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.     

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.     

陈旧性髋臼骨折的手术重建

目的 探讨陈旧性髋臼骨折的手术技术和影响临床效果的相关因素.方法 2001年4月至2008年12月,经手术治疗并有完整随访资料的陈旧性髋臼骨折患者61例.男47例,女14例;平均年龄(38±3)岁.按Letournel分型:简单型骨折16例中,后壁骨折7例,后柱骨折2例,前柱骨折1例,横行骨折6例;复合型骨折45例中,后柱伴后壁骨折3例,横行伴后壁骨折7例,"T"形骨折4例,伴后方半横行骨折6例,双柱骨折25例.交通伤52例,坠落伤6例,挤压伤3例.伴颅脑损伤11例,胸腹脏器损伤15例,膀胱尿道损伤7例,伴多处骨折25例,术前有坐骨神经损伤症状者3例.损伤至手术的平均时间39 d.选择单一手术入路13例,前后联合入路48例;手术平均耗时(248±45)min,术中平均失血(2160±100)ml.结果 术后平均随访(61±8)个月.采用Matta的复位标准:解剖复位45例,不满意13例,差3例;根据改良Merle d'Aubingne和Postel临床结果评分:优38例,良13例,可6例,差4例.术后发生股骨头坏死3例(4.9%),异位骨化28例(45.9%),坐骨神经一过性麻痹4例(6.6%).结论 对陈旧性髋臼骨折通过适当的切开复位内固定,也可达到满意的临床结果.对简单型陈旧性髋臼骨折可选择单一入路,而对于复合型骨折原则上采用前后联合入路.手术医生的经验与复位优良率密切相关.

Abstract：

Objective To discuss the surgical technique of delayed acetabular fractures and its possible prognosis factors.Methods From April 2001 to November 2008,61 patients with delayed acetabular fractures were surgically treated.There were 47 males and 14 males,with an average age of 38 years.According to Letourael classification,16 simple fractures included 7 cases of posterior wall fractures,2 of posterior column fractures,1 of anterior column fractures and 6 of transverse fractures.Forty-five patients with mixed fractures included 3 cases with both fractures posterior column and wall,7 of transverse and posterior wall fractures,4 of T-shape fractures,6 of posteriorly semi-transverse fractures and 25 of both-columns fractures.Fifty-two patients suffered from traffic accident;6 patients were caused by falling from height and 3 suffered from crush injuries.Brain injuries occurred in 11 cases,thorax-abdominal injuries in 15,urinary tract injuries in 7,multiple fractures in 25.The injury of sciatic nerve was found in 3 patients preoperatively.The average interval form injury to surgery was 39 days.A single approach was employed in 13 cases,and combined antero-posterior approaches were employed in 48.The operation time was (248±45) min with a blood loss of (2160±100) ml averagely.Results The average follow-up was (61±8) months.The clinical result was evaluated by Matta reduction criteria,modified Merle d'Aubingne and Postel scoring system.Anatomical reduction was achieved in 45 cases;however,13 were unsatisfactory and 3 were poor.For clinical results,38 were graded as excellent,13 as good,6 as fair and 4 as poor.Osteonecrosis of the femoral head occurred in 3 cases (4.9%),and heterotopic ossification developed in 28 cases (45.9%).Additionally,4patients (6.6%) had a transient sciatic nerve paralysis.Conclusion Open reduction and internal fixation is a liable method for delayed acetabular fractures.Single approach is suitable for simple fractures;in principle and combined approaches are for compound delayed acetabular fractures.The reduction quality is closely related to surgeon's experience.     

Treatment of comminuted trochanteric fractures and non-union of trochanteric osteotomy in revision total hip arthroplasty

To explore the clinical efficacy of thetreatment of comminuted trochanteric fractures andtrochanteric osteotomy non-union in revision total hiparthroplasty with tension-band f‘Lxation.     

