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1、髋臼骨折影像学评估&入路选择,目 的,髋臼的解剖特点及影像学评估髋臼骨折损伤机制及分类髋臼骨折处理策略髋臼骨折的手术入路髋臼骨折的复位固定技术典型病例介绍,髋臼壁包容作用,髋臼柱力线传导,髋臼骨折分型,由Letournel提出（1964）基于髋臼的两个柱和壁的解剖两大类：简单和复杂对应OTA分型：62-A,-B和-C型,简单,复杂,Emil Letournel,Mller AO分型,62-A 单柱骨折,A1 后壁骨折A2 后柱骨折A3 前柱骨折,A1,A2,A3,62-B 横行为主的骨折,B1 横行骨折B2 T形骨折B3 前柱+后半横行骨折,B1,B2,B3,62-C 双柱骨折,C1 高位骨折
2、C2 低位骨折C3 累及骶髂关节,C1,C2,C3,骨折分类是对骨折线走向的具体描述,正位片:（6条标志线）,X线评估:,1 后唇线2 前唇线3 臼顶线4 髂耻线5 髂坐线6 泪点线,R.Judet,闭孔斜位片:,(骨盆向健侧斜45度),前柱线,后唇线,1 髋臼上缘线2 臼顶线3 髋臼后缘线4 髂耻线,Judet view,(骨盆向患侧斜45度),髂骨斜位片:,1.髋臼前缘线2.臼顶线3.髋臼后柱线,Judet view,髋臼骨折的CT诊断,显示常规X线片不能显示的骨折,有助于诊断可清楚显示关节内碎骨片可清楚显示关节面压缩精确显示骨折移位程度定量显示后壁缺损帮助术后分析,3DCT,定位骨折线及
3、骨块,直视髋臼,后壁骨折,Note that fracture line involves posterior rim of acetabulum(arrows).Importantly,superior fracture line is located lateral to medial cortex of posterior column,半月征,2023/3/8,失去完整性,后壁骨折大于40%,关节面下密度增高提示有压缩,后壁撞击压缩骨折,Kocher-Langenbeck approach,31-year-old man,Note that fracture extends super
4、iorly to involve iliac wing(arrow)and inferiorly to involve obturator ring(arrowhead).,前柱骨折,44-year-old man,Note that fracture line extends to sciatic notch(arrow)and extends inferiorly to involve obturator ring(arrowhead).,后柱骨折,T-型骨折,Note that it is three-part fracture that has component that exten
5、ds inferiorly to disrupt obturator ring(arrowhead).This inferior component of fracture consequently splits into anterior and posterior parts,顶弧角测量,股骨头中心与骨折线之间的夹角残余髋臼的主体是否足够稳定？负重力线是否完整,Matta顶弧角测量前顶弧 内顶弧 后顶弧,手术指征30 40 50（平均45）,正位,闭孔斜位,髂骨斜位,双柱骨折,“spur”sign,Spur sign,正常,影像学评估：4个问题,哪条线中断？1)髂耻线 前柱骨折2)髂坐线
6、后柱骨折其他骨折：3)髂骨？前柱骨折 双柱骨折4)闭孔环？前柱骨折 后柱骨折 T形骨折髋臼壁完整性如何？,3D打印有利于缩短手术时间、提高手术效果。,the surgeon 1 2(2 0 1 4)3 2 8-3 3 3,Three dimensional(3D)modelling and surgicalplanning in trauma and orthopaedicsPatrick Eniola Fadero*,Mahir Shah a,入路选择手术设计预后判断,影像学评价,关于髋臼骨折至今有三个重要观点,Pennal:疗效与复位满意度密切相关;Judet:复位满意度与手术暴露密切相关
7、;Letournel:没有一个切口能暴露全部骨折。,髋臼骨折常用手术入路,Korcher-Langenbeck Ilioinguinal（髂腹股沟入路）联合入路Extended iliofemoral(扩大髂股入路)改良Stoppa入路Surgical hip dislocation（GANZ）,髂腹股沟入路,由Letournel提出针对前柱和前关节面的入路,1960s,Letournel:Ilioinguinal approach,髂腹股沟入路：显露,无法直接显露关节,髂腹股沟入路：适应症,前壁骨折前柱骨折横行骨折并前方移位后方移位前柱后半横行骨折双柱骨折,窗口操作,1st window,3
8、rd window,2nd window,体表标志,优 点:,(1)与Langer氏皮纹平行,手术疤痕小美观(2)臀肌未剥离,术后功能恢复快(3)几乎无HO,关节活动满意(4)不切开关节囊,手术创伤小(5)易于显露和固定作为髋臼延伸段的髂骨骨折,有利于髋臼的解剖复位,缺 点,入路不熟悉不能直接显露关节-尤其在骨折复位时达不到后壁无法直接达到后柱,并发症,股外侧皮神经损伤 50%其他 1%-损伤髂/股动静脉-髂/股静脉血栓形成-股神经损伤-感染-异位骨化-疝气形成,改良Stoppa入路,Cole JD,Bolhofner BR.Acetabular fracture fixation via a
