髋臼骨折的非手术疗法

报告16例髋臼骨折非手术治疗的结果,71％的病例疗效满意,不满意者为负重顶受累和头臼关系不对应的移位骨折。分析了治疗成败的原因,对非手术疗法在髋臼骨折中的作用、地位与适应证进行了讨论。     

Fractures of the acetabulum. A retrospective analysis

A roentgenographic analysis of 204 acetabular fractures is presented. In addition, 64 displaced fractures (43 treated surgically) are evaluated clinically and roentgenographically (average follow-up period, 3.7 years). Most fractures can be adequately evaluated from anteroposterior and oblique roentgenograms of the pelvis. The roentgenographic and clinical results correlate closely. Fractures must be reduced to a displacement of 3 mm or less, in addition to congruent reduction of the femoral head with the weight-bearing dome of the acetabulum, to achieve a satisfactory clinical result. Most displaced fractures involve the weight-bearing dome and require surgery. With an intact weight-bearing dome, nonoperative treatment is considered. Quantification of this dome with three measurements termed the medial, anterior, and posterior roof arc obtained from the standard roentgenograms is valuable in determination of appropriate treatment for displaced acetabular fractures.     

不稳定骨盆骨折并存移位髋臼骨折的手术治疗

目的　探讨不稳定骨盆骨折并存移位髋臼骨折手术治疗的效果。方法　本组 2 1例采用联合Tile -Letournel分类法确定并行手术治疗。结果　平均随访 2年 ,骨盆骨折均获复位。累及髋臼负重顶的骨折 17例 ,15例复位满意 ,疗效优良。结论　手术可有效复位固定骨折 ,矫正畸形 ,重建骨盆环的稳定性、恢复髋臼关节面的平整和正常的头臼关系     

Acetabular disruption and central fracture-dislocation of the hip. A long-term study.

Displaced acetabular fractures are serious injuries often resulting in permanent disability. Fifty-five patients with fifty-six such injuries seen at the Campbell Clinic between 1927 and 1970 had either central dislocation with or without fracture of the weightbearing dome, or acetabular disruption usually associated with posterior displacement of the hip. After an average follow-up of 8.6 years, 56 per cent of those treated without surgery had good or satisfactory results compared with 54 per cent good or satisfactory results in those treated surgically. Patients with displaced fractures of the acetabular dome not reduced by manipulation and traction should be considered candidates for open reduction.     

Roof-arc angle and weight-bearing area of the acetabulum

Background

Unreduced fracture crossing the weight-bearing dome of the acetabulum leads to arthritis. Thus the integrity of the weight-bearing dome is considered to be an important prognostic indicator for acetabular fracture. The decision of whether or not to operate is based on the location of the fracture relative to the weight-bearing dome. A displaced fracture crossing the weight-bearing dome is an indication for surgery.

Objective

To measure the medial, anterior, and posterior roof-arc angles that cross the weight-bearing dome.

Methods

Twenty cadeveric hip joints were dissected and simulated transverse fractures of acetabuli through the transtectal area were made. The radiographic examinations were taken in three views: AP, obturator oblique, and iliac oblique. Roof-arc angle was measured in all three views (medial, anterior, and posterior).

Results

The medial roof-arc angle was 46 ± 6.3°, anterior roof-arc angle was 52 ± 7.0°, and posterior roof-arc angle was 62° ± 8.5°.

Conclusions

In acetabular fracture, a medial roof-arc angle less than 46°, an anterior roof-arc angle less than 52°, or posterior roof-arc angle less than 61° is considered to be involved in a weight-bearing area.

Clinical relevance

These roof-arc angle values may be used as a surgical guideline for an acetabular fracture around the weight-bearing area.     

髋关节中心性骨折脱位的外科治疗

目的探讨髋关节中心性骨折脱位的诊断、分类及外科治疗的特点。方法采用回顾性研究方法对髋关节中心性骨折脱位的外科治疗病例进行总结分析。结果 8例髋关节中心性骨折脱位均为臼底部骨折并股骨头中心型脱位突入盆腔,其中仅累及臼底部骨折3例,臼底部骨折合并髋臼前柱骨折2例,臼底部骨折合并髋臼前柱骨折及前壁骨折3例。8例均采用术前下肢股骨牵引使脱位的股骨头复位及改良扩大的髂股入路进行髋臼底骨折的切开复位钢板螺丝钉内固定术,其中2例臼底破损严重的病例采用取带缝匠肌髂骨骨瓣植骨重建术。髋臼骨折复位按Matta标准,术后解剖复位4例,满意复位4例,无不满意复位。结论髋关节中心性骨折脱位为髋臼较少见的严重损伤。对中心性脱位的股骨头宜采用三向分力的股骨牵引进行复位,因髋臼底位置深在手术复位较困难,故采取髂股手术入路,直视下可显露髋臼底骨折处。采用重建钢板进行骨折固定可确保髋臼内壁的光滑,髋臼底破损严重病例采用带肌蒂髂骨骨瓣植骨可起到重建臼底及加速骨折愈合的目的 。     

