綜述：復雜髖臼骨折的外科技術

Safe surgicaltechnique for associated acetabular fractures

復雜髖臼骨折的外科技術

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.

復雜髖臼骨折的處理極具挑戰性。為了獲得解剖復位而需掌握的復雜外科入路和技術難點意味著學習曲線極其陡峭。本文介紹了標準外科技術、術中要點和技巧、各型復雜髖臼骨折的安全管理。

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.

不管復雜還是簡單的髖臼骨折，理論上都要求解剖復位內固定，這沒有什么區別。只不過從外科入路、解剖復位技巧到堅強內固定技術都更加復雜。

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].

復雜髖臼骨折，按照Judet and Letournel分類，是指兩條以上骨折線通過髖臼并有復雜的幾何形狀。除了后柱后壁骨折還包括前后雙柱骨折。因為受累廣泛，外科顯露創傷大，相比較于單一前路或后路，廣泛顯露必然增加并發癥風險，如手術時間延長、失血量增加、感染、神經損傷、肌力減退和異位骨化等。為了降低并發癥，單一切口非廣泛顯露，間接復位技術已經可以用于某些復雜髖臼骨折。

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].

手術指征和簡單髖臼骨折相同：髖臼頂明顯的骨折移位影響負重，髖關節不匹配，和髖關節不穩定。為確定負重區，Matta介紹的頂弧角技術很有幫助，CT掃描髖臼最高點下10mm的負重區，和Matta角配合使用做出手術指征判斷。（注：更詳細知識可以參考周東生骨盆創傷學第二版314-334）。三維CT掃描可以更加精確測量髖臼軟骨下負重區，可更加容易判明髖臼骨折未解剖復位或近似解剖復位導致應力改變發展成創傷后關節炎的潛在可能性。通常，移位小于2mm可以認為無需手術也可得到滿意結果。但是這一標準太簡單而沒有考慮其它一些影響臨床結果的因素，包括但不限于
游離體存在、缺口、股骨頭骨折和軟組織狀況。其它因素如老年人、病人放棄復位固定而選擇關節成形，或經皮螺釘固定及有限切開內固定后二期關節成形。

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].

對于一些困難的骨折，醫師的經驗相當重要，經驗豐富的醫師自然獲得解剖復位的可能性就高，當然，不管經驗是否豐富，必須徹底理解骨盆和髖臼的三維解剖，熟悉骨折形態和復位技巧，熟練使用復位器械。必須認識到，骨折復位是否理想關系到預后好壞。

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].

理想的情況下，髖臼手術應當由一個經驗豐富的團隊進行，包括護士、麻醉和器械助手。一般傷后48小時內進行的急診手術主要是防止大出血，傷后3周內手術內固定比較從容無需擔心因追求復位而加重創傷或擴大顯露。很明顯，傷后5-7天復位內固定比較好盡量避免延遲。如果手術推遲至3周之后，因骨折血腫機化、軟組織攣縮和骨痂形成而降低術后預期。

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.

圍手術期計劃每個醫生的經驗和喜好不同可以有變化。比如是否應用牽引床是有爭議的，雖然傷側下肢術中需要牽引，但是牽引床限制肢體活動必然影響一些體位下的術野顯露和X光透視。變換一下骨折牽引方法可以改為股骨近端斯氏針牽引，為了確保精確復位和固定物不進入關節，術中透視肯定是必須的。

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.

確定金屬位于關節外的最有效方法是觀察側位，X線順螺釘方向照射可以確定是否進入關節。每上一顆釘或一根針都要明確是否在關節外。另外，術中活動髖關節可幫助發現螺釘誤入關節、骨折不穩定和復位不良。

Associatedposterior column and posterior wall fractures

后柱和后壁骨折

Take home message for safe surgical technique

看家招數

·Prone or lateral positioning; the patients’ hipshould be extended and the knee flexed to reduce tension on the sciatic nerve

俯臥或側臥位，患側伸髖屈膝減輕坐骨神經張力

·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.

