【作者】 吴啸波；

【导师】 张英泽； 潘进社；

【作者基本信息】 河北医科大学 ， 外科学， 2010， 博士

【摘要】 近年来髋臼骨折的发生率呈逐渐增多的趋势,移位的髋臼骨折多由高能量损伤所致,常伴有其它组织器官损伤。髋臼骨折的治疗对于多数骨科医生均具有挑战性。对于存在髋关节不稳定和头臼匹配不良的髋臼骨折治疗而言,内固定手术为治疗的金标准。通过手术治疗达到骨折的解剖复位和坚强内固定,重建关节的稳定性,从而有利于肢体功能的恢复,减少伤残率的发生。内固定手术操作过程中螺钉进入关节的情况虽较为罕见,但该并发症可严重损害髋关节功能。髋臼后柱部位的骨折,尤其是累及髋臼危险区的骨折最为常见,该部位的内固定操作应引起创伤骨科医生的高度关注,术中采用正确的置钉角度操作,可避免螺钉进入关节情况的发生。许多学者对髋臼解剖结构进行了研究,但多集中于髋臼的解剖特点或与人工关节置换操作相关的解剖研究,涉及髋臼骨折术中螺钉内固定安全操作的相关解剖研究较少。髋臼危险区的概念首先由Tile提出,该区域位于髋臼后壁和后柱的中部,坐骨棘之上的范围,该区域骨质非常薄弱,在此区域垂直于后柱表面行螺钉固定时,螺钉有进入关节的危险,Tile认为应尽量避免在危险区进行螺钉固定。Ebraheim等学者将髋臼危险区的概念加以补充完善,将其定义为髋臼在后柱部位表面的投影区域。并通过对平行切割的髋臼标本进行测量,提出髋臼危险区螺钉固定安全角度的概念及相关螺钉固定角度的数据。目前尚未见关于采用螺旋CT的多平面重建技术研究髋臼危险区相关解剖的报道,本研究拟通过相关实验及临床研究探讨以下内容:1.采用多层螺旋CT ( multislice spiral CT,MSCT )的三维表面遮盖显示(surface shadow display,SSD )和多平面重建( multiplanar reconstruction,MPR )技术对成人髋臼危险区各点位的螺钉固定安全角度和厚度进行研究;2.建立髋臼后柱骨折模型,比较髋臼后柱骨折接骨板内固定和拉力螺钉内固定的稳定性;3.设计W型髋臼安全角度接骨板,将W型髋臼安全角度接骨板与重建接骨板内固定稳定性进行比较研究;4.通过前瞻性临床随机对照研究,评估采用W型髋臼安全角度接骨板内固定治疗髋臼后壁骨折的疗效;5.评估早期康复治疗对髋臼后壁粉碎骨折患者术后肢体功能的影响。第一部分成人髋臼危险区螺钉固定安全角度和厚度解剖学研究目的:研究成人髋臼危险区的螺钉固定安全角度和厚度,为髋臼骨折的解剖重建提供相关依据。方法:采用多层螺旋CT三维重建和多平面重建测量32个男、女成年国人新鲜半骨盆标本和30个男、女健康成年志愿者髋臼危险区的螺钉固定安全角度和厚度。结果:男性标本距髋臼外缘0.5,1.0,1.5,2.0,2.5,3.0 cm点位螺钉固定安全角度为(49.23±11.54)°,(42.48±8.97)°,(29.53±7.86)°,(23.68±6.20)°,(18.42±5.41)°,(15.91±4.37)°;女性标本距髋臼外缘0.5,1.0,1.5,2.0,2.5 cm点位螺钉固定安全角度为(45.02±8.82)°,(35.98±7.60)°,(23.77±6.29)°,(19.96±4.36)°,(14.68±3.48)°。男性标本距髋臼外缘0.5,1.0,1.5,2.0,2.5,3.0 cm点位髋臼危险区的厚度为(0.64±0.13)cm,( 0.97±0.25)cm,( 1.46±0.40)cm,(2.14±0.46)cm,(2.61±0.47)cm,(2.96±0.42 )cm;女性距髋臼外缘0.5,1.0,1.5,2.0,2.5 cm点位髋臼危险区的厚度为(0.51±0.08)cm,(0.93±0.22)cm,(1.45±0.31)cm,(2.02±0.39)cm,( 2.50±0.50 ) cm。以上数据在相同性别的标本与志愿者之间差异无统计学意义( P > 0.05 ),在异性之间差异有统计学意义( P < 0.05 )。结论:本研究数据对于髋臼骨折术中螺钉固定操作有指导意义。在髋臼危险区行内固定操作时,男性距髋臼外缘0.5,1.0,1.5,2.0,2.5,3.0 cm点位进钉角度不小于75°,65°,50°,45°,35°,30°;女性距髋臼外缘0.5,1.0,1.5,2.0,2.5 cm点位进钉角度不小于65°,55°,45°,40°,25°,可防止螺钉进入关节。在髋臼危险区行内固定操作时,男性距髋臼外缘0.5,1.0,1.5,2.0,2.5,3.0 cm点位垂直进钉,深度应不大于进钉点到髋臼外缘距离的1/2,1/3,1/3,1/2,1/2,1/2;女性距髋臼外缘0.5,1.0,1.5,2.0,2.5 cm点位垂直进钉,深度均应不大于进钉点到髋臼外缘距离的1/2。第二部分髋臼后柱骨折模型建立及髋臼后柱骨折接骨板内固定和拉力螺钉内固定稳定性比较研究目的:建立髋臼后柱骨折模型,比较髋臼后柱骨折接骨板内固定和拉力螺钉内固定的稳定性。方法:取成年防腐半骨盆标本20个,建立髋臼后柱骨折模型。根据随机数字法将骨折模型标本分为接骨板内固定组和拉力螺钉内固定组,进行轴向压缩实验,比较两种固定方式骨折断端的水平位移和剪切刚度。结果:接骨板内固定组和拉力螺钉内固定组骨折断端的水平位移分别为( 1.64±0.17 ) mm和( 1.70±0.20 ) mm;剪切刚度分别为( 392.40±41.22 ) N/mm和( 386.33±50.07 ) N/mm。两组间水平位移以及剪切刚度相比,差异均无统计学意义( P > 0.05 )。结论:髋臼后柱骨折模型适用于髋臼后柱骨折内固定稳定性的评估研究,髋臼后柱骨折采用拉力螺钉内固定与接骨板内固定的稳定性无统计学差异。第三部分W型髋臼安全角度接骨板固定髋臼后柱骨折的稳定性研究目的:比较采用W型髋臼安全角度接骨板与重建接骨板固定髋臼后柱骨折的稳定性研究。方法:取半骨盆标本20个,建立髋臼后柱骨折模型。根据随机数字法依内固定方式的不同将骨折模型分为A,B,C,D 4组:A组采用W型髋臼安全角度接骨板固定;B,C,D组采用重建接骨板固定,其中B组为骨折线两侧各固定4枚螺钉;C组同样为骨折线两侧各固定4枚螺钉,但接骨板两侧紧邻骨折线的螺孔首次置钉时固定螺钉进入关节,经矫正后螺钉重新置入;D组为接骨板两端各固定2枚螺钉,行轴向压缩实验,观察骨折断端水平位移和剪切刚度。结果:A,B,C,D组断端水平位移为(1.58±0.17)mm,(1.62±0.14)mm,(2.66±0.26)mm,(4.68±0.35)mm;剪切刚度为(414.71±34.29)N/mm,(394.75±32.52)N/mm,(219.93±22.04)N/mm,(129.42±9.60)N/mm。水平位移及剪切刚度比较,A,B两组差异无统计学意义;A,B两组与C或D组差异均有统计学意义;C,D两组差异有统计学意义。结论:W型髋臼安全角度接骨板可强化髋臼后柱骨折内固定的稳定性,为该技术的临床应用奠定了基础。第四部分W型髋臼安全角度接骨板治疗髋臼后壁骨折的临床研究目的:探讨采用W型髋臼安全角度接骨板治疗髋臼后壁骨折的疗效。方法:2009年7月～2010年2月,收治22例髋臼后壁骨折患者。男20例,女2例;年龄18～61岁,平均35.7岁。采用随机数字法分为实验组(n=10)和对照组(n=12),分别采用W型髋臼安全角度接骨板和骨盆重建接骨板内固定治疗。评估两组术中X线监测螺钉位置情况,骨折复位质量,手术时间及出血量,骨折复位质量按Matta标准进行评估。结果:术中X线监测显示实验组中螺钉均未进入关节,对照组中螺钉未进入关节6例,螺钉进入关节2例,可疑螺钉进入关节4例,两组之间差异有统计学意义( P < 0.05 )。骨折复位质量两组之间差异无统计学意义( P > 0.05 )。手术时间及出血量两组之间差异均有统计学意义( P < 0.05 )。结论:采用W型髋臼安全角度接骨板治疗髋臼后壁骨折,可有效杜绝螺钉误入关节情况的发生,减少手术时间和出血量。第五部分早期康复对髋臼后壁粉碎骨折术后功能影响目的:观察早期康复治疗对髋臼后壁粉碎骨折患者术后肢体功能的影响。方法:选取河北医科大学第三医院骨科收治的髋臼后壁粉碎性骨折患者40例,男36例,女4例;年龄23 ~ 61岁,平均35.3岁;采用随机数字法分为康复组和对照组,每组20例。行重建钢板内固定后,康复组早期进行规范康复治疗,对照组自行遵医嘱进行功能锻炼。患者均于术后3,6,12个月进行随访,采用改良Merle d’Aubigne和Postel评分系统对患者髋关节功能进行评估。结果:术后3个月,6个月和12个月康复组改良Merle d’Aubigne和Postel评分为(13.10±2.05),(14.50±1.32)和(15.80±1.36);对照组为(11.20±2.80),(13.00±2.10)和(14.25±1.74),两组之间差异有统计学意义( P < 0.05 ),两组骨折复位质量之间差异无统计学意义( P > 0.05 )。结论:早期进行规范康复治疗有助于髋臼后壁粉碎骨折患者肢体功能恢复。更多还原

