改良Stoppa入路联合髂嵴前入路及K-L入路治疗复杂髋臼骨折合并骨盆骨折

[目的]探讨应用改良Stoppa联合髂嵴前入路及Kocher-Langenbeck三种手术入路联合治疗髋臼骨折合并骨盆环骨折的临床疗效。[方法]2013年6月~2014年7月,采用改良Stoppa入路联合髂嵴前入路重建钛板固定髋臼前柱及前壁骨折结合K-L入路固定髋臼后壁及后柱技术,治疗10例骨盆骨折患者,男7例,女3例;年龄31~60岁,平均42.8岁。髋臼骨折按照Judet分型:分为T型骨折、双柱骨折。采用Matta评估标准评定骨折复位情况,采用Matta评分标准评定术后功能情况。[结果]10例患者均获随访,时间4~13个月,平均7.3个月。手术时间80~140 min,平均100 min。术中出血量500~900 ml,平均780 ml。骨折愈合时间为12~16周,平均14周。骨折复位按照Matta评估标准:解剖复位6例,满意复位4例。术后功能评定按Matta评分标准:优7例,良2例,可1例。[结论]应用改良Stoppa联合髂嵴前入路及K-L入路治疗复杂髋臼骨折合并骨盆骨折,可以充分利用每种切口的优势,具有相对减少创伤、手术操作安全、并发症少、复位容易、固定牢靠、可早期活动的优点,是一种比较理想的手术方法。     

复杂髋臼骨折的早期手术治疗

[目的] 探讨复杂髋臼骨折早期手术治疗的临床效果.[方法] 1998年9月～2006年10月对228例复杂髋臼骨折早期手术治疗.[结果] 随访5～84个月(平均36.3个月),骨折复位和关节功能按Matta标准评定:解剖复位102例,满意复位105例,不满意复位21例;关节功能优良率90.8%.[结论] 复杂髋臼骨折通过早期手术,合理的手术入路选择,解剖复位和满意复位率高,不满意复位率较低;后遗症较少,关节功能优良率较高.     

陈旧性髋臼骨折的治疗

目的探讨陈旧性髋臼骨折手术和影响临床结果的相关因素。方法2001年2月～2005年7月，收治陈旧性髋臼骨折37例，其中简单型骨折10例，复合型骨折27例。受伤至手术时间平均44．8d，选择Kocher—Langenbeek入路6例，髂腹沟入路1例，延长髂腹沟人路2例，前后联合入路28例。手术平均耗时226min，术中平均失血l798mL。结果全部患者平均随访18．9个月，采用Matta的复位标准以及改良的D’Aubigne和Postel临床结果评分。解剖复位31例，不满意4例，差2例；临床结果优21例，良9例，一般5例，差2例，优良率为81．1％。股骨头坏死1例，异位骨化11例，坐骨神经一过性麻痹4例。结论除单纯的后壁或／和后柱、前壁与前柱骨折选择单一的入路外，对于陈旧性髋臼骨折原则上采用前后联合入路或延长的髂腹沟人路；骨关节炎的发生与骨折的严重程度有关；股骨头坏死与术前股骨头是否向内或向后移位并无直接关系；临床结果、手术耗时和术中失血不仅与骨折程度和损伤至手术的时间有关，而且与手术医生的经验有关。     

改良Stoppa入路手术治疗髋臼骨折的体会

目的探讨改良Stoppa入路在髋臼骨折手术治疗中的应用。方法笔者自2012-01—2015-12应用改良Stoppa入路手术治疗26例髋臼骨折,观察术后疗效。结果术后骨折复位情况根据Matta影像学评分标准评定:解剖复位6例,满意复位18例,不满意复位2例。26例获平均16.5(6~26)个月随访,末次随访疗效按照Matta功能评分标准评定:优15例,良10例,可1例。结论改良Stoppa入路在手术治疗髋臼骨折时能清楚显露耻骨梳、髋臼内壁、方形区,方便骨折复位固定,并发症少,疗效满意。     

