髋臼上方骨盆外固定技术相关研究

骨盆外固定术是骨盆损伤患者复苏阶段治疗颇为重要的环节,传统的骨盆外固定架对骨盆前环提供足够的稳定性,但对后环的稳定性不足。髋臼上方外固定的钉道位于髂前下棘至髂后上棘间髋臼上方致密骨质内髂嵴前缘自髂前上棘向下至髋臼边缘,熟悉股外侧皮神经解剖可避免损伤。生物力学研究表明置钉于髋臼上方密质骨中可比传统置钉法获得更佳的骨盆稳定性,外固定针插入髋臼上方4～5 cm深能提供足够稳定性,联合应用骨盆闭孔-出口位、闭孔入口位及髂骨斜位像可确保螺钉安全植入。经髋臼上方通道的外固定针可获得更长的钉-骨界面,并实现对骨盆后环的加压,增加固定可靠性。     

髋臼后柱的CT测量及其X线投照角度的探讨

目的 探讨C型臂X线机透视下经皮置入髋臼后柱螺钉的最佳透视角度. 方法 对10具尸体标本的20侧髋臼进行CT扫描,在扫描结果中包含股骨头最大界面的扫描平面内,测量后柱后表面与冠状面的交角(α角)及后柱后表面与髋臼口所在平面的交角(β角). 结果 髋臼后柱后表面与冠状面的交角(α角)为28.2°±2.3°,髋臼后柱后表面与髋臼口所在平面交角(β角)为95.4°±5.3°.结论 当C型臂X线机以平行于后柱后表面的方向进行投照时,球管与冠状面成约30°角,即在闭孔斜位的基础上增加15°,与闭孔斜位投照相比,能更准确地了解螺钉与后柱后表面之间的关系.     

CT三维重建模型下模拟髋臼前柱2种经皮置钉方法的比较

目的对比CT三维重建模型下模拟髋臼前柱2种经皮置钉方法的效果。方法选取55例正常成人骨盆CT资料构建三维模型,共110侧髋臼前柱,调整模型透明度使其类似常规X线片,分别用2种置钉方法进行置钉,A组利用出口闭孔位和入口髂骨位引导置钉,B组利用髋臼前柱轴位引导置钉,置钉完成后恢复图像为不透明状态,记录螺钉是否进入髋关节及与耻骨支的位置关系。结果55例110侧髋臼,4侧未能找到髋臼前柱轴位影像予以剔除,106侧髋臼前柱纳入研究。2组模型均无螺钉进入髋臼。A组螺钉置入优秀、良好、尚可率分别为59.4%、17.0%、23.6%,B组分别为59.4%、22.6%、17.9%,2组总体置钉质量差异无统计学意义(Z=-0.829,P=0.407)。A组女性骨盆置钉优秀、良好、尚可率分别为7.1%、21.4%、71.4%,B组分别为28.6%、21.4%、50.0%,B组置钉质量显著高于A组(Z=-3.000,P=0.003)。A组男性骨盆置钉优秀率78.2%,良好率15.4%,尚可率6.4%,B组分别为70.5%、23.1%、6.4%,2组差异无显著性(Z=-0.969,P=0.333)。结论髋臼前柱轴位可以作为引导置钉的一种手段,尤其适用于女性患者,对于男性患者,2种方法均可实现较好的置钉。     

