经皮骶髂螺钉与骶髂关节前方钢板固定治疗不稳定性骨盆骨折的对比研究

 目的 比较骨盆骨折合并骶髂关节脱位经皮空心螺钉内固定与切开复位重建钢板内固定治疗的临床疗效, 并评价其安全性和实用性。方法 2004年 3月至 2010年 10月, 收治 37例不稳定 性骨盆骨折。在野C冶型臂 X线机引导下, 20例患者接受经皮骶髂关节螺钉内固定, 17例患者接受切开复 位重建钢板内固定, 比较和分析两组的围手术期参数和术后影像学指标。结果 对全部病例随访 6~26 个月, 平均 15个月。经皮螺钉组与切开钢板组在手术时间、术中出血量、术后疼痛程度、术后平均发热 时间和住: 时间等方面比较差异均有统计学意义, 两组根据术后 X线评价的复位效果差异无统计学意 义。骨折平均愈合时间: 经皮螺钉组为 32个月, 切开钢板组为 36个月, 两组差异无统计学意义。经皮 螺钉组无感染、弯钉及断钉等并发症发生。结论 经皮骶髂空心螺钉内固定术治疗骨盆骨折具有定位 准确、损伤小、出血少、疼痛轻、恢复快等优点, 是一种理想的微创手术方法, 前后环固定适用于骨折及 脱位不明显者;该术式对术者操作技术要求较高, 充分的术前准备及患者术后配合能减少并发症发生。 重建钢板或桡骨远端野T冶形钢板可用于固定垂直不稳定性骨盆骨折。     

Die perkutane transiliosakrale Zugschraubenosteosynthese des hinteren Beckenrings

BACKGROUND: In recent years, the closed reduction and percutaneous fixation of posterior pelvic ring fractures by sacroiliac screws has become a well established treatment option for stabilization of posterior pelvic ring disruptions. Stable percutaneous pelvic ring fixation also implies a very low complication rate, e.g., in operative blood loss, wound healing, and operative time. To avoid malpositioning of the screws, sufficient reduction and radiologic visualization are essential. The surgical technique has been described in several studies; however, great importance is attached to the personal experience of the surgeon. Therefore, this study was conducted to establish a standard procedure that allows different surgeons a safe positioning of sacroiliac screws. RESULTS: A total of 41 injuries of the posterior pelvic ring were stabilized with 73 sacroiliac lag screws inserted by 7 different surgeons using a standardized technique. In all cases adequate reduction of the fracture and radiologic visualization were achieved. No wound infections, no relevant bleedings, and no spiral fractures of screws were observed. In two cases malpositioning led to revision of the screws. Of interest, one case of S1 paresthesia resulting from a malpositioned screw could be revised. In contrast, two cases of screw loosening and one case of screw bending did not require further intervention. CONCLUSION: We conclude that safe positioning of the sacroiliac screws was accomplished by all surgeons given a standardized technique. For safe insertion preparation of the patients, accurate visualization of the fracture zone, and potential closed reduction is always required.     

急诊介入动脉栓塞术联合经皮微创螺钉内固定术救治骨盆骨折合并失血性休克(附21例分析)

目的探讨急诊介入动脉栓塞术联合经皮微创螺钉内固定术治疗骨盆骨折合并失血性休克的可行性及安全性。方法回顾性分析21例骨盆骨折并失血性休克患者的资料,21例患者均接受急诊介入动脉栓塞术联合经皮微创螺钉内固定术。经皮微创螺钉内固定术均在介入栓塞术后立即进行。结果 21例患者中,经股动脉造影明确动脉出血18例,均接受相应介入栓塞治疗;另3例造影未见明显动脉出血,接受可疑出血侧髂内动脉预防性栓塞治疗。每例患者经皮微创螺钉内固定术用时均不超过90min。患者术后均未出现严重介入动脉栓塞相关并发症。18例术后好转出院;3例死亡,其中2例术后因多器官衰竭或弥散性血管内凝血死亡,1例术后仍继续出血,因失血性休克死亡。术后随访3个月~18个月,平均(10.81±2.62)个月,所有存活患者骨折均达到骨性愈合,功能良好。结论急诊介入动脉栓塞术联合经皮微创螺钉内固定术治疗骨盆骨折并失血性休克安全、快速、有效且并发症少。     

Perkutane dorsale Instrumentierung der thorakolumbalen Wirbelsäule

Minimally invasive percutaneous instrumentations are increasingly being used for stabilization of thoracolumbar fractures, mainly due to the advantages of reduced soft tissue damage. While percutaneous instrumentation can be generally used in less displaced fractures, it remains controversial whether such techniques should also be performed in patients with severe fracture dislocation. This includes patients with severe traumatic kyphosis and/or dislocation in the coronar plane, particularly in concomitant neurological deficits that require additional decompression surgery. Here we show the different indirect fracture reduction techniques in three cases with severe fracture dislocation and discuss the use of percutaneous stabilization techniques in combination with an additional midline approach for decompressing laminectomy.     

Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results

PURPOSE: To present the technique and early results of percutaneous stabilization of U-shaped sacral fractures with attention to neurologic recovery and maintenance of fracture reduction of the sacrum. DESIGN: Retrospective clinical study. SETTING: Level I trauma center. PATIENTS: During a thirty-eight-month period, 442 patients with pelvic ring disruptions were treated at a Level I trauma center. Thirteen (2.9 percent) of these patients had displaced U-shaped sacral fractures treated with percutaneous stabilization. INTERVENTION: Fracture stabilization was accomplished using fluoroscopically guided iliosacral screws inserted percutaneously with the patient positioned supine. Neurodiagnostic monitoring was not used during screw insertions. This technique was limited to patients with sacral kyphotic deformities, which allowed in situ fixation. Sacral neurologic decompression was not performed. MAIN OUTCOME MEASUREMENTS: Fracture healing and the stability of fixation were assessed on inlet and outlet radiographs and a lateral sacral view. Detailed neurologic examinations were performed at injury and at follow-up. RESULTS: The sacral fractures were classified based on plain pelvic radiographs and computed tomography scans and included one Type 1, eight Type 2, and four Type 3 fracture patterns. Twenty-five fully threaded cancellous 7.0-millimeter cannulated screws were used. Eleven patients had bilateral screw fixations; one patient had unilateral double screw fixation; and one patient had unilateral single screw fixation. Operative time for screw insertion averaged forty-eight minutes, with 2.1 minutes of fluoroscopy per screw. Accurate screw insertions without neuroforaminal or sacral spinal canal violations were confirmed in all patients with postoperative pelvic plain radiographs and computed tomography scans. A paradoxical inlet view of the upper sacral segments on the injury anteroposterior pelvis was seen in twelve of thirteen patients (92.3 percent), and the diagnosis was confirmed with the lateral sacral view in all thirteen (100 percent) patients. Preoperatively, sacral kyphosis averaged 29 degrees, whereas postoperative sacral kyphosis averaged 28 degrees. Screw disengagement occurred without a change in position of the sacral fracture in the only patient treated with a single unilateral screw. All fractures healed clinically and radiographically. Of the nine patients with preoperative neurologic abnormalities, two (22 percent) patients had residual neurologic deficits. Both patients had associated multiple level lumbar burst fractures, which required decompression and instrumented stabilization. CONCLUSIONS: These sacral fractures are rare and occur after significant spinal axial loading. A paradoxic inlet view of the upper sacrum on the anteroposterior plain pelvic radiograph heralds the diagnosis. Delayed diagnosis is avoided by a high clinical suspicion, early lateral sacral radiographs, and pelvic computed tomography scans. Surgical stabilization may assist in early mobilization of the patient from recumbency and prevents progressive deformity with associated nerve root injury. Percutaneous fixation diminishes potential blood loss and operative times, yet still allows subsequent sacral decompression of the local neural elements using open techniques when necessary. Early percutaneous iliosacral screw fixation is effective treatment for these injuries.     

严重骨盆骨折的初期救治体会

目的 探讨复杂性骨盆骨折的诊断分类和急救方法。方法 回顾性分析了23例复杂性骨盆骨折的初期救治情况。结果 22例存活，1例死于失血性休克。结论 严重骨盆骨折的正确分类对急诊处理具有指导作用。多学科合作、多种外科手段综合运用，早期稳定血流动力学、及时修复损伤器官、骨外固定器固定骨盆环，是提高骨盆骨折的有效手段。     