陈旧性舟骨骨折的手术疗效分析

目的 探讨陈旧性舟骨骨折的治疗方法及临床疗效.方法 2005年6月至2008年6月,对16例陈旧性舟骨腰部骨折患者,采用腕关节背侧入路,去除骨折处硬化骨后加自体骨植骨,并用Herbert螺钉加克氏针进行固定.术后定期复查X线片,观察骨折愈合情况.根据Krimmer评分评估腕关节功能.结果 术后16例获得随访(平均为8.5个月),所有骨折均获得愈合,平均愈合时间为16周.按Krimmer评分:优8例,良5例,可2例,差1例;优良率达81.3%.结论 对于陈旧性舟骨骨折,通过自体骨植骨及Herbert钉加克氏针内固定,能取得较理想的临床效果.

Abstract：

Objective To discuss the surgical methods and treatment effects of old scaphoid fractures.Methods From June 2005 to June 2008, 16 cases of old scaphoid waist fractures were treated by debridement of necrotic bone, autologous bone graft and Herbert screw plus Kirschner wire internal fixation through a dorsal approach. Postoperative X-rays were taken on a regular basis to observe fracture healing. Wrist function was evaluated according to Krimmer score. Results Postoperatively the 16 cases were follow-up for an average of 8.5 months. All the fractures healed and the average healing time was 16 weeks. Krimmer score determined wrist function to be excellent in 8 cases, good in 5 cases, fair in 2 cases and poor in 1 case. The overall satisfactory rate was 81.3%. Conclusion Herbert screw and K-wire internal fixation combined with autologous bone graft can attain good clinical results in the treatment of old scaphoid fiactures at the waist.     

Surgical treatment for complicated acetabular fractures

Objective: To sum up the surgical approaches and clinical outcome of complicated acetabular fractures.Methods: 17 patients with complicated acetabular fractures (including 4 cases of transverse with posterior wall fractures,7 cases of posterior column and wall fractures, 4 cases of anterior and posterior columns fractures, 1 cases of T-type fracture and 1 cases of anterior column with posterior hemitransverse fractures) underwent open reduction and internal fixation with screws and plates by Kocher-Langenbeck (8 cases), ilio-inguinal (2 cases), extended iliofemoral (4 cases) or ilio-inguinal combined with K-L approaches (3 cases). Results: 12 patients with anatomical reduction, 4 patients with satisfactory reduction and 1 patient with non-satisfactory reduction. 15 out of 17 cases were followed up for 6 months to 5 years, and the excellent and good rate was 70.5%. Conclusion: Surgical treatment for complicated acetabular fractures can get a satisfactory reduction and a good clinical outcome.     

距骨体骨折的手术治疗

目的 探讨距骨体骨折的手术治疗效果及注意事项.方法 2002年4月至2008年7月,手术治疗距骨体骨折患者44例,男41例,女3例;年龄15～61岁,平均31.7岁;左侧26例,右侧18例.根据Sneppen分型,Ⅱ型24例,V型20例.开放性骨折11例,根据Gustilo和Anderson分型,Ⅰ型3例,Ⅱ型7例,ⅢA型1例.致伤原因:高处坠落伤18例,交通事故伤13例,重物砸伤8例,扭伤4例,刀砍伤1例.开放性骨折平均在伤后5.3 h手术,闭合性骨折平均在伤后8.9 d手术.闭合性骨折采用前内侧切口15例,前外侧切口3例,内外侧联合切口15例.44例患者中,3例单纯应用克氏针固定;5例采用螺钉辅以克氏针短期固定;2例采用可吸收螺钉固定;34例采用空心拉力螺钉固定,其中4例辅以全螺纹松质骨螺钉固定.结果 35例患者获得随访,随访时间21～89个月,平均44.5个月.4例出现切口皮缘坏死,1例出现伤口感染,均经治疗后愈合.骨折均愈合,愈合时间为17～41周,平均22周.美国足与踝关节协会(AOFAS)功能评分为43～100分,平均77.3分;优11例,良13例,可10例,差1例,优良率为68.6%.5例患者发生距骨缺血性坏死;19例患者发生创伤性关节炎,其中4例行关节融合术.结论 治疗距骨体骨折时应根据骨折和软组织损伤的具体情况选择手术时机和入路,保护血供、解剖复位及早期功能锻炼是取得良好疗效的关键.

