| Background:Calcaneal fracture is one of the most common tarsal fractures of the foot and ankle,accounting for 2%of the total fractures,among which calcaneus intra-articular fracture accounts for 65-70%,and the later stage disability rate of calcaneus fracture reaches 20%-30%,among which the complications of traditional approach of calcaneus intra-articular fracture in soft tissue reach 17%-38%.The purpose of this study was to explore the safe and effective surgical approach for intra-articular calcaneal fractures by studying the anatomical characteristics around the calcaneus.Objective:1.The anatomic study was conducted to understand the anatomic relationship between the anterior and posterior margin of the tendon sheath of the lateral calcaneus,the peroneal nerve and the lateral calcaneus artery walking rules and the peroneal tip marked by the body surface,so as to provide anatomical basis for the design of the bilateral window approach for the lateral transection of the calcaneus2.To compare the clinical efficacy of open reduction internal fixation and percutaneous reduction in the treatment of intra-articular calcaneal fractures3.To describe the clinical key points of the treatment of intra-articular calcaneus fracture by the cross-section and double-window approach and to review the early clinical effect4.To compare and study the clinical effect of traditional expanded L type approach and lateral transverse incision double window approach in the treatment of intra-articular calcaneus fractureMethods:1.Charge 6 corpse specimens,define fibular tip to define external ankle pointed to F dot,foot along the fibula pointed to the remote node to point P attachment(FP),fibula pointed to fifth metatarsal base(M)the attachment for the line(FM)and fibular tip to the heel bone nodules after trailing surface(C)the attachment for the line(FC),through the anatomical observation of sural nerve,before and after the length of the lateral calcaneal artery,the peroneal tendon sheath edge and three surface marker anatomic relationship and the distance between measured points of intersection and fibular tip.2.Retrospective analysis was used to select 57 patients with Sanders type Ⅱcalcaneal fractures in our hospital from February 2013 to December 2014,,divided into percutaneous reduction group and open reduction internal fixation group。Compare the operation time,hospitalization days,imaging changes and AOFAS score between the two groups.3.Retrospective analysis was conducted on the efficacy,complication rate and imaging improvement of preoperative and postoperative Bohler Angle and Gissane Angle measured by lateral X-ray in the treatment of 29 cases(31 feet)of intra-articular calcaneus fractures treated by the transverse incision double-window approach from May 2014 to April 2016.4.Sixty patients with intra-articular calcaneal fractures admitted to the second affiliated hospital of Anhui medical university from July 2016 to April 2018 were selected.The control group was randomly divided into two groups,and the experimental group was treated with the surgical method of lateral transverse incision and double window approach(30 cases).The control group was treated with conventional expanded L approach(30 cases).Surgical complications,imaging improvement and AOFAS scores in the last follow-up were compared between the two groups.Results:1.The peroneal tendon sheath intersects FM,FP and FC lines,and the distances from the intersection point to the F point are 31.21±1.39mm,4.45±1.09mm and 3.15±0.59mm,respectively.The posterior edge of the peroneal tendon sheath intersects the FC and FP lines and is located below the FM line.The distance from the intersection point to the F point is 7.42±1.39mm and 10.45±1.02mm.The sural nerve intersects FM,FP and FC lines,and the distances from the intersection point to the F point are 10.45 ±1.62 mm,6.01±0.52 mm and 17.55±1.92 mm,respectively.The calcaneus lateralis artery mainly originates from the peroneal artery and forms a vascular network behind the peroneal tendon and the plantar blood supply system.The main branches are shaped on the surface and posterior margin of the peroneal tendon sheath.2.The operative time and blood loss in the calcaneal fracture group were 19.4±7.2min and 17.8±6.5ml,which were significantly less than that in the open reduction internal fixation group(71.5±10.1min and 66.5±16.4 ml)respectively.The soft tissue complications in the percutaneous reduction group(3.7%)were lower than that in the open group(10.0%).The AOFAS scores were 92.2±7.3 and 91.8±6.7,with no significant difference.3.All the 29 patients in the early stage were followed up for 6～29 months,an average of 13 months.Through the analysis of patients’ lateral calcaneal X-ray,the patients’ Bohler Angle and Gissane Angle were significantly improved before and after surgery(30.43±14.65 vs 2.77±12.46),(120.59±8.09 vs 117.9±21.21)respectively.Among all the patients followed up,1 patient had skin flap necrosis,which healed after dressing change,and 1 patient had sural nerve injury.After 5 months of physiotherapy and drug treatment,sural nerve numbness disappeared.At the last follow-up,the AOFAS score was 90.55±4.25,and the excellent and good rate was 93.5%.4.In the experimental group,only 1 case was complicated with incision infection,and there was no skin edge necrosis,the rate of skin edge necrosis was 0%,and the incision infection rate was 3.70%.In the control group,there were 5 cases of skin edge necrosis,among which 3 cases were complicated with wound infection,the rate of skin edge necrosis was 19.23%,and the rate of wound infection was 11.54%.Postoperative foot function was evaluated according to the American association of foot and ankle surgeons(AOFAS)ankle and hind foot scoring system:the experimental group had excellent 18 feet,good 9 feet,good 3 feet and poor 0 feet,with an excellent and good rate of 90.00%.In the control group,18 feet were superior,8 feet were good,3 feet were good,and 1 foot was poor.Conclusion:1.The lateral calcaneus peroneal nerve and the long and short peroneal tendon sheath are relatively constant,so it is safe and reliable to select the lateral transection of calcaneus through body surface positioning for the protection of the peroneal tendon sheath and peroneal nerve.2.The clinical efficacy of percutaneous reduction is superior to the open reduction internal fixation in Sanders II calcaneal fractures,with less complications3.The treatment of intra-articular calcaneal fracture by the cross-section double-window approach combined with the steel plate has achieved good clinical results,reducing the postoperative incision complications and the incidence of subtalar arthritis.4.There was no significant difference in clinical efficacy between the traditional expanded 1-type approach and the double-window approach with lateral transection,but the application of the double-window approach with lateral transection had fewer soft tissue complications and higher patient satisfaction,making it a safe and effective treatment for intra-articular calcaneus fractures. |
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