【作者】 宋磊；

【导师】 钟世镇；

【作者基本信息】 第一军医大学 ， 临床解剖学， 2007， 博士

【摘要】 骶髂关节损伤是严重骨盆创伤中最为常见的严重损伤,随着现代交通运输、煤矿采掘、高层建筑等行业迅速发展,骶髂关节骨折在骨盆严重创伤中所占的比例亦呈现逐年上升的趋势。由于受伤原因多样且解剖位置复杂,严重的骶髂关节部位的损伤,常伴有多处严重的合并伤,如大出血,盆腔脏器的损伤等,死亡率较高。没有严重合并症的骨盆骨折,尤其是骨盆的前环骨折,既往多采用非手术的保守疗法,但患者的愈后往往因为各种不同原因而较差。但对于复杂骨盆骨折,尤其是伴随有骶髂关节损伤的骨盆后环骨折,得出的诊断则具有一定的局限性。CT技术的不断提高和更新使骨盒骨折的诊断和分型更为确切,并有助于拟定详细的早期治疗计划。但对于严重复杂的骨盆骨折,由于骨块互相重叠,X线片和二维CT扫描则很难全面客观地显示骨折和移位的程度。CT是检查明显骨盆损伤的一种重要诊断方法,特别是对于有后部复合损伤(骶髂关节损伤)的骨折效果极佳,其可检查普通X线片上显示不清楚的骨盆环后部,包括骶骨骨折,骶髂关节骨折脱位、髂骨翼及髂骨后嵴骨折等等。螺旋CT三维重建已广泛应用于临床,特别是三维重建以其立体、直观、准确的图像显示优点更为广泛地应用于骨骼系统。通过三位重建技术,采用旋转切割技术,可从各方向立体地观察骨折线,对骨折断端移位情况显示得立体直观。而且根据临床需要,可选择进行冠状位或矢状位重建,弥补二维CT每个单一体位扫描存在的不足,为骨折的诊断、分类及治疗方案的制定提供了极大的帮助。快速成型技术,简称RP或RPM技术,是80年代后期首先从美国发展起来的一门新兴制造技术,它基于材料累加概念和叠层制造方法,在计算机的控制下,根据物体的CAD模型或CT/MRI等数据,不借助其他设备,通过材料的精确堆积,制造原型的一种基于离散、堆积成型原理的新的数字化成型技术,集机械工程、CAD、激光加工、数控和新材料等技术成果于一身,可自动而迅速地将设计思想转化为物理试验模型或直接制造零件。该零件是CAD模型的物理体现,分层堆积原理的实质就是通过离散把三维制造转化为一系列二维制造叠加,是一个分解——综合的过程。将所得STL数据输入快速成型机。制作出与实体1∶1大小的模型。RP技术自动化程度高,从数字模型(CAD模型)到物理模型(原型和零件)的转化,都是计算机控制下的自动完成而无需人工干预。可制造高度复杂的零件,特别对形状复杂的人体组织器官很有用处。快速成型技术原则上可以制造出任意形状的模型。人体组织器官经CT、MRI或激光等获取图像数据输入计算机,经图形处理软件处理,重建三维模型,经快速成型系统就能制造出人体局部组织或器官的模型,并用于临床辅助诊断、复杂手术方案的确定、制作个性化的假体,也可用于医学教学。欧洲已经把医学作为快速成型技术应用的主要研究方面之一。运用RP技术,技师根据患者的CT或MRI数据体外制造出模拟患者具体情况的解剖模型,医师可以通过模型进行术前规划,指导手术。将三维重建技术与RP技术有效的结合起来,即将CT检查所获得的详尽患者病情资料,经过有效的转换为STL格式的文件,在计算机的控制下,不借助其他设备,通过材料的精确堆积,迅速的制造出仿真的创伤模型。术者可以根据骶髂关节损伤模型明确损伤的类型。根据模型所反映的情况选择最佳的手术方式、入路以及内固定器材,根据其制定治疗方法(手术或非手术)、选择手术入路切口,并在模型上模拟合适的内固定类型和安装方法(预弯钢板、更多还原

