骶髂关节经皮拉力螺钉固定钉道参数的解剖学测量

目的 为经S_1椎弓根水平骶髂关节拉力螺钉固定术提供应用解剖学依据.方法 2008年6月至2009年7月收集50个成人骨盆的螺旋CT扫描数据,重建骨盆三维模型,模拟经皮托力螺钉固定.测量S_1椎弓根的宽和高、骶髂关节拉力螺钉的进针点和进针方向、进针点至S_1椎体对侧前皮质和髂后上棘的距离.结果 S_1椎弓根的宽和高分别为(20.43±1.63)mm和(20.26±0.99)mm;2枚螺钉的进针点均在髂前上棘和髂后上棘的连线上方,至髂后上棘的距离分别为(49.87±6.80)mm和(51.11±7.15)mm.螺钉平行进入S_1椎弓根,与髂骨翼后外侧面垂直,与冠状面和欠状面的夹角分别为18.35°±5.20°和77.62°±3.98°.进针点到S1椎体对侧前皮质的距离分别为(76.08±4.32)mm和(77.62±3.98)mm.骶髂关节拉力螺钉的长度、S_1椎弓根的高度和宽度、进针点到髂后上棘的距离、进针点与冠状面的夹角在男女之间差异有统计学意义(P<0.05).结论 正常成人在S_1椎弓根水平均町置入2枚直径为6.5 mm的拉力螺钉,钉道参数的解剖学测量为骶髂关节拉力螺钉固定手术导航模板的设计提供了理论基础.     

骶髂关节螺钉固定应用及CT与解剖学研究

目的 :采用CT扫描测量髂骨翼后外侧面至第 1骶椎 (S1)的距离和S1椎弓根宽 ,为临床上经骶髂关节螺钉固定治疗后骨盆环不稳定提供参考。方法 :对 2 2例中国成人的骨盆标本共 4 4侧骶髂关节进行CT和解剖学研究 ,测量S1椎弓根宽 ,髂骨翼后外侧面的进针点至S1椎弓根中心距离 ,进针点至S1椎体对侧前皮质距离 ,并对解剖测量值和CT测量值进行比较。在实验研究的基础上 ,对 11例垂直不稳定后骨盆环骨折进行骶髂螺钉固定。结果 :髂骨翼后外侧面的进针点至椎弓根中心距离解剖和CT测量值分别为 4 9 5± 4 0mm和 4 9 2± 3 9mm ,两者差异无显著性 (P >0 0 5 ) ;进针点至S1椎体对侧前皮质距离解剖和CT测量值分别为 86 9± 4 6mm和 86 4± 4 4mm ,两者差异无显著性 (P >0 0 5 ) ;S1椎弓根宽解剖和CT测量值分别为 2 7 7± 2 0mm和 2 0 7± 2 5mm ,两者差异有显著性 (P <0 0 1)。临床 11例共 13枚骶髂螺钉均准确置入 ,无骨皮质穿破或神经血管损伤等并发症。结论 :术前CT扫描可准确地推算骶髂螺钉长度 ,具有临床实用意义。     

经S2椎弓根骶髂关节螺钉固定CT和解剖学研究

目的 :为经S2 椎弓根水平骶髂关节螺钉固定提供解剖学依据。方法 :对 2 2个骨盆标本进行解剖学研究 ,测量经S2 椎弓根骶髂关节螺钉固定的进针点、进针方向、钉道直径、进针点至S2 椎体中心和椎弓根中心距离、S2 椎弓根横断面形状。结果 :螺钉进针点在髂后下棘前方 2 8 7mm (15 0～34 5mm) ,坐骨切迹上方 15 3mm(10 0～ 2 2 0mm) ;进针方向垂直于正中矢状面且与髂骨翼外侧面夹角为 6 2 4°(5 5°～ 72°) ;钉道直径为 11 5mm (8 5～ 14 0mm) ;进针点至S2 椎体中心距离 6 4 7mm(5 5 3～ 77 6mm) ;进针点至S2 椎弓根中心距离为 5 3 1mm(45 3～ 6 4 8mm) ;S2 椎弓根横截面呈三角形。结论 :经S2 椎弓根水平骶髂关节螺钉固定的进针点应位于髂后下棘前方 30mm ,坐骨切迹上方15mm ;进针方向垂直于正中矢状面且与髂骨翼外侧面夹角为 6 0°;S2 椎弓根钉道直径较小 ,经S2 椎弓根水平骶髂关节螺钉固定应选择直径较小的短螺钉。     

