髋臼骨折手术治疗的临床研究和荟萃分析
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摘要
虽然髋臼骨折的发生率相对较低——还不到骨科创伤病例总数的2%,但因其多由高速交通伤所致,往往合并其它脏器、血管神经损伤,并对髋关节解剖结构毁损严重,故髋臼骨折具有相对较高的致死率和致残率,因此,髋臼骨折的治疗从一开始就受到了众多研究者的重视。基于Letoumel和Judet等人的开创性工作,在过去的几十年中,髋臼骨折的治疗理念和治疗方法得到了迅速发展,对移位髋臼骨折尽早进行手术已经成为了共识,早期手术治疗不仅能减少患肢制动时间,并能及早进行功能康复,缩短住院时间,还可以减少并发症的发生,有效地降低髋臼骨折的致残率。但由于髋臼骨折发生率低,对髋臼骨折的处理往往集中在大型三甲医院少数医师手中,甚至成为一种亚专业,因此多数骨科医师对髋臼骨折治疗的认识有限。
决定髋臼骨折预后的因素根据能否受人为因素影响可分为两类：可控性与非可控性因素。非可控性因素在创伤发生的同时已经被决定,如患者的年龄、身体健康情况、骨折类型、股骨头损伤程度、髋关节脱位与否、有无合并伤等,这些虽然对髋臼骨折的治疗效果有所影响,但医师却无法进行干预。相反,可控性因素中包括手术入路、复位质量、围手术期并发症等主要取决于医师的认知水平和操作技巧,可通过医师的努力得以改良和提高。
南方医院创伤骨科较早地开展了髋臼骨折的手术治疗,深刻体会到手术治疗对于取得良好髋臼骨折预后的重要性,并对改良Stoppa入路的优势有所了解,但由于髋臼骨折发病率低,文献报道分散,无法将其与传统髂腹股沟入路进行比较,有必要通过统计学方法对现有的文献资料进行总结,并对髋臼骨折手术并发症的发生率进行统计,对其影响因素和防治方法进行初步总结。
第一部分：髋臼骨折手术的临床研究
研究目的：探讨髋臼骨折手术的临床疗效,并总结相关的手术经验和技巧。
研究方法：总结分析自2008年3月-2012年4月治疗髋臼骨折47例。主要观察指标包括：手术时间、失血量、输血量、骨折复位程度、患髋功能恢复情况以及手术并发症等。
研究结果：本组患者男31例,女16例；年龄13～58岁,平均37.4±11.7岁,手术时间为80～260min,平均162.1±46.4min。术中失血500-1100ml,平均693.8±129.7ml,输血0～600ml,平均306.4±196.9ml。本组病例解剖复位32例,满意复位11例,不满意复位4例,复位满意率达91.5%。按照Matta改良的Merle D'Aubigne和Postel评分系统进行评估,临床疗效：优14例,良20例,可5例,差2例,优良率为82.9%。X线标准：优12例,良19例,可8例,差2例,优良率为75.6%。手术并发症包括：1)膀胱破裂1例(3.2%)：术中一直未见到伤口内有血性尿液流出,但关腹前探查时触及尿管,检查发现膀胱破裂,急诊请泌尿外科医师上台协助处理,行膀胱连续缝合后留置尿管两周,术后未出现伤口感染。2)异位骨化：单纯改良Stoppa入路患者未发现异位骨化情况,8例辅助K-L入路患者中于髋关节后方出现Brooker I级(9.7%)异位骨化。3)2年后发现股骨头坏死1例(3.2%),行全髋关节置换术。4)3例术前合并坐骨神经损伤患者,经神经营养治疗及功能康复锻炼,1例随访8个月后感觉和肌力完全恢复,而其余2例感觉明显恢复,但仍残存不同程度的肌力障碍。本组无医源性坐骨神经损伤。未发现伤口感染、深静脉血栓等并发症。
结论：本组病例中术后髋臼骨折满意复位率超过90%,临床优良率和X线优良率近80%,和Matta JM、Letournel E等报道的结果相仿,因此我们认为通过手术可以实现髋臼骨折的满意复位和牢固固定,能够缩短患肢制动时间,早期进行功能康复,从而减少并发症的发生,具有良好的治疗效果。另外,根据我们的经验,我们认为手术入路的选择对于充分显露手术视野、避免组织损伤具有重要意义,使用改良Stoppa入路相对于传统髂腹股沟入路具有以下优点：1)解剖简单,不需要对腹股沟管进行分离,避免了对股神经、髂外血管束以及精索或子宫圆韧带等重要结构组织的损伤。2)暴露广泛,对耻骨联合与骶髂关节之间的广大区域尤其是四边体部分可以充分显露,能够在直视下进行骨折复位和固定,显著缩短了手术时间。3)不对髋关节后外侧肌肉进行剥离,髋周肌肉恢复快,绝大部分患者髋外展肌力能够恢复到术前水平。4)腹直肌和腹内斜肌的联合腱部分得以保留,大大降低了腹壁疝发生的可能性。5)在双侧髋臼骨折的情况下,可以用一处切口完成多处骨折的手术处理。6)手术创伤小,软组织疤痕少,髋关节周围异位骨化发生率低,便于2期髋关节置换术的施行。但因临床病例数量相对缺乏,改良Stoppa入路的优点尚未得到统计学证实。
第二部分：改良Stoppa入路和髂腹股沟入路治疗髋臼骨折临床疗效的荟萃分析比较
研究目的：通过对改良Stoppa入路和髂腹股沟入路治疗髋臼骨折的临床文献进行荟萃分析(即meta分析),评价两种手术入路的临床疗效。
研究方法：检索1961年1月1日至2014年1月1日Pubmed、Cochrane library、 Web of Science、Biosis Previews数据库和中国科技期刊数据库有关改良Stoppa入路和髂腹股沟入路的临床研究文献,使用R软件meta软件包中的meta prop函数合并数据,对其中的手术时间、术中出血量、输血量、解剖复位率、临床疗效以及各种并发症的发生率等数据进行meta分析。
研究结果：共16篇文献纳入本研究,其中前瞻性研究2篇,回顾性分析14篇。病人总数为954例。对临床效果优良率、骨折解剖复位率以及涉及到各特定术后并发症发生率的文献通过I2统计量来进行同质性检验,报道临床效果优良率的文献8篇,I2=0%,报道感染率的文献10篇,I2=0%,报道严重异位骨化的文献11篇,I2=35.4%,报道血栓形成的文献11篇,I2=25%,报道血管损伤的文献10篇,I2=7.2%,报道疝形成的文献8篇,I2=0%,因这几组数据I2<50%,采用固定效应模型。报道解剖复位率的文献13篇,I2=79.8%,报道并发症总数的文献12篇,I2=85.1%,报道医源性神经损伤的文献11篇,I2=79.1%,这几组数据I2>50%,故采用随机效应模型。
使用R软件meta软件包中的meta prop函数合并数据,改良Stoppa入路组/髂腹股沟入路组各种术后常见并发症的发生率分别为：感染4.74%(95%CI:2.87%-7.72%)/6.31%(95%CI:4.06%-9.70%)(P=0.39),严重异位骨化1.54%(95%CI:0.69%-3.38%)/7.76%(95%CI:4.20%-13.91%)(P=0.02),血栓形成5.04%(95%C:2.80%-8.91%)/3.11%(95%CI:1.56%-6.11%)(P=0.29),医源性神经损伤3.42%(95%CI:1.87%-6.16%)/8.86%(95%CI:2.93%-23.85%)(P=0.13),医源性血管损伤2.6%(95%CI:1.24%-5.37%)/4.54%(95%CI:2.04%-9.81%)(P=0.31),疝2.08%(95%CI:0.97%-4.42%)/3.33%(95%CI:0.47%-20.20%)(P=0.65)。改良Stoppa入路组并发症总发生率为12.49%(95%CI：7.78%-19.44%),髂腹股沟入路组并发症总发生率为28.91%(95%CI：13.77%-50.87%),两组之间的差别无统计学意义(P=0.06)。改良Stoppa入路的解剖复位率为70.46%(95%CI：61.33%-78.20%),髂腹股沟入路的解剖复位率为52.35%(95%CI：39.41%-64.98%),P=0.02<0.05,组间存在差异。改良Stoppa入路的优良率为87.06%(95%CI：81.27%-91.26%),髂腹股沟入路的优良率为82.84%(95%CI:76.13%-87.97%), P=0.28>0.05,组间不存在差异。