髋臼骨折合并髋关节脱位的手术治疗策略

目的探讨髋臼骨折合并髋关节脱位复位时机、手术入路、内固定方式的选择及手术疗效。方法回顾性分析自2014-01—2017-10采用手术治疗的25例髋臼骨折合并髋关节脱位,选择Kocher-Langenbeck(K-L)入路、髂腹股沟入路或前后联合入路,24例行切开复位重建钢板内固定术,1例行切开复位重建钢板内固定+全髋关节置换术。结果 25例均获得随访,随访时间平均16(3～34)个月。随访期间复查X线片无髋关节再脱位,骨折均获得骨性愈合。骨折复位采用Matta标准评价:解剖复位20例,满意复位4例,复位较差1例。末次随访时疗效采用改良Merle d’Aubigne-Postel功能评分标准评定:优8例,良10例,可4例,差3例,优良率72.0%。结论手术治疗髋臼骨折合并髋关节脱位时,需进行髋关节早期复位,根据患者具体情况选择正确的手术入路充分显露,获得术中满意的骨折复位及牢靠的内固定。     

关节周围辅助复位治疗髋臼骨折

目的探讨关节周围辅助复位在髋臼骨折手术治疗中对骨折的复位作用及治疗效果。方法总结2007年5月至2012年6月对21例有移位的髋臼骨折患者进行切开复位内固定治疗,其中男15例,女6例;年龄26~61岁,平均42岁。车祸伤14例,高空坠落伤4例,重物砸伤3例。根据骨折类型的不同,分别在采用髂腹股沟入路或"K-L"入路为主的同时,结合髂嵴小切口、股骨颈或股骨干持续牵引,或经前后联合入路,采取从周围至中央的思路间接复位髋臼骨折。结果根据Matta影像学复位标准,术后骨折解剖复位16例,复位满意3例,复位不满意2例。21例患者随访时间6~18个月,平均12个月。据Merled'Aubigne和Postel功能评分标准,术后6个月关节功能评分优良率90.47%。结论关节周围辅助复位治疗髋臼骨折能有效提高髋臼骨折解剖复位的概率,提高髋臼骨折的临床治疗效果。     

前后联合入路治疗髋臼骨折并中心性脱位

目的探讨前后联合入路治疗髋臼骨折并中心性脱位的疗效。方法对2008年6月～2011年12月采用前后联合入路治疗的24例髋臼骨折并中心性脱位进行回顾性分析。均采用切开复位重建钢板螺钉内固定术。结果所有患者获得6～36个月(平均15个月)随访。临床结果按照Matta标准:解剖复位15例,满意复位9例。髋关节功能采用Matta改良的d’Aubigne-Postel评分标准评定:优7例,良14例,可3例,优良率87.5%。创伤性关节炎6例,异位骨化4例。医源性股外侧皮神经损伤3例,均为不完全性损伤,术后1个月左右完全恢复。结论手术治疗髋臼骨折并中心性脱位时,采用前后联合入路显露较好,方便骨折复位及固定,并发症较少,可获得满意的临床疗效。     

髋臼骨折的手术治疗

目的 探讨髋臼骨折的分型、手术入路的选择及手术效果.方法 手术治疗22例髋臼骨折患者,后壁骨折和后柱加后壁骨折选择K-L入路,前柱、前壁骨折及横断骨折选择髂腹股沟入路,前后移位明显的横断骨折、T形骨折、双柱骨折选择前后联合入路.结果 22例均获随访,时间6个月~5年,骨折6~9个月均愈合.按Matta评定标准:解剖复位 9例,满意复位13例.根据改良的Merle d′Aubigne-Poster髋关节功能评分标准:优7例,良10例,可4例,差1例.1例股骨头坏死,3例创伤性关节炎,2例异位骨化.结论 按髋臼骨折的分型选择合适的手术入路和良好的骨折复位内固定是获得满意疗效的前提.     