数字化仿真技术确定最佳骶髂螺钉通道的研究

目的:探索一种基于数字化仿真技术的最佳骶髂螺钉通道测量方法,用于指导计算机导航下的进钉。方法:将8例成人无病变骨盆CT数据集导入Mimics 10.01进行三维重建,利用数字化仿真技术建立骶椎阴模,利用透视阴模内表面的方法确定最佳骶髂螺钉通道,利用计算机辅助作图结合空间解析几何计算测量相关参数。结果:8例16侧的S1最佳骶髂螺钉通道均可用此方法确定。最佳骶髂螺钉通道参数值:半径,均>7.3mm,其中男8.75±0.72mm,女8.38±0.67mm;进钉深度,男78.44±3.43mm,女74.07±6.04mm;与矢状面夹角,男72.62°±5.01°,女79.65°±7.59°;与横截面夹角,男13.28°±6.33°,女9.60°±4.17°;与冠状面夹角,男9.99°±7.67°,女2.01°±1.58°;与S1椎体上表面夹角,男14.91°±6.48°,女7.62°±5.88°;S1最佳进钉终点位于导航出口位透视图像上上下方向最大径的2∶5处,左右方向最大径1∶1处及入口位上下方向最大径3∶1处;S1最佳进钉点位于导航出口位透视图像上上下方向最大径的3∶5处,左右方向最大径2∶5处及入口位上下方向最大径5∶2处;S1最佳进钉终点约在S1椎体中轴线上下2∶3及前后径3∶5处。与矢状面夹角、与冠状面夹角、与S1椎体上表面夹角男女比较有统计学差异(P<0.05),余无统计学差异(P>0.05)。结论:利用数字化仿真技术可以在几何学上精确确定并测量最佳骶髂螺钉通道,用以指导计算机导航下进钉。双侧S1最佳骶髂螺钉通道具有对称性。S1椎弓根可以置入2枚直径7.3mm的骶髂螺钉。     

经皮骶髂关节螺钉导向装置的数字化研究

[目的]经皮拉力螺钉固定骶髂关节脱位及骶骨骨折导向装置数字化研究的可行性。[方法]利用Mimics 10.01软件对100例正常成人骨盆(200例半骨盆)的螺旋CT扫描数据重建三维模型,以髂前上棘(A)与髂后上棘(B)骨性突出点,S_1棘突顶点为置钉平面(CP1),髂前上棘与髂后上棘骨性突出点连线后1/3为进针点,探索安全置钉终点(O)到S_1棘突定位点的最大、最小轴心距离(SO_1,SO_2)及置钉安全长度。根据此结论设计导向装置。[结果]200例三维半骨盆置钉平面有180例(90.0%)平均分割S_1椎弓根狭窄处,良好14例,差6例,成功率为97%。在成功置入平面骨盆模型中置入模拟螺钉,测得男性MSO_1为(37.64±7.26)mm,MSO_2为(60.74±11.43)mm,FSO_1为(35.15±7.17)mm,FSO_2为(55.89±11.17)mm。利用SPSS 17.0软件分析,其中t值分别为12.574,24.122,11.434,17.213;男女SO_1、SO_2差异有统计学意义(P0.05)。[结论]以CP1为操作平面,AB连线后1/3为进针点,O点为置钉终点可作为导向装置设计思路。     

