Clinical efficacy of hyperbaric oxygen therapy combined with locking plate for intra-articular calcaneal fractures

doi:10.3969/j.issn.2095-4344.2014.48.019

Abstract

Abstract:

BACKGROUND: Wound infection, skin flap necrosis, local skin defects, and osteomyelitis are common complications following extensile lateral approach for calcaneal fracture, and these complications are very intractable. Hyperbaric oxygen therapy has been widely applied in treatment of severe crush injury, chronic osteomyelitis, chronic skin ulcers and defects, and other orthopedic diseases. Hyperbaric oxygen therapy may be a potential means to treat wound complications after calcaneal fracture fixation.
OBJECTIVE: To assess the effectiveness of hyperbaric oxygen therapy in displaced intra-articular fractures after open reduction and internal fixation through an extensile lateral approach.
METHODS: From January 2010 to September 2012, 80 patients with intra-articular calcaneal fractures after open reduction and internal fixation were randomized into two groups, receiving hyperbaric oxygen therapy (HBOT group) or hyperbaric air treatment (control group). Each group contained 40 patients.
RESULTS AND CONCLUSION: Three cases in HBOT group and four cases in control group were excluded due to intolerance to hyperbaric oxygen therapy, and the remaining 73 patients were followed and assessed for a minimum of two years of follow-up. The demographic data showed no significant difference between the two groups (P > 0.05). The rates of infection were 3% (one case) in HBOT group and 8% (three cases) in control group. The overall complication rates for HBOT group and control group were 11% (four cases) and 33% (12
cases), respectively (P = 0.020). At 6 months after hyperbaric oxygen therapy, American Orthopaedic Foot and Ankle Society score, SF-36 score, VAS score were significantly better outcomes for HBOT group as compared with control group (P < 0.05). However, these outcome measures did not differ significantly between the two groups after 2 years of follow-up (P > 0.05). Adjunctive hyperbaric oxygen therapy would prevent and reduce the overall complication rate after open reduction and internal fixation through an extensile lateral approach. Hyperbaric oxygen therapy obviously improve clinical efficacy after treatment, but has no difference after 2 years.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: calcaneus, hyperbaric oxygen, bone lamella, internal fixators

CLC Number:

R318

Xu Yun1, Shi Yong, Ouyang Lin-zhi, Tao Wei-jian, Jian Zheng-guang, Sun Xue-feng, Ma Chun-yan, Tang Tian-si. Clinical efficacy of hyperbaric oxygen therapy combined with locking plate for intra-articular calcaneal fractures[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(48): 7816-7821.

Figures/Tables 4

2.1 扩大外侧入路切开复位内固定的跟骨关节内骨折患者数量分析及一般资料共入选80例患者，其中7例患者在研究过程中不能耐受高压氧治疗而退出(高压氧治疗组3例，对照组4例)。73例患者进入最终结果分析。其中高压氧治疗组37例，男26例，女11例；年龄(45.19±10.02)岁；Sanders CT分型，Ⅱ型19例，Ⅲ型15例，Ⅳ3例。对照组36例，男27例，女9例；年龄(42.46±11.22)岁；Sanders CT分型，Ⅱ型18例，Ⅲ型16例，Ⅳ2例。两组患者人口学统计学情况差异均无显著性意义(P > 0.05，表1)。 2.2 扩大外侧入路切开复位内固定的跟骨关节内骨折患者围手术期情况两组患者固定前吸烟史、并发糖尿病、下肢周围血管病变情况组间差异无显著性意义(P > 0.05；表1)。 2.3 高压氧治疗扩大外侧入路切开复位内固定的跟骨关节内骨折患者的短期疗效经高压氧治疗10 d，接受高压氧治疗的患足肿胀、疼痛明显减轻，切口无水疱形成，皮肤色泽红，开始出现皱缩，未发生切口皮缘发黑坏死病例。对照组患者足部软组织红肿、颜色发暗，肿胀时间较长，难以消退，部分患者跟骨外侧切口边缘皮肤发黑坏死裂开(图3)。 2.4 高压氧治疗扩大外侧入路切开复位内固定的跟骨关节内骨折患者的影像学结果固定后随访2年时，两组患者Bohler角和Gissane角与固定前比较均有明显恢复，跟骨高度宽度纠正，关节面恢复解剖位置(图4)。2组患者Bohler角和Gissane角差异无显著性意义(P > 0.05；数据未显示)。 2组患者固定后发展为距下、跟骰、胫距关节炎情况差异无显著性意义(Z=-0.228，P=0.819；表2)。 2.5 高压氧治疗扩大外侧入路切开复位内固定的跟骨关节内骨折患者的固定后并发症情况高压氧治疗组有1例"

