骨盆损伤的诊断及外科治疗

骨盆损伤的诊断范畴主要包括损伤机制、骨折类型、稳定程度、影像评估、合并损伤等一系列内容。一、损伤机制骨盆的稳定性主要由骶髂关节复合体、骶棘韧带及骶结节韧带维持。机械性损伤导致骨盆骨折的能量转换主要通过以下途径实现[1,2]:(一)前后压迫(ａｎｔｅｒｉｏｒｐｏｓｔｅｒｉｏｒｃｏｍｐｒｅｓｓｉｏｎ,ＡＰＣ):暴力经骨盆前后方向传递,先使前环结构耻、坐骨支骨折或耻骨联合分离。随着应力的继续,髂骨翼不断外翻,致骶结节韧带与骶棘韧带损伤,进而累及骶髂关节使其周围的骶髂前韧带甚或骶髂骨间韧带断裂。髂骨翼的旋转形变,使骨盆…     

关节外科人体解剖学系列讲解（八）髋臼骨折的髂腹股沟人路

一、适应证与禁忌证 髂腹股沟入路是由Letournel开展的显示髋臼前柱和髂骨体的内侧面的入路.它可由骶髂前面至耻骨联合范围内显露内髂骨的全部和骨盆入口.也可进入髂骨体部的四边形面和上下支.也可进入髂骨外侧面.所有骨盆前面和前柱的骨折均可采用髂腹股沟入路.     

骨盆韧带损伤对骶髂关节稳定性影响的生物力学研究

目的 探讨骨盆韧带损伤对骶髂关节稳定性的影响,为骨盆骨折的临床治疗提供理论依据. 方法取骨盆标本10具,完整保留关节及韧带结构,左侧组逐级离断耻骨联合、骶棘韧带、骶结节韧带、骶髂前韧带及骶髂前关节囊、骶髂骨间韧带,右侧组逐级离断耻骨联合、骶髂后长、后短韧带、髂腰韧带、骶髂骨间韧带,模拟人体单足站立位,力学机上给予轴向加载,测量并记录骶骨相对于髂骨的垂直位移及矢状面骶骨旋转角度(角移位). 结果左侧力学试验中,仅切断耻骨联合周围韧带、骶结节韧带,骶骨垂直位移、骶骨角位移,差异无统计学意义(P＞0.05).逐步切断骶髂前韧带、骶髂骨间韧带,骶骨的垂直位移数值由完整骨盆测量的(4.144±0.538)mm增至(5.853±0.368)mm;骶骨的旋转角度由骨盆完整时的0.226°±0.061°增至0.616°±0.086°,差异有统计学意义(P＜0.05).右侧力学试验中,逐次切断骶髂关节后部韧带,骶骨的垂直位移数值由完整骨盆测量的(3.610±0.696)mm增至(6.825±0.565)mm;骶骨的旋转角度由骨盆完整时的0.271°±0.094°增至0.746°±0.192°,差异有统计学意义(P＜0.05).结论 耻骨联合及其周围韧带的损伤对骶髂关节的稳定性无显著性影响;骶结节韧带、骶棘韧带对限制骶骨的角位移有很大作用;骨间韧带对骶髂关节稳定性的作用较大;骶髂后韧带与骨间韧带共同组成了骶髂关节后部韧带复合体,是骶髂关节周围韧带中的重要部分.     

半骨盆离断术最早的报告

<正>半骨盆离断是下肢的完整切除,实际上是髂骨与腹部间的离断或耻骨联合及骶髂关节离断,与之对应的是肩胛胸部离断术。适用于单侧骨盆部或股骨近端的恶性肿瘤。前提是无其他部位转移,单纯截肢不能彻底切除肿瘤,同时周身状况良好。以髂前上棘、耻骨联合、坐骨结节为交汇点,分别行前、后、会阴部三个切口。术中注意保护腹膜及盆腔脏     

