Conservatively treated acetabular fractures: A retrospective analysis

Background:

There are a few studies reporting the long term outcome of conservatively treated acetabular fractures. The present study aims to evaluate the quality of reduction, and radiological and functional outcome in displaced acetabular fractures treated conservatively.

Materials and Methods:

Sixty-nine patients (55 men and 14 women) with 71 displaced acetabular fractures (mean age 38.6 years) managed conservatively were retrospectively evaluated. There were 11 posterior wall, 5 posterior column, 6 anterior column, 13 transverse, 2 posterior column with posterior wall, 9 transverse with posterior wall, 6 T-shaped, 1 anterior column with posterior hemi-transverse, and 18 both-column fractures. The follow-up radiographs were graded according to the criteria developed by Matta J. Functional outcome was assessed using Harris hip score and Merle d’Aubigne and Postel score at final followup. Average follow-up was 4.34 years (range 2–11 years).

Results:

Patients with congruent reduction (n=45) had good or excellent functional outcome. Radiologic outcome in incongruent reduction (n=26) was good or excellent in 6 and fair or poor in 20 hips. The functional outcome in patients with incongruent reduction was good or excellent in 16 and satisfactory or poor in 10 hips. Good to excellent radiologic and functional outcome was achieved in all patients with posterior wall fractures including four having more than 50% of broken wall. Good to excellent functional outcome was observed in 88.8% of both-column fractures with secondary congruence despite medial subluxation.

Conclusions:

Nonoperative treatment of acetabular fractures can give good radiological and functional outcome in congruent reduction. Posterior wall fractures with a congruous joint without subluxation on computed tomography axial section, posterior column, anterior column, infratectal transverse or T-shaped, and both-column fractures may be managed conservatively. Small osteochondral fragments in the cotyloid fossa or non–weight-bearing part of the hip with a congruous joint do not seem to adversely affect the functional outcome. Displaced transverse fractures with “V” sign may require operative treatment.     

髋臼边缘压缩骨折

目的 认识并掌握髋臼边缘压缩骨折的诊断及治疗。方法 对26例髋臼骨折合并边缘压缩中的18例患者进行了回顾性总结,15例患者的压缩骨折在术前的CT扫描片得到证实,另3例在术中得到证实。所有患者均采用手术切开复位,对压缩骨折进行撬起和植骨(1例未植骨),钢板螺丝钉内固定术。结果 平均随访36．7个月(5—71个月)。根据改良的Merle d’Aubingne和Postel的髋臼骨折临床结果评分标准,本组优6例;良7例;一般2例;差3例。优良率为73．3％。结论 髋臼后方骨折合并后脱位的患者容易发生边缘压缩骨折,术前CT扫描可对这种骨折进行确诊。要认识到皮质骨压缩这一特殊类型。术中要对压缩骨折部分进行撬起和植骨。     

Operative strategy of acetabular fractures

Anatomic structure of acetabular fractures are complex and operative exposure and fixation are extremely difficult. For those obviously displaced acetabular fractures, close reduction is doomed to cause deformative healing. Open reduction with internal fixation (ORIF) not only results in anatomic reduction, but also brings complications. No matter which method will be adopted, traumatic arthritis or avascular necrosis of femoral head might occur. In order to treat acetabular fractures more effectively, orthopedic surgeons should be required to fully master the acetabular anatomy,biomechanics, classification and the necessary knowledge for complication prevention.     