结论：改良Stoppa入路不仅术后解剖复位率(70.46%>52.35%)和临床效果优良率(87.06%>82.84%)高于髂腹股沟入路,而且各种并发症的发生率也要低于后者(严重异位骨化1.54%<7.76%,疝2.08%<3.33%,医源性神经损伤3.42%<8.86%,医源性血管损伤2.6%<4.54%),这说明改良Stoppa入路相对于髂腹股沟入路具有复位准确、固定牢靠、组织损伤小、并发症少、预后良好的特点,但两者仅在解剖复位率和异位骨化上表现出统计学差异,在临床效果优良率和其他并发症如感染、医源性血管、神经损伤、深静脉血栓等的发生率上并未显示出统计学差异(P>0.05),这说明改良Stoppa入路虽对髋关节周围软组织损伤较小,但仍然存在特定的手术风险,术中应针对该手术入路的特点采取相应措施进行预防。并且,临床上许多髋臼骨折往往合并髂骨翼骨折,而改良Stoppa入路因在真骨盆缘下操作,不能暴露髂骨翼,也不能对髋臼前壁做有效固定,因此对于涉及髂骨翼的髋臼骨折(如前柱+后半横行骨折、双柱骨折),还需髂窝入路复位固定髂骨翼骨折,对于髋臼前壁骨折块,则仍需经髂腹股沟入路钢板直接压迫固定。
第三部分：髋臼骨折手术并发症的荟萃分析
研究目的：通过对髋臼骨折的临床文献进行荟萃分析(即meta分析),对各种手术并发症的发生率进行统计,并对其影响因素和防治方法进行初步总结。
研究方法：检索2001年1月1日至2013年1月1日Pubmed、Cochrane library、 Web of Science、Biosis Previews数据库和中国科技期刊数据库有关髋臼骨折治疗的临床研究文献,使用R软件meta软件包中的meta prop函数合并数据,对其中的异位骨化、严重异位骨化、骨性关节炎、股骨头坏死、医源性神经损伤、感染、深静脉血等各种并发症的发生率进行meta分析。
研究结果：纳入41篇文献(前瞻性研究9篇,回顾性分析32篇),病人总数为3205例。对涉及到各特定术后并发症发生率的文献通过I2统计量来进行同质性检验,报道异位骨化的文献34篇,I2=92.6%,报道严重异位骨化的文献27篇I2=77.7%,报道骨性关节炎的文献29篇I2=81.0%,报道医源性神经损伤的文献34篇I2=76.9%,报道感染的文献32篇I2=57.9%,报道深静脉血栓的文献20篇I2=58.9%,因这几种并发症I2>50%,故采用随机效应模型,而报道股骨头坏死的文献27篇I2=25.2%<50%,采用固定效应模型。异位骨化20.1%(95%CI：14.6%-26.2%),严重异位骨化5.3%(95%CI：3.2%-7.7%),骨性关节炎15.2%(95%CI:11.8%-19.0%),股骨头坏死5.6%(95%CI：4.6%-6.7%),医源性神经损伤5.1%(95%CI:3.3%-7.2%),感染3.3%(95%CI：2.2%～4.7%),深静脉血栓1.4%(95%CI：0.4%-2.9%)。消炎痛对异位骨化无预防作用。
结论：异位骨化总发生率高达20.1%(95%CI：14.6%～26.2%),但真正对术后髋关节功能造成严重影响的BrookerⅢ级以上的异位骨化发生率并不高,仅为5.3%(95%CI：3.2%～7.7%)。使用消炎痛进行预防时,异位骨化的发生率组间无差异——消炎痛的预防作用未能经meta分析证实,并且消炎痛还存在胃肠道出血、肾功能不全和延迟骨愈合等副作用,因此消炎痛对异位骨化的预防作用仍需进行深入研究(P=0.08>0.05)。
进行全髋关节置换的主要原因为骨关节炎和缺血性骨坏死,但根据我们的研究,术后关节炎和缺血性骨坏死的发生率分别为15.2%(95%CI：11.8%～19.0%)和5.6%(95%CI:4.6%-6.7%),两者之和就远远大于现有的全髋关节置换率8.5～11%,可能有部分患者症状较轻,尚未选择手术治疗,同时也不排除数据脱落的可能,因此需要对髋臼骨折术后患者进行更长期的密切随访。
医源性神经损伤总的发生率为5.1%(95%CI：3.3%～7.2%),但其发生率和好发种类根据手术入路不同而有所差别,因此,其预防方法也需根据手术方式进行调整,术中保持髋关节在神经走形方向上的屈曲、仔细解剖和小心牵拉有助于坐骨神经的保护。
根据当前研究,在最为常见的几个并发症中,下肢深静脉血栓发生率最低,为1.4%(95%CI:0.4%-2.9%),但这些数据来自于文献中对髋臼骨折术后并发症的记录,只对术后表现出临床表现的进行登记,而多数髋臼骨折术后深静脉血栓发生时并无临床症状,故该数据并不能反映下肢深静脉栓塞真实的发生率,其发生率远远高于此值。有文献报道术后常规预防性使用低分子肝素可显著降低术后深静脉血栓的形成,具有良好的安全性,但本研究中因所采集信息量不足,未能对其预防作用进行验证。
术后伤口感染在髋臼骨折术后并不少见,本研究统计其发生率为3.3%,其发生和手术入路、创伤严重程度、肥胖、局部伤口情况等多种因素有关,一旦发生治疗周期长,恢复效果差,严重影响髋臼骨折预后。
Although the incidence of acetabular fractures is relatively low which represents less than2%of all fractures, it has a high rate of mortality and disability as it is always caused by traffic accidents and associated with polytrauma. The pathological mechanism and treatment has long been studied by many researchers, and the philosophy and method of treatment has developed rapidly during the past decades based on the pioneering work of Letournel and Judet. Operation is a common sense for the displaced acetabular fractures nowadays, and early operation could not only shorten the time to ambulation and hospital discharge, and motivate the patient to rehabilitation exercise early, but also could avoid complications and reduce the rate of disability. The knowledge about acetabular fractures of the average orthopaedists is relatively limited because of the low incidence. The management of these injuries has become a sub-speciality with orthopaedics, and generally takes place in a tertiary referral setting.
