Radnay Craig S, Clare Michael P, Sanders Roy W
Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, Florida, USA.
J Bone Joint Surg Am. 2009 Mar 1;91(3):541-6. doi: 10.2106/JBJS.G.01445.
Many patients with displaced intra-articular calcaneal fractures require subtalar arthrodesis for the treatment of posttraumatic arthritis. We hypothesized that patients who underwent initial operative treatment would have better functional outcomes as compared with those who underwent initial nonoperative treatment before undergoing a subtalar arthrodesis.
A consecutive series of sixty-nine patients with seventy-five displaced intra-articular calcaneal fractures underwent subtalar arthrodesis for the treatment of painful posttraumatic subtalar arthritis. Group A comprised thirty-four patients (thirty-six fractures) who initially were managed with open reduction and internal fixation and subsequently underwent in situ subtalar fusion at an average of 22.6 months later. Group B comprised thirty-five patients (thirty-nine fractures) who initially were managed nonoperatively and had development of a symptomatic painful malunion and subsequently underwent a subtalar distraction arthrodesis. The two groups were similar with respect to age, sex, injury mechanism, and smoking status. All complications were noted and functional outcomes were assessed at a minimum of forty-eight months after fusion.
All sixty-nine patients were available for follow-up. The average duration of follow-up was 62.5 months for Group A and 63.5 months for Group B. There were three nonunions of the subtalar fusion requiring revision in each group. Group A had fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B.
In our study population, better functional outcomes and fewer wound complications were associated with subtalar fusion for the treatment of symptomatic posttraumatic subtalar arthritis after initial open reduction and internal fixation of a displaced intra-articular calcaneal fracture as compared with subtalar arthrodesis for the treatment of symptomatic posttraumatic subtalar arthritis secondary to calcaneal malunion following initial nonoperative treatment. Initial open reduction and internal fixation restores calcaneal shape, alignment, and height, which facilitates the fusion procedure and establishes an opportunity to create a better long-term functional result. We recommend open reduction and internal fixation for the treatment of displaced intra-articular calcaneal fractures when appropriately indicated.
许多移位的关节内跟骨骨折患者需要进行距下关节融合术来治疗创伤后关节炎。我们假设，与在接受距下关节融合术之前接受初始非手术治疗的患者相比，接受初始手术治疗的患者会有更好的功能结果。
连续纳入69例患有75处移位关节内跟骨骨折的患者，他们接受距下关节融合术以治疗创伤后距下关节疼痛性关节炎。A组包括34例患者（36处骨折），这些患者最初接受切开复位内固定治疗，随后平均在22.6个月后接受原位距下关节融合术。B组包括35例患者（39处骨折），这些患者最初接受非手术治疗，出现了有症状的疼痛性畸形愈合，随后接受距下撑开融合术。两组在年龄、性别、损伤机制和吸烟状况方面相似。记录所有并发症，并在融合术后至少48个月评估功能结果。
所有69例患者均获得随访。A组的平均随访时间为62.5个月，B组为63.5个月。每组均有3例距下关节融合不愈合需要翻修。A组术后伤口并发症较少，马里兰足部评分（90.8比79.1；p<0.0001）和美国矫形足踝协会踝-后足评分（87.1比73.8；p<0.0001）均显著高于B组。
在我们的研究人群中,与初始非手术治疗后因跟骨畸形愈合继发创伤后距下关节疼痛性关节炎而进行的距下关节融合术相比，对于移位关节内跟骨骨折初始切开复位内固定后因创伤后距下关节疼痛性关节炎而进行的距下关节融合术，功能结果更好，伤口并发症更少。初始切开复位内固定可恢复跟骨的形状、对线和高度，这有利于融合手术，并为获得更好的长期功能结果创造机会。我们建议在适当指征下，对移位关节内跟骨骨折采用切开复位内固定治疗。
