腹直肌外侧入路髋臼周围截骨治疗陈旧性髋臼骨折的手术方法及疗效评价

Periacetabular osteotomy through the lateral-rectus approach for obsolete acetabular fractures

目的探讨经腹直肌外侧入路(LRA)显露、髋臼周围截骨治疗陈旧性髋臼骨折的手术技巧,并评价其临床疗效。方法回顾性分析2012年6月至2019年6月期间南方医科大学第三附属医院骨科医学中心创伤骨科收治的22例陈旧性髋臼骨折患者资料。男16例,女6例;年龄为22~61岁,平均45.0岁;髋臼骨折按Judet-Letournel分型:前方伴后半横形骨折4例,T形骨折2例,双柱骨折16例。受伤至手术时间:3~12周15例,3~6个月5例,9个月1例,3年1例。所有患者经LRA于腹膜外显露髋臼周围,直视下截骨、复位后应用多块重建钢板或髋臼一体化翼形解剖钢板固定。记录患者的手术时间、术中出血量、骨折复位质量、患髋功能及并发症发生情况等。结果本组患者的手术时间为110~205 min,平均140.5 min;术中出血量为500~2100 mL,平均1250.4 mL。术后按照Matta X线复位标准评定骨折复位质量:优7例,良11例,差4例,优良率为81.8%(18/22)。22例患者术后获12~36个月(平均22.1个月)随访。所有患者骨折均获愈合。术后1年随访患者改良Merle d'Aubigné&Postel评分为6~18分,平均14.6分;优6例,良10例,可3例,差2例,优良率为72.7%(16/22)。2例患者术后出现股骨头坏死,其中1例行全髋关节置换术。结论LRA能从骨盆内侧显露整个半骨盆环,可直视下经髋臼内侧实施髋臼周围截骨、复位髋臼前后柱及方形区骨折,多块重建钢板或髋臼一体化翼形解剖钢板固定能达到理想效果。

Objective To investigate the surgical techniques and clinical efficacy of periacetabular osteotomy through the lateral-rectus approach(LRA)for obsolete acetabular fractures.Methods The 22 patients with old acetabular fracture were retrospectively analyzed who had been admitted to Department of Traumatic Surgery,The Third Affiliated Hospital to Southern Medical University from June 2012 to June 2019.They were 16 males and 6 females,aged from 22 to 61 years(average,45.0 years).By the Judet-letournel classification,there were 4 anterior+posterior hemitransverse fractures,2 T-shaped fractures and 16 both column fractures.The time from injury to surgery was 3 to 12 weeks in 15 cases,3 to 6 months in 5 cases,9 months in one case,and 3 years in one case.After the whole acetabulum was exposed outside the peritoneum through LRA in all patients,periacetabular osteotomy was conducted under direct vision,followed by fixation with multiple reconstruction plates or integrated acetabular airfoil anatomical plates after reduction.Recorded were the operation time,intraoperative blood loss,fracture reduction quality,affected hip function and complications in the patients.Results In this cohort the operation time ranged from 110 to 205 min,averaging 140.5 min;intraoperative blood loss ranged from 500 to 2,100 mL,averaging 1,250.4 mL.According to the Matta X-ray criteria,the postoperative reduction was assessed as excellent in 7 cases,as good in 11 and as poor in 4,yielding an excellent and good rate of 81.8%(18/22).All the 22 patients were followed up for 12 to 36 months(mean,22.1 months)and achieved fracture union.The one-year follow-up showed that their modified Merle d'Aubigné&Postel scores ranged from 6 to 18 points,averaging 14.6 points and giving 6 excellent,10 good,3 fair and 2 poor cases[an excellent and good rate of 72.7%(16/22)].Osteonecrosis of the femoral head developed in 2 patients one of whom underwent total hip replacement.Conclusions As LRA can expose the entire hemipelic ring from the medial side of the pelvis,the periacetabular osteotomy can be performed and the fractures of anterior or posterior column and the quadrilateral area can be reduced under direct vision through the medial side of the acetabulum.Moreover,ideal results can be achieved with the use of multiple reconstruction plates or integrated acetabular airfoil anatomical plates.