楼主micro9112013-07-09 17:16:53看了一篇文献，与爱友分享，水平有限，谬误难免。体会是手头放着一本骨盆书，一个骨盆模型，逐句翻译一遍，加深了对骨盆双柱解剖的理解。爱友看看一些手术要点权当省了看书的力气。
Safe surgicaltechnique for associated acetabular fractures
复杂髋臼骨折的外科技术
Takashi Suzuki,1
Wade R Smith,2
Cyril Mauffrey,3
and
Steven J Morgan2
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Abstract
Associated acetabular fractures are challenging injuriesto manage. The complex surgical approaches and the technical difficulty inachieving anatomical reduction imply that the learning curve to achievehigh-quality care of patients with such challenging injuries is extremelysteep. This first article in theJournal’s
“Safe Surgical Technique” section presentsthe standard surgical care, in conjunction with intraoperative tips and tricks,for the safe management of all subgroups of associated acetabular fractures.
复杂髋臼骨折的处理极具挑战性。为了获得解剖复位而需掌握的复杂外科入路和技术难点意味着学习曲线极其陡峭。本文介绍了标准外科技术、术中要点和技巧、各型复杂髋臼骨折的安全管理。
Keywords: Acetabular fractures,Safe surgical technique, Acetabular fixation, Patient safety
Introduction
The anatomic reduction remains the rationale for thesurgical reduction and fixation of associated acetabular fractures, and is notdifferent from simple acetabular fracture patterns. However, the surgicalapproaches required, the ability to receive an anatomic reduction, and theapplication of rigid internal fixation techniques is more complex.
不管复杂还是简单的髋臼骨折，理论上都要求解剖复位内固定，这没有什么区别。只不过从外科入路、解剖复位技巧到坚强内固定技术都更加复杂。
Associated fractures, according to the Judet andLetournel classification [ 1], are comprised oftwo or more fracture lines that pass through the acetabulum and have complexgeometries. With the exception of associated posterior column posterior wallpattern, the remaining associated fractures involve both the anterior andposterior columns. Due to the extensive involvement of both columns, the use ofan extensile surgical exposure to visualize and reduce these fractures has beenpreviously recommended. Compared to either the anterior or posterior approach,extensile exposures are associated with increased morbidity with respect tooperative time, blood loss, infection, nerve injury, muscle weakness andheterotopic ossification. To minimize these complications a singlenon-extensile surgical exposure utilizing indirect reduction techniques haveevolved and are utilized for the treatment of certain associated acetabularfractures [ 2].
复杂髋臼骨折，按照Judet and Letournel分类，是指两条以上骨折线通过髋臼并有复杂的几何形状。除了后柱后壁骨折还包括前后双柱骨折。因为受累广泛，外科显露创伤大，相比较于单一前路或后路，广泛显露必然增加并发症风险，如手术时间延长、失血量增加、感染、神经损伤、肌力减退和异位骨化等。为了降低并发症，单一切口非广泛显露，间接复位技术已经可以用于某些复杂髋臼骨折。
The indications for surgical treatment are similar to thedecision making for simple fractures. Significant displacement of fracturesextending to the weight bearing dome of the acetabulum, incongruity of the hipjoint, and hip instability generally require operative management [ 3]. To determine theinvolvement of the weight-bearing dome, the technique for roof arc measurementdeveloped by Matta et al. [ 4, 5] is helpful, inaddition the assessment of the fracture relationship to the superior 10 mmof the acetabulum on axial CT scans corresponds to the roof arc measurementtechnique of Matta [ 4]. More recentlythe use of three-dimensional CT may provide a more accurate assessment of theinvolvement of the weight bearing subchondral arc of the acetabulum.
It is becoming clear that fractures of the acetabulumdespite anatomic or near-anatomic reduction can potentially lead to alteredstress distribution with the potential for the development of post traumaticarthritis. In some cases, displacement of less than 2 mm can be consideredfor nonoperative treatment and a reasonable outcome anticipated [ 3]. However, thiscriteria alone should not determine the surgical decision to operate withoutconsideration of other confounding factors that may influence the clinicalresult including but not limited to: the existence of loose bodies, gaps,fractures of the femoral head, and local soft tissue conditions. In certainsituations such as advanced age, patients other choices may be considered suchas primary arthroplasty or secondary arthroplasty following percutaneous screwfixation or limited exposure internal fixation [ 6].
手术指征和简单髋臼骨折相同：髋臼顶明显的骨折移位影响负重，髋关节不匹配，和髋关节不稳定。为确定负重区，Matta介绍的顶弧角技术很有帮助，CT扫描髋臼最高点下10mm的负重区，和Matta角配合使用做出手术指征判断。（注：更详细知识可以参考周东生骨盆创伤学第二版314-334）。三维CT扫描可以更加精确测量髋臼软骨下负重区，可更加容易判明髋臼骨折未解剖复位或近似解剖复位导致应力改变发展成创伤后关节炎的潜在可能性。通常，移位小于2mm可以认为无需手术也可得到满意结果。但是这一标准太简单而没有考虑其它一些影响临床结果的因素，包括但不限于
游离体存在、缺口、股骨头骨折和软组织状况。其它因素如老年人、病人放弃复位固定而选择关节成形，或经皮螺钉固定及有限切开内固定后二期关节成形。
These are difficult fractures and the surgeon’sexperience level should also be taken into consideration when consideringoperative fixation, as experience often increases the likelihood of the surgeonobtaining an anatomic or near anatomic reduction. Regardless of surgeonexperience, one must have a good understanding of the three dimensional anatomyof the pelvis and acetabulum, the fracture configuration and be comfortablewith the techniques, and equipment required to treat these injuries. It must berecognized that the prognosis is poor for patients who receive an inadequatesurgical reduction when compared to those who are treated conservatively withsimilar fracture displacement [ 7].
对于一些困难的骨折，医师的经验相当重要，经验丰富的医师自然获得解剖复位的可能性就高，当然，不管经验是否丰富，必须彻底理解骨盆和髋臼的三维解剖，熟悉骨折形态和复位技巧，熟练使用复位器械。必须认识到，骨折复位是否理想关系到预后好坏。
Surgery for these fracture patterns should be performedunder ideal circumstances with an experienced supporting ancillary staff ofnurses, anesthetists, and scrubbed assistants. In general acute surgery withinthe first 48 hours of injury should be avoided in most cases to preventexcessive bleeding associated with the acuteness of the injury. In generaloperative fixation in the first three weeks following injury is satisfactoryand does not lead to an escalation in surgical care or expansion of thesurgical approaches required to achieve reduction [ 7]. It is clear,however, that the fracture reduction and associated co-morbidity with delayedsurgery is avoided when surgical reduction and fixation is performed in thefirst 5 to seven days following injury. Surgical delay beyond three weeks isassociated with a diminished prognosis secondary to organization of the fracturehematoma, soft tissue contracture and callus formation [ 7].
理想的情况下，髋臼手术应当由一个经验丰富的团队进行，包括护士、麻醉和器械助手。一般伤后48小时内进行的急诊手术主要是防止大出血，伤后3周内手术内固定比较从容无需担心因追求复位而加重创伤或扩大显露。很明显，伤后5-7天复位内固定比较好尽量避免延迟。如果手术推迟至3周之后，因骨折血肿机化、软组织挛缩和骨痂形成而降低术后预期。
The perioperative planning and set-up may take intoaccount a number of variables that depend on surgeon experience and preference.The universal use of a traction table is still controversial. Certainly theintraoperative traction of affected lower extremity is essential, but tractiontable devices may limit full motion of the extremity and prevent visualizationin some positions either directly or with fluoroscopy. Alternatives to the useof the fracture table include intraoperative placement of a Schanz pin into theproximal femur for manual distraction of the joint. Intraoperative fluoroscopy isusually recommended to confirm the adequacy of the reduction, andextra-articular placement of the fixation.
围手术期计划每个医生的经验和喜好不同可以有变化。比如是否应用牵引床是有争议的，虽然伤侧下肢术中需要牵引，但是牵引床限制肢体活动必然影响一些体位下的术野显露和X光透视。变换一下骨折牵引方法可以改为股骨近端斯氏针牵引，为了确保精确复位和固定物不进入关节，术中透视肯定是必须的。
The lateral view is the most effective view to confirmthat the hardware is extra-articular. More importantly with the x-ray beamoriented in a linear array with the screw, extra-articular placement can alwaysbe confirmed or denied on this alone. Additionally, ranging the hip jointintraoperatively and checking the range of motion would help to findintra-articular screw misplacement, remaining instability, and malreduction ofthe fragments.
