髂腹股沟入路短支撑钢板固定髋臼后柱治疗复杂髋臼骨折

A short infrapectineal buttress plate fixing posterior column for complex acetabular fractures through Ilioinguinal approach

目的评价采用髂腹股沟入路及使用骨盆缘下短支撑钢板固定髋臼后柱治疗复杂髋臼骨折的临床疗效。方法回顾性分析2008年9月至2012年8月采用单一髂腹股沟入路并骨盆缘下短支撑钢板固定髋臼后柱治疗29例复杂髋臼骨折患者资料，男22例，女7例；年龄25～72岁，平均（53±6．3）岁；Letournel-Judet髋臼骨折分型，前柱＋后半横骨折14例，双柱骨折11例，T型骨折4例，其中6例合并关节面压缩骨折（海鸥征）。手术方法包括术前3D打印重建骨盆模型并预手术，自行设计牛角形克氏针套筒帮助通过髂腹股沟入路下放置骨盆缘下支撑钢板固定髋臼后柱。随访时使用Mede d’Aubigné评分评价患髋功能，采用Matta分类方法评价骨折复位情况，记录手术时间及术中出血、骨折再次移位、创伤性骨关节炎、深静脉血栓等并发症。结果29例患者中，2例失访，其中1例于术后15d因肺栓塞而突发死亡，1例术后12个月失去联系；余27例获得随访，随访时间24～75个月，平均40个月。29例患者手术时间（180±35．5）min，术中出血量（500±43．9）ml；术后无一例发生骨折再次移位，采用Matta方法评价骨折复位质量，其中优17例，良8例，差4例，优良率为86％（25／29）。28例患者骨折均愈合，愈合时间（3．5±0．9）个月。末次随访时，Merle d’Aubigné评分为10～18分，平均16分；其中优12例，良8例，可5例，差2例，优良率为74％（20／27）。术后3例患者出现下肢深静脉血栓，其中1例于术后15d因肺栓塞而死亡，2例术后3～4d发现下肢深静脉血栓，给予华法林抗凝治疗6个月后血栓消失；2例术后即刻出现股外侧皮神经损伤症状，未特殊处理，至末次随访时症状均消失；1例患者术后伤口发生浅表感染，给予抗感染治疗并VSD负压吸弓l后，术后1个月伤口愈合；1例骨折复位差合并海鸥征的患者术后35个月因创伤性关节炎行全髋关节置换术；29例患者总的并发症发生率为24％（7／29）。结论单一髂腹股沟入路并骨盆缘下短支撑钢板固定髋臼后柱治疗复杂髋臼骨折，术后骨折复位伟．固定牢靠，无骨折再次移位．临床疗效满意，并未增加并发症的发生率。

Objective To evaluate the clinical outcomes of ilioinguinal approach with short infrapectineal buttress plate fixing posterior column for patients with complex acetahular fractures. Methods Data of 29 consecutive patients （male 22, fe- male 7, age range 25-72 years, average age 53±6.3 years） with complex acetabular who had operated by single ilioinguinal ap- proach with infrapectineal buttress plate from September 2008 to August 2012 were retrospectively analyzed. According to Letour- nel-Judet classifications, there were 4 cases of anterior column and posterior hemi-transverse, 11 cases of associated both-column, 4 of T-shaped and 6 with seagull sign. The acetabular fractures model was printed preoperatively by 3D printing technique for sur- gical simulation, open reduction and internal fixation through single ilioinguinal approach with a short infrapectineal plate fixing posterior column, particularly an ox horn shape K-wire sleeve was developed for drilling and screw insertion using flexible screw- driver. Clinical, radiographic, and functional outcomes assessed by the modified Merle d＇ Aubign6 score were collected. Results Two patients were lost to follow-up, including one patient who died at 15 days postoperative because of pulmonary embolism, and the other one who had moved abroad at 12 months postoperative. The remaining 27 （93%） had a mean follow-up of 40 months （range, 24-75 months）. The operating time was 180±35.5 rain;the time for the fracture union was 3.5±0.9 month;blood loss during the operating was 500±43.9 ml; no case had fracture re-displacement. At the latest follow-up, radiographic grades were excellent in 17, good in 8, poor in 4, including one poor patient who had a total hip arthroplasty （3%） at 35 months after the internal fixation. The average modified Merle d＇ Aubign6 score was 16 （range, 10-18）, and categorized as excellent in 12, good in 8, fair in 5, and poor in 2. Three patients had developed deep venous thrombosis of the lower extremities, and one of them died of pulmonary embo- lism 15 days after operation; two cases of deep venous thrombosis of the lower extremity were found 3-4 days after operation. Thrombosis disappeared 6 months after anticoagulant therapy by warfarin. One case who had superficial wound infection after oper- ation was treated by anti-infection and VSD negative pressure, and incision was healed after one month. One case with poor quality of fracture reduction and seagull sign was treated with total hip arthroplasty after 35 months because of traumatic arthritis. The to- tal complication rate was 24% （7/29）. Conclusion In the patient with complex ac, etabular fractures combining posterior column medial displacement, single llioinguinal approach with infrapectineal buttress plates could achieve a stable concentric hip joint, and immediate postoperative ambulation can result in reasonable clinical, radiographic, and functional outcomes.