骨盆前环入口位结合闭孔出口位透视辅助下经皮置入耻骨支螺钉的临床研究

目的：探讨骨盆前环入口位结合闭孔出口位透视辅助下经皮置入耻骨支螺钉的临床效果。方法：回顾性分析2020年1月至2021年1月收治的25例髋臼前柱骨折患者。男14例,女11例;年龄22～73岁,平均（41.3±11.6）岁。所有患者术前于CT上测量骨盆前环入口位透视角度。术中使用C型臂X线机在骨盆前环入口位结合闭孔出口位透视技术辅助下经皮置入骨盆前环耻骨支通道螺钉,术后采用CT验证耻骨支螺钉位置。结果：25例患者共植入32枚螺钉,其中逆行耻骨支螺钉20例,顺行耻骨支螺钉12例。每枚螺钉置入时间为20～32 min,平均（21.9±1.5）min;术前测量骨盆前环入口位角度为31.2°～38.9°,平均35.38°±3.63°,在男女患者之间无统计学差异（P>0.05）。术后采用CT验证,所有耻骨支螺钉均位于前环骨通道内,无螺钉错位、突破前后侧骨皮质等情况发生。25例患者术后随访时间为7～12个月,平均（8.5±1.2）个月。骨折愈合时间为16～24周,平均（18.0±2.8）周。25例患者伤口均一期愈合,随访期间无切口感染、内固定物松动及断裂等并发症发生。术后骨折复位质量根据Mat...     

60例复杂髋臼后壁骨折的诊治

目的探讨复杂髋臼后壁骨折的诊断及手术疗效。方法自2008年1月至2013年3月,以三种体位X线平片、CT扫描、CT三维图像重建技术诊断髋臼后柱合并后壁骨折42例、横形骨折合并后壁骨折18例。采用俯卧位Kocher-Langenbeck入路,开放复位髋臼重建接骨板和拉力螺钉固定,治疗复杂髋臼后壁骨折。结果按Matta评定标准,骨折解剖复位率80.49%、满意复位率8.54%、不满意复位率10.97%。术后早期并发症:坐骨神经损伤1例,股神经损伤1例,髂外动脉损伤血栓形成1例,下肢深静脉血栓形成2例;晚期并发症:异位骨化3例,股骨头坏死1例,髋关节创伤性关节炎2例。结论复杂髋臼后壁骨折正确诊断主要依靠骨盆前后位、闭孔斜位、髂骨斜位X线平片检查,对于判断髋臼骨折部位、类型非常重要,CT扫描提供髋臼冠状面骨折线、骨折块等清晰图像,为复杂髋臼后壁骨折的治疗,提供选择手术入路和内固定术方案有重要意义。     

基于CT图像解剖学测量和数字重建透视的经皮骶髂螺钉固定术中透视方法研究

目的 基于CT图像对骶髂螺钉置入所涉及的重要解剖边界进行测量和分析,并应用数字重建透视(DRR)技术探讨术中获取理想透视图像的方法. 方法 收集30例患者的平卧位骨盆CT 扫描数据,使用三维重建技术,在图像中确定骶髂螺钉在S1椎体内安全通道的上方、前方和后方骨皮质边界,螺钉在骶孔区的前方、下方骨皮质边界,以及骶骨翼斜坡.测量这些边界与骨盆前后位垂线(基准线)在矢状面的夹角.应用DRR技术,确定透视人口位、出口位和侧位的理想拍摄角度,并观察关键解剖标志的特征性表现,分析术中标准透视图像的采集方法. 结果 S1椎体的上方、前方、后方骨皮质与基准线在矢状面的夹角平均分别为37.7°±8.6°(23.2°～50.8°)、22.9°±6.7°(13.1°～ 32.O°)、41.9°±6.8°(33.0°～54.8°),骶孔区的前方、下方骨皮质切线与基准线的夹角平均分别为37.0°±12.0°(19.9°～ 63.1°)、38.8°±8.0°(25.7°～ 54.6°),骶骨翼斜坡与基准线的夹角平均为82.4°±13.0°(70.3°～117.3°).通过基于DRR技术的透视模拟和对相应解剖结构的观察,可以得到拍摄标准入口位、出口位和侧位的透视方法,并能清楚显现各图像上的相应解剖标志. 结论 本研究所测得的数据个体差异较大,临床上应该根据每例患者的实际情况,并以相关解剖标志的特征性表现为依据,决定术中骨盆入口位和出口位的透视角度.为防止骶髂螺钉穿出斜坡伤及Ló神经和髂血管,需要从骨盆侧位透视图像上确认螺钉位置.     

