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Chinese Journal of Reparative and Reconstructive Surgery logoLink to Chinese Journal of Reparative and Reconstructive Surgery
. 2022 Dec;36(12):1453–1458. [Article in Chinese] doi: 10.7507/1002-1892.202206104

改良Stoppa入路联合髂窝入路及Kocher-Langenbeck入路重建钢板内固定治疗复杂髋臼骨折的近期疗效

Short-term effectiveness of reconstruction plate internal fixation via improved Stoppa approach combined with iliac fossa approach and Kocher-Langenbeck approach for complex acetabular fractures

Guozhao CHEN 1,2, Jianqiang MO 2, Yong ZHANG 2, Rongqun LI 2, Huilin YANG 2, Jinhui SHI 2,*
PMCID: PMC9763074  PMID: 36545851

Abstract

Objective

To investigate the short-term effectiveness of reconstruction plate internal fixation via improved Stoppa approach combined with iliac fossa approach and Kocher-Langenbeck approach for complex acetabular fractures.

Methods

Between January 2015 and January 2020, 30 patients with complex acetabular fractures were treated with reconstruction plate internal fixation via improved Stoppa approach combined with iliac fossa approach and Kocher-Langenbeck approach. There were 20 males and 10 females with an average age of 52.1 years (range, 25-71 years). The cause of injury included traffic accident in 17 cases and falling from height in 13 cases. Among them, 14 cases were left acetabular fractures and 16 cases were right acetabular fractures. According to Letournel classification, there were 16 cases of double column fractures, 2 cases of transverse fracture with posterior wall fracture, 4 cases of anterior column and posterior hemi-transverse fractures, 8 cases of T-shaped fracture. The displacement distance of fracture ranged from 6 to 30 mm (mean, 11.6 mm). The time from injury to operation was 6-14 days (mean, 8.7 days).

Results

The operation time was 2.0-4.5 hours (mean, 3.0 hours). The intraoperative blood loss was 200-800 mL (mean, 450.0 mL). All patients were treated with autologous blood transfusion during operation. All incisions healed by first intention after operation, and no infection occurred. All patients were followed up 12-15 months (mean, 13.4 months). The drainage tube was removed at 2-3 days after operation. After extubation, X-ray film and three-dimensional CT were performed to recheck the fracture reduction. According to Matta score system, 20 cases were excellent, 5 were good, and 5 were poor, the excellent and good rate was 83.3%. All fractures healed with the healing time of 16-25 weeks (mean, 17.7 weeks). According to Merle d’Aubigne-Postel score system, the hip function at 1 year after operation was rated as excellent in 18 cases, good in 6 cases, and fair in 6 cases, and the excellent and good rate was 80.0%. Two cases suffered from sciatic nerve injury due to traction during operation, 7 cases had heterotopic ossification, 2 cases had traumatic hip arthritis, and no other complications occurred.

Conclusion

For complex acetabular fractures, the reconstruction plate internal fixation via improved Stoppa approach combined with iliac fossa approach and Kocher-Langenbeck approach can obtain good short-term effectiveness with good reduction and hip joint function, and less complications.

Keywords: Complex acetabular fracture, improved Stoppa approach, iliac fossa approach, Kocher-Langenbeck approach, reconstruction plate, internal fixation, short-term effectiveness

髋臼骨折多由高能量暴力所致，骨折移位明显时需手术治疗[1]，手术方案、手术视野显露、关节面复位、固定以及术后功能锻炼是影响术后关节功能恢复的主要因素[2-4]。髋臼解剖结构复杂，周围血管神经及组织脏器密布，手术风险、手术难度及术后并发症发生率均较高[5]。目前，临床常用髋臼骨折手术入路较多，包括Kocher-Langenbeck入路、髂腹股沟入路、二腹肌截骨入路、Stoppa入路、改良Stoppa入路、腹直肌旁入路及腹直肌外侧入路等，可根据髋臼骨折分型选择合适的手术入路及内固定方式[6]。对于Letournel分型[7]为复杂髋臼骨折者，选择单一前方或后方手术入路，存在术野显露不清、血管神经被过度牵拉、骨折复位欠佳、固定强度差、术后并发症发生率高等问题[6]，可以选择前后联合入路以避免上述问题。2015年1月—2020年1月，苏州大学附属第一医院骨科采用改良Stoppa入路联合髂窝入路及Kocher-Langenbeck入路重建钢板内固定治疗30例复杂髋臼骨折患者，取得满意近期疗效。报告如下。

