经转子入路大转子截骨治疗Ⅳ型Pipkin骨折

TREATMENT OF TYPE IV PIPKIN FRACTURE THROUGH TRANSTROCHANTERIC APPROACH WITH TROCHANTERIC OSTEOTOMY

目的探讨经转子入路大转子截骨治疗Ⅳ型Pipkin骨折的临床疗效。方法 2007年1月-2010年1月,采用经转子入路大转子截骨治疗Ⅳ型Pipkin骨折15例。男9例,女6例;年龄27～55岁,平均42.5岁。致伤原因:交通事故伤12例,高处坠落伤2例,重物压伤1例。伤后至入院时间为4 h～7 d,平均2.3 d。患侧髋关节活动障碍。X线片及CT三维重建检查显示髋关节后脱位,合并髋臼及股骨头骨折,均无股骨颈骨折。股骨头骨折位于圆韧带以下9例,圆韧带以上6例。入院后积极处理合并症,入院至手术时间为2～10 d,平均4.5 d。结果患者术后切口均Ⅰ期愈合,无早期并发症发生。15例均获随访,随访时间12～48个月,平均26个月。X线片检查示,大转子截骨及髋臼骨折均于术后6～8周达骨性愈合,股骨头骨折愈合时间为6～10个月。术后3个月出现异位骨化2例,未给予特殊处理;8个月时出现股骨头缺血性坏死1例,行人工全髋关节置换术。末次随访时髋关节屈曲60～120°,平均92.5°。按Thompson等的临床和影像学评定标准,获优5例,良7例,中2例,差1例,优良率80%。结论采用经转子入路大转子截骨治疗Ⅳ型Pipkin骨折可以获得良好的手术视野,同时保护股骨头残存血运。

Objective To summarize the short-term effectivness of type IV Pipkin fracture through transtrochanteric approach with trochanteric osteotomy.Methods Between January 2007 and January 2010,15 cases of type IV Pipkin fracture were treated through transtrochanteric approach with trochanteric osteotomy.There were 9 males and 6 females with an average age of 42.5 years（range,27-55 years）.The causes of fractures included traffic accident（12 cases）,falling from height（2 cases）,and heavy pound injury（1 case）.The time from injury to hospitalization was 4 hours to 7 days（mean,2.3 days）.All patients had limitation of activity in the injured hips.The X-ray films and CT three-dimensional reconstruction indicated posterior dislocation of the hip joints and fractures of the femoral head and acetabulum,with no fracture of femoral neck.The locations of the femoral head fractures were under the round ligament in 9 cases and above the round ligament in 6 cases.Complications were treated firstly in all patients.The time from hospitalization to operation ranged from 2 to 10 days（mean,4.5 days）.Results All patients got primary wound healing with no early complication.All the patients were followed up 12-48 months with an average of 26 months.All osteotomies and acetabular fractures healed within 6 to 8 weeks.All patients achieved healing of femoral head fracture after 6-10 months.Mild heterotopic ossification occurred in 2 cases at 3 months after operation which were left untreated;and necrosis of the femoral head occurred in 1 case at 8 months after operation,was treated by total hip arthroplasty.At last follow-up,the flexion of the injuried hips ranged from 60 to 120°（mean,92.5°）.Based on Thompson et al.scoring scales,the results were excellent in 5 cases,good in 7 cases,fair in 2 cases,and poor in 1 case;the excellent and good rate was 80%.Conclusion Treatment of type IV Pipkin fracture through transtrochanteric approach with trochanteric osteotomy can provide good visualization and protection of the blood supply of the femoral head.