正中矢状面上S2和S1椎体前缘夹角对骨盆入口位的影响

目的:探讨正中矢状面上S2、S1椎体前缘夹角对骨盆入口位的影响.方法:筛选出58例患者的骨盆轴向CT扫描图像作为研究对象,其中男43例,女15例;年龄18～68岁,平均40.7岁.于每一例骨盆CT的正中矢状面上分别测量S2、S1椎体前缘与水平面间夹角来模拟由骨盆正位进行骨盆入口位投照时所需要的最佳X线调整角度.以S2与水平面间夹角为基数并减去S1与水平面间夹角来计算两者间的差值,进而评判S2、S1椎体前缘夹角对骨盆入口位的影响.应用SPSS16.0统计软件对测量结果进行配对t检验,可信区间设为95％,差异的显著性设为P＜0.05.结果:S2椎体前缘与水平面间夹角平均(30.5±6.5)°,S1椎体前缘与水平面间夹角平均(25.7±5.9)°,两组角度间差异有统计学意义(t=3.35,P=0.001).S2、S1椎体前缘夹角为零度者10例;负角14例,平均-(8.9±8.1)°;正角34例,平均(11.8±6.4)°.结论:正中矢状面上S2、S1椎体前缘夹角使得S1入口位在绝大多数情况下不同于S2入口位,且对S1、S2入口位的成像及应用的可靠性均有影响.根据术前骨盆CT正中矢状面的测量结果透视出患者个体化的S1、S2入口位可准确地指导相应S1、S2骶髂螺钉的置入操作.     

髋臼骨折的诊断和处理

一、髓臼骨折的Ｘ线诊断（一）髓臼的应用解剖髓臼呈杯状,由髋骨、坐骨、耻骨联合组成,由前、后两个骨柱构成。前柱又称髂耻柱,始于耻骨支,经前方臼面向上、前延伸达髂前上棘或髂棘。后柱又称髂坐柱,始于坐骨大切迹,经负重区和后方臼面向下延伸达坐骨结节。臼内侧壁又称方形区（ｑｕａｄｒｉｌａｔｅｒａｌａｒｅａ）,是骨折分类的重要标志之一（图１）。（二）ＪｕｄｅｔＸ线检查和解剖学标志ＪｕｄｅｔＸ线检查包括摄患髋正位、髂骨斜位（骨盆向患侧斜４５）和闭孔斜位（骨盆向健侧斜４５）片。正位Ｘ线片可显示下述解剖学标志：（…     

髋臼后柱解剖形态的三维重建模型研究

目的 通过骨盆数字化三维重建模型探讨髋臼后柱及股骨头的解剖形态学特征,为术中接骨板塑形及髋臼后柱解剖型接骨板的研发提供依据.方法 111例因单侧髋臼、骨盆损伤行骨盆螺旋CT扫描的成年患者,男72例,女39例;年龄18～80岁,平均45.4岁.依据CT扫描数据建立骨盆数字化三维模型.于模型中测量股骨头直径,髋臼后柱接骨板途经的髋臼后壁、近端、远端三段近似圆弧的曲率半径(R1、R2和R3)和反映三段圆弧相对位置关系的髋臼后壁圆弧展角.结果 股骨头直径平均(47.43±3.74) mm,R1 (47.96±7.80) mm,R2(67.71±13.35) mm,R3 (9.76±0.43) mm,髋臼后壁圆弧展角平均51.38°±6.83°.男女两组股骨头直径及髋臼后壁圆弧展角的差异有统计学意义(t=12.37,P=0.00;t=2.63,P=0.01),而R1、R2、R3两组差异无统计学意义(t=1.05,P=0.30;t=1.36,P=0.18;t=0.72,P=0.47).髋臼后壁圆弧展角与股骨头直径呈正相关(r=0.37,P=0.00),R1、R2和R3与殷骨头直径不相关(r=0.09,P=0.34;r=0.08,P=0.43;r=-0.00,P=0.98).R2总体上随R1增大而增大,髋臼后壁圆弧展角随R1及R2增大而减小,R3变化范围不大.结论 髋臼后柱的解剖形态存在个体差异,其形态与股骨头直径及患者性别不相关,其中髋臼后壁弧度是决定髋臼后柱接骨板形态的主要因素.     

