外固定架联合髂腰固定术治疗垂直不稳定型骨盆骨折

目的 探讨应用外固定架联合髂腰固定术治疗垂直不稳定型骨盆骨折的临床效果.方法 对2008年1月至2009年3月收治的9例垂直不稳定型骨盆骨折患者进行手术治疗.男4例,女5例;年龄19～56岁,平均37岁.9例均为Tile C型骨折,其中C1.2型3例,C1.3型6例.采用后路患侧下腰椎旁切口入路,垂直移位复位后,椎弓根钉棒系统固定L4.5椎体和髂后上棘,前路双侧髂前上棘组合式外固定器固定.结果 9例患者术后获得12～18个月随访,平均14.3个月.术后X线片均示骨盆骨折复位满意,后环形态恢复良好;根据Matta骨盆骨折复位评定标准,优6例,良3例.术后2例患者骶丛损伤压迫症状解除,未出现医原性神经、血管损伤.下肢行走、蹲屈功能恢复满意.术后12个月Majeed评分:优7例,良2例.结论 外固定架联合髂腰固定术治疗垂直不稳定型骨盆骨折疗效满意,且具有操作简便、并发症少的特点.

Abstract：

Objective To evaluate the clinical outcomes of external fixator with lumbopelvic distraction spondylodesis in treatment of vertically unstable pelvic fractures. Methods From January 2008 to March 2009, 9 patients (4 males and 5 females) with a vertically unstable pelvic fracture were treated with modular external fixator with lumbopelvic distraction spondylodesis. According to the classification of Tile, 9fractures were classified as type C. This fixation construct comprises a vertical lumbopelvic distraction component which fixed L4.5 and the posterior superior iliac spine and a transverse fixation which fixed anterior iliac spine with external fixator. Results All patients were followed up 12-18 months after surgery, with an average of 14.3 months. Postoperative X-ray showed satisfactory reduction of pelvic fracture. Pelvic fractures healed in all patients without loss of reduction 3-6 months after operation. According to Matta reduction evaluation criteria, 6 patients were excellent and 3 good. For the two patients with sacral neurological injuries,appropriate surgical decompression was performed to improve the symptom and minimize the deformity. No iatrogenic complications of neurovascular injury occurred. Patients now walk unassistedly without pain in the waist or legs, and with no shortening of lower limbs or claudication. By considering symptom and satisfactory scores, the Majeed functional assessment revealed that seven patients had excellent results and two good at one year. Conclusion External fixator with lumbopelvic distraction spondylodesis that allowed early mobilization and ambulation, with general applicability and definite safety, is an effective surgical technique for the treatment of vertically unstable pelvic fracture.     

Relationships of the Lateral Femoral Cutaneous Nerve to Bony Landmarks

Background  

The lateral femoral cutaneous nerve (LFCN) can be at risk during, for example, the insertion of pins in the anterior superior iliac spine (ASIS) during external fixation of the pelvis, total hip arthroplasty through a direct anterior approach, open surgery for impingement in the hip through an anterior approach, and periacetabular osteotomy. During surgery, the surgeon usually assumes the location of the LFCN by using the ASIS as a landmark.     

冲击载荷作用下骨盆三维有限元分析及其生物力学意义

目的:探讨骨盆受到冲击载荷作用的力学行为特征,为临床分析及判断骨盆骨折类型、力学分布、冲击载荷影响提供力学基础。方法:采用计算机仿真模拟方法,将所构建骨盆三维实体模型导入三维有限元分析软件AN-SYS7.0,计算单侧髂前上棘和单侧髂骨正后方部位冲击载荷作用下骨盆的力学行为表现,冲击载荷为0～8000N,峰值8000N,时间自0～40ms,分析主应力值、应力分布情况以及主应力方向上骨盆单元的位移。结果:冲击载荷作用于单侧髂前上棘时,0～10ms主要的应力沿髂后上棘到髂前上棘分布,在冲击后期10ms以后,骶髂关节、髋臼和耻骨支都会产生较大的应力分布;作用于单侧髂骨正后方部位时,0～20ms主要的应力沿髂骨纵行传导,应力分布并没有在冲击峰值10ms时达到最大,而是从20ms之后,应力开始向骶髂关节、双侧耻骨支、坐骨支以及髋臼等部位传导并可见到明显的应力分布。结论:分析冲击载荷作用下骨盆各部位应力分布以及骨盆各个单元在应力作用下的位移变化,有助于临床上进行骨盆损伤内固定力点的选择以及进一步明确骨盆内在应力值分布。     