Abstract：

Objective To investigate the results and related key points in operative treatment of talar body fractures. Methods From April 2002 to July 2008, 44 patients with talar body fractures underwent the operation. There were 3 females and 41 males. The mean age of the patients was 31.7 years. The fractures occurred on the left side in 26 patients and on the right side in 18 patients. According to Sneppen classification, 24 type Ⅱ, 20 type V. Eleave cases were open fractures, according to the Gustilo-Anderson classification, there were 3 cases in type Ⅰ , 7 in type Ⅱ, 1 type in Ⅲ A. The mean interval between injury and surgical treatment for open fractures and close fractures was 5.3 hours and 8.9 days. The mechanism of injury was a fall from the height in 18 patients, a traffic accident in 13 patients, a crush injury in 8 patients, a sprain injury in 4 patients and a cut injury in 1 patient. Anteromedial approach was used for 15 close fractures, anterolateral approach for 3 and combined anteromedial-anterolateral approach for 15. K-wires fixation were utilized for 3 fractures, screws and temporary K-wires fixation for 5 cases, bioabsorbable screws for 2fractures, cannulated screws for 30 fractures and cannulated screws and threaded cancellous screws for 4cases. Results Thirty-five patients were followed up 21 to 89 months (average, 44.5 months). Necrosis of incision was found in 4 cases, wound infection occurred in 1 case. All fractures had achieved bone union;the average healing time was 22 weeks. Functional results were assessed according to AOFAS score, the average score was 77.3, There were 11 patients in excellent results, 13 in good, 10 in fair and 1 in poor. The overall excellent and good rate was 68.6%. Avascular necrosis occurred in 5 cases. Traumatic arthritis occurred in 19 cases. Arthrodesis was needed in 5 cases. Conclusion The timing and approach of surgery is determined by the condition of the talar fractures and soft tissue. Anatomical reduction, preservation of the blood supply and early active pain-free mobilization are key points in the treatment of the talar body fractures.     

后侧入路内固定治疗胫骨平台后侧骨折

目的 探讨后侧入路内固定治疗胫骨平台后侧骨折的近期疗效.方法 对2008年6月至2010年6月采用后侧入路内固定治疗且随访资料完整的11例胫骨平台后侧骨折患者进行回顾性分析.男7例,女4例;年龄33～60岁,平均47.8岁.AO/OTA分型:41-B2.2.4型2例,41-B3.1.2型3例,41-B3.3.2型3例,41-B3.1.2型+41-B3.3.2型2例,41-C3.3型1例.5例后外侧骨折采用膝关节Carlson后外侧入路;3例后内侧骨折采用Carlson后内侧入路;3例累及胫骨平台前、后侧及胫骨髁间嵴骨折者采用Carlson后内和(或)后外入路,辅以前侧入路行钢板螺钉内固定.关节面塌陷者采用自体髂骨植骨.结果 随访3个月至2年,平均1.6年.全部病例均获得影像学上的骨性愈合,愈合时间12～16周.Rasmussen放射学评分15～18分,平均16.7分.骨折愈合后美国特种外科医院(the Hospital for Special Surgery,HSS)膝关节评分75～96分,平均86.2分.后外侧入路5例膝关节活动范围平均0°-135°,后内侧入路3例0°-130°,混合入路3例-10°-125°.结论 胫骨平台骨折表现为以后侧为主时,应选择后外或后内侧手术入路,于直视下进行复位及固定,便于操作,术后近期疗效满意.