俯臥位有助于利用重力牽引和復位，髖關節外旋有助于后壁骨塊復位。

·Retractors placed in the sciatic notchesshould be released as often as possible to prevent lengthy compression againstthe sciatic nerve

放置在坐骨切跡的牽開器要經常松開以免持續壓力損傷坐骨神經。

·Posterior wall capsular attachments should bemaintained to prevent devascularization

后壁骨瓣關節囊附著應予保護以防失血供。

·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)

過度牽開外展肌有損傷臀上神經血管之虞，建議不要用太長鋼板并維持髖外展（髖關節遠近端各2枚螺釘足夠了。）

·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（即骨盆雙斜位）觀察一直確保沒有螺釘打入關節，如果懷疑干脆換個角度重新打入螺釘。

Surgical approach and patient positioning

入路與體位

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 過度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].

這是復雜髖臼骨折中唯一沒有前后柱均受累的，最佳顯露是K-L入路，病人可以側位或俯臥位，側臥在可透視床上有兩個優勢，一是不需牽引床二是避免俯臥位不熟悉。股骨牽開器或人工牽引下肢可以幫助骨折復位和看清髖關節。主要缺點是助手牽引并不可靠，過度牽拉可致坐骨神經損傷，另一個主要缺陷是側臥位時后柱頑固性移位因為地心引力作用難以復位。俯臥位的主要優點恰恰是因為地心引力作用消失后柱復位容易。下肢伸髖屈膝避免牽拉坐骨神經大大降低神經損傷機會。后柱復位后通過牽引股骨近端外側可以從后壁骨折窗口觀察關節面。

Operative procedure

手術操作

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.

先把后柱骨折復位，后壁骨折塊就有了穩定的落腳點。通過手術入路可以顯露髖臼后壁、大小坐骨切跡并觸摸到四方區表面，完成后柱復位。一定要避免對坐骨神經的持續牽拉和壓迫，間歇松開拉鉤。不處理骨折塊時拉鉤放松，沒經驗的助手可能意識不到這一點，主刀醫師有義務提醒。由于坐骨周圍軟組織牽拉，骨塊一般向內側移位旋轉。

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觸診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.

直徑5-6mm Schanz螺釘
插入坐骨控制旋轉，斯氏針安上通用T型把手可以矯正后柱旋轉移位，選擇不同型號骨盆復位鉗（angled jaw clamp彎鉗, a Weber clamp, or aFareboeuf clamp）垂直于骨折線反向旋轉合攏復位骨折。或者用骨鉤持續牽拉坐骨切跡復位，缺點是上螺釘或復位鉗之前你不能松骨勾。如果這些復位手法還不行，可以Faraboeuf 或 Jungbluth鉗（國內叫螺釘復位鉗），即用兩螺釘技術（圖1）。此技術非常有效糾正旋轉縮小縫隙，Jungbluth鉗比Faraboeuf鉗能力更強大。缺點是復位鉗占據了有限的手術野影響鋼板螺釘安放。手指觸摸四方區和坐骨大切跡確定骨折復位，牽引關節通過髖臼后壁骨折塊直視下檢查髖關節內部，內旋關節致再脫位，沖洗掉關節內碎屑。后柱復位完成，短3.5mm重建板放置于坐骨大切跡，3.5mm拉力螺釘從后柱過骨折線達四方區深面以便撤掉復位鉗方便鋼板固定。

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. ...

圖1 臨時兩螺釘技術復位骨折A螺釘沿坐骨大切跡放置以免影響鋼板安放，B術中視圖螺釘和復位鉗

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 ...

彈性板示意圖：A1/3管型板放置在后壁。B彈性板拉住骨塊。

第二步是復位后壁，操作過程應保護骨塊上面關機囊附著以免破壞血供，關節囊上縫合牽引線以便觀察后柱復位。松開牽引線以股骨頭為模板復位后壁骨塊，如有邊緣嵌壓，用一把彎曲骨刀撬起關節表面骨瓣彌補空虛，也可從大轉子取自體骨瓣。游離骨塊以股骨頭為模板仔細復位。較大骨瓣復位后用球頭頂棒維持克氏針臨時固定，全部后壁復位用弧形板螺釘固定，單獨螺釘固定不穩定。3.5mm重建板或髖臼專用板是常用材料，如果后壁邊緣有小的碎骨塊，可用小彈性板固定（圖2）。彈性板可用1/3管型板尾孔修剪制備，彈性板輕微過度塑形以便重建板覆于其上，螺釘擰緊施壓使其抓牢骨瓣。弧形重建板遠端要延伸至坐骨，螺釘打入恥坐骨支。螺釘放置后柱中心區以免進入關節。一般來說，弧形板遠近端各兩枚螺釘足夠。鋼板近端部分要用Hohmann拉鉤牽開肌肉直視下固定在髂骨上。過度牽拉外展肌群有損傷臀上神經血管風險，因此不宜用過長鋼板，并保持髖外展。結束手術時要檢查螺釘是否進入關節，活動髖關節傾聽聲音并透視檢查。

Tips and tricks 要點和技巧

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.

