Rammelt S, Zwipp H
University Center for Orthopaedics and Traumatology, University Hospital Carl-Gustav Carus, Dresden, Germany.
Acta Chir Orthop Traumatol Cech. 2014;81(3):177-96.
Displaced, intra-articular fractures of the calcaneus represent a surgical challenge and the ideal choice of treatment remains a subject of continued debate. Open reduction and stable internal fixation without joint transfixation has been established as the standard treatment for most of these fractures with good to excellent results in more than two thirds of patients in larger clinical series. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposition of the fractured lateral wall, the subtalar and calcaneocuboid joints, but wound healing problems cannot be completely avoided despite meticulous soft tissue handling. Percuatneous and less invasive procedures have successfully lowered the rates of wound complications but exact anatomic reduction remains an important issue. Care must be taken not to overlook atypical fractures like sustentacular fractures and fracture-dislocations of the calcaneus that are treated with a small medial or curved epimalleolar lateral approach, respectively. The use of bone grafting or bone substitutes for defect filling appears not necessary in most cases. Prognostic factors that can be influenced by the surgeon are anatomical reduction of the overall shape of the calcaneus and congruity of the subtalar joint which should both be controlled intraoperatively. Treatment results are adversely affected by severity of injury, open fractures, bilateral fractures, a high body mass index and smoking. Early, stable soft tissue coverage with pedicled or free flaps appears to lower infection rates and improve the functional results after open fractures. Calcaneal malunions and nonunions are disabling conditions resulting from either non-operative treatment or inadequate reduction and fixation of displaced fractures. Deformity correction is tailored to the type of deformity and individual patient needs. Treatment options include lateral wall decompression, in situ- or corrective subtalar arthrodesis and calcaneal osteotomies accompanied by soft tissue-balancing.
跟骨移位性关节内骨折是一项手术挑战，理想的治疗选择仍是持续争论的话题。对于大多数此类骨折，切开复位并稳定内固定而不进行关节贯穿固定已被确立为标准治疗方法，在大型临床系列中，超过三分之二的患者取得了良好至优异的效果。扩大外侧入路尊重足跟的神经血管供应，能很好地显露骨折的外侧壁、距下关节和跟骰关节，但尽管对软组织进行了细致处理，伤口愈合问题仍无法完全避免。经皮和微创操作已成功降低了伤口并发症的发生率，但精确的解剖复位仍是一个重要问题。必须注意不要忽视不典型骨折，如载距突骨折和跟骨骨折脱位，分别采用小内侧或弯曲的外踝外侧入路进行治疗。在大多数情况下，似乎没有必要使用骨移植或骨替代物来填充缺损。外科医生能够影响的预后因素是跟骨整体形状的解剖复位和距下关节的一致性，两者均应在术中进行控制。治疗结果会受到损伤严重程度、开放性骨折、双侧骨折、高体重指数和吸烟的不利影响。早期用带蒂或游离皮瓣进行稳定的软组织覆盖似乎可以降低感染率，并改善开放性骨折后的功能结果。跟骨畸形愈合和不愈合是由于非手术治疗或移位骨折复位及固定不充分导致的致残情况。畸形矫正需根据畸形类型和个体患者需求进行调整。治疗选择包括外侧壁减压、原位或矫正性距下关节融合术以及跟骨截骨术并辅以软组织平衡。
