中国修复重建外科杂志

中国修复重建外科杂志

两种前后联合入路治疗复杂髋臼骨折的疗效比较

查看全文

目的 比较改良髂腹股沟入路与 Stoppa 入路分别联合后外侧 Kocher-Langenbeck(K-L)入路治疗复杂髋臼骨折的疗效。 方法 回顾分析 2011 年 5 月—2016 年 5 月,应用前后联合入路治疗的 62 例复杂髋臼骨折患者临床资料。其中,采用改良髂腹股沟入路联合 K-L 入路 34 例(A 组),Stoppa 入路联合 K-L 入路 28 例(B 组)。两组患者性别、年龄、致伤原因、骨折类型、受伤至手术时间、合并伤等一般资料比较,差异均无统计学意义(P>0.05)。记录两组手术时间、术中出血量及住院时间。X 线片复查,参照 Matta 复位标准评价骨折复位情况,观察骨折愈合以及骨关节炎、异位骨化发生情况。根据改良 d’Aubigne 和 Postel 的髋臼骨折临床评分标准,评价患者髋关节功能恢复情况。 结果 两组手术时间、术中出血量及住院时间比较,差异均无统计学意义(P>0.05)。术后 A、B 组各 2 例 K-L 切口发生脂肪液化,A 组 1 例发生下肢深静脉血栓形成;均无医源性损伤发生。术后 56 例患者获随访,A 组 30 例随访时间为 12~48 个月,平均 31.8 个月;B 组 26 例随访时间为 12~46 个月,平均 30.2 个月。术后 12 个月,根据改良 d'Aubigne 和 Postel 的髋臼骨折临床评分标准,A 组获优 9 例、良 16 例、一般 3 例、差 2 例,优良率为 83.3%;B 组获优 7 例、良 14 例、一般 2 例、差 3 例,优良率为 80.8%;两组比较差异无统计学意义(Z=0.353,P=0.724)。X 线片复查示,A 组骨折达解剖复位 23 例、满意复位 6 例、不满意复位 1 例,B 组分别为 20、5、1 例,组间差异无统计学意义(Z=0.011,P=0.991)。两组骨折均达骨性愈合,骨折愈合时间比较差异无统计学意义(t=0.775,P=0.106)。随访期间 A 组出现明显骨关节炎改变 5 例、异位骨化 2 例、股骨头缺血性坏死 2 例,B 组分别为 4、2、1 例,两组各并发症发生率比较差异均无统计学意义(P>0.05)。 结论 根据髋臼骨折部位和类型,合理选择改良髂腹股沟入路或 Stoppa 入路,再联合 K-L 入路治疗复杂性髋臼骨折,均可获满意疗效。

Objective To compare the effectiveness between modified ilioinguinal approach combined with Kocher-Langenbeck (K-L) approach and Stoppa approach combined with K-L approach for the treatment of complicated acetabular fractures. Methods Between May 2011 and May 2016, Sixty-two patients with complicated acetabular fractures were treated with combined anterior and posterior approaches. Thirty-four cases (group A) were treated with modified ilioinguinal approach combined with K-L approach, and 28 cases (group B) were treated with Stoppa approach combined with K-L approach. There was no significant difference in gender, age, injury causes, the type of fracture, time from injury to operation, and associated injury between 2 groups (P>0.05). The operation time, intraoperative blood loss, and hospitalization time were recorded. X-ray film was performed to evaluate the fracture reduction according to the Matta reduction criteria and observe the fracture healing, osteoarthritis, and heterotopic ossification. Clinical results were evaluated according to the grading system of modified d’Aubigne and Postel. Results There was no significant difference in operation time, intraoperative blood loss, and hospitalization time between 2 groups (P>0.05). Postoperative incision fat liquefaction occurred in 2 cases in group A and group B respectively, and deep vein thrombosis of lower extremity occurred in 1 case in group A. No iatrogenic injury was found in 2 groups. Fifty-six patients were followed up after operation. Thirty patients in group A were followed up 12-48 months (mean, 31.8 months). Twenty-six patients in group B were followed up 12-46 months (mean, 30.2 months). At 12 months after operation, according to the grading system of modified d’Aubigne and Postel, the hip function was rated as excellent in 9 cases, good in 16 cases, fair in 3 cases, and poor in 2 cases, with the excellent and good rate of 83.3% in group A; the hip function was rated as excellent in 7 cases, good in 14 cases, fair in 2 cases, and poor in 3 cases, with the excellent and good rate of 80.8% in group B. There was no significant difference in the hip function between 2 groups (Z=0.353, P=0.724).The X-ray films showed that there were 23 cases of anatomical reduction, 6 cases of satisfactory reduction, and 1 case of unsatisfactory reduction in group A, and 20 cases, 5 cases, and 1 case in group B, respectively. There was no significant difference in the results of fracture reduction between 2 groups (Z=0.011, P=0.991). Fracture healing was observed in both groups. There was no significant difference in fracture healing time between 2 groups (t=0.775, P=0.106). During follow-up, 5 cases of osteoarthritis changes, 2 cases of heterotopic ossification, and 2 cases of avascular necrosis of femoral head occurred in group A, and 4 cases, 2 cases, and 1 case in group B, respectively. The difference between 2 groups was not significant (P>0.05). Conclusion According to the location and type of fracture, making a choice between the modified anterior approach and Stoppa approach, and then combined with K-L approach for treatment of complicated acetabular fracture, can obtain satisfactory effectiveness.