【Abstract】 Acetabular fractures are rapidly increasing recently. Displaced acetabular fractures frequently result from high-energy traumatic events?and may have significant primary organ system associated injuries. Rapid increase in the incidence of acetabular fractures and high expectations of the patients has compelled the orthopaedic surgeons across the world to do more research and study acetabular fractures. Surgery is the gold standard to treat unstable and incongruous acetabular fractures. Joint stability and early mobilization are the main goals of the surgery for acetabular fracture which can be achieved by anatomic reduction and rigid internal fixation. Screw penetration into the hip joint during operation is an unusual but potentially serious complication.Acetabular fractures in the posterior column, particularly involving the danger zone, are the most common form of acetabular fracture. They remain technically challenging to the orthopedic surgeons. Proper screw placement can avoid the complication. Some basic researches are indicated to evaluate the acetabulum characters. The majority of these studies focus on the orientation and morphology of the acetabulum, the transacetabular screw fixation and related vital structures for total hip arthroplasty. There are only a few anatomic studies regarding plate-screw fixation for acetabular fractures. The danger zone of the acetabulum, which was defined by Tile as that part of the posterior wall and column at the mid-acetabulum lying above the ischial spine, is frequently used in the fixation of posterior wall and posterior column. Screws directed perpendicular to posterior column in the danger zone would violate the hip joint. Ebraheim et al determined the exact configuration of the danger zone of the acetabulum, and proposed the safe pathway for screw placement in this zone based upon their study on the parallel cross-sections of cadaveric hemiplevises. After an extensive review of the existed literature, the comprehensive studies on the danger zone of the acetabulum by CT images have been barely reported so far. Therefore,our studies aim was to designed to measure and record the safe angles for screw placement and the thickness of posterior wall for different points in the danger zone of the acetabulum first, using the images of surface shadow display and multiplanar reconstruction of multislice spiral CT scan. Then the model of posterior column fracture of acetabulum was established, and the stability of internal fixation with the plate and lag screw for the posterior column fracture of acetabulum was evaluated. After that the W-shaped acetabular angular plate was designed, and the stability of internal fixation with the W-shaped acetabular angular plate and reconstruction plate for the simulated posterior column fracture of acetabulum was evaluated. Further investigation on the results of reconstruction of posterior wall