[Abstract] Objective To investigate the clinical efficacy of internal fixation with a lateral incision pry-out repositioning plate in the treatment of comminuted fractures of the heel. Methods The Department of Orthopaedics of our hospital started to use the modified lateral incision pry-out repositioning plate internal fixation method to treat comminuted fractures of the heel in 2003, and 162 patients have been treated by this surgical method so far. Results: 160 patients had good functional recovery and satisfactory results; 2 patients had early weight-bearing on their own, which caused loss of heel bone height after repositioning, resulting in plate deformation and plate fracture. Conclusion The modified lateral incision pry-out repositioning plate internal fixation method has the advantages of wide indications, early functional exercise, and few complications in treating comminuted heel fractures, which can achieve good results.
【Key words】 External incision, prying and repositioning, internal fixation, comminuted heel fracture
Heel fractures account for 2% of all fractures in the body and are the most common of all tarsal fractures, accounting for about 60% of all tarsal fractures. Comminuted fractures cause serious loss of heel bone height, arch collapse, and destruction of the subtalar articular surface, making treatment more difficult and the disability rate higher. Comminuted fractures of the heel bone are mostly caused by high fall injuries and strong impact on the heel bone. From September 2003 to March 2010, 162 cases of comminuted heel fractures were treated by internal fixation with modified lateral incision pry-out repositioning plate in our orthopedic department, with good results, as reported below.
1. Clinical data and methods
1.1 Case data
There were 107 male cases, 55 female cases, age 19-65 years old, average 36 years old, 92 cases on the right side, 62 cases on the left side, and 8 cases on the left and right sides. X-rays showed that the Bohler angle was -5 o to l0 o. The average was 3.9o. The width of the heel bone was wider than that of the healthy side by about 0.9-2.8 cm, with an average of 1.5 cm. According to Sanders typing, there were 35 patients with type I, 33 patients with type II, 94 patients with type III, and 8 cases combined with lumbar fractures. The timing of surgery was based on the local swelling. Most of the patients with mild swelling were operated about 1 week after the injury, while those with heavy swelling should be operated after the swelling subsided about 2 weeks.
1.2 Surgical methods
Under epidural (or lumbar anesthesia) anesthesia and tourniquet, an “L”-shaped incision is made on the lateral aspect of the heel, starting from the midpoint of the Achilles tendon and the outer ankle vertically downward to the lower posterior arc of the heel along the lateral black and white junction line of the heel to the heel dice joint, and cutting directly to the surface of the heel, paying attention to the protection of the peroneal nerve and the peroneal long and short tendons, and sharply peeling the periosteum against the bone surface. Until the entire lateral surface of the heel bone and the collapsed superior articular surface are revealed, the electric knife is prohibited, and the flap should avoid clamping, pulling and squeezing to prevent necrosis. The lateral elevation of the heel bone is uncovered and the collapsed articular surface is pried up to restore the normal Bohler and GESAN angles and the interlocking heel talonavicular joint. In general, no bone grafting is required; for severe comminuted compression fractures, autogenous iliac bone, allograft bone or artificial bone filling graft is taken. In this group of cases, the shortest operation was 30 minutes and the longest was 60 minutes. After the operation, negative pressure drainage was placed, appropriate pressure dressing was applied, the affected limb was elevated, and blood-activating and anticoagulant drugs were applied. The active and passive functional exercises were started painlessly in 3 d after surgery, and the stitches were removed in 2-3 weeks. 2-3 months later, weight-bearing activities were gradually carried out with the help of double crutches according to the X-ray film.
1.3 Results
In the follow-up of cases, 2 patients could not fully implement the doctor’s instructions after surgery and took weight-bearing activities early on their own, which caused the loss of heel bone height after repositioning and led to deformation and fracture of the steel plate; 2 other cases had necrosis at the corners of the skin flap and the steel plate was exposed, which was healed by the growth of smooth granulation and skin crawling coverage after a period of drug change; the rest of the patients had satisfactory recovery results.