髋臼前部骨折疗效与负重弓完整性的关系

本文回顾复习了12例髋日前壁、前柱或前柱并后方半横切骨折.牵引治疗9例,手术治疗3例.疗效优7例,良2例,可2例,差1例.对这12例正位及闭孔斜位X片进行负重弓完整性测量,发现疗效不佳者骨折均累及负重弓,作者对该种骨折的诊治及负重弓测量的意义作了探讨.     

Anterior column fractures of the acetabulum.

We retrospectively reviewed 20 patients at three to 19 years after displaced anterior fracture-dislocations of the hip. Eighteen of them were treated by traction, after ensuring that the femoral head was adequately reduced beneath the undisrupted part of the weight-bearing dome. Two required operation. Although none of the 18 conservatively treated fractures was reduced anatomically, the results were good in ten patients and excellent in the seven in whom the fracture did not involve the weight-bearing dome. We conclude that anterior column fractures have a favourable prognosis after conservative treatment.     

Acetabular fractures in older patients

Retrospective review of 25 patients over 65 years of age with unilateral acetabular fractures managed conservatively showed that seven of the 23 survivors (30%) had an unacceptable functional result. Poor results were associated with: displaced posterior column fractures, osteoporosis, femoral head fracture, delayed diagnosis, inadequate radiographs, inappropriate or too brief traction, and early weight-bearing. In this age group acetabular fractures tend to be low-velocity injuries of osteoporotic bone and are not comparable with those in younger patients.     

Results after operative treatment of transverse acetabular fractures

Background Treatment of the transverse acetabular fracture is known to have worse results than other fracture types, although this fracture belongs to the elementary fracture group. The operative results of the transverse acetabular fracture, however, have not been well documented. To determine the results and factors that affect the choice of operative treatment for transverse acetabular fractures, we retrospectively reviewed 15 cases of transverse fracture. Methods A total of 15 patients had a transverse fracture, with an average follow-up period of 43 months; there were 8 patients with and 7 without a posterior wall fracture. There were 11 men and 4 women, with a mean age of 46.6 years. In seven cases there was also comminution of the weight-bearing dome. The surgical approaches used were the anterior ilioinguinal approach in 4 patients, the posterior approach in 10 patients, and the combined approach in 1 patient. Postoperative radiographic results were evaluated by Matta's criteria. Final clinical results were evaluated by a modified Merle d'Aubigne scoring system. Results All of the fractures healed. The average time for fracture healing was 17.5 weeks. Postoperative radiology revealed six cases of anatomical reduction, five cases of imperfect reduction, and four cases of poor reduction. According to the clinical results, nine patients had satisfactory results (three excellent, six good), and six had unsatisfactory results (three fair, three poor). Regarding complications, there were four cases of traumatic osteoarthritis and three of heterotopic ossification. The patients with an anatomical reduction had a higher satisfactory result rate. Comminution of the transverse fracture seemed to have an adverse influence on the postoperative radiologic result as well as a correlation with the development of traumatic arthritis. Conclusions Transverse acetabular fractures, if not reduced anatomically, may have a tendency toward traumatic osteoarthritis and poor clinical outcome. Comminution of the dome may portend poor results.     

Fractures of the acetabulum. Early results of a prospective study

One hundred two patients with 105 displaced fractures of the acetabulum were treated for fractures involving at least one column of the acetabulum and displaced at least 5 mm (rim fractures were excluded). The patients were primarily young adults with multiple injuries secondary to motor-vehicle-associated trauma. Fractures were classified according to the classification of Letournel. The most common fractures were the complex associated types with 44 complete both column, 19 T-shaped, and 18 associated transverse and posterior wall. Seventeen fractures were treated closed, and 88 were treated operatively. Closed treatment with skeletal traction was undertaken if roof arc measurements demonstrated a satisfactory remaining acetabular dome following fracture and in some cases of apparent congruence following complete both column fractures. Fractures not meeting these criteria were operated upon through the Kocher-Langenbeck, extended iliofemoral, or ilioinguinal approach. Ninety percent of the operations produced a satisfactory reduction of the fracture (3 mm or less displacement). A follow-up study longer than one year was obtained for 50 fractures. Clinical results were 80% satisfactory overall. Operative complications included 3% infection, 5% nerve palsy, and 7% significant ectopic bone. Operative treatment can produce satisfactory fracture reductions and clinical results with an acceptably low complication rate.     