fractures of the acetabulum by using the W-shaped acetabular angular plate. Finally the effect of early rehabilitation on the hip joint function for patients of the comminuted posterior wall fractures of the acetabulum after internal fixation was investigated.Part 1 Anatomic study of the safe angle for screw placement and the thickness of posterior wall in the danger zone of the adult acetabulumObjective: To evaluate the safe angle for screw placement and the thickness of posterior wall of the danger zone in adult acetabulum, and provide the data for the reconstruction of acetabular fracture.Methods: Thirty-two cadaveric adult bony semipelvic specimens and thirty adult volunteers were obtained to investigate the safe angle for screw placement and the thickness of posterior wall at the different points in the danger zone of acetabulum through analysis of the images of surface shadow display and multiplanar reconstruction of multislice spiral CT scan.Results: In specimens, the safe angles for 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0cm entry points medial to the lateral acetabular brim were( 49.23±11.54 )°, ( 42.48±8.97 )°, ( 29.53±7.86 )°, ( 23.68±6.20 )°,(18.42± 5.41)°, and (15.91±4.37)°respectively in males and those for 0.5, 1.0, 1.5, 2.0, and 2.5cm entry points were (45.02±8.82)°, (35.98±7.60)°, (23.77±6.29)°, (19.96±4.36)°, and (14.68±3.48)°respectively in females. The differences of the safe angle measured between the specimens and the volunteers were not statistically in the same gender ( P > 0.05 ). The safe angles for screw placement were statistically different between males and females for both specimens and volunteers ( P < 0.05 ).In specimens, the thickness of posterior wall for 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0cm entry points medial to the lateral acetabular brim were ( 0.64±0.13)cm, ( 0.97±0.25)cm, (1.46±0.40)cm,(2.14±0.46)cm,(2.61±0.47)cm, and (2.96±0.42)cm respectively in males and those for 0.5, 1.0, 1.5, 2.0, and 2.5cm entry points were (0.51±0.08)cm,(0.93±0.22)cm,(1.45±0.31)cm,(2.02±0.39)cm, and(2.50±0.50)cm respectively in females. The differences of the thickness measured between the specimens and the volunteers were not statistically in the same gender ( P > 0.05 ). The thickness were statistically different between males and females for both specimens and volunteers ( P < 0.05 ).Conclusion: The data derived from the study will be valuable for screw placement during internal fixation of posterior column and posterior wall fractures.Screw insertion at the points of 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0cm medial to the lateral acetabular brim and angled medially no less than 75°, 65°, 50°, 45°, 35°, and 30°in males, and those at the points of 0.5, 1.0, 1.5, 2.0, and 2.5cm angled medially no less than 65°, 55°, 45°, 40°, and 25°in females respectively, could avoid screw penetration of the hip joint.The length of screw at the points of 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0cm medial to the lateral acetabular brim would be less than that of 1/2,1/3,1/3,1/2,1/2 , and 1/2 from entry point to lateral acetabular brim in males , and those for 0.5, 1.0, 1.5, 2.0, and 2.5cm points would be all less than that of 1/2 in females when screw insertion perpendicular to the surface of posterior column. Part 2 Establishing the model of posterior column fracture