1. 临床资料

1.1. 患者选择标准

纳入标准：① 年龄20～75岁；② Letournel分型为复杂髋臼骨折（即双柱骨折、T形骨折、后柱伴后壁骨折、横形伴后壁骨折、前柱或前壁伴后半横形骨折），骨折移位超过3 mm；③ 采用改良Stoppa入路联合髂窝入路及Kocher-Langenbeck入路重建钢板内固定治疗；④ 患者知情同意且随访资料完善。 排除标准：① 代谢性骨病及病理性髋臼骨折；② 基础条件差，存在严重心、脑血管系统疾病。

2015年1月—2020年1月，共30例复杂髋臼骨折患者符合选择标准纳入研究。

1.2. 一般资料

本组男20例，女10例；年龄25～71岁，平均52.1岁。致伤原因：交通事故伤17例，高处坠落伤13例。骨折累及左侧髋臼14例，右侧16例；Letournel分型：双柱骨折16例，横形伴后壁骨折2例，前柱伴后半横形骨折4例，T形骨折8例；骨折均移位，移位距离6～30 mm，平均11.6 mm。合并同侧髋关节中心脱位9例，髂骨翼骨折、骶骨骨折及耻骨支骨折5例，同侧坐骨神经损伤5例，轻中度颅脑外伤3例，尿道损伤2例，胸、腹腔脏器损伤1例。受伤至手术时间6～14 d，平均8.7 d。

1.3. 手术方法

全身麻醉后，患者取漂浮体位。首先行髂窝入路，沿髂嵴前2/3作切口，切开皮下组织，于骨盆内侧缘剥离附着髂肌，显露髂骨翼及真骨盆上缘，向后显露至骶髂关节，显露过程中注意髂骨翼表面滋养孔血管出血，及时给予骨蜡止血。

然后行改良Stoppa入路。于耻骨联合上2 cm处作长约8 cm横切口，根据骨折固定需要可适当延长。切开皮肤，分离皮下组织，显露腹白线；纵形切开腹白线，向两侧牵开腹直肌，髂内外动/静脉、股神经、腰大肌等重要解剖结构均同时向外侧牵开。于腹膜前间隙进入，注意保护膀胱及腹腔内脏器；钝性分离腹膜前间隙至耻骨联合，显露耻骨联合及耻骨上支，沿耻骨梳韧带切开骨膜，顺骨盆环自前向后逐渐显露髋臼前、后柱骨折部位、四边体及坐骨大切迹，显露过程中注意保护血管神经。显露耻骨上支时，注意横跨于耻骨上支处的“死亡冠”（Corona mortis）；显露四边体时，注意保护闭孔神经血管；显露髋臼前壁及髋臼顶时，注意保护髂血管，防止过度牵拉导致血管损伤。充分显露髋臼骨折后，清理骨折断端，患肢屈曲牵引下顶棒推顶髋臼顶及髋臼内侧壁，运用骨盆复位器辅助复位、斯氏针撬拨、螺钉辅助复位等技术复位骨折。克氏针临时固定后，将塑形的重建钢板紧贴真骨盆上缘及内侧缘放置，近端及远端钻孔后拧入普通螺钉。C臂X线机透视明确骨折复位及螺钉位置，防止螺钉进入关节腔，注意检查腹膜及膀胱完整性。