人体跌坐条件下骨盆有限元模型构建及生物力学分析

目的分析人体跌坐在木地板和瓷砖地面时骨盆所受的冲击力情况。方法重建骨盆的三维模型,运用显式动力学计算研究人体跌坐在木地板和瓷砖地面时骨盆所受的冲击力情况。结果结构静力学分析显示,骨盆应力沿着髂骨纵行方向、髂骨与骶髂关节部位连线方向、同侧耻骨上支传导,而等效应力和等效应变在骶髂关节处最大;模拟人体跌坐时结构显式动力学分析结果显示,在0.033 s时骨盆碰撞木板和瓷砖,撞击木板和瓷砖的等效应力分别为348.64 MPa和383.37 MPa,等效应变分别为0.011 351 mm和0.012 488 mm;骨盆在撞击瓷砖时的等效应力和等效应变比撞击木板时分别大9.96%和10.02%。结论本研究所建立的骨盆三维模型,可分析跌坐状态下受力,研究的结果可为临床骨盆骨折的诊断和治疗提供生物力学依据。     

锁定加压钢板固定骶骨不稳定骨折的应用及三维有限元分析

目的探讨锁定加压钢板治疗骶骨不稳定骨折的效果。方法应用三维有限元方法模拟骶骨Ⅰ、Ⅱ及Ⅲ区伴同侧耻骨上下支骨折的不稳定骨折,分别用骶髂螺丝钉和锁定加压钢板固定骨盆后环,用螺丝钉固定耻骨上支骨折,于L5椎体施以500N的轴向应力,计算骶骨及耻骨上支处的位移,并将加载下的骨应力分布同正常骨盆加载下骨的应力分布进行比较。对11例骶骨不稳定骨折采用锁定加压钢板固定,并用Majeed评分标准评定术后功能。结果生物力学研究发现骶髂螺丝钉的固定效果很好,锁定加压钢板的固定效果接近骶髂螺丝钉。两种方法固定后加载下,应力分布均同正常骨盆相似。11例患者术后功能评定为:4例优,5例良,2例可。结论用锁定加压钢板治疗骶骨不稳定骨折是一种可行的方法,尤其是对伴有髂骨翼骨折的骶骨不稳定骨折,或骶骨Ⅱ或Ⅲ区粉碎性骨折。     

髂骨肿瘤Ⅰ型切除后骨盆的应变分析

目的 对髂骨肿瘤Ⅰ型切除后骨盆的应变进行分析.方法 选择健康成人尸体骨盆标本6例,按照Ennecking对骨盆肿瘤Ⅰ型切除标准行髂骨大部分切除;双足站立位,0～500 N垂直分级载荷下,采用应变片对缺损骨盆关键部位的应变进行检测,并和正常骨盆各对应点的应变值进行对照.结果 与正常组比较,缺损骨盆各测点应变变化较大.双侧耻骨上支由正常状态下的压应变变为拉应变.双足站立位,500 N垂直载荷下,缺损组骨盆健侧骶1侧块、髂骨弓状线应变值分别为-554.5±251.2及-1105.5±352.7,为正常组的2.86、3.77倍,差异有统计学意义(P＜0.05).结论 建立了人体双足站立位髂骨肿瘤Ⅰ型切除的生物力学模型;髂骨肿瘤Ⅰ型切除后,缺损骨盆健侧应变值增大,传递压应力,耻骨联合区域应变绝对值增大,传递拉应力,必须进行修复重建,以恢复骨盆正常的应力传导功能;电阻应变片法测试骨盆表面应变的方法具有测试方法简单、结果可靠.     