The factors which could affluence the outcome of acetabular fractures can be divided into controllable factors and uncontrollable factors according to the role of surgeons. The uncontrollable factors including patient age, fracture type, femoral head damage, dislocation of hip, medical comorbidities and associated injuries were decided during and even before the trauma which cannot be changed. Controllable factors which are under surgeon control and could be improved and reformed include surgical approach, reduction achieved and the avoidance of further complications.
The department of trauma and orthopaedic of Nanfang hospital began the operation of the acetabular fractures comparatively early in our region. We knew how much the outcome of displaced acetabular fractures depends on the operative treatment and learn advantages of the modified Stoppa approach from experience. There are no convincing comparisons yet between the modified Stoppa approach and traditional ilioinguinal approach for the small number of cases. It is necessary to summarize the literature now available by the statistical method to compare the two approaches, evaluate the incidence of the complications and the influencing factors of acetabular fracture operations, and sum up the experience of the preventive measures.
Part1:The clinical study of acetabular operative treatment of acetabular fractures
Objective:To investigate the clinical outcome of the operative treatment of acetabular fractures and sum up the relevant operation techniques and experiences.
Methods:A consecutive cohort of47patients was treated operatively with use of modified Stoppa approach from March2008to April2012in our hospital. The major data including operation time, blood loss, blood transfusion, fracture reduction, the clinical evaluation score of Merle D' Aubigne and postoperative complications.
Results:47cases were analyzed in this study, including31men and16women with a mean age of37.4±11.7y (range,13to58y). The mean operation time was162.1±46.4min(range:80to260min) and the mean blood loss was693.8±129.7ml(range:500to1100ml) with a mean blood transfusion of306.4±196.9ml(range:0to600ml). There were32cases with anatomic reduction,11cases with satisfactory reduction and4case with unsatisfactory reduction with a satisfying reduction rate of91.5%. Based on the Merle D' Aubigne clinical grading system modified by Matta,14cases show excellent results,20cases good,5fair and2poor. The excellent and good rate was82.9%.The radiographic manifestation was evaluated according to the Matta criteria.12cases were rated as excellent,19cases as fine,8cases as fair and2 case as poor with an excellent and good rate of75.6%. The complications are listed behind.1)1case of bladder laceration (3.2%):The bloody urine was not observed during the operation in the operative view, but the catheter was palpable before abdominal closure which indicated the laceration of bladder. The laceration was sutureed by a consultant from urinary surgery department. There was no postoperative infection after the drainage for2weeks.2) Heterotopic ossification was not observed in cases approached by the modified Stoppa.8cases (9.7%) which were approached by the combined K-L approach and anterior approach are diagnosed first grade heterotopic ossification.3)1case (3.2%) of femoral head necrosis was observed during the2year follow-up and the total hip arthroplasty was performed。4)3cases of sciatic nerve injury were observed before the operation. After neurotrophic treatment and rehabilitation therapy1case recovered completely, and2case recovered sense perception partly but remains nerve symptom of motion function. There were no cases of iatrogenic sciatic nerve injury, infection and deep vein thrombosis.
Conclusion:The satisfying reduction rate of our casess is more than90%and the excellent and good rate according to the Matta criteria is near80%which is considered the outcome of the operative treatment with establishing satisfied reduction in acetabular fractures. According to our experience, a correct approach is of great importance for the acetabular fractures treatment to have adequate surgical view, reduce and fix the fracture. It could reduce the blood loss, shorten the operation time and avoid complications. According to our experience, the modified approach has the six following advantages comparing to the traditional ilioinguinal approach.1) It has a relatively simple anatomical structure. It is not necessary in ilioinguinal approach to sever inguinal canal as to avoid the damage to the femoral nerve, external iliac vessels bundle and spermatic cord or round ligament of uterus.2) It can expose the broad area from the symphysis ossium pubis to articulationes sacroiliaca especially the quadrilateral surface, and the surgeon can gain direct access to the acetabular fractures in the above area which could shorten the operation time notably.
3) The modified Stoppa approach dose not stip off the posterior lateral muscle of the hip from the joint, so the muscle around the hip recover sooner and the patient could gain vast majority of the abductor strength after the operation.4) Tendo conjunctivis inguinalis was spared and the possibility of abdominal hernia was reduced.5) It could be used to manage the bilateral acetablar fractures through one surgical approach.6) There is less soft tissue scar for the relative simple anatomical structure which could avoid the happening of heterotopic ossification around the hip and is convenient for the late total hip arthroplasty. But the above advantages could not be affirmed statistically for the lack of enough cases.
Part2:Meta-analysis of the modified Stoppa approach comparing the traditional ilioinguinal approach in the operative treatment of acetabular fractures
Objective:To compare the modified Stoppa approach and traditional ilioinguinal approach in the operative treatment of acetabular fractures summarizing the literature now available.
Methods:Clinical studies of modified Stoppa approach and ilioinguinal approach were searched in the data base of Pubmed、Cochrane library、Web of Science、Biosis Previews and Chinese sci-tech periodical full-text database from January1,1961to January1,2004. A proportion meta-analysis across the studies was performed for the operation time, blood loss, blood transfusion, anatomical reduction, clinical outcome and complications after acetabular operation with the use of R software.
