【作者】 李西成；

【导师】 张英泽； 潘进社；

【作者基本信息】 河北医科大学 ， 外科学， 2007， 博士

【摘要】 跟骨骨折是临床上较常见的骨折之一,大约占所有骨折的2%,跗骨骨折的75%,而且75%为关节内骨折。最常见的受伤原因是高处坠落,少部分为交通事故伤。临床上分为关节内骨折和关节外骨折两大类型,其中关节内骨折,无论是保守治疗还是手术治疗效果都不理想,骨折后期常常出现功能障碍甚至永久性的功能丧失。治疗的远期效果在很大程度上取决于骨折块的正确复位。近年来,随着对跟骨骨折创伤机制及骨折类型的深人研究,骨科医师对跟骨骨折的诊疗经验已有很大提高。外科手术作为治疗有移位的跟骨骨折,尤其是关节内骨折的有效手段,已得到广泛认同。但跟骨的解剖结构及骨折类型复杂多样,跟骨周围皮肤软组织抵御缺血坏死和感染的能力较为脆弱等因素,使得跟骨骨折手术治疗难度较大,长期疗效难以预测,对创伤骨科医生极具挑战性。全面了解跟骨的解剖是判断损伤类型,决定治疗方案,达到治疗目的的关键。跟骨的外侧面平坦并位于皮下,中间有腓骨滑车为跟腓韧带的附著点。内侧有强有力的骨间韧带和较厚的距跟韧带。载距突位于内侧面的前面,其下面的沟内有母长屈肌腱通过。神经血管束紧邻跟骨的内侧缘,在受伤或手术时容易损伤这些组织,因此手术切口的部位也是一个不容忽视的问题。首先对跟骨骨折提出分型的是B?hler,Essex-Lopresti提出的分型原则仍在使用。这些作者将跟骨骨折分为关节内和关节外骨折,而且本质不同,一个是压缩性骨折,一个是舌形骨折。由于CT能够对骨折块影像学特征进行精确分析,因此对跟骨骨折的分型提出了很多的建议,同时也对骨折块的精确评估对跟骨骨折的治疗提出了一个相当有益的分型方案。目前最常用的分型是Sander’s分型。这个分型方式是基于CT半冠状位扫描图像的骨折块来分型的。图像的部位是距骨后关节面最宽的部位。Sanders的描述是用两条线将距骨分为三个柱,这两条线将跟骨的后关节面分为三个可能出现的骨折块,内侧、中间、和外侧骨折块;并将这三条线命名为外侧的A骨折线、中间的B骨折线、和内侧的C骨折线。第三条骨折线位于内侧缘,形成可能出现的第四个骨折块-载距突骨折块。此分型如下:Ⅰ型:所有无移位的骨折(无论骨折块多少);Ⅱ型:一条骨折线有移位;Ⅲ型:二条骨折线有移位;Ⅳ型:三条骨折线或更多的骨折线有移位。这一分型系统能够决定手术治疗方案和预测手术的难度和预后。跟骨骨折的治疗已经争论了150年,虽然近20年来对跟骨骨折的诊断和治疗手段有了跨越性的进展,但这种损伤的处理仍是争论的课题。早期跟骨骨折是保守治疗,后来逐渐发展到手术治疗。而对于跟骨关节内骨折,其治疗的理念也经历了一系列变化。骨折的理想治疗方法仍是一个未解决的难题。保守治疗及手术治疗的流行在不同的时期摇摆不定。在最近20年间,由于影像学技术的发展,涉及关节面的骨折逐渐倾向于手术治疗。CT的出现,使我们清楚地了解了这些骨折的影像学特征,同时也给临床提供了能够预测预后的分型系统。治疗方法的选择可以分为几大类:急症手术、非手术治疗、微创钢板内固定、切开复位内固定和初期关节融合术。非手术治疗包括抬高患肢、冰敷、早期功能锻炼,和足弓的压迫。保守治疗跟骨移位的骨折常常引起严重的功能障碍和致残。为了避免软组织的并发症,一些微创和经皮入路的手术方法在跟骨骨折治疗史上渐臻完善,逐渐成熟,最近获得了广泛应用。手术治疗包括闭合复位和经皮穿针固定,切开复位内固定以及关节融合术等。手术治疗与非手术治疗的效果成为了对比研究的主要课题。切开复位内固定的主要目的是:1)重建后关节面的正常解剖;2)恢复跟骨的正常宽度以防外侧的腓骨肌腱撞击综合症和腓肠神经的损伤;3)重建跟骨的正常高度。这些目的应在最短的手术时间内完成,以减少伤口感染等并发症的发生。坚强的内固定可以使踝关节和距下关节早期活动。严重的粉碎性跟骨骨折可以在切开复位内固定的同时进行距下关节融合术。对于移位的关节内骨折来说,在大量的临床资料中显示,切开复位加上外侧的钢板内固定的优良率已达到了三分之二或四分之三,因此已成为一个标准的治疗方案。大量的病例显示骨移植并没有多大的用处,而关节的解剖复位和跟骨的完整形状才是重要的预后因素。外侧延长的“L”形切口在大多数的病例都可注意到神经血管束的分布,并且能够很好的暴露骨折的外侧壁、距下关节和跟骰关节。因此是目前临床上常用的手术入路之一。某些骨折类型有可能在关节镜的帮助下经皮螺钉固定也是一项较好的选择。要确定关节面的良好复位应该在手术中进行Broden’s位的观察和高分辨率的X断层以及切开后的距下关节镜的帮助。治疗的效果还受以下因素的影响,开放性骨折,超过14天后的延迟切开复位,以及个体因素如肥胖指数、糖尿病、吸烟等。由于没有统一的分型方法和疗效评定标准,因此各种手术方法的比较也就无法进行。一个共认的事实,跟骨骨折常发生在青壮年工作者,跟骨骨折的后遗症可以造成相当大的社会经济影响,给社会带来负担。。跟骨骨折的治疗不仅要依据每个人的骨折类型,也要看病人的功能要求、有无并发症以及患者能否耐受手术的情况。虽然手术固定跟骨骨折产生了很好的效果,但并发症的发生率也比较高。主要的手术并发症是伤口的并发症。跟骨周围的软组织非常薄,大部分的手术切口都在外侧,而且外侧壁的软组织又非常脆弱,所以容易出现并发症。内侧途径的危险部位在于邻近的神经血管束。经外侧可延长的“L”型切口行跟骨骨折切开复位内固定术,伤口边缘坏死率是0.4~14%。感染率为1.3~7%.内外侧联合途径伤口边缘的坏死率为27%。Folk等报道了190例跟骨骨折术后并发症为25%,有21%需要二次手术。目前的研究显示在普通病人当中伤口并发症是相当高的。吸烟、糖尿病、和开放性骨折都增加了伤口并发症的危险。一些外侧壁小切口的应用,如Plamer切口,也没有明显减少软组织并发症的问题;通过跗骨窦的小切口需要牵开腓骨肌腱和腓肠神经,结果感染率为8.5%,而腓骨肌腱炎、跗骨窦综合症、甚至窒筋膜综合症等软组织并发症为9.2%。本课题通过对跟骨骨折的一系列研究,从跟骨及其周围的解剖学、跟骨的形态学、跟骨骨折的生物力学,手术方法的改进等方面进行了深入的探讨,并自行设计研制了跟骨解剖型钢板,易断螺栓,并改进了手术切口,达到了微创治疗跟骨骨折,减少软组织并发症的目的。第一部分与跟骨骨折内固定有关的解剖学研究一、跟骨标本表面参数测量与螺旋CT扫描测量的比较目的:为跟骨骨折的切开复位内固定新型钢板和螺栓的研制提供解剖学数据基础,为设计辅助治疗跟骨骨折的机器人提供精确解剖学依据。方法:对40例成人跟骨干标本的一些与其骨折内固定有关的骨性标志,通过实际测量,和螺旋CT三维成像进行测量后进行对比。结果:跟骨全长72.88±4.19mm;跟骨结节至跟骨沟长54.99±3.61mm;跟骨后高40.80±2.84mm;跟骨最高45.10±2.89mm;跟骨沟部高23.72±2.21mm;跟骨前高25.10±2.64mm;跟骨后宽30.13±2.93mm;跟骨最宽50.68±2.46;跟骨沟部宽26.52±2.19mm;跟骨前宽22.08±2.33mm;载距突长23.12±1.88mm;载距突宽15.68±1.55mm;载距突高10.15±1.16mm。Bohler’s角35.4±3.71o;Gissane’s角120.9±7.08o结论:从本文的测量结果来看,在我们测量的标本中,跟骨大小差异较大,故各项测量数据之间的差距也较大。根据测量的结果发现跟骨标本的实际测量和螺旋CT测理的结果无显著性差异。二、正常人群跟骨形态数据库的建立目的:跟骨骨折治疗的关键在于恢复跟骨的外形、跟距关节的对位关系、跟骨的负重模式。对于单侧跟骨骨折可参照健侧跟骨的解剖数据来恢复外形,而双侧跟骨骨折患者失去了局部参考,术中很难准确判断跟骨大小,因此有必要建立跟骨与身高关系的数据库。方法:根据随即抽样原则选取北方成年男女各200名(平均年龄男38.9岁,女36.2岁),经体格检查排除骨关节系统疾病。测量所有受试者的身高,并进行64层螺旋CT薄层扫描。图像在CT工作站采用多平面重建方法(Multiplanar reconstructions,MPR),表面遮盖法(Surface shaded display,SSD)进行三维、二维重建。