The efficacy of posterior plating and anterior column screw fixation in the management of T-shaped acetabular fractures - CART analysis of prospective cohort study

T-shaped acetabular fractures are challenging injuries. The goal of surgical treatment is to achieve a stable and a concentric reduction of the femoral head under the anatomically reduced weight-bearing dome. There is an ongoing debate about the ideal approach and fixation method for T-shaped fractures. In this study, a group of 34 patients with T-shaped acetabular fractures were treated by posterior plating and anterior column screw. All patients, were followed for at least two years or until hip replacement. The aim of this prospective cohort study was to report the rate of postoperative radiological results together with the early clinical outcome. Anatomical reduction was achieved in 62%, satisfactory reduction of the anterior column with restoration of hip congruency in 82% with excellent to good clinical outcome in 75% of cases. We used classification regression trees (CART) to select the important predictors and generate hypotheses on interaction among them. Residual anterior column displacement >3.5 mm was associated with poor clinical results. In cases with residual displacement <3.5 mm, the presence of a posterior wall fracture was an independent negative predictor.     

Conservative therapy of acetabular fractures--indications and results

Conservative treatment of acetabular fractures seems to be indicated either in cases of little displacement or wherever reconstruction of the acetabulum by operation is impossible. Following the classification of Judet and Letournel a satisfactory result can be expected only in fractures with little dislocation, such as the caudal transverse type and the anterior wall type. The indication for open reduction and reconstruction is given if cranial and/or dorsal components of the acetabulum are involved. In special cases treatment by vertical traction must be combined with a side traction by means of a trochanter screw; in the early phase of traction frequent radiological controls are obligatory. Early physiotherapy is also necessary to achieve satisfactory functional results. Based on the follow-up examination of 38 patients with 39 fractures of the acetabulum, conservative treatment is discussed in respect of fracture type, the extent of displacement and the clinical results.     

髋臼记忆合金三维内固定系统治疗涉及臼顶负重关节面的髋臼骨折

目的 探讨髋臼记忆合金三维内固定系统(ATMFS)治疗涉及臼顶负重关节面髋臼骨折的临床疗效.方法 2003年8月至2009年2月共收治28例涉及臼顶负重关节面的髋臼骨折患者,男19例,女9例;年龄18～70岁,平均39.2岁.伤后3周内(3～15 d)手术的新鲜骨折24例,超过3周(29～58 d)的陈旧性骨折4例.髋臼骨折根据Letournel & Judet分型:后壁骨折17例,后柱骨折5例,横形骨折5例,T形骨折1例.根据张春才等的髋臼三柱浮动分类法分型:28例均为涉及中柱壁的骨折,其中Aml型19例,Am2型6例,Am3型3例.所有患者均采用改良髋关节后外侧入路ATMFS治疗.结果 28例患者术后获6～30个月(平均8.5个月)随访.术中直视下骨折复位情况根据Matta标准评定:解剖复位25例(89.3%),满意复位3例(10.7%).术后摄X线片复查未发现骨折再移位.28例于术后11.1～15.0周(平均12.7周)获骨性愈合,患侧髋关节功能达到健侧水平.按照改良Aubigne & Postal临床分级标准评定疗效:优18例,良8例,可2例,优良率为92.9%.结论 ATMFS是治疗涉及臼顶负重关节面髋臼骨折的有效方法,其合理的设计更贴服于臼顶不规则解剖结构,持续应力加压作用可促进骨折愈合,多点多维锁定固定方式为局部植骨或重建提供了空间.