9、 modified stoppa limited intrapelvic approach:description of operative technique and preliminary treatment results.Clin Orthop 1994;305:2030.,体位：仰卧位/漂浮体位皮肤切口：下腹正中 耻骨联合上2厘米处 横切口,纵劈腹白线,牵开腹直肌,Safe Zone,Pierre Guy,J Orthop Trauma Volume 24,Number 5,May 2010,Comparison of Acetabular Fracture Reduction Qu
10、ality by the Ilioinguinal or the Anterior Intrapelvic(Modified RivesStoppa)Surgical Approaches,J Orthop Trauma 2014;28:313319,Conclusions:The AIP approach is a safe alternative that offersbetter exposure and possibly improved reduction quality of acetabularfractures compared with the ilioinguinal ap
11、proach.We believe that the major advantage of the AIP approach is that it enablesreduction of the posterior column and the uadrilateral plate from the contralateral side and enables application of a buttress plate below the pelvic brim.,手术时间、复位质量stoppa入路优越,Randomized,Controlled Trial of the Modified
12、 Stoppa Versus the Ilioinguinal Approach for Acetabular Fractures,ORTHOPEDICS|H,OCTOBER 2013|Volume 36 Number 10,The study showed no significant differences in all measured preoperative variables between the 2 groups(all P.05).In addition,no significant differences were found in the intraoperative c
13、omplication rate,early operative complication rate,late operative complication rate,quality of reduction,radiological results,and clinical outcomes(all P.05).However,compared with the ilioinguinal approach,the modified Stoppa approach reduced intraoperative blood lossand in doing so decreased wound
14、drainage and the need for blood transfusionand shortened operative time(all P,.05).,手术时间、术中失血stoppa入路优越复位质量、并发症、总体疗效无差别,Kocher-Langenbeck入路,针对后柱及后关节面由两人提出-Kocher(1874)-Langenbeck(1904),1958s,Judet and Lagrange:Kocher-Langenbeck Approaches,Kocher Langenbeck入路:显露,整个后柱坐骨大切迹、坐骨小切迹坐骨棘反髋臼面坐骨结节,适应症,-后壁骨折-合
15、并股骨头后脱位-后柱骨折-横行骨折-横行+后壁骨折-T形骨折,Kocher-Langenbeck入路:并发症,异位骨化 8-25%坐骨神经麻痹（神经失用）3-5%感染 2-5%,体位：侧卧切口：Gibson/K-L大转子截骨翻转掀开臀中肌髋关节前脱位不影响股骨头的血供 显露显露髋臼顶部、股骨头及整个髋臼内面减少对髋后部肌肉的剥离减少异位骨化的发生,2001s,Ganz R:Surgical dislocation of the adult hip.femoral head anf acetabulum withou the risk of AVN,JBJS BR,83(8),Surgical
16、hip dislocation（GANZ）,大转子截骨翻转掀开臀中肌,大转子截骨翻转掀开臀中肌,Z型切开关节囊,直视髋臼,Surgical hip dislocation,Surgical Dislocation Technique for the Treatment of Acetabular Fractures,ClinicalOrthopaedicsand Related ResearchA Publication of The Association of Bone and Joint Surgeons,Clin Orthop Relat Res(2013)471:40564064DO
