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Chapter 1. The LITERATURE REVIEW

Treatment of patients with calcaneus fractures represents till now appreciable difficulties and quite often comes to an end with loss trudoyosposobnosti. Thus 70,3-90 % of the given category of patients are males of the most able-bodied age - from 20 till 50 years, that uvelichivayoet the social importance of the given problem [77, 85, 113, 123, 129, 147].

Questions of clinic, diagnostics and treatment of fractures of a calcaneus otyorazheny in numerous works of domestic and foreign authors [6, 53, 66, 72, 78, 82,91, 131].

The calcaneus is largest of all bones of foot, participates in formation of three joints (podtarannogo, taranno-CALCANEONAVICULAR and pjayotochno-cuboidal), plays the important role in maintenance elastic basic, balancing and tolchkovoj foot functions. In position standing and at walking the calcaneus maintains a load of mass of a body and is the basic back leg of foot. Thus the basic gravitational load is necessary on podyotarannyj a joint that causes high frequency of passage through it of fracture lines - to 75-80 % [4, 8, 44, 89, 109].

Calcaneus fractures concern one of most frequent vstreyochajushchihsja kinds of damages of foot and make 0,7-4,0 % among all pereloyomov bones of a skeleton and from 12 to 60 % of fractures of bones of foot. Thus 15-20,7 % among all fractures of a calcaneus are necessary on bilaterial povrezhdeyonija ^, 13,89, 109, 115, 116].

Quite often fractures of a calcaneus meet in a combination with pereloyomami malleoluses, tarannoj, cuboidal and other bones of foot, and also soputyostvujut to fractures of femurs, a basin, compression to fractures of bodies of vertebra [4, 24,45, 62, 89, 124].

Distinctive feature is the variety of types of fractures of a calcaneus that does impossible use any one of set of the methods of treatment offered for this purpose [107, 116, 130, 141].

Calcaneus fractures get into 75-80 % of cases in podtarannyj a joint and are accompanied by shift of fragments, thus from 34,6 to 92,8 % poyovrezhdeny it is necessary on intraarticulate compression fractures back susyotavnoj facings. From here disharmony and disturbance kongruentnosti articulate surfaces, early degenerate changes, late painful attacks and in - valndizatsija. Destruction of articulate cartilages and subchondral plates sushcheyostvenno burdens a disease current, worsens the forecast of treatment and aftertreatment of such patients [109, 116, 125, 127, 146, 150].

The mechanism of fractures of a calcaneus is studied full enough. In podavyoljajushchem the majority of cases calcaneus fractures occur - in rezultayote a direct trauma when the basic influencing moment is the immediate trauma of a plantar surface of a calcaneus. Fracture can be also result of a prelum of a calcaneus. Immediate causes of fracture of a calcaneus are falling from the big height on feet more often; falling from height on turned up foot; transport kayotastrofy; a foot prelum between two subjects; blow by a serious subject on a heel [8, 39, 109, 128].

At falling from height the body gravity is transferred on an axis through bolyoshebertsovuju and tarannuju to a bone. Thus tarannaja the bone puts in pjatochyonuju, splitting and squeezing it, sometimes crushing articulate surfaces. Character of fracture of a calcaneus depends not only on the mechanism povrezhdeyonija, but also from arhitektoniki the bone which at the heart of the has spoigi - oznoe a structure [8, 109, 132, 133,145].

There are numerous various classifications of fractures pjayotochnoj bones [8, 42, 47, 57, 109, 114].

The majority of them very difficult, taking into account many nuances of the mechanism of damage, unduly detailed and not always are applicable for practical purposes. At the present stage the international recognition has received klassifikayotsija the joint-stock company, developed Regatstsonn [4]:

And - peripheric fractures:

А1 - Peripheric vnssustavnoj;

А2 - An abruption sustentaculum;

AZ intraarticulate procesus anterior.

In - fractures of a taranno-calcaneal joint:

В1 ~ simple fracture of a back side;

In 2 - multisplintered fracture of a back side;

VZ - sinus tarsi both (or) average and (or) a forward side.

With - fractures of taranno-calcaneal and calcaneocuboid joints:

Cl - simple fractures of both joints;

С2 - Fracture of one joint splintered or sinus tarsi;

SZ - multiple fractures of both joints.