Abstract：

Objective To evaluate the clinical results of operative treatments for the complex posterior tibial plateau fractures via posterior approach. Methods Eleven cases with complex posterior tibial plateau fracture from June 2008 through June 2010 were reviewed retrospectively. There were 7 males and 4females, with age from 33 years to 60 years (average, 47.8 years). According to AO classification, there were 41-B2.2.4 type in 2 cases, 41-B3.1.2 type in 3, 41-B3.3.2 type in 3, 41-B3.1.2 type combined 41-B3.3.2 type in 2, 41-C3.3 type in 1. Carlson posterior lateral approach were used in 5 cases, posterior medial approach were used in 3 cases, and posterior medial and/or lateral approach combined with anterior approach were used in 3 cases. All fractures were fixed with plates. Autogenous ilium grafts were used if necessary.Results All cases were followed up. The average follow-up time was 1.6 years (range, 3-24 months). At the final follow-up visit, bone union was obtained in all cases. The mean Rasmussen score was 16.7 (range, 15-18), and the mean HSS was 86.2 (range, 75-96). The postoperative knee range of motion were 0°-135°, 0°-130° and -10°-125° in 5 cases with posterior lateral plateau fractures, 3 cases with posterior medial plateau fractures and 3 cases with anterior and posterior plateau and intercondylar fractures respectively. There was no vascular and nerve injuries. Loosing or breaking of hardware's was not found. Conclusion The Carlson posterior lateral and/or medial approach is preferred for the complex posterior plateau fractures, with the advantages of direct reduction and stabilization.     

踝关节骨折畸形愈合的重建手术

目的 总结踝关节骨折畸形愈合重建术的临床疗效.方法 2006年1月至2009年1O月,共收治23例踝关节陈旧性骨折畸形愈合患者.男14例,女9例;平均年龄45岁(21～69岁).初次受伤至最终重建术平均间隔18个月(12～36个月),其中11例患者曾接受切开复位内固定术.术前常规行X线及CT检查,对畸形进行个体化评估:所有患者均有不同程度的腓骨短缩或旋转,合并内、外翻畸形者4例,下胫腓联合间隙增宽者5例.对所有腓骨短缩或旋转的患者行腓骨延长截骨术,内外翻畸形则行开放或闭合楔形截骨,而下胫腓增宽者则须行下胫腓功能性融合.术后定期行影像学随访评估骨愈合情况,记录并发症发生情况,并采用美国骨科足踝外科协会(American Orthopedic Foot Ankle Society,AOFAS)踝关节与后足功能评分来评估治疗效果.结果 共21例患者获随访,平均随访36个月(12～58个月).所有随访患者均无感染、内固定失败、骨不连、畸形复发等发生.影像学随访显示于术后平均12周(10～14周)骨愈合,且力线恢复良好.AOFAS踝关节与后足功能评分从术前平均28分(15～39分)改善为术后1年平均82分(70～94分).2例患者因严重创伤性关节炎分别于术后18个月和术后2年行踝关节融合术.结论 对于踝关节骨折畸形愈合的患者,通过早期重建手术恢复腓骨长度和旋转及踝穴的匹配,踝关节功能可获得极大的改善,也可延缓创伤性关节炎的发展.

Abstract：

Objective To summarize the clinical outcomes of reconstruction of malunited ankle fractures.Methods From January 2006 to October 2009,23 malunited ankle fractures were treated in our department.All deformities were evaluated individually based on pre-operatively X-ray and CT scan.Varying degrees of fibular shortening or rotational deformity were found in all patients,with 4 cases of varus or valgus deformity,and 5 of a widen syndesmosis.Then different reconstructive techniques were chosen according to the type of malunion:a lengthening fibular osteotomy was performed in patients with fibular shortening or rotational deformity;an opening or closing wedge osteotomy was chosen correspondingly in patients with varus or valgus deformity;functional fusion of syndesmosis was performed in cases of widen syndesmosis.The postoperative follow-up included standard radiography to evaluate bone union;relative complications were also recorded and functional outcome were assessed with American Orthopedic Foot Ankle Society (AOFAS)ankle-hindfoot scores.Results Twenty-one patients were followed up with an average period of 36 months (12-58 months).There were no complications of infection,implant failure,nonunion or malunion.Solid union with a favorable alignment was obtained at an average of 12 weeks (10-14 weeks).The mean pre-operative AOFAS ankle-hindfoot score was 28 (15-39).While the score increased to 82 (70-94) one year after operations.But 2 patients underwent ankle arthrodesis correspondingly 18 months and 24 months post-operatively due to severely post-traumatic arthritis.Conclusion An early realignment reconstruction of the length and rotation of fibula and the congruity of ankle mortise may improve the ankle function and slow down the development of post-traumatic arthritis for patients who suffered from malunited ankle fractures.     

