Rammelt S, Dürr C, Schneiders W, Zwipp H
Klinik und Poliklinik für Unfall- und Wiederherstellungschirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
Oper Orthop Traumatol. 2012 Sep;24(4-5):383-95. doi: 10.1007/s00064-012-0172-9.
Anatomic reduction of displaced calcaneal fractures with minimal soft tissue alteration.
Extra-articular and selected intra-articular calcaneal fractures (simple fracture pattern: Sanders type II, critical soft tissue conditions, contraindications to open reduction), temporary stabilization of complex injuries or polytraumatized patients.
Impossible percutaneous reduction and fixation.
Gross reduction of the main fragments is achieved with a Schanz screw introduced percutaneously into the tuberosity fragment. Fine reduction is obtained through percutaneous manipulation of the fragments wit Kirschner wires, Steinmann pins, sharp and smooth elevators via stab incisions. Anatomic reduction of the subtalar joint is controlled arthroscopically in cases of displaced intra-articular fractures. Fixation is achieved with screws introduced percutaneously.
Early range of motion exercises of the ankle and subtalar joints are initiated the first postoperative day. Beginning on postoperative day 2, patients are mobilized with partial weight bearing for 6-8 weeks. As soon as the edema has subsided, patients are encouraged to wear their own shoes.
Between 1998 and 2008, 68 patients were treated with definite percutaneous fixation for displaced calcaneal fractures. In 37 patients with intraarticular fractures (Sanders types IIA and IIB), anatomic joint reduction was verified with subtalar arthroscopy. No soft tissue-related complications were observed. Thirty-five patients were followed for a minimum of 2 years postoperatively, the average was 5 years postoperatively. Subjectively, 33 of 35 patients were satisfied with the clinical outcome. The AOFAS Hindfoot Score averaged 90.7 (range 64-100) at a mean of 5 years after surgery. Percutaneous screw fixation of calcaneal fractures is associated with minimal soft tissue traumatization and low complication rates. It allows early rehabilitation and excellent results with proper patient selection. With intra-articular fractures, proper reduction of the articular surface has to be confirmed intraoperatively.
以最小的软组织改变实现移位跟骨骨折的解剖复位。
关节外及部分关节内跟骨骨折（简单骨折类型：Sanders II型，严重软组织条件，切开复位禁忌证），复杂损伤或多发伤患者的临时稳定。
无法经皮复位与固定。
通过经皮插入斯氏针至结节骨折块实现主要骨折块的大体复位。通过经皮用克氏针、斯氏针、锐性及钝性骨膜剥离器经小切口操作骨折块实现精细复位。对于移位的关节内骨折，通过关节镜控制距下关节的解剖复位。经皮插入螺钉实现固定。
术后第1天开始早期进行踝关节和距下关节的活动度练习。术后第2天开始，患者部分负重活动6 - 8周。一旦肿胀消退，鼓励患者穿自己的鞋子。
1998年至2008年期间，68例患者接受了移位跟骨骨折的确定性经皮固定治疗。在37例关节内骨折（Sanders IIA和IIB型）患者中，通过距下关节镜证实关节解剖复位。未观察到与软组织相关的并发症。35例患者术后至少随访2年，平均随访5年。主观上，35例患者中有33例对临床结果满意。术后平均5年时，美国足踝外科协会（AOFAS）后足评分平均为90.7（范围64 - 100）。跟骨骨折的经皮螺钉固定与最小的软组织创伤和低并发症发生率相关。通过适当选择患者，可实现早期康复并获得良好效果。对于关节内骨折，术中必须确认关节面的正确复位。
