Combined Anterior Pelvic (CAP) approach for fracture acetabulum fixation - Functional outcome evaluation and predictors of outcome

ObjectiveIlio-inguinal approach has been considered standard anterior approach for acetabulum fracture fixation. Different modifications of this approach have been described. This study analysed the patients treated using a Combined Anterior Pelvic (CAP) approach - minimal AIP (anterior intra-pelvic) with modified ilio-femoral along with ’anterior superior iliac spine’ osteotomy. This combined approach provides wide exposure of pelvis to direct visualise the entire anterior column from sacroiliac joint to pubic symphysis, medial side of quadrilateral plate and entire iliac wing with minimal retraction of soft tissues required.MethodsData of patients treated from July 2014 to June 2018 for acetabulum fracture using CAP approach was retrieved from hospital record system. Inclusion criteria were - acetabulum fractures treated surgically using CAP approach. Exclusion criteria were – age less than 18 years, associated pelvis ring injury and incomplete peri-operative radiological record (pre-operative/post-operative antero-posterior, 45° obturator and 45° iliac oblique radiographs and pre-operative computed tomographic (CT) scans. 62 patients who met inclusion exclusion criteria were called in out-patient-department for final functional evaluation using Matta modified Merle d’aubigne score.ResultsOut of 62 patients 47 patients who turned up for final functional evaluation were included in study. 19 patients had excellent, 15 had good, 2 had fair and 11 had poor results. Age less than 40 years, anterior column fracture pattern, Pre-operative fracture displacement >20 mm, fracture comminution and post-operative fracture reduction within 3 mm were the predictors of the functional outcome. When analysed using logistic regression model, post-operative fracture reduction was found to be the only significant predictor of functional outcome.ConclusionCAP approach is useful anterior approach to acetabulum. Fracture reduction is the independent predictor of functional outcome. Comparison of this approach with other anterior approaches to acetabulum can be area of further research.     

重组核因子κB活化因子受体蛋白预防小鼠骨质疏松的研究

目的:探讨Stoppa入路结合后方经皮钢板技术治疗C型骨盆骨折的临床疗效.方法:2009年6月至2011年7月,采用Stoppa入路重建钢板固定骨盆前环骨折结合后方经皮重建锁定钢板固定骨盆后环骨折的技术治疗16例C型骨盆骨折患者,男11例,女5例;年龄22～59岁,平均38.8岁.按照Tile分型:C1型10例,C2型4例,C3型2例.采用Tometta评估标准评定骨折复位情况,采用Majeed评分标准评定术后功能情况.结果:16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200～500 ml,平均280 ml.骨盆骨折的愈合时间为12～16周,平均14周.骨折复位按照Tometta评估标准:优9例,良6例,可1例.术后功能评定按Majeed评分标准:优9例,良5例,可2例.结论:Stoppa入路重建钢板固定骨盆前环骨折结合后方经皮重建锁定钢板固定骨盆后环骨折技术治疗C型骨盆骨折具有创伤小、手术操作安全、并发症少、固定牢靠、可早期活动的优点,是一种比较理想的微创手术方法.     

Surgical exposures and options for instrumentation in acetabular fracture fixation: Pararectus approach versus the modified Stoppa

BackgroundAs an alternative to the modified Stoppa approach, the Pararectus approach is used clinically for treatment of acetabular fractures involving the anterior column. The current study assessed the surgical exposure and the options for instrumentation using both of these approaches.MethodsSurgical dissections were conducted on five human cadavers (all male, mean age 88 years (82–97)) using the modified Stoppa and the Pararectus approach, with the same skin incision length (10 cm). Distal boundaries of the exposed bony surfaces were marked using a chisel. After removal of all soft-tissues, distances from the boundaries in the false and true pelvis were measured with reference to the pelvic brim. The exposed bone was coloured and calibrated digital images of each inner hemipelvis were taken. The amount of exposed surface using both approaches was assessed and represented as a percentage of the total bony surface of each hemipelvis. For instrumentation, a suprapectineal quadrilateral buttress plate was used. Screw lengths were documented, and three-dimensional CT reconstructions were performed to assess screw trajectories qualitatively. Wilcoxon's signed rank test for paired groups was used (level of significance: p < 0.05).ResultsAfter utilization of the Pararectus approach, the distances from the farthest boundaries of exposed bone towards the pelvic brim were significantly higher in the false but not the true pelvis, compared to the modified Stoppa approach. The percentage (mean ± SD) of exposed bone accessible after utilizing the Pararectus approach was 42 ± 8%, compared to 29 ± 6% using the modified Stoppa (p = 0.011). In cadavers exposed by the Pararectus approach, screws placed for posterior fixation and as a posterior column screw were longer by factor 1.8 and 2.1, respectively (p < 0.05), and screws could be placed more posteromedial towards the posterior inferior iliac spine or in line with the posterior column directed towards the ischial tuberosity.ConclusionCompared to the modified Stoppa, the Pararectus approach facilitates a greater surgical access in the false pelvis, provides versatility for fracture fixation in the posterior pelvic ring and allows for the option to extend the approach without a new incision.     