陈旧性髋臼骨折的手术治疗

目的探讨陈旧性髋臼骨折手术治疗的方法及疗效。方法手术治疗陈旧性髋臼骨折17例,分别从分型、手术入路及方法、功能结果等方面进行回顾性分析。结果平均随访17个月,临床评分结果优3例,良7例,一般5例,差2例。结论陈旧性髋臼骨折手术治疗应认真考虑手术指征、手术入路,制定合适的复位和固定方案,并预防并发症的发生,可获得较满意的结果。     

采用联合入路治疗复杂型陈旧性髋臼骨折

目的总结采用联合入路治疗复杂型陈旧性髋臼骨折的手术方法和治疗效果。方法从1993年2月～2005年9月,共手术治疗复杂型陈旧性髋臼骨折21例,其中横形合并后壁骨折3例,T形骨折4例,双柱骨折11例,前柱合并后半横形骨折3例。手术采用联合入路(髂腹股沟 K-L入路)。结果解剖复位12例(57.1%),复位满意5例(23.8%),复位不满意4例(19.1%)。解剖复位率在最初和最近6年手术组分别为44.4%和66.7%。获2～8年随访的15例中,临床和X线优良率分别为65.3%和67.2%,其中解剖和非解剖复位组的临床优良率分别为78.6%和32.8%(P<0.01)。并发症:坐骨神经不全性牵伸损伤1例;深部感染1例;静脉血栓形成1例;中、重度骨关节炎2例,轻度3例;股骨头缺血性坏死2例;异位骨化BrookerⅠ、Ⅱ度4例,Ⅲ度2例。结论采用联合入路治疗复杂型陈旧性髋臼骨折可取得满意的骨折复位和临床疗效;复位质量与疗效密切相关。     

髋臼旋转截骨术治疗髋臼发育不良

目的探讨髋臼旋转截骨术治疗髋臼发育不良的疗效。方法应用髋臼旋转截骨术治疗髋臼发育不良16例（18髋）,截骨线距臼周缘2 cm,做穹隆状截骨,凿断后再用弧度骨凿将髋臼向前外下方旋转。髋臼矫正到较正常位置后,截骨间隙呈楔形状,用类似间隙大小的楔形同种异体骨块嵌入,并用可注射状人工骨填满间隙,最后用2枚可吸收螺钉固定。测定并比较术前和术后JOA评分、CE角和Sharp角。结果16例均获随访,时间442个月。术后摄片髋关节复位位置好,股骨头及髋臼形状基本正常。髋臼旋转截骨及植入骨块2个月后骨性愈合,6个月后髋关节功能恢复正常17髋,较差1髋,无患髋的骨性关节炎病变继续恶化。JOA评分：术前为75.2分±3.1分,术后为93.5分±3.5分;CE角：术前为15.8°±1.3°,术后为33.4°±1.7°;Sharp角：术前为47.3°±2.5°,术后为29.8°±2.1°。JOA评分术后增加18.3分;CE角增加17.6°,Sharp角减少17.5°,差异有统计学意义（P〈0.05）。结论髋臼旋转截骨术可矫正头臼间异常的匹配关系,使疼痛得到缓解,并使骨性关节炎的过程得到有效遏制,是治疗髋臼发育不良合并早、中期骨性关节炎的理想术式。     

Cementless acetabular reconstruction after acetabular fracture.