逆行耻骨上支髓内螺钉固定应用解剖研究

目的探讨耻骨上支髓内螺钉的正确进钉方法和位置,为临床应用提供解剖学基础。方法解剖6具成人尸体,制成骨性骨盆标本。在直视下,以克氏针模拟逆行耻骨上支髓内螺钉固定法。分别测量钉长、进钉点与耻骨结节的关系、螺钉与两侧髂前上棘和耻骨结节构成平面的夹角、与矢状面的夹角及耻骨上支直径等。结果对于耻骨上支内1／2、外1／2的骨折,平均钉长、螺钉与两侧髂前上棘和耻骨结节构成平面及矢状面的夹角,最窄处直径为皆有差异。结论耻骨上支髓内螺钉固定对于耻骨支不同部位的骨折进钉点和进钉方向不同,用于治疗骨盆前环的耻骨支骨折是安全、可行的。     

Unilaterale trianguläre lumbopelvine Stabilisierung

Operative fixation has become treatment of choice for unstable sacral fractures. Osteosynthesis for these fractures results in loss of reduction in up to 15%. Vertical sacral fractures involving the S1 facet joint (Isler 2 and 3) may lead to multidirectional instability. Multidirectional instability of the posterior pelvic ring and lumbopelvic junction may be stabilized and forces balanced by a so-called lumbopelvic triangular fixation. Lumbopelvic triangular fixation combines vertical fixation between the lumbar vertebral pedicle and the ilium, with horizontal fixation, as an iliosacral screw or a transiliacal plate osteosynthesis. The iliac screw is directed from the posterior superior iliac spine (PSIS) to the anterior inferior iliac spine (AIIS). Thereby, lumbopelvic fixation decreases the load to the sacrum and SI joint and transfers axial loads from the lumbar spine directly onto the ilium. Triangular lumbopelvic fixation allows early full weight bearing and therefore reduces prolonged immobilization. The placement of iliac screws may be a complex surgical procedure. Thus, the technique requires thorough surgical preparation and operative logistics. Wound-related complications may occur. Preexisting Morell–Lavalée lesions increase the risk for infection. Prominent implants cause local irritation and pain. Hardware prominence and pain are markedly reduced with screw head recession into the PSIS.     

A modified extensile exposure for the treatment of complex or malunited acetabular fractures

A modification of the extended iliofemoral incision of Letournel and Judet facilitates the operative exposure of T-type, complex transverse, and both-column acetabular fractures and malunions. The modification includes the utilization of a T-shaped skin incision with large flaps, and osteotomies of the iliac crest, greater trochanter, and anterior superior iliac spine. The iliotibial band is transected and the abductor muscle mass is rotated posteriorly, hinged on the superior gluteal neurovascular bundle. Twenty patients had open reduction and internal fixation of a complex acetabular fracture using this surgical approach. Excellent surgical exposure allowed good or excellent reduction of the acetabulum in all patients. No flap necrosis developed, and all fractures healed. One non-union of a trochanteric osteotomy needed revision. This approach provides increased exposure of the posterior column and visualization of the entire surface of the joint and it allows fixation of the fracture from both sides of the iliac wing. The T-shaped skin incision allows utilization of a standard posterior approach with conversion to the extensile exposure if necessary. Options for late reconstruction are not compromised. Lagscrew fixation of the osteotomies allows aggressive rehabilitation of the joint.     

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。     

Avulsion fracture of the iliac spine during sporting activity: Report of 30 fractures and their outcome

Avulsion fractures of the pelvis were analyzed in 30 adolescents (29 males and 1 female). The average age at injury was 14.4 years, and the average follow-up period was 2.6 years. We treated 20 fractures of the anterior superior iliac spine and 10 of the anterior inferior iliac spine. Eleven patients were treated by open reduction and internal fixation, and conservative treatment was selected for the remainder. The outcome was good whether the fractures were treated surgically or conservatively, and none of the patients had pain during daily activities. In 8 of the patients treated conservatively, hypertrophic deformity of the avulsed fragment was seen. However, 6 of these patients had no symptoms, while 2 noted excessive fatigue during long-distance walking. Surgical treatment may be necessary only when the displacement of a large fragment is more than 20 mm or when the patient desires to be a professional athlete. Careful observation for at least 6 months, especially of those conservatively treated, is necessary for patients who have had avulsion fracture of the iliac spine. This work was supported by a Grant-in Aid for Cooperation Research (62771105) Ministry of Education, Science and Culture, Japan     