Results:16articles were analyzed in this study, including2perspective studies and14retrospective observational studies with a total of954patients. The clinical outcome satisfactory rate, anatomical reduction rate and specified complication rate in the relevant studies were homogeneity tested by the statistics of I2. There were8studies reporting clinical outcome with I2=0%,10studies reporting infection with I2=0%,11studies reporting serious heterotopic ossification with I2=35.4%,11studies reporting thrombogenesis with I2=25%,10studies reporting iatrogenic vascular injury with I2=7.2%and8studies reporting abdominal hernia with I2=0%during which the fixed effect model was used for the I2<50%. There are13studies reporting anatomical reduction with I2=79.8,12studies reporting total complication rate with I=85.1%and11studies reporting Iatrogenic vascular injury with I=79.1%during which the random effect model was used for the I2>50%.
A proportion meta-analysis across the studies was performed with the use of R software. The incidence of infection, serious heterotopic ossification, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia with the modified Stoppa approach was4.74%(95%CI:2.87%to7.72%),1.54%(95%CI:0.69%to3.38%),5.04%(95%CI:2.80%to8.91%),3.42%(95%CI:1.87%to6.16%),2.6%(95%CI:1.24%to5.37%) and2.08%(95%CI:0.97%to4.42%). The incidence of infection, serious heterotopic ossification, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia with the ilioinguinal approach was6.31%(95%CI:4.06%～9.70%),7.76%(95%CI:4.2%～13.91%),3.11%(95%CI:1.56%～6.11%),8.86%(95%CI:2.93%～23.85%),4.54%(95%CI:2.04%～9.81%) and3.33%(95%CI:0.47%～20.20%).The P value between the two approaches was0.39,0.02,0.29,0.13,0.31and0.65. The total complication rate with the modified approach was12.49%(95%CI:7.78%～19.44%) and the total complication rate with the ilioinguinal approach was28.91%(95%CI:13.77%～50.87%). The difference between the two approaches is not of statistical significance with a P value greater than0.05. The anatomical redution rate of the modified appraoch and the ilioinguinal was70.46%(95%CI:61.33%～78.20%) and52.35%(95%CI:39.41%～64.98%) with a random effect model for the12=79.8%>50%. The diffenrece between the modified appraoch and the ilioinguinal was significant (P=0.02<0.05). The excellent and good rate of the modified appraoch and the ilioinguinal was87.06%(95%CI:81.27%～91.26%) and82.84%(95%CI:76.13%～87.97%) with a fixed effect model for the12=0%<50%. The diffenrece between the modified appraoch and the ilioinguinal was insignificant (P=0.28>0.05).
Conclusion:Comparing with the ilioinguinal approach, the modified approach has a higher anatomical reduction rate and a lower complication rate such as serious heterotopic ossification, infection, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia, but the difference between the approaches was only of statistical significance in the serious heterotopic ossification. The modified approach and the ilioinguinal approach has similar clinical outcome according to the long time follow-up.
Part3:Mata-analysis of complications of operative treatment for the acetabular fractures
Objective:To provide a cumulative data about the complications of the operative treatment of acetabulum fractures in the literature with statistical methods and to sum up the influencing factors and preventive measures.
Methods:A comprehensive search for all relevant articles in the data base of Pubmed、Cochrane library、Web of Science、Biosis Previews and Chinese sci-tech periodical full-text database published in English and Chinese from January1,2001to December1,2012was conducted. A proportion meta-analysis across the studies was performed for the complications such as heterotopic ossification, serious heterotopic ossification, osteoarthritis, avascular femoral head necrosis, iatrogenic nerve injury, postoperative infection and deep venous thrombosis after acetabular operation with the use of R software.
Results:41articles were analyzed in this study, including9perspective studies and32retrospective observational studies with a total of3205patients. The specified complication rate in the relevant studies were homogeneity tested by the statistics of I2. There were34studies reporting heterotopic ossification with I2=92.6%,27studies reporting serious heterotopic ossification with I2=77.7%,29studies reporting serious osteoarthritis with I=81.0%,34studies reporting iatrogenic nerve injury with I2=76.9%,32studies reporting infection with I2=57.9%and20studies reporting deep venous thrombosis with I2=58.9%during which the random effect model was used for the I2>50%. There are27studies reporting avascular femoral head necrosis with I2=25.2%during which the fixed effect model was used for the I2<50%. The incidence of heterotopic ossification, serious heterotopic ossification, osteoarthritis, avascular femoral head necrosis, iatrogenic nerve injury, postoperative infection and deep venous thrombosis was20.1%(95%CI:14.6%to26.2%),5.3%(95%CI:3.2%to7.7%),15.2%(95%CI:11.8%to19.0%),5.6%(95%CI:4.6%to6.7%).5.1%(95%CI:3.3%to7.2%)、3.3%(95%CI:2.2%to4.7%) and1.4%(95%CI:0.4%to2.9%). The preventive effect of indomethacin is not of statistical significance with a P value greater than0.05.
Conclusion:The overall incidence of heterotopic ossification is as high as20.1%(95%CI:14.6%to26.2%), but the incidence of serious heterotopic ossification is just5.3%(95%CI:3.2%to7.7%) which grades more than Brooker III and really affects the clinical outcome of acetabular fractures. The major preventive methods of heterotopic ossification include low dose irradiation, diphosphonates and non-steroidal anti-inflammatory. The irradiation could affects rapidly dividing cells by altering DNA transcription and preventing osteoblastic precursor cells from multiplying and forming active osteoblasts, but this prophylactic method has a trivial procedure and obvious side effects with relatively inexact curative effect which limit its clinic application. Diphosphonates is negated by relevant researches and the preventive effect of indometacin is also not supported by the statics data for the difference of the incidence of heterotopic ossification between the groups is not of significance (P=0.08>0.05) which cause the gastrointestinal bleeding, renal insufficiency, renal toxicity, and delay fracture healing.
The leading cause of total hip arthroplasty is osteoarthritis and avascular femoral head necrosis. But the incidence of osteoarthritis and avascular femoral head necrosis was15.2%(95%CI:11.8%to19.0%) and5.6%(95%CI:4.6%to6.7%) with a sum percentage much more than the total hip arthroplasty rate during the follow-up which could be caused by the refusal of the less symptomatic patients and the possibility of data loss. So a longer and closer follow-up after the acetabular fracture operation is needs.
The overall incidence of iatrogenic nerve injury is5.1%(95%CI:3.3%to7.2%), but the relevant incidence of a specified iatrogenic nerve injury differs according to the approach which indicate the preventive methods should also change with the approach. In general keeping the joint flexed according to the direction of the nerve, severing carefully and gentle traction during the operation will do help avoiding the iatrogenic nerve injury.
According to our research deep venous thrombosis has the lowest incidence of1.4%(95%CI:0.4%to2.9%) among the common complications. But the data was only exactly accurate for the literature only recorded the symptomatic deep venous thrombosis and always ignored the asymptomatic ones. The actual incidence of deep venous thrombosis may be much larger than1.4%. Some researchers recommend the use of low molecular weight heparin during perioperative period with a good safety, but the data during this research is not enough to analysis its preventive effect.