计算机虚拟复位结合3D打印技术在髋臼骨折中的临床应用

目的 :探讨应用计算机虚拟复位结合3D打印技术对髋臼手术进行术前规划,评估其应用价值及其疗效。方法:回顾分析2011年3月至2014年3月采用手术内固定方式治疗的35例髋臼骨折患者,按术前是否应用计算机虚拟复位和3D打印技术分为数字组和对照组。数字组15例,男9例,女6例;年龄22~58岁,平均(39.4±8.8)岁;受伤至手术时间(8.8±2.0)d;按Letournel-Judet分型:双柱骨折4例,后壁骨折5例,T型骨折4例,后壁伴横行骨折2例。对照组20例,男12例,女8例;年龄19~59岁,平均(38.7±13.1)岁;受伤至手术时间(8.2±2.3)d;按LetournelJudet分型:双柱骨折6例,后壁骨折8例,T型骨折3例,后壁伴横行骨折3例。比较两组患者的术中出血量、输血量、手术时间、骨折复位满意率和d`Aubigne Postal功能评定优良率,并进行统计分析。结果:所有患者切口均Ⅰ期愈合,无切口感染情况发生;骨折均Ⅰ期愈合,无内固定断裂或松动。两组各有1例术后出现神经刺激症状。数字组1例在术后6个月发现股骨头坏死。常规组1例在术后8个月发现异位骨化。35例患者获得随访,时间13~28个月,平均17.6个月。数字组患者的术中出血量、输血量显著少于对照组患者,手术时间短于对照组患者,差异有统计学意义(P0.05)。数字组和对照组骨折复位优良率分别92.9%(14/15)和85%(17/20),差异无统计学意义(P0.05)。两组末次随访时d`Aubigne Postal功能评定优良率分别为86.7%(13/15)和80%(16/20),差异无统计学意义(P0.05)。结论 :计算机虚拟复位结合3D打印技术可以减少髋臼骨折患者的手术时间、术中出血量和输血量,是一种切实有效的术前规划方式,值得推广。     

髋臼骨折并移位的手术治疗

目的 提高对复杂髋臼骨折的治疗水平。方法 总结１９９３年３月～１９９８年５月对５６例有移位髋臼骨折进行手术治疗的经验。按Ｌｅｔｏｕｒｎｅｌ－ｊｕｄｅｔ骨折分型,髋臼后壁骨折７例,后柱骨折６例,前柱骨折４例,横断骨折６例,Ｔ型骨折６例,后柱伴后壁骨折６例,前方伴后方半横形骨折２例,双柱骨折９例。根据不同骨折类型,分别采用Ｋｏｃｈｅｒ－Ｌａｎｇｅｎｂａｃｋ入路、髂腹股沟和、髂骨股骨入路、扩展的髂骨股骨     

髋臼骨折手术并发症的预防

目的 提高髋臼骨折手术治疗的疗效。方法 总结1993年8月至2000年12月178髋髋臼骨折手术治疗的病例,对患者功能结果及主要并发症进行统计分析。结果 112髋获得随访,平均随访时间45．7个月。手术后出现异位骨化26髋,发生创伤性关节炎22髋,8例股骨头坏死,术后坐骨神经损伤7例,未发生感染和死亡。结论 异位骨化主要发生在扩展的髂股骨入路及Kocher-Langenbeck入路;术后创伤性关节炎的出现与手术复位质量有关,与股骨头软骨损伤也有关。     

影响髋臼骨折疗效的相关因素分析

目的 探讨影响髋臼骨折疗效的相关因素及其防治措施。方法 回顾性总结１９９０年３月～２０００年３月收治的资料完整的髋臼骨折８６例,其中经牵引复位者４５例,手术治疗者４１例,选择Ｌｅｔｏｕｒｎｅｌ分型标准判断损伤病理改变,按照Ｈａｒｒｉｓ疗效标准评价关节功能。共有简单骨折３７例,复杂骨折４９例,多发伤４５例,合并股骨头、颈骨折和（或）股骨头后脱位者共３６例,并发坐骨神经损伤者１５例。结果 全组８６例患者中７５例获得随访,平均随访２５．６个月,根据Ｈａｒｒｉｓ评分,优３１例（４１．３％）、良１３例（１７．３％）,可５例（６．７％）,差２６例（３４．７％）。并发股骨头坏死９例（１２％）,创伤性关节炎１５例（２０％）,异位骨化１６例（２１．３％）。结论 影响髋臼骨折疗效的主要因素包括骨折类型、患者年龄、治疗方法、手术时机     