利用切割技术对三维图像进行任一平面的切割,从最佳角度和方位显示跟骨大小和形态,从而准确测量跟骨高,宽,载距突宽等解剖数据。建立跟骨解剖数据与身高的直线回归方程结果:跟骨形态结构较复杂,骨皮质薄,骨松质多,跟骨前部跟骨沟下方骨小梁稀疏,后部内侧骨小梁密集。正常跟骨各指标左右两侧无明显差异,而不同性别间除Gissanecs角外,其他各项指标均有显著差异;跟骨高/长的比值>1/2。跟骨全长72.88±4.19mm;跟骨结节至跟骨沟长54.99±3.61mm;跟骨后高40.80±2.84mm;跟骨最高45.10±2.89mm;跟骨沟部高23.72±2.21mm;跟骨前高25.10±2.64mm;跟骨后宽30.13±2.93mm;跟骨最宽50.68±2.46;跟骨沟部宽26.52±2.19mm;跟骨前宽22.08±2.33mm;载距突长23.12±1.88mm;载距突宽15.68±1.55mm;载距突高10.15±1.16mm。Bohler’s角35.4±3.71o;Gissane’s角120.9±7.08o结论:根据我们测量的数据,建立了正常人群的数据库,并研制了各种型号的新型解剖型跟骨钢板和易断螺栓,适用于我们改良的微创小切口手术。在手术前测量患者的正常足,来选择内固定器材的大小、长短、宽窄以及跟骨各个不同部位螺栓所需的长度。三、跟骨周围神经、血管的体表投影测量及其临床意义目的:探讨跟骨及其周围结构的解剖学特点及其在跟骨骨折治疗中的意义。方法:解剖8例16侧成人足部标本,观察测量跟骨周围的肌腱、血管、神经走行,通过可触摸到的体表解剖标志,找出跟骨骨折治疗时,内、外固定穿针时的安全区域。测量载距突的上翻角,以及载距突距内踝尖的距离。结果:经过测量找出了跟骨内、外侧的安全区域,载距突的上翻角是27.4o(25 o~30 o);载距突距内踝尖的距离是2.3cm(1.5~2.5cm)。结论:在跟骨内外侧找到的可触摸到的解剖标志画定的安全区域内穿钉是相对安全的,很少损伤距骨周围的神经血管束;载距突周围的解剖特点决定了载距突在跟骨骨折中不会发生移位,故临床上可利用稳定的载距突骨块作为跟骨骨折行内固定术时的固定点,并且在载距突穿钉时要掌握一个上翻角。四、腓骨长短肌腱鞘造影在跟骨骨折治疗中的意义目的:从影像学上客观证实腓骨长短肌腱受压的现象,以解释跟骨骨折后跟骨增宽引起的跟骨外侧疼痛的原因。方法:对15例波及跟距关节面的跟骨骨折患者以及15例陈旧性跟骨骨折遗留跟骨外侧疼痛的患者进行了腓骨长短肌腱鞘造影术。男23例,女7例,年龄21岁~46岁,平均37岁。左侧18例,右侧12例,均为单侧骨折。双侧腓骨长短肌腱鞘同时造影,然后用DR进行踝关节正位、跟骨侧位和跟骨轴位的X光片,再行螺旋CT二维测量和三维成像观察,并与对侧正常跟骨比较。结果:30例患者均有不同程度的跟骨增宽和腓骨长短肌腱鞘受压现象。结果发现,当跟骨增宽小于3mm时,造影剂可以通过,当跟骨增宽大于3mm时,造影剂通过受阻,腓骨长短肌腱鞘即出现受压现象。对于陈旧性跟骨骨折与对侧正常跟骨相比,增宽超过3mm以上者即出现跟骨外侧疼痛。结论:跟骨骨折后增宽对腓骨长短肌腱的压迫确实是引起跟骨外侧疼痛的原因。第二部分自制跟骨骨折解剖钢板及加压易断螺栓的设计、结构分析以及生物力学稳定性测试目的:阐明自制跟骨解剖型钢板、易断螺栓及复位系统的组成,复位原理和安装通过整体结构分析和生物力学稳定性测试,研究该器械的科学性、稳定性和优越性。方法:用00Cr18Ni15Mo3N医用不锈钢制作该套器械。同时对该器械进行了几何分析和力学分析。用成人男性截肢新鲜标本8具,制作跟骨骨折,SandersⅡ型骨折8例。用自行研制的解剖型钢板进行固定,并进行生物力学稳定性测试,并和正常足进行比较。结果:跟骨骨折采自行研制的解剖型钢板固定后跟骨的生物力学特性、承载能力、跟骨的应力、足弓的位移等与正常足无显著差异(P>0.05),该器械的强刚度等达到了设计要求。结论:该器械的强刚度等达到了设计要求,在治疗跟骨骨折上能满足足部生物力学要求,不但强度大、承载能力高、稳定性好,而且安全可靠、操作简便,具有推广应用价值。第三部分与目前临床常用的跟骨解剖钢板的比较目的:通过与目前临床常用的跟骨解剖型钢板及其复位固定器械的横向对比研究,包括结构比较、生物力学稳定性比较,阐明该器械的稳定性和可行性。方法:成人男性防腐标本8具,制作成Sander’sⅡ型骨折模型,随机分为两组,分别用AO钢板和我们自行研制的解剖型钢板进行固定后,用CSS-44020生物力学实验机分别作轴向压缩实验。选择60例Sander’sⅢ型跟骨骨折患,随机分为A、B两组各30例,A组用自行研制的跟骨解剖钢板螺栓加压内固定系统;B组用AO内固定系统进行固定,观察其跟骨复位后的宽度、高度的丢失、切口感染及临床效果并进行比较。结果:在600N的垂直载荷下,自行设计钢板组(以下简称实验组)与AO钢板组(以下简称对照组)在足弓位移间比较差异具有显著性意义(P<0.01),实验组足弓位移平均为1.54±0.87mm,对照组足弓位移为3.31±1.07mm;在跟骨宽度变化间比较差异具有显著性意义(P<0.01),实验组跟骨宽度变化为0.54±0.37mm,对照组跟骨宽度变化为1.73±0.69mm。最大负载方面实验组平均为7866.74±181.58N,对照组为6702.94±241.06 N,二者间比较差异具有显著性意义(P<0.01)。结论:通过对两种钢板系统的生物力学测试显示,我们自行设计的解剖型钢板系统无论是在循环加载还是加裁失败都比AO系统有更大的强度。第四部分小切口钢板螺栓加压内固定治疗跟骨骨折的初步临床研究目的:研究小切口自制钢板螺栓加压内固定治疗跟骨骨折的临床的可行性、手术注意事项,总结优缺点,探讨切开复位内固定治疗跟骨关节内骨折的新方法及其临床疗效。方法:自2005年2月,利用跟骨外侧小切口,用自行研制的跟骨解剖钢板及加压螺栓内固定系统治疗跟骨关节内骨折150例183侧。男104例,女46例。年龄13~61岁,平均37.6岁。其中单侧跟骨关节内骨折117例,双侧33例。术前根据跟骨X线片及螺旋CT扫描结果进行分型,其中SandersⅡ型62侧,SandersⅢ型87侧,SandersⅣ型34侧。结果:所有患者术后获6~24个月(平均16个月)随访。术后X线片显示跟骨高度、宽度、长度及Bohler’s角和Gissane’s角均获不同程度的恢复,无一例切口感染。按Maryland足部评分系统(Maryland foot Score)评价术后功能。本组183侧中,优(90~100分)87侧(47.54%),良(75~89分)80侧(43 .72%),可(50~74)16侧(8.74%),优良率91.3%。结论:小切口自制跟骨解剖钢板加压螺栓内固定治疗跟骨关节内骨折可获得满意的临床疗效。第五部分:术前、术后螺旋CT扫描对跟骨关节内骨折的评价目的:通过螺旋CT扫描确定距下关节的后关节面的术后完整性和临床效果之间的关系。方法:所有病人均行切开复位内固定,未植骨。主要测量结果:根据术后CT发现移位的程度分为三组:解剖复位——无移位。近似解剖复位——移位小于2mm;大概复位——移位大于2mm。结果:当我们分析术前、术后的CT时发现,粉碎程度越重手术后复位的情况越差。解剖复位64.81%(35/54);近似解剖复位24.07%(13/54);均获得了优良的临床结果。相反,大概复位的病人未获得优良结果。结论:术后距下关节的后关节面的移位小于2mm就能获得优良的临床效果。更多还原

