Insall Scott Kelly Institute, 4th Floor, New York, NY 10065, USA.
J Bone Joint Surg Am. 2010 Mar;92 Suppl 1 Pt 1:32-43. doi: 10.2106/JBJS.I.01267.
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.
许多患有移位关节内跟骨骨折的患者需要行距下关节融合术来治疗创伤后关节炎。我们假设与初始非手术治疗后行距下关节融合术的患者相比，初始接受手术治疗的患者功能预后更好。
连续系列的 69 例 75 例移位关节内跟骨骨折患者行距下关节融合术治疗创伤后距下关节炎疼痛。A 组包括 34 例（36 例骨折）患者，他们最初接受切开复位内固定治疗，然后平均在 22.6 个月后行原位距下融合。B 组包括 35 例（39 例骨折）患者，他们最初接受非手术治疗，出现症状性疼痛性畸形愈合，然后行距下关节撑开融合术。两组在年龄、性别、损伤机制和吸烟状况方面相似。所有并发症均被记录，并在融合后至少 48 个月时评估功能结果。
所有 69 例患者均可随访。A 组平均随访时间为 62.5 个月，B 组为 63.5 个月。两组各有 3 例距下融合不愈合需翻修。A 组术后伤口并发症较少，Maryland 足部评分（90.8 分对比 79.1 分；p < 0.0001）和美国矫形足踝协会踝关节后足评分（87.1 分对比 73.8 分；p < 0.0001）均明显高于 B 组。
在我们的研究人群中，与初始非手术治疗后出现症状性创伤后距下关节炎行距下关节融合术的患者相比，初始切开复位内固定治疗移位关节内跟骨骨折后出现症状性创伤后距下关节炎的患者功能预后更好，伤口并发症更少。初始切开复位内固定可恢复跟骨形态、对线和高度，从而有利于融合手术，并为获得更好的长期功能结果提供机会。当适当指征时，我们建议对移位关节内跟骨骨折行切开复位内固定治疗。
