髂骨螺钉骨盆置钉方法的临床解剖研究
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摘要
[目的]：通过影像学测量与分析中国成人髂骨髂后上棘至髂前下棘髂骨并且锚定螺钉进入的通道,同时对经髂后上棘植入髂骨螺钉的角度参数进行明确,对髂骨螺钉置入的可行性以及安全性进行全方位的探讨,加强对骶髂关节毗邻结构解剖的了解,为研制适合国人的髂骨钉提供参考数据。
[方法]：采用18具防腐骨盆标本,对骨盆周围软组织仔细剔除。测量的数据有：(1)S1椎弓根测量和观测：①S1椎弓根高；②S1椎弓根宽；③观察骼骨翼后外侧面臀后线的形状和出现率；④S1进针的具体点位与s1椎体对侧前皮质之间的测量距离；⑤S1进针的具体点位到椎弓根中心之间的测量距离；⑥进针的点位与坐骨大切迹以及骼后下棘之间的关系；⑦髂骨翼后外侧而与骶髂螺钉进针方向关系。(2)对S2椎弓根的测量数值：①S2椎弓根的宽度测量数值：②S2椎弓根的高度测量数值；③S2椎弓根中心与植入点具体点位距离；④钉道直径测量数值；⑤进针具体点位到坐骨切迹以及髂后下棘之间的关系；⑥S2椎体中心至植入点距离；⑦骼骨翼后外侧面和进针方向的夹角。(3)采用该研究确立的进钉方法用骶骨钉治疗18例骨盆后环损伤患者,随访追踪其治疗效果。
[结果]：(1)S1椎弓根测量结果：①本实验可作为S1进针点定位标志在臀后线向下延伸呈直线在54侧骼骨翼中出现26侧；②S1椎弓根高20.2±2.3mm；③S1椎弓根宽27.7±2.Omm：④S1进针点至椎弓根中心距离49.1±3.6mm；⑤进针点至S1椎体对侧前皮质距离86.5±3.8mm；⑥S1进针点位于髂后下迹前方24.6±2.9mm,坐骨大切迹上方41.8±3.4mm；⑦进针方向为垂直于髂骨翼后外侧面,然后向尾端倾斜7.1±2.3。,向后侧倾斜7.7±3.8。。
(2)S2椎弓根测量结果：①S2椎弓根宽14.8±1.9mm；(2)S2椎弓根高17.6±1.9mm；③钉道直径11.5±1.4mm：④S2进针点至椎弓根中心距离53.1±5.1mm；⑤进针点至S2椎体中心距离64.7±4.9mm；⑥髂骨翼后外侧面与进针方向垂直于正中矢状面的夹角为62.3±2.7°(水平面)。⑦S2植入点位于坐骨大切迹上方15.3±3.1mm；骼后下迹前方28.7±4.1mm。
(3)临床应用评价：应用18例标本中共放置19枚骶骨钉,术后X线拍片复查对比见骶骨钉位于骶1椎体和弓根内,位置良好,骨盆对位对线良好,全部患者均随访6个月以上,以Majeed疗效评价标准,分析患者站立、疼痛、坐、性生活等相关情况,17例患者达优良,骨盆未出现移位,未出现脱钉、断钉。无1例出现神经、血管损伤并发症,2例遗留患侧马鞍区感觉减退。
[结论]：①经S1椎弓根骶髂关节螺钉固定应选长为75mm螺钉为适宜；②经S1椎弓根水平骶髂关节螺钉固定的植入点位于髂后下棘前方25mm,坐骨切迹上方40mm；③垂直于髂骨翼后外侧面的植入方向,然后向尾端倾斜(5-10)度,向后侧倾斜(5-10)度；④经S2椎弓根水平骶髂关节螺钉固定的植入点位于坐骨切迹上方15mm,髂后下棘前方30mm；⑤经S2椎弓根骶髂关节螺钉固定应选择较小直径的短螺钉；⑥植入方向垂直于正中矢状而垂且与髂骨翼外侧而夹角为60°(水平面)：⑦S1椎弓根钉道直径明显大于S2椎弓根。
[Objectives] To China adult after coming through the coming on to before the anchor channel under high measurement and analysis of imaging, determine the qia the use of ilium after implantation screw nails way Angle parameters, this paper discusses the feasibility of the ilium screw placement and security, to strengthen the sacroiliac joint adjacent to the understanding of the anatomical structure, developed for the americans to provide the reference data of ilium nail.
