Direct posterior approach for the treatment of posterior acetabular fractures / 中华骨科杂志

ABSTRACT

Objective To explore surgical technique and clinical results of the direct posterior approach (DPA) for ace?tabular fractures involving posterior column, posterior wall, or posterior column and wall. Methods From January 2016 to June 2017, data of 10 cases (7 males, 3 females, an average age of 37 years, ranging from 17 to 54 years) with posterior acetabular frac?tures treated by the DPA were retrospectively analyzed. Fractures were caused by traffic accident in 6 cases and by falling in 4 cas?es. According to Letournel?Judet classification of acetabular fractures, there were 6 cases of posterior acetabular wall fractures, 4 cases of posterior wall fractures involving posterior column. A straight skin incision was made from the middle of the line between the posterior margin of the tip of the femoral greater trochanter and the posterior superior iliac spine, to the posterior margin of the femoral greater trochanter. The gluteus maximus muscle was cleaved longitudinally. A view of the area from hip capsule to the su?perior margin of the greater sciatic foramen was obtained by entering along the interspace of the gluteus medius and pyriformis muscle, and the superior gluteal neurovascular bundle was protected. Acetabular posterior column and posterior wall fractures were reduced and fixed under direct vision. The fracture reduction, fracture healing, femoral head necrosis, sciatic nerve injury, su?perior gluteal neurovascular injury and heterotopic ossification were evaluated by the postoperative X?ray and CT examination. The function of hip joint was assessed by the Merle d’Aubigné?Posteal score modified by Matta. Results The average operative incision length was 9.6 cm (range, 8-11 cm). The average operation time was 50 min (range, 35-80 min). The average blood loss was 310 ml (range, 200-440 ml). The time of follow?up was 12-30 months. All the patients were healed within 8-12 weeks with?out any complications such as superior gluteal nerve injury, superior gluteal vessel injury, or sciatic nerve injury. One case of ace? tabular posterior wall and posterior column fracture with posterior dislocation of hip joint, suffered from femoral head necrosis at the 9th months after surgery, which was treated by total hip arthroplasty and was recovered one year after surgery. In one case of actebular posterior wall and posterior column fracture, heterotopic ossification occurred 3 month after operation, without any spe?cial treatment and the hip joint activity was not affected at the follow?up of 15 months after surgery. During the 12?month follow?up after surgery, the Merle d’Aubigné?Postel score modified by Matta was 13-18, among which there were excellent in 6 cases, good in 2, acceptable in 2, with an overall excellent and good rate of 80% (8/10). Conclusion The direct posterior approach for poste?rior acetabular fractures can obtain satisfactory clinical results. The advantages of the DPA include decreasing trauma, shortening operation time, reduing blood loss and decreasing risks of iatrogenic injury to the gluteus medius muscle, the external rotators, the arteriae circumflexa femoris medialis and sciatic nerves as well as reducing and fixing the fractures under direct vision. Thus, the DPA is a relatively safe surgical approach for acetabular posterior wall/column fracture.