Delayed posterior internal fixation of unstable pelvic fractures

Fifteen patients with unstable pelvic fractures were treated with immediate anterior external fixation followed by delayed posterior fixation, including five sacroiliac lag screws, six transiliac rods, and four iliac plates. Initial anterior external fixation aided in resuscitation of hemodynamically unstable patients and allowed early mobilization. Delayed posterior internal fixation avoided infection and hemorrhage but failed to achieve anatomic reduction of disrupted sacroiliac joints and sacral fractures. Followup examination confirmed maintenance of fixation and fracture healing but pain and persistent neurologic deficits were common findings. Lumbosacral nerve plexus injuries occurred in patients with fractures through the sacral foramina. Fixation of these fractures with sacroiliac screws and transiliac rods caused overcompression and the resulting foraminal encroachment may be a factor in the lack of neurologic recovery. In this study, delayed posterior internal fixation was not associated with perioperative morbidity and achieved better reductions than those obtained with external fixation alone. Delaying the fixation, however, increased the difficulty of obtaining anatomic reduction of certain posterior arch disruptions.     

Modified triangular posterior osteosynthesis of unstable sacrum fracture

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22–41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.     

Combined Anterior Pelvic (CAP) approach for fracture acetabulum fixation - Functional outcome evaluation and predictors of outcome

ObjectiveIlio-inguinal approach has been considered standard anterior approach for acetabulum fracture fixation. Different modifications of this approach have been described. This study analysed the patients treated using a Combined Anterior Pelvic (CAP) approach - minimal AIP (anterior intra-pelvic) with modified ilio-femoral along with ’anterior superior iliac spine’ osteotomy. This combined approach provides wide exposure of pelvis to direct visualise the entire anterior column from sacroiliac joint to pubic symphysis, medial side of quadrilateral plate and entire iliac wing with minimal retraction of soft tissues required.MethodsData of patients treated from July 2014 to June 2018 for acetabulum fracture using CAP approach was retrieved from hospital record system. Inclusion criteria were - acetabulum fractures treated surgically using CAP approach. Exclusion criteria were – age less than 18 years, associated pelvis ring injury and incomplete peri-operative radiological record (pre-operative/post-operative antero-posterior, 45° obturator and 45° iliac oblique radiographs and pre-operative computed tomographic (CT) scans. 62 patients who met inclusion exclusion criteria were called in out-patient-department for final functional evaluation using Matta modified Merle d’aubigne score.ResultsOut of 62 patients 47 patients who turned up for final functional evaluation were included in study. 19 patients had excellent, 15 had good, 2 had fair and 11 had poor results. Age less than 40 years, anterior column fracture pattern, Pre-operative fracture displacement >20 mm, fracture comminution and post-operative fracture reduction within 3 mm were the predictors of the functional outcome. When analysed using logistic regression model, post-operative fracture reduction was found to be the only significant predictor of functional outcome.ConclusionCAP approach is useful anterior approach to acetabulum. Fracture reduction is the independent predictor of functional outcome. Comparison of this approach with other anterior approaches to acetabulum can be area of further research.     

Combined Anterior Pelvic (CAP) approach for fracture acetabulum fixation - Functional outcome evaluation and predictors of outcome

ObjectiveIlio-inguinal approach has been considered standard anterior approach for acetabulum fracture fixation. Different modifications of this approach have been described. This study analysed the patients treated using a Combined Anterior Pelvic (CAP) approach - minimal AIP (anterior intra-pelvic) with modified ilio-femoral along with ’anterior superior iliac spine’ osteotomy. This combined approach provides wide exposure of pelvis to direct visualise the entire anterior column from sacroiliac joint to pubic symphysis, medial side of quadrilateral plate and entire iliac wing with minimal retraction of soft tissues required.MethodsData of patients treated from July 2014 to June 2018 for acetabulum fracture using CAP approach was retrieved from hospital record system. Inclusion criteria were - acetabulum fractures treated surgically using CAP approach. Exclusion criteria were – age less than 18 years, associated pelvis ring injury and incomplete peri-operative radiological record (pre-operative/post-operative antero-posterior, 45° obturator and 45° iliac oblique radiographs and pre-operative computed tomographic (CT) scans. 62 patients who met inclusion exclusion criteria were called in out-patient-department for final functional evaluation using Matta modified Merle d’aubigne score.ResultsOut of 62 patients 47 patients who turned up for final functional evaluation were included in study. 19 patients had excellent, 15 had good, 2 had fair and 11 had poor results. Age less than 40 years, anterior column fracture pattern, Pre-operative fracture displacement >20 mm, fracture comminution and post-operative fracture reduction within 3 mm were the predictors of the functional outcome. When analysed using logistic regression model, post-operative fracture reduction was found to be the only significant predictor of functional outcome.ConclusionCAP approach is useful anterior approach to acetabulum. Fracture reduction is the independent predictor of functional outcome. Comparison of this approach with other anterior approaches to acetabulum can be area of further research.     