17、I 10.1007/s11999-013-3228-8,Conclusions In complex cases,surgical dislocation presents several advantages;a single approach may reduce surgical time,permit direct intraarticular assessment,and facilitate screw placement closer to the articular surface.It also presents several limitations;some diffic
18、ulties with bonereduction clamp positioning,limited fixation of the anterior column,and a small risk of greater trochanter malunion.,直视髋臼关节面、后柱容易、前柱难臼顶压缩最直接,其他：扩展的髂股入路,优点：同时显露双柱,缺点：入路相关的合并症：-延长手术时间-增加失血-增加感染率-神经麻痹-外展减弱-关节僵硬-异位骨化,1974s,Letournel:extensile Iliofemoral approach,extensile Iliofemoral ap
19、proach,前后联合入路,侧卧悬浮体位,Kocher-Langenbeck+髂腹股沟入路,适应于：前方伴后方横形骨折 双柱骨折 T形骨折 横断骨折,Stoppa联合髂窝入路,显露：整个真骨盆缘全程，能得到骨盆前环及四边体的完整信息优点：操作简单，显露充分，复位方便，固定满意，软组织修复容易 缺点：不能显露髋臼关节面、有时需联合其他入路，髂外血管损伤风险注意：既往有下腹部手术史，腹膜外粘连可能非常严重,前壁，前柱，前柱伴后半横 双柱，T型，骶髂关节和耻骨联合骨折脱位,改良Stoppa入路,骨折类型局部软组织条件相关系统损伤年龄及相关功能手术时机,手术入路选择,满足关节面解剖复位和固定要求!,A
20、2-3后柱后壁：后方入路,典型病例,Kocher-Langenbeck approach,A3前柱前壁,A3前柱前壁,A3前柱前壁,A3前柱前壁,Ilioinguinal approach,典型病例,.,A3前柱前壁,典型病例,经stoppal联合髂窝入路,.,经stoppa入路,B1横行骨折AP and Judet films 前方移位大,典型病例,前方重灾区：Ilioinguinal approach,B1 AP and Judet films 后方移位大伴后壁,典型病例,B1 AP and Judet films 后方移位大,Kocher-Langenbeck approach,CT s
21、can and 3D reconstruction images.,B2T型骨折,典型病例,浮动体位，两手准备 Kocher-Langenbeck approach.,T-type with associated posterior wall,典型病例,CT images of the acetabulum demonstrating the transverse aspect of the fracture and the posterior lesion.,B2 T型后壁骨折,ORIF through Kocher-Langenbeck approach.,3D reconstructio
22、n images T-type fracture with associated comminution of the anterior wall.,B2 T型前壁骨折,Kocher-Langenbeck+ilioinguinal a pproachsequential approach,T-型骨折,典型病例,改良K-L:Surgical hip dislocation,T-型骨折伴臼顶压缩,典型病例,改良Stoppa,Oper Orthop Traumatol 2009;21:25169DOI 10.1007/s00064-009-1803-7,Operative Treatment of
23、T-Type Fractures of the Acetabulum via Surgical Hip Dislocation or Stoppa Approach.Moritz Tannast,Klaus-Arno Siebenrock1,Surgical hip dislocation（GANZ）,A-P and Judet anterior column posterior hemitransverse acetabular fracture.,典型病例,CT and 3D films,B3 前柱后半横,ORIF:an ilioinguinal approach,AP and Judet
24、 both column acetabular fracture,spur sign,Type C3,典型病例,CT scan demonstrates extensive comminution of the left Iliac wing and displacement of the columns.,ORIF through an ilioinguinal approach.,spur sign,Type C,典型病例,Type C,Type C,小联合入路：短IlioinguinalK-L approach 钢板+螺钉+Cabel,手术机会：增多手术时机：因多发伤延长骨折类型：复杂复位质量：无显著提高入路选择：K-L&Ilioinguinal内固定方式：钢板&螺钉为主临床效果：因高龄及骨折复杂无显著提高,挑战依然！,谢谢！,
