动力化前路方形区钛板螺钉治疗累及臼顶的髋臼骨折
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摘要
[目的]探讨动力化前路方形区钛板螺钉系统(DAPSQ)内固定治疗伴髋臼顶骨折的复杂性髋臼骨折的手术技巧及临床疗效。[方法]回顾性分析2009年6月～2016年9月手术治疗的66例伴髋臼顶骨折的复杂性髋臼骨折患者资料,男44例,女22例,平均年龄(46.63±10.52)岁。按Letournel-Judet分型:双柱骨折33例,前柱伴后半横行骨折12例,前柱骨折9例, T型骨折12例。所有臼顶骨折病例均采用单一髂腹股沟入路开窗+截骨行DAPSQ内固定治疗,需要时联合骨盆前缘短钢板固定。[结果]所有患者顺利手术,手术时间(182.50±56.28) min;术中出血量(550.35±102.94) ml。4例患者术后股外侧麻木,1～4个月症状消失。随访12～46个月,平均(30.36±10.23)个月。随术后时间延长VAS评分减少,而Harris评分和Merle d’Aubigne-Postel评分显著增加(P<0.05)。影像评估方面:依据Matta标准,骨折复位评定为优35例,良好20例,一般7例,差4例。3例出现Brooker I型异位骨化,6例出现创伤性骨关节炎改变。末次随访时,3例改行全髋关节置换。[结论]单一髂腹股沟入路联合开窗、截骨为臼顶骨折复位提高良好的术野,DAPSQ内固定能够固定和维持髋臼顶的解剖位置,恢复头臼匹配关系,从而保留髋关节的功能,临床疗效良好。
[Objective] To investigate the surgical technique and clinical outcomes of dynamic anterior plate-screw System for quadrilateral area(DAPSQ) of complex acetabular fractures involving the dome. [Methods] A retrospective study was conducted on 66 patients who underwent surgical treatment for complex acetabular fractures involving the dome between June 2009 and September 2016, including 44 males and 22 females aged(46.63±10.52) years on average. According to Letournel-Judet classification, 33 patients were of double-column fractures, 12 of anterior column accompanied by posterior hemitransverse fractures, 9 of anterior column fractures, and 12 of T-type fractures. All patients had acetabular fractures involving the dome treated by open reduction and internal fixation(ORIF) with DAPSQ through single ilioinguinal approach combined with fenestration plus osteotomy, and anterior pelvic short plate was added if necessary. [Results] All the 66 patients had operation performed smoothly with operation time of(182.50±56.28) min and intraoperative blood loss of(550.35±102.94) ml. Of them, 4 patients had lateral femoral numbness after operation, which subsided in 1-4 months. The follow-up period lasted for 12-46 months with an average of(30.36±10.23) months. The VAS score decreased over time, while Harris score and Merle d' Aubigne-Postel score increased significantly(P<0.05). In terms of imaging evaluation, according to the Matta standard, fracture reduction was assessed as excellent in 35 cases, good in 20 cases, fair in 7 cases and poor in 4 cases. Brooker I type heterotopic ossification occurred in 3 patients and traumatic osteoarthritis in 6 patients. At the last follow-up, 3 patients underwent total hip replacement.[Conclusion] This single ilioinguinal approach combined with fenestration plus osteotomy provides proper visual field for anatomic reduction of complex acetabular fracture involving the dome, while internal fixation with DAPSQ does effectively maintain the anatomic position of the acetabular dome to restore head-acetabular congruence, which leads to satisfactory clinical outcomes with preserving hip function.
[Objective] To investigate the surgical technique and clinical outcomes of dynamic anterior plate-screw System for quadrilateral area(DAPSQ) of complex acetabular fractures involving the dome. [Methods] A retrospective study was conducted on 66 patients who underwent surgical treatment for complex acetabular fractures involving the dome between June 2009 and September 2016, including 44 males and 22 females aged(46.63±10.52) years on average. According to Letournel-Judet classification, 33 patients were of double-column fractures, 12 of anterior column accompanied by posterior hemitransverse fractures, 9 of anterior column fractures, and 12 of T-type fractures. All patients had acetabular fractures involving the dome treated by open reduction and internal fixation(ORIF) with DAPSQ through single ilioinguinal approach combined with fenestration plus osteotomy, and anterior pelvic short plate was added if necessary. [Results] All the 66 patients had operation performed smoothly with operation time of(182.50±56.28) min and intraoperative blood loss of(550.35±102.94) ml. Of them, 4 patients had lateral femoral numbness after operation, which subsided in 1-4 months. The follow-up period lasted for 12-46 months with an average of(30.36±10.23) months. The VAS score decreased over time, while Harris score and Merle d' Aubigne-Postel score increased significantly(P<0.05). In terms of imaging evaluation, according to the Matta standard, fracture reduction was assessed as excellent in 35 cases, good in 20 cases, fair in 7 cases and poor in 4 cases. Brooker I type heterotopic ossification occurred in 3 patients and traumatic osteoarthritis in 6 patients. At the last follow-up, 3 patients underwent total hip replacement.[Conclusion] This single ilioinguinal approach combined with fenestration plus osteotomy provides proper visual field for anatomic reduction of complex acetabular fracture involving the dome, while internal fixation with DAPSQ does effectively maintain the anatomic position of the acetabular dome to restore head-acetabular congruence, which leads to satisfactory clinical outcomes with preserving hip function.