顶弧角的测量在髋臼骨折治疗方案选择中的应用

目的探讨顶弧角的测量与髋臼骨折治疗方案选择之间的相关性。方法术前测量并记录48例髋臼骨折骨盆正位片、髂骨斜位片、闭孔斜位片上的顶弧角度数,同时对比患者最终治疗方案(手术组与非手术组)的临床资料,统计分析二者相关性。结果手术组骨盆正位片上测量平均顶弧角为(14.5±7.8)°,非手术组(42.1±12.5)°,依据Matta评价标准(中顶弧角<30°):敏感性100%,特异性92.1%;手术组髂骨斜位片测量平均顶弧角为(21.3±8.4)°,非手术组(50±14.2)°,依据Matta评价标准(前顶弧角<40°):敏感性100%,特异性92.1%;手术组闭孔斜位片测量平均顶弧角为(23.2±8.9)°,非手术组(52.3±13.6)°,依据Matta评价标准(后顶弧角<50°):敏感性100%,特异性88.6%。结论顶弧角的大小与是否采取手术治疗有较大的相关性,可以作为临床医生判断髋臼骨折预后与治疗方案选择的重要参考指标。     

Obturator Oblique and Pubic Ramus Inlet Views Can Better Guide the Insertion of an Anterior Column Acetabular Screw

ObjectiveThe objective of the present paper was to investigate the value of obturator oblique and pubic ramus inlet views in guiding anterior column acetabular screw insertion.MethodsWe collected pelvic CT scans at the diagnostic imaging center of our hospital between 2017 and 2019. Virtual three‐dimensional (3D) models of the pelvis were created based on the CT scans. Then the transparency was adjusted to 30%. Two identical copies of the 3D model data were made. 3D model replications were divided into a control group and an experimental group. In the control group, the screw was inserted into the anterior acetabular column using obturator‐outlet and iliac‐inlet views. In the experimental group, the screw was guided under obturator oblique and pubic ramus inlet views. Based on whether the screw penetrated the hip joint and/or exited the pubic ramus, models were divided into three grades. Grade I: the screw travels completely within the anterior column bone corridor; Grade II: the screw exits the superior pubic ramus, but the length of the screw outside the channel does not exceed 1/2 of the anterior column; Grade III: the screw exits the superior pubic ramus and the length of the screw outside the corridor exceeds 1/2 of the anterior column. We compared the screw placement quality of the two groups and analyzed differences between genders. In addition, the distance between the screws and the acetabulum was recorded and compared among the two groups.ResultsA total of 110 hemipelves were selected, including those of 80 men and 30 women, with an average age of 46.76 ± 14.26 years. In the control group, the screw quality of 64 models (58.2%) was Grade I. In the experimental group, 94 models (85.5%) had Grade I screw placement quality. Grade II screw placement quality accounted for 18.2% of the control group and 7.3% of the experimental group. In the control and the experimental groups, there were 26 and 8 cases with Grade III screw placement quality, respectively. The quality of screw placement in the experimental group was significantly better than that in control group, and the difference between the two groups was statistically significant (P < 0.01). The distance between the screw and the acetabulum in the control group and experimental group was 0.92 ± 0.49 mm and 2.78 ± 1.15 mm, respectively. The difference between the two groups was statistically significant.ConclusionAnterior column acetabular screws can be inserted successfully and more accurately using the obturator oblique and pubic ramus inlet views.     