The incidence of infection after the operation is3.3%, and is not unusual according to our research. The infection is related to the approach, injury severity, obesity and local traumatic condition. The treatment of infection is troublesome, always need a long time to recovery and has a relative worse outcome. Prophylactic method should be recruited to avoid the occurrence of infection.
决定髋臼骨折预后的因素根据能否受人为因素影响可分为两类：可控性与非可控性因素。非可控性因素在创伤发生的同时已经被决定,如患者的年龄、身体健康情况、骨折类型、股骨头损伤程度、髋关节脱位与否、有无合并伤等,这些虽然对髋臼骨折的治疗效果有所影响,但医师却无法进行干预。相反,可控性因素中包括手术入路、复位质量、围手术期并发症等主要取决于医师的认知水平和操作技巧,可通过医师的努力得以改良和提高。
南方医院创伤骨科较早地开展了髋臼骨折的手术治疗,深刻体会到手术治疗对于取得良好髋臼骨折预后的重要性,并对改良Stoppa入路的优势有所了解,但由于髋臼骨折发病率低,文献报道分散,无法将其与传统髂腹股沟入路进行比较,有必要通过统计学方法对现有的文献资料进行总结,并对髋臼骨折手术并发症的发生率进行统计,对其影响因素和防治方法进行初步总结。
第一部分：髋臼骨折手术的临床研究
研究目的：探讨髋臼骨折手术的临床疗效,并总结相关的手术经验和技巧。
研究方法：总结分析自2008年3月-2012年4月治疗髋臼骨折47例。主要观察指标包括：手术时间、失血量、输血量、骨折复位程度、患髋功能恢复情况以及手术并发症等。
研究结果：本组患者男31例,女16例；年龄13～58岁,平均37.4±11.7岁,手术时间为80～260min,平均162.1±46.4min。术中失血500-1100ml,平均693.8±129.7ml,输血0～600ml,平均306.4±196.9ml。本组病例解剖复位32例,满意复位11例,不满意复位4例,复位满意率达91.5%。按照Matta改良的Merle D'Aubigne和Postel评分系统进行评估,临床疗效：优14例,良20例,可5例,差2例,优良率为82.9%。X线标准：优12例,良19例,可8例,差2例,优良率为75.6%。手术并发症包括：1)膀胱破裂1例(3.2%)：术中一直未见到伤口内有血性尿液流出,但关腹前探查时触及尿管,检查发现膀胱破裂,急诊请泌尿外科医师上台协助处理,行膀胱连续缝合后留置尿管两周,术后未出现伤口感染。2)异位骨化：单纯改良Stoppa入路患者未发现异位骨化情况,8例辅助K-L入路患者中于髋关节后方出现Brooker I级(9.7%)异位骨化。3)2年后发现股骨头坏死1例(3.2%),行全髋关节置换术。4)3例术前合并坐骨神经损伤患者,经神经营养治疗及功能康复锻炼,1例随访8个月后感觉和肌力完全恢复,而其余2例感觉明显恢复,但仍残存不同程度的肌力障碍。本组无医源性坐骨神经损伤。未发现伤口感染、深静脉血栓等并发症。
结论：本组病例中术后髋臼骨折满意复位率超过90%,临床优良率和X线优良率近80%,和Matta JM、Letournel E等报道的结果相仿,因此我们认为通过手术可以实现髋臼骨折的满意复位和牢固固定,能够缩短患肢制动时间,早期进行功能康复,从而减少并发症的发生,具有良好的治疗效果。另外,根据我们的经验,我们认为手术入路的选择对于充分显露手术视野、避免组织损伤具有重要意义,使用改良Stoppa入路相对于传统髂腹股沟入路具有以下优点：1)解剖简单,不需要对腹股沟管进行分离,避免了对股神经、髂外血管束以及精索或子宫圆韧带等重要结构组织的损伤。2)暴露广泛,对耻骨联合与骶髂关节之间的广大区域尤其是四边体部分可以充分显露,能够在直视下进行骨折复位和固定,显著缩短了手术时间。3)不对髋关节后外侧肌肉进行剥离,髋周肌肉恢复快,绝大部分患者髋外展肌力能够恢复到术前水平。4)腹直肌和腹内斜肌的联合腱部分得以保留,大大降低了腹壁疝发生的可能性。5)在双侧髋臼骨折的情况下,可以用一处切口完成多处骨折的手术处理。6)手术创伤小,软组织疤痕少,髋关节周围异位骨化发生率低,便于2期髋关节置换术的施行。但因临床病例数量相对缺乏,改良Stoppa入路的优点尚未得到统计学证实。
第二部分：改良Stoppa入路和髂腹股沟入路治疗髋臼骨折临床疗效的荟萃分析比较
研究目的：通过对改良Stoppa入路和髂腹股沟入路治疗髋臼骨折的临床文献进行荟萃分析(即meta分析),评价两种手术入路的临床疗效。
研究方法：检索1961年1月1日至2014年1月1日Pubmed、Cochrane library、 Web of Science、Biosis Previews数据库和中国科技期刊数据库有关改良Stoppa入路和髂腹股沟入路的临床研究文献,使用R软件meta软件包中的meta prop函数合并数据,对其中的手术时间、术中出血量、输血量、解剖复位率、临床疗效以及各种并发症的发生率等数据进行meta分析。
研究结果：共16篇文献纳入本研究,其中前瞻性研究2篇,回顾性分析14篇。病人总数为954例。对临床效果优良率、骨折解剖复位率以及涉及到各特定术后并发症发生率的文献通过I2统计量来进行同质性检验,报道临床效果优良率的文献8篇,I2=0%,报道感染率的文献10篇,I2=0%,报道严重异位骨化的文献11篇,I2=35.4%,报道血栓形成的文献11篇,I2=25%,报道血管损伤的文献10篇,I2=7.2%,报道疝形成的文献8篇,I2=0%,因这几组数据I2<50%,采用固定效应模型。报道解剖复位率的文献13篇,I2=79.8%,报道并发症总数的文献12篇,I2=85.1%,报道医源性神经损伤的文献11篇,I2=79.1%,这几组数据I2>50%,故采用随机效应模型。
使用R软件meta软件包中的meta prop函数合并数据,改良Stoppa入路组/髂腹股沟入路组各种术后常见并发症的发生率分别为：感染4.74%(95%CI:2.87%-7.72%)/6.31%(95%CI:4.06%-9.70%)(P=0.39),严重异位骨化1.54%(95%CI:0.69%-3.38%)/7.76%(95%CI:4.20%-13.91%)(P=0.02),血栓形成5.04%(95%C:2.80%-8.91%)/3.11%(95%CI:1.56%-6.11%)(P=0.29),医源性神经损伤3.42%(95%CI:1.87%-6.16%)/8.86%(95%CI:2.93%-23.85%)(P=0.13),医源性血管损伤2.6%(95%CI:1.24%-5.37%)/4.54%(95%CI:2.04%-9.81%)(P=0.31),疝2.08%(95%CI:0.97%-4.42%)/3.33%(95%CI:0.47%-20.20%)(P=0.65)。改良Stoppa入路组并发症总发生率为12.49%(95%CI：7.78%-19.44%),髂腹股沟入路组并发症总发生率为28.91%(95%CI：13.77%-50.87%),两组之间的差别无统计学意义(P=0.06)。改良Stoppa入路的解剖复位率为70.46%(95%CI：61.33%-78.20%),髂腹股沟入路的解剖复位率为52.35%(95%CI：39.41%-64.98%),P=0.02<0.05,组间存在差异。改良Stoppa入路的优良率为87.06%(95%CI：81.27%-91.26%),髂腹股沟入路的优良率为82.84%(95%CI:76.13%-87.97%), P=0.28>0.05,组间不存在差异。
