【作者】 汪方；

【导师】 张春才； 王秋根； 党瑞山； 丁祖泉； 纪方； 张秋林；

【作者基本信息】 第二军医大学 ， 外科学， 2008， 博士

【摘要】 目的:对外固定支架结合后路钢板技术固定骨盆骨折的应用解剖、生物力学、临床适应症和疗效等进行研究,探讨这种固定模式的具体适用范围和技术细节,为特定类型的不稳定骨盆骨折处理提供参考依据和理论支持。方法:1、应用解剖学研究:对髋臼上外固定支架置钉技术进行体表定位、入路解剖和钉道解剖学研究;2、实验生物力学研究:构建骨盆骨折模型,采用电阻应变分析、数字散斑分析、刚度分析等技术,比较不同固定方式重建骨盆稳定性的生物力学特点。3、有限元研究:构建骨盆三维有限元模型,对不同固定方式重建进行计算机仿真分析。4、临床研究:对采用外固定支架结合后路钢板固定的临床病例进行随访分析,总结手术适应证和技术细节。结果:临床解剖学研究:1、通过干燥骨盆标本对髂前下棘的形态和体表定位进行测量。提示髂前下棘横径小于矢径,男性横径为12.23±1.91mm,女性为11.05±1.56mm,横径的性别差异有统计学意义。冠状面上男性髂前下棘在髂前上棘下方29.49±7.66mm,内侧21.79±6.48mm;在耻骨结节上方51.70±9.31mm,外侧67.74±5.36mm。冠状面上女性髂前下棘在髂前上棘下方23.74±8.89mm,内侧16.86±8.92mm;在耻骨结节上方43.93±9.04mm,外侧70.16±6.39mm。2、通过防腐骨盆标本对髂前下棘区置钉的入路进行解剖测量。提示股外侧皮神经距离髂前下棘外侧男性为23.24±5.33mm,女性为17.82±3.26mm,性别差异有统计学意义(P=0.001)。旋髂深动脉位于髂前下棘外侧男性为16.26±1.77mm,女性为14.06±2.16mm,性别差异有统计学意义(P=0.001)。股动脉位于髂前下棘内侧男性为27.54±3.53mm,女性为27.15±0.81mm,性别差异没有统计学意义(P=0.670)。股神经位于髂前下棘内侧男性为17.61±3.47mm,女性为19.26±4.21mm,性别差异没有统计学意义(P=0.186)。3、通过切割骨盆标本对钉道的形态和毗邻主要结构进行解剖研究。提示男性钉道长为147.76±7.39mm,女性为142.75±6.36mm,前中线距离和后中线距离平均值女性分别大于男性0.7mm和9.5mm。本研究中将钉道平均分成5个区域,提示由前至后骨质厚度逐渐增加,女性骨盆骨质厚度均小于男性。一区域与髋臼边缘的距离为22.54±4.94mm,二区在弓状线上方,三区域位于坐骨大切迹上方,臀上动静脉和臀上神经受到的损伤可能性较大。第四区域后即达骶髂关节部位。生物力学实验研究:1、构建Tile B1a型骨盆骨折模型,比较髋臼上外固定支架、髂骨翼外固定支架、耻骨联合钢板三种固定类型的生物力学特点;发现骨盆前方稳定性重建后,骶髂关节内旋压缩作用有不同程度增加。髂骨翼支架对骨盆前方的稳定性控制与髋臼上支架接近,而对于骨盆后方稳定性重建上髋臼上支架优于髂骨翼支架。2、构建TileC1-2a1型骨盆骨折模型,比较骶髂螺钉、跨骶骨锁定加压钢板、骶髂螺钉结合跨骶骨锁定加压钢板三种固定类型的生物力学特点。发现对于C1-2a1型骨折,应结合骶髂关节关节脱位和髂骨骨折内固定的治疗技术,跨骶骨LCP钢板通过跨骶骨的方式固定骨折线后方髂骨提供了“张力带”固定的效应。其力学稳定性优于单纯骶髂螺钉固定,骶髂螺钉附加LCP的固定方式能进一步增强LCP固定的稳定程度,但作用并不显著。三维有限元研究:构建包含韧带结构的骨盆三维有限元模型,并模仿Tile B1型骨盆骨折工况。在Abaqus有限元软件中,进行模拟加载。比较髋臼上外固定支架(SA)、髂骨翼支架(IW)、耻骨联合固定(PS)等三种固定类型的生物力学特点。X轴位移值可见PS工况与IS最为接近,而IW工况与FS最为接近,SA处于PS与IW工况之间。说明耻骨联合部位坚强的固定有利于控制水平方向的位移。各工况在Y轴位移值较为接近,并且没有如X轴的明显规律。Mises应力云图显示髂骨翼支架主要通过直接将健侧应力传导到患侧髂骨翼,而不是恢复骶髂关节稳定性的发挥固定骨盆的作用。髋臼上支架一方面将健侧应力直接传导到患侧髋臼上方,另一方面也增加了骶髂关节的应力传导。由于髋臼上骨质厚实,可置入较粗固定钉安全性较好。临床研究:对采用外固定支架结合后方钢板固定的12例病例进行平均6.3月随访,平均手术时间为70分钟(40-120分钟),没有患者术中输血,平均出血量80-400ml。外固定支架固定时间11周(6-16周)。骨折愈合时间平均为14周(12-19周),术后4周可部分负重,没有严重并发症的发生。外固定支架结合后方锁定钢板固定对不稳定骨盆骨折的治疗随访满意,手术时间和创伤也控制到有限范围。结论:髋臼上方置钉外固定支架技术可有效恢复骨盆前方稳定性,并且对后方骶髂关节稳定性重建有一定作用,生物力学性能总体优于传统的髂骨翼支架,是B1型骨盆骨折的良好固定方式。手术医师应熟悉髋臼上方置钉的外固定相关解剖和操作,以在急诊条件下也能迅速实施手术。对于C1-2a型骨盆骨折跨骶骨髂骨间锁定加压钢板固定优于单纯骶髂螺钉,是骶髂关节骨折脱位的有效重建手段。这两种技术结合应用,以简单的操作,较小的创伤迅速达到稳定,为不稳定骨盆骨折提供了一种符合生物力学要求的微创手术选择。更多还原

