Isaacson Mark J, Taylor Benjamin C, French Bruce G, Poka Attila
Department of Orthopaedic Surgery, Doctors' Hospital, Columbus, OH, USA.
Clin Orthop Relat Res. 2014 Nov;472(11):3345-52. doi: 10.1007/s11999-014-3460-x.
Since the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures.
QUESTIONS/PURPOSES: We evaluated our results in patients with acetabulum fractures with the modified Stoppa approach in terms of (1) hip function as measured by the Merle d'Aubigne hip score; (2) complications; and (3) quality of fracture reduction and percentage of fractures that united.
Between September 2008 and August 2012, 289 patients with acetabular fractures were treated at our Level I trauma center. Twelve percent (36 of 289) of patients were treated operatively using the modified Stoppa approach. Ninety-seven percent (35 of 36) of our patients had fracture patterns involving displacement of the posterior column. Six (17%) were converted early to a total hip arthroplasty, and 14 (39%) were lost to final followup, leaving 22 of 36 for subjective clinical outcome analysis at a mean of 32 months (range, 9-59 months). Our general indications for this approach during the period in question were fractures of the anterior column and anterior wall, anterior column with posterior hemitransverse fractures, both column fractures, transverse fractures, and T-type fractures. Followup included regularly scheduled office visits with radiographs (AP pelvis, Judet views) that were graded by the treating surgeon and by the authors of this study (MJI, BCT) and patient outcome surveys.
Merle d'Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22), medium in 18% (four of 22), fair in 5% (one of 22), and poor in 14% (three of 22), and 70% (23 of 33) of patients were able to ambulate without any assistive devices. Complications included one superficial infection and three deep infections, two patients with temporary lateral thigh numbness, no obturator nerve palsies, and one inguinal hernia. Three deaths in the cohort were seen in followup as a result of unrelated causes. Radiographic grading of fracture reductions after surgery revealed that 27 (75%) were anatomic, six (17%) were satisfactory, and three (8%) were unsatisfactory. A total of 94% of the fractures united.
In agreement with prior published data, our results show good functional outcomes with minimal complications using the modified Stoppa approach for a variety of acetabular fractures. Our results highlight the difficulty but feasibility in treating posterior column displacement through an anterior approach. Consideration for dual approaches with posterior column involvement may be warranted to optimize fracture reduction and functional outcomes.
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
自1961年勒图尔内首次描述以来，髂腹股沟入路一直是髋臼前路固定的主要入路。然而，斯托帕描述的改良腹部入路为骨盆和髋臼骨折的复位与固定提供了另一种选择。
问题/目的：我们评估了采用改良斯托帕入路治疗髋臼骨折患者的结果，评估内容包括：（1）用默尔·德奥宾涅髋关节评分衡量的髋关节功能；（2）并发症；（3）骨折复位质量及骨折愈合率。
2008年9月至2012年8月期间，我们一级创伤中心共治疗了289例髋臼骨折患者。其中12%（289例中的36例）患者采用改良斯托帕入路进行手术治疗。97%（36例中的35例）患者的骨折类型涉及后柱移位。6例（17%）患者早期转为全髋关节置换术，14例（39%）患者失访，最终36例中22例纳入主观临床结果分析，平均随访时间32个月（9 - 59个月）。在此期间，我们采用该入路的一般适应证为前柱和前壁骨折、前柱合并后半横行骨折、双柱骨折、横行骨折及T型骨折。随访包括定期门诊就诊及拍摄X线片（骨盆前后位、朱代位片），由主刀医生以及本研究作者（MJI、BCT）进行分级，并进行患者结果调查。
默尔·德奥宾涅髋关节评分结果为：55%（22例中的12例）为优，9%（22例中的2例）为良，18%（22例中的4例）为中，5%（22例中的1例）为可，14%（22例中的3例）为差；70%（33例中的23例）患者能够在无辅助器械的情况下行走。并发症包括1例表浅感染和3例深部感染、2例患者出现大腿外侧暂时麻木、无闭孔神经麻痹病例以及1例腹股沟疝。随访期间该队列中有3例患者因无关原因死亡。术后骨折复位的X线片分级显示，27例（75%）为解剖复位，6例（17%）为满意复位，3例（8%）为不满意复位。骨折愈合率达94%。
与先前发表的数据一致，我们的结果表明，采用改良斯托帕入路治疗各种髋臼骨折，功能结果良好，并发症极少。我们的结果凸显了通过前路治疗后柱移位的困难及可行性。对于合并后柱损伤的情况，考虑采用联合入路可能有助于优化骨折复位及功能结果。
四级，治疗性研究。有关证据水平的完整描述，请参阅《作者指南》。
