Treatment of complex acetabular fractures through a modified extended iliofemoral approach

OBJECTIVES: To assess the rate of anatomic reconstructions as well as approach-related morbidity and complications in the treatment of complex acetabular fractures through a modified extended iliofemoral approach. DESIGN: Prospective clinical study. SETTING: Level I trauma center, University Hospital. PATIENTS: Inclusion criteria were as follows: (a) associated acetabular fracture or transverse fracture with comminuted roof area stated as not sufficiently reconstructable through a single approach, and (b) age between sixteen and sixty-five years. A total of forty-nine patients with fifty complex acetabular fractures could be included out of the series of ninety-six acetabular fractures treated operatively from August 1992 to February 1996. Open reduction and internal fixation of complex acetabular fractures through the modified extended iliofemoral approach were performed. RESULTS: In 80 percent of the fifty fractures the reduction was anatomic with a remaining displacement of less than or equal to one millimeter, in eight cases there was a persistent displacement of two millimeters, and two fractures had a poor result with a three-millimeter displacement. Complications included 8 percent loss of reduction, 13 percent heterotopic ossification grade 3, and 4 percent avascular femoral head necrosis. At the two-year follow-up there were 74 percent good or excellent radiographic and clinical results. Two patients had already been reoperated with total hip replacement, and the two patients with femoral head necrosis are currently scheduled for arthroplasty. CONCLUSIONS: The modified extended iliofemoral approach proved to be appropriate to achieve anatomic reduction in complex acetabular fractures. The high rate of approach-related morbidity has to be considered carefully and may lead to a decreased incidence of extended approaches.     

Superior gluteal artery in the extended iliofemoral approach

OBJECTIVE: To determine the incidence of superior gluteal artery injury following fracture of the acetabulum and to determine whether the combination of a superior gluteal artery injury and the use of an extended iliofemoral approach to the acetabulum creates abductor muscle necrosis. DESIGN: Prospective protocol, consecutive cases. SETTING: A consecutive series from the referral practice of the senior author plus seven cases from the practices of two other authors. PATIENTS: Two hundred twenty-seven patients with fractures of the acetabulum were treated operatively between November 1992 and January 1995. Forty-one were treated with the use of the extended iliofemoral approach. Preoperative angiograms were not performed for any of the patients. All fractures involved the posterior column, and all but two fractures had displacement of the greater sciatic notch. The average displacement of the notch was 2.5 centimeters (range 6 to 60 millimeters). INTERVENTION: All patients were treated with open reduction and internal fixation via the extended iliofemoral approach. Intraoperative Doppler examination of the superior gluteal artery was performed before and after reduction and fixation of the posterior column. MAIN OUTCOME MEASURE: Wound complications, abductor manual muscle testing, hip range of motion. RESULTS: Pulsatile flow was confirmed in forty of forty-one patients. All patients were followed for a minimum of six months with an average follow-up of 1.4 years. At most recent follow-up, no patients had evidence of complete loss of abductor function. Sixty-three percent of patients had achieved Grade 4 of 5 motor strength, and 25 percent of them had achieved normal motor strength. CONCLUSIONS: No instances of superior gluteal artery laceration and only one instance of superior gluteal artery thrombosis were encountered in these forty-one patients despite significant fracture displacement involving the sciatic notch. The incidence of superior gluteal artery injury was significantly less than would be expected from previous studies. Massive abductor necrosis resulting from superior gluteal artery injury combined with an extended approach has been described primarily in animal and cadaver studies. Although arteriograms are useful in the control of hemodynamic instability, we cannot support the recommendation of preoperative angiographic study of all patients undergoing acetabular fracture surgery via an extended approach. In one case, an extended iliofemoral approach was tolerated in a patient with absent superior gluteal artery flow.     