【Abstract】 Calcaneal fractures account for approximately 2% of all fractures, but approximately 75% of fractures of the tarsal bones, and Approximately 75% of calcaneal fractures are intraarticular.Because of the complexity of the joints, functional impairment, and permanent disability often arise, long-term results are often disappointing after both conservative and operative treatment. The long-term results of treatment are to a large extent dependent on the accuracy of the surgical reduction of the bone fragments. The most common causes of injury are falls from a height, either accidental or suicidal, and road traffic crashes. Conventional radiographs are taken mediolaterally and axially. Additional projections are seldom useful, but CT is considered the routine procedure for diagnosis.A sound understanding of the anatomy of the calcaneus is essential in determining the patterns of injury and treatment goals and options. The lateral surface is flat and subcutaneous, with a central peroneal tubercle for the attachment of the calcaneofibular ligament centrally. Medially, the talus is held to the calcaneus firmly by the interosseous ligament and the thick medial talocalcaneal ligaments. The sustentaculum tali is seen at the anterior aspect of the medial surface. The groove inferior to it transmits the flexor hallucis longus tendon. The neurovascular bundle runs adjacent to the medial border of the calcaneus. The neurovascular bundle may be injured during trauma or during surgery by the reduction of the sustentacular fragment, which is a key element in the surgical management of calcaneal fractures.The first classification was introduced by Bohler, and Essex-Lopresti developed a classification the basic principles of which are still used. These authors differentiated intra-articular and extra-articular fractures, and the two distinct entities, the joint-depression, and the tongue-type fractures.Since the introduction of sequential CT, various suggestions have been made for classifying calcaneal fractures. The precise assessment of fracture fragments by CT scan provides a considerable advantage for modern classification schemes. The most widely used classification system is that of Sanders et al. This system bases its classification on the number of fracture fragments that is identified on a semicoronal CT image. The image used is the one that displays the widest undersurface of the posterior facet of the talus. Sanders et al. described the talus as being divided into three columns by two lines. Theses lines divided the posterior articular facet into three potential pieces: a medial, a central, and a lateral fragment. The lines are lettered according to placement on the facet. Lateral fracture lines are type A, central lines are type B, and medial lines are type C. The addition of a third line that is located just medial to the medial edge makes for a fourth possible fracture piece, the sustentaculum portion. All nondisplaced fractures(regardless of the number of fracture lines) are classified as typeⅠ; one fracture lines is a typeⅡ; two fracture lines is a typeⅢ; and three or more fracture lines is a typeⅣ. this system has been useful in terms of determining treatment, and was shown to correlate well with prognosis and level of operative difficulty.The treatment of displaced calcaneus fractures has generated controversy throughout the past 150 years. Although both diagnostic and therapeutic tools have been improved dramatically over the recent two decades, many aspects of the management of these injuries continue to be topics for debate. The irregular anatomy of the calcaneus, the complicated coupling with the talus and tarsus via three joint facets and the highly specialised, delicate soft tissue envelope have