机器人辅助微创三角固定治疗单侧不稳定性骶骨骨折

目的比较机器人辅助微创入路与传统切开入路三角固定治疗单侧不稳定性骶骨骨折的临床疗效。方法回顾性分析2014年8月至2018年2月收治并获得完整随访的24例单侧不稳定性骶骨骨折患者资料。所有患者均合并骨盆前环损伤,均为AO C1.3型骨盆骨折,术前均接受神经核磁检查明确腰骶神经未被骨折断端或骨块卡压;骨盆损伤均一期采用前后联合固定,骶骨骨折采用三角固定。根据不同手术方法分为机器人辅助微创入路组[简称机器人组,12例,男10例,女2例;年龄(36.3±1.2)岁(范围,22~56岁);Dennis骶骨骨折分型,Ⅰ型4例,Ⅱ型8例;神经损伤2例,Gibbons分级Ⅱ级1例,Ⅲ级1例]和传统后正中切开入路组[简称切开组,12例,男11例,女1例;年龄(38.2±1.6)岁(范围,19~58岁);Dennis骶骨骨折分型,Ⅰ型3例,Ⅱ型9例;神经损伤3例,Gibbons分级Ⅱ级2例,Ⅲ级1例]。比较两组患者的手术时间、术中出血量、术中透视时间、骨折愈合时间及Majeed功能评分采用t检验,Mears和Velyvis评价、内固定置入准确度、骨折愈合率采用卡方检验,术后感染率采用Fisher精确检验,Gibbons分级变化采用秩和检验。结果所有患者均获得随访,随访时间(21.2±3.2)个月(范围,14~36个月)。手术时间,机器人组为(100.3±14.5)min,切开组为(202.0±18.5)min;术中出血量,机器人组为(180.0±17.4)ml,切开组为(850.0±15.2)ml;术中透视时间,机器人组为(23.3±4.5)s(包括切开前机器人扫描定位图像时间);切开组为(90.0±7.7)s。Mears和Velyvis评价,机器人组解剖复位7例,满意4例,不满意1例;切开组解剖复位7例,满意4例,不满意1例;两组复位满意率均为91.7%(11/12)。两组均置入36枚螺钉,其中机器人组螺钉置入准确率100%,切开组螺钉置入准确率为77.78%(28/36)。两组骶骨骨折均愈合,愈合率100%;愈合时间,机器人组(8.5±1.9)个月,切开组(12.8±2.4)个月。Majeed评分,机器人组(86.2±3.4)分,其中优7例,良4例,可1例;切开组(84.2±2.7)分,其中优6例,良4例,可2例。机器人组术后均未出现伤口感染,切开组术后出现1例伤口深部感染,2例表浅感染,感染率为25%。Gibbons分级,机器人组1例由术前Ⅱ级恢复至术后Ⅰ级,1例Ⅲ级恢复至术后Ⅱ级;切开组2例由术前Ⅱ级恢复至术后Ⅰ级,1例Ⅲ级恢复至术后Ⅱ级。机器人组与切开组患者Gibbons分级变化、Mears和Velyvis评价、骨折愈合率、Majeed评分及术后伤口感染率无统计学差异(均P>0.05);而在手术时间(t=14.99)、术中透视时间(t=32.13)、术中出血量(t=100.46)、内固定置入准确率(χ2=9.00)及骨折愈合时间(t=4.87)方面,机器人组均优于切开组,两组比较差异均有统计学意义(均P<0.05)。结论机器人辅助微创入路三角固定与传统切开固定相比,具有手术时间短、透视少、出血量小、内固定置入更为准确及骨折愈合时间短等优点,可作为治疗单侧不稳定性骶骨骨折的更优选择。

Minimal-invasive triangular fixation with orthopaedic robot for unilateral unstable sacral fracture

Objective To compare the clinical outcomes between minimal-invasive triangular fixation with orthopedic robot and traditional open fixation method for unilateral unstable sacral fracture patients.Methods Data of 24 consecutive patients with unilateral unstable sacral fracture who were treated from August 2014 to February 2018 were retrospectively analyzed.All patients were associated with anterior ring injuries of pelvis and received magnetic resonance of nerve(MRN)preoperatively to exclude the compression of sacral nerve by bone.All patients received surgical treatment of sacral fractures with triangular fixation and the fixation of pelvic anterior ring injuries simultaneously and two groups were divided according to the different surgical methods of sacral fractures.There were 10 males and 2 females with an average age of 36.3±1.2 years in the orthopaedic robot group.According to Dennis classification,there were 4 typeⅠand 8 typeⅡfractures.Two patients were associated with nerve injuries(GibbonsⅡ1 case,Ⅲ1 case).In traditional posterior-midline open fixation group,there were 11 males and 1 female with an average age of 38.2±1.6 years.According to Dennis classification,there were 3 type I and 9 typeⅡfractures.Three patients were associated with nerve injuries(GibbonsⅡ2 cases,Ⅲ1 case).The clinical data of two group patients were collected and compared statistically.T test was used to compare the operation time,intraoperative bleeding,intraoperative fluoroscopy times,Majeed function assessment which was to evaluate the patients'clinical prognosis and healing time of fracture.χ^2 test was used to compare the healing rate of fracture,accuracy assessment of fixation insertion,and Mears radiological assessment which was applied to evaluate the reduction quality of fractures.The rank sum test was used to compare Gibbons score which was applied as the index of neurological deficiency recovery.The Fisher exact test was used to compare the infection rate.Results All patients were followed up continuously for an average time of 21.2±3.2 months.The average operation time of robot group was 100.3±14.5 minutes,meanwhile the open fixation group was 202.0±18.5 min.The average intraoperative bleeding of robot group was 180.0±17.4 ml,meanwhile the open fixation group was 850.0±15.2 ml.The average intraoperative fluoroscopy time of robot group was 23.3±4.5 s,meanwhile the open fixation group was 90.0±7.7 s.All fractures were healed and no loss of reduction or fail of fixation occurred in both groups.The healing time of fracture of robot group was 8.5±1.9 months,meanwhile the open fixation group was 12.8±2.4 months.The satisfaction rates of reduction which was based on Mears-Velyvis radiological criterion of both groups were 91.7%.The accuracy rate of fixation insertion of robot group was 100%meanwhile the open fixation group was 77.78%.Majeed function assessment score of robot group was 86.2±3.4,meanwhile the open fixation group was 84.2±2.7.There was no infection occurred in robot group,meanwhile 3 patients infected in open fixation group.The Gibbons score of one patient changed fromⅡpreoperative toⅠpostoperative and one case changed fromⅢpreoperative toⅡpostoperative in robot group,meanwhile two patients changed fromⅡpreoperative toⅠpostoperative and one case changed fromⅢpreoperative toⅡpostoperative in open fixation group.The healing rate of fracture,infection rate,Majeed function assessment,Mears-Velyvis radiological evaluation criterion and Gibbons score of two groups had no significant statistical difference(P>0.05),meanwhile the operation time(t=14.99),intraoperative bleeding(t=100.46),intraoperative fluoroscopy time(t=32.13),healing time of fracture(t=4.87)and accuracy rate of fixation insertion(χ2=9.00)of orthopedic robot group were better than traditional open group and had the significant difference(P<0.05).Conclusion The minimal-invasive triangular fixation with orthopedic robot for unilateral unstable sacral fracture had the advantages of less operation time,less intraoperative bleeding and less times of fluoroscopy,more accurate of fixation insertion and less healing time of sacral fractures compared to traditional open fixation method and should be recommended as an effective and advanced choice.