Treatment results for acetabulum fractures using the modified Stoppa approach

Objectives

The aim of this study was to evaluate the clinical and radiological results of the surgical treatment of acetabular fractures using modified Stoppa approach.

Comparison of Therapeutic Outcomes of Transabdominal Pararectus Approach and Modified Stoppa Approach in Treating Pelvic and Acetabular Fractures

ObjectivePelvic and acetabular fractures are common orthopedic diseases, and this research was to investigate the therapeutic effects of pararectus and Stoppa approaches in treating complex pelvic acetabular fractures.MethodsThe clinical information of patients with pelvic and acetabular fractures treated surgically in Lu''an Hospital of Chinese medicine, China from January 2016 to April 2020 was analyzed. There were 30 cases each in the transabdominal pararectus approach and modified Stoppa approach groups. The operation time, incision length, blood loss, and postoperative complications of both groups were recorded according to the Merle d''Aubigné-Postel hip score. The recovery of hip function was evaluated 6 months after surgery, and the clinical and therapeutic efficacies of the two groups were compared.ResultsThe patients were followed up for 6–7 months (average, 6.5 months). The average operation time, incision length, and blood loss in the pararectus and Stoppa approach groups were 180 ± 41.105 min, 8.667 ± 1.373 cm, 259.667 ± 382 mL and 202.667 ± 32.793 min, 11.600 ± 1.958 cm, and 353.667 ± 590 mL, respectively. The satisfactory rate of fracture reduction, excellent and good rate of hip function score, and incidence of complications were 28/30, 27/30, 1/30 and 25/30, 25/30, 3/30, respectively. There were significant differences in operation time, incision length, and blood loss between the two groups (p < 0.05). However, there was no significant difference in the excellent and good rate of hip function score, fracture reduction satisfaction, and complication rate between both groups (p > 0.05).ConclusionsThe pararectus approach can reveal the better anatomical structure of the pelvis and acetabulum, such as the corona mortis and quadrilateral plate, for conducive fracture reduction and fixation. It can also effectively shorten the length of the incision, reduce operative blood loss, and shorten the operation time. It is a better choice for the clinical treatment of complex pelvic and acetabular fractures.     

切开复位内固定术治疗复杂型髋臼骨折疗效分析

髋臼骨折系人体最深在的大关节内骨折。若行保守治疗，髋关节头臼的解剖关系难以复位；而手术治疗的效果不确定，术后并发症较多。而复杂髋臼骨折(complex acetabular fracture，CAF)是导致髋关节对应关系改变、头臼吻合机制紊乱的严重损伤。近年来，随着开放复位内固定技术的不断成熟，髋臼骨折的远期疗效有了显著提高。有资料统计，其满意率为74％～90％。wright等证实，应用手术治疗CAF使其达到解剖复位能降低创伤性关节炎的发病率。如何提高CAF疗效，仍是临床上须重点研讨的课题之一。     

微创经皮桥接钢板技术治疗真骨盆缘完整的髋臼前柱骨折的疗效分析

目的 :探讨微创经皮桥接钢板技术治疗真骨盆缘完整的髋臼前柱骨折的可行性和疗效分析。方法 :对2013年5月至2015年12月收治的8例真骨盆缘完整的髋臼前柱骨折患者进行回顾性分析,根据Judet-Letournel分型,均为单纯的髋臼前柱不稳定骨折。其中男5例,女3例;年龄22~63岁,平均42.8岁;挤压伤4例,压砸伤3例,高处坠落伤1例。受伤至手术时间5~19 d,平均9.5 d。术前CT显示髋臼高位前柱骨折,骨盆真骨盆缘完整,骨折端分离均1 cm。所有患者采用闭合复位微创经皮桥接钢板固定技术治疗。观察并记录患者的骨折复位质量、手术时间、术中出血量、骨折愈合时间、末次随访时的髋关节功能及术后并发症发生情况等。结果:8例患者均获得随访,时间10~19个月,平均14.5个月。依据Matta影像学评分标准评定骨折复位质量,解剖复位4例,复位良好3例,复位较差1例。手术时间30~80 min,平均51.3 min;术中出血量50~120 ml,平均86.2 ml;骨折愈合时间10~19周,平均13.3周。末次随访时髋关节功能采用Merle D’Aubigne评分系统评定:优5例,良2例,可1例。8例患者术后均无血管神经损伤、伤口感染、术中大出血、下肢深静脉血栓形成等并发症发生。结论:微创经皮桥接钢板技术治疗真骨盆缘完整的髋臼前柱骨折具有创伤小、出血少、恢复快、疗效好等优点,是一种治疗髋臼前柱骨折的良好手术方式。     