made operative treatment a challenging task to the fracture surgeon.Assessment and treatment of these injuries has improved significantly over the past 2decades with the use of CT scanning. It has allowed us greater understanding of the pathologic anatomy of these fractures, and has provided us with a prognostic classification system with respect to outcome. Treatment options can be broken down into the following categories: emergent, nonoperativel, minimally invasive ORIF, standare open reduction with internal fixation, and primary arthrodesis.Nonoperative treatment is effective for fractures that are nondisplaced or minimally displaced(<2mm). ORIF is the standard therapy for fractures that are displaced greater than 2mm.The management of intra-articular calcaneal fractures remains controversial. Nonoperative treatment options include elevation, ice, early mobilization, and cyclic compression of the plantar arch. Conservative treatment of displaced calcaneus fractures frequently leads to severe functional impairment with considerable disability.To avoid the feared soft tissue complications, several minimally-invasive and percutaneous approaches have been proposed throughout the history of calcaneal fracture treatment and recently gained popularity for selected injury patterns .Operative treatment options include closed reduction and percutaneous pin fixation, open reduction and internal fixation, and arthrodesis. The effect of operative versus nonoperative treatment has been the focus of several comparative studies.The primary goals of open reduction and internal fixation in the treatment of displaced intra-articular calcaneus fractures are: 1) re-establishment of the normal anatomy of the posterior facet; 2) narrowing of the width of the calcaneus to prevent lateral impingement of the peroneal tendons and the sural nerve; and 3) re-establishment of normal height of the calcaneus. These goals should be achieved with the shortest surgical time to reduce the risk of infection and wound complications. Sufficient rigidity should be established to allow for early motion of the ankle and subtalar joints. Patients who have severely comminuted fractures(Sanders typeⅣ)can be treat with an ORIF of the body of the calcaneus combined with primary subtalar arthrodesis.The management of calcaneus fractures and their associated soft tissue injuries are challenging tasks for the surgeon. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as a standard therapy for displaced intra-articular fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. Bone grafting appears not useful in the vast majority of cases. Anatomical reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposure of the fractured lateral wall, and the subtalar and calcaneocuboid joints in most fractures. In selected fracture patterns percutaneous screw fixation, possibly with arthroscopic control, is a good alternative. The quality of joint reduction should be reliably proven intra-operatively either with Brode′n views, highresolution fluoroscopy or open subtalar arthroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days and individual risk factors such as high body mass index and smoking. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage appears promising in treating complex open fractures.Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, subtalar in situ, or corrective, arthrodesis and calcaneal osteotomy along the former fracture line.Comparison of the various treatment methods is hampered by the lack of a uniform fracture classification and outcome measurement. A well-accepted fact is, however, that the sequelae of calcaneus fractures have a considerable socio-economic impact since a great percentage of these injuries occur in young and middleaged male industrial workers.The treatment of calcaneus fractures has to be tailored not only to the individual fracture pattern and soft tissue damage but also to the functional demand, comorbidities and compliance of the patient.Although surgical stabilization of calcaneus fractures can produce excellent results, the reported rate of wound complications can be puite high. The development of major wound complications is a serious concern in treating calcaneal fractures. The soft-tissue envelope around the calcaneus is particularly thin and vulnerable over the lateral wall, which is exposed for surgery in most cases. The hazard with the medial approaches lies in the nearby neurovascular bundle. After open reduction and internal plate fixation of displaced calcaneal fractures, wound edge necrosis is seen in 0.4—14% with the extended lateral approach . With combined medial and lateral approaches, the rate of wound edge necroses reaches 27%. Infection rates after using the extended lateral approach vary between 1.3% and 7%. After Folk et al reported on 25% of wound complications in a cohort of 190 patients, with 21% requiring further surgery。Several smaller direct approaches to the lateral calcaneal wall, resembling the classical Palmer approach, have been carried out without significantly reducing the soft-tissue problems as they cut through the angiosome of the lateral calcaneal artery. A direct approach over the sinus tarsi requiring retraction of the peroneal tendons and sural nerve with minimal internal fixation resulted in an infection rate of 8.5% and further 9.2% soft-tissue problems like peroneal tendinitis, sinus tarsi syndrome, and even compartment syndrome.The present study demonstrates that wound complications are high in certain patient groups. Smoking, diabetes, and open fractures all increase the risk of a significant wound complication.Part oneA serial anatomic study of calcaneal一.The Clinical Significance of Anatomical of Calcaneus and Iit’s Three-dimension and Multiplanar Reconstruction With Sprial CT MeasurementObjective: To provide the anatomical date experience for the internal fixtion of calcaneal fracture with self-made calcaneal anatomic plate and screw.Methods:An anatomic study was carried out on 40 adult dry calcaneal specimens by the measurement of anatomical of calcaneus and it’s three一dimension and multiplanar reconstruction with sprial CT.Results: The whole length of calcaneus was72.88±4.19mm;The longth between calcaneal tubercle and sulcus calcaneus was 54.99±3.61mm; The height and width in posterior part of calcaneus were 40.80±2.84mm;30.13±2.93mm; Highest of calcaneus was 45.10±2.89mm; The height and width in anterior part of calcaneus were 22.08±2.33mm;25.10±2.64mm respectively . The length,width and height of sustentacdum tali were 23.12±1.88mm;15.68±1.55mm;10.15±1.16mm respectively. There is no difference between various indexes of anatomical of calcaneus and it’s three- dimension and multiplanar reconstruction with sprial CT measurement.and there is no difference between various indexes of ours and before reports .Conclusions: The results of measurement of our play an important role in the the design of self-made new calcaneal anatomic plate and screw for internal fixtion of calcaneal fracture .