Working classification pereloyomov a calcaneus of the Research centre of Tatarstan «VosstanoYOvitelnaja traumatology and orthopedy» (FACE DOWNWARDS G "WTO") [74, 107] is convenient for practical use:

1. On character of damage of tissues:

1.1. The closed fractures;

1.2. Open fractures.

2. On gravity of damage:

2.1. Fractures without shift of fragments and without a lesion of joints;

2.2. Fractures with insignificant shift of fragments, without damage or with damage of articulate surfaces;

2.3. Fractures with appreciable shift of fragments, depression of size of a taranno-calcaneal angle and with a lesion of articulate surfaces.

3. Types of fractures of a calcaneus:

3.1. Extraarticular regional fractures of a calcaneus:

3.1.1. Fractures bufa a calcaneus;

3.1.2. Regional fractures on type of "a duck bill»;

3.2. Extraarticular fractures of a body of a calcaneus.

3.3. Intraarticulate fractures of a body of a calcaneus:

3.3.1. The intraarticulate fractures getting in taranno-calcaneal susyotav;

3.3.2. The intraarticulate fractures getting into a calcaneocuboid joint;

3.3.3. Splintered fractures;

3.3.4. The multisplintered and shattered fractures;

3.3.5. Compression and imprssionno-kompressionnye fractures.

Treatment of fractures of a calcaneus represents one of difficult problems of modern traumatology. The majority of authors is considered, that for primary orientation in a treatment planning by enough two x-ray films in lateral axial the projections, allowing to define accurately expressed signs of fracture, namely expansion and pathological position of a back part stoyopy and shift of a back part of a joint. As parametre of definition of severity level of fracture the angle on Beleru and an axial angle serves bugorkovo-articulate. Angle Belera is defined on the foot roentgenogram in a lateral projection and ocherchivayoetsja by two conditional lines. One line is spent from the top point of a hillock of a calcaneus to the uppermost point of a calcaneus to areas taranno - pjatochnoju a joint. The second line bridges two most acting points of a calcaneus in area podtarannogo a joint. One of criteria of successfully spent reposition and recover is restoration of this angle [8, 39, 47, 89, 148, 159].

All numerous ways of treatment of fractures of a calcaneus existing now (it is known over 70 various ways) it is possible razyodelit on two categories - conservative and operative. Supporters konseryovativnogo treatments limit indications to an operative measure from - for dangers of development of an infection and failures of an open reposition at some types of damages [56, 59, 109, 143, 154, 156 |.

Conservative methods of treatment can be parted on following groups: 1. The closed manual reposition, a plaster immobilisation.

2. The closed reposition with the help repoiirujushchih devices, a plaster bandage.

3. A reposition a skeletal extension method, a plaster immobilisation.

The closed reposition with the subsequent applying of a circular plaster bandage to level of a knee joint with I bury otmodelirovannym a crest stoyopy is now one of the basic methods of treatment at pereyolomah a calcaneus without shift or with insignificant shift of fragments. For the purpose of maintenance of an early load of an extremity recommend vgipsovyvat in a plantar part of a bandage a metal arch support. Term of bracing by a plaster bandage makes 4-6-8-недель [39, 58, 68, 122, 157J.

At the same time, many authors specify in insufficient efficiency of a manual reposition at many fractures of a calcaneus and formation vtoyorichnyh shifts of fragments in the absence of a full reposition of fragments. ForYOmirovanie secondary shifts of fragments in a plaster bandage after the closed reposition, as a rule, it is observed at extraarticular and intraarticulate peyorelomah calcaneus bodies, and also at splintered fractures. There is it at the expense of draught of the muscles having points of an attachment on bones of an anticnemion [59, 109, 112].

Historical interest is represented by methods of a single-step skeletal extension on Beleru by means of screw apparatus Felks-Knohta and two meyotallicheskih the hinges entered into a hillock of a calcaneus and distal meta - fiz to a tibial bone; a reposition on Wcsthaus by means of nail SHtejnmana entered into a hillock of a calcaneus and its updating on Burkle de la Camp, having rather limited application and realizable only in the presence of large fragments of a calcaneus. Multisplintered, impressioino - compression fractures are contraindication to its application [8, 45,48, 107, 109].

The reposition a constant skeletal extension, by carrying out of spoke Kirshnera through a calcaneus hillock is a sparing method of treatment, poyozvoljajushchim, in some cases to achieve favorable outcomes. Extension is carried out within 3-5 weeks, then imposed circular gipsoyo
vaja a bandage with a stirrup for 10-12 weeks with load possibility konechnoyosti. A number of authors recommend application of a double skeletal extension at the serious displaced fractures of a calcaneus. Now the method skeyoletnogo extension has lost the value and has no such wide primeyonenija. It is bound this as to necessity of long stay of the patient on a hospital bed, and with restriction of indications to its use. The skeletal extension often appears noneffective at serious vnutriyosustavnyh, splintered, imprsssionno-kompressionnyh body fractures pjayotochnoj bones, at the displaced fractures of a hillock, and also regional fractures of a calcaneus with appreciable shift of fragments [32, 45, 47, 107, 1091.