最后行Kocher-Langenbeck入路。调整患者体位，使患侧稍向前倾，患肢伸髋屈膝位，使坐骨神经处于松弛状态。自髂后上棘外下5 cm经股骨大转子顶点垂直向下约8 cm作切口，锐性分离皮下组织，电凝止血，钝性分离臀大肌并向两侧牵开，于股骨大转子上附着止点处牵开臀中肌，紧贴股骨大转子锐性切开外旋肌群，紧贴骨面向内侧剥离，显露髋臼后柱及髋臼后壁骨折。显露坐骨大切迹时，注意保护臀上血管及臀上神经。清理骨折断端，前、后入路贯通，直视下采用顶棒、克氏针撬拨复位后柱骨折，重建钢板紧贴坐骨大切迹固定。如合并后壁骨折，需沿后壁放置重建钢板固定后壁骨折块。术中前路复位过程中若出现骨折片卡压导致复位困难时，需在后路切口内辅助复位，恢复关节面平整，最终有效复位髋臼骨折。C臂X线机透视骨盆前后位、髂翼斜位、闭孔斜位，了解髋臼骨折复位情况。

术毕冲洗并逐层关闭切口，严密缝合腹白线，避免腹部切口疝发生，前、后入路切口内各放置引流管1根充分引流。

1.4. 术后处理

术后每2天切口换药，预防性应用抗生素3 d；术后第2天开始皮下注射低分子肝素钙，持续7～10 d，预防下肢深静脉血栓形成。每天记录引流量，当引流量<30 mL/d时拔除引流管。引流管拔除后复查骨盆X线片及三维CT，了解髋臼骨折复位及固定情况，同时嘱患者在医师指导下开始患肢主动屈伸活动锻炼，对于疼痛耐受性差的患者可采用CPM机行关节被动功能锻炼。术后6个月内每月复查骨盆X线片，待骨折端骨痂明显后允许患者扶双拐下地部分负重行走，之后逐渐增加负重，待骨折愈合后完全负重行走。

2. 结果

本组手术时间2.0～4.5 h，平均3.0 h；术中出血量200～800 mL，平均450.0 mL，术中均给予自体血回输。切口均Ⅰ期愈合，无切口感染发生。患者均获随访，随访时间12～15个月，平均13.4个月。术后2～3 d拔除引流管后行骨盆X线片及三维CT复查，骨折复位根据Matta评分标准[8]，获优20例、良5例、差5例，优良率83.3%。X线片复查示髋臼骨折均愈合，愈合时间16～25周，平均17.7 周。术后1年，髋关节功能按Merle d’Aubigne-Postel评价标准[9]，获优18例、良6例、可6例，优良率80.0%。

随访期间7例出现异位骨化，按Brooker等[10]评定标准为Ⅰ度6例、Ⅱ度1例。5例术前合并同侧坐骨神经损伤者，术中探查见坐骨神经挫伤，但连续性完好，术后给予口服甲钴胺营养神经治疗，术后1年踇趾屈伸活动、肌力均明显恢复，麻木感明显减轻；2例术中牵拉导致坐骨神经损伤，术后出现患侧踇趾屈伸活动受限伴麻木感，给予口服甲钴胺营养神经治疗，术后6个月神经症状恢复。2例术后出现创伤性髋关节炎表现，给予口服消炎镇痛药保守治疗。本组均无股神经、闭孔神经、股外侧皮神经及髂血管损伤，以及腹壁切口疝、股骨头坏死、骨不连、内固定物松动断裂等并发症发生。见图1、2。

图 1.

A 48-year-old female patient with T-shaped fracture of left acetabulum and central dislocation of hip

患者，女，48岁，左侧髋臼T形骨折合并髋关节中心脱位

a～f. 术前骨盆前后位X线片及骨盆CT三维重建、冠状位、矢状位、横断位；g～l. 术后3 d骨盆前后位X线片及骨盆CT三维重建、冠状位、矢状位、横断位，示髋臼骨折解剖复位，内固定物位置良好；m. 术后3个月骨盆前后位X线片示骨折端生长良好；n. 术后6个月骨盆前后位X线片示骨折愈合

a-f. Anteroposterior X-ray film and three-dimensional reconstruction, coronal plane, sagittal plane, and transverse plan of CT before operation; g-l. Anteroposterior X-ray film and three-dimensional reconstruction, coronal plane, sagittal plane, and transverse plan of CT at 3 days after operation showed that the acetabular fracture was anatomically reduced and the internal fixator position was good; m. Anteroposterior X-ray film at 3 months after operation showed that the fracture grew well; n. Anteroposterior X-ray film at 6 months after operation showed that the fracture healed

图 1

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图 2.