前环皮下内置外固定架联合后环骶髂螺钉治疗不稳定骨盆骨折

目的评估应用前环皮下内置外固定架(internal fixation,INFIX)联合后环骶髂螺钉治疗不稳定骨盆骨折的临床疗效。方法2016年8月-2017年9月,采用前环皮下INFIX联合后环骶髂螺钉治疗不稳定骨盆骨折19例。其中男14例,女5例;年龄17~69岁,平均40.6岁。致伤原因:交通事故伤11例,高处坠落伤5例,重物砸伤3例。骨折根据Tile分型,B1型2例,B2型6例,C型11例。前环损伤包括双侧耻骨坐骨支骨折12例,单侧耻骨坐骨支骨折5例,耻骨联合分离2例;后环损伤包括骶髂韧带损伤2例,单侧髂骨骨折3例,单侧骶骨骨折11例,单侧骶髂关节脱位2例,双侧骶骨骨折1例。受伤至手术时间2~11 d,平均6.1 d。记录术中出血量及手术时间,观察骨折愈合情况及术后并发症情况。采用Matta评分标准评价骨折复位情况,采用Majeed评分标准评估患者术后功能。结果患者手术时间为47~123 min,平均61.4 min;术中出血量为50~115 mL,平均61.1 mL。术后1例发生植钉处切口浅表感染,1例发生单侧股外侧皮神经激惹,经相应处理后治愈或症状消失。无泌尿系统、生殖系统及肠道等损伤。所有患者均获随访,随访时间12~25个月,平均18.1个月。术后骨折均愈合,愈合时间8~13周,平均9.5周;无骨折不愈合、延迟愈合,内固定物松动、断裂等情况发生。2例术前腰骶丛神经损伤患者中,1例功能完全恢复,1例残留轻度跛行症状。末次随访时采用Matta评分标准评价骨折复位情况,获优13例、良6例,优良率100%;采用Majeed评分标准评价功能,获优15例、良4例,优良率100%。结论应用前环皮下INFIX联合后环骶髂螺钉治疗不稳定骨盆骨折临床疗效满意,并发症较少,是一种微创治疗骨盆环损伤的有效方法。     

Stellenwert der Navigation in der Beckenchirurgie

Definitive therapy of pelvic ring and acetabulum injuries often requires access with extensive deep exposure, thereby causing additional surgical soft tissue trauma. Computed-assisted navigated surgical procedures for percutaneous screw fixation are being applied in practice with increasing success. In addition to the advantage of preserving the soft tissue envelope, the navigation system achieves greater precision in implant insertion and minimizes radiation exposure. Non- or scarcely dislocated as well as unstable fractures are particularly suited for this procedure. When treatment goals are taken into consideration – anatomic reduction and exercise-allowing stabilization – navigated percutaneous surgical procedures on the pelvis and acetabulum are, in selected cases, a promising alternative to conventional surgical procedures.     

不稳定性骨盆环骨折的手术治疗

目的 探讨开放复位内固定治疗不稳定性骨盆环骨折的方法和效果.方法 2001年10月至2006年10月,对78例不稳定骨盆环骨折患者采用切开复位重建钢板内固定和"C"型臂X线机或CT引导下经皮空心螺钉内固定及TSRH系统固定.按照AO分型:B2型3例,B3型4例,C1型12例,C2型34例,C3型25例.患者入院后均在抗休克、输血等治疗的同时急诊用骨盆外固定架暂时固定复位,以稳定病情、减少出血.伤后7～10 d手术,20例前路手术后1周行后路手术,58例为一期前后路同时手术内固定.后路经皮"C"型臂X线机引导下骶髂复合体空心螺钉固定10例,CT引导下经皮空心螺钉固定20例,切开复位TSRH系统固定48例.手术时间2～5 h,平均3 h.结果 术后浅表感染5例,经换药愈合;深部感染2例,经清创引流愈合.3例术中损伤膀胱行及时修补,2例术后发现膀胱损伤行膀胱造瘘后愈合.发生下肢深静脉血栓6例,经溶栓等保守治疗治愈.术前合并骶丛损伤的患者术后3～6个月功能大部分恢复.术后随访6～60个月,平均30个月,无骨折不愈合.下肢长度差异在10 mm内72例,10～20 mm 6例.复位根据Tornetta和Matta评定标准,优58例,良16例,可4例,优良率94.9%.术后功能按照Majeed评分系统,优45例,良20例,可13例,优良率83.3%.结论 对不稳定性骨盆环骨折患者采用前后环切开复位内固定,稳定性好、并发症少,可使患者早期康复.     

Results of open reduction internal fixation versus percutaneous iliosacral screw fixation for unstable pelvic ring injuries: retrospective study of 36 patients

European Journal of Orthopaedic Surgery & Traumatology - Surgical stabilization of posterior pelvic ring fractures can be achieved by closed reduction and percutaneous fixation (CRPF) or by...     

