髂腹股沟入路下拉力螺钉固定后壁在髋臼双柱骨折手术中的应用

Lag screw fixation of posterior wall through single ilioinguinai approach for both column fractures

目的评估在髂腹股沟入路下采用拉力螺钉固定髋臼后壁治疗累及后壁的髋臼双柱骨折的临床效果。方法回顾性分析2008年8月至2014年8月在髂腹股沟入路下治疗35例累及后壁的髋臼双柱骨折患者资料，男25例，女10例；年龄18～72岁，平均（44．4±12．5）岁；Letournel髋臼骨折分型均为累及后壁的髋臼双柱骨折，其中2例合并关节面压缩骨折（海鸥征）。手术在髂腹股沟入路下复位固定髋臼双柱骨折，并贴髂骨外板建立约2cm软组织通道，使用手指顶压复位髋臼后壁骨折，前侧使用拉力螺钉固定髋臼后壁。随访时髋关节功能按照Matta改良的Merle d＇Aubigne和Postel评分进行评价，骨折复位情况采用Matta方法评价，记录手术时间、术中出血、骨折再移位、创伤性骨关节炎、股骨头坏死、深静脉血栓等。结果35例患者均获得随访，随访时间24～96个月，平均（44．7±18．9）个月；手术时间160-490min，平均（257．7±60．4）min：术中出血300-4000ml，平均（742．9±614．5）ml；术后无一例发生后壁骨折块再移位。采用Matta方法评价骨折复位质量，其中优11例，良19例，差5例，优良率为86％（30／35）。末次随访时，MeAed’Aubign6评分为13-18分，平均（16．4±1．4）分；其中优8例，良23例，可4例，优良率为89％（31／35）。术后3-4d，4例患者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；4例于术后即刻出现股外侧皮神经损伤，未特殊处理，至末次随访时症状均消失；1例术后伤口发生浅表感染，给予抗感染治疗并VSD负压吸引后，术后1个月愈合；l例患者骨折复位质量差，并术前合并海鸥征，术后35个月因严重创伤性关节炎而行全髋关节置换术；再手术率为5．7％（2／35），术后无一例发生坐骨神经损伤及异位骨化。结论采用髂腹沟入路治疗累及后壁的髋臼双柱骨折，其中使用拉力螺钉固定后壁可取得满意的临床效果。

Objective To evaluate the clinical outcomes in patients with both column acetabular fractures involvement posterior wall using lag screw through single ilioinguinal approach. Methods Between August 2008 to August 2014, 35 consecutive patients with both columns acetabular fi＇actures and fracture also involved posterior wall and fixed by lag screws were retro- spectively analyzed. There were 25 males and 10 females. The average age was 44.4± 12.5 years （range, 18-72 years）. According to Letournel classifications, the acetabular fracture involved both columns and posterior wall in all cases, and 2 cases with additional seagull sign. The surgeon reduced posterior wall by pressing the fragment through a small tunnel in the soft tissue leaning against the external cortex of iliac bone and fixed the fragment using lag screws from the anterior side. Clinical and functional outcomes were assessed using the modified Merle d＇ Aubigne scoring system. Radiographic results were evaluated based on Matta scoring system. Results The patients were follow for an average of 44.7± 18.9 months （range, 24-96 months）. The average operative time was 257.7±60.4 rain （range, 160-490 rain）. The average blood loss during the operating was 742.9±614.5 ml （range, 300- 4 000 ml）. Loss of reduction of the posterior wall was not found in any case. At the latest follow-up, radiographic results were excellent in 11, good in 19, and poor in 5. The average modified Merle d＇ Aubigne score was 16.4 （range, 13-18）. There were 8 eases of excellent, 23 cases of good, and 4 cases of fair. Four patients developed deep venous thrombosis of the lower extremities after 3-4 days of operation. Warfarin was used for anticoagulation therapy and thrombi disappeared 6 months postoperatively. One ease had superficial wound infection and was treat with vacuum sealed drainage （VSD） and anti-infection therapy. The incision healed with- out infection after one month. One case with poor quality of reduction and remaining seagull sign was treated with total hip arthro- plasty ＇after 35 months because of severe traumatic arthritis. The total reoperation rate was 5.7% （2/35）. Iatrogenic sciatic nerve in- jury＂ as well as heterotopic ossification was not found in any case. Conclusion Satisfactory quality of reduction and good clinical outcomes can be achieved in patients with acetabular fractures involved both columns and posterior wall by single ilioinguinal ap- proach and lag screw fixation for posterior wall. Iatrogenic sciatic nerve injury as well as heterotopic ossification was not found in any case.