Kocher—Langebeck入路中不离断髋外旋短肌群治疗髋臼后壁骨折的疗效评价

Therapeutic efficacy of Kocher-Langenbeck approach without cutting hip spin short muscle tendons for treatment of acetabular posterior column fractures

目的探讨后外侧Kocher—Langebeck（K—L）入路中不离断髋外旋短肌群治疗髋臼后壁骨折的可行性及疗效。方法采用回顾性病例系列研究分析2015年6月-2017年2月治疗的28例髋臼后壁骨折患者的临床资料，其中男23例，女5例；年龄26～71岁，平均43．6岁。髋臼骨折按Letoumel—Judet分型：单纯后壁骨折9例，后柱伴后壁骨折14例，横断伴后壁骨折5例，患者均伴有后脱位。入院复位后给予胫骨结节牵引，术中均采取不离断髋外旋短肌群的K—L入路。记录手术时间、术中出血量。比较术前、术后6个月视觉模拟评分（VAS）。术后1d、6周、3个月、6个月、1年摄x线片复查，评估骨折愈合情况。采用Matta复位标准评价关节面平整度。术后6个月根据改良Mered＇Aubigne-Postel评分系统评定髋关节功能。观察术中术后并发症情况。结果患者均获随访10～24个月，平均16个月。手术时间76—120min，平均94rain；术中出血量120～320ml，平均265ml。术前VAS为5～10分[（7．5±1．3）分]，术后6个月为0～5分[（0．9±0．8）分]（P〈0．01）。骨折均顺利愈合，愈合时间6～12周，平均10．1周。按Matta复位标准：优24例，良4例，优良率100％。Merled＇Aubigne-Postel评分：优23例，良5例，优良率100％。切口愈合良好，无液化、裂开等。共5例并发坐骨神经损伤，其中3例为一过性损伤表现，均于3个月内恢复。无感染、异位骨化等其他并发症。结论在髋臼骨折后外侧K—L入路中，不离断髋外旋短肌群可以完成内固定手术，骨折愈合率高，复位效果好，功能恢复满意，并发症少。

Objective To investigate the feasibility and clinical effect of Kocher-Langebeck （K-L） approach without cutting the short external rotator muscles of hip for treatment of cetabular posterior column fractures. Methods A retrospective case series study was performed on 28 patients with acetabular fractures admitted from June 2015 to February 2017. There were 23 males and 5 females, averagely aged 43.6 years （range, 26-71 years）. According to the Letournel classification, there were 9 patients with simple fractures, 14 back wall and back pillar fractures and 5 cross fractures. All patients were combined with posterior dislocation. The patients were given tibial tubercle traction after hip joint reduction in the hospital. During the surgery, K-L approach was adopted without cutting the short external rotator muscles of hip. Operation duration and intraoperative bleeding were recorded. Visual analogue score （VAS） was recorded before and after operation. The X-ray at 1 day, 6 weeks, 3 months and 1 yearafter operation were reviewed to evaluate fracture healing time. Matta criteria were used to assess the surface flatness of joint. The modified Merle d＇Aubign^-Postel scoring system was applied to evaluate the function of hip joint. Intraoperative and postoperative complications were recorded. Results The operation duration was 76-120 min （ mean, 94 min）, and the intraoperative blood loss was 120-320 ml （mean, 265 ml）. All patients were followed up for average 16 months （range, 10-24 months）. Preoperative VAS was 5-10 points[ （7.5 ± 1.3 ）points], and 0-3 points [ （0.9 ± 0.8）points ] 6 months after operation （ P 〈 0.01 ）. All fractures healed and the average healing duration was 10. 1 weeks （range, 6-12 weeks）. According to the Matta criteria, 24 patients were graded excellent and 4 good, with excellence rate of 100%. According to the modified Merle d＇Aubigne-Postel grading system, clinical results were graded excellent in 23 patients, good in 5, with excellence rate of 100%. Transient sciatic nerve injury occurred in 3 patients after surgery, and the nerve function of these patients fully recovered within 3 months after operation. There were no infection, heterotopic ossification and other complications. The wound healing was good, without liquefaction or cracking. Sciatic nerve injury was found in five patients, three of whom were performed with a transient lesion and recovered within 3 months. Conclusion In the posterior pathway surgery for acetabular posterior column fractures, the K-L approach without cutting the short external rotator muscles of hip can be used to complete the internal fixation with a high rate of fracture healing, sound reduction outcome, satisfactory functional recovery and few complications.