背侧双板固定治疗桡骨远端粉碎性骨折

目的 探讨采用背侧入路复位、双板固定治疗桡骨远端粉碎性骨折的手术指征及疗效.方法 采用背侧人路行骨折复位、植骨、双板固定治疗C型桡骨远端粉碎性骨折10例,其中男2例,女8例;患者平均年龄72岁.结果 术后随访时间6～26个月,平均14个月,按照改良的Garland-Werley评分标准评定:平均为2分(0～12分),其中优5例、良4例、可1例.结论 背侧双板固定治疗桡骨远端粉碎性骨折手术操作难度较高,但是背侧复位、植骨、固定更符合局部的解剖学特点和骨折的受伤机制,是治疗桡骨远端粉碎性骨折的有效方法之一.

Abstract：

Objective To discuss the indications, methods and treatment outcomes of double plate internal fixation of comminuted distal radius fractures via a dorsal approach. Methods Ten patients of type C comminuted distal radius fractures were treated by dorsal approach reduction, bone graft and double plate internal fixation. Among them, 2 were male and 8 were female. The average age of the patients was 72 years. Results Postoperatively the patients were followed up for 6 to 26 month, with an average of 14 months. The mean Garland and Werley score was 2 (range 0 to 12). Results were considered excellent in 5 cases, good in 4 cases and fair in 1 case. Conclusion Dorsal double plate fixation for comminuted distal radius fracture is technically challenging. However dorsal reduction, bone grafting and fixation is more in line with the anatomy of distal radius and the injury mechanism. It is one of the most effective methods for treating this type of complex fractures.     

Sliding trochanteric osteotomy in acetabular fractures: a review of 30 cases

OBJECTIVE: To assess the results of using sliding trochanteric osteotomy as an adjunct procedure for acetabular fractures. DESIGN: Retrospective review. SETTING: Level 1 trauma centre. METHODS: Thirty patients (19 men, 11 women, mean age 40 years, range 23-80 years) having fracture of acetabulum underwent sliding trochanteric osteotomy for a better exposure of the fracture involving the dome of acetabulum during the period January 1999-January 2004. MAIN OUTCOME MEASUREMENTS: Clinical evaluation was based on modified Merle d' Aubigne and Postel scoring. Motor strength of the abductors was evaluated according to the Medical Research Council (MRC) grading system. Radiographic evaluation of the joint was also documented. RESULTS: All the osteotomies healed within 12 weeks without any proximal migration except for one patient with infection in whom nonunion occurred. Two patients underwent removal of implants from greater trochanter because of irritation. The strength of the abductors was of Grade 2/5 in one patient, Grade 3/5 in one patient, Grade 4/5 in six patients and Grade 5/5 in the rest. Clinical scoring was excellent to good in 77%. Heterotopic ossification occurred in six patients and was of modified Brooker's classes 1 and 2. CONCLUSIONS: This technique can be relied upon to provide an adequate exposure of the dome of acetabulum without the associated complications like malunion, non-union, etc., known to occur with standard oblique osteotomy.     