Abstract：

Objective To assess the mid-term results of acetabular three-dimensional memory fixation system (ATMFS) used to reconstruct weight-bearing area of the acetabulum. Methods From August 2003 to February 2009, totally 28 consecutive cases of unilateral severe fracture of the weight-bearing area of the posterior acetabular wall were treated with open reduction and ATMFS in our department. They were 19 males and 9 females, with a mean age of 39. 2 years (range, 18 to 70 years). Four fractures were old and 24 fresh. According to the Letournel & Judet classification system, there were 17 posterior wall fractures, 5 posterior column fractures, 5 transverse fractures, and one T-shaped fracture. According to the Zhang Chun-cai's classification system, the 28 cases all belonged to middle column-wall fracture, of which 19 were type Am1, 6 type Am2 and 3 type Am3. A modified hip posterolateral approach was adopted for all the patients. Results The 28 patients were followed up from 6 to 30 months (average, 8. 5 months). None of the patients lost reduction after surgery, and there was no case of implant failure. By Matta's criteria, 25 cases achieved anatomical reduction (89. 3% ) and 3 satisfactory reduction (10. 7% ) . All the patients achieved bony union in an average time of 12. 7 weeks after operation (from 11. 1 to 15. 0 weeks) . At the final follow-up, according to D' Aubigne & Postal's criteria, 92. 9% of the patients were rated as excellent or good.Conclusions ATMFS, as a wise biomechanical method to treat fractures involving weight-bearing area of the acetabulum, ensures stability of the hip joint, consistent compressive stress which promotes fracture union,and convenience of local grafting and reconstruction. It is an effective internal fixator for treatment of acetabular fractures involving weight-bearing area.     

髋臼骨折术后残留移位与髋关节功能的相关性分析

目的通过术后CT评价髋臼骨折复位质量,探讨累及负重区和非负重区的残留移位(台阶移位和间隙移位)与术后髋关节功能的相关性。方法回顾分析2004年6月-2009年6月48例髋臼骨折患者术后CT检查和临床随访结果。患者均行切开复位内固定。术后均获随访,随访时间24～72个月,平均36个月;骨折均愈合。根据关节面残留移位是否累及负重顶,将患者分为负重区组(30例)和非负重区组(18例)。髋关节功能按Merled’Aubigné-Postel标准评定;术后关节面复位质量采用CT评价,于CT片上测量残留移位的两个指标(台阶移位和间隙移位)最大值。所得数据均采用Spearman秩相关检验分析。结果负重区组残留移位值与髋关节功能成强负相关性(rs=—0.722,P=0.001);非负重区组残留移位值与髋关节功能无相关性(rs=0.481,P=0.059)。临床随访结果与相关性分析一致。负重区组台阶移位值与髋关节功能成极强负相关(rs=—0.825,P=0.002),而间隙移位值与髋关节功能无相关性(rs=0.577,P=0.134)。结论髋臼骨折患者术后髋关节功能不仅与关节面残留移位大小相关,还与残留移位部位相关。与非负重区相比,累及负重区的残留移位是影响术后髋关节功能的关键因素;在负重区台阶移位值越大,髋关节功能越差。     

Surgical treatment of central acetabular fractures

Surgical treatment is indicated in most displaced acetabular fractures in young adults. The fractures are generally intraarticular and almost invariably involve the weight-bearing area of the acetabulum. Complete or near anatomic reduction is essential for an excellent and long-standing recovery of the hip joint, and this is extremely difficult to accomplish by conservative management. Fifty-eight displaced central acetabular fractures treated surgically were followed from one to 12 years. They were evaluated by anteroposterior and oblique roentgenograms and classified according to the Judet-Letournel system. Although surgical treatment was somewhat delayed and the experience in approaching and dealing with these fractures was limited in many of the early cases, excellent or satisfactory reduction to a less than 3-mm displacement at the articular surface was achieved in 81% of cases. A close agreement was found between the quality of surgical reduction and clinical results as well as between roentgenographic and clinical results at the final follow-up examination, which were satisfactory in 72% and 74%, respectively. The surgical complications were infection in 2% of cases, peroneal nerve palsy in 8.5%, and moderate to severe ectopic ossification in 10% of the patients.     

经顶型移位髋臼横形骨折手术疗效分析

目的 探讨手术治疗经顶型移位髋臼横形骨折的疗效及其影响因素.方法 1990年5月至2006年7月,手术治疗经顶型移位髋臼横形骨折37例,男26例,女11例;年龄22～64岁,平均34岁.根据复位质量、臼顶骨折粉碎程度、髋关节稳定性、股骨头软骨损伤等因素进行分组,按Matta术后X线复位标准和放射学评估标准及改良的Merle d'Aubigne和Postel功能评分标准进行评估.结果 所有患者均获随访,随访时间16～121个月,平均88.6个月.术后解剖复位31例,复位欠佳4例,复位差2例.2例患者术后X线片示髋关节不稳.根据改良的Merle d'Aubigne和Postel功能评分,临床疗效:优16例(43.24%),良14例(37.84%),可4例(10.81%),差3例(8.11%),优良率为81.08%;远期随访MattaX线疗效:优14例(37.84%),良15例(40.54%),可4例(10.81%),差4(10.81%),优良率为78.38%.临床疗效与X线疗效存在相关性.临床优良率在解剖复位和非解剖复位组分别为90.32%和33.33%,在臼顶粉碎性骨折和非粉碎性骨折组分别为58.33%和92.00%,在髋关节不稳组和稳定组分别为0和85.71%,在股骨头软骨损伤和无软骨损伤组分别为42.86%和90.00%.结论 骨折复位不佳、臼顶粉碎性旨折、髋关节不稳及股骨头软骨损伤等因素可直接影响经顶型移位髋臼横形骨折的手术疗效.     

