Liu Hua, Department of Orthopedics, PLA 474 Hospital, Sanders II-IV treated with incisional internal fixation
30 cases of Achilles fracture
Liu Hua Hou Wei (Department of Surgery, No. 474 Hospital of the People’s Liberation Army, Urumqi, Xinjiang 830011, China)
Abstract: Objective To discuss the efficacy of incision and internal fixation of Senders type II-IV heel fractures and related problems. Methods Thirty patients (31 feet) were admitted and classified as type II-IV according to Sanders’ classification: 15 feet of type II, 11 feet of type III, and 5 feet of type IV. A modified lateral heel “L”-shaped approach was used for internal fixation of the fracture with an incisional reduction plate screw and an autologous iliac bone graft. Results All 30 patients (31 feet) were followed up for 12 to 24 months. The mean fracture healing time was 5 months, and the postoperative outcome was evaluated according to the Maryland foot scoring system, with an excellent rate of 90.32%. The modified lateral heel “L” approach is a good choice for incisional internal fixation of heel fractures; bone grafting is required for large subarticular bone defects to reduce postoperative complications.
[Keywords] Achilles fracture; internal fixation; incision and reduction
[I.C.C.] R683.42 [I.D.] B
Open reduction and internal fixation surgery for 30 patients with Sanders type II ~ IV calcaneal fractures
Liu Hua, Hou Wei,
Abstract Objective: To investigate the efficacy and related problems of open reduction and internal fixation surgery for sanders type II ~ IV calcaneal fractures. METHODS: 30 patients (31 feet) were enrolled according to Sanders’ classification, including 15 feet in type II, 11 feet in type Improved extended L-shaped lateral approach to the calcaneus was used for open reduction and internal fixation of plate and Improved extended L-shaped lateral approach to the calcaneus was used for open reduction and internal fixation of plate and screws with calcaneal fractures followed by autogenous iliac bone graft. The excellent and good rate was 90.32% according to the Maryland foot score after the operation. The excellent and good rate was 90% according to the Maryland foot score after the operation. The results of this study are summarized below. The calcaneus fractures are treated with an extended L-shaped lateral approach to the calcaneus is a fine apporach choice for open reduction and internal fixation surgery; large bone defects under the articular surface requires bone grafting to reduce postoperative complications.
Key words: calcaneus fracture; internal fixation; open reduction
Heel fracture is a relatively common fracture, accounting for about 2% of all fractures, while it is the most common among tarsal fractures, accounting for 60% of them, and intra-articular fractures occur in about 75% of cases due to the anatomical peculiarities of the heel bone [1]. In the past, traditional treatment methods were unable to anatomically reposition fractures involving the articular surface of the heel, and the affected foot suffered from long-term pain and dysfunction due to secondary traumatic arthritis, which had a serious impact on the patient’s life. With the development of imaging technology and endoprosthesis, orthopaedic surgeons have further understanding of heel fracture staging, which has led to a more scientific and reasonable choice for the treatment of heel fractures, especially for heel fractures involving the articular surface, which tend to be treated surgically with incisional reduction and internal fixation [2-4].
In this study, we followed 30 patients (31 feet) hospitalized from January 2009 to December 2012, who were classified as type II-IV according to Sanders’ typing, and used a modified lateral heel “L” approach for incision and internal fixation. The patients were treated with a modified lateral heel “L” approach for internal fixation, and good results were achieved. The results are reported as follows.
1 Data and methods
1.1 General data: There were 30 cases (31 feet) in this group, 21 males and 9 females, aged 19-58 years. There were 3 cases of bilateral heel fractures. Among them, there were 23 cases of high fall injury, 7 cases of smash injury and traffic accident. According to Sanders’ typing, 15 feet of type II, 11 feet of type III, and 5 feet of type IV.
1.2 Preoperative preparation: After admission, the affected limb was elevated, braked with a brace or plaster rest and mannitol was applied to reduce edema, local swelling subsided 5-9 d after injury, and the skin wrinkle test was positive, and the operation time was 6-10 d after injury.
1.3 Surgical method: Single-foot fracture was performed in the healthy-side position, and bipedal patients were placed in the flat position, and the bed was shaken and reclined as needed during surgery. The lateral “L”-shaped incision of the heel was made from 2 to 75 px above the tip of the outer ankle, parallel to the anterior edge of the Achilles tendon at the dorsum of the foot at the junction of the heel skin toward the 5th toe, with a subperiosteal sharp dissection, paying attention to the protection of the peroneal nerve, turning up the peroneal long and short tendons and the peroneal nerve together with the flap, and drilling at the talus, outer ankle The long and short peroneal tendons and the peroneal nerve were turned up together with the flap, and the soft tissues were retracted at the talus, the tip of the outer ankle, and the dice bone by bending a Kirschner needle. The heel bone was drilled axially into the calcaneal tuberosity with a Searle’s needle, and the heel bone was pried and pulled in a backward and downward direction, while the forefoot was plantarly flexed and the lateral wall of the heel bone was pressed with both hands to restore the length, height and width of the heel bone as much as possible, so that the Böhlers’ angle was restored and the acuity of the internal and external rotation was corrected, and the collapsed joint surface was pried and pulled with a small periosteal stripper to restore the normal anatomy of the inferior talocrural joint surface. Bone grafting with autologous iliac bone extraction. If the fracture is satisfactorily repositioned, a suitable plate is placed on the lateral aspect of the heel according to the fracture line, and the screws are drilled into the medial talocrural process when screw fixation is performed according to the 3-point fixation principle. The incision was closed in two layers and bandaged with pressure.
