【作者】 金伟；

【导师】 蔡林；

【作者基本信息】 武汉大学 ， 外科学， 2010， 博士

【摘要】 骨盆骨折是临床常见的损伤,其发生率虽少于四肢和脊椎骨折,但其并发症较为多见,死亡率高,失血性休克的发生率比后二者高约40%左右。有统计报道称骨盆骨折病例约占骨折病例的4%,其中30%的患者发生失血性休克,死亡率和致残率较高。目前随着经济的发展,交通事故及工伤事故增多,骨盆骨折发病率还在逐年增高。垂直不稳定型骨折是骨盆骨折中最为严重的一种类型,占骨盆骨折的17%至30%,在临床处理中争议颇多,临床效果也不尽相同。以往对垂直不稳定性骨盆骨折多采用保守治疗,如牵引、骨盆悬吊和石膏固定等方法,致残率约为50%—60%。80年代以来,对骨盆骨折广泛开展切开复位固定治疗,取得了满意的疗效。近20年来临床研究发现,内固定手术已成为治疗垂直不稳定骨盆骨折的首选方法。手术可最大限度地复位、固定骨折,恢复骨盆的解剖形态和近似正常的骨盆力学性能,对提高疗效和改善后期功能状况起到积极作用,克服了保守治疗及外固定治疗复位不良、力学强度不足、长期卧床和远期并发症高的缺点。目前骨盆后环内固定技术有：①骨盆钢板固定。②松质骨螺钉固定。③骶骨棒固定。④“π”棒和TOS术式。各种内固定术式在治疗垂直不稳定骨盆骨折的临床应用中都有其相应的优点及其限制性。我们受TOS固定理念的启发,改良了椎弓根钉棒固定系统在骨盆骨折中的应用,并为此做了一系列的研究。本课题共分为三个部分：1.静力位下骨盆的正常生物力学研究；2.改良椎弓根钉棒系统治疗垂直不稳定骨盆骨折的生物力学研究；3.改良椎弓根钉棒系统治疗垂直不稳定骨盆骨折的临床研究。第一部分静力位下骨盆的正常生物力学研究目的：探讨静力位正常骨盆在垂直载荷下的生物力学情况,为骨盆骨折各种力学测试提供生物力学参数。方法：5具成人骨盆标本应用应变电测法,在不同载荷作用下对正常国人骨盆应变分布、刚度及位移进行测定,采集8个反复1500N载荷情况下骨盆的各个部位的应变值进行比较。结果：骶髂关节处应变最大,骨盆能承受3000N以上的载荷,在8次1500N的反复载荷下,骨盆的刚度和应变未出现明显改变。结论：骶髂关节处为骨折的好发部位,极限失效点应在3000N以上,1500N的垂直载荷位于骨盆的弹性区间之内。第二部分改良椎弓根钉棒系统治疗垂直不稳定骨盆骨折的生物力学研究目的：对不同种类的固定方式对垂直不稳定骨盆骨折进行固定后的生物力学测试,包括垂直载荷下骨盆局部的应变、局部分离移位和整体刚度。方法：8具成人骨盆标本,造垂直不稳定骨盆骨折模型(Tile C型),按照随机的顺序对各具骨盆标本进行以下内固定：①改良椎弓根钉棒系统固定②骶髂螺钉固定③TOS术式固定,并测试各种固定方式的刚度及骶髂关节处局部分离位移,同时比较各种不同固定方式骶髂关节及弓状线处的局部应变,通过SPSS13.0进行统计学比较。结果：改良椎弓根钉棒系统与TOS术式固定垂直不稳定骨盆骨折,在整体刚度与局部分离位移之间比较无显著统计学差异(P>0.05),但各项数据显著优于骶髂螺钉固定,有统计学差异(P<0.05)。局部应变改变符合各种固定方式的力学构象。结论：改良椎弓根钉棒系统固定垂直不稳定骨盆骨折生物力学性能良好。第三部分改良椎弓根钉棒系统治疗垂直不稳定骨盆骨折的临床研究目的：利用改良椎弓根钉棒系统对垂直不稳定骨盆骨折的临床病例进行了手术治疗,并对其临床特性进行评价。方法：对18例垂直不稳定骨盆骨折患者进行了改良钉棒系统的固定,改良椎弓根钉棒系统由垂直方向的腰骶钉棒固定系统及横向的钉棒固定系统组成。病人随访12-18个月。比较术前、术中、术后及随访期的X-ray,评价骨盆骨折的愈合情况。采用Majeed评分来测试术后患者康复情况。结果：18例垂直不稳定骨盆骨折3-6月全部愈合,未出现再骨折、复位后位置丢失、畸形愈合、皮肤坏死、医源性血管神经损伤、肢体短缩及跛行等并发症。5例患者诉偶尔性腰背部疼痛,4例患者诉偶尔大腿前外侧过电样疼痛,2例患者诉腰骶部可触及椎弓根钉尾端。通过平均14.3月的随访,对客观症状进行Majeed评分,16例患者术后1年功能为“优异”等级,2例患者术后功能为“好”等级。结论：改良椎弓根钉棒系统是一种安全有效的治疗垂直不稳定性骨盆骨折的手术方式。更多还原

