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。     

髋臼边缘压缩骨折的手术治疗

[目的]认识并掌握髋臼边缘压缩骨折的诊断和手术治疗技巧。[方法]对2008年8月~2013年10月本院收治的髋臼骨折患者中发现并手术治疗的16例合并髋臼边缘骨折患者的临床资料进行回顾性分析,16例髋臼边缘骨折中14例经术前CT检查确诊,2例在髋臼骨折手术中发现。所有患者均通过Kocher-Langenbeck入路采用手术切开复位,对压缩骨折进行撬起和植骨,重建钢板内固定术。[结果]所有患者平均随访29个月(12~46个月),根据改良的Merle d'Aubigne和Postel的髋臼骨折临床结果评分标准:优7例,良5例,可2例,差2例。优良率75%。手术并发症:创伤性关节炎3例,股骨头无菌性坏死1例,无死亡、感染和骨折不愈合病例。[结论]髋臼后方边缘压缩骨折比较隐蔽,术前CT扫描可对这种骨折进行确诊。手术获得解剖复位的关键在于术中对压缩骨折进行精确撬起植骨。     

全髋关节置换术治疗陈旧性髋臼骨折

目的探讨髋臼骨折治疗失败后行全髋关节置换术（THA）的方法和临床疗效。方法本组共对12例陈旧性髋臼骨折治疗失败后的患者行THA,所有患者均为车祸伤,其中髋臼横行骨折5例,后柱及后壁骨折4例,中心性脱位3例。从发生髋臼骨折至进行THA的时间为16～216个月,平均68个月。髋臼缺损采用颗粒性植骨的患者有9例,结构性加颗粒性植骨的有3例,其中支架重建髋臼的有2例。结果12例患者经过14—72个月的随访,平均随访46个月。术后患肢长度平均增加2．6ClYI,所有患者的髋关节功能均明显改善,Harris评分由术前平均42．5分,提高到术后平均85．6分。术后1例患者出现坐骨神经牵拉伤,1例术后3个月髋臼周围出现BrookerⅠ度骨化,随访中未见假体松动。结论髋臼骨折后并发创伤性关节炎行THA可有效改善髋关节功能。术前正确评估髋臼缺损程度,合理重建髋臼是手术成功的关键。     

髋臼后壁边缘压缩骨折的治疗

目的观察切开撬拔复位植骨钢板螺钉内固定术对髋臼边缘压缩骨折的治疗效果。方法对16例髋臼骨折合并边缘压缩骨折的患者采用手术切开复位,对压缩骨折进行撬拨复位和植骨,钢板螺钉内固定术。结果16例平均随访2年,根据Matta的髋臼骨折临床结果评分标准,优9例,良5例,差2例。结论髋臼边缘压缩骨折常见于髋臼后壁骨折患者,易漏诊,要加强对此类型骨折的认识,提高术前确诊率,术中对压缩骨折部分进行撬拔复位和植骨,可获得良好的临床效果。     

全髋关节置换治疗陈旧性髋臼骨折合并髋关节脱位的临床观察

目的探讨髋臼骨折合并髋关节脱位治疗失败后行全髋关节置换的方法及临床疗效.方法本组共11例,男8例,女3例.年龄27～67岁,平均42岁,平均随访28个月(12～48个月).所有病例均为车祸伤致髋臼骨折合并髋关节脱位,中心性脱位5例,其中1例伴股骨颈骨折,髋关节后脱位6例;髋臼横行骨折7例,后柱及后壁骨折4例.所有病例前次手术前均行X线片、CT及三维重建了解骨折情况.结果平均手术时间210min,平均失血量1200ml.术后平均随访28个月,所有病例髋关节功能均获得明显改善.按Harris评分,平均86分(84～94分),髋关节屈伸平均活动度106°.髋臼侧假体固定牢固,无假体松动及骨溶解征象.有3例髋臼周围轻度异位钙化,按Brooker分级,Ⅰ级1例,Ⅱ级2例.无1例发生术后感染.结论髋臼骨折合并髋关节脱位后全髋关节置换重建髋关节功能临床疗效满意,是一种很好的治疗方法.     