前后路联合切口治疗严重移位的髋臼骨折

目的总结应用前后路联合切口治疗累及双柱髋臼骨折的治疗经验。方法应用前后路联合切口治疗累及双柱的髋臼骨折25例。根据Letournel分型：横形骨折3例，横形加后壁骨折8例，双柱骨折9例，T形骨折5例。手术首先在移位明显的一侧进行。15例先选择前入路，后采用后路；10例先选择后入路，后采用前路。结果平均随诊23．2个月。根据改良的Merled Aubigne和Postel评分标准评价临床结果，其中优4例，良14例，一般3例，差4例，优良率为72％。2例出现深部感染，2例发生股骨头坏死，严重异位骨化的发生率为12％。结论对累及双柱的髋臼骨折，当一侧入路不能完成复位及内固定时，选择前后路联合入路可提高手术效果。     

经腹直肌外侧切口入路联合跟骨异形钢板内固定治疗累及四边体的髋臼骨折

目的：探讨应用经腹直肌外侧切口入路联合翼形跟骨钢板治疗累及四边体的髋臼骨折和骨盆后柱骨折的疗效。方法：回顾性分析2017年1月至2021年4月收治的累及四边体的髋臼骨折和骨盆后柱骨折患者21例,其中男12例,女9例;年龄21～73(43.23±6.45)岁。所有患者采用经腹直肌外侧切口入路联合翼形钢板切开复位内固定治疗,其中12例骨盆合并前后柱骨折,7例髋臼骨折并累及四边体,2例髋臼骨折伴中心性脱位。结果：21例患者均获得随访,时间12～36(18.60±6.45)个月,骨折均愈合。术后根据Matta影像学复位评价：11例骨盆前后柱骨折为解剖复位,1例为满意复位,7例累及四边体的髋臼骨折为解剖复位,1例伴中心型脱位为解剖复位,1例为满意复位。改良Merle D’Aubigne-Postel髋关节评分13～17分。结论：腹直肌外侧切口入路辅以联合翼形钢板治疗累及四边体的复杂髋臼、骨盆骨折可以获得良好的放射学及临床结果,对复杂骨盆骨折及髋臼四边体骨折的治疗具有优越性。     

切开复位内固定治疗有移位髋臼骨折的疗效分析

目的观察切开复位内固定治疗有移位髋臼骨折的远期疗效,并分析影响远期疗效的相关因素.方法本组按Letournel-Judet分型简单骨折23例,复杂骨折31例,骨折移位≥3 mm,合并髋关节后脱位16例,中心性脱位13例,股骨头软骨面损伤17例.均采用切开复位钢板螺钉内固定,其中伤后2周内手术42例,3周后手术12例.结果术后平均随访38个月,Matta关节评分＞15分、Liebergall影像学评价A、B的病例43例,优良率79.6%,3年后全髋置换5例,占9.3%.结论切开复位内固定能使髋臼恢复正常解剖形态,有利于关节功能的恢复,远期疗效较好;Letournel-Judet骨折分型、股骨头软骨面是否损伤、骨折后手术时间以及复位质量是主要影响因素,提示髋臼创伤骨折的严重程度直接影响其预后.     

髂腹股沟微创小切口在骨盆前环损伤中的应用

目的：探讨有限切开,微创内固定治疗骨盆前环损伤的可行性、技术要点及临床效果。方法：2009年3月至2012年3月,选择经髂腹股沟微创小切口内固定治疗骨盆前环损伤患者20例,男13例,女7例;年龄25-61岁,平均41．6岁。前环损伤按Tile分型：A2型5例,B1型2例,B2型9例,B3型1例,C1型3例。单纯前环骨折15例,前环骨折合并耻骨联合分离2例,前后环均骨折3例。观察内容包括手术时间、术中出血量、股神经及髂血管损伤情况、术后骨折复位情况等。结果：所有患者伤口I期愈合,无感染、深静脉血栓、股神经及髂血管损伤等并发症发生。根据Matta复位标准,优12例,良7例,可1例。18例患者获得随访,时间6～32个月,平均16.3个月。根据Majeed疗效评价标准,优15例,良3例,Majeed评分94．3±6．0。结论：经髂腹股沟微创小切口内固定治疗骨盆前环损伤具有手术时间短、创伤小、术中出血少等优点,临床操作安全可行,疗效满意。     

