腹股沟韧带下入路治疗髋臼前柱合并前壁骨折

Modified subinguinal approach for treatment of acetabular anterior column and wall fractures

目的探讨腹股沟韧带下入路治疗髋臼前柱合并前壁骨折的临床疗效。方法回顾性分析2011年1月至2015年4月收治的5例髋臼前柱合并前壁骨折患者资料，男3例，女2例；年龄为19-45岁，平均35．6岁。受伤至手术时间为4～10d，平均7．6d。5例患者均采用腹股沟韧带下入路，以腹股沟韧带髂前上棘止点锐性剥离的方式完整保留腹股沟韧带并将其向内上方牵开，保留Farid髂腹股沟下入路显著扩大第1窗显露范围的优点，同时避免髂骨截骨所造成的额外损伤。记录患者手术时间、术中出血量、术后骨折复位质量、骨折愈合时间及末次随访时患肢髋关节功能，髋关节功能采用改良Merled＇Aubigne和Postel评分系统评定。结果5例患者手术时间为110～150min，平均125min；术中出血量为415-550mL，平均450．2mL。术后骨折复位质量根据Matta髋臼骨折复位标准评定：优4例，良l例。5例患者术后获6～43个月（平均32．4个月）随访。5例患者骨折临床愈合时间为3—6个月，平均4．6个月。末次随访时按改良Merled＇Aubign6和Postel评分系统评定患肢髋关节功能：优2例，良3例。随访期间无一例患者发生疝气、内固定物松动或断裂、骨化性肌炎及股骨头缺血性坏死等严重并发症。结论腹股沟韧带下入路手术步骤简单，在显著扩大髋臼前方暴露范围的同时对腹股沟韧带创伤较小，且避免了髂骨截骨损伤，临床疗效良好，可作为髋臼前柱及前壁骨折、前柱合并髋臼顶部骨折患者的一种较为理想入路选择。

Objective To discuss the efficacy of the modified subinguinal approach for the treatment of acetabular anterior column and wall fractures. Methods A clinical retrospective study was performed of the 5 patients who had been treated at our department from January 2011 to April 2015 for acetabular an- terior column and wall fractures and conformed to follow-ups. They were 3 males and 2 females, aged from 19 to 45 years （mean, 35.6 years）. The duration from injury to surgery averaged 7.6 days （range, from 4 to 10 days） . The subinguinal ligament approach was adopted in the $ cases, through which the inguinal ligament was preserved intact after sharp dissection of its insertion at the anterior superior iliac spine and medial-upper advancement, the advantage of expanded exposure of ＂the first window＂ by the Farid sub-ilioinguinal approach was retained, and additional lesions due to iliac osteotomy were avoided. The operation time, intraoperative bleeding, postoperative reduction and time for fracture union were documented. Merle d＇ Aubigne and Postel scoring system was used to assess the hip joint function of the affected limb at the final follow-ups. Results The operation time ranged from 110 to 150 minutes （mean, 125 minutes）; the intraoperative bleeding ranged from 415 to 550 mL （mean, 450. 2 mL）. By the Matta＇s criteria, the postoperative reduction was rated as excellent in 4 cases and good in one. The 5 patients were followed up for an average of 32. 4 months （range, from 6 to 43 months）. Their fractures united clinically after an average of 4. 6 months （range, from 3 to 6 months）. The hip joint function was rated as excellent in 2 and good in 3 by the Merle d＇ Aubigne and Postel scoring system at the final follow-ups. Follow-ups observed no serious complications like inguinal her- nia, internal fixation failure, myositis ossificans, or avascular necrosis of the femoral head. Conclusions As the modified subinguinal approach can provide a broad surgical exposure, lead to minimal injury to the inguinal ligament, avoid lesions caUsod by lilac osteolomy, and decrease operation time and bleeding, it may be a better approach for acetabular anterior column and wall fractures.