后路短螺丝钉固定术治疗骶髂关节骨折脱位实验研究与临床

目的探讨后路短螺丝钉固定治疗骶髂关节骨折脱位的安全性和疗效.方法骶骨应用解剖,骶髂关节脱位模型生物力学实验,11例病人手术方法及疗效分析.结果应用解剖,(1)骶骨耳状面下缘在S2、3后孔连线中下1/3以下者占86.6%;(2)S2、3侧柱呈直角梯形.S2侧柱横截面前后径(28.3±1.7)mm,S3侧柱横截面前后径中部为(21.4±1.5)mm,中下1/3处为(8.4±1.1)mm;(3)骶后中间嵴到耳状面中轴垂直距离S2水平处(26.7±2.6)mm,S3水平处(27.2±2.8)mm.骶后孔连线S1、2间(17.4±1.6)mm,S2、3间(17.6±2.1)mm.生物力学(1)2枚短螺丝钉固定可以控制骶髂关节的移位,同时前部固定后明显增加骨盆的强度和刚度,并可以对抗剪切力.临床部分治疗11例病人平均随访5.4年,优7例,良4例.结论后路短螺丝钉经过骶骨侧柱中上部,不超过骶孔连线固定骶髂关节,不但能获得牢固的固定,同时能有效的避免神经损伤,骶髂关节植骨融合其远期疗效好.     

骶髂关节脱位直视复位空心螺钉固定的基础研究及临床应用

目的研究总结直视复位、经皮空心螺钉固定骶髂关节脱位的解剖学基础、生物力学稳定性以及初步的临床疗效。方法采用12具(24侧)福尔马林固定的尸体标本,测量骶骨翼上缘L_4、L_5神经根前支和闭孔神经至骶髂关节的距离。采用6具新鲜尸体骨盆标本建立骶髂关节脱位模型,比较本固定法与传统后路经皮骶髂关节螺钉和前路钢板固定的稳定性。同期采用本固定法手术治疗17例Tile C型骨折患者,随访疗效。结果①L_4、L_5神经根及闭孔神经分别距离骶髂关节(20．24±1．12)mm、(23．80±1．43)mm、(16．26±2．07)mm；②本固定方式与后路经皮骶髂关节螺钉的稳定性无显著性差异,但优于前路钢板固定；③临床治疗17例患者,平均随访2．2年,根据Matta功能评定标准,功能恢复均为优良。结论该固定系统具有良好的生物力学稳定性,同时可避免神经损伤、临床效果好、操作简便,便于基层医院开展。     

后路短螺丝钉固定术治疗骶髂关节骨折脱位实验研究与临床

目的:探讨后路短螺丝钉固定治疗骶髂关节骨折脱位的安全性和疗效。方法:骶骨应用解剖,骶髂关节脱位模型生物力学实验,11例病人手术方法及疗效分析。结果:应用解剖,(1)骶骨耳状面下缘在S_(2、3)后孔连线中下1/3以下者占86.6％;(2)S_(2、3)侧柱呈直角梯形。S_2侧柱横截面前后径(28.3±1.7)mm,S_3侧柱横截面前后径中部为(21.4±1.5)mm,中下1/3处为(8.4±1.1)mm;(3)骶后中间嵴到耳状面中轴垂直距离:S_2水平处(26.7±2.6)mm,S_3水平处(27.2±2.8)mm。骶后孔连线:S_(1、2)间(17.4±1.6)mm,S_(2、3)间(17.6±2.1)mm。生物力学:(1)2枚短螺丝钉固定可以控制骶髂关节的移位,同时前部固定后明显增加骨盆的强度和刚度,并可以对抗剪切力。临床部分:治疗11例病人平均随访5.4年,优7例,良4例。结论:后路短螺丝钉经过骶骨侧柱中上部,不超过骶孔连线固定骶髂关节,不但能获得牢固的固定,同时能有效的避免神经损伤,骶髂关节植骨融合其远期疗效好。     

