股骨头骨折合并髋关节后脱位是一种严重的创伤性疾病。保守治疗卧床时间较长，可能出现肌肉失用性萎缩、坠积性肺炎、下肢深静脉血栓形成或肺栓塞，临床疗效不佳。因此，股骨头骨折合并髋关节后脱位首选手术治疗。髋关节直接前路入路可较好地暴露PipkinⅠ型和Ⅱ型股骨头骨折，无须使髋关节完全脱位。但缺点是破坏了髋关节前方结构的完整性，一定程度上增加了股骨头坏死和异位骨化的风险。PipkinⅠ型和Ⅱ型骨折也可选择内侧入路，但要避免损伤筋膜层的完整性，对一些小的血管分支可以结扎，应避免旋股内侧动脉损伤。外侧入路被认为是治疗PipkinⅢ型骨折的有效方法，但对髋臼后部损伤的暴露有限，且有损伤臀上血管和神经的风险，术后可能继发外展肌无力。PipkinⅣ型骨折的手术入路主要为后侧入路。经典的后侧入路主要包括Kocher-Langenbeck入路和Ganz外科脱位入路。Kocher-Langenbeck入路不破坏外展肌，尤其适用于髋关节后脱位且难复位的患者；Ganz外科脱位入路保护了旋股内侧动脉血供，因此股骨头坏死的发生率较低，可实现股骨头和髋臼的全方位可视化，全面评估股骨头和髋臼病变并发现影像学检查中遗漏的隐匿性损伤。
Femoral head fracture combined with posterior hip dislocation is a serious traumatic condition. Conservative treatment has a long time of bed rest, and may cause muscle apraxia atrophy, hypostatic pneumonia, deep vein thrombosis of the lower limbs, or pulmonary embolism, which has poor clinical efficacy. Therefore, surgical treatment is the first choice for femoral head fracture combined with posterior hip dislocation. The direct anterior approach of the hip can better expose Pipkin type I and type II femoral head fractures without the need to dislocate the hip completely. However, the disadvantage is that it destroys the structural integrity of the anterior hip joint, which increases the risk of femoral head necrosis and heterotopic ossification to a certain extent. The medial approach can also be chosen for Pipkin type I and II fractures, but it is important to avoid damaging the integrity of the fascial layer, some small vascular branches can be ligated, and injury to the medial rotary femoral artery should be avoided. The lateral approach is considered to be an effective treatment for Pipkin type III fractures, but there is limited exposure of the posterior acetabular injury and a risk of injury to the superior gluteal vessels and nerves, which may be secondary to adductor weakness postoperatively. The posterior approach is the main surgical approach for type IV Pipkin fracture. The classic posterior lateral approaches mainly include the Kocher - Langenbeck approach and the Ganz surgical dislocation approach. The Kocher - Langenbeck approach does not destroy the abductors and is particularly suitable for patients with posterior hip dislocation and difficult to reposition. Ganz surgical approach protects the blood supply of the medial femoral circumcator artery, so the incidence of femoral head necrosis is low. It can achieve all-round visualization of the femoral head and acetabulum, comprehensively evaluate the lesions of the femoral head and acetabulum, and find the occult injuries missed in imaging examinations..
蒋新港,高肇篷,常波,等. 股骨头骨折合并髋关节后脱位的治疗进展[J]. 中华骨科杂志,2024,44(22)：1489-1495.
DOI:10.3760/cma.j.cn121113-20240107-00017版权归中华医学会所有。
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