腹直肌外侧切口入路复位固定髋臼双柱骨折并四方体移位的临床体会

摘要

目的 探讨经腹直肌外侧切口入路直视下复位固定髋臼双柱骨折并四方体移位的手术操作要点及临床疗效.方法 回顾性分析2012年1月至2013年12月南方医科大学第三附属医院骨科采用腹直肌外侧切口入路治疗的15例髋臼双柱骨折并四方体移位患者资料.其中男性11例,女性4例;年龄19～61岁,平均40岁.髋臼骨折按Letoumel-Judet分型:前柱伴后半横形骨折9例,双柱骨折6例;有8例合并骨盆环骨折.手术采用全身麻醉下平卧位操作,经腹直肌外侧切口入路,直视下对髋臼前壁、前柱、四方体骨折进行复位、钢板固定,然后显露后柱骨折,复位后经小骨盆环上缘向坐骨棘方向打入顺行空心螺钉固定后柱.术后4周、12周、6个月、1年进行随访,随访时行骨盆正位及患髋侧位X线片检查.结果 本组15例均顺利完成手术.术后X线及CT均显示髋臼前后柱骨折及四方体均复位固定良好,无手术并发症发生;按照Matta影像学复位评估标准:优9例,良3例,差3例,总体优良率12/15;随访8～18个月,中位随访时间14个月,骨折均愈合.根据改良的Merle D'Aubigne和Postel评分系统,髋关节功能:优9例,良4例,可2例,总优良率13/15.结论 经腹直肌外侧切口入路能充分显露并复位、固定合并四方体骨折的髋臼双柱骨折,临床疗效良好.%Objective To study the clinical effect and surgical operating points of pararectus approach for the internal fixation of acetabular both-column fractures with concurrent displaced quadrilateral plate fractures.Methods From January 2012 to December 2013,in the Third Affiliated Hospital of Southern Medical University,15 patients with acetabular both-column fractures and displaced quadrilateral plate fractures were surgically managed through the pararectus approach.There were 11 male and 4 female patients,with an average age of 40 years(from 19 to 61 years).According to Judet-Letournel classification,there were 9 anterior column plus posterior hemitransverse fractures,6 both-column fractures,8 cases involving the pelvic fracture.All these fractures were treated through the pararectus approach,in the horizontal position with general anesthesia.The pre-bended plate was placed in interior pelvic ring to fix the anterior wall,anterior column and quadrilateral plate in direct sight.Then,the posterior column was exposed and fixed with antegrade lag screw.Patients were followed up in 4 weeks,12 weeks,6 months,1 year after the operation,and the anteroposterior radiograph of pelvis and the X-ray examination of the fractured hip was performed.Results All the 15 cases underwent the operation successfully.Postoperative X-ray and CT exams showed excellent and good reduction of anterior column,posterior column and quadrilateral plate,with none surgical complication occurred.According to the Matta radiological evaluation postoperatively,reduction of acetabular fracture was rated as excellent in 9 cases,good in 3 cases and poor in 3 cases.The rate of excellent and good was 12/15.After 8 to 18 months' follow-up (median follow-up time was14 months),all the patients gained bone union.According to the modified Merle D'Aubigne and Postel scoring system,9 cases were excellent,4 were good,and 2 were fair.The rate of excellent and good was 13/15.Conclusions Surgical management of acetabular fractures through the pararectus approach can provide adequate exposure of reducing and fixing both-column acetabular fractures with concurrent displaced quadrilateral plate fractures,which has a good effect in clinical application.