骶髂螺钉置入S1椎弓根的形态学研究

目的研究S1椎弓根的形态学特点，探讨经骶髂关节置入S1椎弓根螺钉的可行性。方法测量16具尸体骨盆标本双侧S1椎弓根前后缘的高度、深度(S1椎弓根最狭窄处的宽度)、骶翼深度、骶翼高度。测量骨盆出口位X线片上S1椎弓根的高度，并与肉眼解剖比较。在轴位CT图像上测量髂骨后缘到骶翼、S1椎弓根、S1椎弓根纵轴的距离、髂骨外板与骶椎前缘皮质的距离。观察S1椎弓根矢状切面，评估置入2枚经S1椎弓根骶髂螺钉的安全区。结果椎弓根前后缘的高度平均为30．2mm、26．Imm，椎弓根深度和骶翼深度平均为27．8mm、45．8mm，骶翼后部平均高度为28．7mm。骨盆出口位X线片上S1椎弓根的平均高度是20mm，小于肉眼解剖测量结果(P＜0．0001)。轴位CT图像上，S1椎弓根纵轴在髂骨外板投影点到髂骨后缘的距离平均为32．5mm，到坐骨大切迹最高点的距离平均为38．6mm，髂骨外板到S1椎体前缘皮质的距离平均为105．2mm。结论置入1枚S1椎弓根螺钉是安全的，常规置入2枚椎弓根螺钉可能较困难。     

髂一髂拉力螺钉在骨盆后环损伤中应用的安全性研究

目的利用CT测量数据,为跨骶骨的髂一髂拉力螺钉技术在骨盆后环损伤中的应用提供理论依据。方法选取2008--2012年问在我院行骨盆cT检查的患者资料,男、女各60例,分别测量骨盆后环在髂后上棘水平双侧髂骨最佳进针点之间连线的距离以及该连线距离骶管后缘和髂后上棘高点的距离,通过SPSS14．0软件对数据进行分析,计量数据以（x±s）来表示,以获得最佳进针范围。结果髂后上棘高点距离最佳进针点连线的垂直距离男性为（1．66±0．358）cm,女性为（1．38±0．267）cm;最佳进针点连线距离骶管后缘的垂直距离男性为（0．76±0．204）cm,女性为（1．34±0．328）cm;髂后上棘水平在安全进针范围内双侧髂骨外板之间的距离的平均数值,男性为（11．56±0．652）cm,女性为（12．36±0．968）cm。结论跨骶骨的髂一髂拉力螺钉技术在骨盆后环损伤中的应用安全。     

Correlating preoperative imaging with intraoperative fluoroscopy in iliosacral screw placement

Background

Percutaneous iliosacral screw placement can successfully stabilize unstable posterior pelvic ring injuries. Intraoperative fluoroscopic imaging is a vital component needed in safely placing iliosacral screws. Obtaining and appropriately interpreting fluoroscopic views can be challenging in certain clinical scenarios. We report on a series of patients to demonstrate how preoperative computed tomography (CT) imaging can be used to anticipate the appropriate intraoperative inlet and outlet fluoroscopic views.

Materials and methods

24 patients were retrospectively identified with unstable pelvic ring injuries requiring operative fixation using percutaneous iliosacral screws. Utilizing the sagittal reconstructions of the preoperative CT scans, anticipated inlet and outlet angle measurements were calculated. The operative reports were reviewed to determine the angles used intraoperatively. Postoperative CT scans were reviewed for repeat measurements and to determine the location and safety of each screw.

Results

Preoperative CT scans showed an average inlet of 20.5° (7°–37°) and an average outlet of 42.8° (30°–59°). Intraoperative views showed an average inlet of 24.9° (12°–38°) and an average outlet of 42.4° (29°–52°). Postoperative CT scans showed an average inlet of 19.4° (8°–31°) and an average outlet of 43.2° (31°–56°). The average difference from preoperative to intraoperative was 4.4° (−21° to 5°) for the inlet and 0.45° (−9° to 7°) for the outlet. The average difference between the preoperative and postoperative CT was 2.04° (0°–6°) for the inlet and 2.54° (0°–7°) for the outlet.

