Rammelt Stefan, Gavlik Johann Marian, Barthel Sven, Zwipp Hans
Department of Trauma and Reconstructive Surgery, University Hospital Carl Gustav Carus, TU Dresden, Germany.
Foot Ankle Int. 2002 Oct;23(10):906-16. doi: 10.1177/107110070202301004.
A wealth of clinical and experimental data suggests, that anatomical restoration of the posterior calcaneal facet is a major predictor of outcome after intra-articular calcaneus fractures. The value of subtalar arthroscopy was examined in three clinical study groups (I-III.
(I) The subtalar joint was inspected arthroscopically in 28 patients during hardware removal one year after open reduction and internal fixation (ORIF). This procedure was accompanied by subtalar arthrolysis in all cases. (II) Open subtalar arthroscopy was performed to evaluate the quality of reduction after ORIF of intra-articular calcaneus fractures in 59 cases. Arthroscopy was performed after seemingly exact reconstruction of the posterior facet as judged visually and fluoroscopically. (III) Arthroscopically assisted percutaneous reduction and screw fixation (PRSF) was performed in 18 patients with Sanders II fractures. Reduction was achieved with a Schanz screw introduced percutaneously into the tuberosity fragment and controlled fluoroscopically, while fine corrections were made under arthroscopic guidance.
(I) Clinical results after ORIF of intra-articular calcaneus fractures were highly correlated to the degree of residual incongruities and chondromalacia of the posterior facet as seen arthroscopically during hardware removal (P < 0.01). (II) In 13 of 59 cases (22.0%) during ORIF despite seemingly accurate reduction, steps between 1-2 mm were detected arthroscopically in the posterior calcaneal facet and reduction was repeated subsequently in these cases. (III) Fifteen patients who underwent arthroscopically guided PRSF were re-evaluated after a minimum of one year with excellent clinical results (94.1 pts. with the AOFAS scales). No wound complications were seen.
Subtalar arthroscopy provides a most precise and thorough view of the posterior facet of the calcaneus both in assessing the quality of initial reduction as well as evaluation during hardware removal after intra-articular calcaneus fractures. It is more precise than intra-operative fluoroscopy and less time consuming than standard Brodén views during surgery. The use of arthroscopy allows anatomical percutaneous reduction and screw fixation of Sanders II fractures. It therefore provides a useful additional tool in treating intra-articular calcaneus fractures.
大量临床和实验数据表明，跟骨后关节面的解剖复位是关节内跟骨骨折预后的主要预测指标。在三个临床研究组（I - III）中对距下关节镜检查的价值进行了研究。
（I）在28例患者切开复位内固定（ORIF）术后一年取出内固定物时，通过关节镜检查距下关节。所有病例均同时进行距下关节松解术。（II）对59例关节内跟骨骨折切开复位内固定术后的患者进行开放性距下关节镜检查，以评估复位质量。在肉眼和透视检查看似精确重建后关节面后进行关节镜检查。（III）对18例Sanders II型骨折患者进行关节镜辅助下经皮复位及螺钉固定（PRSF）。通过经皮插入结节骨折块的斯氏针实现复位，并在透视下控制，同时在关节镜引导下进行精细矫正。
（I）关节内跟骨骨折切开复位内固定术后的临床结果与取出内固定物时关节镜下所见后关节面残余不平整和软骨软化程度高度相关（P < 0.01）。（II）在59例病例中的13例（22.0%）切开复位内固定术中，尽管看似复位准确，但关节镜检查发现跟骨后关节面有1 - 2毫米的台阶，随后对这些病例再次进行复位。（III）对15例行关节镜引导下经皮复位及螺钉固定的患者进行了至少一年的重新评估，临床结果良好（AOFAS评分为94.1分）。未见伤口并发症。
距下关节镜在评估关节内跟骨骨折初始复位质量以及取出内固定物时的评估中，能提供跟骨后关节面最精确、全面的视野。它比术中透视更精确，且比手术中标准的Brodén位片耗时更少。关节镜的应用可实现Sanders II型骨折的解剖学经皮复位及螺钉固定。因此，它为治疗关节内跟骨骨折提供了一种有用的辅助工具。
