The incidence of calcaneal fractures accounts for 60% of the incidence of tarsal fractures, and 2% of systemic fractures. For displaced calcaneal fractures, surgical treatment is often used in clinical practice. The most common surgical approach is to expand the outside of the foot. Type incision approach for reduction and plate fixation. The surgical field of this operation is well exposed, but the probability of skin necrosis is high. It is reported that about 25% of patients with calcaneal fractures will have complications such as skin necrosis around the incision after surgery. If there is a large area of skin Necrosis, soft tissue defects, and exposed steel plates can cause catastrophic consequences. How can we reduce the probability of skin necrosis?
In order to reduce the probability of skin necrosis, the following points need to be paid attention to:
- Avoid high-risk factors; diabetes and smoking are high-risk factors that lead to postoperative skin necrosis. For smoking patients, they should be informed in detail of the possible adverse consequences before the operation, and they should be banned from smoking before the incision is healed. Diabetes patients should control their fasting blood sugar below 8.0mmol/L and postprandial blood sugar below 10.0mmol/L.
- Assessment of soft tissue conditions; for severe calcaneal fractures, the soft tissue damage is severe, and tension blisters will form on the skin surface. Do not puncture the blisters, because the blister will lose its barrier when the epidermis ruptures, and bacteria will easily cover the surface and increase infection Probability. In addition, the blisters should be avoided when designing the skin incision.
- Selection of the timing of surgery; the timing of surgery can be selected within 12-24 hours after injury, because soft tissue edema is still relatively mild at this time, if emergency surgery cannot be performed, the surgery time should be postponed to 7-14 days later, until the swelling subsides , Surgery is performed when the skin appears wrinkled. For severe soft tissue damage, the time can be extended appropriately, and surgery must not be performed before the swelling has subsided.
- Preoperative treatment of the affected area; patients with calcaneal fractures should be given a plaster cast or brace for fixation before the operation to prevent the fracture from stimulating the soft tissue and aggravate the damage. At the same time, encourage the patient to move the toe, which is beneficial to reduce swelling. Preoperative local cold compresses and intermittent compression pump treatment can promote the swelling to subside and shorten the waiting time for surgery.
- Surgical technique
(1) The design of the surgical incision The most commonly used clinically expanded L-shaped incision on the outside of the foot should be composed of two parts. The distal end starts from the base of the fifth metatarsal and runs horizontally along the border between the dorsum of the foot and the sole of the foot, starting from the longitudinal incision From 6-8 cm above the heel, the Achilles tendon and fibula extend to the distal midpoint. Because such an incision is located at the watershed of the two different blood supply distribution areas on the outside of the foot, it does little damage to the blood supply of the skin and can reduce the probability of skin necrosis. In addition, if technical conditions permit, try to choose minimally invasive surgery, such as sinus tarsi incision. road.
(2) The subperiosteal dissection incision should go straight to the cortex, and perform subperiosteal separation forward and upward to form a full-thickness flap, which must not be separated layer by layer.
(3) To control the operation time, you should master surgical reduction techniques, avoid unnecessary operations, and try to complete the operation within one expulsion band time, which can effectively reduce postoperative soft tissue swelling and reduce the probability of skin necrosis. (4) The suture technique recommends using the Allgower-Donati method to suture the incision. This suture method has little effect on the blood supply of the skin around the incision and helps reduce the probability of skin necrosis.
(5) Intraoperative negative pressure drainage should be placed after the operation is completed. After the operation, the accumulated blood should be fully drained to avoid the formation of subcutaneous hematoma and affect the healing of the incision.
(6) Dressing change and suture removal Periodically change the dressing, keep the skin around the incision dry, remove the sutures about 2-3 weeks after the operation, and ask the patient to avoid activities before removing the sutures to avoid excessive suture tension affecting the skin blood supply.