Conclusion

There is significant anatomic variation of the posterior pelvic ring. The preoperative CT sagittal reconstruction images allow for appropriate preoperative planning for anticipated intraoperative fluoroscopic inlet and outlet views within 5°. Having knowledge of the desired intraoperative views preoperatively prepares the surgeon, aids in efficiently obtaining correct intraoperative views, and ultimately assists in safe iliosacral screw placement.

Level of evidence

IV, Retrospective case series.     

骶髂关节螺钉联合钉棒系统在Tile B型骨盆骨折中的临床应用

目的分析经皮骶髂关节螺钉联合前环钉棒系统内固定在Tile B型骨盆骨折中联合应用的临床疗效。方法自2010-01—2014-01诊治64例Tile B型骨盆骨折,随机分为试验组(采用经皮骶髂关节螺钉联合前环钉棒系统内固定)和对照组(采用经皮骶髂关节螺钉联合前环外固定架固定),对2组手术时间、术中出血量、术后下地时间、Majeed功能评分、术后并发症发生率进行分析比较。结果 2组术中出血量及手术时间比较差异无统计学意义(P0.05),试验组的术后下床时间明显短于对照组,差异有统计学意义(t=2.754,P=0.019)。试验组的术后平均Majeed功能评分明显高于对照组,差异有统计学意义(t=45.120,P=0.033)。2组肢体功能优良率比较差异无统计学意义(P0.05)。试验组并发症发生率明显低于对照组,差异有统计学意义(P0.05)。结论经皮骶髂关节螺钉联合前环钉棒系统内固定是Tile B型骨盆骨折的一种有效安全的治疗方法,能提高术后肢体功能,且有效减少术后并发症的发生。     

Accuracy of computer-assisted iliosacral screw placement using a hybrid operating room

IntroductionIn recent years hybrid operating rooms were established all over the world. In our setting we combined a 3D flat-panel c-arm (Artis zeego, Siemens) with a navigation system (BrainLab curve, BrainLab). This worldwide unique combination enables the surgeon to visualise an entire pelvis in CT-like image quality with a single 3D-scan. The aim of our study was to investigate, if utilisation of a hybrid operating room increases the accuracy of SI-screws in comparison to standard 3D-navigation.Material and methodsRetrospective, not randomised single centre case series at a level I trauma centre. Inclusion criterion was insertion of a percutaneous iliosacral screw using image-guidance in the hybrid operating room. 61 patients (35 female, 26 male) were included from June 2012 till October 2014. 65 iliosacral screws were inserted. Intraoperative 3D-scans and postoperative scans were examined to investigate screw placement. The results were compared to a preceding study performed in 2012 using conventional 3D-navigation. Statistical calculations were performed with Microsoft Excel 2011 and SPSS.Results65 iliosacral screws were implanted. Two different types of screws were implanted: 1. “Standard” iliosacral screws stabilizing one joint/a unilateral fracture. 2. Single SI-screws stabilizing both SI-joints and if present a bilateral fracture. Forty one patients were included in group 1 (screws n = 45). There was no perforation in 43 screws, grade 1 perforation in 2 screws. There was no grade 2 or 3 perforation in this group. Compared to the conventional 3D-navigated screws there was a highly significant difference (p < 0.001). Twenty patients could be included in group 2. Eleven screws showed a complete intraosseous position. There was grade 1 perforation in 2 screws, grade 2 perforation in 5 screws and grade 3 perforation in 2 screws.ConclusionImprovements in image quality and enlargement of the display window lead to better intraoperative visualisation of the entire dorsal pelvis. Thereby the accuracy of computer-assisted iliosacral screws could be increased using a hybrid operating room. Furthermore difficult tasks like a single screw for both joints can be accomplished.     