【Abstract】 Pelvic fractures are common injuries, which not so many as the limbs and spine fractures. The incidence (about 40%) of hemorrhagic shock is more than the formers, with the common complications and high mortality. There are statistics of reported cases about pelvic fracture, of which 30% of the patients with hemorrhagic shock, a higher mortality and morbidity. With the economic development, traffic accidents and industrial accidents increased the incidence of pelvic fracture year by year. Pelvic fracture is a serious trauma with complex injury, especially the vertically unstable pelvic fracture. Unstable fractures of the pelvic fracture is the most serious type, accounting for 17% to 30%, which result in a lot of controversy in the clinical treatment and clinical results.Conservative treatment is used for the vertical unstable pelvic fractures in the past, such as traction, pelvic suspension and plaster immobilization method, while the incidence of disability is about 50%-60%. From the 1980s, Open reduction and fixation was used to treat pelvic fracture, and achieved satisfactory results. Internal fixation of unstable pelvic fractures has become the preferred treatment method in the past 20 years of clinical study. Operation can maximize the fracture reduction and fixation to restore pelvic anatomy and mechanical properties similar to a normal pelvis, improve the efficacy and improved functional status, play a positive role in overcoming the external fixation with conservative treatment, poor reduction, lack of mechanical strength, prolonged bed rest and the shortcomings of long-term complications.There are three parts of the study to treat the unstable pelvic fracture:Part one, Biomechanical Research on the Statically Determinate Pelvis under Vertical Loading.Part two, Biomechanical research on the improved pedicle screw system to treat vertically unstable pelvic fracture. Part three, Treatment of vertically unstable sacrum fracture by pedicle screws system fixation. Part one Biomechanical Research on the Statically Determinate Pelvis under Vertical LoadingObjective:To explore the normal pelvic biomechanical distribution under the vertical loading in statically determinate model and obtain the biomechanical parameters for various biomechanical tests in the pelvis fracture in future.Methods:With the strain electrometric methods, we detect the strain distributions, stiffness, displacements under the different load, then gather and compare the eight repeated strain values in different locations of pelvis under the load of 1500N in five specimens.Result:The greatest variance of strain is at the iliosacral joint, the load more than 3000N can be endured by the pelvis; after the eight-cycle loads of 1500N, the strain and stiffness do not change conspicuously.Conclusion:Iliosacral joint is a predilection site in the pelvis fracture. The ultimate failure point is more than 3000N.The load of 1500N is between the elastic interval of pelvis.Part two Biomechanical research on the improved pedicle screw system to treat vertically unstable pelvic fracture.Static position of the pelvis through biomechanical testing has established successfully the vertically unstable pelvic fractures biomechanical test model.Objective:The different types of fixation of vertical unstable pelvic fractures were performed the biomechanical testing, including the vertical load of local pelvic strain, partial separation of displacement and the overall stiffness.Methods:8 adult pelvic specimens,which has been made vertically unstable pelvic fracture model (Tile C-type); with the following internal fixation in random order of pelvic specimens:①pedicle screw systems,②triangular osteosynthesis (TOS),③iliosacral screw. We test a variety of fixation of sacroiliac joint stiffness and displacement at the local separation, and compare the different fixation methods and the sacroiliac joint local strain at the arcuate line, by SPSS 13.0 for statistical comparison.Results:Improved screw-rod fixation system and surgical TOS vertically unstable pelvic fractures was no significant difference (P> 0.05),in the overall stiffness and the local separation but the data was significantly better than the sacroiliac screws that were significant differences (P<0.05). Local strain changes meet all the mechanical fixed conformation.Conclusion:The modified pedicle screw system successfully treats vertically unstable pelvic fractures biomechanically.Part three Treatment of vertically unstable sacrum fracture by pedicle screws system fixation.Objective:To evaluate the clinical properties of new technique of posterior pelvic fixation by pedicle screw system.Methods:Eighteen patients with vertically unstable sacral fracture were treated with new pedicle screws system fixation. The operation consisted of a posterior fixation in combine with a vertical and transverse fixation. The patients were followed up for a minimum time of 14 months (from 12 months to 18 months). Preoperative, postoperative and follow-up radiography were conducted to assess the reduction and union. The Majeed function assessment was performed at six month and a year follow-up.Results:Sacral fractures healed in eleven patients without loss of reduction at 3-6 months, no skin necrosis, iatrogenic neurovascular injury, shortening of lower limbs or claudication occurred. All patients presented complaints of pain at the incision sites occasionally, four patients complained electric-like pain at the frontal thigh sometimes, and two patients complained of symptoms related to the prominence of the pedicle screw tail. By considering symptom and satisfactory scores, the functional assessment revealed that eight patients had good results and three fair at six months and all had excellent results at one year. Conclusions:Pedicle screw system fixation that allowed early mobilisation and ambulation, with general applicability and definite safety, is an effective surgical technique for treating the unstable sacral fractures.更多还原