不同影像学检查在髋臼骨折诊断中的价值

目的探讨X线片、CT平扫及CT三维重建在髋臼骨折诊断中的价值。方法1997年11月～2004年3月对74例髋臼骨折患者拍前后位、多方位即闭孔斜位、髂骨斜位、骨盆出、入口位X线片,其中57例行CT平扫,17例行CT三维重建。分别计算并比较各种方法对髋臼骨折的检出率,同时根据影像学所见进行诊断、分型,并在术中验证得出分型符合率后进行对比。结果骨折检出率:前后位X线片为90.54%,多方位X线片为97.30%,CT平扫为98.25%,CT三维重建为100%;其分型符合率分别为41.79%,97.22%,100%,100%。结论传统的前后位与多方位X线片为髋臼骨折诊断中经济实用的首选方法,CT平扫与三维重建可提高诊断率,并对准确分型、制定合理的治疗方案起关键作用。     

Use of fluoroscopy to evaluate iliac screw position

Iliac screw fixation is often used for long fusions to the sacropelvis. Maximum iliac screw purchase is obtained both by placing the screws within 1.5 cm of the greater sciatic notch and by extending them anterior to the axis of rotation in flexion-extension. Screw insertion is "blinded" or dependent on tactile feedback, and hence extreme care is necessary to avoid incorrect placement and damage to vital neurovascular structures in the pelvis and sciatic notch. Long screws may violate the hip joint while medial placement may injure the lumbosacral plexus and the nearby vessels. To explore the best intraoperative fluoroscopic method of determining optimal iliac screw placement, we used a synthetic pelvis model to investigate screw placement conditions: (1) optimal anatomic placement, (2) violation of the sciatic notch, (3) hip joint violation, (4) medial wall violation, and (5) lateral wall violation. Each condition was examined utilizing fluoroscopy with posteroanterior, inlet, outlet, lateral, iliac oblique, and obturator oblique Judet views to simulate operative conditions. These views were obtained to evaluate critical malposition of iliac screws. We found that, for a sciatic notch violation, the obturator oblique view best demonstrated the cortical breech, while for a hip joint violation, the inlet and outlet views were best. For a medial wall violation, the iliac oblique view best showed the violation. For a lateral wall violation, we were unable to demonstrate the cortical breech using these fluoroscopic views. Fluoroscopy is an effective method to determine sciatic notch, hip joint, and medial wall violations after iliac screw placement; however, it is not effective in identifying a lateral wall violation.     

Is the lateral sacral fluoroscopic view essential for accurate percutaneous sacroiliac screw insertion? An experimental study

The aim of this study was to evaluate the role of the lateral fluoroscopic view in optimising percutaneous sacroiliac screw insertion. Plastic pelvic models (n=26) were used for the introduction of 104 cannulated screws into the first and second sacral (S1 and S2) vertebral bodies, controlled with an image intensifier using either two views (inlet/outlet) for the right side (group A, n=52) or three views (inlet/outlet/lateral) for the left side (group B, n=52). The mean radiation exposure times for S1 were 18.6s and 14s, in groups A and B, respectively, and for S2 were 16.1s and 12.2s, respectively; 13 cortex perforations were noted in group A and 20 in group B. After insertion into S1, in both groups there were three cases of foraminal and none of central canal perforation, but after S2 insertion in both groups there were ten foraminal and five canal perforations. A higher incidence of misplacement of S1 screws was found in group A in comparison with group B (p=0.001), with sufficient data to support percutaneous screw fixation using inlet, outlet and lateral views rather than only inlet and outlet acquisition images.     

标准骶骨侧位像上骶神经根管前缘线对置入骶髂螺钉的作用

目的：了解骶神经根管于S1、S2骶段内的方位、走行,探讨标准骶骨侧位像上骶神经根管前缘线对置入骶髂螺钉的作用.方法：将全骨盆2.0 mm层厚轴向平扫数据导入到Mimics 10.0,并应用其分别将骶骨、双侧无名骨、骶管及骶神经根管制作成3D图像并旋转至标准骶骨侧位及骨盆出入口位后观察骶神经根管的方位、走行.辨识标准骶骨侧位及骨盆出入口位X线片上骶神经根管并观察其特点.结果：在S1、S2骶段内骶神经根管始于同节段椎管的头端前缘的两侧,止于同节段骶前孔,其走行由头端、后方、内侧至尾端、前方、外侧;在X线片上其密度低,尤其在标准骶骨侧位像上常仅其前缘线显像且多有中断现象而需要仔细辨识.结论：在标准骶骨侧位像上辨识骶神经根管前缘线并以之作为骶髂螺钉安全通道的尾后界,则可以避免内置物进入神经根管及骶管,从而提高置钉的安全性.     