K-L入路重建钢板交叉固定治疗髋关节后脱位伴髋臼后壁粉碎骨折

目的探讨经K-L入路采用3.5 mm重建钢板+T型弹性钢板交叉固定治疗髋关节后脱位伴髋臼后壁粉碎骨折的效果。方法采用K-L入路重建钢板交叉固定治疗25例髋关节后脱位伴髋臼后壁粉碎骨折患者。结果患者均获得随访,时间12~32个月,骨折均骨性愈合。Matta影像学评分:优19例,良4例,差2例。关节功能Merle d'Aubigné评分:优18例,良3例,可2例,差2例。结论 3.5 mm重建钢板+T型弹性钢板交叉固定能够为髋臼后壁提供足够的稳定性,利于患者早期功能锻炼,促进髋关节功能恢复,是治疗髋关节后脱位伴髋臼后壁粉碎骨折的有效方法。     

髋臼后壁骨折伴髋关节后脱位与坐骨神经损伤的临床分析

目的 探讨髋臼后壁骨折伴髋关节后脱位合并坐骨神经损伤的创伤机制、类型和预后关系.方法 笔者收治髋臼后壁骨折伴髋关节后脱位合并坐骨神经损伤21例,在骨折内固定时,均行坐骨神经探查术,按MCRR标准评定神经功能恢复情况.结果 21例在术后24个月内,神经均有不同程度的功能恢复,优11例,良9例,可1例,优良率为95.2%.本组无一例出现医源性损伤.结论 髋臼后壁骨折伴髋关节后脱位常合并坐骨神经损伤者,在骨折内固定时应探查神经,结合损伤性质和程度,采取相应疗措施,有利于正确判断预后和恢复神经功能.     

前后联合入路内固定治疗髋臼横断伴后壁骨折及股骨头后脱位

目的探讨前后联合入路骨盆重建钛板内固定治疗髋臼横断伴后壁骨折及股骨头后脱位的可行性与临床效果。方法对22例髋臼横断伴后壁骨折及股骨头后脱位采用Kocher-Langenbeck和髂腹股沟联合入路,应用专用骨盆髋臼复位器械行骨盆重建钛板和螺钉内固定治疗。结果骨折复位质量按照Matta标准评价:解剖复位18例,满意复位4例。术后随访12～38个月(平均25个月),采用Modified d'Aubigne and Postel功能评定标准判定:优17例,良4例,可1例,优良率95.6%。结论选择髋臼横断伴后壁骨折及股骨头后脱位中前方骨折线高且移位大者采用前后联合入路行内固定治疗,可使髋臼骨折达到最大限度的复位并获得理想的髋关节功能康复。     

重建钢板内固定治疗髋关节后脱位伴髋臼后壁骨折

目的探讨重建钢板内固定治疗髋关节后脱位伴髋臼后壁骨折的临床疗效及影响预后的相关因素。方法对35例髋关节后脱位伴髋臼后壁骨折的患者采用K-L入路、AO重建钢板内固定治疗。结果 35例均获随访,时间2年～5年4个月。采用改良Merle d’Aubingne-Postel评分系统评价:优16例,良12例,一般4例,差3例。Matta影像学分级:优13例,好16例,一般5例,差1例。临床结果与X线分级呈显著正相关。患者年龄≥55岁、复位时间≥12 h及复杂性骨折患者中临床评分明显降低。结论对于髋关节后脱位伴髋臼后壁骨折,及时确诊和满意复位、恢复髋臼的连续性和稳定性是取得满意手术疗效的关键;患者年龄、复位时间、骨折类型是影响患者预后的重要因素。     

自制弹簧钢板在髋臼后壁骨折手术中的应用

目的探讨自制弹簧钢板在手术治疗髋臼后壁骨折中的应用及疗效。方法 2013年6月-2017年6月,收治髋臼后壁骨折患者38例。男27例,女11例;年龄28~68岁,平均53岁。致伤原因:交通事故伤18例,高处坠落伤15例,跌倒伤5例。其中,单纯后壁骨折4例,后壁骨折伴髋关节后脱位18例,后壁骨折伴后柱骨折10例,后壁骨折伴横断骨折6例。受伤至入院时间1~4 d,平均2.5 d;受伤至手术时间4~8 d,平均5 d。采用Kocher-Langenbeck入路(35例)和联合髂腹股沟入路(3例)复位骨折后,首先采用弹簧钢板压住固定后壁骨折,然后使用重建钢板压住弹簧钢板固定于后柱。结果术后切口均Ⅰ期愈合。患者均获随访,随访时间12~36个月,平均28个月。发生创伤后坐骨神经损伤5例及术中牵拉致坐骨神经损伤2例,均在术后3个月完全恢复。影像学复查示骨折均愈合,骨折愈合时间10~16周,平均12周。随访期间无内固定物断裂和失效发生;末次随访时发生股骨头坏死2例,创伤性关节炎1例,骨化性肌炎1例。术后12个月根据Harris评分标准评价髋关节功能,获优27例,良5例,可2例,差4例。结论髋臼后壁骨折术中使用弹簧钢板固定后壁骨折块后,再使用重建钢板压住弹簧钢板固定于后柱,具有手术操作简便、固定可靠的优点。     