确定金属位于关节外的最有效方法是观察侧位，X线顺螺钉方向照射可以确定是否进入关节。每上一颗钉或一根针都要明确是否在关节外。另外，术中活动髋关节可帮助发现螺钉误入关节、骨折不稳定和复位不良。
Associatedposterior column and posterior wall fractures
后柱和后壁骨折
Take home message for safe surgical technique
看家招数
·Prone or lateral positioning; the patients’ hipshould be extended and the knee flexed to reduce tension on the sciatic nerve
俯卧或侧卧位，患侧伸髋屈膝减轻坐骨神经张力
·Prone positioning will allow mechanicaltraction and facilitate reduction through gravity. External rotation of the hipwill be possible, facilitation the reduction of a displaced posterior wallfragment.
俯卧位有助于利用重力牵引和复位，髋关节外旋有助于后壁骨块复位。
·Retractors placed in the sciatic notchesshould be released as often as possible to prevent lengthy compression againstthe sciatic nerve
放置在坐骨切迹的牵开器要经常松开以免持续压力损伤坐骨神经。
·Posterior wall capsular attachments should bemaintained to prevent devascularization
后壁骨瓣关节囊附着应予保护以防失血供。
·The superior gluteal neurovascular structurescan be injured from excessive retraction of the abductor muscle mass. It isrecommended to not use a very long plate and to keep the hip abducted (2 screwsproximal and distal to the hip joint are usually sufficient)
过度牵开外展肌有损伤臀上神经血管之虞，建议不要用太长钢板并维持髋外展（髋关节远近端各2枚螺钉足够了。）
·Always confirm that no screws are penetratingin the hip joint by using Judet views, if in doubt, reposition the screws in adifferent angle
Judet 位（即骨盆双斜位）观察一直确保没有螺钉打入关节，如果怀疑干脆换个角度重新打入螺钉。
Surgical approach and patient positioning
入路与体位
This is the only associated fracture that does notinvolve both anterior and posterior columns and is best visualized utilizingthe Kocher-Langenbeck approach. The patient can be positioned lateral or prone.Lateral positioning on a radiolucent table has the advantage of not requiringthe use of a fracture table or the unfamiliarity of operating in the prone position.Reduction aids like a femoral distractor or manual traction can aid in thereduction of the fracture or visualization of the joint. The main disadvantageof this technique is the unreliable nature of the manually applied traction,the potential for undue 过度tension on the sciatic nerve and the increased risk ofsciatic nerve injury. Another major challenge to reduction is related to thepersistent displacement of the posterior column as the result of gravity thatcan not be eliminated in this position. Prone positioning in traction offersthe main advantage of gravity elimination and aids in the reduction of theposterior column [ 8]. The leg can beheld flexed at the knee and extended at the hip to avoid traction on thesciatic nerve greatly reducing the chance of nerve injury. Controlled lateraltraction can also be applied to help visualize the joint surface through thewindow of the posterior wall fracture after the posterior column has beenreduced [ 9].
这是复杂髋臼骨折中唯一没有前后柱均受累的，最佳显露是K-L入路，病人可以侧位或俯卧位，侧卧在可透视床上有两个优势，一是不需牵引床二是避免俯卧位不熟悉。股骨牵开器或人工牵引下肢可以帮助骨折复位和看清髋关节。主要缺点是助手牵引并不可靠，过度牵拉可致坐骨神经损伤，另一个主要缺陷是侧卧位时后柱顽固性移位因为地心引力作用难以复位。俯卧位的主要优点恰恰是因为地心引力作用消失后柱复位容易。下肢伸髋屈膝避免牵拉坐骨神经大大降低神经损伤机会。后柱复位后通过牵引股骨近端外侧可以从后壁骨折窗口观察关节面。
Operative procedure
手术操作
Reduction of the posterior column fracture provides for astable surface to reduce the posterior wall fracture. Thus, the posteriorcolumn fractures should be addressed first. Following the surgical approach andexposure of the retroacetabular surface and the lesser and greater sciaticnotches including the ability to digitally palpate the quadrilateral surface,reduction of the posterior column can be undertaken. Care must be taken withretraction of the sciatic nerve. During this procedure retractors should beremoved or retraction relaxed frequently to allow the nerve to have periodsthat are tension free. When work on the fracture surfaces is not beingundertaken, the retractors should be released. Inexperienced assistants may notrecognize this necessity, and it is incumbent on the operative surgeon to makesure this occurs. The fracture is generally displaced medially and rotated onthe soft tissue attachment in the area of the ischium.
先把后柱骨折复位，后壁骨折块就有了稳定的落脚点。通过手术入路可以显露髋臼后壁、大小坐骨切迹并触摸到四方区表面，完成后柱复位。一定要避免对坐骨神经的持续牵拉和压迫，间歇松开拉钩。不处理骨折块时拉钩放松，没经验的助手可能意识不到这一点，主刀医师有义务提醒。由于坐骨周围软组织牵拉，骨块一般向内侧移位旋转。
Rotational control can be obtained by using a 5 or6 mm Schanz screw inserted into the ischium. A universal T-handle can thenbe attached to the Schanz pin to serve as a handle to assist in derotating thecolumn and to some extent reducing its medial displacement. The superior aspectof the fracture following derotation can be potentially reduced with severaldifferent types of clamps including the angled jaw clamp, a Weber clamp, or aFareboeuf clamp placed directly perpendicular to the fracture line.Alternatively, a bone hook can be introduced through the notch to reduce thefracture, but it requires continuous traction pending placement of a lag screwor a clamp. If these reduction maneuvers fail, the reduction can be obtainedusing Faraboeuf or Jungbluth clamps applied by means of temporary screws, whatis called the two-screw technique (Figure 1).The former is particularly helpful in reducing gap displacement with minimalrotational abnormality while the later is useful for both significantmedialization, rotational and gap displacement. The problem with the clamps andtheir increasing size is the difficulty they present with the introduction ofplate fixation or lag screw placement secondary to the occupation of theavailable operative space by these tools. The reduction is confirmed by digitalpalpation触诊of the quadrilateral surface and the greater sciatic notch. The intra-articularsurface may be directly visualized by reflecting the posterior wall fragmentsin continuity with the joint capsule and by distracting the hip joint. Byinternal rotation, the hip may be re-dislocated and washed off all smallfragments of debris. After posterior column reduction, stabilization isachieved with a short 3.5 mm reconstruction plate positioned near thegreater sciatic notch. A 3.5 mm lag screw from the posterior columnthrough the fracture line alongside the deep aspect of the quadrilateralsurface may facilitate the removal of clamps and maintenance of the reductionduring the subsequent plate fixation.
直径5-6mm Schanz螺钉
插入坐骨控制旋转，斯氏针安上通用T型把手可以矫正后柱旋转移位，选择不同型号骨盆复位钳（angled jaw clamp弯钳, a Weber clamp, or aFareboeuf clamp）垂直于骨折线反向旋转合拢复位骨折。或者用骨钩持续牵拉坐骨切迹复位，缺点是上螺钉或复位钳之前你不能松骨勾。如果这些复位手法还不行，可以Faraboeuf 或 Jungbluth钳（国内叫螺钉复位钳），即用两螺钉技术（图1）。此技术非常有效纠正旋转缩小缝隙，Jungbluth钳比Faraboeuf钳能力更强大。缺点是复位钳占据了有限的手术野影响钢板螺钉安放。手指触摸四方区和坐骨大切迹确定骨折复位，牵引关节通过髋臼后壁骨折块直视下检查髋关节内部，内旋关节致再脱位，冲洗掉关节内碎屑。后柱复位完成，短3.5mm重建板放置于坐骨大切迹，3.5mm拉力螺钉从后柱过骨折线达四方区深面以便撤掉复位钳方便钢板固定。
Figure 1
Temporary two-screwtechnique to facilitate fracture reduction using a Faraboeuf or Jungbluthreduction clamp.(A) Screws applied along with the greatsciatic notch in order not to preclude plate placement. (B) Intraoperative view of screws and clamp. ...