The role of trochanteric flip osteotomy in fixation of certain acetabular fractures

Purpose: Complete visualization of certain acetabular fractures of posterior wall or column with cranial extension involving superior dome from standard surgical exposures is a challenge. Osteotomy of the greater trochanter has been used to enhance fracture visualization, especially the dome, in posterior and lateral exposures of the acetabulum. It also decreases the need for excessive muscle retraction. The purpose of the study was to investigate the outcome associated with trochanteric flip osteotomy in the management of certain acetabulum fractures. Methods: From January 2011 to December 2013, 25 displaced acetabular fractures were treated by open reduction and internal fixation. The fractures were managed using a KochereLangenbeck approach along with trochanteric flip osteotomy. At 3rd, 6th and 24th month follow-up, all patients had radiographic examination and underwent a final clinical evaluation based on the modified Merle d''Aubigne and Postel score. The strength of the abductors was assessed according to the Medical Research Council (MRC) grading system. Results: Congruent reduction was achieved in all patients and all osteotomies healed within an average period of 3.8 months. All our patients were allowed full weight bearing at the end of 3 months and with no abductor lurch at the end of 6 months follow-up. There were no cases of avascular necrosis of femoral head. None of the patients had any neurovascular complication or infection by the end of the follow-up period. Conclusion: Trochanteric flip osteotomy is a very effective technique to fix certain acetabular fractures especially those with dome involvement. It is more accurate and associated with no significant complications compared with conventional way.     

大转子后半截骨术在累及臼顶的髋臼骨折中的应用

目的：介绍一种新的大转子截骨方法,并评估后外侧入路联合该方法治疗累及髋臼顶部骨折的治疗效果。方法：2008年3月至2010年11月,采用髋关节后外侧入路联合大转子后半截骨治疗累及臼顶的髋臼骨折30例,其中男21例,女9例;年龄18—70岁,平均35．2岁。按照Letournel—Judet分型：后壁骨折10例,后柱骨折7例,横形骨折5例,T形骨折2例,横形伴后壁骨折1例,后柱伴后壁骨折3例,双柱骨折2例。根据Matta标准评估复位结果,改良的Merled＇Aubigne—Postel评分标准评定髋关节功能及美国医学研究委员会标准评定标准评估外展肌力。结果：所有患者获得随访,时间18—40个月,平均25个月。所有截骨获骨性愈合,平均愈合时间为8．4周（6-12周）。无骨不连、截骨块近端移位、内固定松动、断裂及深部感染等并发症发生。根据Matta标准：解剖复位17例,满意复位12例,不满意1例。末次随访时髋关节功能结果优11例,良15例,可3例,差1例。外展肌力4级3例,5级27例。结论：大转子后半截骨术可以增加臼顶部手术视野,有效提高股骨头与髋臼的解剖对应率,降低复位和固定难度,并发症少,为累及髋臼顸的骨折治疗提供了新思路。     

The use of trochanteric slide osteotomy in the treatment of displaced acetabular fractures

From January 2003 and February 2006, 31 displaced acetabular fractures were treated by open reduction and internal fixation. The fractures were managed using a single approach, involving a straight lateral incision centered over the greater trochanter, trochanteric osteotomy and dislocation of the femoral head. The mean age of the patients was 48 (range 20-74 years) with a mean follow up 24 months (range from 20 to 42 months). Ten fractures were classified as simple, and 21 as complex fractures. The mean time to surgery was 4.5 days (range from 0 to 14 days). Mean operating time was 118 min (range 52-168). Five patients presented with posterior dislocation of the hip joint at the time of initial presentation. The trochanteric fragment was fixed with three 3.5mm cortical screws. Congruent reduction was achieved in all patients and all osteotomies healed within 5 months. Clinical evaluation was based on the modified Merle d'Aubigne and Postel scoring. Motor strength of abduction was evaluated according to the Medical Research Council grading. Clinical scoring was excellent to good in 24%. The strength of the abductors was grade 0/5 in a patient with Brooker's class IV heterotopic ossification, and 3/5 in the two patients with necrosis of the femoral head. There were five patients with grade 4/5 and the 5/5 in the rest. Complications included two segmental femoral head necrosis, one of them combined with necrosis of the weight bearing acetabular dome area. These patients required total hip replacement. Mild heterotopic ossification grade II was seen in one patient and significant (grade IV), in another patient. Two patients developed superficial wound infection over the trochanteric area and another two patients persistent pain due to irritation caused by the screws. One patient developed peroneal nerve palsy which resolved 3 months after the surgery. The trochanteric slide osteotomy can enhance the exposure of the whole acetabulum and the femoral head. This allows better evaluation of any osteochondral lesions, intra-articular bony fragments and fracture steps, providing a more accurate reduction and easier fixation of the acetabular fracture.     