Supplemental S1 fixation for type C pelvic ring injuries: biomechanical study of a long iliosacral versus a transsacral screw

Background

A single iliosacral screw placed into the S1 vertebral body has been shown to be clinically unreliable for certain type C pelvic ring injuries. Insertion of a second supplemental iliosacral screw into the S1 or S2 vertebral body has been widely used. However, clinical fixation failures have been reported using this technique, and a supplemental long iliosacral or transsacral screw has been used. The purpose of this study was to compare the biomechanical effect of a supplemental S1 long iliosacral screw versus a transsacral screw in an unstable type C vertically oriented sacral fracture model.

Materials and methods

A type C pelvic ring injury was created in ten osteopenic/osteoporotic cadaver pelves by performing vertical osteotomies through zone 2 of the sacrum and the ipsilateral pubic rami. The sacrum was reduced maintaining a 2-mm fracture gap to simulate a closed-reduction model. All specimens were fixed using one 7.0-mm iliosacral screw into the S1 body. A supplemental long iliosacral screw was placed into the S1 body in five specimens. A supplemental transsacral S1 screw was placed in the other five. Each pelvis underwent 100,000 cycles at 250 N, followed by loading to failure. Vertical displacements at 25,000, 50,000, 75,000, and 100,000 cycles and failure force were recorded.

Results

Vertical displacement increased significantly (p < 0.05) within each group with each increase in the number of cycles. However, there was no statistically significant difference between groups in displacement or load to failure.

Conclusions

Although intuitively a transsacral screw may seem to be better than a long iliosacral screw in conveying additional stability to an unstable sacral fracture fixation construct, we were not able to identify any biomechanical advantage of one method over the other.

Level of evidence

Does not apply—biomechanical study.     

Safe corridor for iliosacral and trans-sacral screw placement in Indian population: A preliminary CT based anatomical study

ObjectivesNonsurgical management of unstable pelvic ring injuries is associated with poor outcomes. Posterior pelvic ring injuries include sacroiliac joint disruption and sacral fractures or a combination of the two. Morbidity is high in non-operatively managed patients. Screw fixation is being increasingly used to manage unstable posterior pelvic injuries. Limitations include a steep learning curve and potential for neurovascular injury. This is the first study in Indian population to describe the safe corridor for screw placement and check the feasibility of screw in both upper and lower sacral segments.MethodsThis study involved retrospective analysis of 105 pelvic CT scans of patients admitted to the emergency department of a Level 1 trauma centre. Vertical height at the level of constriction (vestibule) of S1 and S2 was measured in coronal sections and anteroposterior width of constrictions was measured in axial sections. We created a trajectory for 7.3 mm cylinder keeping additional 2 mm free bony corridor around it and confirmed that bony limits were not breached in axial, coronal and sagittal sections. Whenever there was breach in bony limit we checked applicability of 6.5 mm screw.ResultsThe vertical height and anteroposterior width of vestibule/constriction of S1 was significantly higher in males, whereas S2 vestibule height and width were similar in males and females. Both male and female pelves were amenable to S1 Trans-sacral and S1 Iliosacral screw fixation with a 7.3 mm screw when a safe corridor of 2 mm was kept on all sides. However, when S2 segment was analysed, only 42.9% of male pelves and 25.7% of female pelves were amenable to insertion of trans-sacral 7.3 mm screw.ConclusionAn individualized approach is necessary and each patient’s CT must be carefully studied before embarking on sacroiliac screw fixation in Indian population.     