兩塊弧形重建板盡可能分開放置，不僅要支撐后壁而且要使后柱固定獲得足夠強度。（圖3）特別強調弧形板放置髖臼邊緣跨越后壁主要區域，鋼板塑形稍欠可以施加更大壓力使后壁更穩定。

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

前柱和后半橫行骨折

Take home message for safe surgical technique

看家招數

·Safe positioning of the patient in the supineposition with option for traction of the affected extremity is recommended.

推薦仰臥位，傷側肢體自由牽引。

·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.

髂腹股溝入路或改良Stoppa入路可選，當前柱骨折位置低不包括髂骨翼時后路。

·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入路時閉孔血管神經（其直接接觸四方區）和髂腰血管有風險，Stoppa入路和髂腹股溝入路的中間窗10-30%病例能見到死亡之冠。

·Reduction technique should proceed in acentripetal direction, towards the articular surface.

朝關節面方向復位骨折塊。

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.

前柱和后半橫行骨折，可以認為是不典型T型骨折或T型到雙柱骨折的過度型。一般來說，后柱部分沒有或輕微移位，股骨頭位置隨著前柱走，手術比雙柱和T型骨折要容易，入路一般選前路。

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，其中以髂腹股溝入路最常見。如果骨折塊包含大部髂骨翼，遠端又延伸到髂恥隆起，則可選髂股入路。若前柱骨折位置低又不含髂骨翼，也可用改良Stoppa入路。一般來說，若骨折不是以前柱為主則改良Stoppa入路也很少用到。病人取仰臥位置于骨折床或可透視床，股骨遠端和股骨近端外側牽引幫助復位。瑞士人Beme介紹了20例用腹膜外直腸旁入路，需要解剖髂外血管和腹壁下動脈，精索或圓韌帶，分5個窗口，完全顯露四方區并通過四方區骨折線觀察關節內。

Operative procedure

手術操作

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.

前柱復位是將髂骨快向關節面靠攏，用一球形頂棒置于前柱骨折遠端骨盆邊緣，向內側面推壓糾正向外旋轉移位，Faraboeuf鉗置于髂骨脊或者髂前上下棘之間反向旋轉前柱。復位第一步從髂嵴開始，骨膜下開一窗手指觸摸髂骨翼外板，確定一鉗夾點可以向骨折線施加壓力。如果效果不好，可以在骨折線兩邊鉆孔以增加復位鉗抓握力。或者上兩顆螺釘用于復位鉗抓握合攏。一旦髂嵴穩定了，骨盆緣骨折線加壓，同時，通過髂腹股溝入路第二窗口用一把帶角度復位鉗（大、小球端彎鉗）可以完成余下的復位。或者是用尖頭球形頂棒在骨盆緣加壓完成復位。立刻用交叉克氏針臨時固定前柱。正式內固定也是從髂嵴開始的，一到兩枚3.5mm長螺釘髂板內固定骨折。如果內板破壞不允許螺釘固定則在髂嵴內面用重建板，塑形后沿髂嵴或髂板放置，螺釘穿透雙皮質固定。現在都喜歡直接在髂嵴前面放置重建板以防止內固定物刺激反應。螺釘固定比3.5mm重建板固定髂嵴還要穩定。髂嵴固定完成繼續固定骨盆邊緣，某些骨折塊用單獨螺釘固定即可，可以附加內板螺釘從髂前上棘和髂前下棘朝向坐骨支打入。假如后半橫行骨折塊還未完全復位，用兩枚螺釘從髖臼上方骨盆緣打向后柱，途經髖臼和坐骨大小切跡之間進入坐骨。若后柱需要復位則在打入這兩枚螺釘之前完成。如果病人骨質較好前柱骨折塊位置較高則這些固定就應該足夠了，可以不用鋼板固定了。如果后柱還需要進一步復位，用一枚螺釘從前柱平骨盆緣向后方坐骨區域打入避開前柱。還有一個方法，前柱用12-14孔3.5mm重建板沿骨盆緣跨過髂恥隆起到恥骨聯合。皮質骨螺釘打向坐骨支復位前柱，后柱復位完成再上其余螺釘。鋼板固定一般不需過恥骨聯合。鋼板需要完美塑形，但鋼板過緊下壓可能會引起柱的復位丟失，注意螺釘不要上在復位不良的后柱上，影響進一步復位。

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.