Foot pressures during gait: a comparison of techniques for reducing pressure points

PURPOSE: Various methods have been used to redistribute plantar surface foot pressure in patients with foot ulcers. This study was conducted to determine the effectiveness of four modalities (fracture walker, fracture walker with insert, and open and closed toe total contact casts) in reducing plantar foot pressure. METHODS: Ten healthy, normal volunteer subjects had an F-scan sensor (ultra thin shoe insert pressure monitor) placed under the right foot. They then ambulated on a flat surface, maintaining their normal gait. Dynamic plantar pressures were averaged over 10 steps at four different sites (plantar surface of great toe, first metatarsal head, base of fifth metatarsal, and plantar heel). All subjects repeated this sequence under five different testing conditions (barefoot, with a fracture walker, fracture walker with arch support insert, open and closed toe total contact cast). Each subject's barefoot pressures were then compared with the pressures during the different modalities. RESULTS: All four treatment modalities significantly reduced (p < 0.05) plantar pressure at the first metatarsal head (no method was superior). The fracture walker, fracture walker with insert, and open toe total contact cast significantly reduced pressure at the heel. Pressures at the base of the fifth metatarsal and great toe were not significantly reduced with any treatment form. CONCLUSION: The fracture walker, with and without arch support, and total contact cast can effectively reduce plantar pressure at the heel and first metatarsal head.     

Fracture of the anterior superior iliac spine following anterior cervical fusion using iliac crest. Case report.

A case is presented in which fracture of the right anterior superior iliac spine occurred 2 weeks after the right iliac crest had been used as the donor site for a two-level anterior disectomy and fusion.     

Anthropometric Determinations of Umbilical Position in Iraqi Adults

Introduction  Umbilicus is an important surface landmark on the anterior abdominal wall in addition to its aesthetic and psychological effect. Objectives  The objective of the study is to determine the position of umbilicus in Iraqi adults to provide a guide for the neoumbilicus in abdominoplasty. Subjects and Methods  This is an observational study performed on 100 volunteers with no abdominal wall abnormality. Measurements included weight, height, body mass index (BMI), distance from xiphoid to umbilicus, distance from xiphoid process to pubic symphysis, distance from xiphoid process to both anterior superior iliac spine (ASIS), distance from pubic symphysis to umbilicus and from pubic symphysis to xiphisternum, distance of umbilicus to both ASIS, and distance of umbilicus to interspinous line and to inter-anterior hypochondrium line. Results  The study included 100 volunteers, with 50% male and 50% female whose age ranges between 18 to 60 years. The results were a follows: distance from xiphoid process to umbilicus and distance from xiphoid process to pubic symphysis were 18.03 ± 3.25 cm and 32.21 ± 4.64 cm, respectively; distances from xiphoid process to right ASIS and left ASIS were 25.95 ± 5.72 cm and 25.84 ± 6.02 cm, respectively; distance from pubic symphysis to umbilicus was 17.66 ± 3.12 cm; distance of umbilicus to interspinous line was 9.25 ± 1.84 cm. The distance from umbilicus to inter anterior hypochondrium line was 9.905 ± 2.19 cm. Conclusion  These measurements can determine the neoumbilicus position, reduce practical mistakes, and improve postsurgical outcomes.     