图1 临时两螺钉技术复位骨折A螺钉沿坐骨大切迹放置以免影响钢板安放，B术中视图螺钉和复位钳
The second step is the reduction of the posterior wall.Throughout the procedure, care must be taken to preserve the capsularattachment to all posterior wall fragments to avoid excessivedevascularization. A suture can be placed in the capsule to facilitateretraction and visualization of the posterior column reduction. The tractionshould be released and the femoral head is used as a template for the reductionof the posterior wall fracture. Marginal impaction, when present, requireselevation of the articular surface by a curved chisel or osteotome withadditional support obtained by bone grafting the void left following elevationof the impacted segment. The autologous bone graft can be obtained from the greatertrochanter. Free pieces of articular surface should then be relocated inappropriate position utilizing the femoral head as a guide. The main wallfragments can then be correctly reduced with the ball spike pusher, followed byprovisional fixation with K-wires. Fixation should consist of buttress platingwith the adjunctive lag screw fixation when fragment size is sufficient. Lagscrews alone do not provide sufficient stabilization. A 3.5 mmreconstruction plate, or acetabluar specialty plates are the traditionalimplants of choice for buttress fixation. If the fragments are comminuted,small or very peripheral then a spring plate can be applied (Figure 2).This is achieved by cutting a one-third tubular plate through the end hole andplacing it over the fragment. The spring plate is slightly over-contoured sothat when the reconstruction plate is applied over the spring plate, thecaptured fragments are held firmly in position. Application of the buttressplate requires the distal portion of the plate to extend low enough on theischium to permit the most distal screw to be placed into the ischiopubicramus. Screw placement in the central area of the posterior column is avoidedto prevent intra-articular placement. Generally, 2 distal screws and 2 proximalscrews are sufficient for adequate buttress fixation. Visualization of theproximal part of the plate by muscle retraction may be obtained by carefulplacement of a Hohmann retractor hammered into the intact ilium. However, thesuperior gluteal neurovascular structures can be injured from excessiveretraction of the abductor muscle mass. It is recommended to not use a verylong plate and to keep the hip abducted. At the end of the operation, it isadvisable to check for intra-articular screws by both moving the hip whilelistening for audible crepitance and by using fluoroscopy.
Figure 2
Schematic drawing onthe use of spring plates.
(A) One third tubular plate placed over the posterior wallfragments. (B) A spring platepushes and holds fracture fragments which are deemd to small for fixation witha screw. The plate must be oriented ...
弹性板示意图：A1/3管型板放置在后壁。B弹性板拉住骨块。
第二步是复位后壁，操作过程应保护骨块上面关机囊附着以免破坏血供，关节囊上缝合牵引线以便观察后柱复位。松开牵引线以股骨头为模板复位后壁骨块，如有边缘嵌压，用一把弯曲骨刀撬起关节表面骨瓣弥补空虚，也可从大转子取自体骨瓣。游离骨块以股骨头为模板仔细复位。较大骨瓣复位后用球头顶棒维持克氏针临时固定，全部后壁复位用弧形板螺钉固定，单独螺钉固定不稳定。3.5mm重建板或髋臼专用板是常用材料，如果后壁边缘有小的碎骨块，可用小弹性板固定（图2）。弹性板可用1/3管型板尾孔修剪制备，弹性板轻微过度塑形以便重建板覆于其上，螺钉拧紧施压使其抓牢骨瓣。弧形重建板远端要延伸至坐骨，螺钉打入耻坐骨支。螺钉放置后柱中心区以免进入关节。一般来说，弧形板远近端各两枚螺钉足够。钢板近端部分要用Hohmann拉钩牵开肌肉直视下固定在髂骨上。过度牵拉外展肌群有损伤臀上神经血管风险，因此不宜用过长钢板，并保持髋外展。结束手术时要检查螺钉是否进入关节，活动髋关节倾听声音并透视检查。
Tips and tricks 要点和技巧
The two posterior plates should be separated from eachother as far as possible as the close placement of these two plates precludesnot only the sufficient buttress effect on the posterior wall fragments butalso the attainment of sufficient mechanical strength of the posterior column fixation(Figure 3).It is especially important to place the buttress plate accurately over the mainportion of the posterior wall fragment and just outside the margin of the hipjoint. A slight undercontouring of this plate will direct compressive forcesacross the fragment and can buttress the entire posterior wall firmly.
两块弧形重建板尽可能分开放置，不仅要支撑后壁而且要使后柱固定获得足够强度。（图3）特别强调弧形板放置髋臼边缘跨越后壁主要区域，钢板塑形稍欠可以施加更大压力使后壁更稳定。
Figure 3
Example of anassociated posterior column and posterior wall fracture treated with two3.5 mm reconstruction plates.
(A-C) Preoperative X-rays (a.p., obturator oblique, iliacoblique). (D-F) PostoperativeX-rays (a.p., obturator oblique, iliac oblique)
Associatedanterior column and posterior hemitransverse fractures
前柱和后半横行骨折
Take home message for safe surgical technique
看家招数
·Safe positioning of the patient in the supineposition with option for traction of the affected extremity is recommended.
推荐仰卧位，伤侧肢体自由牵引。
·The ilio-inguinal or modified Stoppaapproaches are valid options. The latter approach when the anterior columnfracture is low and does not involve the iliac wing.
髂腹股沟入路或改良Stoppa入路可选，当前柱骨折位置低不包括髂骨翼时后路。
·Structures at risk during the Stoppa approachinclude the obturator vessels and nerve (because of their direct contact toquadrilateral surface) and the iliolumbar vessels. A corona mortis is alsopresent in 10-30% of cases and is at risk during both the Stoppa and the medialwindow of the Ilio-inguinal approach.
Stoppa入路时闭孔血管神经（其直接接触四方区）和髂腰血管有风险，Stoppa入路和髂腹股沟入路的中间窗10-30%病例能见到死亡之冠。
·Reduction technique should proceed in acentripetal direction, towards the articular surface.
朝关节面方向复位骨折块。
This fracture pattern is comprised of an anterior columnfracture with an additional posterior half of a pure transverse fracture. Thispattern may be considered as an atypical or transitional fracture from T-shapedto both column fractures. In general the posterior column portion of thefracture remains non or minimally displaced, and the displacement of thefemoral head is associated with the position of the anterior column. Theoperative treatment is less difficult than that of a both column or T-Typefracture, and the surgical approaches are generally anterior.
前柱和后半横行骨折，可以认为是不典型T型骨折或T型到双柱骨折的过度型。一般来说，后柱部分没有或轻微移位，股骨头位置随着前柱走，手术比双柱和T型骨折要容易，入路一般选前路。
Surgical approach 入路
These fractures are best fixed utilizing an anteriorbased surgical approach. Of the anterior approaches, the ilioinguinal approachis usually used. If there is one large fragment comprising the anterior part ofthe iliac wing and the distal fracture line exists around the iliopectinealeminence, the iliofemoral approach can be utilized. The modified Stoppaapproach can be utilized, when the anterior column fracture is low and does notinvolve the iliac wing. In general, however, this fracture pattern of theanterior column in this grouping is rare and the modified Stoppa rarelyutilized [ 10]. The patient canbe placed supine on a fracture table or supine on a radiolucent table. Skeletaltraction via the distal femur and lateral displacement traction via theproximal femur utilizing a fracture table or manual traction will help aid thereduction process.
The Swiss group from Berne[ 11] has recentlydescribed a case series of 20 patients treated with a single para-rectal extra-peritonealapproach. This approach involves dissection of the external iliac vessels, theinferior epigastric vessels, and the spermatic cord or round ligament with fiveseparate windows described allowing full exposure of the quadrilateral plate andan intra-articular view through the displaced fracture of the quadrilateralplate.