As a whole, despite the big number of supporters conservative metoyoda treatments of fractures of a calcaneus, the indication to it should be strictly limited. The majority of modern writers consider possible it isyopolzovanie only at treatment vnssustavnyh fractures of a calcaneus without shift or with insignificant shift, and a specific gravity such pereyolomov does not exceed 15-20 % [50, 54, 74, 97, 109, 112].

Unsatisfactory outcomes of application of a conservative method, dosyotigajushchie at treatment of various types of fractures of a calcaneus of 25-80,5 %, development of a posttraumatic platypodia, deformation of a body of a calcaneus, the serious arthroses breaking function of the bottom extremity and leading to an invalidism, put before surgeons and traumatologists-orthopedists a problem of search of more rational and effective methods of treatment [16, 25, 76, 153].

Operative treatment, according to the authors offering it primeneyonie, has advantage before a conservative method as allows to reach the best reposition and to warn secondary shift of fragments [46, 55,93, 106, 126, 151].

At scheduling of operative treatment by the basic diagnosticheyoskim a method is the computer tomography, allowing to receive full representation about a calcaneus condition, and also to define poloyozhenie driven and I will develop tyh fragments [13, 22, 134, 135].

For specification of character of damage of articulate surfaces otdelyonye authors recommend artroskopnju podtarainogo a joint [160].

Now all kinds of operative treatment of fractures of a calcaneus can be parted on following basic groups:

1. The closed reposition, an osteosynthesis spokes.

2. An open reposition, an osteosynthesis pogruzhnymi fixatives.

3. An open reposition, osteal plasty.

4. An artificial ankylosis of a taranno-calcaneal joint.

5. CHreskostnyj an osteosynthesis apparatus of external bracing.

The closed reposition and bracing by spokes at calcaneus fractures has rather limited application. As the relative indication to perkuyotannomu fractures of a calcaneus without shift under condition of the dynamic radiological and clinical control koyonechnosti [93, 108, 117, 138] can serve an osteosynthesis.

The open reposition with application pogruzhnyh metallokonstruktsy is now the basic method of treatment of fractures calcaneal kosyoti among foreign traumatologists-orthopedists [140, 144, 149].

As fixatives plates, osteal kompresyosirujushchie screws, screws, spokes, elastic pegs are widely applied. Their basic role is reduced to stable deduction of fragments in correct position to srayoshchenija fracture. It is considered, that calcaneal plates of joint-stock company [3,21, 80, 137, 139, 152] most meet these demands.

However the open reposition of fractures of a calcaneus and the subsequent pogruzhnoj metalloosteosintez at all advantages of the given method of treatment has a number of essential disadvantages. The main thing among them is itself vmeyoshatelstvo which can lead to additional disturbance krovoobyorashchenija in the damaged tissues and to cause their ischemia. It is especially actual at the multisplintered and shattered fractures of a body of a calcaneus. The open reposition always carries danger of development of an inflammation of a wound,

That demands excision of a fixative and a choice of other method of treatment [33, 37, 58, 104, 158, 163].

Recommended by a number of authors the open reposition of fracture of a calcaneus with the subsequent osteal plasty korgikalnym or spongiform autoyotransplantatom does not find now wide application because of rasyoshirenija volume and rising travmatichnosti an operative measure, that adversely affects process of consolidation of fracture. At the same time, use of various variants kostyonoj plastics is represented rational at replacement posttravmatichesknh defects of a calcaneus [34, 52, 83,84,96, 162].

Separate authors recommend now a primary artificial ankylosis podtarannogo a joint, thus they limit indications to operation tjazheyolymi to the shattered intraarticulate fractures with massive razrusheyoniem articulate surfaces [15, 25, 79, 112, 155]. The overwhelming majority of authors consider undesirable operation of a primary artificial ankylosis taranno - a calcaneal joint. Last can be observed in late terms, at stroyogih the limited indications and at development the serious statiko-dynamic disturbances limiting function of an extremity [41,59, 86, 100, 110, 161].