of acetabulum and biomechanical evaluation of the stability between plate and lag screw internal fixationObjective: To establish the model of posterior column fracture of acetabulum, and evaluate the stability of internal fixation with the plate and lag screw for the posterior column fracture of acetabulum.Methods: A total of 20 preserved cadaveric semipelvic specimens were randomly divided into two groups. Models of isolated posterior column fracture of acetabulum were established. The models were fixed with plate or lag screw. Under vertical compression load of 3 times body weight, the horizontal displacements of the fracture site were measured and the shear rigidity of two fixation conditions was compared.Results: The horizontal displacements of the fracture site fixed with plate and lag screw were (1.64±0.17) mm and (1.70±0.20) mm. The shear rigidity fixed with plate and lag screw were (392.40±41.22) N/mm and (386.33±50.07) N/mm. The differences of both horizontal displacements and shear rigidity between the two groups were not significant (P > 0.05).Conclusions: The fracture model provides an ideal tool for biomechanical evaluation of the stability of internal fixation for the posterior column fracture of acetabulum. There was no significant difference in the stability of internal fixation with the plate and lag screw for the posterior column fracture of acetabulum.Part 3 Biomechanical evaluation on the W-shaped acetabular angular plate internal fixation of the fractures of acetabular posterior columnObjective: To evaluate the stability of internal fixation with the W-shaped acetabular angular plate and reconstruction plate for the simulated posterior column fracture of acetabulum.Methods: Twenty preserved cadaveric semipelvic specimens were divided into four groups randomly. Models of isolated posterior column fractures of acetabulum were established. Group A was fixed with the W-shaped acetabular angular plate. Group B, C, and D were fixed with one of the three methods of reconstruction plate:four screws on each side of the fracture (group B); four screws on each side of the fracture , but the screw closest to the fractrue on each side malplaced into the acetabulum primarily and correct placement finally(group C); two screws at the each end of plate(group D). Under vertical compression load of 3 times body weight, the horizontal displacements of the fracture site were measured and the shear rigidity of different internal fixation methods were compared.Results: The horizontal displacements of the fracture site in Group A, B, C, and D were (1.58±0.17) mm, (1.62±0.14) mm, (2.66±0.26) mm, and (4.68±0.35) mm respectively. The shear rigidity of internal fixation methods in Group A, B, C, and D were (414.71±34.29) N/mm, (394.75±32.52) N/mm, (219.93±22.04) N/mm, and (129.42±9.60) N/mm respectively. The differences of both horizontal displacements and shear rigidity between Group A and B were not statistically different ( P > 0.05 ). The horizontal displacements and shear rigidity in both Group A and B were statistically different from those of the?Group C or D ( P < 0.05 ). The differences of both horizontal displacements and shear rigidity between Group C and D were statistically different ( P < 0.05 ).Conclusion: The W-shaped acetabular angular plate can improve the internal fixation stability of posterior column fracture of