结论：改良Stoppa入路不仅术后解剖复位率(70.46%>52.35%)和临床效果优良率(87.06%>82.84%)高于髂腹股沟入路,而且各种并发症的发生率也要低于后者(严重异位骨化1.54%<7.76%,疝2.08%<3.33%,医源性神经损伤3.42%<8.86%,医源性血管损伤2.6%<4.54%),这说明改良Stoppa入路相对于髂腹股沟入路具有复位准确、固定牢靠、组织损伤小、并发症少、预后良好的特点,但两者仅在解剖复位率和异位骨化上表现出统计学差异,在临床效果优良率和其他并发症如感染、医源性血管、神经损伤、深静脉血栓等的发生率上并未显示出统计学差异(P>0.05),这说明改良Stoppa入路虽对髋关节周围软组织损伤较小,但仍然存在特定的手术风险,术中应针对该手术入路的特点采取相应措施进行预防。并且,临床上许多髋臼骨折往往合并髂骨翼骨折,而改良Stoppa入路因在真骨盆缘下操作,不能暴露髂骨翼,也不能对髋臼前壁做有效固定,因此对于涉及髂骨翼的髋臼骨折(如前柱+后半横行骨折、双柱骨折),还需髂窝入路复位固定髂骨翼骨折,对于髋臼前壁骨折块,则仍需经髂腹股沟入路钢板直接压迫固定。
第三部分：髋臼骨折手术并发症的荟萃分析
研究目的：通过对髋臼骨折的临床文献进行荟萃分析(即meta分析),对各种手术并发症的发生率进行统计,并对其影响因素和防治方法进行初步总结。
研究方法：检索2001年1月1日至2013年1月1日Pubmed、Cochrane library、 Web of Science、Biosis Previews数据库和中国科技期刊数据库有关髋臼骨折治疗的临床研究文献,使用R软件meta软件包中的meta prop函数合并数据,对其中的异位骨化、严重异位骨化、骨性关节炎、股骨头坏死、医源性神经损伤、感染、深静脉血等各种并发症的发生率进行meta分析。
研究结果：纳入41篇文献(前瞻性研究9篇,回顾性分析32篇),病人总数为3205例。对涉及到各特定术后并发症发生率的文献通过I2统计量来进行同质性检验,报道异位骨化的文献34篇,I2=92.6%,报道严重异位骨化的文献27篇I2=77.7%,报道骨性关节炎的文献29篇I2=81.0%,报道医源性神经损伤的文献34篇I2=76.9%,报道感染的文献32篇I2=57.9%,报道深静脉血栓的文献20篇I2=58.9%,因这几种并发症I2>50%,故采用随机效应模型,而报道股骨头坏死的文献27篇I2=25.2%<50%,采用固定效应模型。异位骨化20.1%(95%CI：14.6%-26.2%),严重异位骨化5.3%(95%CI：3.2%-7.7%),骨性关节炎15.2%(95%CI:11.8%-19.0%),股骨头坏死5.6%(95%CI：4.6%-6.7%),医源性神经损伤5.1%(95%CI:3.3%-7.2%),感染3.3%(95%CI：2.2%～4.7%),深静脉血栓1.4%(95%CI：0.4%-2.9%)。消炎痛对异位骨化无预防作用。
结论：异位骨化总发生率高达20.1%(95%CI：14.6%～26.2%),但真正对术后髋关节功能造成严重影响的BrookerⅢ级以上的异位骨化发生率并不高,仅为5.3%(95%CI：3.2%～7.7%)。使用消炎痛进行预防时,异位骨化的发生率组间无差异——消炎痛的预防作用未能经meta分析证实,并且消炎痛还存在胃肠道出血、肾功能不全和延迟骨愈合等副作用,因此消炎痛对异位骨化的预防作用仍需进行深入研究(P=0.08>0.05)。
进行全髋关节置换的主要原因为骨关节炎和缺血性骨坏死,但根据我们的研究,术后关节炎和缺血性骨坏死的发生率分别为15.2%(95%CI：11.8%～19.0%)和5.6%(95%CI:4.6%-6.7%),两者之和就远远大于现有的全髋关节置换率8.5～11%,可能有部分患者症状较轻,尚未选择手术治疗,同时也不排除数据脱落的可能,因此需要对髋臼骨折术后患者进行更长期的密切随访。
医源性神经损伤总的发生率为5.1%(95%CI：3.3%～7.2%),但其发生率和好发种类根据手术入路不同而有所差别,因此,其预防方法也需根据手术方式进行调整,术中保持髋关节在神经走形方向上的屈曲、仔细解剖和小心牵拉有助于坐骨神经的保护。
根据当前研究,在最为常见的几个并发症中,下肢深静脉血栓发生率最低,为1.4%(95%CI:0.4%-2.9%),但这些数据来自于文献中对髋臼骨折术后并发症的记录,只对术后表现出临床表现的进行登记,而多数髋臼骨折术后深静脉血栓发生时并无临床症状,故该数据并不能反映下肢深静脉栓塞真实的发生率,其发生率远远高于此值。有文献报道术后常规预防性使用低分子肝素可显著降低术后深静脉血栓的形成,具有良好的安全性,但本研究中因所采集信息量不足,未能对其预防作用进行验证。
术后伤口感染在髋臼骨折术后并不少见,本研究统计其发生率为3.3%,其发生和手术入路、创伤严重程度、肥胖、局部伤口情况等多种因素有关,一旦发生治疗周期长,恢复效果差,严重影响髋臼骨折预后。
Although the incidence of acetabular fractures is relatively low which represents less than2%of all fractures, it has a high rate of mortality and disability as it is always caused by traffic accidents and associated with polytrauma. The pathological mechanism and treatment has long been studied by many researchers, and the philosophy and method of treatment has developed rapidly during the past decades based on the pioneering work of Letournel and Judet. Operation is a common sense for the displaced acetabular fractures nowadays, and early operation could not only shorten the time to ambulation and hospital discharge, and motivate the patient to rehabilitation exercise early, but also could avoid complications and reduce the rate of disability. The knowledge about acetabular fractures of the average orthopaedists is relatively limited because of the low incidence. The management of these injuries has become a sub-speciality with orthopaedics, and generally takes place in a tertiary referral setting.