二.The establishment of calcaneal morphous database for health adult crowdObjective:The criticality of treatment of calcaneal fracture is to recovery calcaneal outline ,the paratopic relationship of talocalcaneal joint and the loading model of calcaneus.The half-lateral calcaneal fracture can be regained according to the anatomic data of uninjuried-side calcaneus.There was no local reference data to patients of bilataral calcaneal factures and was difficult to judge the nomal size of calcaneus accutly in operation.Thereby it is necessary to build the database of the relationship of calcaneus and stature.Method: Select 200 adult men and 200 adult women in north according to the randomization principle(average age of men 38.9y;avrage age of women 36.2y),who are free from diseases of bone and joint by medical examination.Mesure all the body height of subjects and scan their calcaneus by 64-layer spiral CT.Images were 3D or 2D reconstructed by the way of Multiplanar reconstructions and Surface shaded display.The cutting techniqiue was used to cut the 3D images in any plane so that to show the shape and size of calcaneus at the best angle and direction.Thereby measure the height,width and the width of sustantaculum tali accurately and get anatomic datas.Finally we try to set up linear regression equation of calcaneal anatomic data and the stature.Results:The shape and structrue of calcaneus is complicated whose cortex is thin and cancelloeus bone is much. Bone trabecula is rare in the anterior of calcaneus and intensive in the posterior.The normal data between left and right calcaneus is no significant difference.However,there are significant difference among each index except Gissanecs’angle between male and female. The ratio of body height and width of calcaneus is more than 1/2. The whole length of calcaneus was72.88±4.19mm;The longth between calcaneal tubercle and sulcus calcaneus was 54.99±3.61mm; The height and width in posterior part of calcaneus were 40.80±2.84mm;30.13±2.93mm; Highest of calcaneus was 45.10±2.89mm; The height and width in anterior part of calcaneus were 22.08±2.33mm;25.10±2.64mm respectively . The length,width and height of sustentacdum tali were 23.12±1.88mm ; 15.68±1.55mm ; 10.15±1.16mm respectively.Conclusion:we set up the database of normal people according to the measured data and manufacture many sorts of new type of anatomic calcaneal plate and breakdown-easily screw which is adapt to operation with improved microinvasive small incision.Before operation we measured patients’normal feet and select the size,longth and width of internal fixation equipment and different length of screws in different sites of calcaneus.三.External Fixation of the Calcaneus: An Anatomical Study for Safe Plate placement and Pin InsertionObjective: to investigate areas in the hindfoot where external fixation pins could be safely inserted with the least risk to underlying nerves, vessels, and tendons.Methods: Sixteen fresh adult amputated feet were dissected .Using palpable anatomic landmarks, two relative“safe zones”on the calcaneus were delineated. These included an area on the medial calcaneus, the lateral calcaneus .Results: The medial calcaneal safe zone was a large, easily definable rectangular area on the posterior aspect of the tuberosity, posterior to the neurovascular bundle and extrinsic tendons. The lateral calcaneal safe zone consisted of a large area of the lateral calcaneal tuberosity, located posterior to the peroneal tendons and sural nerve trunk.Conclusions: The data presented here provide information to assist selection of pin sites that minimize risk to underlying soft tissues during external fixation of the calcaneus.