| Background:Acetabular fracture is a rare fracture, with the rapid development of China’s industrialization and modernization process, industrial buildings and traffic accidents, and natural disasters have increased every year in recent years, the number of acetabular fractures showed an upward trend, in which 74% of acetabular fractures due to high energy damage caused by traffic accidents caused by motor vehicles is the most important factor in acetabular fractures. Acetabular fractures, while often associated with other system damage, organ damage often leads to a large number of injured blood loss, which has long been associated injuries are often very complex gave clinical management and treatment of difficult, but potentially life-threatening. Acetabular fracture fracture morphology varied, complex three-dimensional anatomical structures, coupled with important nerves and blood vessels around the distribution, but also because of its location in the deep, so acetabular fractures revealed, open reduction and internal fixation of orthopedic trauma physicians are an enormous challenge.Acetabular fractures and clinical fractures of limbs in anatomical structures are very different, so the diagnosis, and a fixed reset method has its unique characteristics, the mastery of three-dimensional anatomical acetabular region, the correct diagnosis is to determine injury guide treatment especially surgical approach options and prognosis foundation. In addition to attention as check imaging and medical attention to the wounded symptoms are the same as required, its fracture diagnosis, classification and development of specific surgical plan is extremely important. In addition to attention as check imaging and medical attention to the wounded symptoms are the same as required, its fracture diagnosis, classification and development of specific surgical plan is extremely important. Pelvic anteroposterior X-ray film should, as a routine examination of the pelvis trauma, even taking into account the injured stable condition should also be added to Sign iliac oblique and obturator oblique (Judet series slices), although pelvic CT scan can reflect acetabular fracture displacement situation and the degree of compression, but also to determine whether the additional information within the relevant section of fractures. Anteroposterior pelvis and Judet oblique X-ray film is still accurately determine the classification of acetabular fractures gold standard. Matta use in 1986 Judet series presents top slice of arc angle based on the concept to cover Letournel & Judet classification only shows when the fracture site and does not indicate the degree of comminution deficiencies. For acetabular fracture top, four sides fractures, femoral head fractures and intra-articular loose bodies, etc., X-ray film is difficult to accurately assess, by reason of intra-articular fracture, to a detailed evaluation of acetabular fracture of CT examination is essential. Three-dimensional CT is the imaging diagnosis of acetabular fractures a major leap forward, to show the clarity and completeness of bone fractures in terms of three-dimensional CT imaging has other incomparable superiority. Acetabular fracture surgery classified as a first step, and it is understood that the fracture is an important element of injury, surgery is the first step in the plan. Currently the international classification of acetabular fractures are commonly used Letournel & Judet classification and AO classification two kinds. Acetabular fractures Letournel & Judet classification change from its anatomy to divide, so that it is easily understood and accepted, since 1961, first proposed in 1965 after some changes essentially unchanged, and has been widely accepted and applications. Tile is to design a common to various types of fractures common method Letournel & Judet divided improvements proposed acetabular fractures AO type, in order to facilitate data entry and statistical classification, each class has a single fracture mark character, fully reflects the relationship between the classification and surgical approach and reset programs.Before the late 1960s, because of acetabular fixation and difficult surgical exposure, surgical treatment is recommended literature rarely appears, when the complex acetabular fractures are basically non-surgical treatment, the prognosis is substantially better than the poor. Since 1964, Judet reported cases shows that for the bulk of its displaced acetabular fracture surgical repair to achieve a good reduction rate and a more satisfactory outcome, and is recommended for all acetabular fractures should anatomical reduction and internal fixation, in this after that, a lot of the literature have suggested that surgery helps to get good prognosis for non-surgical treatment did not meet all the criteria of acetabular fractures should be considered for surgical treatment, surgical treatment of acetabular fractures orthopedic surgeons become widely accepted concept. History of acetabular fracture surgery is still very far short of its surgical approach significant learning curve, and the operation is technically demanding. Due to the special nature of the acetabular anatomy, particularly the requirements of attending physician surgeon specializing in formal training. For acetabular fractures awareness has only 50 years of history, although more scholars believe that surgery can get the ideal outcome, but some scholars believe that conservative treatment can also get a good outcome. Whether conservative treatment or surgical treatment, most scholars advocate such a basic principle-to get long-term satisfactory results, the key lies in the femoral head and the acetabulum must have good alignment. Select acetabular fracture treatments sometimes still is very difficult, because both non-surgical treatment or surgical treatment, different scholars vary its efficacy evaluation.Clinical experience shows that factors influencing the prognosis of many acetabular fractures, injury before the existing basic conditions including age, bone, fracture type and degree, as well as nerves, blood vessels and other diseases associated injuries as well as injuries caused by the process, are not controllable factors, the relative, the selected surgical approach, surgical decision time, the surgeon’s skill