VSD)治療,愈合良好。1例患者術(shù)后隨訪跟骨運動及疼痛程度較術(shù)前減輕不明顯,加強(qiáng)功能鍛煉后,較之前好轉(zhuǎn)。其余患者跟骨內(nèi)外翻活動度增加,疼痛緩解。所有病例沒有發(fā)生跟骨二次骨折等并發(fā)癥,能從事正常工作及生活。統(tǒng)計學(xué)分析比較術(shù)前及術(shù)后6個月足的觀察指標(biāo),內(nèi)翻活動度t=-34.790,P0.001,外翻活動度t=-19.363,P0.001、踝關(guān)節(jié)跖屈角度t=-1.973,P=0.0.0530.05,背伸運動角度t=-1.918,P=0.0600.05,運動時疼痛采用視覺模擬評分(visual analogue scale,VAS)比較t=28.796,P㩳0.001,美國足踝外科協(xié)會(American orthopaedic Foot and Ankle Society,AOFAS)足部功能評分t=-42.249,P0.001,術(shù)前可4足,差56足。術(shù)后6個月優(yōu)11足,良46足,可3足,優(yōu)良率95.0%。統(tǒng)計學(xué)分析比較術(shù)后6個月與術(shù)后12個月足的觀察指標(biāo),內(nèi)翻活動度t=-0.753,P=0.454,外翻活動度t=0.055,P=0.956、踝關(guān)節(jié)跖屈角度t=-0.406,P=0.686,背伸運動角度t=0.335,P=0.739,運動時疼痛采用視覺模擬評分(visual analogue scale,VAS)比較t=1.926,P=0.059,美國足踝外科協(xié)會(American orthopaedic Foot and Ankle Society,AOFAS)足部功能評分t=0.947,P=0.347。結(jié)論:1術(shù)前與術(shù)后6個月跟骨內(nèi)翻及外翻角度、AOFAS足功能評分、疼痛視覺模擬評分(VAS)有統(tǒng)計學(xué)差異;術(shù)前與術(shù)后踝關(guān)節(jié)屈伸運動無統(tǒng)計學(xué)差異。術(shù)后6個月與術(shù)后12個月各項指標(biāo)無統(tǒng)計學(xué)差異。2踝關(guān)節(jié)及距下關(guān)節(jié)僵硬有多種因素共同影響:腓骨肌痙攣、腓骨肌腱粘連、跟骨外側(cè)壁外膨、距下關(guān)節(jié)關(guān)節(jié)間隙變窄,關(guān)節(jié)面不平整或關(guān)節(jié)面未完全恢復(fù),關(guān)節(jié)“咬合”度減低。Ⅰ、Ⅱ型跟骨骨折畸形愈合對于踝關(guān)節(jié)僵硬的影響較小。3腓骨肌腱延長或松解,距下關(guān)節(jié)松解手術(shù)可有效治療Ⅰ、Ⅱ型跟骨骨折畸形愈合引起的踝關(guān)節(jié)及距下關(guān)節(jié)僵硬,能減輕疼痛,而且保留關(guān)節(jié)活動度,提高患者的生活質(zhì)量。要根據(jù)患者的病情,結(jié)合術(shù)前影響檢查、患者的癥狀及對足功能的要求,選擇保留距下關(guān)節(jié)的功能的手術(shù)治療。
[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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3
本文編號：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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3
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