髂腹股沟下入路在髋臼骨折治疗中的初步应用

目的 探讨采用髂腹股沟下入路治疗累及髋臼前方和内侧壁或合并髋关节前方损伤的髋臼骨折的可行性和优缺点.方法 对2008年5月至2010年1月采用切开复位内固定治疗的17例累及髋臼前方、内侧壁或合并髋关节前方损伤的髋臼骨折患者资料进行回顾性研究,男13例,4例;年龄23～55岁,平均39.5岁;左侧11例,右测6例.根据Letournel-Judet分类:前壁骨折2例,前柱骨折6例,前柱伴后方半横形骨折4例,双柱骨折3例,T型骨折2例.采用单一髂腹股沟下入路8例,髂腹股沟下+Kocher-Langenbeck(K-L)联合入路9例.结果 所有患者随访4～24个月,平均8.7个月,骨折愈合时间平均为14周,无切口感染,内固定松动、断裂,医源性坐骨神经或股神经损伤发生.3例患者发生Brooker Ⅰ级髋关节周围异位骨化,5例出现无症状的髂前上棘截骨处骨赘形成.根据Matta髋臼骨折复位标准:解剖复位12例,满意复位5例.按照髋关节功能的d'Aubigne和Postel标准:优13例,良3例,可1例.结论 髂腹股沟下入路可提供扩大的髋臼前壁、内侧壁及髋关节前方结构的手术显露,有利于累及髋臼前方和内侧壁或合并髋关节前方结构损伤的髋臼骨折的手术操作,对于经典的髂腹股沟入路是一良好的改进和补充.     

经腹直肌外侧入路与髂腹股沟入路手术治疗骨盆髋臼骨折的疗效比较

目的比较腹直肌外侧入路与髂腹股沟入路手术治疗骨盆髋臼骨折的临床疗效。方法纳入自2017-12—2018-12诊治36例的骨盆髋臼骨折,行切开复位内固定手术,18例采用腹直肌外侧入路(腹直肌外侧入路组),18例采用髂腹股沟入路(髂腹股沟入路组)。结果 36例均获得随访,随访时间平均18(7~32)个月。腹直肌外侧入路组术中出现1例髂外静脉损伤,1例腹膜损伤,1例闭孔神经损伤。髂腹股沟入路组出现2例股外侧皮神经损伤,2例血管栓塞,2例腹股沟疝。与髂腹股沟入路组比,腹直肌外侧入路组手术时间较短,术中出血量较少,差异有统计学意义(P <0.05)。2组骨折复位质量、术后6个月髋关节功能比较差异无统计学意义(P>0.05)。结论与髂腹股沟入路相比,腹直肌外侧入路手术治疗骨盆髋臼骨折可充分显露四边体骨折,便于骨折复位及钢板置入,进而缩短手术时间并减少术中出血量。     

改良Stoppa入路与髂腹股沟入路手术治疗髋臼骨折疗效比较

目的比较采用改良Stoppa入路与髂腹股沟入路切开复位内固定治疗髋臼骨折的效果。方法回顾性分析自2011-01—2016-06行切开复位内固定治疗的32例髋臼骨折,16例采用改良Stoppa入路(观察组),16例采用髂腹股沟入路(对照组)。比较2组切口长度、手术时间、术中出血量、切口引流量、住院时间,术后骨折复位质量,以及末次随访时髋关节功能Harris评分。结果 32例均获得随访,随访时间平均13(8~25)个月。观察组切口长度较对照组短,差异有统计学意义(P0.05);但2组手术时间、术中出血量、切口引流量、住院时间、骨折复位质量、末次随访时髋关节功能Harris评分比较差异无统计学意义(P0.05)。结论改良Stoppa入路和髂腹股沟入路切开复位内固定治疗髋臼骨折均可获得满意的疗效,但改良Stoppa入路手术切口小,软组织损伤少,显露良好,能直视四边体骨折,骨折复位质量可靠。     

Stoppa入路与髂腹股沟入路在髋臼骨折中的应用对比分析

目的比较髂腹股沟入路与Stoppa入路治疗骨盆及髋臼骨折的临床疗效。方法我院2012年6月至2015年6月收治的120例骨盆及髋臼骨折患者随机分为两组,A组和B组各60例,A组采用髂腹股沟入路,B组采用Stoppa入路,比较两组切口长度、出血量、手术时间、骨折复位质量、髋关节功能以及并发症。结果两组切口长度、出血量及手术时间的对比,差异具有统计学意义(P0.05);A组骨折复位质量和髋关节功能优良率分别为83.3%和88.3%,与B组的90.0%和91.7%对比,差异无统计学意义(P0.05);B组并发症发生率为3.3%,明显低于A组的15.0%(P0.05)。结论与髂腹股沟入路相比,Stoppa入路治疗骨盆髋臼骨折在切口长度、出血量、手术时间及并发症方面具有明显优势,值得临床进一步推广和运用。     