A 46-year-old male patient with double column fractures of left acetabulum

患者，男，46岁，左侧髋臼双柱骨折

a～f. 术前骨盆CT三维重建、冠状位、矢状位、横断位；g、h. 术中切口示意图；i～o. 术后3 d骨盆前后位X线片及骨盆CT三维重建、冠状位、矢状位、横断位，示髋臼骨折解剖复位，内固定物位置良好；p. 术后1个月骨盆前后位X线片示骨折端生长良好；q～s. 术后6个月骨盆前后位、闭孔斜位、髂翼斜位X线片示骨折愈合，内固定物位置良好

a-f. Three-dimensional reconstruction, coronal plane, sagittal plane, transverse plane of CT before operation; g, h. Schematic diagram of incision; i-o. Anteroposterior X-ray film, three-dimensional reconstruction, coronal plane, sagittal plane, and transverse plane of CT showed that the acetabular fracture was anatomically reduced and the internal fixator position was good; p. Anteroposterior X-ray film at 1 month after operation showed that the fracture grew well; q-s. X-ray films of anteroposterior, obturator oblique, and iliac wing oblique positions at 6 months after operation showed that the fracture healed and the internal fixator position was good

图 2

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3. 讨论

3.1. 复杂髋臼骨折手术入路选择

Letournel分型复杂髋臼骨折包括双柱骨折、T形骨折、后柱伴后壁骨折、横形伴后壁骨折、前柱或前壁伴后半横形骨折。骨折移位超过3 mm、髋臼骨折合并股骨头脱位或半脱位、髋臼骨折合并髋关节内游离骨块、后壁骨折缺损>40%或移位骨折累及髋臼顶时，即存在手术指征[11]。Kocher-Langenbeck入路能有效显露髋臼后柱、后壁结构[12]，同时对术前存在坐骨神经损伤症状患者可行神经探查，但对前柱、髋臼前壁显露有限，适用于髋臼后柱、髋臼后壁骨折和向后方移位为主的T形、横形髋臼骨折。改良Stoppa入路可以显露前、后柱及四边体[13]，主要适用于前柱骨折和部分横形骨折，在处理坐骨切迹和邻近骶髂关节部位的骨折方面具有优势，但对于单纯前后壁、后柱骨折以及累及后柱为主的 T 形骨折、部分位置较低的横形骨折，术中常出现显露骨折端困难的情况。因此，对于复杂髋臼骨折，单一改良Stoppa入路或者Kocher-Langenbeck入路往往无法全面显露、有效复位及固定，术中过多剥离附着臀肌可引起术后髋关节外展功能受限，过度牵拉可能导致血管神经损伤等并发症[14]。而前后联合入路术中显露更充分，固定操作方便，能在直视下复位髋臼前、后柱及后壁，更好地获得复位，同时有效避免了对腹腔脏器及血管神经等重要组织结构的暴力牵拉，降低了术中血管神经损伤风险。1990年Routt等 [15]首次提出骨折块移位超过3 mm的复杂髋臼骨折可前后联合入路治疗，临床应用显示骨折解剖复位率达88%。李来峰等[16]应用前后联合入路治疗复杂髋臼骨折，术后髋关节功能评价优良率达90%。

在前后联合入路中，后方入路常用Kocher-Langenbeck入路，但前方入路选择较多。其中，传统髂腹股沟入路需暴露外侧窗、中间窗、内侧窗进行骨折复位与固定，对于四边体的骨折和低位前柱骨折显露不充分，难以复位；同时由于此区域有神经、大血管、精索或子宫圆韧带等重要组织结构，解剖结构复杂，手术时间较长、手术创伤较大，术后并发症发生率高，特别是术后感染，影响临床疗效及患者满意度[17]；由于手术操作复杂，该入路学习曲线长而曲折。改良Stoppa入路不仅能有效显露髋臼前柱前壁，对于四边体及低位前柱、后柱骨折也能有效显露，可以直视下处理“死亡冠”，同时更好地复位骨折，骨折解剖复位率高，而且术中出血少，血管神经损伤发生率较低。Briffa 等[18]比较了改良 Stoppa 入路与髂腹股沟入路术后骨折复位质量，发现改良Stoppa入路术后骨折解剖复位率（82.5%）明显高于髂腹股沟入路（68.9%）。本组30例复杂髋臼骨折患者均选择前后联合入路手术，其中前方入路均为改良Stoppa入路联合髂窝入路，未出现髂血管损伤及股神经牵拉损伤。依据Matta评分标准骨折复位优良率达83.3%。

