【作者】 刘松；

【导师】 张英泽；

【作者基本信息】 河北医科大学 ， 外科学， 2012， 硕士

【摘要】 目的：螺钉穿入髋关节是一种少见但严重的并发症。目前,涉及骨盆缘下钢板螺钉内固定安全操作的相关解剖学研究极少。本研究中我们采用多层螺旋CT的容积重建(volume reconstruction, VR)和多平面重建(multiplanar reconstruction, MPR)技术对髋臼危险区在方形区范围内骨盆缘下钢板螺钉内固定平面各位点的髋臼厚度和螺钉固定安全角度进行研究。方法：取12个成年男性防腐半骨盆标本,剥离全部软组织。首先,对骨盆标本进行扫描。将骨盆标本置于CT扫描床,仰卧位,保持髂前上棘和耻骨联合在同一额状面上,两侧髋臼扫描范围自髂嵴至坐骨结节。然后,对扫描的原始数据行VR重建和MPR重建处理。MPR图像平面与方形区表面部位相垂直,第1个扫描断面经过髂耻线,扫描范围为96mm。骨盆重建板的宽度为10mm,螺孔直径为椭圆形,长径为7mm,短径为4mm,短径垂直于重建板的长轴。螺钉的进钉中心位置距髂耻线的距离为5mm,因此我们将骨盆缘下第5个扫描断面作为基准断面。分析基准断面及其上方1个及下方2个断面,测量各断面相关数据。我们将髋臼在方形区的投影区域定义为方形区髋臼危险区。自髋臼前、后缘软骨下骨板向骨盆内侧做垂线,确定危险区及安全区。测量髋臼前界在方形区的投影点至耻骨联合的距离以及髋臼后界在方形区投影点至骶髂关节的距离。测量危险区长度,于髋臼内侧距髋臼前界投影点向后每间隔5mm标记点位,即螺钉的进钉点。自进钉点做骨盆内侧的垂线,测量进钉点到髋臼关节面的最短距离。距离髋臼内缘5mmm做髋臼内缘的平行线,自进钉点向髋臼内缘平行线做切线,该切线与相应进钉点骨盆内侧垂线的夹角为θ角,即螺钉的安全进钉角度。测量并记录危险区各进钉点0角的大小。应用SPSS13.0统计学软件对所测数据进行统计学处理,不同平面点位数据进行区组设计方差分析,P<0.05为差异有统计学意义。如果差异有统计学意义,进一步应用SNK (Student-Newman-Keuls)检验和LSD(least significant difference)检验进行两两比较。结果：4至7断面上髋臼前界在方形区的投影点至耻骨联合的距离分别为(62.29±4.39)mmm、(60.98±5.83)mm、(60.75±3.88)mmm和(59.67±3.58)mm,数据在断面之间差异无统计学意义(P>0.05),在标本之间差异有统计学意义(P<0.05)。4至7断面上髋臼后界在方形区投影点至骶髂关节的距离分别为(40.53±7.06)mm、(40.38±6.41)mm、(40.52±7.07)mm和(41.15±6.66)mm。数据在断面之间差异无统计学意义(P>0.05),在标本之间差异有统计学意义(P<0.05)。4至7断面上危险区长度分别为(25.83±2.19)mm、(27.81±1.97)mm、(28.46±2.12)mm和(30.45±2.61)mm。数据在标本和断面之间差异有统计学意义(P<0.05)。向前方倾斜进钉时,骨盆内侧前界投影点、距前界投影点5mm、10mm、15mmm、20mmm及后界投影点的安全进钉角度,在断面4上分别为(10.54±0.53)。、(22.01±2.94)。、(32.50±4.28)。、(41.09±5.34)。、(48.10±5.27)°和(59.00±4.22)。；在基准断面(断面5)上分别为(10.46±1.35)。、(22.31±2.65)。、(32.68±2.76)°、(41.23±2.27)°、(49.63±4.37)。和(63.15±3.66)。；在断面6上分别为(10.08±1.16)。、(23.45±2.22)°、(32.47±4.13)°、(42.61±2.61)°、(51.55±4.37)。和(65.72±4.29)°；在断面7上分别为(10.52±1.18)。、(22.23±2.30)。、(33.46±4.23)。、(42.91±4.31)。、(51.76±7.02)。和(69.41±3.27)。。向前方倾斜进钉时,骨盆内侧前界投影点、距前界投影点5mmm、10mm点位的安全进钉角度在断面之间差异无统计学意义(P>0.05),骨盆内侧后界投影点、距前界投影点15mmm、20mmm点位的安全进钉角度在断面之间差异有统计学意义(P<0.05)。向后方倾斜进钉时,骨盆内侧前界投影点、距前界投影点5mm、10mm、15mmm、20mm及后界投影点的安全进钉角度,在断面4上分别为(55.01±5.31)。、(41.50±4.64)。、(33.75±4.27)。、(25.23±4.21)。、(21.26±5.16)。和(8.15±0.89)。；在基准断面(断面5)上分别为(58.59±5.37)。、(50.76±5.28)。、(43.43±5.60)。、(34.93±6.08)。、(25.89±5.14)。和(8.45±0.74)。；在断面6上分别为(62.96±6.02)。、(54.66±6.97)。、(47.76±9.40)。、(38.51±6.15)。、(28.00±5.10)°和(9.03±1.10)。；在断面7上分别为(65.27±6.26)。、(57.91±5.95)。、(51.04±4.48)°、(42.44±4.19)°、(33.47±5.56)°和(8.81±1.31)。。向后方倾斜进钉时,骨盆内侧前界投影点、距前界投影点5mm、10mm、15mm、20mm及后界投影点的安全进钉角度在断面之间差异有统计学意义(P<0.05)。骨盆内侧前界投影点、距前界投影点5,10,15,20mm及后界投影点的髋臼厚度,在断面4上分别为(27.24±1.76)mm、(21.39±1.62)mm、(19.50±2.15)mm、(19.93±2.34)mm、(22.95±2.66)mm和(36.02±2.41)mm;在基准断面(断面5)上分别为(27.29±2.29)mm、(20.73±1.70)mm、(18.38±2.10)mm、(18.21±2.16)mm、(19.90±2.14)mm和(36.19±2.13)mm；在断面6上分别为(27.46±2.57)mm、(19.86±1.40)mm、(17.56±1.73)mm、(17.36±2.51)mm、(18.82±2.43)mm和(36.41±2.89)mm；在断面7上分别为(27.70±2.72)mm、(19.86±2.26)mm、(16.83±2.20)mm、(16.38±2.28)mm、(17.74±2.35)mm和(35.50±3.07)mm。骨盆内侧前界及后界投影点点位的髋臼厚度在断面之间差异无统计学意义(P>0.05),其他各点位的髋臼厚度在断面之间差异有统计学意义(P<0.05)。结论：本研究数据对于骨盆缘下钢板螺钉内固定操作具有指导意义。在骨盆缘下髋臼危险区放置螺钉时,前界投影点、距髋臼前缘5mm及10mm点位应斜向前方进钉,角度分别不小于15°、30°和45°,可防止螺钉穿入髋关节。距离前缘15mm、20mm及髋臼后界投影点点位应斜向后方置钉,进钉角度依次不小于50°、45°和15°,可防止螺钉穿入髋关节。该研究方式有助于对拟使用骨盆缘下钢板的患者进行个体化治疗。更多还原

