自体髂骨结构性植骨结合微型螺钉治疗髋臼后壁粉碎性骨折

Treatment of comminuted posterior acetabular wall fractures with structural autologous iliac bone graft combined with mini screws

目的探讨髂骨结构性植骨结合微型螺钉治疗髋Et后壁粉碎性骨折的近中期疗效。方法回顾性分析2010年1月至2014年1月期间收治的29例髋臼后壁粉碎性骨折患者资料，男2l例，女8例；平均年龄为44．2岁（22。58岁）。受伤至手术时间平均为7．8d（1-25d）。手术均采用Kocher．Langenbeck人路，术中应用微型螺钉解剖复位固定骨折块，清除血供已破坏的碎裂小骨块，应用髂骨结构性植骨重建髋臼后壁，再予以重建钢板压于植骨块表面固定。术后骨折复位质量采用Matta复位标准评定，末次随访时采用改良Merled’Aubingne和Postel评分系统评定患髋功能。结果术后骨折复位质量根据Matta复位标准评定：优10例，良16例，差3例，优良率为89．7％。29例患者术后获平均31．5个月（12-48个月）随访。末次随访时采用改良Merled’Aubign6和Postel评分系统评定患髋功能：优16例，良9例，可3例，差1例，优良率为86．2％。2例患者术后18个月磁共振成像发现股骨头缺血性坏死征象；3例患者术后2年出现创伤性关节炎；5例患者术后发生轻度异位骨化，均无明显症状；2例术前伴有坐骨神经损伤的患者于术后4个月完全恢复。结论对于髋臼后壁粉碎性骨折，自体髂骨结构性植骨结合微型螺钉固定可以重建后壁的稳定性和完整性，避免后壁骨坏死等并发症的发生，是一种有效的内固定方法。

Objective To evaluate the short and mid-term effects of fixing comminuted posterior acetabular wall fractures with structural autologous iliac bone graft combined with mini screws. Methods From January 2010 to January 2014, 29 patients with comminuted posterior acetabular wall fracture were treated by structural autologous iliac bone graf combined with mini screws. They were 21 males and 8 females, with a mean age of 44. 2 years （range, from 22 to 58 years）. The mean time form injury to operation was 7.8 days （range, from 1 to 25 days）. The operations were performed through the Kocher-Langenbeck approach, with the patients in the lying position on the uninjured side. The fragments were reduced and fixed by mini screws and the ischemic ones were removed. Structural autologous iliac bone graft was used to reconstruct the posterior wall of acetabulum before a reconstruction plate was applied to compress and maintain it. The functional outcomes were evaluated by the modified Merle d＇Aubigne and Postel clinical grading system at the last follow-ups. The radiographs were graded according to the Matta criteria. Results By the Matta criteria, 10 cases achieved excellent reduction, 16 good reduction, and 3 poor reduction, giving a good to excellent rate of 89. 7%. Of this series, 29 patients were followed up for 31.5 months on average （range, from 12 to 48 months）. By the modified Merle d＇Aubigne and Postel criteria, the functional recovery was rated as excellent in 16 cases, good in 9, fair in 3 and poor in one, giving a good to excellent rate of 86. 2%. Two cases developed femoral head necrosis according to the magnetic resonance imaging 18 months postoperation.Three patients developed traumatic arthritis two years postoperation.Five patients developed beterotopic ossification postoperation,with no obvious clinical symptoms.Two patient with injury to the sciatic nerve recovered 4 months postoperation.Conclusions Structural autologous iliac graft combined with mini screws can reconstruct the integrity and stability of the fractured acetabular posterior wall,avoiding osteonecrosis of the acetabulum.This aurgical technique is effective and safe in treatment of comminuted fracture of the acetabular posterior wall.