Department of Orthopaedic Surgery, Konan Hospital, 1-5-16 Kamokogahara, Higashinada-ku, Kobe 658-0064, Japan.
Injury. 2013 Nov;44(11):1640-3. doi: 10.1016/j.injury.2013.04.019. Epub 2013 Jun 2.
In the treatment of avulsion fractures of the posterior calcaneal tuberosity, open reduction and internal fixation are prone to several complications. We describe a new treatment using an Ilizarov external fixator, which can minimise the complications and achieve sufficient stability of the displaced fragment.
A 55-year-old woman sustained an avulsion fracture of the calcaneus. Examination revealed the development of bruising with extremely taut skin over the posterior prominence of the displaced bone. Radiographs demonstrated grossly proximal displacement of the tuberosity fragment. Surgery was exclusively percutaneous using an Ilizarov external fixator. The displaced fragment was adequately reduced and stabilised. Progressive weight bearing in the equinus position was initiated at the third week after surgery and the external fixator was removed at the seventh week. There was no skin necrosis or loss of reduction while the fixator was maintained. Postoperative follow-up for 2 years revealed full recovery.
Major postoperative complications after conventional open reduction and internal fixation include skin necrosis, skin irritation by metal implants and re-displacement of the reduced fragment. Our method of using an external fixator may decrease the incidence of these three complications. Skin incision and the risk of skin necrosis are inevitable during internal fixation. On the other hand, the use of an external fixator reduces or eliminates skin necrosis, as it is applied percutaneously for reduction and stabilisation of the fragment. External fixation is mostly recommended in cases of poor vascularity or bruising. In addition, skin irritation can be avoided upon removal of the external fixator. Re-displacement occurs occasionally as a serious complication in lag screw fixation, particularly in cases with poor purchase of the osteoporotic bone. Tension band wiring and application of an Ilizarov external fixator in avulsion fractures of the calcaneus can neutralise tension on the Achilles tendon during the healing process. Thus, both these methods are believed to provide sufficient mechanical stability to fix the fragment.
This new method, involving application of an Ilizarov external fixator, is recommended when the avulsion fragment is large enough to accommodate Ilizarov wires, especially in cases of circulatory problems or bruising.
在治疗跟骨后结节撕脱骨折时，切开复位内固定容易出现多种并发症。我们介绍一种新的治疗方法，使用伊利扎洛夫外固定器，可减少并发症并使移位骨块获得足够的稳定性。
一位 55 岁女性，遭受跟骨撕脱骨折。检查发现，后凸骨块的皮肤瘀斑伴紧绷，皮肤张力极高。X 线片显示结节骨块明显近侧移位。手术完全采用经皮伊利扎洛夫外固定器进行。通过该方法，可充分复位并稳定移位骨块。术后 3 周开始在马蹄位逐渐负重，术后第 7 周拆除外固定器。在维持外固定器期间，无皮肤坏死或复位丢失。术后随访 2 年，患者完全康复。
传统切开复位内固定术后的主要并发症包括皮肤坏死、金属植入物引起的皮肤刺激和复位骨块再移位。我们使用外固定器的方法可能会降低这三种并发症的发生率。在切开复位内固定时，皮肤切开和皮肤坏死的风险是不可避免的。另一方面，使用外固定器可以减少或消除皮肤坏死，因为它是经皮用于复位和稳定骨块。在血运差或瘀斑时，通常推荐使用外固定器。另外，在去除外固定器时可以避免皮肤刺激。在拉力螺钉固定中，复位骨块偶尔会发生再移位，这是一种严重的并发症，特别是在骨质疏松骨骨质不佳的情况下。张力带钢丝固定和伊利扎洛夫外固定器应用于跟骨撕脱骨折，可在愈合过程中使跟腱张力得到中和。因此，这两种方法都被认为可以为固定骨块提供足够的机械稳定性。
当撕脱骨块足够大，可以容纳伊利扎洛夫钢丝时，尤其是在存在循环问题或瘀斑的情况下，建议使用伊利扎洛夫外固定器这种新方法。