Anterior Dislocation of the Hip Associated with an Actebular Fracture: Case Report

Abstract Anterior hip joint dislocation is less common than posterior dislocation. Although fractures of the acetabulum can occur in anterior hip dislocations, they are infrequently. In this article, we report an uncommon lesion in a woman who sustained an anterior dislocation of the hip associated with a fracture of the acetabular wall. Close reduction was performed immediately the initial injury. The patient underwent open reduction and internal fixation since the hip joint was result unstable and the CT scan showed the presence of a bone fragment of the anterior acetabular wall. At 2-year follow-up, the clinical and radiological results are excellent.     

手术治疗髋臼后壁骨折伴股骨头脱位

目的探讨手术治疗髋臼后壁骨折伴股骨头脱位的临床疗效。方法18例髋臼后壁骨折伴股骨头脱位患者全部采用K-L入路复位钢板螺丝钉内固定治疗。结果手术时间60～120（90±30）min,失血量200～480（340±140）ml,18例均获随访,时间18～53（35.5±17.5）个月。采用Matta改良的d′Anbigne和Postel临床评价标准：优12例,良3例,可3例。结论髋臼后壁骨折伴股骨头脱位手术治疗可获得良好的临床效果,股骨头脱位复位越早越好,对伴有广泛粉碎性骨折者出现较差结果可能性更大。     

Surgical dislocation of the femoral head for joint debridement and accurate reduction of fractures of the acetabulum

OBJECTIVES: To evaluate fracture reduction, femoral head viability, and outcome of selected acetabular fractures treated operatively using a modified Kocher-Langenbeck approach with a trochanteric flip osteotomy and surgical dislocation of the femoral head. DESIGN: Prospective. PATIENTS: Twelve patients predominantly with combined transverse and posterior wall fractures or multifragmentary posterior wall fractures. OUTCOME EVALUATION: Clinical and radiographic analysis after a minimum 2-year follow-up. METHODS: A single modified approach, including anterior ( = 8) or posterior ( = 4) surgical dislocation of the femoral head, was done in 12 patients 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 35 months (24-48 months), the 12 patients presented with a good to excellent clinical result according to the D'Aubigné score. One patient developed postoperative osteoarthritic changes after an imperfect reduction. No heterotopic ossification interfering with hip function was found. None of the hip joints developed signs of avascular necrosis of the femoral head, even though seven patients sustained a posterior dislocation at time of the injury. CONCLUSION: This study indicates that this technique for surgical dislocation of the femoral head is safe and facilitates assessment of fracture reduction in selected acetabular fractures.     

髋臼后壁骨折并髋关节脱位手术治疗的疗效分析

目的探讨髋臼后壁骨折合并股骨头后脱位的手术治疗方法及影响预后的因素。方法本组25例患者,伤后均急诊行手法复位．多数在伤后5～7天应用Kocher—langenback切口行手术治疗,髋臼后壁骨折复位后,应用螺丝钉或加钢板内固定,必要时植骨。结果全部患者均随诊6～36个月．根据相关资料评定：X线评定结果优19例、良4例、可2例,优良率：92％。临床功能评定优13例、良8例、可3例,差1例,优良率：84％。结论髋臼后壁骨折并关节脱位解剖复位及手术内固定可提高此类损伤疗效和减少并发症发生。     

前路钢板螺钉内固定治疗髋臼骨折伴骶髂关节脱位的疗效分析

目的探讨前路钢板螺钉内固定治疗髋臼骨折伴骶髂关节脱位的临床疗效。方法回顾性分析自2011-01—2015-12采用髂腹股沟入路切开复位骨盆重建接骨板加骶髂关节星形接骨板内固定治疗的24例髋臼骨折伴骶髂关节脱位。髋臼骨折复位质量按Matta复位评分标准评定。骶髂关节分离复位评定采用PACS系统分别对术前及术后的CT横断面及矢状面骶髂关节间隙最宽处进行测量。髋关节功能采用Majeed评分标准评定。结果术前CT横断面骶髂关节间隙为(11.86±3.43)mm,术后为(4.05±0.76)mm,手术前后差值为(7.58±2.87)mm;术前CT矢状面骶髂关节间隙为(16.29±3.84)mm,术后为(4.27±0.95)mm,手术前后差值为(11.83±3.19)mm;结果显示术后髋臼及骶髂关节脱位复位良好。24例均获得随访7~30个月,平均12.8个月。骨折愈合时间3~9个月,平均4.8个月。髋臼骨折复位质量按Matta标准评定:优13例,良8例,可3例,优良率为87.5%。髋关节功能采用Majeed评分标准评定:优7例,良11例,可5例,差1例,优良率为75.0%。结论前侧髂腹股沟入路骨盆重建接骨板加骶髂关节星形接骨板内固定治疗髋臼骨折伴骶髂关节脱位是一种简单有效的方法,具有操作安全、骨折复位满意、术后疗效肯定的优点。     