此骨折最常用前方入路，其中以髂腹股沟入路最常见。如果骨折块包含大部髂骨翼，远端又延伸到髂耻隆起，则可选髂股入路。若前柱骨折位置低又不含髂骨翼，也可用改良Stoppa入路。一般来说，若骨折不是以前柱为主则改良Stoppa入路也很少用到。病人取仰卧位置于骨折床或可透视床，股骨远端和股骨近端外侧牵引帮助复位。瑞士人Beme介绍了20例用腹膜外直肠旁入路，需要解剖髂外血管和腹壁下动脉，精索或圆韧带，分5个窗口，完全显露四方区并通过四方区骨折线观察关节内。
Operative procedure
手术操作
The reconstruction of the anterior column begins with thereduction of the iliac fragments to portions of the intact pelvis, proceedingsequentially toward the articular surface. The anterior column is usuallyexternally rotated and the reduction is initiated by derotating the anteriorcolumn with a ball spike pusher placed just above the pelvic brim on the distalto middle aspect of the inferior portion of the anterior column fragment. AFaraboeuf clamp can be placed at the iliac crest or between the anterior superiorand inferior iliac spines to further assist in the derotation of the anteriorcolumn. The first point of reduction should occur at the iliac crest. A smallwindow in a subperiosteal fashion is developed so digital palpation of theouter table of the iliac wing can be performed. A pointed reduction clamp cancompress the iliac crest together at the fracture line. When significantpurchase cannot be obtained, the grip of the reduction forceps can be improvedby drilling two separate holes on either side of the fracture for the clamptips. Alternatively, a Faraboeuf clamp placed on the iliac crest after twoscrews are placed parallel to the fracture line can be utilized to obtain thesame goal. Once the iliac crest is stabilized, compression at the pelvic brimfracture line and final reduction can be obtained by placing a small angled jawclamp across the fracture line typically via the second window of theilioinguinal exposure. An alternative to clamp placement is final reductionwith the ball spike pusher at the level of the pelvic brim and provisionalfixation with divergent K-wires. Internal fixation is commenced at the iliaccrest. The fracture line at this level can be stabilized by using one or two3.5 mm lag screws placed between the tables of the iliac crest. If innertable screws are not possible a pelvic reconstruction plate can be contoured tothe inner table of the crest, or the crest itself, and fixed with bicorticalscrews. Placement of the plates directly on the crest is generally avoided secondaryto the associated hardware irritation that becomes prevalent with timeespecially on the anterior aspect of the iliac crest. Lag screw fixation mayprovide more stable fixation than a 3.5 mm reconstruction plate applied tothe iliac crest alone [ 12]. Fixation shouldthen proceed closer to the pelvic brim. Some fracture patterns lend themselvesto screw fixation alone. An additional inner table screw can be placed frombetween the anterior superior and inferior iliac spines towards the sciaticbuttress. Assuming the posterior hemitransverse component remains reduced, anadditional two screws are then placed form the pelvic brim superior to theacetabulum directly in to the posterior column and when possible in to theischium passing between the acetabulum and the greater and lesser sciaticnotches. If the posterior column requires reduction, it can be reduced asdescribed below prior to placement of the lag screws. In good quality bone witha high anterior column component this amount of fixation is likely sufficientand plate fixation can be avoided. If the posterior column requires furtherreduction, a single screw can often be placed from the anterior column at thelevel of the posterior aspect of the pelvic brim to the area of the sciaticbuttress avoiding the anterior column. Alternatively, the anterior column canbe buttressed with a long 3.5 mm reconstruction plate, which is usually 12to 14 holes long. This is contoured along the pelvic brim, across theiliopectineal eminence to the pubic tubercle and the body of the pubis.Cortical screws are then placed in the area of the sciatic buttress aiding inthe reduction of the anterior column. Additional screw fixation is avoideduntil the posterior column is reduced. The symphysis should not need to beroutinely incorporated in to the plate construct. It is essential that theplate be perfectly contoured; otherwise, tightening down the plate may resultin malreduction of the column fracture. It is essential that screws do notcapture a malreduced posterior column, preventing further reduction.
前柱复位是将髂骨快向关节面靠拢，用一球形顶棒置于前柱骨折远端骨盆边缘，向内侧面推压纠正向外旋转移位，Faraboeuf钳置于髂骨脊或者髂前上下棘之间反向旋转前柱。复位第一步从髂嵴开始，骨膜下开一窗手指触摸髂骨翼外板，确定一钳夹点可以向骨折线施加压力。如果效果不好，可以在骨折线两边钻孔以增加复位钳抓握力。或者上两颗螺钉用于复位钳抓握合拢。一旦髂嵴稳定了，骨盆缘骨折线加压，同时，通过髂腹股沟入路第二窗口用一把带角度复位钳（大、小球端弯钳）可以完成余下的复位。或者是用尖头球形顶棒在骨盆缘加压完成复位。立刻用交叉克氏针临时固定前柱。正式内固定也是从髂嵴开始的，一到两枚3.5mm长螺钉髂板内固定骨折。如果内板破坏不允许螺钉固定则在髂嵴内面用重建板，塑形后沿髂嵴或髂板放置，螺钉穿透双皮质固定。现在都喜欢直接在髂嵴前面放置重建板以防止内固定物刺激反应。螺钉固定比3.5mm重建板固定髂嵴还要稳定。髂嵴固定完成继续固定骨盆边缘，某些骨折块用单独螺钉固定即可，可以附加内板螺钉从髂前上棘和髂前下棘朝向坐骨支打入。假如后半横行骨折块还未完全复位，用两枚螺钉从髋臼上方骨盆缘打向后柱，途经髋臼和坐骨大小切迹之间进入坐骨。若后柱需要复位则在打入这两枚螺钉之前完成。如果病人骨质较好前柱骨折块位置较高则这些固定就应该足够了，可以不用钢板固定了。如果后柱还需要进一步复位，用一枚螺钉从前柱平骨盆缘向后方坐骨区域打入避开前柱。还有一个方法，前柱用12-14孔3.5mm重建板沿骨盆缘跨过髂耻隆起到耻骨联合。皮质骨螺钉打向坐骨支复位前柱，后柱复位完成再上其余螺钉。钢板固定一般不需过耻骨联合。钢板需要完美塑形，但钢板过紧下压可能会引起柱的复位丢失，注意螺钉不要上在复位不良的后柱上，影响进一步复位。
The next step is the reduction of the posterior column.If the hemitransverse fracture line is located low, the posterior column isalready reduced or slightly displaced and may be neglected after the reductionof the anterior column. If the fracture line is high, it is not automaticallyreduced. When using ilioinguinal approach, the reduction should be indirectthrough the first or second window. The displaced posterior column is usuallyrotated internally and the reduction may be possible with the jaws of anasymmetrical clamp applied, between the outer surface of the anterior inferioriliac spine and the other on the quadrilateral surface attached to theposterior column (Figure 4).A small bone hook or coaxial pelvic clamp, gently slid down the quadrilateralsurface, can help with manipulation of the posterior column. The reduction ismaintained by 3.5 mm screws which can be inserted from the posterior ormiddle third of the upper aspect of the pelvic brim, either apart from theplate or through the holes of the plate (Figure 5).These screws start at the pelvic brim superior to the acetabulum and aredirected from proximal to distal into the posterior column paralleling thequadrilateral surface, aiming for the ischial spine. The screw length isusually more than 80 mm and often up to 110 mm. Care must be taken toavoid intra-articular placement of these screws; therefore, it is important toappreciate the location of the acetabulum relative to the fixed pelviclandmarks, that is, inferior to the anterior inferior iliac spine and under theiliopubic eminence. Additional fixation of the plate to the pubic symphysis cannow be undertaken completing the case.
下一步是后柱复位，如果后半横骨折线较低，前柱复位完成后，后柱基本复位或有轻度移位则可忽略不做处理。若骨折线较高，又没有自动复位，可以通过髂腹股沟入路的第一第二窗口间接复位。后柱通常有内旋移位，可以用不对称骨盆复位钳夹住髂前下棘和四方区向后柱靠拢（图4）。一把小号骨勾或者同轴复位钳（枪式复位钳）轻柔下压四方区帮助复位。用一枚3.5mm螺钉从骨盆缘近端中后1/3经重建板或者不经重建板（图5），平行于四方区插向后柱，瞄向坐骨棘。螺钉长度通常80-110mm.小心不要进入关节内，因此，精确鉴别髋臼与骨盆缘界标，找准进钉点非常重要，即髂前下棘下方和髂耻隆起下面是髋臼。视情需要附加钢板固定耻骨联合现在可以进行了。
Figure 4
Asymmetric pelvic reduction clamp (A).Intraoperative view using the asymmetric clamp (B).
Figure 5
Schematic model oflag screw positioning from the pelvic brim directed to the posterior column.
Small fragment (3.5 mm) corticalscrews are usually used at a length of more than 80 mm.
从骨盆缘向后柱打入螺钉示意图。通常超过80mm长。
Tips and tricks
要点和技巧
After the reduction of the anterior column, instead ofK-wires, 6.5 to 7.5 mm cannulated screw placement from the anteriorinferior iliac spine though the iliac fracture site toward the superiorposterior iliac spine can provide sufficient stability during the reduction ofthe posterior column (Figure 6).This screw fixation was first reported for iliac wing fractures of the pelvicring, but is also useful for the fixation of the acetabular fractures thatinvolve the anterior column. Its position in the ilium is checked usingintraoperative fluoroscopy on both the inlet-obturator oblique view and on theiliac oblique view [ 13] (Figure 7).
前柱复位后，6.5到7.5mm的中空螺钉从髂前下棘过骨折线向髂后上棘拧入，后柱可获得足够稳定（图6）。螺钉固定方法首见于骨盆环髂骨翼骨折，其实也同样可用于前柱受累的髋臼骨折。术中透视闭孔斜位和髂骨斜位检查螺钉在髂骨中的位置（图7）。
Figure 6
Example of ananterior column and posterior hemitransverse fracture treated through amodified ilioinguinal approach, using 3.5 mm reconstruction plates and a7.3 mm cannulated screw.
(A-C) Preoperative X-rays (a.p., obturator oblique, ...
前柱和后半横行骨折病例，改良髂腹股沟入路，3.5mm重建板和7.3mm中空钉应用。
Figure 7
Intraoperative fluoroscopicimages of cannulated screw placement from the anterior inferior iliac spinetoward the superior posterior iliac spine.