reset, the degree of fracture reduction, stable or not, etc., since human intervention be classified as controllable factors. Reset mass acetabular fractures injured long-term effect is good or bad is the most important factor. Lowell and Rowe believes acetabular roof load, the femoral head injury, the degree of fracture reduction and fixation is solid, to a large extent determine the prognosis of surgical treatment, Letournet and Judet reported acetabular articular surface damage by surgical fixation after residual ladder than 2mm or not a decisive factor in the prognosis, unsatisfactory reduction fixation of the articular surface residue ladder than 2mm cases will be more likely to accept total hip replacement at a later stage. Related literature suggests, can achieve anatomic reduction time-dependent, difficult anatomic reduction over this period of time will be greatly increased. For complex fractures of the time it was 11 days, and about two weeks for simple fractures. Matta research shows that acetabular fractures due to the complexity of the three-dimensional complex anatomy, surgical treatment also had a learning curve, by his surgical repair of the early cases clearly illustrate the treatment with the accumulation of experience, improve satisfaction reset and good anatomic reduction rate.Displaced acetabular fractures pelvis must obtain satisfactory results by surgical reduction and fixation can effectively has become a consensus, and fully reveal the fracture and a good surgical field exposure restricts the surgery. Classic surgical approach there is trauma surgery, revealed insufficient for surgical procedures require high levels of disadvantage, in the course of several decades, although many scholars improved, but still no significant improvement. Selection and implementation of surgical approach not only directly affect the prognosis of acetabular fractures, but also as fixation quality and perioperative complications indirectly affect the treatment of the injured by other controllable factors. Correct choice of surgical approach is to obtain a good exposure of the fracture, satisfactory reduction, the most critical factor to achieve good efficacy. The choice of surgical approach is usually determined by the type of fracture. On the front pillar, front wall and side shift before the main recommendations of the transverse fracture by anterior surgery. Extended or combined approaches complications than single approach, trauma, anterior approach is more secure than posterior approach. For complex acetabular fracture, or if you can not shift after the column by anterior anatomical reduction, before a single anterior approach can be reset after column fracture, fracture of the anterior column reconstruction plate, posterior column fractures after column screw navigation template into force of screws anterograde assisted. Good surgical approach can be achieved in as little trauma as possible conditions for a broad view of exposure, trauma means that the probability of perioperative complications is reduced and the rehabilitation of patients with relatively good prognosis, and open operative field is to achieve a more satisfactory reduction in fracture prerequisite, therefore, surgical approach is directly related to clinical efficacy, is a hot development of the sector. Currently for acetabular surgery in the treatment of common front approach Ilioinguinal approach to (IIA), modified Stoppa approach (MSA) and Para-Rectus approach (PRA). Complications associated with surgery:postoperative infection; formation of deep vein thrombosis (DVT); sciatic nerve injury (iatrogenic); traumatic osteoarthritis (TOA) and heterotopic ossification (HO).The appropriateness of treatment of pain and universality is clinical go up to often be discussed problems in recent years, more and more attention of the clinical signs, the pain as the pulse, blood pressure, respiration and temperature after the fifth vital sign was put forward by the American Pain Society in 1995. To quantify the pain intensity in the whole process of diagnosis and treatment is also an effective treatment of pain in the first step and the key step has become an indispensable clinical diagnosis and treatment work in an important work. The trauma caused by pain in patients with pain assessment is a complex and painstaking work, pain is the subjective feelings of the patients of pain experience, there are very large individual differences, so the patient complained of very important, the correct understanding of pain is the first key step of the diagnosis and treatment of, some scholars put forward "the chief complaints of the patients in the control process of pain, for pain assessment is the first important part, of pain objectively correct assessment in the process of diagnosis and treatment of clinical pain disease has important significance. Clinical pain assessment methods commonly used are:visual analog scale score method, the digital quantity table score method, mask method, related studies have shown that, visual analog scale score and digital scale score method has higher correlation.The series of neuroendocrine responses, metabolic and internal environment disturbance, and tissue cell damage are important issues in the perioperative period. Creatine kinase (CK) is a main exist in skeletal muscle, myocardium and brain tissue or organ specific enzyme. It is widely distributed in tissues, in skeletal muscle was the highest and CK in ATP metabolism, play an important role in cellular energy metabolism, it can enough transformation of catalytic creatine phosphocreatine and stores it in the high-energy phosphate bonds of ATP. Normal serum has a certain amount of enzyme release, in muscle tissue trauma and post-traumatic secondary mediators of inflammation reaction, infection, necrosis, increased muscle cell damage or cell membrane permeability, CK release into the blood, the release speed is greater than the inactivation rate will cause elevated CK levels in the blood, the most common is trauma patients due to muscle injury caused elevation of serum CK and surgical trauma can induce muscle damage will make serum creatine kinase increased in varying degrees. And is closely related to the surgical site and the degree of trauma. Data suggest that, had no obvious change during the period of the