前后联合入路翻修治疗复杂髋臼骨折的疗效分析

Combined anterior and posterior approach revision for complex acetabular fractures

目的探讨前后联合入路翻修治疗复杂髋臼骨折的临床效果。方法采用回顾性病例系列研究分析2012年6月— 2017年6月山西省人民医院收治的21例复杂髋臼骨折经单一手术入路治疗后失败患者的临床资料,其中男16例,女5例;年龄24~45岁,平均34.6岁。髋臼骨折按Letournel-Judet分型:横形+后壁骨折7例,前柱+后半横形骨折5例,双柱骨折4例,"T"形骨折5例。首次手术采用髂腹股沟入路9例,Kocher-Langebeck(K-L)入路12例。翻修手术入路均采用前后联合入路。记录手术时间和术中出血量。观察骨折愈合情况。按照Matta复位标准评估骨折复位质量,按照改良的D'Aubigne和Postel评分标准评定髋关节功能。观察术中、术后并发症情况,按Brooker等标准评价异位骨化。结果患者均获随访12~36个月,平均27个月。手术时间180~360 min,平均270 min。术中出血量1 000~3 800 ml,平均2 000 ml。骨折均愈合,愈合时间为3.5~7个月,平均5个月。按Matta复位标准:解剖复位8例,满意复位12例,不满意复位1例。改良D'Aubigne和Postal评分术前为(11.1±1.9)分,术后6个月为(15.6±1.7分)(P<0.05)。髋关节功能优3例,良14例,一般3例,差1例,优良率为81%。坐骨神经一过性损伤3例,创伤性关节炎1例,BrookerⅡ度异位骨化1例。未出现股骨头坏死和下肢深静脉血栓患者。结论前后联合入路翻修治疗复杂髋臼骨折可促进骨折愈合和骨折复位,促进功能恢复,并发症发生率低。

Objective To investigate the clinical effect of combined anterior and posterior approach revision on complex acetabular fractures. Methods A retrospective case series study was performed on the clinical data of 21 patients with complex acetabular fractures who underwent failed surgery through single approach from June 2012 to June 2017. There were 16 males and five females, averagely aged 34.6 years (range, 24-45 years). According to Letournel-Judet classification, there were seven patients with transverse+ posterior wall fracture, five patients with anterior column+ posterior semi-transverse fracture, four patients with double column fracture and five patients with "T" fracture. The first operation was performed by ilioinguinal approach in nine patients and by Kocher-Langebeck (K-L) approach in 12 patients. Revision surgery was performed using a combined anterior and posterior approach. The operation time and intraoperative blood loss were recorded, and the fracture healing was observed. The quality of fracture reduction was assessed according to Matta reduction criteria, and hip function by the modified D Aubigne and Postel score. The complications during and after operation were recorded. Heterotopic ossification was evaluated according to Brooker's criteria. Results The patients were followed up for 12 to 36 months, with an average of 27 months. The operation time ranged from 180 to 360 minutes, with an average of 270 minutes. Intraoperative bleeding was 1 000-3 800 ml, with an average of 2 000 ml. Fractures were healed, with the healing time ranging from 3.5 to 7 months, with an average of 5 months. According to Matta reduction criteria, there were eight patients with anatomical reduction, 12 with satisfactory reduction and one with unsatisfactory reduction. The improved D Aubigne and Postal score was (11.1±1.9)points preoperatively and (15.6±1.7)points six months after operation (P<0.05), the outcome of hip function was excellent in three patients, good in 14, fair in three, and poor in one, with the excellent and good rate of 81%. There were three patients with transient injury of sciatic nerve, one patient with traumatic arthritis and one with heterotopic ossification of Brooker II. No femoral head necrosis or deep venous thrombosis in the lower extremities was found. Conclusion For complex acetabular fractures, combined anterior and posterior approach revision can promote fracture reduction, fracture healing, and functional recovery, with low incidence of complications.