四.The application and clinical significance of the imageology of peroneal tendon sheath in calcaneal fractureObjective:To explain the cause of the pain of calcaneal outer flank caused by calcaneus broadening after calcaneal fracture through the imaging verification of the phenomenon of the oppression of fibular tendon .Methods: The peroneal tendon sheath imaging were carried on 15 patients of calcaneal fracture associated with talocalcaneal joint surface and 15 patients of calcaneal oboslete fracture left with lateral calcaneal pain between May 2006 and November 2006.The patients are composed of 23 men and 7 women.Their age range from 21 to 46 years with average year 37.18 left feet and 12 feet were involved and ecch one is half fracture. Bilateral visulasition of peroneal tendon sheath were carried out at the same time following with ankle posterioanterior radiograph,calcaneal lateral radiograph and calcaneal axial radiograph with DR.Then they were measured on 2-dimensional CT and obersed on the 3-dimensional CT graph compared with opposite normal calcneus.Results: All 30 patients have varying degrees of the calcaneal widening and the oppression of peroneal tendon sheath phenomenon.Conclusion: The broadening of calcaneus after calcaneal fracture and the oppression of fibular tendon are the cause of calcaneus lateral pain. The calcaneus of all 30 patients become wider and sheaths are compessed to different degree.When the involved calcaneus are wider less than 3mm than normal calcaneus,the medium can flow through;When the involved calcaneus are wider more than 3mm ,the medium can’t come through and the peroneal tendon sheath shows up compressed .Compared with normal calcanues the patients suffer from lateral calcaneal pain when the involved calcaneus are wider more than 3mm.Conclusion:The pain of lateral calcaneus is caused by compression of sheath of resulted from widen calcaneus after fracture.Part twoThe Design , Mechanics Annlysis and Biomechanical Evaluation of Ourself Designed Reduction and Fixation System for Calcaneal FractureObjective: To introduce the composion and mechanism of reduction of the calcaneal fracture internal fixation system, to evaluate its stability by mechanics analysis and biomechanical investigation.Methods: The calcaneal fracture internal fixation system is made of stainless steel composing of anatomic plate, reduction rod, and stud bolt. Sixteen amputated fresh adult feet and sixty patient were used in this investigation. Axial compressive load of 500N,700N was provided by biomechanic machine.Results: Mechanics analysis note that the calcaneal fracture internal fixation system is a stable system, and the stud bolt is important part of this system which can reducted the wildth of the calcaneal.Conclusions: The calcaneal fracture fixation system is a stable system. The stud bolt is the key point of this device.Part threeA Comparison of Ourself Designed Plate and AO Plate in a Calcaneal Fracture Model and Clinical applicationObjective: To compared different plates in an experimental calcaneal fracture model under