acetabulum.Part 4 Application of the W-shaped acetabular angular plate in treatment of posterior wall fracture of acetabulumObjective: To assess the results of reconstruction of posterior wall fractures of the acetabulum by using the W-shaped acetabular angular plate.Methods: Twenty-two patients ( 20 men, 2 women, mean age 35.7 years, range 18–61 years ) with posterior wall fracture of the acetabulum underwent reconstruction of the posterior wall were randomly divided into study group ( 10 cases ) and control group ( 12 cases ) during the period of July 2009 to February 2010. The patients of study group was fixed by using the W-shaped acetabular angular plate and control group by pelvic reconstruction plate. The results of the intraoperative fluoroscopic images,radiographic evaluation of the quality of reduction,the duration of operation, and the loss of blood were compared. Radiographic evaluation of the quality of reduction was according to criteria developed by Matta.Results: The intraoperative fluoroscopic images confirmed extra-articular screw placement in all cases in study group. In the control group, no intra-articular screw was noted in 6 patients, intra-articular screw placement was seen in 2 patients, and definitive location of periarticular hardware could not be determined in 4 patients. The differences between the two groups were statistically significant ( P < 0.05 ). Radiographic evaluations of the quality of reduction were not significantly different between the two groups. There were significant differences in both the duration of operation and the loss of blood between the two groups ( P < 0.05 ).Conclusion: Reconstruction of posterior wall fractures of the acetabulum via the W-shaped acetabular angular plate could avoid screw penetration of the hip joint , reduce the duration of operation and the loss of blood during surgery.Part 5 Effect of early rehabilitation on the hip joint function in patients of comminuted posterior wall fractures of the acetabulum after internal fixationObjective: To investigate the effect of early rehabilitation on the hip joint function for patients of the comminuted posterior wall fractures of the acetabulum after internal fixation.Methods: Forty patients of comminuted posterior wall fractures of the acetabulum were divided into rehabilitation group ( n = 20 ) and control group ( n = 20 ) randomly.All the patients were fixed with reconstruction plate, the patients in rehabilitation group received early standard rehabilitation exercises intervention and those in control group received usual care. The clinical result was evaluated with the score of Merle d’Aubigne and Postel.The fracture reductions were judged according to the criteria of Matta.Results: The scores of Merle d’Aubigne and Postel for 3, 6 , and 12 month after operation were ( 13.10±2.05 ), ( 14.50±1.32 ), and ( 15.80±1.36 ) respectively in rehabilitation group and those were ( 11.20±2.80 ), ( 13.00±2.10 ) , and ( 14.25±1.74 ) respectively in control group. The differences of the scores between the two groups were significant ( P < 0.05 ). In regard of fracture reductions, there was insignificant statistical difference between the two groups ( P > 0.05 ).Conclusion: The early rehabilitation exercises may improve the hip joint function for patients of the comminuted posterior wall fractures of the acetabulum after surgery.更多还原