(3%)浅表感染，经口服抗生素，切口换药治愈，未发生深部感染病例，对照组固定后切口感染3例(8%)，深部感染1例，细菌培养证实为耐药金黄色葡萄菌感染，经抗感染、反复清创换药等处理，伤口愈合。2组患者固定后切口感染率差异无显著性意义(χ2=1.17，P=0.291)。高压氧治疗组所有患者均未发生切口皮缘坏死，对照组切口边缘坏死4例，3例坏死面积小，经换反复换药处理后切口愈合，1例患者皮瓣坏死面积较大，钢板外露，后行钢板取出，游离植皮覆盖创面。2组切口边缘坏死率差异有显著性意义(χ2=4.349，P=0.037)。高压氧组与对照组各有1例浅表切口裂开。两组患者随访两年骨折均获骨性愈合。对照组有1例患者(SandersⅣ型)。固定后2年随访时感足踝部疼痛明显，行走时疼痛加剧，影像学检查示距下关节密度增高，关节间隙狭窄，诊断距下关节创伤性关节炎，而行距下关节融合。2组患者均未发生急慢性骨髓炎、肺栓塞或下肢深静脉血栓形成、下肢骨筋膜室综合征等并发症(表3)。2.6 高压氧治疗扩大外侧入路切开复位内固定的跟骨关节内骨折患者的临床疗效固定后随访6个月，行高压氧治疗患者均获得较为满意的临床效果，患足外观恢复满意，患者主观感觉患肢无明显疼痛，患足无肿胀，患足活动范围明显恢复，无内外翻活动受限(图5)。而对照组患者则存在不同程度的患足肿胀，患者自觉患足酸痛不适，行走疼痛。2组患者美国足踝外科协会评分、SF-36评分、目测类比评分差异均有显著性意义(P < 0.05)。固定后随访2年， 2组患者患足肿胀、疼痛等症状均有明显改善，2组患者美国足踝外科协会评分、SF-36评分、目测类比评分差异无显著性意义(P > 0.05；表4)。"

References

[1] Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82(2):225-250.
[2] Gupta A, Ghalambor N, Nihal A, et al. The modified Palmer lateral approach for calcaneal fractures: wound healing and postoperative computed tomographic evaluation of fracture reduction. Foot Ankle Int. 2003;24(10):744-753.
[3] Gordillo GM, Sen CK. Revisiting the essential role of oxygen in wound healing. Am J Surg. 2003;186(3):259-263.
[4] 李彬彬,李厚成,陈文,等.高压氧综合治疗跟骨骨折术后切口皮瓣愈合的临床疗效观察[J].中华航海医学与高气压医学杂志,2013, 20(6):410-411.
[5] 和艳红,李志强,栗申,等.高压氧治疗跟骨骨折局部软组织损伤的临床观察[J].中华航海医学与高气压医学杂志,2013,20(2): 101-103.
[6] Bhattacharya R, Vassan UT, Finn P, et al. Sanders classification of fractures of the os calcis. An analysis of inter- and intra-observer variability. J Bone Joint Surg Br. 2005; 87(2):205-208.
[7] Baumhauer JF, Nawoczenski DA, DiGiovanni BF, et al. Reliability and validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: a pilot study for the hallux and lesser toes. Foot Ankle Int. 2006;27(12):1014-1019.
[8] Hildebrand KA, Buckley RE, Mohtadi NG, et al. Functional outcome measures after displaced intra-articular calcaneal fractures. J Bone Joint Surg Br. 1996;78(1):119-123.
[9] Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473-483.
[10] Lim EV, Leung JP. Complications of intraarticular calcaneal fractures. Clin Orthop Relat Res. 2001;(391):7-16.
[11] Broussard CL. Hyperbaric oxygenation and wound healing. J Vasc Nurs. 2004;22(2):42-48.
[12] Koomanachai P, Keel RA, Johnson-Arbor KK, et al. Linezolid penetration into wound tissue of two diabetic patients before and after hyperbaric oxygen therapy. Undersea Hyperb Med. 2011;38(1):11-16.
[13] Thom SR, Milovanova TN, Yang M, et al. Vasculogenic stem cell mobilization and wound recruitment in diabetic patients: increased cell number and intracellular regulatory protein content associated with hyperbaric oxygen therapy. Wound Repair Regen. 2011;19(2):149-161.
[14] Stoekenbroek RM, Santema TB, Legemate DA, et al. Hyperbaric oxygen for the treatment of diabetic foot ulcers: a systematic review. Eur J Vasc Endovasc Surg. 2014;47(6): 647-655.
[15] Dauwe PB, Pulikkottil BJ, Lavery L, et al. Does hyperbaric oxygen therapy work in facilitating acute wound healing: a systematic review. Plast Reconstr Surg. 2014;133(2): 208e-215e.
[16] Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18(1):1-6.
[17] Court-Brown CM, Schmied M, Schutte BG. Factors affecting infection after calcaneal fracture fixation. Injury. 2009;40(12): 1313-1315.
[18] Schepers T, Den Hartog D, Vogels LM, et al. Extended lateral approach for intra-articular calcaneal fractures: an inverse relationship between surgeon experience and wound complications. J Foot Ankle Surg. 2013;52(2):167-171.
[19] Huang KC, Tsai YH, Hsu RW. Hyperbaric oxygen therapy facilitates surgery on complex open elbow injuries: preliminary results. J Shoulder Elbow Surg. 2007;16(4): 454-460.
[20] Löndahl M, Landin-Olsson M, Katzman P. Hyperbaric oxygen therapy improves health-related quality of life in patients with diabetes and chronic foot ulcer. Diabet Med. 2011;28(2): 186-190.
[21] Rammelt S, Zwipp H, Schneiders W, et al. Severity of injury predicts subsequent function in surgically treated displaced intraarticular calcaneal fractures. Clin Orthop Relat Res. 2013; 471(9):2885-2898.