[Methods] the anticorrosion pelvic specimens with18, pelvic area of soft tissue carefully done. Measurement data are:(1) the S1pedicle observation and measurement:(1) the S1pedicle high;(2) SI pedicle wide;(3) to observe the lateral aspect of the ilium after wing after the shape of the hip line and occurrence rate;(4) the s1needle into the point to pedicle center distance;(5) needle into the s1points to s1cortex of vertebral body before side distance:(6) needle into the point and siatic big cut trace and after the relationship between the qia;(7) the sacroiliac screws into the needle with the direction of the ilium after wing the lateral aspect of the relationship.(2) the S2pedicle measurement results:(1) S2pedicle wide;(2) the s2pedicle high;(3) the diameter nails;(4) needle into the S2points to pedicle center distance;(5) points to the needle thorn and siatic after coming under cut trace relationship;(6) points to needle into the S2vertebral center distance;(7) ilium after wing drills and the lateral aspect of the Angle.(3) using sacral nailing for pelvic ring after injury patients18patients, the establishment of the nail into the research method, the follow-up tracking its therapeutic effect.
[Results](1) the S1pedicle measurement results:(1) the experiment after hip line extending down a straight line can be used as S1needle into the point positioning symbol in54of ilium appeared in the wing26side;(2) the S1pedicle high20.2+/-23mm;(3) S1pedicle wide and27.7+/-2.0mm:(4) S1point to needle into the pedicle center distance49.1+/-3.6mm;(5) the needle1point to s1cortex of vertebral body before side range86.5+/-3.8mm;6the needle point is located in s1under24.6ahead after iliac mark+/-2.9mm, sciatic big cut above mark41.8+/-3.4mm;7direction perpendicular to the needle for the lateral aspect of the ilium after wing, then end to tilt7.1+1-23°, back to tilt7.7+/-3.8°.
(2) the S2pedicle measurement results:(1) S2pedicle wide and14.8+/-1.9mm;(2) the s2pedicle high17.6+/-1.9mm;(3) the diameter was11.5+/-1.4mm:(4) needle into the s2points to pedicle center distance53.1+/-5.1mm;(5) points to needle into the S2vertebral center distance64.7+/-4.9mm;(6) in vertical direction needle into the middle of the sagittal and the lateral aspect of the ilium after wing with an Angle of62.3+/-2.7°(level).(7) the needle in qia s2point after mark28.7ahead+/-4.1mm, sciatic big cut above mark15.3+/-3.1mm;(3) clinical application evaluation:18cases of sacral was placed specimen19pieces, review the X-ray films see sacral nail position normal, pelvic reset is good, which both are located in s1pedicle and vertebral body, for more than half a year after patients with follow-up, Majeed curative effect according to the evaluation standard, to stand, sit, pain, the sex life and work in his recovery evaluation, the excellent-good is seventeen cases, pelvic did not appear shift, did not appear to take off the screw, screw breakage. Two cases of the saddle area left feeling decline, did not appear, the blood vessel damage nerve complications.
[Conclusion](1) the s1pedicle sacroiliac joint screws should choose long for75mm screws for appropriate:(2) the s1pedicle level sacroiliac joint screws into the needle is located in the point of sciatic cut trace40mm above, after coming under the front was25mm;(3) the direction perpendicular to the needle for the lateral aspect of the ilium after wing, then end to tilt (5～10)°, back to tilt (5～10)°;(4) the s2pedicle screws level sacroiliac joints of needle points out in15mm above sciatic cut trace, after coming under30mm ahead spines;(5) the S2pedicle sacroiliac joint screws should choose smaller diameter short screws;6in the middle of the perpendicular to the direction the needle sagittal and the lateral aspect of the wing and the high an Angle of60°(plane);7S2pedicle nail is smaller than the diameter s1pedicle.
[方法]：采用18具防腐骨盆标本,对骨盆周围软组织仔细剔除。测量的数据有：(1)S1椎弓根测量和观测：①S1椎弓根高；②S1椎弓根宽；③观察骼骨翼后外侧面臀后线的形状和出现率；④S1进针的具体点位与s1椎体对侧前皮质之间的测量距离；⑤S1进针的具体点位到椎弓根中心之间的测量距离；⑥进针的点位与坐骨大切迹以及骼后下棘之间的关系；⑦髂骨翼后外侧而与骶髂螺钉进针方向关系。(2)对S2椎弓根的测量数值：①S2椎弓根的宽度测量数值：②S2椎弓根的高度测量数值；③S2椎弓根中心与植入点具体点位距离；④钉道直径测量数值；⑤进针具体点位到坐骨切迹以及髂后下棘之间的关系；⑥S2椎体中心至植入点距离；⑦骼骨翼后外侧面和进针方向的夹角。(3)采用该研究确立的进钉方法用骶骨钉治疗18例骨盆后环损伤患者,随访追踪其治疗效果。
