Woon Colin Yi-Loong, Chong Keen-Wai, Yeo William, Eng-Meng Yeo Nicholas, Wong Merng-Koon
Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
J Trauma. 2011 Oct;71(4):917-25. doi: 10.1097/TA.0b013e318202f1d0.
Fixation of intra-articular calcaneal fractures has traditionally been guided by intraoperative fluoroscopy. Recent reports indicate that there is a role for subtalar arthroscopy in surgical fixation of these fractures. The earliest reports described the use of subtalar arthroscopy for joint assessment during late hardware removal. It then served as an adjunct for joint inspection in open reduction and internal fixation. In its final permutation, percutaneous arthroscopy was performed with minimally invasive reduction and fixation, minimizing soft tissue complications commonly associated with the open approach. In practiced hands, this technique yields good results with minimal morbidity.
We performed a prospective analysis of 22 consecutive patients with Sanders II, AO-OTA 83-C2 intra-articular calcaneal fractures who underwent dual-modality imaging (subtalar arthroscopic- and intraoperative fluoroscopic-) guided percutaneous fracture fixation with a minimum follow-up of 2 years. Maximum accepted postreduction step-off was 1 mm. Fractures were fixed definitively with four to eight percutaneous cancellous screws.
There was significant correction of Böhler's tuberosity-joint angle from 4.2 degrees±11.1 degrees preoperatively to 21.3 degrees±8.8 degrees on immediate postoperative radiographs, with minimal subsidence to 20.1 degrees±8.2 degrees at 2 years. Böhler's angle correction and joint surface restoration could not be achieved percutaneously in one patient with an impacted, depressed joint fragment. Compared with preoperative values, there was significant improvement in mean Visual Analog Scale, American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score, and Short Form-36 (Physical Function) scores at 3 months, with further improvement up to 2-years.
Subtalar arthroscopy augments intraoperative fluoroscopy in anatomic reduction of the posterior calcaneal facet of the subtalar joint and is most useful for Sanders type II, AO-OTA 83-C2 fractures. The percutaneous approach further avoids soft tissue complications associated with open reduction. However, this procedure has a steep learning curve, and conversion to open reduction must be considered when percutaneous reduction fails.
跟骨关节内骨折的固定传统上是在术中透视引导下进行的。最近的报告表明，距下关节镜检查在这些骨折的手术固定中发挥着作用。最早的报告描述了在后期取出内固定器械时使用距下关节镜检查进行关节评估。随后，它在切开复位内固定术中作为关节检查的辅助手段。在其最终形式中，经皮关节镜检查与微创复位和固定一起进行，将通常与开放手术相关的软组织并发症降至最低。在熟练的操作者手中，这项技术能产生良好的效果，且发病率极低。
我们对22例连续的Sanders II型、AO-OTA 83-C2型跟骨关节内骨折患者进行了前瞻性分析，这些患者接受了双模式成像（距下关节镜和术中透视）引导下的经皮骨折固定，且至少随访2年。复位后最大可接受的台阶移位为1毫米。骨折用4至8枚经皮松质骨螺钉进行确定性固定。
Böhler结节-关节角从术前的4.2度±11.1度显著矫正至术后即刻X线片上的21.3度±8.8度，2年时仅有轻微下沉至20.1度±8.2度。1例有关节碎片嵌插、凹陷的患者无法经皮实现Böhler角矫正和关节面恢复。与术前值相比，3个月时视觉模拟评分、美国矫形足踝协会踝-后足评分和简明健康状况调查量表（身体功能）评分均有显著改善，至2年时进一步改善。
距下关节镜检查可增强术中透视对距下关节后关节面的解剖复位效果，对Sanders II型、AO-OTA 83-C2型骨折最为有用。经皮手术方法进一步避免了与切开复位相关的软组织并发症。然而，该手术有陡峭的学习曲线，当经皮复位失败时必须考虑转为切开复位。