不同路径髂骨钉钉道的CT影像学研究

目的：研究髂骨钉的最佳路径,为腰骶骨盆重建手术提供参考依据。方法：2009年2月至8月,选门诊或住院因各种原因进行骨盆CT扫描及三维重建并且无阳性表现的50例患者影像学资料进行研究,男28例,女22例;年龄19～65岁,平均41.2岁。设计4条路径,A、B、C路径均以CLIC点（Chiotic线与后髂嵴的交叉点,位于髂后上棘上方24mm处）为起点,方向分别为髋臼上缘、髂前下棘、髋臼中心;D路径以髂后上棘起点,指向髂前下棘。对每条路径中不同钉道的长度及钉道中两处狭窄点的骨板厚度进行数据分析。结果：A（CLIC点到髋臼上缘）、B（CLIC点到髂前下棘）、D（髂后上棘与髂前下棘）路径钉道长度相当,但A路径髂骨板厚度明显较B、D路径大。A、C（CLIC点到髋臼中心）路径髂骨板厚度无明显差异,但A路径通道长度明显大于C路径。结论：A路径即从CLIC点到髋臼上缘方向的髂骨钉钉道路径最长且髂骨板最厚,能够容纳相对最长最粗的髂骨钉,又能承受的拉力最大,是最理想的髂骨钉钉道。     

钉-棒系统与外固定支架固定骨盆不稳定损伤模型的生物力学比较

目的 通过对钉-棒系统和骨盆髂骨翼外固定支架固定骨盆水平旋转不稳定损伤模型的生物力学进行测试,对比两者固定骨盆的力学稳定性,为临床治疗提供理论依据. 方法 取经福尔马林处理的正常成人骨盆标本7具,保留从L5至股骨近端中上20 cm的骨盆标本,保留完整的耻骨联合、双侧髋关节、双侧骶髂关节、双侧骶结节韧带、双侧骶棘韧带、双侧骶髂前韧带、双侧骶髂后韧带.将骨盆置于AGX生物力学试验机上,模拟人体正常双足站立中立位,由L5垂直向下加压至500 N,依次测量下述4种情况下的耻骨联合位移:①完整骨盆;②骨盆水平旋转不稳定Tile B1型损伤模型;③钉-棒系统固定骨盆Tile B1型损伤模型;④骨盆髂骨翼外固定支架固定骨盆Tile B1型损伤模型.结果 在500 N的压力下,4组耻骨联合位移由小到大依次为完整骨盆[(0.121 ±0.025) mm]、钉-棒系统固定模型[(0.656±0.103) mm]、髂骨翼外固定支架固定模型[(1.512±0.101) mm]、Tile B1型损伤模型[(4.512±0.391) mm],4组间两两比较差异均有统计学意义(P＜0.05).结论钉-棒系统固定骨盆水平旋转不稳定损伤模型的生物力学稳定性明显优于骨盆髂骨翼外固定支架,能有效恢复骨盆环的力学稳定性.     

骨盆髋臼骨折机器人辅助治疗的研究进展

骨盆髋臼骨折是一种常见的骨折,主要由暴力或髋关节脱臼引起,通常由前部(耻骨联合和耻骨支)和后部(髂骨翼、骶骨、骶髂关节)的损伤组成[1].手术治疗骨盆髋臼骨折的目的是恢复骨盆髋臼解剖结构的完整性和稳定性.近年来,手术机器人逐渐应用到骨盆髋臼骨折手术治疗的过程中.手术机器人是目前工业技术水平在医疗器械上集中应用的最成功的...     

Three-Dimensional Evaluation of Innominate Bone Rotation in Female Patients with Developmental Dysplasia of the Hip

BackgroundPatients with developmental dysplasia of the hip (DDH) are known to have abnormal pelvic morphologies; however, rotation of innominate bone features remains unclear. Thus, we investigated innominate bone rotation in patients with DDH by measuring the associated angles and distances using three-dimensional (3D) computed tomography.MethodsWe defined four straight lines in pelvic 3D models: from the anterior superior iliac spine to the posterior superior iliac spine, from the anterior inferior iliac spine to the posterior inferior iliac spine, from the pubic tubercle to the ischial spine, and from the pubic tubercle to the ischial tuberosity. Similarly, we measured the angles formed by these lines using the vertical axis of the anterior pelvic plane on the horizontal plane and the horizontal axis on the sagittal plane. Additionally, we measured the distances between the femoral head centers and the acetabular centers in the coronal plane.ResultsThe difference in internal rotation angle between the superior and inferior parts of the iliac bone was significantly lower, by approximately 1.7°, in the DDH group than in the control group (p = 0.007); the difference between the inferior and superior parts of the ischiopubic bone was significantly higher, by approximately 1.5°, in the DDH group (p < 0.001). In the sagittal plane, the sum of the superior aspect of the iliac bone and the inferior aspect of the ischium was significantly lower in the DDH group (p = 0.001) than in the control group. The distances between the femoral heads and the acetabula were significantly greater in the DDH group than in the control group (p = 0.03, p < 0.01, respectively).ConclusionsPatients with DDH had a more internally rotated ilium and ischiopubic bone than normal individuals; however, it should be emphasized that internal rotation was reduced near the acetabulum, and the acetabulum was shifted laterally. Similarly, it was shown that patients with DDH had different rotations of the ilium and ischiopubic bone in the sagittal plane.     

