Zwipp H, Rammelt S, Amlang M, Pompach M, Dürr C
Klinik und Poliklinik für Unfall- und Wiederherstellungsschirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland,
Oper Orthop Traumatol. 2013 Dec;25(6):554-68. doi: 10.1007/s00064-013-0246-3. Epub 2013 Dec 6.
Anatomic reduction of displaced intra-articular calcaneal fractures with restoration of height, length, and axial alignment and reconstruction of the subtalar and calcaneocuboid joints.
Displaced intra-articular calcaneal fractures with incongruity of the posterior facet of the subtalar joint, loss of height, and axial malalignment.
High perioperative risk, soft tissue infection, advanced peripheral arterial disease (stage III), neurogenic osteoarthropathy, poor patient compliance (e. g., substance abuse).
Extended lateral approach with the patient placed on the uninjured side. Reduction of the anatomic shape and joint surfaces according to the preoperative CT-based planning. Reduction of the medial wall and step-wise reconstruction of the posterior facet from medial to lateral. Reduction of the tuberosity and anterior process fragments to the posterior joint block and temporary fixation with Kirschner wires. Internal fixation with an anatomic lateral plate in a locking or nonlocking mode. Alternatively less invasive internal fixation with a calcaneus nail over a sinus tarsi approach for less severe fracture types.
The lower leg is immobilized in a brace until the wound is healed. Range of motion exercises of the ankle and subtalar joints are initiated on the second postoperative day. Patients are mobilized in their own shoe with partial weight bearing of 20 kg for 6-12 weeks depending on fracture severity and bone quality.
Over a 4-year period, 163 patients with 184 displaced, intra-articular calcaneal fractures were treated with a lateral plate via an extended approach. In all, 102 patients with 116 fractures were followed for a mean of 8 years. A surgical revision was necessary in 4 cases (3.4%) of postoperative hematoma, 2 (1.7%) superficial and 5 (4.3%) deep infections. Of the latter, 2 patients needed a free flap for definite wound coverage, no calcanectomy or amputation was needed. Secondary subtalar fusion for symptomatic posttraumatic arthritis was performed in 9 cases (7.8%). At follow-up, the AOFAS Ankle/Hindfoot Score averaged 70.2, the Zwipp Score averaged 76.0, the German versions of the Foot Function Index and SF-36 physical component averaged 32.8 and 42.2, respectively. Scores were significantly lower with increasing fracture severity according to the Sanders and Zwipp classifications, bilateral fractures, open fractures, and with work-related injuries. With less invasive fixation using a calcaneal nail, superficial wound edge necrosis was seen in 2 of 75 cases (2.7%).
使移位的关节内跟骨骨折达到解剖复位，恢复高度、长度及轴向对线，并重建距下关节和跟骰关节。
距下关节后关节面不平整、高度丢失及轴向畸形的移位关节内跟骨骨折。
围手术期风险高、软组织感染、晚期外周动脉疾病（Ⅲ期）、神经源性骨关节病、患者依从性差（如药物滥用）。
患者置于未受伤侧，采用延长外侧入路。根据术前基于CT的规划恢复解剖形态和关节面。复位内侧壁，从内侧向外侧逐步重建后关节面。将结节和前突骨折块复位至后关节块，并用克氏针临时固定。采用锁定或非锁定模式用解剖型外侧钢板进行内固定。对于较轻度骨折类型，也可经跗骨窦入路采用跟骨钉进行微创内固定。
小腿用支具固定直至伤口愈合。术后第二天开始进行踝关节和距下关节的活动度锻炼。根据骨折严重程度和骨质情况，患者穿着自己的鞋子部分负重20kg活动6至12周。
在4年期间，163例患者的184例移位关节内跟骨骨折采用延长入路外侧钢板治疗。其中，102例患者的116例骨折平均随访8年。4例（3.4%）术后血肿需要手术翻修，2例（1.7%）表浅感染，5例（4.3%）深部感染。对于深部感染患者，2例需要游离皮瓣进行确切的伤口覆盖，无需行跟骨切除术或截肢。9例（7.8%）因创伤后关节炎症状行二期距下关节融合术。随访时，美国足踝外科协会（AOFAS）踝/后足评分平均为70.2分，Zwipp评分平均为76.0分，德文版足功能指数和SF-36身体成分评分分别平均为32.8分和42.2分。根据Sanders和Zwipp分类，骨折严重程度增加、双侧骨折、开放性骨折以及工伤时，评分显著降低。采用跟骨钉微创固定时，75例中有2例（2.7%）出现伤口边缘浅表坏死。