3.2. 前后联合入路手术技巧及经验

① 术中我们常先取改良Stoppa入路复位前柱骨折，因为前柱复位后，依靠关节囊的张力性牵拉作用，后柱大多能不同程度地间接复位。当髋臼内存在骨块卡压，尤其是髋臼顶位置，造成前柱骨折复位困难时，需同时结合Kocher-Langenbeck入路切口内贯通，前后辅助复位，恢复髋臼关节面平整；复位时以股骨头为模板协助复位，通过下肢牵引，顶棒推顶髋臼顶及髋臼内侧壁，骨盆复位器辅助、斯氏针撬拨、螺钉辅助复位等技术，骨折往往能满意复位。当髋臼柱骨折同时合并骨壁骨折时，先复位髋臼柱再复位骨壁。② 前路内固定时术者经验极其重要，术中重建钢板需良好塑形，紧贴骨面插入，近端紧贴真骨盆边缘，远端放至患侧耻骨结节处，由于静脉管壁薄，术中钢板插入时有损伤静脉管壁的风险，注意不能反复取出前路重建钢板，以避免损伤血管神经。同时，前路手术时患者应屈髋、屈膝，松弛腰大肌、股神经及股血管，以便术中操作。③ 作Kocher-Langenbeck入路时需紧贴股骨大转子切断并牵开外旋肌群，由于坐骨神经从梨状肌深面向远端走行，将外旋肌群于股骨大转子止点切开并贴骨面向外剥离时，可有效保护坐骨神经，一般术中不予特别显露；当患者术前存在坐骨神经损伤时，术中需显露探查坐骨神经；在显露坐骨大切迹时，需注意避免损伤臀上血管及臀上神经，尤其是后柱骨折累及坐骨大切迹，剥离时需紧贴骨面，警惕臀上动脉损伤造成大出血；在经Kocher-Langenbeck入路显露时患肢需伸髋、屈膝位，使坐骨神经处于松弛状态，降低术中坐骨神经牵拉伤发生率；在行后路固定时重建钢板应紧贴坐骨大切迹放置，在坐骨大切迹内侧缘1.5 cm范围内不累及髋臼关节面，螺钉垂直钢板固定且可行双层皮质固定。当后柱合并后壁骨折时，后壁同样需要重建钢板贴附固定，重建钢板塑形后近端固定至髂骨翼，远端固定至坐骨结节。

3.3. 手术并发症分析

本组术后出现7例异位骨化，分析原因其中颅脑轻中度外伤2例、胸腹联合伤1例，因病情较重术后长期卧床导致功能锻炼欠佳；另4例均为术后未严格按照指导锻炼患肢功能所致。2例发生医源性坐骨神经损伤，考虑为术中牵拉损伤所致，经营养神经治疗后症状明显改善。2例发生创伤性髋关节炎，均行保守治疗，目前仍在随访中，远期关节炎若加重，必要时需行关节置换术。

综上述，采用改良Stoppa入路联合髂窝入路及Kocher-Langenbeck入路重建钢板内固定治疗复杂髋臼骨折，骨折复位及术后髋关节功能均恢复良好，并发症发生率低，近期疗效满意。但本研究随访时间短，远期疗效需进一步随访。随着3D打印技术在临床诊疗中的广泛应用[19-21]，下一步可以在复杂髋臼骨折中应用3D打印技术，以期提高骨折复位及固定的准确性，有效缩短手术时间，提高围术期安全性。

利益冲突　在课题研究和文章撰写过程中不存在利益冲突

伦理声明　研究方案经苏州大学附属第一医院医学伦理委员会批准［（2022）伦研批第405号］

作者贡献声明　陈国兆：收集整理数据及文章撰写；史金辉：研究设计，文章构思及撰写，数据分析；张勇、李荣群、莫建强、杨惠林：手术实施、文章审核

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