侧卧位前后路联合手术治疗C型髋臼骨折

C型（Tile分类）髋臼骨折是高能量骨折,往往伴有其他部位的损伤,其创伤大,出血多,移位明显,非手术治疗易致髋部多种功能消失。本院自2003年8月至2007年12月收治该类骨折14例,通过侧卧位,前后路联合手术,取得满意疗效。     

骶髂关节前入路钢板治疗骨盆后环损伤17例

目的：评价骶髂关节前入路钢板治疗骨盆后环损伤的临床疗效。方法：回顾性分析骶髂关节前入路钢板治疗骨盆后环损伤17例临床效果。结果：17例中TileB型8例,C型9例,双钢板治疗5例,单钢板12例,手术时间平均3．6h（2．0-4．5h）,平均出血1800ml（800-4200m1）,14例随访平均27．4个月（6-42个月）,后环损伤平均移位16mm（4-28mm）,骨折愈合,轻度跛行3例。无感染发生。结论：骶髂关节前入路钢板治疗骨盆后环损伤能获得良好的复位和稳定的固定。     

改良Stoppa入路在骨盆髋臼骨折治疗中的初步应用

目的 探讨改良Stoppa入路在骨盆髋臼骨折治疗中的应用疗效.方法 2008年3月至2009年12月共收治26例骨盆骨折和9例髓臼骨折患者,男28例,女7例;年龄18～61岁,平均37岁.26例骨盆骨折按Tile分型:B1型2例,B2型4例,B3型7例;C1-1型4例,C1-2型2例,C1-3型4例,C2型3例.9例髋臼骨折按Letournel分型:前柱骨折1例,横形骨折3例,T形骨折2例,前柱伴后半横形骨折1例,双柱骨折2例.26例骨盆骨折中单独使用改良Stoppa入路10例,联合髂窝入路15例,联合后路1例.9例髋臼骨折中单独使用改良Stoppa入路3例,联合Kocher-Langenbeck入路4例,联合髂窝入路及Kocher-Langenbeck入路2例.结果 除1例患者外,其余34例患者的平均手术时间为90 min(65～135min),平均出血量为320 mL(150～1200 mL).术后根据Matta影像学评分,骨盆骨折前后环损伤均复位优;髋臼骨折解剖复位8例,满意复位1例.4例骨盆骨折患者失访,其余22例患者平均随访4个月,钢板断裂及螺钉松动各1例.2例髋臼骨折患者失访,其余7例患者获平均4个月随访,1例屈髋轻度受限,1例BrookerⅡ型异位骨化,无股骨头坏死.29例获随访患者骨折均获愈合,平均愈合时间为2.7个月(2.5～4.0个月).结论 改良Stoppa入路可单独或联合其他入路治疗骨盆髋臼骨折,其具有操作便捷、并发症少的优点.     

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。     

髋臼后柱骨折经皮逆行拉力螺钉固定的三维重建模型研究

目的 为髋臼后柱骨折经皮逆行拉力螺钉固定提供应用解剖学基础. 方法 收集60个正常成人骨盆的螺旋CT扫描数据,重建骨盆三维模型.模拟逆行拉力螺钉固定,在髋臼后柱置入虚拟三维圆柱体.计算其最大直径、长度、置入角度以及置入点(A)到坐骨结节远端(B)的距离.同时在相同的三维重建骨盆模型上,垂直髋臼内侧面对后柱进行重切,每间隔1 cm取一个截骨面,测量每个截骨面的内外径和上下径. 结果 男性半骨盆58个,女性半骨盆62个.虚拟三维圆柱体的平均最大直径为(13.16±1.45)mm,虚拟三维圆柱体与水平面、冠状面和矢状面的夹角分别为72.02°±6.05°、14.71°±6.98°和8.61°±3.96°,置入点位于坐骨结节内外侧缘的中线上,AB间距离为(15.18±1.97)mm.平均最小内外径和上下径分别为20.11 mm、19.19 mm,明显大于虚拟三维圆柱体的平均最大直径.虚拟三维圆柱体的直径、长度、与矢状面的夹角在男女之间的差异有统计学意义(P＜0.001). 结论 髋臼后柱可容纳7.3 mm的拉力螺钉,但男女的进针角度不同.螺钉的直径不能仅仅靠截骨面的直径确定.     