改良髂股入路前后显露治疗复杂髋臼骨折

目的介绍自行设计的手术入路在复杂髋臼骨折中的应用经验。方法采用平侧结合的漂浮体位将髂股入路向后延伸至大转子前方再沿股骨干前侧向远侧10～15cm,前后显露治疗复杂髋臼骨折17例。结果17例需前后同时显露的复杂髋臼骨折全部得到良好的暴露,术中全部病例均解剖复位,重建钢板固定。经6个月～4年,平均15个月的随访关节功能优12例,良3例,可2例,优良率88.24%。结论改良的髂股入路具有手术切口较短,可暴露大部分类型的髋臼前后柱骨折,显露充分,直视下复位,便于固定,损伤和出血均较扩大的髂股入路少,体位合理,操作简便,术后恢复快,我们认为是一个值得推荐的手术入路。     

Minimal-invasive posterior approach in the treatment of the posterior wall fractures of the acetabulum

We examined patients affected by a posterior wall fracture of the acetabulum treated with a minimally invasive posterior approach (from 12 to 18 cm). During 2004–2006 19 patients were treated by this approach. 4 patients had a combined surgery by the ileo-inguinal approach. Fracture fixation was performed using reconstruction plates and screws. All the patients were studied with typical X-rays projection for pelvis and iliac oblique view and obturator oblique view (Judet view) and CT scan with 3D reconstruction. After 3 months a CT scan was performed on about 30% of our patients, which demonstrated the perfect healing of the fractures. The most important advantages we observed using this approach were a lesser split of the gluteus maximus and no risk of damage for the superior gluteal nerve. In the early post-operative rehabilitation we examined the trophism of the gluteus maximus, which was found to be better than in patients treated with the typical Kocher–Langenbeck approach. The only absolute contraindication for this technique is in obese patients. The post-operative complications include one case of heterotypic ossification of the gluteus minimus and one case of peroneal-nerve palsy with the spontaneous and complete recovery within 6 months. According to our experience this kind of approach could be used for posterior wall fracture of the pelvis and it can be extended to transverse fractures. In the post-operative period the greatest advantage is the lesser muscle damage and therefore a most effective rehabilitation.     

复杂髋臼骨折的手术治疗

目的探讨复杂髋臼骨折的治疗方法及疗效。方法对67例Letournel和Judet分型复杂髋臼骨折患者采用骨盆重建钢板及螺钉内固定,其中后侧入路33例,前侧髂腹股沟入路5例,前后联合入路28例,扩大髂股入路1例。结果 67例均获得随访,时间8～47（26.6±12.4）个月。根据Matta影像学评定标准,解剖复位38例,满意复位20例,不满意复位9例;关节功能按Merle d′Aubign啨和Postel评定标准：优24例,良31例,一般6例,差6例。股骨头坏死4例,局部骨化性肌炎6例,髋关节骨性关节炎7例,术后感染1例,术后4周股动脉血栓形成1例;无死亡、骨不愈合发生。结论及时手术、良好复位及早期功能锻炼可使复杂髋臼骨折的治疗获得较好的临床效果。     

复杂髋臼骨折的手术治疗

目的总结复杂髋臼骨折的治疗效果。方法手术治疗复杂髋臼骨折16例,根据骨折类型采用重建钢板及拉力螺钉固定。结果患者均获随访,时间3～24个月。复位情况按Matta标准:解剖复位10例,满意复位6例。关节功能按改良D′Aubigne和Postel评定标准:优8例,良5例,可2例,差1例。结论术前明确骨折分类、手术时机适当、合适入路、可靠内固定及满意复位是提高髋臼骨折治疗效果的关键。     

手术治疗18例复杂髋臼骨折

目的：探讨复杂髋臼骨折手术治疗的效果。方法：本组骨折切开复位采用前后联合入路12例,延伸髂腹股沟入路4例,改良S－P入路2例,结果：平均随访3年。11例解剖复位,疗效优,5例复位满意,4例优,1例良;2例陈旧性骨折复位不满意,疗效差,结论：手术可有效复合固定此类骨折,恢复髋关节的稳定性和正常的头臼关系。     

移位性髋臼骨折的手术治疗

移位性髋臼骨折是一种高能量损伤,随着现代化工业和交通事业的发展,这种损伤日渐增多。由于关节面受累和骨折移位,如未能及时达到确切的复位,日后发生骨折畸形愈合和不愈合,将严重影响髋关节功能。目前,对移位性髋臼骨折多倾向于早期确切复位和牢固的内固定,以改善和提高治疗效     

移位性髋臼骨折的手术治疗

移位性髋臼骨折是一种高能量损伤,随着现代化工业和交通事业的发展,这种损伤日渐增多。由于关节面受累和骨折移位,如未能及时达到确切的复位,日后发生骨折畸形愈合和不愈合,将严重影响髋关节功能。目前,对移位性髋臼骨折多倾向于早期确切复位和牢固的内固定,以改善和提高治疗效果[1-3]。1998年6月以来,我们应用骨盆重建钢板固定技术治疗18例移位性髋臼骨折,疗效满意,现报告如下。1临床资料本组18例,男16例,女2例;年龄28⁴6岁,平均38·5岁。受伤原因:交通事故伤9例,砸伤3例,高处坠落伤6例。其中伴有脾破裂2例,肋骨骨折2例,脊柱骨折1例,四肢骨折2例,坐骨神经不全损伤2例。18例均为闭合性骨     