Investigation of bone quality of the first and second sacral segments amongst trauma patients: concerns about iliosacral screw fixation

Background

Iliosacral screw fixation has become a common method for surgical stabilization of acute disruptions of the pelvic ring. Placement of iliosacral screws into the first sacral (S1) body is the preferred method of fixation, but size limitations and sacral dysmorphism may preclude S1 fixation. In these clinical situations, fixation into the second sacral (S2) body has been recommended. The objective of this study was to evaluate the bone quality of the S1 compared to S2 in the described “safe zone” of iliosacral screw fixation in trauma patients.

Materials and methods

The pelvic computed tomography scans of 25 consecutive trauma patients, ages 18–49, at a level 1 trauma center were prospectively analyzed. Hounsfield units, a standardized computed tomography attenuation coefficient, was utilized to measure regional cancellous bone mineral density of the S1 and S2. No change in the clinical protocol or treatment occurred as a consequence of inclusion in this study.

Results

A statically significant difference in bone quality was found when comparing the first and second sacral segment (p = 0.0001). Age, gender, or smoking status did not independently affect bone quality.

Conclusion

In relatively young, otherwise healthy trauma patients there is a statistically significant difference in the bone density of the first sacral segment compared to the second sacral segment. This study highlights the need for future biomechanical studies to investigate whether this difference is clinically relevant. Due to the relative osteopenia in the second sacral segment, which may impact the quality of fixation, we feel this technique should be used with caution.

Level of evidence

III     

Percutaneous screw fixation of the iliosacral joint: A case-based preoperative planning approach reduces operating time and radiation exposure

IntroductionA preoperative planning approach for percutaneous screw fixation of the iliosacral joint provides specific entry points (EPs) and aiming points (APs) of intraosseous screw pathways (as defined by CT scans) for lateral fluoroscopic projections used intraoperatively. The potential to achieve the recommended EPs and APs, to obtain an ideal screw position (perpendicular to the iliosacral joint), to avoid occurrence of extraosseous screw misplacement, to reduce the operating time and the radiation exposure by utilizing this planning approach have not been described yet.MethodsOn preoperative CT scans of eight human cadaveric specimen individual EPs and APs were identified and transferred to the lateral fluoroscopic projection using a coordinate system with the zero-point in the center of the posterior cortex of the S1 vertebral body (x-axis parallel to upper S1 endplate). Distances were expressed in relation to the anteroposterior distance of the S1 upper endplate (in%). In each specimen on one side a screw was placed with provided EP and AP (New Technique) whereas at the contralateral side a screw was placed without given EP and AP (Conventional Technique). Both techniques were compared using postoperative CT scans to assess distances between predefined EPs and APs and the actually obtained EPs and APs, screw angulations in relation to the iliosacral joint in coronal and axial planes and the occurrence of any extraosseous screw misplacement. The “operating time (OT)” and the “time under fluoroscopy (TUF)” were recorded. Statistical analysis was performed by the Wilcoxon signed-rank test.ResultsEPs were realized significantly more accurate using the new technique in vertical direction. The screw positions in relation to the iliosacral joint showed no significant difference between both techniques. Both techniques had one aberrantly placed screw outside the safe corridor. The (mean ± SD) “OT” and the (mean ± SD) “TUF” were significantly decreased using the new technique compared to the conventional technique (OT: 7.6 ± 2 min versus 13.1 ± 5.8 min, p = 0.012; TUF: 1.5 ± 0.8 min versus 2.2 ± 1.1 min).ConclusionThe presented preoperative planning approach increases the accuracy in percutaneous screw fixation of the iliosacral joint, reduces operating time and minimizes radiation exposure to patient and staff.     

Intra- and postoperative complications of navigated and conventional techniques in percutaneous iliosacral screw fixation after pelvic fractures: Results from the German Pelvic Trauma Registry

Background

Percutaneous iliosacral screw placement following pelvic trauma is a very demanding technique involving a high rate of screw malpositions possibly associated with the risk of neurological damage or inadequate stability. In the conventional technique, the screw's correct entry point and the small target corridor for the iliosacral screw may be difficult to visualise using an image intensifier. 2D and 3D navigation techniques may therefore be helpful tools.The aim of this multicentre study was to evaluate the intra- and postoperative complications after percutaneous screw implantation by classifying the fractures using data from a prospective pelvic trauma registry. The a priori hypothesis was that the navigation techniques have lower rates of intraoperative and postoperative complications.