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并评价术后疗效。方法：对1993年8月-2001年8月手术治疗的陈旧性髋臼骨折32例的手术入路、手术方法、功能结果及并发症进行回顾性分析。结果：平均随访时间49.6个月。髋关节功能评分优3例,良16例,中10例,差3例,优良率为59.4％。术后出现坐骨神经损伤1例,出现异位骨化6例,股骨头坏死3例。结论：陈旧性髋臼骨折的治疗要慎重选择手术指征,经恰当的手术入路,正确的复位固定方法,可以获得相对满意的结果。     

Management of acetabular fractures in elderly patients

Management of acetabular fractures in elderly patients is challenging. The challenges arise due to associated medical comorbidities, poor bone quality and comminution. There are multiple modalities of treatment. the exact algorithms or treatment remain undefined. Treatment is still based on experience and some available evidence. The options include conservative treatment, percutaneous fixation, open reduction internal fixation and the acute fix and replace procedure. There is a well recognised risk of each treatment option. We present a narrative review of the relevant available evidence and our treatment principles based on experience from a regional tertiary pelvic-acetabular fracture service.     

Management of acetabular fractures in elderly patients

Management of acetabular fractures in elderly patients is challenging. The challenges arise due to associated medical comorbidities, poor bone quality and comminution. There are multiple modalities of treatment. the exact algorithms or treatment remain undefined. Treatment is still based on experience and some available evidence. The options include conservative treatment, percutaneous fixation, open reduction internal fixation and the acute fix and replace procedure. There is a well recognised risk of each treatment option. We present a narrative review of the relevant available evidence and our treatment principles based on experience from a regional tertiary pelvic-acetabular fracture service.     

有移位复杂髋臼骨折的手术治疗

目的 对移位复杂髋臼骨折采用不同手术入路与方法，探讨提高其疗效的方法。方法 手术治疗有移位髋臼骨折86例，对其中27例有移位复杂髋臼骨折进行了随访。所有骨折均按Letournel-Judet的方法进行分型。根据骨折类型及移位情况，分别采用Kocher-Langenback入路13例，髂腹股沟入路2例，前后联合入路12例，分别进行复位应用骨盆重建钢板和螺钉固定。结果 平均随访18．3个月(5～38个月)。根据改良的Merled’Aubigne和Poste评分标准进行评分，优10例，良12例，一般3例，差2例，优良率81．4％。术后发生骨性关节炎2例，异位骨化7例，经保守治疗痊愈，无死亡、感染及不愈合的病例。结论 手术前分析骨折的类型及骨折的移位方向，选择恰当的手术入路及手术中良好的复位是提高髋臼骨折疗效的关键。     

髋臼骨折术后创伤性关节炎发生的相关危险因素分析

目的探讨影响髋臼骨折手术治疗后创伤性关节炎发生的相关危险因素。方法 2000年1月至2009年1月我院收治年龄为20～60岁,行手术治疗的髋臼骨折患者共88例,术后并发创伤性关节炎23例。根据可能影响创伤性关节炎发生的相关危险因素,采用χ2检验及logistic回归分析方法分析各因素是否与创伤性关节炎的发生有关。结果 Logistic回归分析显示,手术时机、骨折类型、复位质量及术后其它并发症的发生是影响髋臼骨折术后功能恢复的独立危险因素。结论选择恰当的手术时机、正确对骨折类型进行分型、提高手术技巧及加强对术后相关并发症的防治可降低创伤性关节炎的发生率,提高患者术后的生活质量。     

手术治疗髋臼双柱骨折(附21例报告)

目的 :探讨髋臼双柱骨折的手术治疗效果。方法 :对手术治疗的 2 1例髋臼双柱骨折患者进行回顾性分析。单纯K L入路 1例 ,单纯髂腹股沟入路 3例 ,K L联合髂腹股沟入路 17例。全部采用重建钢板及螺钉固定。结果 :骨折复位程度按照Matta标准 ,解剖复位 15例 ,满意复位 4例 ,不满意复位 2例。 17例获得随访 ,随访 1～ 5年 (平均 1.7年 ) ,髋关节功能评分采用改良Merled’Aubigne和Postel髋关节评分标准 :优 8例 ,良 5例 ,可 2例 ,差 2例 ,优良率为 78.6%。结论 :严格掌握手术指征、选择合适入路、骨折准确复位、牢固固定、可取得良好治疗效果     