下一步是后柱復位，如果后半橫骨折線較低，前柱復位完成后，后柱基本復位或有輕度移位則可忽略不做處理。若骨折線較高，又沒有自動復位，可以通過髂腹股溝入路的第一第二窗口間接復位。后柱通常有內旋移位，可以用不對稱骨盆復位鉗夾住髂前下棘和四方區向后柱靠攏（圖4）。一把小號骨勾或者同軸復位鉗（槍式復位鉗）輕柔下壓四方區幫助復位。用一枚3.5mm螺釘從骨盆緣近端中后1/3經重建板或者不經重建板（圖5），平行于四方區插向后柱，瞄向坐骨棘。螺釘長度通常80-110mm.小心不要進入關節內，因此，精確鑒別髖臼與骨盆緣界標，找準進釘點非常重要，即髂前下棘下方和髂恥隆起下面是髖臼。視情需要附加鋼板固定恥骨聯合現在可以進行了。

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.

從骨盆緣向后柱打入螺釘示意圖。通常超過80mm長。

Tips and tricks

要點和技巧

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).

前柱復位后，6.5到7.5mm的中空螺釘從髂前下棘過骨折線向髂后上棘擰入，后柱可獲得足夠穩定（圖6）。螺釘固定方法首見于骨盆環髂骨翼骨折，其實也同樣可用于前柱受累的髖臼骨折。術中透視閉孔斜位和髂骨斜位檢查螺釘在髂骨中的位置（圖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, ...

前柱和后半橫行骨折病例，改良髂腹股溝入路，3.5mm重建板和7.3mm中空釘應用。

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.

放置中空螺釘術中透視圖，從髂前下棘穿向髂后上棘。A閉孔入口斜位。B髂骨斜位。

Associatedtransverse and posterior wall fractures

橫行加后壁骨折

Take home message for safe surgical technique

看家招數

·The safety and choice of approaches isdetermined by the location of the transverse fracture: infra-tectal（負重區？） fractures can be dealt with via a KLapproach while juxta and trans-tectal will require anatomical reduction usuallyvia an anterior approach.

入路選擇取決于橫行骨折位置：覆蓋層下方骨折可選K-L入路，靠近或經覆蓋層骨折需要前方入路。

·Lateral decubitus will allow for a twoincision technique

側臥位可以兼顧雙切口。

·The sciatic nerve is at risk, especially whenattempting an indirect reduction of the anterior fracture line through a KLapproach

當KL入路試圖間接復位前方骨折線時，小心坐骨神經

·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.

從后向前打入前柱螺釘時，穿過前柱的鉆頭或螺釘有損傷股神經血管風險，若穿過前柱上方皮質有損傷髂外動靜脈風險。操作中髂骨斜位和閉孔斜位觀察非常關鍵。

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.

橫行加后壁骨折并不罕見，橫行的骨折塊部分關系到髖臼負重區需要考慮手術入路和體位。

Surgical approach

手術入路

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.

后壁骨折當然毫無疑問需要后側入路，但并不排除有時需要前方入路。橫行骨折在覆蓋區下方需要后側KL入路。經覆蓋區骨折和靠近覆蓋區骨折要求解剖復位，有時可以KL入路，有時則需要擴大的前方入路或雙切口技術。擴展的髂股入路和雙切口技術才能完成髖臼復位固定。因為擴展的髂股入路并發癥多，作者更愿意使用側臥位雙切口入路。

Operative procedure

手術操作

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.

首先要完成橫行骨折的復位，后壁骨折正好作為觀察關節內復位好壞的窗口，最后再復位。

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.