改良前入路髂腹股沟切口治疗骨盆及髋臼骨折的病例对照研究

目的：通过对63例骨盆及髋臼骨折患者手术前入路的治疗过程回顾性分析,获得改良髂腹股沟入路方法.方法：自2006年1月至2013年1月应用髂腹股沟前入路手术治疗骨盆、髋臼骨折63例,男45例,女18例;年龄12～68岁,平均（37.71±13.41）岁.分别选用标准前入路和改良前入路手术处理,标准前入路（A组）手术处理37例,男26例,女11例,年龄（38.49±13.64）岁;改良前入路（B组）手术治疗26例,男19例,女7例,年龄（36.62±13.29）岁.观察比较两组手术切口（从切皮至完成髂腹股沟前方3个“窗口”）暴露时间、其间失血量、切口关闭时间,并采用Majeed功能评分比较两组治疗效果.结果：两组比较,B组手术从切皮至完成髂腹股沟前方3个“窗口”暴露时间较短（P=0.006）,失血量（暴露过程中出血）较少（P=0.002）,关闭髂腹股沟切口时间短（P=0.002）,而两组治疗效果差异无统计学意义.术后全组获得随访,时间3～36个月,平均（18.6±9.2）个月.术后随访期间未发现内固定松动及螺钉钢板断裂.骨折复位情况根据Matta标准评定：A组优28例,良8例,可1例;B组优20例,良5例,可1例.髋关节功能根据Ma-jeed评分标准,A组优20例,良12例,中4例,差1例,平均（82.51±9.72）分;B组优13例,良10例,中3例,差0例,平均分（80.54±10.79）分.结论：改良入路能提供良好的术野暴露范围,不易损伤到腹股沟韧带下方股神经及股动静脉,无须切开腹股沟管,可以避免出现腹股沟疝的发生,也减少了手术步骤,缩短了操作时间.     

单一髂腹股沟入路联合顺行拉力螺钉治疗髋臼骨折

目的 探讨单一髂腹股沟入路联合顺行拉力螺钉治疗髋臼骨折的疗效。方法 采用单一髂腹股沟入路联合顺行拉力螺钉治疗8例髋臼骨折患者。记录复位质量、愈合时间、髋关节功能及并发症发生情况。结果患者均获得随访,时间12～18(14. 5±3. 2)个月。术后切口周围软组织感染1例,经引流及抗感染治疗后伤口愈合。术后2例出现患侧大腿前外侧麻木,术后3个月逐渐消失。术后按Matta评分标准评价髋臼骨折复位质量:优6例,良1例,差1例。骨折均愈合,时间10～16(12. 5±3. 6)周。末次随访时采用改良Merle d'AubignéPostel评分标准评定患髋功能:优7例,良1例。结论 采用单一髂腹股沟入路联合顺行拉力螺钉治疗髋臼骨折,复位好,固定有效,创伤小,效果好。     

髂腹股沟入路与改良Stoppa入路治疗髋臼骨折及比较

髋臼骨折的手术治疗仍然具有一定的挑战,手术成功的关键之一在于手术入路的选择。髂腹股沟入路是治疗髋臼骨折的经典前方入路,近年有文献报道采用改良Stoppa入路代替原本应用髂腹股沟入路治疗髋臼骨折,并取得满意效果。该文通过文献回顾,就髂腹股沟入路和改良Stoppa入路的手术暴露要点、临床疗效、并发症和禁忌证等作一综述,以明确两者的优缺点。     

髂腹股沟入路手术治疗髋臼骨折

目的 探讨应用髂腹股沟入路手术治疗髂臼骨折的实用性。方法 应用该切口手术治疗髋臼前方骨折18例，采用髋臼钢板或钢丝张力带固定，结果 12例达解剖复位，5例满意复位，平均随访3年，髋关节功能优良率77.8%。结论 髂腹股沟入路是手术治疗髋臼前柱骨折的较理想的入路。     

经改良髂腹股沟入路治疗髋臼骨折的疗效观察

目的探讨经改良髂腹股沟入路治疗髋臼骨折的优缺点及疗效观察。方法经改良髂腹股沟入路(部分联合K-L入路)应用骨盆重建钢板内固定治疗髋臼骨折12例。结果术后8~14个月显示骨折骨性愈合,按Matta标准评估:解剖复位9例,满意复位2例,复位欠佳1例。结论改良髂腹股沟入路具有解剖相对简单,创伤小,复位质量高,并发症少等优点。     