(A) Inlet-obturator oblique view. (B) Iliac oblique view.
放置中空螺钉术中透视图，从髂前下棘穿向髂后上棘。A闭孔入口斜位。B髂骨斜位。
Associatedtransverse and posterior wall fractures
横行加后壁骨折
Take home message for safe surgical technique
看家招数
·The safety and choice of approaches isdetermined by the location of the transverse fracture: infra-tectal（负重区？） fractures can be dealt with via a KLapproach while juxta and trans-tectal will require anatomical reduction usuallyvia an anterior approach.
入路选择取决于横行骨折位置：覆盖层下方骨折可选K-L入路，靠近或经覆盖层骨折需要前方入路。
·Lateral decubitus will allow for a twoincision technique
侧卧位可以兼顾双切口。
·The sciatic nerve is at risk, especially whenattempting an indirect reduction of the anterior fracture line through a KLapproach
当KL入路试图间接复位前方骨折线时，小心坐骨神经
·When fixation of the transverse component isdone through a posterior to anterior screw (anterior column screw), overpenetration of the anterior column (anteriorly) with the drill or screw candamage the femoral neuro-vascular bundle or the external iliac vein or arteryif the over penetration is through the superior cortex of the anterior column.Iliac and obturator oblique (Judet) views are crucial during this process.
从后向前打入前柱螺钉时，穿过前柱的钻头或螺钉有损伤股神经血管风险，若穿过前柱上方皮质有损伤髂外动静脉风险。操作中髂骨斜位和闭孔斜位观察非常关键。
The association of a transverse fracture with a posteriorwall fracture is not uncommon. The position of the transverse component of thefracture in relationship to the weight-bearing dome of the acetabulum willdictate the surgical approach and the subsequent positioning of the patient.
横行加后壁骨折并不罕见，横行的骨折块部分关系到髋臼负重区需要考虑手术入路和体位。
Surgical approach
手术入路
The presence of a posterior wall fracture will alwaysrequire the use of a posterior approach but this alone does not necessarilypreclude the use of the anterior approach. Infratectal transverse fractures canbe treated with a posterior Kocher-Langenbeck approach alone. Transtectal andjuxta tectal fractures require anatomic reductions for optimal outcomes [ 14, 15]. While many ofthese can be treated utilizing the posterior Kocher-Langenbeck approach, somemay benefit from the use of an extensile incision or two incision technique toinsure anatomic reduction of the anterior portion of the transverse componentof the fracture. This can be facilitated by utilizing a two incision approachto acetabular reduction and fixation, or the use of the extended illofemoralapproach [ 16]. Secondary tothe morbidity of the extended illiofemoral approach the authors prefer asimultaneous two incision approach in the lateral position.
后壁骨折当然毫无疑问需要后侧入路，但并不排除有时需要前方入路。横行骨折在覆盖区下方需要后侧KL入路。经覆盖区骨折和靠近覆盖区骨折要求解剖复位，有时可以KL入路，有时则需要扩大的前方入路或双切口技术。扩展的髂股入路和双切口技术才能完成髋臼复位固定。因为扩展的髂股入路并发症多，作者更愿意使用侧卧位双切口入路。
Operative procedure
手术操作
These fractures are best treated by approaching thereduction of the transverse fracture first, utilizing the posterior wallfracture as a window to the joint to directly visualize the quality of thereduction, before fixation of the posterior wall fracture.
首先要完成横行骨折的复位，后壁骨折正好作为观察关节内复位好坏的窗口，最后再复位。
The reduction is carried out in a fashion similar to thatin a posterior column fracture. The inferior fragment is manipulated by theappropriate pelvic clamps while rotation is controlled by a Schanz screwinserted into the ischial tuberosity. Traction of the affected lower extremitycan help this manipulation. The reduction is temporarily maintained by aFaraboeuf or Jungbluth clamp using a two-screw technique (Figure 8).The anterior reduction is confirmed by digital palpation of the quadrilateralsurface to the iliopectineal line. If the anterior column is still displaced,then it is likely due to rotation of the fragment and not from simple inwarddisplacement. This is corrected with a Schanz screw or an angled pelvicreduction clamp, with one jaw on the proximal intact ilium and the other jawthrough the greater sciatic notch placed on the quadrilateral surface justbelow the pelvic brim of the anterior column (Figure 8).During this process, the sciatic nerve should be monitored and undue tensionavoided. If reduction of the anterior column portion of the acetabulum is feltto be less than satisfactory, an anterior approach utilizing either theillioinguinal or illiofemoral exposure can be employed. The anterior portion ofthe fracture can be directly visualized and generally reduced utilizing a ballspike pusher, Faraboeuf clamp, or antiglide plate.
和后柱骨折复位大体相同，Schanz螺钉拧入坐骨结节纠正骨折成分的旋转移位，合适的骨盆复位钳完成复位。伤侧下肢牵引可以辅助操作。Faraboeuf o或 Jungbluth钳夹住骨折两侧的临时螺钉维持复位（图8）。手指触摸前方的四方区到髂耻线区域检查前方复位情况。若前柱还有移位，需要旋转骨折块而不是简单向内挤压复位，用Schanz螺钉或带角度骨盆复位钳（即球端弯钳），一端钳住近端髂骨侧，另一端通过坐骨大切迹钳住内侧骨盆缘四方区夹持复位（图8）。此过程中要注意坐骨神经避免过度牵张。如果髋臼前柱部分还留有部分欠满意，可以走髂腹股沟或髂股入路，直视下用球形顶棒、Faraboeuf钳或antiglide（抗滑？）板完成复位。
Figure 8
Pelvic saw bone modelof an associated transverse and posterior wall fracture.
The reduction is temporarily maintained byusing a two-screw technique with a Jungbluth clamp (see Figure 1)and an angled pelvic reduction clamp through the greater ...
Once reduction is obtained the inferior segment of thetransverse component can frequently be provisionally fixed with a single lagscrew. The screw placed either from the intact ilium just above the angle ofthe greater sciatic notch to the distal posterior column or from the angle ofthe greater sciatic notch to the intact ilium may be effective. A singleposterior plate can also secure this portion of the transverse fracturepattern. The plate should be placed along the margin of the greater sciaticnotch where the plate does not preclude the reduction and fixation of theposterior wall fracture. This plate should be overcontoured to achievecompression of the anterior column segment. A long lag screw placed down to theanterior column can be placed from the superior aspect of the retroacetabularsurface into the anterior portion of the fracture. The starting point for thisscrew is approximately 3 to 4 cm above the acetabulum along with theanterior pillar of the iliac wing. This posterior-to-anterior lag screw isinserted across the obliquity of the transverse fracture line into the anteriorcolumn. This screw runs parallel to the quadrilateral surface, taking purchasein the anterior column. Its position in the anterior column is checked usingthe obturator oblique and iliac oblique views intraoperatively. It is importantto avoid excessive anterior penetration with the drill bit to prevent damage tothe femoral vessels. If a two incision approach is utilized, placement of theposterior to anterior screw can frequently be directly visualized.Alternatively, an anterior plate can also be utilized in these situations toreduce and secure the anterior column portion of the fracture with a plate.
横行骨折部分复位后可以用螺钉临时固定。螺钉即可以从髂骨之坐骨大结节角上方向后柱远端拧入也可以相反方向。一块后侧板也可以有效固定后柱横行骨折。钢板应该沿坐骨大切迹边缘放置以免影响后壁骨折复位固定。钢板要过度塑形以达到加压前柱骨折作用。固定前柱的长螺钉可以从髋臼后表面上方进入骨折前方。螺钉进钉点位于髋臼上方3-4cm沿髂骨翼前弓。这个后—前螺钉斜跨横行骨折线拧入前柱，与四方区平行。术中透视闭孔斜位和髂骨斜位检查螺钉位置。钻头向前方钻孔时不要损伤股动静脉，若是双切口入路，则这枚螺钉可以在直视下完成。当然，既然前方切口了，用一块钢板复位固定前柱更加安全。
The next step is the reduction of the posterior wall. Theprinciple is the same as that in the associated posterior column and posteriorwall fractures. Traction through the femoral head assures that all of thedebris is out of the joint. Marginally impacted fragments are realigned to theintact femoral head by releasing the traction and using osteotomes and bonegraft. Lag screws may help maintain the reduction. A 3.5 mm reconstructionplate is then placed on the medial border of the posterior column, from thesciatic buttress to the ischium, and is fixed with 3.5 mm screws. A springplate (Figure 2)may be applied in fractures with multiple fragments and small fragments thatlocate close to the acetabular rim. It is very important to contour theposterior plate precisely to avoid both the anterior gapping of the column andthe lack of a buttress of the posterior wall when applying the posterior plate.To avoid avascular necrosis, the posterior wall fragments must not be detachedfrom the capsule. Intraoperative fluoroscopy in multiple views should be usedto ensure that all screws are safely placed. An additional lag screw can be placedfrom the superior aspect of the plate across the transverse fracture line foradditional fixation (Figure 9).