biocompatible loading and clinical application. Methods:Two plates were tested:ourself designed plate and AO plate. Syntheticcalcanel(sawbone)were osteotomized to create a fracture model, and the plates were fixed onto them. Eight specimins for each plate model were subjected to loading and load to failure. Motion, forces, plastic deformation of the lpate, and comsequent depression of the posterior joint facet were analyzed.Results: During loading, ourself designed plate showed statistically significant lower displacement in the primary loading direction than the AO plate.Mean values(mm)of maximal displacements for each plate during loading were as follows:Conclusions: Our results showed that ourself designed plate provided greater stability during loading than the AO plate.Part fourCompression fixation with small incision steel plate and stud bolt for calcaneal fracturesObjective To explore the effect of surgical operation on intraarticular fracture of calcaneus by new method.Methods: From February 2005 feet in 150 patients with calcaneal fracture were treated differently based on the results of X-ray and coronal CT scan performed before and after the treatment, with micro-invasive technique, small incision(2~3 cm)was made at lateral of calcaneus, self-made calcaneal anatomical plate and screw were used. based on the results of X-ray and coronal CT scan ,According to Sanders classification system,there were 18 cases of typeⅡ,26 cases of typeⅢand10 cases of typeⅣ.Results:The internal fixation with the calcaneal anatomical plate almost restored the height,length ,width、angle of Bohler and Gissane of the calcaneus for the 150 patients. No one infection of incision happened. The results were validated using Maryland Foot Score . 183 fractures were followed up for 6-24 monihs(average,16monihs)after treatment . Excellent results were noted in 87 (47.54%)fractures,good in 80(43.72%),and fair in 16(8.74%).Conclusion : The open-reduction with micro-invasive and internal fixation with our self-made calcaneal anatomical plate and screw is one of the best ways for treatment of fracture of calcaneus.Part fivePreoperative and Postoperative Evaluation of Intra-articular Fractures of the Calcaneus Based on Sprial CT ScanningObjective: To define the relationship between postoperative congruency of the posterior facet of the subtalar joint based on Sprial CT and clinical results.Methods: Twenty-nine displaced fractures in twenty-five patients. All patients were treated with open reduction and internal fixation without bone graft. Preoperative and postoperative CT scans were taken prospectively and analyzed. Postoperative CT findings were classified into three groups, according to the degree of displacement: anatomic, no displacement; nearly anatomic, displaced less than two millimeters; and approximate, displaced more than two millimeters.Results: The reduction state after operative treatment for the cases with more comminution showed worse results when analyzed in both preoperative and postoperative CT scans. 35 of 54 fractures (64.81 percent) with anatomic reduction and 13of 54 fractures (24.07percent) with nearly anatomic reduction had excellent or good clinical results. In contrast, no fracture with an approximate reduction had an excellent result.Conclusion: An excellent or good clinical result can be expected when the postoperative displacement of the posterior facet of the subtalar joint is less than two millimeters.更多还原