1.4 Postoperative treatment: elevate the affected foot after surgery, routinely prevent infection, reduce swelling, promote circulation and other symptomatic treatment, and encourage patients to perform active ankle flexion and extension activities in bed, according to the amount of drainage, generally remove the drainage tube 48-72 h after surgery. After good wound healing, the stitches were removed in 14 days after surgery, and the foot could be walked without weight-bearing on crutches, with the exception of bipedal patients, who started to perform partial weight-bearing in 8-10 weeks after surgery, and could gradually become fully weight-bearing in 10-12 weeks according to the review of X-ray.
1.5 Statistical treatment: spss 18 statistical software was used, and the measurement data were expressed as ± s. The t-test was used to compare between two groups, and P < 0.05.
2 Results
All 30 cases (31 feet) in this group were followed up for 12 to 24 months. The mean fracture healing time was 5 months, and the efficacy was evaluated according to the Maryland foot scoring system. 18 feet were excellent, 10 feet were good, 2 feet were acceptable, and 1 foot was poor, with an excellent rate of 90.32%, including an excellent rate of 93.33% for Sanders II, 90.9% for Type III, and 80% for Type IV. See Table 1 and Figure 1.
Table 1 Postoperative foot function assessment by Maryland foot scoring system
Type of fracture
Excellent
Good
OK
Poor
Excellent rate (%)
SandersII type
12
2
1
0
93.33
Sanders III
6
4
1
0
90.9
Sanders IV
0
4
0
1
80
Total
18
10
2
1
88.07
A: preoperative Böhlers angle of -5°; B: postoperative lateral X-ray Böhlers angle of 40°.
C: fracture healed and internal fixation removed at 18 months postoperatively
Figure 1 Lateral x-ray of the patient before and after surgery
3 Discussion
At present, incisional internal fixation for heel fractures has been made as the gold standard [5-6]. And due to the special anatomical structure of the heel bone, the intraoperative operation, fracture repositioning implant and the choice of internal fixation all play an important role in the postoperative recovery of patients after surgery [7-9].
3.1 Preoperative preparation: because of the obvious local bleeding and swelling after heel fracture, and the anatomical peculiarities of the soft group blood flow in the heel, it is not suitable for emergency surgery, while the operation is too late, the intraoperative fracture repositioning will be affected, our operation time is 6-10 days, preoperative mannitol is routinely given and the affected limb is elevated to reduce swelling, and the skin soft tissue tension should be checked before surgery, generally after preoperative treatment in about 5-9 days are Oztekin et al [10] concluded that after swelling treatment of the heel fracture, surgery is usually performed within 7-10 days after the injury, which is conducive to intraoperative operation and prevention of postoperative local skin necrosis.
3.2 Surgical approach: At present, the modified lateral heel “L” approach is commonly used [11], because the blood flow of the soft tissue of the lateral heel skin mainly originates from the lateral heel artery, so the protection of the lateral heel artery is the key to prevent postoperative skin necrosis, and a large number of anatomical studies have fully proved this view [5,12,13 The author believes that intraoperative incision of the lateral heel artery is the key to prevent postoperative skin necrosis.] In the author’s opinion, the transverse part of the incision should be along the “blue-white” junction as much as possible and “rather low than high”, while the longitudinal part should be in the posterior 1/3 of the line between the Achilles tendon and the posterior border of the fibula. The flap should be lifted close to the periosteum, and the operation should be gentle, and the flap should be retracted only with a Kristen needle.
3.3 Fracture repositioning and bone grafting: due to the special anatomical structure of the heel bone, reversal and collapse of the articular surface easily occur in its fracture, which cannot be solved by conservative treatment and simple closed pry repositioning and fixation, the patient’s prognosis will be tibiofibular collision syndrome, peroneal tendon friction and other symptoms affecting the patient’s daily life, and patients with serious articular surface injury often have premature manifestations of traumatic arthritis, which seriously affects The quality of life of patients is seriously affected. Therefore, the goal of treatment is to restore the anatomical relationship of the heel bone and to flatten the subtalar articular surface as much as possible. The author believes that bone grafting is often necessary when there are more bone defects under the articular surface of the heel fracture after resetting, because it has an impact on the postoperative joint surface collapse again.