Corona Mortis血管解剖学研究及其临床意义

目的:探讨闭孔血管和髂外血管在腹股沟区的分支,为减少髂腹股沟入路术中出血提供解剖学基础。方法:对25具新鲜中国成人尸体标本共50侧半骨盆进行解剖学研究,观测闭孔血管和髂外血管在腹股沟区的分支及其吻合支(CoronaMortis血管)的大小、出现率、吻合血管行径和吻合血管至耻骨联合的距离。结果:72%(36侧)耻骨上支表面至少存在1条血管吻合支,其中28%(14侧)存在2条或3条血管吻合支,24%(12侧)同时存在动脉吻合支和静脉吻合支。耻骨上支表面的血管吻合支平均直径2.6mm(2.0～4.2mm)。血管吻合支紧贴耻骨上支或髂耻隆起,几乎垂直地下行于髋臼窝壁或耻骨支后方,经闭膜管出盆腔,血管吻合支与耻骨联合的平均距离52mm(38～68mm)。在此区域手术以及髋臼或骨盆前环骨折极易损伤CoronaMortis血管。结论:闭孔血管和髂外血管的吻合支较粗,出现率高,位于耻骨上支表面。髂腹股沟手术入路应特别注意CoronaMortis血管的存在。     

An anatomical study of corona mortis and its clinical significance

Objective: To provide detailed information of corona mortis for ilioinguinal approach as an anterior approach to the acetabulum and pelvis. Methods: The course, branches and distribution of the vascular connection between the obturator system and the external iliac or inferior epigastric systems located over the superior pubic ramus were observed on 50 hemipelvises with intact soft tissues. Results：During the dissections, 72 % of the cadavericsides had at least one communicating vessel between the obturator system and the external lilac or inferior epigastric systems on the superior pubic ramus. The average diameter of the connecting vessel was 2.6 nun (range, 2.0-4.2 mm). It coursed over the superior pubic ramus or iliopubic eminence vertically to enter the obturator foramen and exit the pelvis. The average distance from pubic symphysis to the vascular connections between the obturator and external iliac systems was 52 nun ( range, 38-68 ram). Conclusions: Vascular connections between the obturator system and the external iliac or inferior epigastric systems were found over the superior pubic ramus with a high incidence. They are prone to damage during the ilioinguinal approach as an anterior approach to the acetabulum and pelvis. Thus, corona mortis located over the superior pubic ramus deserves great attention during the ilioinguinal approach.     

髋臼前柱螺钉固定解剖学研究及导向器的设计

目的为经髋臼前柱螺钉固定提供解剖学依据。方法对22只成人尸体骨盆标本,共44侧髋臼进行解剖学研究,观测髋臼前柱横断面形状,测量髋臼前柱螺钉固定在髂骨翼外侧面的进针点、进针方向、钉道直径、进针点至闭孔沟的距离。结果髋臼前柱横断面呈近似直角三角形,钉道直径10.5±0.8mm;螺钉进针点位于髂骨翼后外侧面坐骨大切迹和髂前上棘连线上方9.2±2.4mm,距坐骨大切迹38.5±3.8mm;螺钉进针方向于水平面与中心线夹角为40.7±3.8°,矢状面向尾端成角54.2±5.5°。钉道长度84.1±6.2mm。并设计出髋臼前柱螺钉固定导向器。结论髋臼前柱可接受1枚直径6.5mm、长70mm的螺钉,螺钉进针点位于髂骨翼后外侧面坐骨大切迹和髂前上棘连线上方10mm,距坐骨大切迹40mm。螺钉进针方向于水平面与中心线夹角40°,矢状面向尾端成角55°。髋臼前柱螺钉固定导向器将提高前柱螺钉固定的安全性。     