和后柱骨折復位大體相同，Schanz螺釘擰入坐骨結節糾正骨折成分的旋轉移位，合適的骨盆復位鉗完成復位。傷側下肢牽引可以輔助操作。Faraboeuf o或 Jungbluth鉗夾住骨折兩側的臨時螺釘維持復位（圖8）。手指觸摸前方的四方區到髂恥線區域檢查前方復位情況。若前柱還有移位，需要旋轉骨折塊而不是簡單向內擠壓復位，用Schanz螺釘或帶角度骨盆復位鉗（即球端彎鉗），一端鉗住近端髂骨側，另一端通過坐骨大切跡鉗住內側骨盆緣四方區夾持復位（圖8）。此過程中要注意坐骨神經避免過度牽張。如果髖臼前柱部分還留有部分欠滿意，可以走髂腹股溝或髂股入路，直視下用球形頂棒、Faraboeuf鉗或antiglide（抗滑？）板完成復位。

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.

橫行骨折部分復位后可以用螺釘臨時固定。螺釘即可以從髂骨之坐骨大結節角上方向后柱遠端擰入也可以相反方向。一塊后側板也可以有效固定后柱橫行骨折。鋼板應該沿坐骨大切跡邊緣放置以免影響后壁骨折復位固定。鋼板要過度塑形以達到加壓前柱骨折作用。固定前柱的長螺釘可以從髖臼后表面上方進入骨折前方。螺釘進釘點位于髖臼上方3-4cm沿髂骨翼前弓。這個后—前螺釘斜跨橫行骨折線擰入前柱，與四方區平行。術中透視閉孔斜位和髂骨斜位檢查螺釘位置。鉆頭向前方鉆孔時不要損傷股動靜脈，若是雙切口入路，則這枚螺釘可以在直視下完成。當然，既然前方切口了，用一塊鋼板復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).

下一步是復位后壁，原則也是和后柱后壁骨折一樣，牽引股骨頭確保關節內沒有碎屑，髖臼邊緣嵌壓骨塊用骨刀撬起，松開股骨牽引以股骨頭為模板排列骨塊或取骨瓣移植，螺釘可以幫助維持復位，3.5mm重建板置于后柱內側緣從坐骨拱璧到坐骨結節螺釘固定。若髖臼緣有多發碎塊可用彈性板固定（圖2）。精確塑形后側鋼板非常重要，以免前柱留有縫隙和后壁支撐不夠。避免缺血壞死，保護后壁骨折塊依附的關節囊，術中還要多角度透視確保螺釘位置合適，從鋼板上方擰入一枚螺釘穿過橫行骨折線加強固定（圖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

要點和技巧

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負重區，Reinhold Ganz報道的KL入路輔以轉子截骨可以幫助顯露（圖10）髖臼上面，減輕對臀上血管牽拉，并可以直視前柱而無需使用擴展入路。因此，轉子截骨也可以用于T型骨折，與其他方法相比較，轉子截骨有幾個好處，如不需分離股外側肌，保護股骨頭血供，很少異位骨化和骨不連。

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介紹的轉子截骨入路。箭頭所指為截骨平面，臀中肌和股外側肌都保留在轉子骨瓣上。

T-shaped fractures

T型骨折

Take home message for safe surgical technique

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·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

采用雙入路時，要防止從后往前固定前柱或者從前往后固定后柱時螺釘位置不準確。

·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.

試圖從后側入路間接復位前柱時，醫師應該熟悉從坐骨大切跡放入球形頂棒或小骨勾，沿四方區表明輕柔滑入操作前柱。

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型骨折是簡單的橫行骨折加一條分開前后柱的縱向骨折線。后側關節囊經常撕裂，前后柱需要單獨復位。是外科處理最困難的骨折之一，達到解剖復位難度大，和其他復雜髖臼骨折比較，功能愈合也較差。

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.

即想顯露好又不用擴展切口，若T型骨折后柱移位較大，則常用K-L入路。若前柱移位較大，可以髂腹股溝入路，改良Stoppa入路和改良髂腹股溝入路可以直視四方區并可直視下復位后柱，與標準髂腹股溝入路比較的話。最終是否能達到完美復位某種程度上取決于醫師的經驗，有些骨折類型必須使用擴展的外科入路，如前后聯合入路。擴展的髂股入路可以直接顯露并控制雙柱便于復位。擴展的髂腹股溝入路可用于下列情況：骨折線經負重區，垂直分離嚴重，恥骨聯合移位，或對側恥骨支骨折。

Operative procedure

手術操作

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入路時首先復位后柱，要確保螺釘不要進入前柱骨塊，這一過程與單獨后柱骨折很相似。但是因為前柱也不穩定所以會有困難。用Schanz螺釘或者Faraboeuf鉗夾持兩個臨時螺釘維持復位。復位情況可以通過檢查坐骨大切跡骨折線排列和觸摸前方四方區表面的橫行骨折線得知。一旦復位，3.5mm重建板沿坐骨大切跡外側緣放置。可以先用3.5mm螺釘從髂骨向四方區固定后柱以便去除復位鉗。要小心螺釘不要固定前柱妨礙其復位。

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.