经单一髂腹股沟入路治疗复合髋臼骨折

目的评价经单一髂腹股沟入路治疗某些复合类型髋臼骨折的疗效。方法自1994年6月～2003年10月,通过单一髂腹股沟入路手术治疗46例复合类型髋臼骨折,对患者的功能结果和并发症进行随访。结果有完整随访结果者40例,平均随访40.4个月,40例骨折全部愈合,未发生感染。异位骨化发生率为2.5%(1例)。髋关节功能优良率为82.5%。结论髋臼骨折中,前方伴后半横形骨折、大部分双柱骨折及有些T形骨折可以通过单一髂腹股沟入路完成骨折的复位及内固定,手术中能达到解剖复位或接近解剖复位,术后功能良好。经单一入路完成手术减少了手术创伤,可以及早进行功能锻炼,且术后并发症发生率较低。     

髂腹股沟微创切口内固定技术在骨盆骨折中的应用

目的研究采用髂腹股沟微创切口内固定技术治疗髋臼前柱或耻骨支骨折的疗效及特点。方法自2007年7月至2011年9月,对31例骨盆骨折患者（其中耻骨支骨折23例,髋臼前柱骨折8例）采用髂腹股沟微创切口内固定技术治疗。患者采用全麻或腰硬联合麻醉,取传统髂腹股沟入路的内外侧两端切口,分别自内外两个切口紧贴骨面向中间潜行剥离,相互贯通,形成耻骨支、髋臼前柱相通的隧道,并用骨膜剥离器撬拨扩大通道。根据通道内骨面预弯重建钛板,自外侧切口紧贴骨面插入预弯钛板,分别于钛板远近端钻孔拧入3枚左右螺钉固定钢板。结果本组患者获得5～29个月随访,平均14.1个月。骨折全部临床愈合。按照Matta复位标准,术后解剖复位14例,复位良好16例,复位较差1例,优良率96.7%。按照Majeed评分,优19例,良11例,可1例,优良率96.7%。无感染、股神经或股血管损伤、静脉血栓、异位骨化及骨关节炎和股骨头缺血坏死等并发症发生。结论应用髂腹股沟微创切口内固定技术治疗骨盆骨折,手术创伤小、手术时间短、手术安全性高、术后并发症少、功能恢复好。     

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.     

Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

Introduction

Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation.

Methods

This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients.

Results

The average time to operation was 4 days. Average blood loss was 110 mL. Operative time averaged 95 min. Maximum fracture displacement averaged 10 mm preoperatively and 1.3 mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d’Aubigné score, functional outcome was good to excellent in all patients.

Discussion and conclusion

Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures.     

髂腹股沟微创小切口内固定治疗髋臼前柱或耻骨支骨折

 目的 探讨经髂腹股沟微创小切口内固定治疗髋臼前柱或耻骨支骨折的临床效果。 方法 2008 年6 月至2011 年6 月, 对16 例髋臼前柱骨折、10 例耻骨支骨折患者采用髂腹股沟微创小切口内 固定治疗。所有患者均采用全麻, 于髂结节至髂前上棘做3~5 cm 斜行切口, 沿髂骨内侧骨膜下剥离至 髂前下棘、髂耻隆起、髋臼前柱, 再于耻骨结节向外2~3 cm 横行切口, 沿耻骨支前上方骨膜下剥离显露 耻骨支, 两个切口分别向中间潜行剥离后形成沿耻骨支髋臼前柱相贯通的骨膜下隧道, 复位骨折, 将重 建钛板预弯后导入隧道, 固定骨折。 结果 根据Matta标准, 术后解剖复位13 例, 复位良好11 例, 复位 较差2 例。23 例患者获得平均15.6 个月随访(6~30 个月)。髋关节功能按照D’Aubigne 评分:优13 例, 良6 例, 可4 例。骨盆功能按照Majeed评分:优12例, 良9 例, 可2 例。无感染、股神经或股血管损伤、静 脉血栓、异位骨化等并发症发生。 结论 经髂腹股沟微创小切口内固定治疗髋臼前柱或耻骨支骨折创 伤小, 手术时间短, 安全性相对较高。髂耻前柱放置钢板对钢板塑形的要求低, 固定可靠。     

复合型髋臼骨折治疗的临床研究

目的：探讨采用手术方法治疗复合型髋臼骨折的疗效。方法：回顾分析58例患者，按Letournel分类，后壁伴后柱骨折15例，横形伴后壁骨折17例，T型骨折6例，双柱骨折12例，前柱骨折伴后半横形骨折8例。根据不同的骨折类型，选择髂腹股沟入路7例，Kocher—Langenbech入路9例，联合入路31例，延长髂股入路11例，全部采用重建钢板进行固定。结果：58例患者，平均随访时间14．6个月，根据Matta评分，优41例，良9例，可7例，差1例。异位骨化3例，中重度创伤性关节炎2例，股骨头坏死1例，骨折块有移位2例。结论：术前正确分析骨折类型，选择合适的手术入路及及时的手术是提高髋臼骨折治疗效果的关键。     