引文
[1]Tannast M,Najibi S,Matta JM.Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures[J].J Bone Joint Surg Am,2012,94(17):1559-1567.
[2]Matta JM,Mehne DK,Roffi R.Fractures of the acetabulum.Early results of a prospective study[J].Clin Orthop,1986(205):241-250.
[3]Matta JM.Fractures of the acetabulum:accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury[J].J Bone Joint Surg Am,1996,78(11):1632-1645.
[4]Brooker AF,Bowerman JW,Robinson RA,et al.Ectopic ossification following total hip replacement.Incidence and a method of classification[J].J Bone Joint Surg Am,1973,55(8):1629-1632.
[5]王攀峰,许硕贵,张春才,等.臼顶不同程度台阶状移位对髋臼负重区生物力学的影响[J].国际骨科学杂志,2012,33(1):64-66.
[6]Lubovsky O,Wright D,Hardisty M,et al.Importance of the dome and posterior wall as evidenced by bone density mapping in the acetabulum[J].Clin Biomech(Bristol,Avon),2011,26(3):262-266.
[7]王满宜,吴新宝.髋臼骨折[M].北京:北京科学技术出版社,2016.
[8]Anglen JO,Burd TA,Hendricks KJ,et al.The"Gull Sign":a harbinger of failure for internal fixation of geriatric acetabular fractures[J].J Orthop Trauma,2003,17(9):625-634.
[9]Peter RE.Open reduction and internal fixation of osteoporotic acetabular fractures through the ilio-inguinal approach:use of buttress plates to control medial displacement of the quadrilateral surface[J].Injury,2015,46(Suppl 1):2-7.
[10]蔡贤华,陈庄洪,徐永年,等.有移位髋臼骨折开放复位策略分析[J].中国矫形外科杂志,2007,15(20):1543-1545.
[11]Butterwick D,Papp S,Gofton W,et al.Acetabular fractures in the elderly:evaluation and management[J].J Bone Joint Surg Am,2015,97(9):758-768.
[12]庄岩,雷金来,魏星,等.伴有“海鸥征”表现的髋臼顶压缩性骨折的手术治疗[J].中华骨科杂志,2014,(10):1000-1007.
[13]Hammad AS,El-Khadrawe TA,Waly AH,et al.The efficacy of posterior plating and anterior column screw fixation in the management of T-shaped acetabular fractures-CART analysis of prospective cohort study[J].Injury,2017,48(3):680-686.
[14]Firoozabadi R,O'Mara T J,Swenson A,et al.Risk factors for the development of heterotopic ossification after acetabular fracture fixation[J].Clin Orthop,2014,472(11):3383-3388.
[2]Matta JM,Mehne DK,Roffi R.Fractures of the acetabulum.Early results of a prospective study[J].Clin Orthop,1986(205):241-250.
[3]Matta JM.Fractures of the acetabulum:accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury[J].J Bone Joint Surg Am,1996,78(11):1632-1645.
[4]Brooker AF,Bowerman JW,Robinson RA,et al.Ectopic ossification following total hip replacement.Incidence and a method of classification[J].J Bone Joint Surg Am,1973,55(8):1629-1632.
[5]王攀峰,许硕贵,张春才,等.臼顶不同程度台阶状移位对髋臼负重区生物力学的影响[J].国际骨科学杂志,2012,33(1):64-66.
[6]Lubovsky O,Wright D,Hardisty M,et al.Importance of the dome and posterior wall as evidenced by bone density mapping in the acetabulum[J].Clin Biomech(Bristol,Avon),2011,26(3):262-266.
[7]王满宜,吴新宝.髋臼骨折[M].北京:北京科学技术出版社,2016.
[8]Anglen JO,Burd TA,Hendricks KJ,et al.The"Gull Sign":a harbinger of failure for internal fixation of geriatric acetabular fractures[J].J Orthop Trauma,2003,17(9):625-634.
[9]Peter RE.Open reduction and internal fixation of osteoporotic acetabular fractures through the ilio-inguinal approach:use of buttress plates to control medial displacement of the quadrilateral surface[J].Injury,2015,46(Suppl 1):2-7.
[10]蔡贤华,陈庄洪,徐永年,等.有移位髋臼骨折开放复位策略分析[J].中国矫形外科杂志,2007,15(20):1543-1545.
[11]Butterwick D,Papp S,Gofton W,et al.Acetabular fractures in the elderly:evaluation and management[J].J Bone Joint Surg Am,2015,97(9):758-768.
[12]庄岩,雷金来,魏星,等.伴有“海鸥征”表现的髋臼顶压缩性骨折的手术治疗[J].中华骨科杂志,2014,(10):1000-1007.
[13]Hammad AS,El-Khadrawe TA,Waly AH,et al.The efficacy of posterior plating and anterior column screw fixation in the management of T-shaped acetabular fractures-CART analysis of prospective cohort study[J].Injury,2017,48(3):680-686.
[14]Firoozabadi R,O'Mara T J,Swenson A,et al.Risk factors for the development of heterotopic ossification after acetabular fracture fixation[J].Clin Orthop,2014,472(11):3383-3388.