The method chreskostnogo an osteosynthesis apparatus Ilizarova has found wide application at treatment of patients with calcaneus fractures. Various variants of configurations of apparatus Ilizarova, and also original spitsevye and a spoke-rod apparatus of external bracing [2, 5, 9, 65, 88, 118] are developed.

The method chreskostnogo an osteosynthesis allows to reach repositions of fracture of a calcaneus with restoration kongruentnosti articulate surfaces and anatomy of a calcaneus and to provide stable bracing for the period srayostanija osteal and soft tissues. [20, 38, 51, 73, 87, 103]. This method has allowed to improve essentially results of the treatment, however known ways of treatment with its help of various types of fractures of a calcaneus not always to the full consider biomechanical features of damages [26,40, 84, 112].

During the long period of time in modern travmatoyologii the attention has been accented on working out of new methods operativnoyogo treatments of various damages and perfection of the existing. However without high-grade postoperative aftertreatment any most difficult and "clever" operation the in itself nanosecond provides restoration of function of the injured extremity in full.

Among orthopedists-traumatologists till now is not present uniform mneyonija concerning the concrete maintenance проіраммьі complex posleopeyoratsionnoj aftertreatment of patients with fractures of bones of extremities. Including are absent concrete.metodicheskie references on aftertreatment of patients with calcaneus fractures, is not present accurately sformulirovannoju algorityoma rehabilitational actions. Data on ways and agents reabiliyotatsii are isolated and are not systematised, quite often contradict each other.

The concept of medical aftertreatment treats the majority of authors as a complex of active medical actions, the purpose kotoroju is polyonoe restoration broken owing to disease or a trauma of functions, or if it is impossible - optimum realisation physical, psihicheyoskogo and social potential of the invalid, its most adequate integration into a society [31,61, 63, 81, 102].

In connection with the various purposes of medical actions allocate two peyorioda postoperative aftertreatment: immobilizatsionnyj and postimmobi - lizatsionnyj. Immobilizatsionnyj the period proceeds from the moment of the termination of operation before the termination of plaster or other immobilisation. The basic zadayochej this period is creation of favorable conditions for reparativnoj neogeneses of the damaged structures of an ankle joint, improvement reyogionarnogo circulations and microcirculation, prevention of an oligotrophy of muscles and reduction of postoperative pains. In postimmobilizatsionnom the period the primary goal is restoration of volume of movements in sustayovah and strengthening of muscles, cupping of a painful syndrome, residual local

Vascular disturbances and restoration oporosposobnosti extremities [47,61, 63,81, 102].

To the basic rehabilitational agents carry medicamental leyochenie, a kinesitherapy, massage, manipulation, physiotherapeutic procedures, reflexotherapy, psychotherapy, an occupational therapy with vocational guidance elements [47, 63, 81, 102, 105].

The kinesitherapy, or to treatment by movement, posesses the leading part in aftertreatment of patients with impellent disturbances. A kinesitherapy role zayokljuchaetsja both in correction of private disturbances of a motility, and in reduction of adverse consequences of a hypodynamia as a whole. The basic forms kiyonezoterapii are medical gymnastics (LFK) and the exercises which are carried out with use of various shells and training apparatus. On a Mercedes of restoration of volume of movements in the amazed joint gymnastic exercises dopolnjayojutsja exercises with burdening, with use elastic soprotivyolenija. Isometric, isotonic and isokinetic exercises on the closed cycle on special training apparatus, in some cases with a computer ergometry [47, 63, 81, 102] are used also.

Massage improves krovo - and limifoobrashchenie, promotes activization of oxidation-reduction processes in extremity muscles, joints and para-articular tissues, to rising of excitability, contractility and elastichyonosti the nervously-muscular apparatus [7, 63, 81, 102].

Manipulation apply in postimmobilizatsionnom the period. In the course of manipulation it is necessary to avoid a rasping manual redressment of contractures in view of danger okolosustavnyh fractures [28,48, 63, 81].

For mehanoterapii various designs of pendular and block apparatus are developed. Pendular apparatus are intended for vosstanovleyonija mobility and augmentations of volume of movements in a joint, block apparatus - for the dosed out strengthening of muscles of an extremity. Are offered also avtomayotizirovannye the devices equipped with the electric drive, allowing osushcheyostvljat continuous passive movements in susgave on the closed cycle [47,

61, 63, 81]. For the control over restoration of function of an extremity in process kinezomehanoterapii various ways and devices [10, 35, 36,90, 136] are offered.