Posteriore Zugänge zum Acetabulum

Posterior approaches to the hip joint were developed by Langenbeck and Kocher in the nineteenth century. Letournel created the term Kocher-Langenbeck approach which became one of the most important approaches to the hip joint. The further extension of this approach by digastric trochanteric osteotomy and subsequently by surgical hip dislocation enables visualization of the entire hip joint which allows complete evaluation of articular joint damage, quality of reduction and confirmation of extra-articular hardware. With the increasing incidence of acetabular fractures in the elderly there is a concomitant increase of complicating factors, such as multifragmentary posterior wall fractures, dome impaction, marginal impaction and femoral head damage. These factors are negative predictors and compromise a favorable outcome after acetabular surgery. With direct joint visualization these factors can be reliably recognized and corrected as adequately as possible. Surgical hip dislocation thus offers advantages in complex posterior wall, transverse and T-shaped fractures with or without posterior wall involvement. For these fracture types surgical hip dislocation represents a standard approach in our hands.     

Displaced acetabular fractures in the elderly: Results after open reduction and internal fixation

BackgroundThe optimal management of elderly patients with displaced acetabular fractures remains controversial. This paper aims to summarize the clinical results of open reduction and internal fixation (ORIF) and the possible factors influencing them.MethodsRadiographic and clinical data on 52 elderly patients with displaced acetabular fractures that were treated by ORIF between May 2000 and May 2008 were retrospectively analysed. Data, such as fracture type (Letournel's classification system), quality of reduction, clinical outcomes (Harris hip score and modified Merle d’Aubigne-Postel score), and radiological outcomes (Matta score), were evaluated.ResultsGood to excellent clinical and radiological outcomes were recorded in 43 (82.7%) and 37 patients (71.2%), respectively. Acetabular fractures without radiographic features, such as quadrilateral plate fracture, Gull sign, posterior dislocation of hip, posterior wall marginal impaction, comminuted posterior wall fracture, and femoral head injury, can still achieve good to excellent outcomes. However, patients with the abovementioned radiographic features tend to achieve fair or poor outcomes. When an acetabular fracture with the aforementioned features, except for femoral head injury, can achieve and maintain anatomic reduction until complete fracture healing, the difference between fractures with and without the radiographic features is no longer significant. The results indicate that the outcomes are more affected by reduction rather than radiographic features.ConclusionORIF may be suggested for displaced acetabular fractures in the elderly. Good to excellent outcomes and a high degree of patient satisfaction can be achieved in majority of the patients. We recommend ORIF as the preferred treatment for displaced acetabular fractures without the abovementioned radiographic features.Level of evidenceTherapeutic level IV.     

The direct posterior gluteal muscle splitting approach for posterior access to acetabular fractures: Surgical technique and case series

We present a minimally invasive direct posterior, gluteal muscle splitting approach (PMS) as an alternative to the traditional Kocher-Langenbeck (KL) approach for posterior access to acetabular fractures. We believe it offers significant advantages and provides improved access while maximizing the range of fracture patterns that can be addressed through a posterior approach.One hundred and eighty-four consecutive patients treated with this approach by the senior author (RMS) between 2001 and 2018 were reviewed. The most common individual fracture pattern addressed was a posterior wall (66/36%) but more complex combination fracture types were the dominant group (106/58%), and included transverse with posterior wall, posterior wall / posterior column, and T types. A radiographically congruent reduction was consistently obtained at surgery, without any operative sciatic nerve palsies and a comparable heterotopic bone formation rate to previous reports. We have reviewed all 120 patients who were followed beyond 6 months and noted the hip replacement conversion rates to be different with each fracture type. The rate was highest with Transverse/ posterior wall injuries (36%), 16% of the posterior wall injuries were converted, a history of dislocation was not specifically associated with conversion.We believe this approach improves the posterior access to the acetabulum, but this study also confirms the poor prognosis of specific groups of higher energy multi-fragmentary, posterior acetabular injuries and suggests the need for a classification system that better predicts the prognosis for the hip joint.Level of Evidence4