【Abstract】 Pelvic fracture is a common serious damage in trauma. Along with rapid development of modern transportation, coal mine excavation, high-rise construction, the proportion of fracture of articulatio sacroiliaca in the serious damage also rise year by year. Because of the diversity of injured reasons and complex anatomical position, the serious damage of articulatio sacroiliaca, often is accompanied by many serious associated injuries, for example, the massive hemorrhage, the pelvic cavity internal organs damage and so on, and the mortality rate is high. Pelvic fracture without serious complications, in particular fracture of pelvic front ring, formerly be treated with the non-surgery conservative treatments, but which always has a bad outcome because of different reasons. Diagnoses about complicated pelvic fracture especially sacroiliac joint damage accompanied is local. Development of CT made the precisely diagnoses and intimate treatment plan possible. CT has become a important diagnoses method in the complicated pelvic fracture. Spiral volumetric CT three-dimensional reconstruction has been applicated in clinic. Circuitation cutting technique in Spiral volumetric CT can observe the fracture three-dimensional. It is important in the diagnoses of pelvic fracture. Rapid prototyping (RP) is a new technic developed in American during later period of 1980’s. RP can manufacture the prototype ofobject by CAD models or CT/MRI date controlled by compute. RP technic comprise Machinery mechanic, CAD, laser processing and numerical control technic, can manufacture experiment models rapidly and automated. RP is a process of demix and general, controlled by compute. It is useful in manufacture complex human organ. Rapid prototyping can manufacture any type organ models controlled by computer, and applicated in clinical diagnoses and education. Clinic is the major area of RP application in Europe. Doctor can make plan of operation according three-dimensional view and RP technic. Accurate models can guide the operation method and choice of internal fixation device. Prognosis can be identify. Long-term manufacture and expensive spend are the important problem of RP technic hinder its clinical application. Another problem is the radiating spokes suffered by doctor and patient in the process of CT guide. The model can be used once. Analogue technic based on simulate principle, information technology(IT) and system technic etc. It’s a technic about describe and a method about quantitative analysis. Doctor make operation decision according to the results of quantitative analysis by computer simulation. Analogue technics can solve a lot of problems in engineering and technology. The direction and plan of engineering can be checked by analogue technics. We can modify our plan if it doesn’t satisfy the expectant requests in time. Analogue technics can be used in many process includes choice of assembly and design of the system or engineering. Doctor can modify the accurate models of the fracture of patients according CT or MRI view by computer simulation. It is the base of diagnosis and treatment. The recent viewpoint believed that, regarding the unstable pelvic fracture, the conservative treatment was difficult to get a precise reposition. For restoring the health, reducing the mortality rate and disabled rate, the majority scholars and clinician advocated surgical treatments. Because of the complex structure of pelvis, the explicit phantom study examination, in front of the accurate diagnosis and the technique surgery simulation, has the important value in diagnosis and treatment on fracture of articulatio sacroiliaca. This research discusses the diagnosis and treatment of fracture of articulatio sacroiliaca, on the basis of successful establishment of clinical anatomy digitization simulation model platform for individual articulatio sacroiliaca fracture.First part: Establishment of clinical anatomy digitization simulation model platform for individual articulatio sacroiliaca fracture and related research.Objective.1. establishment of digitized simulation model platform for individual articulatio sacroiliaca fracture.2. Carrying on the analysis using the digitized simulation platform for individual cases data: evaluation of different diagnosis methods for articulatio sacroiliaca fracture, as well as the individual clinical operative design before the operation; providing the useful informations for the clinical diagnosis and treatment. Methods: 15 cases of preservative adult pelvis specimens, 160～179 cm height, 32～78 year old, average 50 years old, no osseous pathological changes such as abnormalities, tumor and fracture. All pelvis specimens were performed X-ray and CT examination, as well as image reconstruction after scanning. The digitized simulation modeling of data was completed, and the comparison was performed between diagnose accordance rates of different diagnosis methods. Results: According to the establishment of individual digitized simulation model platform, difference of diagnose accordance rates between different diagnosis methods can be well evaluated; and the preoperative simulation can be carried out according to different data on the computer, to formulate more reasonable operative treatment plan.Second part: Clinical anatomical verification of digitized simulation model platform for individual articulatio sacroiliaca fracture and the simulated effect of operation on corpse specimen. Objective: comparison of effects of operative simulation with digitized simulation model platform for individual articulatio sacroiliaca fracture and with corpse specimen, and comparison of effects of guiding clinical practice. Methods: 1. operative simulation for articulatio sacroiliaca fracture on preservative adult pelvis specimens; 2. operative simulation on digitized simulation model platform for individual articulatio sacroiliaca fracture, hypothesized stimulated operative model same as the real situation of individual data; 3. performing the comparison between two; Results: the use of digitized simulation model platform for individual articulatio sacroiliaca fracture on preoperative diagnosis and operative simulation, can obtain the satisfactory effect. Conclusions: 1. The establishment of clinical anatomy digitized simulation model platform for individual articulatio sacroiliaca fracture, may have a good use on the diagnosis and operative simulation for different state of injury simulated models; 2. digitized simulation model platform for individual articulatio sacroiliaca fracture can stimulate the injury state of articulatio sacroiliaca accurately and assists to formulate the operative treatment plan, which is satisfied on the confirmation effect, and can provide exhaustive reference for the clinical treatments.更多还原