Effect of pin location on stability of pelvic external fixation

Pelvic external fixators allow two locations of pin purchase: anterosuperior (into the iliac crest) and anteroinferior (into the supraacetabular dense bone, between the anterior superior and anterior inferior iliac spine). The purpose of this study was to compare the stability of these two methods of fixation on Tile Type B1 (open book) and C (unstable) pelvic injuries. Five unembalmed cadaveric pelves (mean age, 68 years; four males and one female) were loaded vertically in a servohydraulic testing machine in a standing posture. The AO tubular system and Orthofix were used. On each pelvis, a Type B1 injury was simulated. Each external fixator was applied in each location in random order. Cyclic loads were applied through the sacral body to a maximum of approximately 200 N while force and displacement of the pelvic ring were recorded digitally. Sacroiliac joint motion was quantified tridimensionally with displacement transducers, mounted on the sacrum and contacting a target fixed to the posterior superior iliac spine. A Type C injury was created and augmented with two iliosacral lag screws, and the tests were repeated. For the Type B1 injuries with anteroinferior pin purchase, the mean stiffness was 201.2 N/mm for the AO frame and 203.2 N/mm for the Orthofix. For the anterosuperior frames the mean stiffness was 143.9 N/mm for the AO frame and 163.3 N/mm for the Orthofix. For Type B1 and Type C injuries, the anteroinferior location of pin purchase resulted in significantly reduced sacroiliac joint separation. There were no significant differences between the frame types. Dissection of the preinserted anatomic specimen revealed no evidence of injury to the lateral femoral cutaneous nerve after blunt dissection and drilling with protective drill sleeves. It is concluded that the anteroinferior location of external fixation pins is a safe technique with the potential for increased stability of fixation.     

髋臼前柱钢板内固定的解剖学研究

目的研究髋臼前柱钢板内固定技术中螺钉的最佳进钉点、方向和长度,预防发生螺钉穿入关节内的严重并发症。方法取成年男性半骨盆标本20个,分别测量髋臼前、后缘到髂前下棘、髂耻隆起和耻骨结节的距离,确定和制作髋臼前柱系列断面,分别测量各断面上各进钉点的安全进钉角度,将测量数据输入到SPSS10.0软件进行统计学分析。结果髋臼前缘到髂前下棘、髂耻隆起和耻骨结节的距离分别为(25.4±1.4)mm,(11.8±0.7)mm和(37.4±1.5)mm,后缘到髂前下棘和髂耻隆起的距离分别为(15.5±0.9)mm和(29.1±1.6)mm。在各断面距离骨盆界线0.5cm点、1.0cm点和1.5cm点上螺钉的安全进钉角度的最大值分别为(8.2±2.2)°、(14.9±3.4)°和(26.1±4.5)°。结论在前柱髋臼区使用钢板内固定时,可以采用3种方法避免螺钉穿入关节内。第一种方法是使用短螺钉,螺钉方向随意;第二种方法是使用长螺钉紧贴骨盆界线进钉,方向平行于四方区;第三种方法为根据不同的进钉点选择不同的进钉角度和长度。     

Men and women have similar Q angles: a clinical and trigonometric evaluation

The Q angle is an important determinant of patellar tracking, though its clinical relevance is debatable. One controversy centres around any possible differences in its value between men and women. The accepted, though unproven explanation, for the greater Q angle in women is that a woman has a wider pelvis. However, because of the long distance between the pelvis and patella, relative to the distance from the patella to the tibial tuberosity, large changes in the position of the anterior superior iliac spine are necessary to effect significant changes in the Q angle. In our study of 69 subjects, we did not find such large differences in the position of the anterior superior iliac spine, and found a mean difference of only 2.3 degrees between the Q angles of men and women. Furthermore, we found that men and women of equal height demonstrated similar Q angles, with taller people having slightly smaller Q angles. The slight difference in Q angles between men and women can be explained by the fact that men tend to be taller.     

Anatomy of the posterior iliac crest as a reference to sacral bar insertion

There are no detailed anatomic studies focusing on the posterior iliac crest although it frequently is used for posterior stabilization of unstable pelvic fractures. Anatomic dissections were done to evaluate the size of the extraarticular region of the posterior iliac crest and its relationship to the lumbosacral lamina and to show on cadavers the level of sacral bar placement that offers safe and solid fixation. Sixty cadavers were dissected bilaterally. Fifty-one were male and nine were female. The distance between the posterior wall of the sacral canal and the tip of the iliac crest was measured at various levels between the level of the upper border of L5 lamina to the level of the posterosuperior iliac spine. In all the dissections the greatest distances were at the level of the L5-S1 junction, which consequently is the safest level for good bony purchase. The entire length of the posterior iliac crest from the level of the upper border of L5 lamina to the posterosuperior iliac spine was shown to be appropriate for safe and solid bar fixation because all of the distance measurements were greater than 13 mm, which is the smallest safe distance. Below the posterosuperior iliac spine level, insertion of the sacral bars was dangerous because the average measured distance was only 10.38 mm.