Pseudoaneurysm of the superior gluteal artery during iliosacral screw fixation

We present a case of a pseudoaneurysm of the superior gluteal artery following placement of an iliosacral screw in a patient with an unstable pelvic ring fracture. Percutaneous fixation of posterior pelvic ring injuries is becoming a popular method for pelvic stabilization. Several techniques are available t achieve stability and allow early mobilization in patients with displaced pelvic fractures. Percutaneous screw fixation of sacral fractures or sacroiliac joint disruptions should reduce operative and anaesthesia times as well as blood loss, while lowering the risk of surgical wound problems are decreased. The risks with this technique are generally iatrogenic, related with surgeon's lack of experience or imaging difficulties at the time of screw placement. The present case report describes an injury to the superior gluteal arterial system during percutaneous iliosacral screw insertion.     

Standardized osteosynthesis techniques for the pelvic ring. Analysis of a patient sample and surgical technique]

A total of 1566 patients with fractures of the pelvis were treated at the Department of Traumatology at the Hannover Medical School between 1972 and 1990. Of these, 1350 patients had fractures of the pelvic ring, 216 isolated acetabulum fractures, and 398 combinations of pelvic ring fractures and acetabular involvement. Of these patients, 718 were admitted with severe polytrauma. For 1254 patients complete files were available for clinical and radiological evaluation of fracture distribution, classification (Tile and anatomical location) and concomitant injuries. A significant increase in the severity of trauma, the severity of the pelvic fractures and the rate of internal stabilization, especially of the posterior pelvic ring, was observed during the observation period. The overall mortality after pelvic fracture was 18.1%. This mortality was correlated to the Hannover Polytrauma Score (PTS) and the associated extrapelvic blunt trauma. Internal fixation of pelvic fractures was performed in 195 patients. Our experience led to standardized procedures for the different fracture locations. In fractures type Tile B, an anterior procedure led in all cases to anatomic or near anatomic healing. In unstable pelvic ring fractures (Tile C), external fixation led to a significantly higher rate of posterior dislocations (over 1 cm) than did internal fixation. In these situations a combined posterior and anterior internal fixation procedure improved the result compared to posterior internal stabilizations alone. As a result, internal stabilization using a standardized technique for every fracture location is recommended for all unstable pelvic ring fractures.     

External fixation in pelvic fractures

Pelvic fractures account for 4–5% of all fracturated patients, and they occur in 4–5% of politraumatized patients. In the most of the cases, they are consequent to high-energy trauma with a high percentage of lesions of other organs (cerebral, thoracic, and abdominal lesions. The most of the patients (80%) who die are dying within the first hours after trauma for a massive hemorrhagic shock. When the pelvic fracture and the patient’s hemodynamic conditions are both unstable, osteosynthesis of the fracture is mandatory. Fracture stabilization should be performed within the first hour after trauma (as soon as possible), and it should be considered as part of the resuscitation procedure. We usually make an urgent stabilization of pelvic fracture with an anterior external fixator technique. We have revised all unstable pelvic fractures treated in our department (Orthopaedic Clinic Pisa University) from 2000 up to the 2005 to determine a correct treatment protocol for these lesions. Pelvic stabilization, reducing the pelvic volume and bleeding from the stumps of fracture, determines the arrest of the hemorrhage, as evidenced by the sharp decline in the number of transfusions in postoperative period. In these cases, there is an absolute indication for an urgent pelvic stabilization. Pelvic stabilization, whether temporary or permanent, allows to control the bleeding because it (1) leads to a reduction in the volume pelvis with a containment on the retro-peritoneal hematoma (2) reduces bleeding from the fracture fragments (3) reduces motility fracture promoting the blood clotting. The stabilization of the pelvis also makes it easier to manage the patient and his mobilization for the implementation of subsequent investigations. In our experience, external fixator accounts for its characteristics the gold standard approach for the urgent stabilization of these lesions, and, for most of them, it can be used as the definitive treatment. External fixation is a quick and easy procedure for pelvic fractures stabilization for surgeons with experience with this technique.     

Endoscopy for anterior pelvis fixation

The objectives of this study are to describe the anatomic findings relative to anterior pelvic endoscopy, determine the potential use of endoscopy for reduction and fixation of fractures of the anterior pelvic ring, and report two illustrative cases performed using this method. Using the windows described, endoscopy permits placement of plates and screws on top of the symphysis pubis, reduction of internally displaced fragments, and performance of percutaneous procedures that do not harm anatomic structures.     