Digastric trochanteric flip osteotomy and surgical dislocation of hip in the management of acetabular fractures

Objectives

To assess the efficacy and safety of digastric trochanteric flip osteotomy technique in the management of acetabular fractures and to evaluate surgical outcome in terms of fracture reduction, femoral head viability of selected acetabular fractures treated operatively using a digastric trochanteric flip osteotomy and a modified Kocher–Langenbeck approach with surgical dislocation of the femoral head.

Design

Prospective.

Patients

Eighteen patients predominantly with combined transverse and posterior wall fractures or multifragmentary posterior wall fractures.

Outcome evaluation

Clinical and radiographic analysis after a minimum 18 months follow-up.

Methods

A single modified approach involving digastric trochanteric flip osteotomy and a modified Kocher–Langenbeck approach with anterior (n = 14) or posterior (n = 4) surgical dislocation of the femoral head, was done for one or more of following reasons: intra-articular assessment of reduction in fractures with comminution, marginal impaction and involvement of the anterior column, removal of intra-articular fragments, and confirmation of extra-articular screw placement.

Results

At a mean follow-up of 26 months (18–40 months), the 17 patients presented with a good to excellent clinical result according to the d’Aubigné score. In all subjects, anatomical reduction was achieved during surgery. The osteotomy site healed at an average of 7 weeks and all the patients recovered abductor strength at 12 weeks. One avascular necrosis occurred in a case of posterior column plus wall fracture (who presented to us after 3 weeks). No heterotopic ossification interfering with hip function was found.

Conclusion

This technique gives good exposure (especially in posterior wall, dome area, posterior fracture-dislocation with intra-articular fragments/femoral head fractures and T-fractures), preservation of abductor strength (which may be lost with excessive retraction of abductors to see dome area in classical posterior approach), reliable healing of osteotomy (in contrast to conventional trochanteric osteotomy) without risking the vascularity of femoral head.     

Modified sliding trochanteric osteotomy in revision total hip arthroplasty

Traditional trochanteric sliding osteotomy preserves the lateral aspect of the greater trochanter, the abductors, and vastus lateralis in continuity. Our modification uses a lateral approach to the hip and osteotomy immediately anterior to the insertion of the posterior capsule and external rotators onto the greater trochanter. The osteotomy and attached abductors and vastus lateralis are translated anteriorly, leaving the posterior capsule and external rotators attached to the proximal femur. This surgical approach preserves the posterior soft-tissue stabilizing structures that resist posterior dislocation of the hip. In a retrospective review of 2 consecutive 2-year series of acetabular component revisions only between 1997 and 2001, 4 of 27 acetabular revisions using a traditional trochanteric slide subsequently dislocated; only 1 of 30 subsequent cases using a modified sliding trochanteric osteotomy dislocated. Modified sliding trochanteric osteotomy facilitated surgical exposure and produced a trend toward a lower dislocation rate that did not reach statistical significance with the small numbers of patients available.     

Exposure for revision: total hip replacement

The author uses four basic approaches for the majority of revision total hip replacements (THRS). The posterior approach is used for most simple revisions of loose endoprostheses, short, loose, cemented stems, and straightforward cup revisions. The key technical maneuvers are the soft tissue releases necessary to adequately displace the proximal femur anteriorly. The sliding trochanteric osteotomy is used when greater exposure of the femoral shaft is necessary to remove implant materials, to treat deformities or fractures, when abductor tension must be adjusted, or when enhanced acetabular exposure is required. Proper orientation of the osteotomy and excision of anterior pseudocapsule are necessary to mobilize the muscular osseous sleeve created by this approach. The extended trochanteric osteotomy is recommended for the most difficult femoral revisions, including the removal of well-fixed cementless and cemented components. The lateral 1/3 of the femoral shaft is removed as far distally as necessary. Careful attention to the creation, elevation, mobilization, and fixation of the osteotomized fragment is important in avoiding fracture or nonunion. The combined AP extensile approach is used for the most difficult acetabular reconstructions, including total acetabular allografting. Cadaveric training and possibly general, vascular, or urologic surgical assistance is recommended for this difficult approach.     