【Abstract】 Objective: To analysis the clinic anatomy, biomechanics, clinic indication and effective about the external fixation combined posterior plate reconstruction the pelvic fracture. Discussion this fixation can be used in the unstable pelvic fracture, the technical details and the clinical indications. The conclusion can offer theoretical support and referring to reconstruct unstable pelvic reconstruction.Methods:1. Anatomy research: To measured the cadaver sample get the anterior inferior iliac spine morphologic, location, and the supraacetabular external fixation pin tract in pelvic bone.2. Biomechanical experiment: Six cadaveric specimens axial loading from the proximal lumbar was applied by electronic universal test machine in the gradient of 100N to 500N, which simulated the double feet standing state. After experiment data acquisition, the mark point was used to analyze the displacement change by Digital Speckle Correlation Method; the strain gauge was used to analyze the strain change by Strain Gauge Method; and the load-displacement data was used to analyze axial stiffness of pelvis under different operating conditions.3. Finite element analysis: The CT images is supplied to established the 3D solid models of intact pelvis and four reconstructed pelvis assembled by different fixations; And after imported into FEA software Abaqus 6.7.2, the models will be executed the preprocessing and finite element calculation to analysis the displacement change and stress distribution.4. Clinic research: Retrospective research the patient who used external fixation combined posterior plate. To conclusion the clinic indication and the operation technical.Results:1. Anatomy research: The transverse diameter of AIIS was 12.23±1.91mm in male, and 11.05±1.56mm in female. In coronal plane the male AIIS down of ASIS 29.49±7.66mm, inner 21.79±6.48mm; the AIIS superior pubic tuberosity 51.70±9.31mm, outer 67.74±5.36mm. In coronal plane the female AIIS down of ASIS 23.74±8.89mm, inner 16.86±8.92mm; the AIIS superior pubic tuberosity 43.93±9.04mm, outer 70.16±6.39mm. The distance form AIIS to Lateral femoral circumflex artery is 23.24±5.33mm in male, and 17.82±3.26mm in female, the discrepance have statistic significance, Deep lilac circumflex artery is 16.26±1.77mm in male, and 14.06±2.16mm in female, the discrepance haven’t statistic significance, femoral artery is 27.54±3.53mm in male, and 27.15±0.81mm in female, the discrepance haven’t statistic significance, femoral nerve is 17.61±3.47mm in male, and 19.26±4.21mm in female, the discrepance haven’t statistic significance. The pintract length is 147.76±7.39mm in male, and 142.75±6.36mm in female, the distance from anterior midline and posterior midine female is large than male 0.7mm and 9.5mm. The male pin track dense is thicker than female. Zone 1 is superior of acetabular rim 22.54±4.94mm, zone 2 is superior of arc line, zone 3 is superior of sciatic arch, and in this zone the superior gluteal artery and nerve ease to injury. Zone 4 is in the sacroiliac joint region.2. Biomechanical experiment: The biomechanical stability in supraacetabular is better than iliac wing external fixation, for it reconstruction the sacroiliac completion. Used supraacetabular external fixation is a good choice in Tile B1 pelvic fracture. In TileC1-2a1 fracture, locking compression plate biomechanical is better than isolate sacroiliac screw. Locking compression plate plus sacroiliac screw may improve the stability by the effection haven’t significance.3. Finite element analysis: The CT images is supplied to established the 3D solid models of intact pelvis and four reconstructed pelvis assembled by different fixations; And after imported into FEA software Abaqus 6.7.2, the models will be executed the preprocessing and finite element calculation to analysis the displacement change and stress distribution. The supracetabular external fixation can reconstruction introduced the stress from the normal iliac to the fracture lateral, and reconstruction the sacroiliac completion. For the dense bony of supraacetabular, more thick pin can be inset and offer more strength.4. Clinic research: The follow up period was 6.3 months (range, 3-12months). The average intraoperative time was 70 minutes (range, 40-120minutes), and no patient underwent blood transfusion for the intraoperative blood loss was only 80-400ml. The external fixation maintained for 11 weeks (range 6-16 weeks). Mean fracture healing time were 14 weeks (range 12-19 weeks), partial weight bearing was 4 weeks. There was no severe iatrogenci nerve injury and complications.Conclusion: External fixation especially supraacetabular pin insert were useful ways for instability for anterior pelvic ring fractures, it can also support the stability of sacroiliac joint. The biomechanical stability was better than iliac wing pin location, and was the good fixation choice for Tile B1 pelvic fracture. Locking compression plate can use in posterior pelvic ring fractures, combine these two technical in specially type of pelvic fracture, can reconstruct pelvic ring by simply and rapidly ways with minimal invasive methods.更多还原