下一步是复位后壁，原则也是和后柱后壁骨折一样，牵引股骨头确保关节内没有碎屑，髋臼边缘嵌压骨块用骨刀撬起，松开股骨牵引以股骨头为模板排列骨块或取骨瓣移植，螺钉可以帮助维持复位，3.5mm重建板置于后柱内侧缘从坐骨拱璧到坐骨结节螺钉固定。若髋臼缘有多发碎块可用弹性板固定（图2）。精确塑形后侧钢板非常重要，以免前柱留有缝隙和后壁支撑不够。避免缺血坏死，保护后壁骨折块依附的关节囊，术中还要多角度透视确保螺钉位置合适，从钢板上方拧入一枚螺钉穿过横行骨折线加强固定（图9）。
Figure 9
Example of anassociated transverse and posterior wall fracture treated throughKocher-Langenbeck approach, using a 3.5 mm reconstruction plate, twothird-tubular spring plates, and a 3.5 mm anterior column screw.
(A-C) Preoperative X-rays ...
Tips and tricks
要点和技巧
If the posterior wall fracture is comminuted and extendsthrough the weight bearing dome, the trochanter flip approach as reported byReinhold Ganz from Berne, Switzerland, may be useful inaddition to the Kocher-Langenbeck approach [ 16] (Figure 10).This may facilitate the exposure of the superior aspect of the acetabulum,lessen the traction of the superior gluteal vessels, and allow direct vision ofthe anterior column without a combined or extensile approach. Thus, this may beused in T-shaped fractures as well. Compared with other techniques of thetrochanter osteotomy, this approach has several merits such as not detachingvastus lateralis muscle, preserving the blood supply to the femoral head, andless frequency of heterotopic ossification and non-union.
如果后壁骨折粉碎并累及负重区，Reinhold Ganz报道的KL入路辅以转子截骨可以帮助显露（图10）髋臼上面，减轻对臀上血管牵拉，并可以直视前柱而无需使用扩展入路。因此，转子截骨也可以用于T型骨折，与其他方法相比较，转子截骨有几个好处，如不需分离股外侧肌，保护股骨头血供，很少异位骨化和骨不连。
Figure 10
Trochanter flipapproach, as originally described by Reinhold Ganz.
The arrow indicates the osteotomy plane.The gluteus medius and vastus lateralis remain attached to the trochantericfragment.
Reinhold介绍的转子截骨入路。箭头所指为截骨平面，臀中肌和股外侧肌都保留在转子骨瓣上。
T-shaped fractures
T型骨折
Take home message for safe surgical technique
看家招数
·When performing a dual approach, care must betaken to avoid inaccurate fixation of the anterior column from the back and/orposterior column from the front
采用双入路时，要防止从后往前固定前柱或者从前往后固定后柱时螺钉位置不准确。
·When indirect reduction of the anteriorcolumn is attempted from a posterior approach, the surgeon must be familiarwith the placement of instruments into the greater sciatic notch. A ball spikeor small bone hook can be gently introduced along the quadrilateral surface tomanipulate the anterior column.
试图从后侧入路间接复位前柱时，医师应该熟悉从坐骨大切迹放入球形顶棒或小骨勾，沿四方区表明轻柔滑入操作前柱。
T-shaped fractures are simply transverse fractures with afracture line separating the anterior column from the posterior column. Inthese fractures, the posterior capsule is frequently disrupted so there is aneed to reduce the two columns separately [ 17]. This is one ofthe most difficult fractures to treat surgically, achieving anatomic reductionis difficult, and it tends to have a poorer functional prognosis then the otherassociated fracture patterns.
T型骨折是简单的横行骨折加一条分开前后柱的纵向骨折线。后侧关节囊经常撕裂，前后柱需要单独复位。是外科处理最困难的骨折之一，达到解剖复位难度大，和其他复杂髋臼骨折比较，功能愈合也较差。
Surgical approach
外科入路
Ideally the fracture should be approached, when possiblewith a single non-extensile incision. The typical T-shaped fracturedemonstrates a greater displacement in the posterior column portion of thefracture and the Kocher-Langenbeck approach is common. If the anterior columnis more displaced, the ilioinguinal approach may be used. The modified Stoppaapproach or the modified ilioinguinal approach can facilitate the visualizationof the quadrilateral surface and aid in the visualization and reduction of theposterior column when compared to the standard ilioinguinal approach [ 10, 18]. Ultimately oneshould strive for a perfect reduction and in some cases based on eitherexperience or fracture pattern it may be necessary to utilize a more extensivesurgical approach to achieve the goal. The combination of the anterior andposterior approach may be used, or the extended iliofemoral approach can permitsimultaneous exposure and direct control of both columns facilitating thereduction. The extended ilioinguinal exposure is advocated as a primaryapproach in the following conditions: transtectal fracture line, wideseparation of the vertical stem, symphysis displacement, or contralateral ramifractures.
即想显露好又不用扩展切口，若T型骨折后柱移位较大，则常用K-L入路。若前柱移位较大，可以髂腹股沟入路，改良Stoppa入路和改良髂腹股沟入路可以直视四方区并可直视下复位后柱，与标准髂腹股沟入路比较的话。最终是否能达到完美复位某种程度上取决于医师的经验，有些骨折类型必须使用扩展的外科入路，如前后联合入路。扩展的髂股入路可以直接显露并控制双柱便于复位。扩展的髂腹股沟入路可用于下列情况：骨折线经负重区，垂直分离严重，耻骨联合移位，或对侧耻骨支骨折。
Operative procedure
手术操作
When using the Kocher-Langenbeck approach, the reductionof the posterior column is usually carried out first, ensuring that none of thescrews cross into the anterior column fracture segment. The reduction itself isvery similar to the pure posterior column fracture. Difficulty is encounteredbecause the lack of a stable anterior column segment. The use of a Schanz screwor two temporary screws with a Faraboeuf clamp may facilitate the reduction andits maintenance. The reduction is checked by the alignment of the greater sciaticnotch and at the level of the posterior part of the transverse fracture linedividing the quadrilateral surface by digital palpation. Once reduced, a3.5 mm reconstruction plate is applied on the lateral border of thegreater sciatic notch. The posterior column may be initially fixed with a3.5 mm lag screw from the intact ilium toward the quadrilateral surface ofthe fractured posterior column, which allows the removal of the clamps. Careshould be taken to assure that no hardware is fixating the anterior columninhibiting its future reduction.
采用KL入路时首先复位后柱，要确保螺钉不要进入前柱骨块，这一过程与单独后柱骨折很相似。但是因为前柱也不稳定所以会有困难。用Schanz螺钉或者Faraboeuf钳夹持两个临时螺钉维持复位。复位情况可以通过检查坐骨大切迹骨折线排列和触摸前方四方区表面的横行骨折线得知。一旦复位，3.5mm重建板沿坐骨大切迹外侧缘放置。可以先用3.5mm螺钉从髂骨向四方区固定后柱以便去除复位钳。要小心螺钉不要固定前柱妨碍其复位。
Indirect reduction of the anterior column is thenattempted. The successful reduction of T-shaped fractures through the posteriorapproach is dependent on this indirect reduction of the anterior column. Thus,the surgeon must be familiar with the placement of instruments into the greatersciatic notch. A ball spike or small bone hook can be gently introduced alongthe quadrilateral surface to manipulate the anterior column. The techniqueusing an angled reduction clamp through the greater sciatic notch to pull thedisplaced anterior column distally to fit the intact anterior column and thereconstructed posterior column is also frequently used. One jaw of this clampshould be placed on the quadrilateral surface of the fractured anterior columnand the other on the above-the-roof area of the intact ilium, withoutcontacting the posterior column (Figure 11).Traction of the affected lower extremity can help this manipulation. Reductionis confirmed by palpation of the quadrilateral surface, and the anterior columnis stabilized using posterior-to-anterior lag screws. This screw startsapproximately 3 to 4 cm above the superior edge of the acetabulum andextends directly to the superior pubic ramus as mentioned for associatedtransverse and posterior wall fractures (Figure 9).However, if possible, the anterior column should be stabilized to thereconstructed posterior column using posterior-to-anterior lag screws. Thescrew starts from the posterior aspect of the posterior column below thefracture line, directed parallel with the quadrilateral surface, crossing thefracture line, and possibly reaching the pelvic brim (Figure 12).Care must be taken not to injure the anterior neurovascular bundles and not topenetrate the joint. The hip is taken through a range of movements to rule outintra-articular screw penetration. If the reduction of the anterior column isnot possible through the posterior approach, a sequential anterior approach canbe performed. It is important to assure that no screws are preventing itsreduction before changing the approach.