Short-term results of surgical treatment of acetabular fractures using the modified Stoppa approach

BackgroundAs the more commonly used ilioinguinal approach is extensive and associated with complications arising from the dissection along the inguinal canal, we attempt to evaluate the efficacy of the modified Stoppa approach as an alternative in the operative management of acetabular fractures.MethodsTwenty-three patients with acetabular fractures, were operated by the modified Stoppa approach. Fractures were classified; operative time and blood loss were recorded; the radiological and clinical outcomes were prospectively analysed. We analysed the radiological results according to the criteria of Matta and the clinical results by the Merle d’Aubigne and Postel score with a mean follow up of 15.13 months.ResultsThe clinical outcomes were excellent or good in nineteen cases, fair and poor in two patients each. In eighteen of our cases the reduction was anatomic, imperfect in two cases, and poor in three cases. The mean pre-operative displacements on axial, sagittal and coronal NCCT sections were 3.8, 3.1 and 3.6 mm, respectively; and mean post-operative displacements were 0.2, 0.3 and 0.2 mm, respectively. The mean pre-operative and post-operative fracture gap were 12.8 mm and 1.1 mm respectively.ConclusionsMinimizing perioperative morbidity and simultaneously allowing access for anatomical reduction are the major benefits of the approach. The modified Stoppa approach can substitute the ilioinguinal approach for the surgical fixation of acetabular fractures.     

Short-term results of surgical treatment of acetabular fractures using the modified Stoppa approach

BackgroundAs the more commonly used ilioinguinal approach is extensive and associated with complications arising from the dissection along the inguinal canal, we attempt to evaluate the efficacy of the modified Stoppa approach as an alternative in the operative management of acetabular fractures.MethodsTwenty-three patients with acetabular fractures, were operated by the modified Stoppa approach. Fractures were classified; operative time and blood loss were recorded; the radiological and clinical outcomes were prospectively analysed. We analysed the radiological results according to the criteria of Matta and the clinical results by the Merle d’Aubigne and Postel score with a mean follow up of 15.13 months.ResultsThe clinical outcomes were excellent or good in nineteen cases, fair and poor in two patients each. In eighteen of our cases the reduction was anatomic, imperfect in two cases, and poor in three cases. The mean pre-operative displacements on axial, sagittal and coronal NCCT sections were 3.8, 3.1 and 3.6 mm, respectively; and mean post-operative displacements were 0.2, 0.3 and 0.2 mm, respectively. The mean pre-operative and post-operative fracture gap were 12.8 mm and 1.1 mm respectively.ConclusionsMinimizing perioperative morbidity and simultaneously allowing access for anatomical reduction are the major benefits of the approach. The modified Stoppa approach can substitute the ilioinguinal approach for the surgical fixation of acetabular fractures.     

相对微创有限切开髂腹股沟入路重建钢板内固定治疗髋臼骨折的临床疗效分析

目的 探讨相对微创有限切开髂腹股沟入路重建钢板内固定治疗髋臼骨折的临床疗效。方法 回顾性分析2013年3月至2017年3月在我院采用相对微创有限切开髂腹股沟入路重建钢板内固定治疗的15例髋臼骨折病人,其中男9例,女6例,年龄为（44.13±8.64）岁（28~58岁）,左侧6例,右侧9例,高处坠落伤7例,车祸伤8例。按Letournel分型,双柱骨折6例,前柱骨折2例,T形骨折4例,横行骨折3例,骨折移位均超过3 mm。术后采用Matta、Merle d''Aubigne和Postel标准评价髋关节功能。结果 病人手术时间为（2.70±0.49） h（2.0~3.5 h）,术中出血量为（413.33±130.20） ml（200~600 ml）;骨折均愈合,愈合时间为（16.93±2.66）周（14~24周）。所有病人均获得随访,随访时间为（14.00±2.95）个月（9~20个月）。依据Matta评定标准,优8例,良5例,差2例,优良率为86.67%。按Merle d''Aubigne和Postel的标准评价髋关节功能,优7例,良6例,可2例,优良率为86.67%。异位骨化Ⅰ度1例。1例发生创伤性关节炎,予保守治疗。短期随访无股外侧皮神经损伤、股骨头缺血性坏死、切口感染及骨折不愈合等并发症发生。结论 相对微创有限切开髂腹股沟入路重建钢板内固定治疗髋臼骨折复位效果良好、并发症发生率较低,短期疗效满意。