Assessment of trochanteric osteotomy fragment union after acetabular fracture surgery

BackgroundTrochanteric osteotomies are performed in conjunction with standard approaches to improve surgical exposure during open reduction and internal fixation (ORIF) of acetabular fractures. The literature on total hip arthroplasty reports nonunion rates as high as 30% associated with trochanteric osteotomies; however, few data exist regarding the outcomes of trochanteric osteotomies for acetabular fracture surgery. Our hypotheses were 1) patients receiving trochanteric osteotomies during ORIF of acetabular fractures have a low rate of nonunion of the osteotomy fragment, and 2) hip abduction precautions are not necessary with digastric type osteotomies.Patients and methodsA retrospective review was conducted to identify patients with acetabular fractures between July 2002 and June 2010 (n = 734 fractures) who required trochanteric osteotomies (n = 64, 9% of fractures). Forty-seven met inclusion criteria of adequate follow-up (>56 days). No excluded patient experienced a complication. Fractures were classified using the Letournel-Judet classification system.ResultsOnly seven (20%) of 35 patients who received digastric osteotomies had hip abduction precautions applied during the postoperative period. All study patients were shown to have radiographic union at the trochanteric osteotomy site (100% union rate, n = 47). Hip abduction precautions intended to protect the osteotomy site and reduce the risk of nonunion and fixation failure were infrequently applied to patients with digastric osteotomies (20%) in this cohort. Multiple protective factors against nonunion were present in this study population compared with previous arthroplasty studies from other institutions.ConclusionsTrochanteric osteotomies are not associated with a significant nonunion rate, and digastric osteotomies might be safely managed without hip abduction precautions.     

全髋关节置换术中大转子骨折的原因与治疗

目的探讨全髋关节置换术及翻修术中股骨大转子骨折的原因与治疗方法。方法对1996年5月至2005年1月,471髋行全髋关节置换及96例全髋关节翻修术发生大转子骨折及大转子截骨不愈合的14例患者进行回顾性分析。其中大转子骨折11例,截骨不愈合3例。2例保守治疗,12例采用螺钉或克氏针加张力带钢丝固定的方法治疗。结果术后随访5~64个月,平均25个月。14例患者全部愈合。Harris评分从术前平均48分恢复到术后随访时平均90分。结论骨质疏松、髋内翻、髋脱位及股骨颈截骨不当等因素是全髋关节置换术及翻修术中股骨大转子骨折的主要原因。采用螺钉或克氏针加张力带钢丝固定的方法治疗效果良好。     

A modified extensile exposure for the treatment of complex or malunited acetabular fractures

A modification of the extended iliofemoral incision of Letournel and Judet facilitates the operative exposure of T-type, complex transverse, and both-column acetabular fractures and malunions. The modification includes the utilization of a T-shaped skin incision with large flaps, and osteotomies of the iliac crest, greater trochanter, and anterior superior iliac spine. The iliotibial band is transected and the abductor muscle mass is rotated posteriorly, hinged on the superior gluteal neurovascular bundle. Twenty patients had open reduction and internal fixation of a complex acetabular fracture using this surgical approach. Excellent surgical exposure allowed good or excellent reduction of the acetabulum in all patients. No flap necrosis developed, and all fractures healed. One non-union of a trochanteric osteotomy needed revision. This approach provides increased exposure of the posterior column and visualization of the entire surface of the joint and it allows fixation of the fracture from both sides of the iliac wing. The T-shaped skin incision allows utilization of a standard posterior approach with conversion to the extensile exposure if necessary. Options for late reconstruction are not compromised. Lagscrew fixation of the osteotomies allows aggressive rehabilitation of the joint.