接下来可以试着间接复位前柱，后入路能否完成T型骨折就取决于这一步。医师必须熟悉从坐骨大切迹放入器械，一个球形长钉或小骨勾轻柔滑过四方区操作前柱。一把带角度复位钳（球端弯钳）通过坐骨大切迹夹持移位的前柱远端完成前柱复位。这把复位钳一端插到骨折的四方区，另一端插到髂骨近端完整处而不接触后柱（图11）。牵引伤侧下肢可以帮助复位。触摸四方区确定复位后就可以用后—前螺钉稳定前柱了。这枚螺钉从距髋臼缘上方3-4cm打向耻骨上支，就如在横行加后壁骨折部分提到的那样（图9）。原则上，如果可能，前柱应该用后-前螺钉稳定在完成复位的后柱上。螺钉起自后柱后侧面低于骨折线，平行于四方区跨越骨折线抵于骨盆缘（图12）。注意不要损伤前方的血管神经束，不要穿入关节。活动髋关节以排除螺钉打穿。如果通过后方入路无法完成前柱复位，则要改为前方入路，但一定要先确保后路的螺钉不会影响复位。
Figure 11
Pelvic saw bone modeldemonstrating fracture reduction by the use of an angled reduction clamp.
(A) The posterior jaw of the clamp is placedon the above-the-roof area of the intact ilium. (B) The anterior jaw is placed on thequadrilateral surface of ...
带角度复位钳使用示意图。A复位钳后脚扼住髋臼顶完整髂骨区域，B前脚扼住四方区。
Figure 12
Schematic drawing oflag screw placement from the posterior to the anterior column.
The screw must be parallel to thequadrilateral surface and checked by intraoperative fluoroscopy to ensure theextraarticular placement.
从后柱固定前柱示意图。螺钉必须平行于四方区，术中透视保证螺钉在关节外。
When using the anterior approach primarily, the anteriorcolumn is reduced first, and indirect reduction of the posterior column is thenattempted. The reduction and fixation of the anterior column is the same as inthe associated anterior column and posterior hemitransverse fracture. Then thereduction of the posterior column is performed through the quadrilateralsurface by using a small bone hook, an asymmetric clamp, or a coaxial pelvicclamp, combined with lateral traction using a Schanz screw in the femoral head.The accuracy of the posterior column reduction may be assessed by inspectingthe reduction of the quadrilateral surface to the anterior column. Fixation iscarried out using anterior-to-posterior lag screws placed along the pelvicbrim, parallel to the quadrilateral surface, and directed toward the ischialspine. These screws may be placed either inside or separate from the pelvicbrim plate. If the reduction of the posterior column appears unfeasible, aposterior approach is subsequently performed (Figure 13).
如果手术是从前方入路开始，则首先复位前柱并试图间接复位后柱。前柱复位固定与前柱加后半横行骨折相同。后柱的复位是通过四方区用一把小骨勾，一把不对称钳或一把同轴骨盆钳（枪式复位钳），配以股骨头Schanz螺钉施加侧方牵引。直视检查四方区可以评估后柱复位情况，沿骨盆缘拧入前—后螺钉，平行于四方区直到坐骨棘。这颗螺钉可以经过骨盆缘的钢板也可以在钢板之外。若是后柱复位难以实施则加后路切口（图13）。
Figure 13
Example of a T-shapedfracture treated via a combined ilioinguinal and Kocher-Langenbeck approach,using two 3.5 mm reconstruction plates and two 3.5 mm lag screws.(A-C) Preoperative X-rays (a.p., obturatoroblique, iliac oblique). (...
T型骨折联合髂腹股沟入路和KL入路。3.5mm重建板和3.5mm螺钉固定。
The extended iliofemoral approach can provide completeaccess to and control of the transverse fracture line. The reduction may bestarted from either of the columns. They are manipulated and temporarilymaintained by means of clamps applied on the outer surface of the innominatebone. The anterior column is usually fixed with a long screw inserted along itsaxis exactly as described above. The posterior column is fixed with a3.5 mm reconstruction plate.
扩展的髂股入路可以完全显露和处理横行骨折。复位可以从任一柱开始，用骨盆复位钳在无名骨外侧面操作并维持，前柱通常用长螺钉插入长轴固定，就如前面所述。后柱用3.5mm重建板固定。
Tips and tricks
要点和技巧
The modified Stoppa approach developed by Cole et al. [ 18] or the modifiedilioinguinal approach reported by Karunakar et al. [ 19] that uses themidline incision instead of the third window of the standard ilioinguinalapproach, is often useful to treat associated anterior column and posteriorhemitransverse, T-shaped, and both column fractures, especially in the casethat the quadrilateral surface is not comminuted and the posterior fragment isrelative large. This allows access to the pubic symphysis, pubic rami, thewhole quadrilateral surface, the inner aspect of the greater sciatic notch, andthe sacroiliac joint. Both of the anterior and posterior columns may bedirectly visualized from the inside of the pelvis. It becomes easier to reducethe medially displaced posterior column fragment by means of pushing thequadrilateral surface through the midline incision with a ball spike(Figure 14).With these approaches, the reduction of the quadrilateral surface may bemaintained with lag screws from that surface through the fracture line towardthe intact ilium above the greater sciatic notch.
改良Stoppa入路和改良髂腹股沟入路可以用正中切口显露代替标准髂腹股沟入路的第三窗口。经常可以用于前柱和后半横行骨折、T型骨折和双柱骨折。尤其是四方区没有粉碎，后部骨折块又比较大。这种情况允许使用耻骨联合、耻骨支、四方区、坐骨大切迹内侧面和骶髂关节。前柱和后柱均可以在真骨盆内直视。通过正中切口用尖头球形顶棒推压四方区复位移位的后柱内侧面非常容易（图14）。这两个入路，用螺钉从四方区表面向坐骨大切迹上方髂骨拧入螺钉维持四方区复位。
Figure 14
Reduction of themedially displaced posterior column fragment by pushing the quadrilateralsurface through the midline incision with a ball spike pusher (arrow).
(A) Saw bone model. (B) Intraoperative view.
尖头球形顶棒推压四方区复位后柱骨折块之内侧面。A模型B术中
Both columnfractures
双柱骨折
Take home message for safe surgical technique
看家招数
·Intact capsular attachments to both columnsusually allow this injury to be approached via and anterior approach withindirect reduction of the posterior column.
关节囊完整的双柱骨折，经前方入路运用间接复位后柱技术即可。
·Safe fixation of the posterior column fromthe lateral window of the ilio-inguinal approach can be performed using Judetviews to avoid penetration of the hip joint.
经髂腹股沟入路外侧窗固定后柱采用Judet视图（闭孔斜位和髂骨斜位）可以避免穿入髋关节。
·In obese patients this antegrade screw fixingthe posterior column can be a challenge. Fixation can be achieved by insertinga retrograde screw on a supine patient. Structures at risk in this case are thesciatic nerve which runs just lateral to the entry point (tip of ischialtuberosity) and the para-rectal space medial to it.
肥胖病人顺行固定后柱充满
挑战。可以仰卧位逆行固定。但要小心坐骨神经，就行走在入点外侧（坐骨结节）和直肠周围间隙内侧。
The both column fracture is the most frequent pattern ofthe associated acetabular fractures. The joint capsule and acetabular labrum,typically, remain firmly attached to both the anterior and posterior columnfragments so the fragments can be lined up around the femoral head and thejoint surface may appear to be congruent. This phenomenon is known as secondarycongruence radiographically, regardless of the medial displacement of femoralhead and gaps between articular fragments. Situations of secondary congruencecan be managed nonoperatively, but only represent approximately 5% of thefractures [ 9] (Figure 15).However, the vast majority of these fractures require operative treatment.
双柱骨折是复杂髋臼骨折里最常见的骨折类型。关节囊和髋臼唇还保持着双柱骨折块的链接，则骨折块围绕股骨头排列紧密关节面相当平整，放射学上这种现象称作继发匹配，
没有股骨头中心脱位和关节面裂缝。继发匹配情况可以保守治疗。但是仅仅大约5%骨折有这种情况（图15）。所以绝大多数双柱骨折需要手术。
Figure 15
Example of secondarycongruence of an associated both column fracture.
This 56-year-old patient was successfullytreated conservatively. (A) Anteroposterior view. (B) Obturator oblique view. (C) Iliac oblique view.