髋臼骨折手术治疗的并发症

目的总结分析手术治疗髋臼骨折的并发症。方法1994年1月～2004年1月,我院行髋臼骨折切开复位内固定术46例。合并髋关节脱位或股骨头骨折的患者术后行骨牵引3～4周,术后3d开始髋关节被动活动和股四头肌功能锻炼。8～16周逐渐扶拐下地行走,16～24周逐步进行负重活动。所有患者术毕给予吲哚美辛口服,剂量为25mg,每日2次,持续3个月。有坐骨神经损伤的患者,给予神经营养药对症处理。为预防下肢血栓性静脉炎,对老年及高危患者术后预防性使用肝素等抗凝剂,出院后继续使用华法令等抗凝剂3～4周,直至能主动。结果本组优28例,良9例,一般5例,差4例,优良率为80.4%。本组病例中1例发生深部感染,11例术后发生异位骨化。术前6例合并坐骨神经损伤的患者中4例有不同程度的恢复。本组有3例合并下肢血栓性静脉炎,经抗凝剂治疗,2例已完全康复。本组有6例出现股骨头缺血性坏死,其中有4例已行人工髋关节置换术。结论对于绝大多数移位的髋臼骨折应以手术治疗为主,但应注意并发症的防治。     

移位髋臼骨折合并不稳定型骨盆后环损伤的临床特征及复位顺序

目的 探讨移位髋臼骨折(displaced acetabular fracture,DAF)合并不稳定型骨盆后环损伤(posterior pelvic injury,PPI)的临床特征及复位顺序.方法 1997年3月至2007年3月,资料完整的DAF合并PPI患者39例,合并同侧PPI 25例、对侧9例、双侧5例.根据AO/OTA分型方法,髋臼A型骨折9例,B型25例,C型5例;骨盆后环B型损伤31例,C型8例.DAF与PPI同期切开复位内固定33例,分期手术3例,另3例PPI行非手术治疗.术中首先复位DAF 10例,首先复位PPI 18例,DAF与PPI同时复位11例.结果 术后随访12～120个月,平均33.7个月.根据Matta的评价标准,DAF解剖复位27例、复位满意4例、不满意8例.根据Meats的评价标准,PPI解剖复位24例、复位满意8例、不满意7例.其中因PPI移位而影响DAF满意复位者7例.DAF术后Matta功能评分为4～18分,平均14.7分.PPI术后Majeed疗效评分为51～100分,平均87.8分.以两个损伤部位的最低评分作为总体治疗结果,优25例、良3例、可2例、差9例.结论 在处理累及髋臼双柱的DAF合并PPI时,PPI的准确复位是DAF获得满意复位的解剖基础,DAF的损伤类型及其复位质量是决定远期疗效的主要因素.     

Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures

IntroductionPatients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures.MethodsAdults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality.ResultsAfter propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality.ConclusionCirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture.Level of EvidencePrognostic Level III.     

