踵骨骨折手術における2D vs 3D透視の術中効果

Intraoperative Effect of 2D vs 3D Fluoroscopy on Quality of Reduction and Patient-Related Outcome in Calcaneal Fracture Surgery.

• Jens A Halm
• M Suzan H Beerekamp
• Robert Jan de Muinck-Keijzer
• Ludo F M Beenen
• Mario Maas
• J Carel Goslings
• Tim Schepers

抄録

背景:

踵骨骨折の開腹縮小術および内固定術（ORIF）では，3 次元（3D）透視が有利であると考えられている．この多施設無作為化比較試験の目的は、従来の2次元（2D）透視検査と比較して、踵骨関節内骨折患者の術中3D透視検査を追加した場合の術後の質の低下と固定、および患者の報告された転帰に対する臨床効果を検討することであった。

BACKGROUND: Three-dimensional (3D) fluoroscopy is thought to be advantageous in the open reduction and internal fixation (ORIF) of calcaneal fractures. The goal of this multicenter randomized controlled trial was to investigate the clinical effect of additional intraoperative 3D fluoroscopy on postoperative quality of reduction and fixation and patient-reported outcome as compared to conventional 2-dimensional (2D) fluoroscopy in patients with intra-articular fractures of the calcaneus.

方法:

METHODS: Patients were randomized to 3D or conventional 2D fluoroscopy during operative treatment of calcaneal fractures. Primary outcome was the difference in quality of fracture reduction and implant position on postoperative computed tomography (CT). Secondary endpoints included intraoperative corrections (prior to wound closure), complications, and revision surgery (after wound closure). Function and patient-reported outcome were evaluated after surgery and included range of motion, Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short-Form 36 (SF-36) questionnaires, and Kellgren-Lawrence posttraumatic osteoarthritis classification. A total of 102 calcaneal fractures were included in the study in 100 patients. Fifty fractures were randomized to the 3D group and 52 to the 2D group.

結果:

手術時間には群間で統計学的に有意な差があった（2D 125分 vs 3D 147分；＜0.001）。3D透視検査後、28例（56％）で合計57回の術中修正が行われた。術後のCTスキャンでは、3D群の69％対2D透視群の60％で縮小またはインプラント位置の追加修正の適応が示された。2年後の時点では、再置換術の回数、合併症、FAOS、AFASスコア、SF-36スコア、外傷後変形性関節症に差はなかった。

RESULTS: There was a statistically significant difference in duration of surgery between the groups (2D 125 min vs 3D 147 min; < .001). After 3D fluoroscopy, a total of 57 intraoperative corrections were performed in 28 patients (56%). The postoperative CT scan revealed an indication for additional revision of reduction or implant position in 69% of the 3D group vs 60% in the 2D fluoroscopy group. At 2 years, there was no difference in number of revision surgery, complications, FAOS, AOFAS score, SF-36 score, or posttraumatic osteoarthritis.

結論:

関節内踵骨骨折の治療に術中3D透視検査を使用することは、縮小と固定の質を向上させることなく、術式を長期化させる。術後合併症、QOL、機能的転帰、外傷後の変形性関節症については、術中3D透視検査の有用性は認められなかった。 レベルI、前向き無作為化比較試験。

CONCLUSION: The use of intraoperative 3D fluoroscopy in the treatment of intra-articular calcaneal fractures prolongs the operative procedures without improving the quality of reduction and fixation. There was no benefit of intraoperative 3D fluoroscopy with regard to postoperative complications, quality of life, functional outcome, or posttraumatic osteoarthritis. Level I, prospective randomized controlled study.