BACKGROUND: Total hip arthroplasty in patients with posttraumatic arthritis has produced results inferior to those in patients with nontraumatic arthritis. The use of cementless acetabular reconstruction, however, has not been extensively studied in this clinical context. Our purpose was to compare the intermediate-term results of total hip arthroplasty with a cementless acetabular component in patients with posttraumatic arthritis with those of the same procedure in patients with nontraumatic arthritis. We also compared the results of arthroplasty in patients who had had prior operative treatment of their acetabular fracture with those in patients who had had prior closed treatment of their acetabular fracture. METHODS: Thirty total hip arthroplasties were performed with use of a cementless hemispheric, fiber-metal-mesh-coated acetabular component for the treatment of posttraumatic osteoarthritis after acetabular fracture. The median interval between the fracture and the arthroplasty was thirty-seven months (range, eight to 444 months). The average age at the time of the arthroplasty was fifty-one years (range, twenty-six to eighty-six years), and the average duration of follow-up was sixty-three months (range, twenty-four to 140 months). Fifteen patients had had prior open reduction and internal fixation of their acetabular fracture (open-reduction group), and fifteen patients had had closed treatment of the acetabular fracture (closed-treatment group). The results of these thirty hip reconstructions were compared with the intermediate-term results of 204 consecutive primary total hip arthroplasties with cementless acetabular reconstruction in patients with nontraumatic arthritis. RESULTS: Operative time (p < 0.001), blood loss (p < 0.001), and perioperative transfusion requirements (p < 0.001) were greater in the patients with posttraumatic arthritis than they were in the patients with nontraumatic arthritis. Of the patients with posttraumatic arthritis, those who had had open reduction and internal fixation of their acetabular fracture had a significantly longer index procedure (p = 0.01), greater blood loss (p = 0.008), and a higher transfusion requirement (p = 0.049) than those in whom the fracture had been treated by closed methods. Eight of the fifteen patients with a previous open reduction and internal fixation required an elevated acetabular liner compared with one of the fifteen patients who had been treated by closed means (p = 0.005). Two of the fifteen patients with a previous open reduction and internal fixation required bone-grafting of acetabular defects compared with seven of the fifteen patients treated by closed means (p = 0.04). The thirty patients treated for posttraumatic arthritis had an average preoperative Harris hip score of 41 points, which increased to 88 points at the time of follow-up; there was no significant difference between the open-reduction and closed-treatment groups (p = 0.39). Twenty-seven patients (90%) had a good or excellent result. There were no dislocations or deep infections. The Kaplan-Meier ten-year survival rate, with revision or radiographic loosening as the end point, was 97%. These results were similar to those of the patients who underwent primary total hip arthroplasty for nontraumatic arthritis. CONCLUSIONS: The intermediate-term clinical results of total hip arthroplasty with cementless acetabular reconstruction for posttraumatic osteoarthritis after acetabular fracture were similar to those after the same procedure for nontraumatic arthritis, regardless of whether the acetabular fracture had been internally fixed initially. However, total hip arthroplasty after acetabular fracture was a longer procedure with greater blood loss, especially in patients with previous open reduction and internal fixation. Previous open reduction and internal fixation predisposed the hip to more intraoperative instability but less bone deficiency.     

Revision of failure acetabular components with cementless acetabular components

Outcomes of cemented acetabular components show unacceptably high rates of loosening over the short-term, and increased failure over the long term. The use of uncemented acetabular components with porous coatings and supplemental screw fixation has improved the success rates of revision surgery with bone loss. Intermediate follow-up results of uncemented acetabular components for revision surgery suggest excellent outcomes with superior fixation compared with cemented components. Use of large components that rely on the posterior column and acetabular dome for fixation appear to function satisfactorily, even in a significantly bone deficient acetabulum.     

环髋臼截骨成形术治疗陈旧性髋臼骨折

目的: 探讨治疗陈旧性难以复位的髋臼骨折的新方法。方法: 本组 6例, 男 5例, 女 1例, 年龄平均 33岁 (22~55岁), 骨折时间平均 3个月 (2 5~3 5个月), 骨折类型为骨盆环骨折并髋臼骨折, 髋臼骨折并中心性脱位或移位, 采用环髋臼内移截骨成形术。结果: 随访平均 3年 (1~6年), 关节无痛, 关节活动度及步态恢复正常。恢复原来工作。X线示关节间隙正常, 无股骨头坏死。髋臼指数 18°(16 ~22°), CE角平均 32°(28 ~35°)。优 5例, 良 1例。病人满意率 100%。结论: 治疗陈旧性难以复位的髋臼骨折可以应用环髋臼内移截骨成形术, 符合生物力学原则。     