关键词: 复杂髋臼骨折; 前后联合入路; 改良髂腹股沟入路; Stoppa 入路; Kocher-Langenbeck 入路; 内固定

Key words: Complicated acetabular fracture; combined anterior and posterior approaches; modified ilioinguinal approach; Stoppa approach; Kocher-Langenbeck approach; internal fixation

登录后 ,请手动点击刷新查看全文内容。 没有账号,
登录后 ,请手动点击刷新查看图表内容。 没有账号,
1. Verbeek DO, van der List JP, Villa JC, et al. Postoperative CT is superior for acetabular fracture reduction assessment and reliably predicts hip survivorship. J Bone Joint Surg (Am), 2017, 99(20): 1745-1752.
2. Magu NK, Rohilla R, Singh A, et al. Modified Kocher-Langenbeck approach in combined surgical exposures for acetabular fractures management. Indian J Orthop, 2016, 50(2): 206-212.
3. Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective. Clin Orthop Relat Res, 1994, (305): 10-19.
4. Wang H, Utku K, Zhuang Y, et al. Post wall fixation by lag screw only in associated both column fractures with posterior wall involvement. Injury, 2017, 48(7): 1510-1517.
5. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis, 1957, 16(4): 494-502.
6. Harris AM, Althausen P, Kellam JF, et al. Simultaneous anterior and posterior approaches for complex acetabular fracture. J Orthop Trauma, 2008, 22(7): 494-497.
7. Phruetthiphat OA, Willey M, Karam MD, et al. Comparison of outcomes and complications of isolated acetabular fractures and acetabular fractures with associated injuries. J Orthop Trauma, 2017, 31(1): 31-36.
8. 朱仕文, 王满宜, 吴新宝, 等. 经单一 Kocher-Langenbeck 入路治疗复合髋臼骨折. 中华医学杂志, 2011, 91(5): 327-330.
9. Hammad AS, Ei-Khadrawe TA, Waly AH, et al. The efficacy of posterior plating and anterior column screw fixation in the management of T-shaped acetabular fractures—CART analysis of prospective cohort study. Injury, 2017, 48(3): 680-686.
10. Kavalakkatt T, Mathew MA. Complex acetabular fractures: Combined anterior and posterior approaches during same procedure. Kerala J Orthop, 2013, 26: 83-86.
11. 陈林, 张伟, 时珂, 等. 前后联合入路重建带及重建钢板治疗复杂髋臼骨折的疗效比较. 中国修复重建外科杂志, 2016, 30(6): 680-684.
12. Mesbahi SAR, Ghaemmaghami A, Ghaemmaghami S, et al. Outcome after surgical management of acetabular fractures: A 7-year experience. Bull Emerg Trauma, 2018, 6(1): 37-44.
13. 秦晓东, 李翔, 吕天润, 等. 改良髂腹股沟下入路治疗髋臼骨折的解剖研究和临床应用. 中国修复重建外科杂志, 2014, 28(1): 47-52.
14. Kloen P, Siebenrock KA, Ganz R. Modification of the ilioinguinal approach. J Orthop Trauma, 2002, 16(8): 586-593.
15. Xue Z, Qin H, Ding H, et al. A novel approach for treatment of acetabular fractures. Med Sci Monit, 2016, 22: 3680-3688.
16. Seyyed Hosseinzadeh HR, Eajazi A, Hassas Yeganeh M, et al. Modified ilioinguinal approach to the acetabulum and pelvis from beneath the inguinal ligament: a subinguinal approach. Hip Int, 2010, 20(2): 150-155.
17. Ruchholtz S, Taeger G, Zettl R. A novel two-incision minimally invasive method for the treatment of anterior acetabular fractures. Unfallchirurg, 2013, 116(3): 277-282.
18. Cutrera NJ, Pinkas D, Toro JB. Surgical approaches to the acetabulum and modifications in technique. J Am Acad Orthop Surg, 2015, 23(10): 592-603.
19. Gänsslen A, Grechenig ST, Nerlich M, et al. Standard approaches to the acetabulum part 2: Ilioinguinal approach. Acta Chir Orthop Traumatol Cech, 2016, 83(4): 217-222.
20. Zhang R, Yin Y, Li S, et al. Minimally invasive treatment of both-column acetabular fractures through the Stoppa combined with iliac fossa approach. Sci Rep, 2017, 7(1): 8044.
21. Wang XJ, Lu Li, Zhang ZH, et al. Ilioinguinal approach versus Stoppa approach for open reduction and internal fixation in the treatment of displaced acetabular fractures: A systematic review and meta-analysis. Chin J Traumatol, 2017, 20(4): 229-234.
22. Elmadag M, Guzel Y, Aksoy Y, et al. Surgical treatment of displaced acetabular fractures using a modified Stoppa approach. Orthopedics, 2016, 39(2): e340-345.
23. 杨亚军, 岳建明, 温鹏. 改良 Stoppa 入路内侧壁弹力接骨板治疗累及髋臼方形区骨折. 中国修复重建外科杂志, 2015, 29(3): 270-274.