髋臼骨折的治疗建议

髋臼骨折常由高能量暴力所致,是髋关节的严重损伤.髋臼骨折形态复杂多样,手术显露困难,因此治疗难度大.回顾髋臼骨折的治疗历史,早期多采用非手术治疗,但效果较差.     

前方入路联合MIPO技术治疗肱骨干骨折的有效性和安全性

背景：由于术中广泛剥离、牵拉骨折周围软组织、影响骨折端血供,传统接骨板在治疗肱骨骨折有较高的骨不连发生率和医源性神经损伤发生率。 目的：探讨前方入路联合微创经皮接骨板内固定（MIPO）技术治疗肱骨干骨折的有效性和安全性。 方法：回顾性分析2010年1月至2012年12月收治的77例肱骨干骨折患者的临床资料。根据治疗方法分为MIPO组和对照组。MIPO组采用微创经皮接骨板置入技术进行骨折固定,对照组采用传统的切开复位内固定技术进行骨折固定。对两组患者的手术情况和术后功能恢复进行比较。 结果：两组患者手术顺利,MIPO组手术时间比对照组稍长,住院时间比对照组稍短,但两组间差异无统计学意义（P＞0.05）。MIPO组术中失血量、骨折愈合时间均显著少于对照组（P＜0.05）。末次随访时,MIPO组的肩、肘关节活动度和DASH评分均显著优于对照组（P＜0.05）。两组患者术后均无严重并发症发生。 结论：采用MIPO技术治疗肱骨干骨折具有微创、固定牢靠、并发症少、术后功能恢复迅速且良好等优点,应在肱骨干骨折治疗中推广使用。     

复合型髋臼骨折24例的外科治疗

目的：探讨复合型髋臼骨折的治疗效果。方法：本组24例骨折按Judet-Letournel分类法分类。非手术治疗9例，手术治疗15例。结果：平均随访3年，9例非手术治疗骨折均复位不满意，3例良，2例中，4例差，手术治疗15例，8例解剖复位，疗效优；5例复位满意，4例优，1例良；2例陈旧性骨折复位不满意，疗效差。结论：手术可有效复位此类骨折，恢复髋关节的稳定性和正常的头臼关系。     

经髂腹股沟入路治疗髋臼骨折的疗效分析

近年来 ,髋臼骨折的手术治疗越来越受到重视。而选择适当的手术径路 ,对于术中骨折的显露和复位以及术后取得满意的疗效具有重要的意义[1,2 ] 。我科自 1993年 12月 - 2 0 0 0年 12月手术治疗髋臼骨折 4 3例 ,其中经髂腹股沟入路 2 0例 ,报告如下。1　临床资料本组 2 0例 ,男 15例 ,女 5例 ;年龄 2 1～ 6 3岁 ,平均 35 2岁。骨折按Letournel[3 ] 分型标准 ,双柱骨折6例 ,前柱骨折 5例 ,横行 3例 ,前柱伴前壁 3例 ,T型 2例 ,前柱伴后半横行 1例。合并其他损伤 13例 ,其中合并发生颅脑损伤 3例 ,股骨干骨折 2例 ,胫腓骨骨折 2例 ,脾破裂 2例…     

Indications for surgical treatment of fractures of the acetabulum

The indications for surgery in fractures of the acetabulum within 3 weeks from the accident are currently based on 2 main factors: 1) post-traumatic articular incongruence doubtlessly is the cause of traumatic coxitis: 2) however, it has been proved that fractures with partial post-traumatic incongruence that have not been treated may produce very good results. The current problem is that it is impossible to assess the degree of incongruence that can be tolerated to avoid surgery and guarantee good long-term results. Computers will maybe help to solve this problem. The indications are currently based on the approximate assessment of congruence on the basis of 3 plain radiographs, tomography and CT. Osteonecrosis of the femoral head is much less frequent than it is said to be, and most often actually consists in the wear of the femoral head on a non-reduced line of fracture, whether or not the patient has been operated.     

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.