骨盆骨折合并髋臼骨折的手术治疗

Internal fixation for pelvic plus acetabular fractures

目的 探讨骨盆骨折合并髋臼骨折的手术治疗策略及临床效果. 方法 回顾性分析2004年1月至2013年6月采用手术治疗的127例骨盆骨折合并髋臼骨折患者资料,男87例,女40例;平均年龄为35.6岁（14 ～ 69岁）.首先处理休克和危及生命的合并伤,采用外固定支架或骨盆捆扎带配合下肢骨牵引复位临时固定骨盆骨折.受伤至骨折确定性手术时间为4h至71d,平均10.5d.髋臼骨折均采用钢板和（或）螺钉内固定;骨盆骨折固定方式：耻骨联合及耻骨支骨折采用重建钛板螺钉固定81例、经皮耻骨支螺钉固定7例,骨盆后环骨折采用髂骨重建板螺钉固定23例、骶髂关节前钢板固定12例、经皮骶髂关节螺钉固定8例、髂骨后M型板固定11例、髂腰固定5例. 结果 术后髋臼骨折复位质量：解剖复位66例,满意复位53例,不满意复位8例,满意率为93.7％.103例患者术后获平均25个月（6～ 48个月）随访.末次随访时根据Majeed骨盆骨折量化评分系统评定疗效：优52例,良36例,可12例,差3例,优良率为85.4％;按照改良d＆#39;Aubigne和Postel评分标准评定髋关节功能：优54例,良32例,可13例,差4例,优良率为83.5％.术后并发症：患侧髋关节创伤性关节炎17例,股骨头缺血性坏死2例,切口脂肪液化5例,切口感染1例,下肢深静脉血栓形成11例,异位骨化4例. 结论 骨盆骨折合并髋臼骨折时,应根据病情制定个体化的治疗方案,首先积极抢救患者生命,处理合并伤,并进行骨折的临时固定.伤后7～10d病情稳定后行骨折的确定性手术,让患者早期活动并进行功能锻炼,可以获得较好的临床效果.

Objective To study the strategies and clinical effects of internal fixation for the pelvic plus acetabular fractures.Methods From January 2004 to June 2013,127 patients diagnosed with pelvic plus acetabular fractures were treated with open reduction and internal fixation in our hospital.They were 87 males and 40 females,aged from 14 to 69 （average,35.6） years.After shock and fatal injuries were dealt with,the unstable pelvic fractures were immobilized with temporary external fixation or leg traction.The time from injury to surgery ranged from 4 hours to 71 days,with an average of 10.5 days.All the acetabular fractures were fixated with a reconstruction plate and/or screws.For pelvic fractures,the symphysis pubis and fractures of the pubic rami were fixated with a reconstruction plate in 81 cases,percutaneous fixation with pubic rami screws was performed in 7,fixation with iliac screws and a reconstruction plate in 23,fixation with an anterior sacroiliac plate in 12,percutaneous fixation with iliosacral screws in 8,fixation with a posterior iliac crest M plate in 11,and iliolumbar fixation in 5.Results The reduction of acetabular fracture was anatomic in 66 cases,satisfactory in 53,and unsatisfactory in 8,giving a satisfaction rate of 93.7%.103 cases were followed up for an average of 25 months （from 6 to 48 months）.Pelvic functional results were excellent in 52 cases,good in 36,fair in 12,and poor in 3 according to the Majeed system,with an excellent to good rate of 85.4%.Hip functions,according to the modified d＆#39;Aubigne system,were excellent in 54 cases,good in 32,fair in 13,and poor in 4,with an excellent to good rate of 83.5%.Postoperative complications included ipsilateral hip traumatic arthritis in 17 cases,femoral head necrosis in 2,incision fat liquefaction in 5,incision infection in one,deep venous thrombosis in 11,and heterotypic ossification in 4.Conclusions Pelvic fractures with concomitant acetabular fractures should be treated according to an individualized protocol.Shock and fatal injuries should be treated first before temporary fixation of the fractures.Definitive internal fixation should not be performed until the vital signs are stable 7 to 10 days later.Early physical therapy and functional exercise are important strategies to obtain satisfactory clinical outcomes