改良髂腹股沟下入路治疗髋臼骨折的解剖研究和临床应用

AN ANATOMICAL STUDY AND CLINICAL EVALUATION OF MODIFIED SUBINGUINAL APPROACH FOR TREATMENT OF ACETABULAR FRACTURES

目的 探讨采用一种改良非髂骨截骨的经腹股沟下骨盆前方入路手术治疗累及前方和内侧壁或合并股骨头颈骨折的髋臼骨折的临床效果。 方法 通过对12具成人标本进行解剖学研究，将腹股沟下入路进一步改良并应用于临床。2010年5月－2012年3月对34例累及髋臼前方、内侧壁或合并髋关节前方损伤的髋臼骨折患者采用经改良髂腹股沟下入路（15例）或改良髂腹股沟下入路联合Kocher-Langenbeck入路（19例）行切开复位内固定治疗。其中男28例，女6例；年龄20～64岁，平均31.1岁。根据Letournel-Judet分类：前壁和/或前柱骨折15例，前壁或前柱骨折加后半横形骨折8例，双柱骨折7例，T形骨折4例。受伤至手术时间5～16 d，平均7.4 d。 结果 解剖结果：腹股沟韧带长度为（11.09 ± 0.24）cm，是腹外斜肌腱膜的反折和延续，与腹壁肌是完整的一体结构；腹股沟韧带与髂腰肌在髂前上棘上附着点直径为（0.69 ± 0.08）cm，大隐静脉距腹股沟韧带的垂直距离为（3.58 ± 0.49）cm。临床应用结果：34例均获随访，随访时间4～24个月，平均14.6个月。无切口感染，内固定物松动、断裂，医源性坐骨神经或股神经损伤等并发症发生。骨折愈合时间12～16周，平均14周。术后1周内影像学检查，根据Matta髋臼骨折复位标准，解剖复位21例，满意复位10例，不满意复位3例。末次随访时按Matta改良的D’Aubigne和Postel标准评价髋关节功能，获优25例，良4例，可3 例，差2例。8例发生BrookerⅠ级髋关节异位骨化。 结论 改良髂腹股沟下入路直接分离髂前上棘腹股沟韧带起点，对腹股沟韧带损伤最小，能扩大髋臼前方手术暴露范围，有利于对累及髋臼前方、内侧壁及关节内结构髋臼骨折的手术操作，是对经典髂腹股沟入路的良好补充和改良。

Objective To investigate the clinical results of modified subinguinal approach without iliac osteotomy for anterior surgical treatment of acetabular fractures which involve the anterior wall and medial wall or in combination with femoral neck fracture. Methods The subinguinal approach was modified after anatomical study on 12 adult cadavers. Between May 2010 and March 2012, 34 patients with acetabular fracture that involved the anterior wall and medial wall or in combination with femoral neck fracture were treated with open reduction and internal fixation through modified subinguinal approach in 15 cases and through modified subinguinal approach combined with Kocher-Langenbeck approach. There were 28 males and 6 females with an average age of 31.1 years （range, 20-64 years）. According to the Letournel-Judet classification, there were 15 cases of anterior acetabular/column fractures, 8 cases of anterior acetabular/column fractures combined with trear half transverse fractures, 7 cases of double column fractures, and 4 cases of T shape fractures. The time between injury and operation was 5-16 days （mean, 7.4 days）. Results Anatomy results： the inguinal ligament was reflection and continuity from the aponeurosis of obliquus externus abdominis with a length of （11.09 ± 0.24） cm, which form part of abdominal muscle. The conjugate of inguinal ligament and iliopsoas muscle on the anterosuperior iliac spine was （0.69 ± 0.08） cm. The vertical distance from the saphenous vein to the inguinal ligament was （3.58 ± 0.49） cm. Clinical results： all the cases were followed up 4-24 months （mean, 14.6 months）. No complication was observed, such as wound infection, internal fixation loosening, and iatrogenic injury to the sciatic or femoral nerve. The bone union time was 12-16 weeks （mean, 14 weeks）. According to Matta reduction criteria for acetabular fractures, anatomic reduction were achieved in 21 cases, satisfactory reduction in 10 cases, and unsatisfactory reduction in 3 cases at 1 week after operation. According to D’Aubigne and Postel criteria for hip function, the results were excellent in 25 cases, good in 4 cases, fair in 3 cases, and poor in 2 cases at last follow-up. Heterotopic ossification （Brooker’s grade I） occurred in 8 cases. Conclusion The modified subinguinal approach can keep the inguinal ligament intact, provide broad visualization of anterior and medial wall of acetabulum and anterior hip capsule, which is a better modification and supplement for classic ilioinguinal approach.