接下來可以試著間接復位前柱，后入路能否完成T型骨折就取決于這一步。醫師必須熟悉從坐骨大切跡放入器械，一個球形長釘或小骨勾輕柔滑過四方區操作前柱。一把帶角度復位鉗（球端彎鉗）通過坐骨大切跡夾持移位的前柱遠端完成前柱復位。這把復位鉗一端插到骨折的四方區，另一端插到髂骨近端完整處而不接觸后柱（圖11）。牽引傷側下肢可以幫助復位。觸摸四方區確定復位后就可以用后—前螺釘穩定前柱了。這枚螺釘從距髖臼緣上方3-4cm打向恥骨上支，就如在橫行加后壁骨折部分提到的那樣（圖9）。原則上，如果可能，前柱應該用后-前螺釘穩定在完成復位的后柱上。螺釘起自后柱后側面低于骨折線，平行于四方區跨越骨折線抵于骨盆緣（圖12）。注意不要損傷前方的血管神經束，不要穿入關節。活動髖關節以排除螺釘打穿。如果通過后方入路無法完成前柱復位，則要改為前方入路，但一定要先確保后路的螺釘不會影響復位。

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 ...

帶角度復位鉗使用示意圖。A復位鉗后腳扼住髖臼頂完整髂骨區域，B前腳扼住四方區。

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.

從后柱固定前柱示意圖。螺釘必須平行于四方區，術中透視保證螺釘在關節外。

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).

如果手術是從前方入路開始，則首先復位前柱并試圖間接復位后柱。前柱復位固定與前柱加后半橫行骨折相同。后柱的復位是通過四方區用一把小骨勾，一把不對稱鉗或一把同軸骨盆鉗（槍式復位鉗），配以股骨頭Schanz螺釘施加側方牽引。直視檢查四方區可以評估后柱復位情況，沿骨盆緣擰入前—后螺釘，平行于四方區直到坐骨棘。這顆螺釘可以經過骨盆緣的鋼板也可以在鋼板之外。若是后柱復位難以實施則加后路切口（圖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型骨折聯合髂腹股溝入路和KL入路。3.5mm重建板和3.5mm螺釘固定。

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.

擴展的髂股入路可以完全顯露和處理橫行骨折。復位可以從任一柱開始，用骨盆復位鉗在無名骨外側面操作并維持，前柱通常用長螺釘插入長軸固定，就如前面所述。后柱用3.5mm重建板固定。

Tips and tricks

要點和技巧

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入路和改良髂腹股溝入路可以用正中切口顯露代替標準髂腹股溝入路的第三窗口。經常可以用于前柱和后半橫行骨折、T型骨折和雙柱骨折。尤其是四方區沒有粉碎，后部骨折塊又比較大。這種情況允許使用恥骨聯合、恥骨支、四方區、坐骨大切跡內側面和骶髂關節。前柱和后柱均可以在真骨盆內直視。通過正中切口用尖頭球形頂棒推壓四方區復位移位的后柱內側面非常容易（圖14）。這兩個入路，用螺釘從四方區表面向坐骨大切跡上方髂骨擰入螺釘維持四方區復位。

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.

尖頭球形頂棒推壓四方區復位后柱骨折塊之內側面。A模型B術中

Both columnfractures

雙柱骨折

Take home message for safe surgical technique

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·Intact capsular attachments to both columnsusually allow this injury to be approached via and anterior approach withindirect reduction of the posterior column.

關節囊完整的雙柱骨折，經前方入路運用間接復位后柱技術即可。

·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.

經髂腹股溝入路外側窗固定后柱采用Judet視圖（閉孔斜位和髂骨斜位）可以避免穿入髖關節。

·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.

肥胖病人順行固定后柱充滿
挑戰。可以仰臥位逆行固定。但要小心坐骨神經，就行走在入點外側（坐骨結節）和直腸周圍間隙內側。

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.