The factors which could affluence the outcome of acetabular fractures can be divided into controllable factors and uncontrollable factors according to the role of surgeons. The uncontrollable factors including patient age, fracture type, femoral head damage, dislocation of hip, medical comorbidities and associated injuries were decided during and even before the trauma which cannot be changed. Controllable factors which are under surgeon control and could be improved and reformed include surgical approach, reduction achieved and the avoidance of further complications.
The department of trauma and orthopaedic of Nanfang hospital began the operation of the acetabular fractures comparatively early in our region. We knew how much the outcome of displaced acetabular fractures depends on the operative treatment and learn advantages of the modified Stoppa approach from experience. There are no convincing comparisons yet between the modified Stoppa approach and traditional ilioinguinal approach for the small number of cases. It is necessary to summarize the literature now available by the statistical method to compare the two approaches, evaluate the incidence of the complications and the influencing factors of acetabular fracture operations, and sum up the experience of the preventive measures.
Part1:The clinical study of acetabular operative treatment of acetabular fractures
Objective:To investigate the clinical outcome of the operative treatment of acetabular fractures and sum up the relevant operation techniques and experiences.
Methods:A consecutive cohort of47patients was treated operatively with use of modified Stoppa approach from March2008to April2012in our hospital. The major data including operation time, blood loss, blood transfusion, fracture reduction, the clinical evaluation score of Merle D' Aubigne and postoperative complications.
Results:47cases were analyzed in this study, including31men and16women with a mean age of37.4±11.7y (range,13to58y). The mean operation time was162.1±46.4min(range:80to260min) and the mean blood loss was693.8±129.7ml(range:500to1100ml) with a mean blood transfusion of306.4±196.9ml(range:0to600ml). There were32cases with anatomic reduction,11cases with satisfactory reduction and4case with unsatisfactory reduction with a satisfying reduction rate of91.5%. Based on the Merle D' Aubigne clinical grading system modified by Matta,14cases show excellent results,20cases good,5fair and2poor. The excellent and good rate was82.9%.The radiographic manifestation was evaluated according to the Matta criteria.12cases were rated as excellent,19cases as fine,8cases as fair and2 case as poor with an excellent and good rate of75.6%. The complications are listed behind.1)1case of bladder laceration (3.2%):The bloody urine was not observed during the operation in the operative view, but the catheter was palpable before abdominal closure which indicated the laceration of bladder. The laceration was sutureed by a consultant from urinary surgery department. There was no postoperative infection after the drainage for2weeks.2) Heterotopic ossification was not observed in cases approached by the modified Stoppa.8cases (9.7%) which were approached by the combined K-L approach and anterior approach are diagnosed first grade heterotopic ossification.3)1case (3.2%) of femoral head necrosis was observed during the2year follow-up and the total hip arthroplasty was performed。4)3cases of sciatic nerve injury were observed before the operation. After neurotrophic treatment and rehabilitation therapy1case recovered completely, and2case recovered sense perception partly but remains nerve symptom of motion function. There were no cases of iatrogenic sciatic nerve injury, infection and deep vein thrombosis.
Conclusion:The satisfying reduction rate of our casess is more than90%and the excellent and good rate according to the Matta criteria is near80%which is considered the outcome of the operative treatment with establishing satisfied reduction in acetabular fractures. According to our experience, a correct approach is of great importance for the acetabular fractures treatment to have adequate surgical view, reduce and fix the fracture. It could reduce the blood loss, shorten the operation time and avoid complications. According to our experience, the modified approach has the six following advantages comparing to the traditional ilioinguinal approach.1) It has a relatively simple anatomical structure. It is not necessary in ilioinguinal approach to sever inguinal canal as to avoid the damage to the femoral nerve, external iliac vessels bundle and spermatic cord or round ligament of uterus.2) It can expose the broad area from the symphysis ossium pubis to articulationes sacroiliaca especially the quadrilateral surface, and the surgeon can gain direct access to the acetabular fractures in the above area which could shorten the operation time notably.
3) The modified Stoppa approach dose not stip off the posterior lateral muscle of the hip from the joint, so the muscle around the hip recover sooner and the patient could gain vast majority of the abductor strength after the operation.4) Tendo conjunctivis inguinalis was spared and the possibility of abdominal hernia was reduced.5) It could be used to manage the bilateral acetablar fractures through one surgical approach.6) There is less soft tissue scar for the relative simple anatomical structure which could avoid the happening of heterotopic ossification around the hip and is convenient for the late total hip arthroplasty. But the above advantages could not be affirmed statistically for the lack of enough cases.
Part2:Meta-analysis of the modified Stoppa approach comparing the traditional ilioinguinal approach in the operative treatment of acetabular fractures
Objective:To compare the modified Stoppa approach and traditional ilioinguinal approach in the operative treatment of acetabular fractures summarizing the literature now available.
Methods:Clinical studies of modified Stoppa approach and ilioinguinal approach were searched in the data base of Pubmed、Cochrane library、Web of Science、Biosis Previews and Chinese sci-tech periodical full-text database from January1,1961to January1,2004. A proportion meta-analysis across the studies was performed for the operation time, blood loss, blood transfusion, anatomical reduction, clinical outcome and complications after acetabular operation with the use of R software.
Results:16articles were analyzed in this study, including2perspective studies and14retrospective observational studies with a total of954patients. The clinical outcome satisfactory rate, anatomical reduction rate and specified complication rate in the relevant studies were homogeneity tested by the statistics of I2. There were8studies reporting clinical outcome with I2=0%,10studies reporting infection with I2=0%,11studies reporting serious heterotopic ossification with I2=35.4%,11studies reporting thrombogenesis with I2=25%,10studies reporting iatrogenic vascular injury with I2=7.2%and8studies reporting abdominal hernia with I2=0%during which the fixed effect model was used for the I2<50%. There are13studies reporting anatomical reduction with I2=79.8,12studies reporting total complication rate with I=85.1%and11studies reporting Iatrogenic vascular injury with I=79.1%during which the random effect model was used for the I2>50%.