Physiotherapeutic procedures stimulate ability of an organism to self-control and self-neogenesis. The intensive early postoperative physiotherapy allows to avoid an immovability, an amyotrophia, and the reflected sympathetic dystrophia. Authors give special value elsktromiostimu - ljatsii muscles of the injured extremity [1, 30, 43, 81, 102].

For the purpose of improvement reparativnyh reactions recommend giperbaricheyoskuju oxygenation [43, 70].

The reflexotherapy is successfully applied to cupping painful sinyodroma in the early postoperative period and at carrying out intensive kinezo - and mehanoterapii [17, 81, 94].

The psychotherapy as system of medical influence on mentality, and through it - on all organism of the patient takes the important place in aftertreatment of patients with fractures of bones of extremities. Necessity of an intervention of the psychotherapist is caused by appreciable number of psychological problems, emotional disorders and other psychopathologic disturbances arising at patsiyoentov in connection with locomotar disturbances because of sharp restriction aktivyonosti and freedoms of movement, pains, changes in family relations and professional work [1, 14, 61, 63, 81].

The occupational therapy with vocational guidance elements has the purpose vosstayonovlenie the broken function of an extremity, vitality rising payotsienta, its working capacity and physical endurance, preparation of the victim for professional work in the conditions close to proizyovodstvennym. Social adaptation provides training of patients prieyomam usings orthopedic adaptations (a cane, ortezami, etc.), to skills of household self-service in the changed conditions at nevozyomozhnosti full restoration of function of an extremity. The important role in this process is taken away to members of a family of the patient [81, 102].

Besides classical treatment of the maintenance rehabilitational meroyoprijaty the postoperative period in the scientific literature a number of new methods of regenerative treatment which we were at a loss klassifitsiroyovat under above surveyed headings is described.

There are reports on high efficiency of vibratory therapy for restoration of function of the injured joints of extremities for what stationary and portable devices are used. Influence napravyolennoj vibrations allows to strengthen krovenasosnuju function of muscles on 10 % and possesses analgezirujushchim action. Use of vibratory therapy in complex treatment of intraarticulate fractures reduces probability razviyotija posttraumatic arthroses in the remote period [23, 27, 29,49, 67, 120].

The method of treatment of traumas of extremities and their consequences ispolyozovaniem with great dispatch-wave therapy [12] is described.

The method of a biological feedback (IS barefooted) consists in transfer payotsientu by means of signals of an external feedback (light, sound, takyotilnoj) information on correctness of performance of exercise. The patient, receiving the information is barefooted about change of function of an extremity, is trained samoyostojatelno to supervise sokratitelnuju function of muscles of an extremity and to control to it. The medical effect is reached by regular training, blayogodarja functional reorganisation new nervous svjayozej and formation of the steady condition close to norm [121] occurs which.

At carrying out of scientific researches the great value has metodiyoka estimations of results of treatment of patients. For this purpose foreign avtorayomi the considerable quantity of various scales, tests and questionnaires is offered. Domestic authors prefer various poliparametrichsskim to techniques of a complex estimation, among them most full reflect a condition of the injured extremity a technique II. A.Ljuboshitsa — E. R.Mattisa and se moyodifikatsii [60, 95,99, 111, 115, 119].

Thus, on the basis of the analysis of the literature devoted probleyome of treatment of fractures of a calcaneus, it is possible to make the conclusion about otsutst -

vii now an optimum way of operative treatment and nedostayotochnoj efficiency of nowadays existing system postoperative reayobilitatsii patients with calcaneus fractures. Long terms of restoration of the working capacity, reaching 5-6 months testify to it, vyyosoky percent of unsatisfactory results (from 13,0 to 27,3 %) and an exit on physical inability of patients with such damages (from 23,5 to 25,0 %) [16, 18, 33, 71, 79, 113, 142, 162].

Thereupon we undertake attempt to improve results of treatment of patients with fractures of a calcaneus by the comparative analysis effekyotivnosti the most perspective ways of operative treatment (nakostnyj an osteosynthesis of joint-stock company and CHKOS apparatus Ilizarova), workings out new, biomehaniyocheski the proved configurations of apparatus Ilizarova and perfection of system of postoperative aftertreatment of patients with such damages.

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Scientific source Ivanov PETER VALENTINOVICH. OPTIMIZATION of TACTICS of SURGICAL TREATMENT And POSTOPERATIVE AFTERTREATMENT of PATIENTS With CALCANEUS FRACTURES. The dissertation on competition of a scientific degree of the candidate of medical sciences. Kazan -.

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