雙柱骨折是復雜髖臼骨折里最常見的骨折類型。關節囊和髖臼唇還保持著雙柱骨折塊的鏈接，則骨折塊圍繞股骨頭排列緊密關節面相當平整，放射學上這種現象稱作繼發匹配，
沒有股骨頭中心脫位和關節面裂縫。繼發匹配情況可以保守治療。但是僅僅大約5%骨折有這種情況（圖15）。所以絕大多數雙柱骨折需要手術。

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

手術入路

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.

雙柱骨折最常用髂腹股溝入路，因為完整的關節囊對后方骨塊的鉸鏈作用，使骨盆內復位成為可能。前柱成功復位產生一個穩定的關節面來重建剩余關節面是雙柱骨折修復重建的關鍵點。能夠廣泛顯露髂骨面的入路最常用。如果四方區骨折復雜并與后柱分離，移位的骨折線跨越骶髂關節，或者前后柱骨折分離寬大，可以用前后聯合入路或者擴展的髂股入路。

Operative procedure

手術操作

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.

既然關鍵點是前柱重建，那首先就是把大的前方骨塊固定到髂骨上。試圖恢復重建正常髂窩的容積是有必要的，髂窩其實比看起來要大。前柱通常外旋并縮短，復位需要用一把球形頂棒放在髂窩骨盆緣上，一把不對稱復位鉗跨過髂骨緣，一把Farabeuf鉗放在髂嵴，可以完成并維持前柱復位。股骨頭一般隨著前柱走，所以會隨著前柱的復位而復位。如果髂嵴有三角型骨折塊或骨盆緣后側折塊，需要精確復位固定，或者先從髂骨翼后面固定。這樣，為隨后后柱的復位提供解剖模板。觸摸髂骨外板感知骨折線確保前柱沒有復位不良。髂骨上微小的復位不良會造成關節面明顯臺階。這有可能是因為髂嵴兩側軟組織牽拉造成。髂嵴用3.5mm或4.5mm螺釘固定，基本和前面前柱和后半橫行骨折里講的相同。

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.

股骨頸安裝Schanz螺釘向前、外側人工牽引或牽引床實施幫助復位后柱。骨盆復位鉗一端扼住髂前下棘外側，另一端通過第一或第二窗口扼住后柱四方區實施復位。也可以用小骨勾或同軸骨盆復位鉗完成復位。復位后用一前—后螺釘固定后柱。有時可以通過骨盆緣上的鋼板螺孔。螺釘起自骨盆緣距骶髂關節前面3-5cm，從近端向遠端穿入后柱，平行于四方區，瞄向坐骨棘。這些螺釘容易穿入關節，需放射透視檢查和觸診受累骨折面（圖16）。如果前方入路不能完成后柱復位，需要KL入路隨后進行。這樣的話，前方的植入材料必須小心放置，不要影響后路復位。

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.

當用擴展的髂股入路時（圖17），整個后柱、整個髂骨翼和前柱到髂恥隆起都可以直視。髂窩內側面可以觸摸到，要小心避免剝離內側髂窩以免前柱骨塊失活。固定順序和前方入路相同。

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

要點和技巧

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同軸骨盆鉗（槍式復位鉗）是設計用來通過一個微創窗口，軸向滑動鉗子機械來控制骨折塊。用它復位后柱非常有用。特別是前方入路處理雙柱骨折和T型骨折的后方移位時，這把鉗子的近端扼住骨盆緣，遠端錨定四方區后緣或坐骨棘，扣動扳機則將后柱拉向前柱（圖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

結論

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”.（法語） In order to achievethis, a number of steps must be followed:

本文我們奉獻了處理復雜髖臼骨折的要點和技巧。目的是達到Letournel所說完美復位之滿意結果，為了達到這樣結果還必須做到：

---Adequate preoperative imaging and preoperativeplanning

充分的術前成像和術前計劃。

---Choice of surgical approach and, if necessary, astaged management

選好外科入路，如果有必要，則分階段實施。

---Good quality intraoperative fluoroscopy views toconfirm perfect reduction and extra-articular placement of hardware.

高質量的術中透視確保完美復位和硬件不進入關節。

---A perfect knowledge of pelvic and acetabular anatomyis essential to prevent potentially lethal complications and a allow safereduction and fixation.

熟練掌握骨盆和髖臼的解剖，對于防止潛在的致命并發癥和安全復位固定都是必須的。