Biomechanical study of load transfer of the pubic ramus due to pelvic inclination after hip joint surgery using a three-dimensional finite element model

We studied load-stress distribution in the pelvis using a three-dimensional finite element model. The results showed that the load-stress on the pubic superior ramus was high in the normal pelvic position without sagittal or coronal inclination following that of the acetabulum in the pelvis. The load-stress on this area was not affected by sagittal pelvic inclination, but it was affected significantly by coronal pelvic inclination. The superior pubic load-stress on the side of the longer leg was higher than that on the opposite side. The tensile stress on the pubic ramus on the side of the longer leg significantly increased compared with compressive stress. We had a patient who had an insufficiency fracture of the pubic ramus on the side of an overcorrected leg after hip joint surgery, so we examined the cause of it. Although insufficiency fractures of the pubic superior ramus are caused by various static and kinetic factors, the alternation of coronal pelvic inclination is an especially important factor in such fractures after hip joint surgery.     

改良Stoppa入路死亡冠血管的解剖学研究

目的研究改良Stoppa入路髂外和腹壁下血管与闭孔血管在耻骨上支区的吻合支（死亡冠）解剖学特点,为提高骨盆髋臼前路手术操作安全性提供解剖学基础。方法模拟改良Stoppa入路对12具国人成人尸体标本共24侧半骨盆进行解剖学研究。观测死亡冠血管的出现率、直径大小、长度及其至耻骨联合和髂耻隆起的距离。结果87．5％（21侧）耻骨上支表面存在死亡冠血管,其中62．5％（15侧）为静脉型,8．3％（2侧）为动脉型,16．7％（4侧）为混合动静脉型。死亡冠血管的长度平均32．1（24．1～40．6）mm,直径平均2．5（2．0～3．7）mm。死亡冠血管至耻骨联合距离平均54．9（47．8～63．8）mm,至髂耻隆起距离平均20.3（6．2～35．0）mm。死亡冠血管紧贴耻骨上支,移动度小。结论死亡冠血管出现率高,变异度大,以静脉型为主。移位骨盆前环髋臼骨折及前入路手术时易损伤死亡冠血管,应注意其存在并妥善处理,推荐骨膜下剥离。     

髋臼后壁重建模型的建立及其生物力学分析

目的 :在尸体上模拟髋臼后壁缺损的模型,评价不同后壁重建方法对髋臼与股骨头接触特性的影响。方法:获取6具成人尸体的骨盆股骨标本,采用随机数字表法分为A组和B组。均采用后壁截骨法建立髋臼后壁60°弧1/2缺损的模型;两侧缺损区分别选用不同的重建方法。其中,A组凿取髂前上棘后方的自体髂骨以制作解剖性自体髂骨;B组于髂后上棘前方凿取髂骨块。将髋关节置于直立位、屈曲位及后伸位,从10~250 N分级加载,使载荷直接作用于髋臼后壁上。采用压敏片检测不同状态下形变位移、载荷、头臼接触面积及接触应力。结果:在不同的髋关节状态下,A组在一定载荷下的形变位移略大于B组,但差异无统计学意义(P0.05)。与完整髋臼相比,后壁重建使头臼接触面积有所减少;在250 N载荷下,A组(解剖重建组)头臼接触面积与B组(普通重建组)比较的差异无统计学意义(P0.05);其平均接触应力小于B组(P0.05),说明A组应力集中小于B组。结论:后壁截骨法建立的尸体髋臼后壁缺损模型可有效模拟临床实际;解剖重建使后壁头臼接触面积及应力分布恢复比较理想,接近正常髋关节,避免了局部应力集中。     

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.