A proportion meta-analysis across the studies was performed with the use of R software. The incidence of infection, serious heterotopic ossification, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia with the modified Stoppa approach was4.74%(95%CI:2.87%to7.72%),1.54%(95%CI:0.69%to3.38%),5.04%(95%CI:2.80%to8.91%),3.42%(95%CI:1.87%to6.16%),2.6%(95%CI:1.24%to5.37%) and2.08%(95%CI:0.97%to4.42%). The incidence of infection, serious heterotopic ossification, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia with the ilioinguinal approach was6.31%(95%CI:4.06%～9.70%),7.76%(95%CI:4.2%～13.91%),3.11%(95%CI:1.56%～6.11%),8.86%(95%CI:2.93%～23.85%),4.54%(95%CI:2.04%～9.81%) and3.33%(95%CI:0.47%～20.20%).The P value between the two approaches was0.39,0.02,0.29,0.13,0.31and0.65. The total complication rate with the modified approach was12.49%(95%CI:7.78%～19.44%) and the total complication rate with the ilioinguinal approach was28.91%(95%CI:13.77%～50.87%). The difference between the two approaches is not of statistical significance with a P value greater than0.05. The anatomical redution rate of the modified appraoch and the ilioinguinal was70.46%(95%CI:61.33%～78.20%) and52.35%(95%CI:39.41%～64.98%) with a random effect model for the12=79.8%>50%. The diffenrece between the modified appraoch and the ilioinguinal was significant (P=0.02<0.05). The excellent and good rate of the modified appraoch and the ilioinguinal was87.06%(95%CI:81.27%～91.26%) and82.84%(95%CI:76.13%～87.97%) with a fixed effect model for the12=0%<50%. The diffenrece between the modified appraoch and the ilioinguinal was insignificant (P=0.28>0.05).
Conclusion:Comparing with the ilioinguinal approach, the modified approach has a higher anatomical reduction rate and a lower complication rate such as serious heterotopic ossification, infection, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia, but the difference between the approaches was only of statistical significance in the serious heterotopic ossification. The modified approach and the ilioinguinal approach has similar clinical outcome according to the long time follow-up.
Part3:Mata-analysis of complications of operative treatment for the acetabular fractures
Objective:To provide a cumulative data about the complications of the operative treatment of acetabulum fractures in the literature with statistical methods and to sum up the influencing factors and preventive measures.
Methods:A comprehensive search for all relevant articles in the data base of Pubmed、Cochrane library、Web of Science、Biosis Previews and Chinese sci-tech periodical full-text database published in English and Chinese from January1,2001to December1,2012was conducted. A proportion meta-analysis across the studies was performed for the complications such as heterotopic ossification, serious heterotopic ossification, osteoarthritis, avascular femoral head necrosis, iatrogenic nerve injury, postoperative infection and deep venous thrombosis after acetabular operation with the use of R software.
Results:41articles were analyzed in this study, including9perspective studies and32retrospective observational studies with a total of3205patients. The specified complication rate in the relevant studies were homogeneity tested by the statistics of I2. There were34studies reporting heterotopic ossification with I2=92.6%,27studies reporting serious heterotopic ossification with I2=77.7%,29studies reporting serious osteoarthritis with I=81.0%,34studies reporting iatrogenic nerve injury with I2=76.9%,32studies reporting infection with I2=57.9%and20studies reporting deep venous thrombosis with I2=58.9%during which the random effect model was used for the I2>50%. There are27studies reporting avascular femoral head necrosis with I2=25.2%during which the fixed effect model was used for the I2<50%. The incidence of heterotopic ossification, serious heterotopic ossification, osteoarthritis, avascular femoral head necrosis, iatrogenic nerve injury, postoperative infection and deep venous thrombosis was20.1%(95%CI:14.6%to26.2%),5.3%(95%CI:3.2%to7.7%),15.2%(95%CI:11.8%to19.0%),5.6%(95%CI:4.6%to6.7%).5.1%(95%CI:3.3%to7.2%)、3.3%(95%CI:2.2%to4.7%) and1.4%(95%CI:0.4%to2.9%). The preventive effect of indomethacin is not of statistical significance with a P value greater than0.05.
Conclusion:The overall incidence of heterotopic ossification is as high as20.1%(95%CI:14.6%to26.2%), but the incidence of serious heterotopic ossification is just5.3%(95%CI:3.2%to7.7%) which grades more than Brooker III and really affects the clinical outcome of acetabular fractures. The major preventive methods of heterotopic ossification include low dose irradiation, diphosphonates and non-steroidal anti-inflammatory. The irradiation could affects rapidly dividing cells by altering DNA transcription and preventing osteoblastic precursor cells from multiplying and forming active osteoblasts, but this prophylactic method has a trivial procedure and obvious side effects with relatively inexact curative effect which limit its clinic application. Diphosphonates is negated by relevant researches and the preventive effect of indometacin is also not supported by the statics data for the difference of the incidence of heterotopic ossification between the groups is not of significance (P=0.08>0.05) which cause the gastrointestinal bleeding, renal insufficiency, renal toxicity, and delay fracture healing.
The leading cause of total hip arthroplasty is osteoarthritis and avascular femoral head necrosis. But the incidence of osteoarthritis and avascular femoral head necrosis was15.2%(95%CI:11.8%to19.0%) and5.6%(95%CI:4.6%to6.7%) with a sum percentage much more than the total hip arthroplasty rate during the follow-up which could be caused by the refusal of the less symptomatic patients and the possibility of data loss. So a longer and closer follow-up after the acetabular fracture operation is needs.
The overall incidence of iatrogenic nerve injury is5.1%(95%CI:3.3%to7.2%), but the relevant incidence of a specified iatrogenic nerve injury differs according to the approach which indicate the preventive methods should also change with the approach. In general keeping the joint flexed according to the direction of the nerve, severing carefully and gentle traction during the operation will do help avoiding the iatrogenic nerve injury.
According to our research deep venous thrombosis has the lowest incidence of1.4%(95%CI:0.4%to2.9%) among the common complications. But the data was only exactly accurate for the literature only recorded the symptomatic deep venous thrombosis and always ignored the asymptomatic ones. The actual incidence of deep venous thrombosis may be much larger than1.4%. Some researchers recommend the use of low molecular weight heparin during perioperative period with a good safety, but the data during this research is not enough to analysis its preventive effect.
The incidence of infection after the operation is3.3%, and is not unusual according to our research. The infection is related to the approach, injury severity, obesity and local traumatic condition. The treatment of infection is troublesome, always need a long time to recovery and has a relative worse outcome. Prophylactic method should be recruited to avoid the occurrence of infection.
引文
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