Externe Fixation am Beckenring

External fixation of the pelvic ring can be indicated both for emergency stabilization and as part of the definitive treatment of an injury to the pelvic ring. In the case of emergency stabilization the type of fixation applied depends on how the pelvic fracture is classified. The external fixator is an adequate stabilizer for the anterior part of the pelvic ring, while for type C fractures posterior compression is needed in addition. Adequate mechanical stabilization of the posterior part of the pelvic ring cannot be achieved by means of the external fixator alone, and in these cases a pelvic clamp is indicated. Its application must be regarded as an emergency surgical procedure. When it is part of the definitive stabilization process, the external fixator applied in a supra-acetabular position is a good solution in all type B fractures. It can also be used for type C fractures for additional definitive stabilization, but because of the instability of the posterior pelvic ring that is always present in the case of this type of fracture simultaneous internal fixation is also required.     

Our results in the treatment of fractures dislocations of Lisfranc's joint

The authors report their experience in the treatment of traumatic injuries of Lisfranc's joint based on 30 cases treated by surgery between 1984 and 1999. All of the patients were re-evaluated clinically and radiographically. What emerges from the study is the need for surgical stabilization with percutaneous Kirschner wires or by open procedure in cases where there are doubts or where reduction is impossible. The prognosis is worse in injuries of the medial column and in exposed fractures or when mortification of the soft tissues is present.     

Posterior stabilization of pelvic fractures by use of threaded compression rods. Case reports and mechanical testing

Threaded compression rods were placed between the posterior-superior spines as a means of posterior stabilization of pelvic fractures. To document the increase in sacroiliac stability afforded by this technique, biomechanical testing was performed. Malgaigne-type fractures with sacroiliac disruptions were created in four cadaver pelvises. The fractures were stabilized with anterior frames of the Slatis or Pittsburgh type and subjected to longitudinal and torsional loading patterns on an Instron machine. The anterior fixation was then augmented with threaded compression rods placed between the posterior-superior spines to compress the disrupted sacroiliac joints, and repeat testing was conducted. Anterior frames alone were found to provide little stabilization of the disrupted sacroiliac joints with either longitudinal or torsional loading. Markedly improved stabilization in both loading modes was achieved with posterior augmentation. Two typical cases are presented to demonstrate that posterior stabilization is as efficacious in clinical practice as in the biomechanics laboratory.     

Anteriore Zugänge zum Beckenring

Anterior approaches for the stabilization of anterior and also posterior B and C type instability of the pelvic ring were the standard procedures before minimally invasive percutaneous methods supported by image intensifiers or navigation devices were established. Anterior approaches are currently still of high relevance for difficult or impossible closed reductions in multiple trauma surgery where the patient must remain in a supine position. They are also used for stabilization of an increasing number of osteoporotic fractures in the elderly which are no longer only treated in specialized pelvic trauma centres. The anterior as well as the posterior part of the pelvic ring can be stabilized via various anterior approaches. A Pfannenstiel incision is appropriate for plating of ruptures of the pubic symphysis and can be extended to a modified Stoppa approach if necessary. Fractures of the iliac wings can be approached either laterally or less traumatically, via an anterolateral approach. The latter equates the lateral window of the ilioinguinal approach to the acetabulum, allows visualization of the entire sacroiliac joint and therefore stabilization of not only iliosacral luxation but also luxated fractures with a small iliac fragment. By a combination of the different approaches it is possible to simultaneously stabilize ventral and dorsal instabilities in type C fractures of the pelvic ring with a minimal amount of iatrogenic soft tissue trauma. Although the described anterior approaches are considered as simple exact knowledge of the endangered structures and general risks for each approach are essential for a safe exposure of the anatomical region addressed.     

Indikation und Technik der externen Stabilisierung instabiler Beckenringfrakturen

The indication for external stabilization of pelvic ring fractures is given in emergencies for which primary internal stabilization is not possible. These are mainly cases of polytrauma and closed and open soft tissue injury. Furthermore, external fixation is a tolerant emergency procedure when applied according to certain techniques and can be maintained until further treatment is possible. If a very few guidelines with regard to technique are followed, external fixation proves to be a simple and tolerant procedure. In special cases of life-threatening instabilities of the posterior pelvic ring, the emergency pelvic clamp should also be considered.     

Iatrogenic ulnar nerve injury after percutaneous cross-pinning of supracondylar fracture in a child

Supracondylar fracture of the humerus is the most common fracture of the elbow in children and has been treated by a variety of methods. Recently, stabilization of reduced fractures with percutaneous pin fixation has become the accepted method of treatment. Ulnar nerve injury is a complication of percutaneous pinning of supracondylar fractures, although many authors have reported that it resolves spontaneously after removal of the pin.