直接后方入路治疗髋臼后部骨折

Direct posterior approach for the treatment of posterior acetabular fractures

目的探讨直接后方入路治疗髋臼后柱、后壁、后柱合并后壁骨折的手术方法及疗效。方法回顾性分析2016年1月至2017年6月,采用直接后方入路治疗10例髋臼后部骨折患者资料,男7例,女3例;年龄17~54岁,平均37岁;车祸伤6例,高处坠落伤4例;髋臼骨折Letournel-Judet分型:后壁骨折6例,后壁伴后柱骨折4例。手术沿股骨大转子顶点后缘与髂后上棘连线中点向股骨大转子顶点后缘做直切口,纵行劈开臀大肌,沿臀中肌-梨状肌间隙进入,显露关节囊至坐骨大孔上缘,保护臀上血管和臀上神经,直视下对后柱、后壁骨折进行复位、固定。术后复查骨盆X线及CT,评价骨折复位、愈合、股骨头坏死、坐骨神经损伤、臀上血管神经损伤、异位骨化等情况;采用Matta改良的Merle d’Aubigné-Postel评分系统评价髋关节功能。按照Matta影像学标准评价髋臼复位质量。结果10例患者手术切口8~11 cm,平均9.6 cm;手术时间35~80 min,平均50 min;术中出血200~440 ml,平均310 ml;伤口均一期愈合。10例患者均获得随访,随访时间12~30个月;骨折均愈合,愈合时间8~12周;无一例发生臀上神经、血管和坐骨神经损伤等并发症。1例后壁伴后柱骨折合并髋关节后脱位患者术后9个月时出现股骨头坏死,术后1年行全髋关节置换术,术后患者髋关节功能恢复良好;1例后壁合并后柱骨折患者术后3个月出现异位骨化,但术后15个月随访时髋关节活动未见明显异常,未予特殊治疗。术后12个月,Matta改良的Merle d’Aubigné-Postel评分为13~18分,其中优6例、良2例、可2例,总优良率80%(8/10)。Matta影像学评价,优7例,良3例,总体优良率100%。结论直接后方入路治疗髋臼后部骨折可获得较满意的临床疗效,其手术创伤小、手术时间短、出血少,术中不切断臀中肌及外旋肌群,不涉及旋股内侧动脉走行区域,避免直接显露或接触坐骨神经,且能直视下复位、固定髋臼后部骨折,是一种处理髋臼后部骨折相对安全的手术入路。

Objective To explore surgical technique and clinical results of the direct posterior approach (DPA) for acetabular fractures involving posterior column, posterior wall, or posterior column and wall. Methods From January 2016 to June 2017, data of 10 cases (7 males, 3 females, an average age of 37 years, ranging from 17 to 54 years) with posterior acetabular fractures treated by the DPA were retrospectively analyzed. Fractures were caused by traffic accident in 6 cases and by falling in 4 cases. According to Letournel-Judet classification of acetabular fractures, there were 6 cases of posterior acetabular wall fractures, 4 cases of posterior wall fractures involving posterior column. A straight skin incision was made from the middle of the line between the posterior margin of the tip of the femoral greater trochanter and the posterior superior iliac spine, to the posterior margin of the femoral greater trochanter. The gluteus maximus muscle was cleaved longitudinally. A view of the area from hip capsule to the superior margin of the greater sciatic foramen was obtained by entering along the interspace of the gluteus medius and pyriformis muscle, and the superior gluteal neurovascular bundle was protected. Acetabular posterior column and posterior wall fractures were reduced and fixed under direct vision. The fracture reduction, fracture healing, femoral head necrosis, sciatic nerve injury, superior gluteal neurovascular injury and heterotopic ossification were evaluated by the postoperative X-ray and CT examination. The function of hip joint was assessed by the Merle d’Aubigné-Posteal score modified by Matta. Results The average operative incision length was 9.6 cm (range, 8-11 cm). The average operation time was 50 min (range, 35-80 min). The average blood loss was 310 ml (range, 200-440 ml). The time of follow-up was 12-30 months. All the patients were healed within 8-12 weeks without any complications such as superior gluteal nerve injury, superior gluteal vessel injury, or sciatic nerve injury. One case of acetabular posterior wall and posterior column fracture with posterior dislocation of hip joint, suffered from femoral head necrosis at the 9th months after surgery, which was treated by total hip arthroplasty and was recovered one year after surgery. In one case of actebular posterior wall and posterior column fracture, heterotopic ossification occurred 3 month after operation, without any special treatment and the hip joint activity was not affected at the follow-up of 15 months after surgery. During the 12-month follow-up after surgery, the Merle d’Aubigné-Postel score modified by Matta was 13-18, among which there were excellent in 6 cases, good in 2, acceptable in 2, with an overall excellent and good rate of 80%(8/10). Conclusion The direct posterior approach for posterior acetabular fractures can obtain satisfactory clinical results. The advantages of the DPA include decreasing trauma, shortening operation time, reduing blood loss and decreasing risks of iatrogenic injury to the gluteus medius muscle, the external rotators, the arteriae circumflexa femoris medialis and sciatic nerves as well as reducing and fixing the fractures under direct vision. Thus, the DPA is a relatively safe surgical approach for acetabular posterior wall/column fracture.