【Abstract】 Objective:Screw penetration into the hip joint during operation is an unusual but potentially serious complication. The comprehensive studies on clinical anatomic study of infrapectineal plate-screw fixation have been barely reported so far. The study is designed to measure and record the the safe angles for screw placement from different entry points and the thickness of the acetabulum in the infrapectineal plate-screw fixation plane, using volume reconstruction (VR) and multiplanar reconstruction (MPR) technology.Methods:Twelve cadaveric adult antiseptic hemipelvic specimens were obtained for the purpose of the study. In preparation for this study, all soft tissue attachments were cleaned from the specimens. The CT images of the bony pelvic specimens from crista iliaca to ischial tuberosity were initially obtained for the purpose of the study. Each specimen was placed in the supine position on a radiolucent carbon fiber table. The data were postprocessed with volume reformation and multiplanar reconstruction technology. Each MPR section was perpendicular to the quadrilateral plate and the scan range was96mm. The first section went through lineae iliopectinea of pelvis. The width of pelvic reconstruction plate is10mm. The screw holes are in the form of an ellipse, of which the major axis is horizontal, and7mm long; the minor axis is vertical, and4mm long. In our study, the fifth section inferior to the pelvic brim was defined as the reference section. Four MPR sections perspecimen were selected, including the reference section, one sections superrior to it, and two sections inferior to it.In our study, the projection that acetabulum projects onto the quadrilateral was defined as the danger zone of acetabulum. The anterior and posterior boundary of the acetabulum were projected and marked on the medial line of pelvic. The distances on the medical line of plate-screw fixation plane from the anterior projection.to pubic symphysis and from posterior projection to sacroiliac joint were recorded for each section. The width of danger zone was measured. Points were then determined at intervals of every5mm posterior to anterior projection and represented proposed entry points for screw placement. The perpendicular distance (thickness) from the entry point to the inner surface of acetabular was measured and recorded for each entry point. The angle, which was formed by a line directly tangent to the subchondral plate of the acetabulum from the entry point and the line perpendicular to the medial line of pelvic, was designated0and recorded. To avoid screw penetration into the hip joint, the nearest thread should be kept more than0.5cm away from the subchondral plate.The data were analyzed using SPSS (Statistical programmed for Social Sciences, version13.0,Chicago, IL) computer software. Comparisons of the data were made by randomized block design analysis of variance. Differences were regarded as statistically significant when P values were less than0.05. In that case, Student-Newman-Keuls test and least significant difference test would be made.Result:From section4to section7,the distances on the medical line of plate-screw fixation plane from the anterior projection to pubic symphysis were (62.29±4.39) mm,(60.98±5.83) mm,(60.75±3.88) mm and (59.67±3.58) mm respectively and those from posterior projection to sacroiliac joint were (40.53±7.06) mm,(40.38±6.41) mm,(40.52±7.07) mm and (41.15±6.66) mm respectively. The differences of the distance from the anterior projection to pubic symphysis and those from posterior projection to sacroiliac joint among the specimens were statistically (P<0.05), but the differences among sections were not statistically (P>0.05). The width of danger zone were (25.83±2.19) mm,(27.81±1.97) mm,(28.46±2.12) mm and (30.45±2.61) mm respectively. The differences of the width of danger zone were statistically between specimens and sections (P<0.05)When the screws inclined forward, the safe angles for anterior projection,5,10,15,20mm and posterior projection entry points were (10.54±0.53)°,(22.01±2.94)°,(32.50±4.28)°,(41.09±5.34)°,(48.10±5.27)°and (59.00±4.22)°respectively in section4. In section5, they were (10.46±1.35)°,(22.31±2.65)°,(32.68±2.76)°,(41.23±2.27)°,(49.63±4.37)°and (63.15±3.66)°respectively. In section6, they were (10.08±1.16)°,(23.45±2.22)°,(32.47±4.13)°,(42.61±2.61)°,(51.55±4.37)°and (65.72±4.29)°respectively. In section7, they were (10.52±1.18)°,(22.23±2.30)°,(33.46±4.23)°,(42.91±4.31)°,(51.76±7.02)°and (69.41±3.27)°respectively. The differences of the safe angles were not statistically among anterior projection,5mm and10mm entry points(P>0.05). However, the differences of the safe angles were statistically among posterior projection,15mm and20mm entry points (P<0.05). When the screws inclined backward, the safe angles for anterior projection,5,10,15,20mm and posterior projection entry points were (55.01±5.31)°,(41.50±4.64)°,(33.75±4.27)°,(25.23±4.21)°,(21.26±5.16)°and (8.15±0.89)°respectively in section4. In section5, they were (58.59±5.37)°,(50.76±5.28)°,(43.43±5.60)°,(34.93±6.08)°,(25.89±5.14)°and (8.45±0.74)°respectively. In section6, they were (62.96±6.02)°,(54.66±6.97)°,(47.76±9.40)°,(38.51±6.15)°,(28.00±5.10)°and (9.03±1.10)°respectively. In section7, they were (65.27±6.26)°,(57.91±5.95)°,(51.04±4.48)°,(42.44±4.19)°,(33.47±5.56)°and (8.81±1.31)°respectively. The differences of the safe angles were statistically among anterior projection,5,10,15,20mm and posterior projection entry points (P<0.05)The thickness of acetabulum for anterior projection,5,10,15,20mm and posterior projection entry points were (27.24±1.76) mm,(21.39±1.62) mm,(19.50±2.15) mm,(19.93±2.34) mm,(22.95±2.66)mm and (36.02±2.41) mm respectively. In section5, they were (27.29±2.29)mm,(20.73±1.70) mm,(18.38±2.10)mm,(18.21±2.16)mm,(19.90±2.14)mm and(36.19±2.13) mm respectively. In section6, they were (27.46±2.57) mm,(19.86±1.40) mm,(17.56±1.73)mm,(17.36±2.51)mm,(18.82±2.43)mmand(36.41±2.89) mm respectively. In section7, they were (27.70±2.72) mm,(19.86±2.26) mm,(16.83±2.20)mm,(16.38±2.28)mm,(17.74±2.35)mmand(35.50±3.07) mm respectively. The differences of the thickness of acetabulum were not statistically among anterior projection and posterior projection entry points (P>0.05). The differences of the thickness of acetabulum were statistically among5,10,15and20mm entry points (P<0.05)Conclusion:The data derived from the study will be valuable for screw placement during infrapectineal plate-screw fixation. Screw insertion inclining forward at the points of anterior projection,5mm and10mm no less than15°,30°and45°respectively, could avoid screw penetration of the hip joint. However, when the screw inclined backward, screw insertion at the points of15mm,20mm and posterior projection no less than50°,45°and15°respectively, could avoid screw penetration of the hip joint. The method of the study is helpful to make individual perioperative planning for safer infrapectineal plate fixation.更多还原