Use of acetabular models in planning complex acetabular reconstructions

The number of patients requiring revision total hip arthroplasty continues to increase each year. Accurate preoperative planning is a key factor in obtaining a good result. Radiographis provide little information concerning the actual extent of the acetabular defects. Computed tomography-generated models ofthe acetabulium can provide the surgeon with accurate information concerning the size and location of the defects. Evaluation of radiographs and models in 24 cases showed that radiographs alone failed to detect all 13 anterior wall defects (P < .001), 8 of 18 posterior wall defects (44.4%, P < .001), and 8 of 19 segmental central defects (42%, P < .001), all of which were easily identified with the models. This study showed that preoperative planning based on the foam models accurately predicted the actual implant used in 22 of 24 cases (92%).     

Uncemented acetabular components for arthritis after acetabular fracture

The purpose of the current study was to evaluate the results of uncemented acetabular components used to treat posttraumatic arthritis after acetabular fracture at a minimum of 10 years. Thirty-four hips in 33 patients (mean age, 49.7 years, range, 19-78 years) were treated from 1984 to 1990 at one institution with a total hip arthroplasty using an uncemented titanium porous-coated socket. Four patients died before 10 years (all with implants intact). Nine patients had the acetabulum revised: four had the shell and liner revised (one for loosening, one for loosening and dislocation, and two for osteolysis) and five had the liner alone revised (three for polyethylene wear and two for dislocation). All patients with unrevised hip replacements who were alive and patients who were not lost to followup had no or minimal pain at final followup (range, 10-16 years); no components were radiographically loose. Uncemented sockets had a low rate of loosening in this challenging patient population, but polyethylene wear and osteolysis were problematic.     

Results for a custom acetabular component for acetabular deficiency

We report our experience with a triflanged titanium cementless custom-made acetabular implant in the management of complex major acetabular deficiency for revision total hip arthroplasty in 27 patients. The mean follow-up period was 58 months (range, 48-72 months). There were 9 men and 18 women. Clinical assessment was performed using Charnley's modification of the Merle d'Aubigne and Postel scoring system. Radiographic assessment was carried out using the DeLee and Charnley grading system. All patients had improved hip scores at latest examination. Six patients (22%) had complications. Two patients (7.4%) required further revision surgery. This procedure is technically demanding and has a high complication rate. Until better long-term results are shown, this procedure should be restricted to patients for whom a Girdlestone pseudarthrosis is the only surgical alternative.     

Periprosthetic acetabular bone loss using a constrained acetabular component

We describe two patients with a constrained acetabular component who required treatment for recurrent dislocation showing postoperative periprosthetic acetabular bone loss. These hips required revision surgery and demonstrated considerable bone loss caused by the migrated acetabular component. Impingement may have occurred with increased stress at the bone-prosthesis interface, and the sharp ends of screws with a metal shell may have gradually plowed up the acetabular bone. These failures illustrate the potential risk of using a constrained acetabular component.     

The Kerboull acetabular reinforcement device in major acetabular reconstructions

Sixty consecutive revision total hip arthroplasties were performed with bulk allograft bone supported by the Kerboull reinforcement acetabular device in 53 patients from 1980 to 1987. The average age of the patients at the time of hip revision was 57.7 years. Acetabular bone loss according to the American Academy of Orthopaedic Surgeons grading system was Type III for 48 hips in 41 patients and Type IV for 12 hips in 12 patients. Three failures, defined as radiologic loosening of the socket, revised or not, were reported in this series at a mean 8-year followup. Eight patients died of unrelated causes at a mean of 5 years. No patient was lost to followup. The mean followup of the series was 10 years +/- 3 years. The mean preoperative Merle d'Aubigné hip functional score was 11.7 +/- 2.4 versus 17.4 +/- 0.6 at the latest followup. Consolidation of the graft was considered completed in all 60 hips and occurred by 12 months. Remodeling of the graft proceeded for 3 to 4 years. The survival rate at 13 years was 92.1% +/- 5% using loosening of the acetabular component as the end point. This study indicated that acetabular allograft reconstructions reinforced by the Kerboull acetabular device were able to provide satisfactory long-term clinical and radiologic results.