Methods

This study is based on data from the prospective pelvic trauma registry introduced by the German Society of Traumatology and the German Section of the AO/ASIF International in 1991. The registry provides data on all patients with pelvic fractures treated between July 2008 and June 2011 at any one of the 23 Level I trauma centres contributing to the registry.

Results

A total of 2615 patients were identified. Out of these a further analysis was performed in 597 patients suffering injuries of the SI joint (187 × with surgical interventions) and 597 patients with sacral fractures (334 × with surgical interventions).The rate of intraoperative complications was not significantly different, with 10/114 patients undergoing navigated techniques (8.8%) and 14/239 patients in the conventional group (5.9%) for percutaneous screw implantation (p = 0.4242).Postoperative complications were analysed in 30/114 patients in the navigated group (26.3%) and in 70/239 patients (29.3%) in the conventional group (p = 0.6542). Patients who underwent no surgery had with 66/197 cases (33.5%) a relatively high rate of complications during their hospital stay. The rate of surgically-treated fractures was higher in the group with more unstable Type-C fractures, but the fracture classification had no significant influence on the rate of complications.

Discussion

In this prospective multicentre study, the 2D/3D navigation techniques revealed similar results for the rate of intraoperative and postoperative complications compared to the conventional technique. The rate of neurological complications was significantly higher in the navigated group.     

经皮骶髂螺钉固定技术治疗不稳定骨盆骨折的疗效评价

目的评价经皮骶髂螺钉技术在不稳定骨盆骨折治疗中的安全性及疗效。方法2003年3月-2007年1月，收治15例Tile C型骨盆骨折患者。男6例，女9例；年龄21～56岁。车祸伤8例，高处坠落伤6例，压砸伤1例。伤后至就诊时间4h～3d。耻骨骨折合并骶骨骨折7例，髂骨骨折合并骶骨骨折2例，耻骨骨折合并骶髂关节脱位4例，前环耻骨骨折、后环骶骨骨折合并骶髂关节脱位2例。采用经皮骶髂螺钉技术固定骨盆后环，合并的前环损伤中7例采用外固定支架固定，3例钢板固定，5例钢板联合外固定支架固定。结果15例住院16～33d，平均22．4d。除4例同时行髋臼骨折固定患者术中失血量1000～1500mL，余失血约50mL。手术时间60～305min，平均153．6min。15例均获随访6个月～3年，平均18个月。根据Matta评分标准，优14例，良1例。最后1次随访时，X线片示患者骨折均愈合，平均28．8个月。1例骨折愈合后骶髂螺钉松动，3例腰骶部劳累后疼痛，2例轻度跛行，均未作特殊处理。9例恢复原工作，3例改变工作，3例仍未工作。Majeed功能评分，优11例，良4例，优良率100％。结论经皮骶髂螺钉固定技术可重建骨盆后环的稳定性，可获得良好的功能康复，同时手术并发症发生率低及创伤小，是不稳定骨盆骨折后环稳定性重建的良好方法之一。     

导航系统在骶髂螺钉内固定手术中的应用

目的探讨CT导航系统在骶髂螺钉内固定手术中应用的可行性。方法骶髂关节脱位或骶骨骨折7例,在CT导航系统下,行骶髂螺钉内固定手术。结果手术时间40~120min,平均出血20ml。随访12~30周,7例术后钉位满意,与术中导航的结果基本吻合,下肢均无神经症状出现。按Matta评定标准,2例30分,2例29分,2例27分,1例26分,均达满意结果。术后8周骨折愈合,离床活动。结论导航系统在骶髂螺钉内固定手术中的应用安全准确,是一种可靠的方法。