activity of anesthesia and surgery, after the surgery elevated, to postoperative peaked on the 1 st day, general in 1 week after recovered normal wells, and tissue injury severity is proportional to, so clinical often to serum creatine kinase often to detect the degree of skeletal muscle injury index in clinical application. Creatine kinase activity as a sensitive indicator of tissue damage.Objective:This study by recording by single all fracture reduction and internal fixing cases of surgical exposure time and exposure process blood loss, by understanding the fracture reduction degree, postoperative pain score and complication incidence, through compared preoperative and postoperative serum creatine kinase values, estimated three anterior surgical approach to the organization of the degree of injury, after a follow-up of hip joint function, compared to in the treatment of acetabular fracture strengths, and to understand the learning curves of different approach operation, sums up its shortcomings, for the anterior approach for the treatment of displaced acetabular fracture to sum up experience and provide reference data and for the future operation mode selection and research provides the basis.Methods:Patients in Third Affiliated Hospital of Southern Medical University orthopedics and trauma in Huizhou First Hospital of orthopaedic trauma with treatment of single anterior approac were selected from June 01 2013 to February 28 2015. According to the preoperative damage control theory to condition stable. According to the inclusion and exclusion criteria, according to the surgical approach for the ilioinguinal approach group (IIA), modified Stoppa approach group (MSA) and lateral rectus approach group (PRA); all patients underwent pelvic anteroposterior X-ray, Judet oblique (obturator oblique, iliac oblique) and CT scan (plain scan and 3D reconstruction), the X-ray measuring top arc angle (Matta angle); intraoperative recording revealed time required for the fracture, by weight method and method of measuring end of exposure to attract blood loss and postoperative fracture; within 72 hours after pelvic oblique X-ray and Judet and CT scan (plain scan and 3D reconstruction), according to Matta imaging quality evaluation standard for evaluation reset reset; all cases were collected preoperatively and 24 hours venous blood samples were measured by substrate rate values of serum creatine kinase; after third days since the discontinuation of intravenous analgesia anesthesiologist 6 hours of pump start using pain visual analogue scale for the first time the degree of pain records. Later in the postoperative 2 weeks,1 month,3 months and 6 months were recorded pain intensity; postoperative full 1 year follow-up hip function was evaluated according to modified Merle D’Aubigne hip score form. At the same time record and the postoperative complications.Results:Each group of patients before surgery include general information (age, sex, time from injury to surgery, the incidence of associated injuries, etc.) were not significantly different. Compared to the amount of blood loss, ⅡA group was significantly higher than MSA and PRA group, the difference was statistically significant (P<0.05), whereas no significant difference between the group and the PRA group MSA bleeding; exposed fracture required surgery time ⅡA significantly higher than the MSA group and PRA group, the difference was statistically significant (P<0.05), whereas no significant difference between the group and the PRA group MSA bleeding; postoperative group ⅡA seen one case of lower extremity deep venous thrombosis 1 lateral femoral cutaneous nerve injury, have received appropriate treatment, while the MSA group and the PRA group no postoperative complications; postoperative Matta score comparison, the PRA and the appraised rate MSA group was significantly higher than ⅡA group, the difference statistically significant (P<0.05), MSA group and PRA group appraised rate no significant difference in scores Matta score quantitative results suggest that MSA and PRA group was significantly higher than ⅡA group, the difference was statistically significant (P< 0.05), MSA group and no significant difference in scores PRA group; postoperative hip function score results suggest ⅡA group was significantly lower than appraised rate and PRA MSA group was significantly higher than ⅡA group, the difference was statistically significant (P<0.05), MSA group and PRA group appraised rate, no significant difference in scores hip score quantitative results suggest that MSA and PRA group was significantly higher than ⅡA group, the difference was statistically significant (P<0.05), MSA group PRA group and no significant difference in scores; postoperative serum creatine kinase (CK) value prompt group IIA CK levels were significantly higher than MSA group and the PRA group, the difference was statistically significant (P<0.05), while MSA group and PRA group no significant difference in levels of serum CK; postoperative pain scores discovery group IIA pain score was significantly higher than higher than MSA group and PRA group, the difference was statistically significant (P<0.05), while the MSA and pain in patients with PRA group group Rating no statistical difference.Conclusion:MSA and PRA time of operative fracture appared, appared of operative blood loss, the extent of reduction fractures, postoperative pain scores and the incidence of complications was significantly better than the IIA, and in vivo serum creatine kinase after rising less than IIA tips MSA and PRA during surgery injuries and fractures and other than the IIA has obvious advantages. Comparative assessment of postoperative follow-up hip function, three approaches to understand the operation of the learning curve discovery, MSA and PRA maintain and restore function acetabulum has a positive effect, it is not difficult to see, MSA and PRA phase in terms of treatment of acetabular fractures there are obvious advantages compared IIA advantage, and PRA in fractures and bleeding and exposed fracture, also due to the MSA group. This results after anterior hip treatment of displaced acetabular fractures lessons and provide reference data provide the basis for future research and selection of surgical approach. |
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