Surgical approach
手术入路
This fracture pattern is most frequently treated by theilioinguinal approach because it often allows the reduction from within thepelvis by hinging fragments on their remaining capsular attachment. Reductionof the anterior column to create a stable surface to reconstruct the remainingarticular surface is the key in the reconstruction of this fracture pattern [ 18]. This isgenerally best performed by an exposure that allows extensive exposure to thisaspect of the ilium. If the fracture involves a complex fracture of thequadrilateral surface that is separated from the posterior column, a displacedfracture line crossing the sacroiliac joint, or a wide separation between the anteriorand posterior column fracture, either the combination of the anterior andposterior approach or the extended iliofemoral approach is appropriate.
双柱骨折最常用髂腹股沟入路，因为完整的关节囊对后方骨块的铰链作用，使骨盆内复位成为可能。前柱成功复位产生一个稳定的关节面来重建剩余关节面是双柱骨折修复重建的关键点。能够广泛显露髂骨面的入路最常用。如果四方区骨折复杂并与后柱分离，移位的骨折线跨越骶髂关节，或者前后柱骨折分离宽大，可以用前后联合入路或者扩展的髂股入路。
Operative procedure
手术操作
The key to reconstruction is anatomic reconstruction ofthe anterior column. Thus, the first step in the procedure is fixation of thelarge anterior fragment to the intact ilium, and it is necessary to attempt torestore the normal concavity of the iliac fossa which is much greater than whatappears under direct visualization. The anterior column is usually rotatedexternally and shortened, and the reduction is carried out using a ball spikepusher placed above the pelvic brim on the intact iliac fossa. An asymmetricreduction forceps placed across the iliac brim and a Farabeuf clamp placed atthe level of the iliac crest may also be advantageous in obtaining andmaintaining the reduction of the anterior column. The femoral head typicallyfollows the anterior column fragment and should become reduced following thereduction of the anterior column. If there is a triangular fragment along theiliac crest or a posterior fragment of the pelvic brim, it should be reducedand fixed accurately, perhaps first to the posterior part of the iliac wing.These provide an anatomic template for the subsequent reduction of theposterior column. Digital palpation of the outer table of the ilium and thefracture line should be undertaken to insure that there is no malreduction ofthe anterior column. A small malreduction in the ilium can result in asignificant step off at the articualr surface. This is made possible byelevating the soft tissue along each side of the fracture line of the iliaccrest. The fixation of the iliac crest is achieved by inserting 3.5 mm or4.5 mm lag screws. Fixation is largely obtained as previously describedfor anterior column posterior hemitransverse fractures.
既然关键点是前柱重建，那首先就是把大的前方骨块固定到髂骨上。试图恢复重建正常髂窝的容积是有必要的，髂窝其实比看起来要大。前柱通常外旋并缩短，复位需要用一把球形顶棒放在髂窝骨盆缘上，一把不对称复位钳跨过髂骨缘，一把Farabeuf钳放在髂嵴，可以完成并维持前柱复位。股骨头一般随着前柱走，所以会随着前柱的复位而复位。如果髂嵴有三角型骨折块或骨盆缘后侧折块，需要精确复位固定，或者先从髂骨翼后面固定。这样，为随后后柱的复位提供解剖模板。触摸髂骨外板感知骨折线确保前柱没有复位不良。髂骨上微小的复位不良会造成关节面明显台阶。这有可能是因为髂嵴两侧软组织牵拉造成。髂嵴用3.5mm或4.5mm螺钉固定，基本和前面前柱和后半横行骨折里讲的相同。
Reduction of the posterior column can be facilitated byplacement of a Schanz screw in the femoral neck for anterior and lateraltraction either manually or with the use of a traction table. Pelvic reductionclamps, with one jaw on the outer surface of the anterior inferior iliac spineand the other jaw through the first or second window on the quadrilateralsurface of the posterior column, help achieve reduction. Reduction may also beachieved by means of a small bone hook or a coaxial pelvic reduction clamp. Theposterior column is stabilized using anterior-to-posterior lag screws, some ofwhich may pass through plate holes placed on the pelvic brim. These screwsstart at the pelvic brim 3 to 5 cm anterior to the sacroiliac joint andare directed from proximal to distal into the posterior column paralleling thequadrilateral surface, aiming for the ischial spine. Joint penetration islikely to occur with these screws. The reduction is checked radiographicallyand with digital palpation of the accessible fracture surfaces (Figure 16).If the reduction of the posterior column is not possible through the anteriorapproach, the sequential Kocher-Langenbeck approach can be performed. In thissetting, anterior implants must be carefully positioned not to impede subsequentreduction from the secondary posterior approach.
股骨颈安装Schanz螺钉向前、外侧人工牵引或牵引床实施帮助复位后柱。骨盆复位钳一端扼住髂前下棘外侧，另一端通过第一或第二窗口扼住后柱四方区实施复位。也可以用小骨勾或同轴骨盆复位钳完成复位。复位后用一前—后螺钉固定后柱。有时可以通过骨盆缘上的钢板螺孔。螺钉起自骨盆缘距骶髂关节前面3-5cm，从近端向远端穿入后柱，平行于四方区，瞄向坐骨棘。这些螺钉容易穿入关节，需放射透视检查和触诊受累骨折面（图16）。如果前方入路不能完成后柱复位，需要KL入路随后进行。这样的话，前方的植入材料必须小心放置，不要影响后路复位。
Figure 16
Example of anassociated both column fracture treated through a modified ilioinguinalapproach with two 3.5 mm reconstruction plates.
(A-C) Preoperative X-rays (a.p., obturatoroblique, iliac oblique). (D-F) Postoperative X-rays (a.p., obturator ...
When the extended iliofemoral approach is selected(Figure 17),the whole posterior column, the whole iliac wing, and the anterior column up tothe iliopectineal eminence can be visually inspected. The internal aspect ofthe iliac fossa can be digitally inspected for fracture reduction. Care must betaken to avoid stripping the internal iliac fossa so as to not devitalize theanterior column segment. The order of fixation remains the same as with ananterior based approach.
当用扩展的髂股入路时（图17），整个后柱、整个髂骨翼和前柱到髂耻隆起都可以直视。髂窝内侧面可以触摸到，要小心避免剥离内侧髂窝以免前柱骨块失活。固定顺序和前方入路相同。
Figure 17
Example of anassociated both column fracture treated through an extended iliofemoralapproach, with a fracture line extending into the sacroiliac joint.
(A-C) Preoperative X-rays (a.p., obturatoroblique, iliac oblique). (D-F) Postoperative X-rays (a.p., ...
Tips and tricks
要点和技巧
The AO coaxial pelvic clamp is designed to controlfragments through the small window via the axial sliding mechanism of itsforceps. It can be useful to reduce the posterior column, especially thoseposteriorly displaced in the both column fractures and T-shaped fractures,through the anterior approach. The jaw located proximal to this clamp is placedon the pelvic brim with its tip anchored on the posterior edge of thequadrilateral surface or ischial spine, and can pull the posterior column up toanterior column by pulling the trigger like a gun (Figure 18).
AO同轴骨盆钳（枪式复位钳）是设计用来通过一个微创窗口，轴向滑动钳子机械来控制骨折块。用它复位后柱非常有用。特别是前方入路处理双柱骨折和T型骨折的后方移位时，这把钳子的近端扼住骨盆缘，远端锚定四方区后缘或坐骨棘，扣动扳机则将后柱拉向前柱（图18）。
Figure 18
The AO coaxial pelvicclamp.
(A) This clamp can pull the posterior columnup to anterior column by pulling the trigger like a “gun”. (B) Application through a small window ofilioinguinal approach.
Conclusion
结论
In this paper we present specific tips and tricks for thesafe surgical management of associated acetabular fractures. The success tosatisfactory outcome is to aim for Letournel’s so-called “reductionparfaite”.（法语） In order to achievethis, a number of steps must be followed:
本文我们奉献了处理复杂髋臼骨折的要点和技巧。目的是达到Letournel所说完美复位之满意结果，为了达到这样结果还必须做到：
---Adequate preoperative imaging and preoperativeplanning
充分的术前成像和术前计划。
---Choice of surgical approach and, if necessary, astaged management
选好外科入路，如果有必要，则分阶段实施。
---Good quality intraoperative fluoroscopy views toconfirm perfect reduction and extra-articular placement of hardware.
高质量的术中透视确保完美复位和硬件不进入关节。
---A perfect knowledge of pelvic and acetabular anatomyis essential to prevent potentially lethal complications and a allow safereduction and fixation.
熟练掌握骨盆和髋臼的解剖，对于防止潜在的致命并发症和安全复位固定都是必须的。
