老年跟骨骨折的手术治疗

perative treatment of displaced calcaneal fractures has become more accepted in the last ten to fifteen years as a result of improvements in preoperative evaluation, the use of intraoperative imaging to verify the quality of the reduction, and advancements in surgical techniques. Despite these favorable results, there are still certain contraindications, including neuropathies, insulin-dependent diabetes mellitus, peripheral vascular disease, venous stasis, lymphedema, immunocompromise, heavy smoking, or other disorders that may impede wound or bone-healing''\ An age of more than fifty years has also been described as a contraindication to surgery because of unfavorable outcomes in older patients'*. In addition, many elderly patients have low physical demands and may have osteopenia or osteoporosis, which can result in loosening of the implants and, ultimately, failure of the fixation^ Thus, elderly patients can have an unacceptable rate of complications, resulting in a difficult salvage. The purpose of this paper was to review the outcomes in elderly pa-
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COPYRIGHT © 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED
OPERATIVE TREATMENT OF CALCANEAL FRACTURES IN ELDERLY PATIENTS
BY DOLFI HERSCOVICI JR., DO, JAMES WIDMAIER, MD, JULIA M . SCADUTO, ARNP, ROY W. SANDERS, MD, AND ARTHUR WALLING, MD
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tients who were managed withernal fixation of a displaced fracture ofthe calcaneus.
iVIateriais and Methods
fter A boardobtaining approvalof from the institutional review ofthe University South Florida (Protocol Number 100590), we performed a retrospective review ofthe charts of all patients who had undergone open reduction and internal fixation of a displaced calcaneal fracture, between November 1987 and June 2000, at a level-one trauma center. During this time-period, 662 patients presented with a calcaneal fracture, and 583 underwent open reduction and internal fixation. Forty-seven ofthe 583 patients were the age of sixty-five years or older. Five patients had a nondisplaced fracture and were treated nonoperatively. The remaining forty-two patients, with a total of forty-four displaced fractures, formed the core study group. From the chart review, we identified the fracture pattern, any pre-existing medical comorbidities, the smoking
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T H E JOUKNAI, OF BONE & ) O I N T SURCI;RY • ims.ORC VOLUME 87-A • NUMBER 6 • JUNE 2005 OPERATIVE TREATMENT OP CALCANEAL FRACTURES IN ELDI;RLV PATIENTS
Investigation performed at Tampa Ceneral Hospital, Tampa, Florida
Background: Operative intervention is an accepted treatment for fractures ofthe calcaneus. However, the literature discourages surgery for these fractures in the elderly. The purpose of this paper was to review the outcomes of surgical treatment of displaced fractures ofthe calcaneus in elderly patients. Methods: Between November 1987 and June 2000, forty-two patients (forty-four fractures) who were sixty-five years of age or older underwent surgery for a calcaneal fracture. The mechanism of injury, fracture pattern, and medical comorbidities were recorded. Thirty-five patients with a total of thirty-seven fractures were available for follow-up, which was conducted with physical and radiographic examinations and outcomes assessment with the Short Form-36 (SF36), the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and the Short Musculoskeletal Function Assessment survey. Results: The minimum duration of follow-up was two years, and the average duration was forty-four months. All but one fracture (97% of the fractures) healed at an average of 110 days. The average active range of motion was 38° of plantar flexion, 10° of dorsiflexion, 16° of inversion, and 11° of eversion. The average American Orthopaedic Foot and Ankle Society score was 82.4 points, the average SF-36 score was 52.8 points, and the average Short Musculoskeletal Function Assessment score was 20.4 points. Posttraumatic subtalar arthritis developed in twelve patients. There were twelve minor complications and four major complications (three cases of osteomyelitis and one nonunion), all of which were treated successfully. Conclusions: Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients. Careful patient selection is necessary because individuals presenting with severe osteopenia, those who are unable to walk or are able to walk only about the house, and those with a medical condition that precludes surgery may be better candidates for nonoperative care. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.