开窗法复位植骨内固定治疗髋臼前柱骨折合并臼顶区关节面压缩塌陷的临床研究

目的：探讨开窗法复位植骨内固定和单纯行前柱复位内固定治疗髋臼前柱骨折合并臼顶区关节面压缩塌陷的治疗效果。方法：2005年7月至2007年2月,收治合并有臼顶区关节面压缩塌陷的髋臼前柱骨折52例,其中24例采用开窗法整复关节面、植骨后再行前柱复位内固定治疗,男17例,女7例;年龄（35.2±6.4）岁;28例单纯行前柱复位内固定,男19例,女9例;年龄（36.4±4.8）岁。所有患者术后采用改良d＇Aubigne Postel功能评分标准进行评估,比较髋关节功能改善情况。结果：所有患者均达到骨性愈合,出现股神经损伤1例,术后2个月恢复,无其他并发症发生。52例患者术后获得随访,时间12～51个月,平均31.5个月。根据改良d＇AubignePostel功能评分,两组患者在疼痛、行走、关节活动范围、总评分比较差异有统计学意义。开窗法治疗组：优13例,良9例,可1例,差1例;单纯前柱复位组：优9例,良11例,可6例,差2例（u=0.613,P〈0.05）。结论：开窗法复位植骨内固定治疗髋臼前柱骨折合并臼顶区关节面压缩塌陷是一种可行的方法,且可明显改善髋关节功能。     

Surgical treatment and prognosis of acetabular fractures associated with ipsilateral femoral neck fractures

Combined ipsilateral acetabular and femoral neck fractures are the result of high-energy trauma. Satisfactory treatment for this injury pattern remains a challenge, since traditional open reduction and internal fixation (ORIF) is always accompanied by a high prevalence of posttraumatic arthritis and avascular necrosis of the femoral head. Eight of 502 acetabular fractures from 1990 to 2008 were diagnosed with combined ipsilateral femoral neck fracture, in which 5 patients' fractures were associated with hip dislocation. These patients were injured from falls, traffic accidents, or crushing accidents. Radiographs and computed tomography scans were taken to check acetabular and femoral neck fractures. All of the patients underwent surgery using appropriate approaches and techniques. Postoperative radiographs demonstrated anatomic or satisfactory reduction for acetabular fractures as well as excellent or good reduction for femoral neck fractures in all of the patients. Follow-up radiographs showed femoral head necrosis in the 5 patients with femoral head dislocations, but not in the other 3 patients. We have seen few patients with this injury pattern, which makes us unable to detect significant differences between the patients associated with femoral head dislocation and those without femoral head dislocation. But by considering the results of our study and those reported in the literature, we believe that for patients with ipsilateral acetabular and femoral neck fractures without hip dislocation, satisfactory results could be expected after ORIF. But for those cases associated with hip dislocation, alternative methods such as acute THR as primary treatment are worthy of consideration.     

Acetabular fractures in children and adolescents

A retrospective study of 29 acetabular fractures in children 2 to 16 years of age with an average followup of 14 years is presented. Nineteen patients had an additional dislocation of the femoral head and 14 patients had an associated neurologic injury. Surgical treatment was performed in 16 patients and consisted of open reduction and internal fixation in 14 patients and a simple arthrotomy in two patients. Thirteen patients were treated nonoperatively with traction or bedrest. The outcome was satisfactory in all patients with undisplaced fractures and fractures with disruption of a small fragment. Eight patients with linear fractures with instability all were treated surgically. All but one of the patients had a satisfactory functional outcome; one patient had early degenerative changes develop after an open pelvic and acetabular fracture. Patients with central fractures and dislocations had a relatively poor outcome, and congruency was achieved in only one of the four patients who were treated surgically. Results may deteriorate with time, as was seen when the results of the current study were compared with those published 10 years previously.