Radiographic evaluation of screw position in revision total hip arthroplasty

Injury to intrapelvic structures during removal of screws in revision acetabular arthroplasty is an uncommon, yet potentially serious complication. Bicortical screws are at greatest risk for causing injury during removal, especially if directed toward intrapelvic vessels and nerves. Complications can be minimized with thorough evaluation of screw position before revision surgery. A study of seven cadaveric pelves was done to determine if plain radiographic views provide useful information regarding screw position. In each pelvis, bicortical transacetabular screws were fixed in all acetabular quadrants 15 mm longer than the measured depth. Afterward, anteroposterior, inlet, Judet, and cross-table lateral radiographic views were obtained and intrapelvic dissections were done. Radiographs and intrapelvic dissections were compared to determine screw position. We found that the obturator and iliac oblique (Judet) views were most useful in defining screw position. The iliac oblique view clearly revealed screws that violated the quadrilateral surface and therefore were directed toward the obturator vessels and nerve. The obturator oblique view revealed screws that violated the anterior column and therefore were directed toward the external iliac vessels. The lateral view additionally clarified such screws by determining general anterior or posterior direction.     

骨盆骨折X线表现及轴向CT相关性研究

目的探讨骨盆骨折时骨盆前后位、出口位、入口位X线表现及轴向CT表现的差异,确定不同部位骨盆骨折投照的最佳位置。方法回顾性分析了55例骨盆骨折患者骨盆前后位、出口位、入口位X线片及轴向CT片。将骨折表现程度分为四个等级。分别观测同一部位骨折在不同位置X线片及CT上的表现程度。结果耻骨联合分离程度在各种投照位置上无明显差异。耻骨支、耻骨体、坐骨、骶孔和L5横突,移位程度在出口位上表现最明显。骶髂关节分离,骶骨翼、髂嵴骨折在入口位上表现最明显。骶骨压缩骨折,半骨盆向后移位,水平旋转不稳在入口位X线片上最明显。垂直旋转不稳在出口位片上最明显。CT在诊断骶髂关节分离及骶骨骨折有独特价值。结论骨盆骨折应首先摄前后位X线片,根据骨折部位,进一步摄入口位、出口位X线片。并根据骨折的表现判断其稳定性,指导临床治疗。CT在诊断骶骨骨折,骶髂关节分离有独特价值。     

Radiological evaluation of pelvic inlet and outlet radiographic view in Indian population

Background

Pelvic fractures represent one of the most challenging clinical problems in which an urgent multidisciplinary approach is required. The early management in a suspected pelvic fracture starts with the good radiological evaluation. The standard radiographic view includes the anteroposterior, inlet and outlet views. The inlet and outlet views are taken with 45° tilt from anteroposterior plane. However, recent studies have shown that there is significant individual variation within the population and these values should be redefined.

Behandlung der Pseudarthrosen des Beckens

Malunion is rare after pelvic fractures. The cardinal symptom is chronic stress-related pain in the pelvic girdle. It is necessary to investigate whether the symptom cluster is caused by malunion, posttraumatic malalignment or a combination of both. The diagnostic workup must include a physical examination with the patient undressed, provocation tests, X-ray investigations (general X-ray view of pelvis, plus views of inlet, outlet, ala, and obturator), and also computer tomography with 2D and 3D reconstructions, which is essential for the analysis of any malalignments, instabilities and malunions in the pelvic girdle. Conservative treatment is not usually adequate for chronic instabilities in the pelvic girdle. The operative procedure selected depends on the localization of the primary injury, malunion and/or malalignment. The basic principle of operative treatment is that all instabilities and/or maluinions in any region must be stabilized. Late operations for reconstruction of the pelvic girdle are challenging and technically difficult interventions, with a complication rate that is anything but negligible. Some of the complications possible are haemorrhage, wound haematomas, vascular and neural lesions, infections, incomplete correction, loss of correction, persisting malunion or symptoms and premature loosening or failure of implants.