后侧手术入路治疗髋臼骨折的临床报告

髋臼骨折往往由高能量损伤所致,治疗不当可引起髋关节功能障碍,严重影响患者生活。2004年11月至2007年12月,对38例髋臼后部骨折的患者采用Kocher-Langenbeck人路行切复内固定治疗,取得良好疗效。     

前路钛板结合方形区螺钉内固定治疗涉及方形区的髋臼骨折

目的 探讨前路钛板结合方形区螺钉内固定治疗涉及方形区的髋臼骨折的疗效. 方法 2005年1月至2011年5月共收治52例涉及方形区的髋臼骨折患者,其中36例获得随访,男21例,女15例;年龄21～59岁,平均43.5岁.骨折按Letournel分型:双柱骨折15例,横形骨折4例,前柱伴后半横形骨折8例,T形骨折9例.所有患者均采用髂腹股沟入路,复位后行重建钛板及经钛板3 ～5枚皮质骨螺钉(方形区螺钉)部分经骨表面内固定.术后应用Matta放射学标准评估骨折复位质量,末次随访时采用改良Merle d'Aubigné和Postel评分标准评定髋关节功能. 结果 36例患者术后获12 ～ 72个月(平均41.7个月)随访.术后骨折复位质量按Matta放射学标准评定:解剖复位19例,良好复位12例,不满意复位5例,复位优良率为86.1％.所有患者骨折均获临床愈合,愈合时间为2～4个月,平均3个月.末次随访时采用改良Merle d'Aubigné和Postel评分标准评定髋关节功能:优16例,良13例,可5例,差2例,优良率为80.6％.本组患者功能优良率与骨折复位质量呈明显正相关(r=0.513,P=0.001).无一例患者发生方形区螺钉松脱、断裂.结论 前路钛板结合方形区螺钉内固定可靠,无进入髋关节腔之虞,是治疗以前柱损伤为主的双柱骨折、向前移位的横形骨折、部分前柱合并后半横形骨折及部分T形骨折的有效方法之一.     

髋臼及其周围肿瘤的分区与重建方法

目的 回顾性分析髋臼及其周围恶性肿瘤行整块切除、不同方法髋臼重建的疗效.方法 72例髋臼及其周围恶性肿瘤患者接受了肿瘤整块切除、髋臼重建手术,男42例,女30例;年龄16～78岁,平均41岁.软骨肉瘤39例、骨肉瘤10例、骨巨细胞瘤9例、Ewing肉瘤5例、恶性纤维组织细胞瘤3例、恶性神经鞘瘤2例、血管外皮瘤l例、单发转移癌3例.肿瘤累及Ⅱ区、Ⅰ+Ⅱ区、Ⅱ+Ⅲ区、Ⅰ～Ⅲ区、Ⅰ～Ⅳ区和Ⅱ+Ⅲ+Ⅴ区者分别为4、16、29、7、10和6例.髋臼重建包括组配式人工半骨盆50例、马鞍式关节置换7例、骨盆灭活再植8例、股骨近端与盆骨融合7例.结果 61例获得随访,平均随访3.5年(1～8年).11例局部复发,8例深部感染,6例脱位.45例行组配式人工半骨盆置换术患者ISOLS评分平均22分.优7例、良24例、可9例、差5例.其中优良病例均为累及Ⅱ区和Ⅱ+Ⅲ区者,评分差的病例均为累及Ⅳ区者.5例行马鞍式关节置换、5例骨盆灭活再植和6例股骨近端与盆骨融合术患者,ISOLS评分平均为10、17和14分.结论 髋臼周围肿瘤切除后重建方法以组配式人工半骨盆置换术后功能最好,骨盆灭活再植次之,马鞍式关节置换术后功能最差.组配式人工半骨盆置换对单纯Ⅱ区肿瘤切除重建功能最好,其次为Ⅱ+Ⅲ区、Ⅰ+Ⅱ区、Ⅰ～Ⅲ区、Ⅱ+Ⅲ+Ⅴ区,术后功能最差为Ⅰ～Ⅳ区.     

介入治疗骨盆骨折大出血(附44例报告)

目的 探讨介入栓塞髂内动脉治疗骨盆骨折大出血的可行性。方法 对44例骨盆骨折大出血合并失血性休克的患者进行动脉造影,发现41例髂内动脉或其分支出血,并对出血动脉进行了栓塞。结果 41例髂内动脉栓塞中39例成功,2例栓塞成功后血压又下降,终因失血性休克而死亡。结论 介入栓塞出血血管是治疗骨盆骨折大出血行之有效的措施,具有快速、准确、干扰小的优点。