1、 CHINA MEDICINE AND PHARMACY Vol.13 No.2 January 2023161 2023年1月第13卷第2期临床医学骨科 基金项目 山东省中医药科技项目（2021M032）。跗骨窦入路结合围手术期中医药干预治疗Sanders型跟骨骨折的效果李楠董汝军郝连升山东省聊城市中医医院骨伤科，山东聊城252000 摘要 目的 研究跗骨窦入路、外侧 L 形入路切开复位内固定治疗 Sanders 型跟骨骨折的实际效果，并对治疗策略加以讨论分析。方法 回顾性分析 2017 年 12 月至 2019 年 12 月于聊城市中医医院骨伤科行切开复位内固定治疗的 Sanders 型跟
2、骨骨折患者 84 例。根据治疗方式不同分为跗骨窦入路组和外侧 L 形入路组，并给予中医药围手术期干预。记录患者术前以及术后 24 h、2 个月、1 年的 X 线检查，以Gissane 角、Bhler 角及美国足与踝关节协会（AOFAS）踝-后足评分为指标，随访术后并发症，进行组间比较分析。结果 手术均顺利完成，无 1 例脱访。跗骨窦入路组手术时间、术后失血量均低于外侧 L 形入路组，差异有统计学意义（P 0.05）；无 1 例出现腓肠神经损伤、切口皮缘坏死，但两组各有 1 例在术后出现创口皮肤轻微感染，给予药物治疗后症状消失，并发症总发生率无差异。在术后随访时间范围内，两组 AOFAS踝-后足
3、评分均大幅提高，差异有统计学意义（P 0.05）；术后 2 个月，跗骨窦入路组 AOFAS 踝-后足评分高于外侧 L 形入路组，差异有统计学意义（P 0.05）。影像学检查结果示，末次随访，两组跟骨 Bhler 角和 Gissane 角较术前均有所提高，差异有统计学意义（P 0.05）。结论 通过采用规范化的中医药围手术期干预，对于 Sanders 型跟骨骨折患者，无论是跗骨窦入路插入锁定钢板亦或外侧 L 形入路治疗，均能实现良好的效果，两组并发症发生率相同，短期内跗骨窦入路组的疗效评分优于外侧 L 形入路组，远期随访评分差异不大。关键词 跟骨骨折；跗骨窦入路；外侧 L 入路；中医药 中图分类
4、号 R687.3 文献标识码 A 文章编号 2095-0616（2023）02-0161-05Therapeutic effect of tarsal sinus approach combined with perioperative intervention of traditional Chinese medicine on Sanders-calcaneal fractureLINanDONGRujunHAOLianshengDepartment of Orthopedics,Hospital of Traditional Chinese Medicine of Liaocheng C
5、ity,Shandong,Liaocheng 252000,ChinaAbstract Objective To investigate the actual effect of open reduction and internal fixation(ORIF)by tarsal sinus approach and lateral L-shaped approach in the treatment of Sanders -calcaneal fracture,and discuss and analyze the treatment strategy.Methods A total of
6、 84 patients with Sanders -calcaneal fracture treated by open reduction and internal fixation in the Department of Orthopaedics of Hospital of Traditional Chinese Medicine of Liaocheng City from December 2017 to December 2019 were retrospectively analyzed.They were divided into the tarsal sinus appr
7、oach group and the lateral L-shaped approach group according to different treatment methods,and were given perioperative intervention of traditional Chinese medicine(TCM).The X-ray examinations of the patients before operation,24 h after operation,2 months after operation and 1 year after operation
8、were recorded.The postoperative complications were followed up and compared between the two groups,with Gissane angle,Bhler angle and American Orthopaedic Foot&Ankle Society(AOFAS)ankle-hindfoot score used as indicators.Results All the operations were successfully completed,and none of them was lost
9、 to follow-up.The operation time and postoperative blood loss in the tarsal sinus approach group were lower than those in the lateral L-shaped approach group,and the difference was statistically significant(P 0.05).None of the patients had sural nerve injury and incision skin margin necrosis,but one
10、 patient in the two groups had mild infection of wound skin after operation,and the symptoms CHINA MEDICINE AND PHARMACY Vol.13 No.2 January 2023162 2023年1月第13卷第2期临床医学骨科disappeared after medication.The incidence of complications was the same,with no significant difference between the two groups.With
11、in the follow-up time after operation,the AOFAS ankle-hindfoot scores of both groups were significantly improved,and the difference was statistically significant(P 0.05).At two months after operation,the AOFAS ankle-hindfoot score was higher in the tarsal sinus approach group than that in the latera
12、l L-shaped approach group,and the difference was statistically significant(P 0.05).The imaging examinations showed that the Bhler angle and Gissane angle of calcaneus were improved compared with those before operation in the two groups at the last follow-up,and the difference was statistically signi
13、ficant(P 0.05).Conclusion For patients with Sanders -calcaneal fracture,whether internal fixation with steel plate by the tarsal sinus approach or the lateral L-shaped approach,the standardized perioperative intervention of TCM can achieve good results.The incidence of complications of the two group
14、s is the same.The short-term therapeutic effect score of the tarsal sinus approach group is better than that of the lateral L-shaped approach group,and their long-term follow-up scores are not significantly different.Key words Calcaneal fracture;Tarsal sinus approach;Lateral L-shaped approach;Tradit
15、ional Chinese medicine跟骨骨折大多数会波及关节面形成关节内骨折，如果不能实现良好的复位，可导致严重的永久性后遗症，影响正常生活1。要实现良好的疗效，一方面需要恢复跟距关节面，特别是后关节面平整，从而有效避免距下关节炎、距下关节僵硬；另一方面需要将跟骨的长、宽、高、Bhler 角、Gissane 角都恢复到正常水平，防范腓骨肌腱炎、平足畸形等造成的足内收、外展畸形情况。传统面对这样的患者，很多医师都会首选外侧 L 形切口入路进行手术治疗，但也有部分缺点，如：创口尺寸大、感染率高、皮缘坏死等，并发症发生率较高2-6。在微创技术日益发展中，对于 Sanders 型跟骨骨折患者而
16、言，微创的跗骨窦切口便可完成复位操作7-9，对切口皮肤及血供影响较小10-11。围手术期中医药的干预，最终也能够实现良好的成效，从根本上避免了传统术式的固有缺陷。1资料与方法1.1一般资料回顾性分析 2017 年 12 月至 2019 年 12 月于聊城市中医医院（我院）骨伤科行切开复位内固定治疗的 Sanders 型跟骨骨折患者 84 例，男、女比例为 48 36；年龄 22 65 岁，平均（40.6010.81）岁；患侧：左、右分别为 41、43 例；受伤原因：高处坠落47例，车祸外伤26例，挤压伤11例；Sanders 44 例，Sanders 40 例。根据治疗方式不同分为跗骨窦入路组和外侧 L 形入路组，经跗骨窦入路组 40 例，经外侧 L 形入路组 44 例。两组患者一般资料比较，差异无统计学意义（P 0.05），具有可比性，见表 1。本研究经医院医学伦理委员会批准。表1 两组患者一般资料比较组别n性别（男/女）年龄（岁，x s）分型（Sanders/）跗骨窦入路组4021/1942.0110.4519/21外侧 L 形入路组 4427/1739.7911.2925/192
