Tannast Moritz, Siebenrock Klaus-Arno
Klinik und Poliklinik für Orthopädische Chirurgie, Inselspital, Universität Bern, Bern, Schweiz.
Oper Orthop Traumatol. 2009 Sep;21(3):251-69. doi: 10.1007/s00064-009-1803-7.
Anatomic reduction and stable fixation by means of tissue- preserving surgical approaches. INDICATIONS Displaced acetabular fractures. Surgical hip dislocation approach with larger displacement of the posterior column in comparison to the anterior column, transtectal fractures, additional intraarticular fragments, marginal impaction. Stoppa approach with larger displacement of the anterior column in comparison to the posterior column. A combined approach might be necessary with difficult reduction. CONTRAINDICATIONS Fractures > 15 days (then ilioinguinal or extended iliofemoral approaches). Suprapubic catheters and abdominal problems (e.g., previous laparotomy due to visceral injuries) with Stoppa approach (then switch to classic ilioinguinal approach).
Surgical hip dislocation: lateral decubitus position. Straight lateral incision centered over the greater trochanter. Entering of the Gibson interval. Digastric trochanteric osteotomy with protection of the medial circumflex femoral artery. Opening of the interval between the piriformis and the gluteus minimus muscle. Z-shaped capsulotomy. Dislocation of the femoral head. Reduction and fixation of the posterior column with plate and screws. Fixation of the anterior column with a lag screw in direction of the superior pubic ramus. Stoppa approach: supine position. Incision according to Pfannenstiel. Longitudinal splitting of the anterior portion of the rectus sheet and the rectus abdominis muscle. Blunt dissection of the space of Retzius. Ligation of the corona mortis, if present. Blunt dissection of the quadrilateral plate and the anterior column. Reduction of the anterior column and fixation with a reconstruction plate. Fixation of the posterior column with lag screws. If necessary, the first window of the ilioinguinal approach can be used for reduction and fixation of the posterior column.
During hospital stay, intensive mobilization of the hip joint using a continuous passive motion machine with a maximum flexion of 90 degrees . No active abduction and passive adduction over the body's midline, if a surgical dislocation was performed. Maximum weight bearing 10-15 kg for 8 weeks. Then, first clinical and radiographic follow-up. Deep venous thrombosis prophylaxis for 8 weeks postoperatively.
17 patients with a mean follow-up of 3.2 years. Ten patients were operated via surgical hip dislocation, two patients with a Stoppa approach, and five using a combined or alternative approach. Anatomic reduction was achieved in ten of the twelve patients (83%) without primary total hip arthroplasty. Mean operation time 3.3 h for surgical hip dislocation and 4.2 h for the Stoppa approach. Complications comprised one delayed trochanteric union, one heterotopic ossification, and one loss of reduction. There were no cases of avascular necrosis. In two patients, a total hip arthroplasty was performed due to the development of secondary hip osteoarthritis.
通过保留组织的手术入路实现解剖复位和稳定固定。
移位髋臼骨折。与前柱相比后柱移位较大的手术性髋关节脱位入路、经髋臼横断骨折、额外的关节内骨折块、边缘嵌插骨折。与后柱相比前柱移位较大的Stoppa入路。复位困难时可能需要联合入路。
骨折超过15天（此时采用髂腹股沟或扩大髂股入路）。耻骨上导管及腹部问题（如因内脏损伤曾行剖腹手术），采用Stoppa入路（此时改为经典髂腹股沟入路）。
手术性髋关节脱位：侧卧位。以大转子为中心的直外侧切口。进入吉布森间隙。双肌转子截骨，保护股内侧旋动脉。打开梨状肌与臀小肌之间的间隙。Z形关节囊切开术。股骨头脱位。用钢板和螺钉复位并固定后柱。沿耻骨上支方向用拉力螺钉固定前柱。
Stoppa入路：仰卧位。按Pfannenstiel切口。纵行劈开腹直肌鞘前部及腹直肌。钝性分离Retzius间隙。如有冠状静脉则结扎。钝性分离四边形板和前柱。复位前柱并用重建钢板固定。用拉力螺钉固定后柱。必要时，可利用髂腹股沟入路的第一个窗口复位并固定后柱。
住院期间，使用持续被动运动机对髋关节进行强化活动，最大屈曲90度。若采用手术性脱位，则禁止主动外展及在身体中线以上被动内收。8周内最大负重10 - 15千克。然后进行首次临床及影像学随访。术后8周预防深静脉血栓形成。
17例患者，平均随访3.2年。10例患者采用手术性髋关节脱位手术，2例采用Stoppa入路，5例采用联合或替代入路。12例患者中有10例（83%）实现解剖复位，未行一期全髋关节置换术。手术性髋关节脱位平均手术时间3.3小时，Stoppa入路平均手术时间4.2小时。并发症包括1例转子延迟愈合、1例异位骨化和1例复位丢失。无缺血性坏死病例。2例患者因继发性髋关节骨关节炎行全髋关节置换术。
