两种入路开放复位内固定累及后壁的髋臼骨折△

Two approaches for open reduction and internal fixation of acetabular fractures involving the posterior wall

摘要:

[目的] 比较采用直接后方入路（direct posterior approach, DPA） 与Kocher-Langenbeck （K-L） 入路开放复位内固定累及后壁的髋臼骨折的临床结果。[方法] 回顾性分析2015 年1 月—2022 年6 月行切开复位内固定术治疗的髋臼后壁骨折43例患者的临床资料，其中，19 例采用DPA 入路，24 例采用K-L 入路。比较两组围手术期资料、随访情况及影像结果。[结果] DPA 组在手术时间[(83.9±13.9) min vs (102.0±20.9) min, P=0.002]、切口长度[(9.8±1.2) cm vs (16.0±1.5) cm, P＜0.001]、术中失血量[(267.4±56.6) ml vs (326.7±84.1) ml, P=0.002]、术中透视次数[(2.4±0.6) 次vs (3.4±0.7) 次, P＜0.001]、术后开始下地行走时间[(40.2±6.8) d vs (50.5±10.1) d, P＜0.001] 显著优于K-L 组。随访时间平均（15.4±1.3） 个月，DPA 组术后完全负重活动时间显著早于K-L 组[(79.4±6.9) d vs (86.2±7.1) d, P=0.003]。随时间推移，两组VAS 评分显著减少（P＜0.05），Harris 评分、Merle D'Au-bigné-Postel 评分及髋伸-屈ROM、内-外旋ROM 均显著增加（P＜0.05）。术后1、6 个月，DPA 组VAS 评分[(4.1±1.0) vs (5.4±1.2), P＜0.001; (1.7±1.0) vs (3.0±0.8), P＜0.001] 、Harris 评分[(74.2±5.0) vs (71.1±3.6), P=0.026; (87.0±3.1) vs (83.3±3.8), P=0.002]、髋伸-屈ROM [(75.5±8.5)° vs (69.5±7.0)°, P=0.014; (92.4±11.8)° vs (86.0±9.2)°, P=0.045] 及术后1 个月的Merle D'Aubigné-Postel 评分[(13.0±1.3) vs (11.7±1.4), P=0.003] 均显著优于K-L 组。影像方面，两组骨折复位质量、骨折愈合时间、Tonnis 髋退变分级、异位骨化及股骨头坏死的差异均无统计学意义（P＞0.05）。[结论] 与传统K-L 入路相比较，DPA 入路治疗累及后壁髋臼骨折出血量少、切口短、并发症少，近期疗效更为满意。

Abstract:

[Objective] To compare the clinical results of open reduction and internal fixation (ORIF) of acetabular fractures involvingthe posterior wall by the direct posterior approach (DPA) versus Kocher Langenbeck (K-L) approaches. [Methods] A retrospective analysiswas conducted on 43 patients who underwent open reduction and internal fixation for acetabular fractures involving the posterior wall fromJanuary 2015 to June 2022. Of them, 19 patients underwent ORIF through DPA approach, while other 24 patients were through the K-L ap-proach. The documents of perioperative period, follow-up, and images were compared between the two groups. [Results] The DPA groupshowed significantly better than the K-L group in terms of surgical time [(83.9±13.9) min vs (102.0±20.9) min, P=0.002], incision length[(9.8±1.2) cm vs (16.0±1.5) cm, P＜0.001], intraoperative blood loss [(267.4±56.6) ml vs (326.7±84.1) ml, P=0.002], intraoperative fluorosco-py frequency [(2.4±0.6) times vs (3.4±0.7) times, P＜0.001], and postoperative walking time [(40.2±6.8) days vs (50.5±10.1) days, P＜0.001].The average follow-up time was of (15.4±1.3) months, and the DPA cohort resumed full weight-bearing activity significantly earlier thanthat in the K-L counterpart [(79.4±6.9) days vs (86.2±7.1) days, P=0.003]. The VAS scores significantly decreased (P＜0.05), while Harrisscore, Merle D'Aobign é-Postel score, hip flexion-extension ROM, and internal-external rotation ROM significantly increased in bothgroups over time (P＜0.05). The DPA group was significantly superior to the K-L group regarding VAS [(4.1±1.0) vs (5.4±1.2), P＜0.001;(1.7±1.0) vs (3.0±0.8), P＜0.001], Harris score [(74.2±5.0) vs (71.1±3.6), P=0.026; (87.0±3.1) vs (83.3±3.8), P=0.002], hip flexion-extensionROM [(75.5±8.5)° vs (69.5±7.0)°, P=0.014; (92.4±11.8)° vs (86.0±9.2)°, P=0.045] at 1 and 6 months postoperatively, and Merle D'Aobigné-Postel score [(13.0±1.3) vs (11.7±1.4), P=0.003] 1 month after surgery. As for imaging, there was no statistically significant difference inthe quality of fracture reduction, fracture healing time, Tonnis hip degeneration grade, ectopic ossification, and femoral head necrosis between the two groups (P＞0.05). [Conclusion] The DPA approach has advantages of fewer bleeding, shorter incisions, and fewer complica-tions for ORIF of acetabular fractures involving the posterior wall, and achieves more satisfactory short-term outcomes over the traditionalK-L approach.