移位复杂型髋臼骨折的手术治疗

目的总结移位复杂型髋臼骨折的手术方法和治疗效果。方法从1990年3月～1999年9月,共手术治疗98例,其中后柱合并后壁骨折9例,横形合并后壁骨折22例,“T”形骨折28例,双柱骨折37例,前柱合并后半横形骨折2例。手术采用Kocher-Langenbeck(K-L)入路28例,髂腹股沟入路21例,延长髂股入路16例,双入路(髂腹股沟 K-L入路)33例。结果解剖复位62例(63.3%),满意复位32例(32.7%),不满意复位4例(4.1%)。解剖复位率在最初和最近4.5年手术组分别为50.0%和72.4%。获2～10年随访的78例中,临床和X线优良率分别为70.5%和71.8%,其中解剖和非解剖复位组的临床优良率分别为83.9%和36.4%(χ2=22.89,P<0.01)。并发症:坐骨神经不全性牵伸损伤1例(1.0%);深部感染2例(2.0%);静脉血栓形成2例(2.0%);中、重度骨关节炎2例(2.0%),轻度5例(5.1%);股骨头缺血性坏死2例(2.0%);异位骨化BrookerⅠ、Ⅱ度24例(24.5%),Ⅲ度8例(8.2%)。结论(1)手术治疗移位复杂型髋臼骨折可取得满意的骨折复位和临床疗效;(2)复位质量与疗效密切相关;(3)医生的临床经验对于提高复位质量,改善远期疗效十分重要。     

髋臼骨盆骨折患者术前深静脉血栓形成的危险因素分析

目的 探讨髋臼、骨盆骨折患者术前发生深静脉血栓形成(DVT)的危险因素. 方法 2005年1月至2009年2月共收治448例髋臼或骨盆骨折患者,男347例,女101例;平均年龄为39 4岁(14～80岁).其中骨盆骨折122例,髋臼骨折326例.受伤至手术时间为0～315 d,平均13.4d.将患者年龄、性别、合并伤、合并系统性疾病、骨折类型(陈旧性骨折与否)、术前牵引制动、术前是否采取预防血栓的措施、D-二聚体水平及吸烟史作为自变量,术前是否发生DVT作为因变量(分为血栓组和非血栓组).利用x2检验确定影响DVT的危险因素,然后采用多因素Logistic回归分析确定影响DVT的独立危险因素及相应比值比(OR)、95％的可信区间(CI). 结果 共有79例(17 6％)患者发生下肢DVT.年龄≥45岁、合并系统性疾病、未采取预防血栓措施、血清D-二聚体＞500μg/L与血栓的发生有关(P＜0.05).多因素Logistic回归分析结果显示:年龄≥45岁[OR=2 114,95％ CI(1.254,3 564),P=0.005]、合并系统性疾病[OR =2.302,95％ CI(1.270,4.175),P =0.006]、未采取血栓预防措施[OR=2.270,95％ CI(1.322,3.897),P=0.003]是影响DVT发生的独立危险因素.结论 年龄≥45岁、合并系统性疾病及未采取血栓预防措施的患者发生DVT的可能性较大.髋臼、骨盆骨折患者术前必须采取预防措施,并严密监测血栓是否形成.     

Results after surgical treatment of transtectal transverse acetabular fractures

Objective: To retrospectively evaluate the results of operative treatment of transtectal transverse fractures of the acetabulum. Methods: From May 1990 to July 2006, 40 patients with displaced transtectal transverse fracture of the acetabulum were treated surgically. A mean postoperative follow‐up of 88.6 months' (range, 16–121 months) was achieved in 37 patients. Final clinical results were evaluated by a modified Merle d'Aubigné and Postel grading system. Postoperative radiographic results were evaluated by the Matta criteria. Fracture and radiographic variables were analyzed to identify possible associations with clinical outcome. Results: Fracture reduction was graded as anatomic in 31 patients, imperfect in 4 and unsatisfactory in 2. Two hips were diagnosed to have subtle instability by postoperative radiography. The clinical outcome was graded as excellent in 16 patients, good in 14, fair in 4 and poor in 3. The radiographic result was graded as excellent in 14 patients, good in 15, fair in 4 and poor in 4. There was a strong association between the final clinical and radiographic outcomes. Variables identified as risk factors for unsatisfactory results included residual displacement greater than 2 mm, comminuted fracture of the weight bearing dome, postoperative subtle hip instability and damage to the cartilage of the femoral head. Conclusion: The uncomplicated radiographic appearance of transtectal transverse fracture belies its complexity. Comminuted fracture of the weight bearing dome, unsatisfactory fracture reduction, subtle hip instability and damage to the cartilage of the femoral head are risk factors for the clinical outcome of transtectal transverse fracture of the acetabulum.     

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.