2.Discussion
The heel bone is spongy cancellous bone, and fracture can lead to changes such as shortening of its length, reduction of its height, unevenness of the inferior talar articular surface, collapse of the articular surface and reduction, disappearance or even reversal of the Bohler angle, which can directly affect the function of the ankle joint [1]. Good repositioning is an important principle in the treatment of comminuted heel fractures, and the aim of heel fracture treatment is to restore the normal anatomical form of the heel as much as possible with a view to achieving good repositioning and aiming for a flat articular surface [2]. The treatment of comminuted heel fractures by internal fixation with a modified lateral incision skid repositioning plate does not require bone grafting in general, and bone grafting with autogenous iliac bone, allograft bone or artificial bone filling is used for severe comminuted compression fractures.
Comminuted fractures of the heel are associated with simultaneous fragmentation of the medial and lateral walls, a significant widening of the heel bone, a significant decrease in height, and an upward displacement of the heel tuberosity due to the pulling of the Achilles tendon and metatarsal fascia, resulting in a shortened heel axis and instability of the heel dice joint [3]. Severe comminuted
After resetting, it is easy to collapse again, so it is important to avoid premature weight-bearing activities after surgical resetting, and the specific time should depend on the X-ray performance.
Through the postoperative recovery of several patients, the following advantages of this procedure were summarized: (1) it facilitates early functional training; (2) it avoids the occurrence of osteoporosis and joint stiffness due to long-term external fixation in plaster; (3) it has wide applicability and few postoperative complications; (4) it effectively reduces the occurrence of traumatic arthritis, joint dysfunction and disuse osteoporosis.
Some issues should be noted during and after the implementation of surgery: ①Lateral and axial x-rays should be carefully studied before surgery to clarify the type of fracture before selecting the position, direction and depth of needle entry [4]; ②The surgery is operated under a tourniquet throughout; ③Pay attention to the skin tension at the affected area, pay attention to aseptic operation, and avoid infection; ④Skin fascia re-injury should be avoided during surgery, and skin incisions should not be made subcutaneously free to avoid affecting the blood supply to the skin margin The skin incision should be sutured deeply, spaced closely, and with wide margins [5]; ⑤ the periosteum should be sharply peeled with a scalpel close to the lateral bone surface of the heel [6], and electrocautery is prohibited; ⑥ negative pressure drainage should be placed postoperatively, and appropriate pressure bandages should be applied to prevent the formation of hematoma infection [7,8], supplemented with the application of blood-activating and anticoagulant drugs.
References
[1] Tan H L, Wang S J, Zhao J K, et al. Treatment of Sanders type II heel fracture by incision and pry repositioning combined with calcium phosphate ceramic bone graft. Chinese Journal of Bone and Joint Injuries, Vol. 23, No. 10, October 2008, 828-830.
[2] Li Junqi, Jiang Shiping, Zhang Lianying. Treatment of heel bone powder fractures with prying repositioning and internal fixation of the heel anatomic plate.
fragmentation fractures in 24 cases. Journal of Practical Medicine, 2006, Vol. 22, No. lO, 1124.
[3] Wang Xiangyu. Treatment of comminuted fractures of the heel with cut-and-repeat internal fixation. Journal of Medical Forum, July 2007
Vol. 28, No. l3, 82.
[4] Li Bingen. Central Plains, Medical Journal. Vol 28, No. 6 June 2001, 46-47.
[5] Xu Xingming. Treatment of 44 cases of comminuted fractures of the heel with prying repositioning and internal fixation of the heel anatomic plate. CHINA FOREIGN MEDICAL TREATMENT, 2008 NO, 33, 37-38.
[6] Peng, A. Chin. Originally published by Joseph Schatzker Marvin Tile. Principles of surgical treatment of fractures. 3rd ed. People’s Health Press.2005.478.
[7] Chen Zhengzeng, Tou Daxiong, Sun Fanggui, et al. Small incision short reconstruction plate for heel fracture. Chinese Journal of Bone and Joint Injury, Vol. 23, No. 1, January 2008, 62-63.
[8] Lu H D, Cai D Z, Jin W T, Wang K K. Application of AO heel plate in intra-articular fractures of the heel bone. Chinese Journal of Bone and Joint Injuries, Vol. 23, No. 1, January 2008, 64-65.