| Objective: 2011.7.1-2014.7.1 the 29 patients who need implementing the subtalar joint arthrodesis because of the traumatic subtalar joint arthritis.15 patients were divided into experimental group who got the surgery with homemade positioning trephine and the others were divided into control group who got the surgery with traditional incision,chisel the joint surface and take the iliac bone graft.The two groups of operation are completed by the same qualifications of physicians.Evaluate the clinical efficacy of two groups of patients by intraoperative blood loss,operation time and iliac bone graft rate, postoperative incision complication rate, osseous fusion rate and postoperative Maryland foot function grading system.Provide the reference to the clinical minimally invasive subtalar joint arthrodesis operation.Methods: This topic research objects are from the 29 patients who need implementing the subtalar joint arthrodesis because of the traumatic subtalar joint arthritis from 2011.7.1 to 2014.7.1.16 cases of them were men and 13 cases were women,age from 36-56,48.86 on average,all of them with clear history of intra-articular calcaneal fractures 12 to 39 months(25 cases get operation, the original incisions are clear and with scar tissue inordinately, poor elasticity of the skin, color dark skin, blood supply in poor conditions,4 cases get conservative treatment) and former medial and lateral ankle pain when walking and the X ray film prompted calcaneal irregularly, subtalar joint local density increased,calcaneal width(X ray film prompted the symptoms of traumatic subtalar joint arthritis,no obvious varus deformity,with or without lateral mound prominent,patients with preoperative local injection treatment effect is poor)Surgical method:①The experimental group:do longitudinal incision on the side of limb tendon lateral calcaneal tubercle above,about 2 cm long,separate the subcutaneous tissue in turn,pull subcutaneous tissue to both sides,to avoid the injury of small saphenous vein and sural nerve tissue,determine the subtalar joint gap with a needle by the X ray,determine the needle is located in the central subtalar joints.Make the core along the needle into the subtalar joint,wedge into the joint gap under the X ray,insert the hollow trephine and twisted hollow trephine into the joint,under the C arm fluoroscopy control bit depth,get the drill cylinder scale,remove the trephine.Promote the core like pushing the syringe,then get bone columnar and check it,we can see the cartilage bone and the hardened or normal bone,evaluate the fusion area of subtalar joint,remove the soft tissue of the bones column,the remaining bone for bone graft.If the depth can not satisfied along the existing tunnel inserted into the core to the deeper parts again,remove the anterolateral articular surface again as above.Adjust the angle after satisfaction(20-25°),until the subtalar joint surface to remove fully(If there is any lateral mound prominent patients,drill tunnel and hammer to make it collapse under the the lateral hill,restore calcaneal width.Take the bone for graft.).Make the bone graft sleeve insert joint gap along the drill,implant the bone into the drill tube,consolidate with bone graft sticks.Such as lack of bone,it requires iliac bone surgery or the allograft bone,make the subtalar joint in neutral position after consolidation.Screw in two needles from foot bottom to talus,measure the length,screw in 2 pieces of hollow screw along the guide pins to fix calcaneus and talus.Counting instrument dressings and closing a wound,record surgical blood loss and related data.②The control group:When the patient get anesthesia satisfaction,keep prone position,make the traditional "L" shape incision,cut full-thickness skin and subcutaneous tissue,screw needles to keep the full thickness skin flap away,revealed the heel bone wall and subtalar joints(some patients with lateral mound prominent,recovery calcaneal width with osteotome chisel),curet shaver subtalar joint cartilage surface to the subchondral bone,to drill grinding joint clearance,forming the bone graft slot with flat inner surface.Take the graft surgery,implant the bone which have been clipped into joint gap,make the subtalar joint in neutral position after consolidation.Screw in two needles from foot bottom to talus,measure the length,screw in 2 pieces of hollow screw along the guide pins to fix calcaneus and talus under X-ray.Counting instrument dressings and closing the wound,record operation time,surgical blood loss and related data.Analysis the two groups of patients with intraoperative blood loss,operation time and the rate of bone graft surgery,follow-up all patients,record the postoperative incision complications rate, osseous fusion rate,use maryland foot function score system to evaluate long-term foot function.Measurement data using mean ±standard deviation( x ±s),comparison between groups using independent sample t test,Count data by x2 test,meaning statistical significance difference(P<0.05),compare the advantages and disadvantages of two kinds of operation method.Results: Intraoperative bleeding,operation time and iliac bone graft condition:experimental group is 41.33±19.50 ml,53±11.30 min,1 cases got iliac bone graft surgery;The control group average blood los is 72.14±22.08 ml,operation time is 77.5±15.90 min,11 cases take the bone graft surgery.The experimental group haemorrhage amount and operation time is less than the control group,the graft rate less than the control group,all have statistical significance(P<0.05).Of all patients were followed up 6 ~ 18 months, an average of 12 months.Postoperative wound complications rate, osseous fusion rate and functional score:The experimental group has 1 cases complication with iliac wound fat liquefaction,15 cases of patients with postoperative osseous healing,functional score 8 people excellent and 7 people are good;Control group 3 postoperative wound complications,2 cases with skin necrosis and 1case with congestion delay healing of the wound,all the 14 cases get osseous healing,functional score 7 people excellent,6 people are good and 1 people get better.The experimental group wound complications rate is lower than the control group,statistically significant(P < 0.05).The osseous fusion rate and postoperative functional score comparison difference of the two groups has no statistical significance(P>0.05).Conclusion:Doing the subtalar joint arthrodesis with the positioning trephine,can reconstruct the subtalar joint stability and keep the advantages that ①minimally invasive,less damage to the soft tissue,less bleeding and operation time,satisfy someone’s operation requirements whose skin condition is poor.②bone utilized fully, reduce iliac bone graft rate and the risk.③evaluate fusion area under look,avoid the demand of arthroscopy,reduce the cost of operation.Get the same effect to the cut graft fusion and check the bone and joint surface,take the pathologic examination when necessary.④positioning effective bone graft.It’s a low damage and low cost, high efficiency method.For the patients need a single joint fusion without inside and outside serious deformity,minimally invasive trepanation positioning subtalar joint arthrodesis is a better way. |
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