关键词：跟骨骨折；流行病学调查 / 方法/ 结果

    切口并发症是跟骨骨折切开复位内固定术后主要并发症。闭合性跟骨骨折术后并发严重感染的比例在0~20%之间，而在开放性跟骨骨折中，这一比例上升至19~31%。在手术治疗跟骨骨折时，常用的软组织牵开方法可分为动态牵开法和静态牵开法二种，静态软组织牵开法是指术时利用克氏针穿过距骨外侧壁来牵开软组织皮瓣的方法，动态的软组织牵开法是指在手术时借助助手 帮助牵开软组织来显露手术视野的方法。

    比较不同的软组织牵开法对跟骨骨折切开复位内固定术后伤口并发症发生率的影响。

    回顾性研究     

    一级创伤中心

    对自2002年~2007年间在本院就诊的360例跟骨骨折患者的病史进行回顾性分析，其中的177例接受了切开复位内固定手术，手术由在本创伤中心接受的创伤住院医师培养的医生进行。术时采用二种软组织牵开方法，以显露骨折端。所有接受手术治疗的患者软组织完整性根据Gustilo分型，分为开放性和闭合性骨折；使用Tscherne分型方法对跟骨骨折分型。病人的一般情况如是否有糖尿病，吸烟史，糖皮质激素使用史，或周围血管疾病等也一并记录并予以分析；从受伤到接受手术的时间，术中止血带使用的时间也予以记录，所有的接受手术患者均接受围手术期抗生素治疗，开放性跟骨骨折患者在急诊时已接受了初步的清创、引流手术并在手术后予以静脉抗生素治疗。伤口并发症根据处理方法不同分成以下两类:(1)局部伤口护理和口服抗生素治疗，（2）手术清创引流和静脉抗生素治疗。另外，伤口并发症发生率也根据术中软组织牵引法进行分别统计

    在177例接受手术治疗的跟骨骨折患者有30例发生了术后伤口并发症，并发症发生率17%。在68例术中使用动态软组织牵引技术的患者，有6例（8.8%）出现术后伤口并发症；而在109例术中使用静态软组织牵引技术的患者，有24例（22%）出现了术后伤口并发症，选用不同的软组织牵开技术对术后伤口并发症发生率的影响存在统计学差异（P<0.028）。术中采取静态软组织牵开法的患者出现术后伤口并发症的比例是采取动态软组织牵开法的2．9倍，与术前患者是否存在并发术后伤口并发症的易感因素，如吸烟史、糖尿病等无关，伤口并发症的种类包括只需要局部伤口护理和口服抗生素治疗的皮肤坏死到需要清创引流和辅以抗生素长期应用的深部感染。

    在选择跟骨骨折治疗方法时，应把伤口并发症出现的可能性放在重要的地位。静态软组织牵开法更容易出现术后伤口并发症，其并发术后伤口并发症的比例是动态软组织牵开法的2.9倍，这一数值与术前患者是否存在伤口并发症的易感因素无关。

 

Wound complications can be a major problem following open reduction and internal fixation (OLIF) of calcaneal fractures. The rate of serious infections following surgical treatment of closed fractures ranges from 0-20%,^1,2 with an even higher incidence of 19-31% associated with open fractures^1,2,3,4. Traditionally, two types of retraction (static and dynamic) have been used for surgical exposure. Static retraction is performed by placing Kirschner wires into the lateral process of the talus to retract the soft tissue flap. Dynamic retraction is performed by an assistant retracting the soft tissue flap during surgery. The purpose of this study was to determine if a difference in wound complications exists based on the type of retraction, static or dynamic, used during surgical treatment. Design: Retrospective cohort. Setting: Level I Trauma Center.
METHODS

Aretrospective chart review was performed on 360 consecutive calcaneal fractures that were treated at a level one trauma center from 2002-2007. Of the 360 total fractures, 177 were treated with ORIF by fellowship-trained orthopaedic trauma surgeons. Some surgeons used static retraction of the soft tissue flap (i.e. K-wires in the lateral process of the talus), while others used dynamic retraction (i.e. skin retraction). Interventions: All fractures requiring surgical treatment were classified as closed or open (utilizing the Tscherne or Gustilo classification) and fracture type. Patient variables, including diabetes mellitus, tobacco use, history of corticosteroid use, or peripheral vascular disease were documented at the time of presentation. The time from injury to surgical intervention, as well as total tourniquet time was also documented. All patients received perioperative antibiotics and all open fractures were treated emergently with surgical irrigation and debridement, and intravenous antibiotics. Main Outcome Measurements: The incidence of wound complications following ORIF of calcaneal fractures was determined through a systematic, retrospective chart review. The wound complications were subdivided according to type of treatment required; oral antibiotics and local wound care only versus surgical irrigation and debridement with intravenous antibiotics. In addition, the incidence of wound complications based on retraction type was determined.
RESULTS

Wound complications developed in 30 (17%) of the 177 patients treated with open reduction and internal fixation. Of the 68 patients treated with dynamic retraction, six (8.8%) developed post-operative wound complications. Of the 109 patients treated with static retraction, 24 (22%) developed wound complications. The difference in wound complications after dynamic and static retraction was noted to be statistically significant, with p<0.028. Overall, patients treated with static retraction were 2.9 times more likely to develop wound complications. This was independent of patient risk factors, including smoking history or systemic disease. Wound complications ranged from wound necrosis requiring local wound care and oral antibiotics, to deep infection requiring surgical irrigation and debridement with prolonged intravenous antibiotics.
DISCUSSION AND CONCLUSION

Wound complications are a major factor in the decision to treat calcaneal fractures. Static retraction is associated with a significantly higher incidence of wound complications following open reduction and internal fixation of calcaneal fractures. Independent of pre-existing risk factors, patients treated with static retraction were 2.9 times more likely to develop post-operative wound complications.