[结果]：(1)S1椎弓根测量结果：①本实验可作为S1进针点定位标志在臀后线向下延伸呈直线在54侧骼骨翼中出现26侧；②S1椎弓根高20.2±2.3mm；③S1椎弓根宽27.7±2.Omm：④S1进针点至椎弓根中心距离49.1±3.6mm；⑤进针点至S1椎体对侧前皮质距离86.5±3.8mm；⑥S1进针点位于髂后下迹前方24.6±2.9mm,坐骨大切迹上方41.8±3.4mm；⑦进针方向为垂直于髂骨翼后外侧面,然后向尾端倾斜7.1±2.3。,向后侧倾斜7.7±3.8。。
(2)S2椎弓根测量结果：①S2椎弓根宽14.8±1.9mm；(2)S2椎弓根高17.6±1.9mm；③钉道直径11.5±1.4mm：④S2进针点至椎弓根中心距离53.1±5.1mm；⑤进针点至S2椎体中心距离64.7±4.9mm；⑥髂骨翼后外侧面与进针方向垂直于正中矢状面的夹角为62.3±2.7°(水平面)。⑦S2植入点位于坐骨大切迹上方15.3±3.1mm；骼后下迹前方28.7±4.1mm。
(3)临床应用评价：应用18例标本中共放置19枚骶骨钉,术后X线拍片复查对比见骶骨钉位于骶1椎体和弓根内,位置良好,骨盆对位对线良好,全部患者均随访6个月以上,以Majeed疗效评价标准,分析患者站立、疼痛、坐、性生活等相关情况,17例患者达优良,骨盆未出现移位,未出现脱钉、断钉。无1例出现神经、血管损伤并发症,2例遗留患侧马鞍区感觉减退。
[结论]：①经S1椎弓根骶髂关节螺钉固定应选长为75mm螺钉为适宜；②经S1椎弓根水平骶髂关节螺钉固定的植入点位于髂后下棘前方25mm,坐骨切迹上方40mm；③垂直于髂骨翼后外侧面的植入方向,然后向尾端倾斜(5-10)度,向后侧倾斜(5-10)度；④经S2椎弓根水平骶髂关节螺钉固定的植入点位于坐骨切迹上方15mm,髂后下棘前方30mm；⑤经S2椎弓根骶髂关节螺钉固定应选择较小直径的短螺钉；⑥植入方向垂直于正中矢状而垂且与髂骨翼外侧而夹角为60°(水平面)：⑦S1椎弓根钉道直径明显大于S2椎弓根。
[Objectives] To China adult after coming through the coming on to before the anchor channel under high measurement and analysis of imaging, determine the qia the use of ilium after implantation screw nails way Angle parameters, this paper discusses the feasibility of the ilium screw placement and security, to strengthen the sacroiliac joint adjacent to the understanding of the anatomical structure, developed for the americans to provide the reference data of ilium nail.
[Methods] the anticorrosion pelvic specimens with18, pelvic area of soft tissue carefully done. Measurement data are:(1) the S1pedicle observation and measurement:(1) the S1pedicle high;(2) SI pedicle wide;(3) to observe the lateral aspect of the ilium after wing after the shape of the hip line and occurrence rate;(4) the s1needle into the point to pedicle center distance;(5) needle into the s1points to s1cortex of vertebral body before side distance:(6) needle into the point and siatic big cut trace and after the relationship between the qia;(7) the sacroiliac screws into the needle with the direction of the ilium after wing the lateral aspect of the relationship.(2) the S2pedicle measurement results:(1) S2pedicle wide;(2) the s2pedicle high;(3) the diameter nails;(4) needle into the S2points to pedicle center distance;(5) points to the needle thorn and siatic after coming under cut trace relationship;(6) points to needle into the S2vertebral center distance;(7) ilium after wing drills and the lateral aspect of the Angle.(3) using sacral nailing for pelvic ring after injury patients18patients, the establishment of the nail into the research method, the follow-up tracking its therapeutic effect.
[Results](1) the S1pedicle measurement results:(1) the experiment after hip line extending down a straight line can be used as S1needle into the point positioning symbol in54of ilium appeared in the wing26side;(2) the S1pedicle high20.2+/-23mm;(3) S1pedicle wide and27.7+/-2.0mm:(4) S1point to needle into the pedicle center distance49.1+/-3.6mm;(5) the needle1point to s1cortex of vertebral body before side range86.5+/-3.8mm;6the needle point is located in s1under24.6ahead after iliac mark+/-2.9mm, sciatic big cut above mark41.8+/-3.4mm;7direction perpendicular to the needle for the lateral aspect of the ilium after wing, then end to tilt7.1+1-23°, back to tilt7.7+/-3.8°.
(2) the S2pedicle measurement results:(1) S2pedicle wide and14.8+/-1.9mm;(2) the s2pedicle high17.6+/-1.9mm;(3) the diameter was11.5+/-1.4mm:(4) needle into the s2points to pedicle center distance53.1+/-5.1mm;(5) points to needle into the S2vertebral center distance64.7+/-4.9mm;(6) in vertical direction needle into the middle of the sagittal and the lateral aspect of the ilium after wing with an Angle of62.3+/-2.7°(level).(7) the needle in qia s2point after mark28.7ahead+/-4.1mm, sciatic big cut above mark15.3+/-3.1mm;(3) clinical application evaluation:18cases of sacral was placed specimen19pieces, review the X-ray films see sacral nail position normal, pelvic reset is good, which both are located in s1pedicle and vertebral body, for more than half a year after patients with follow-up, Majeed curative effect according to the evaluation standard, to stand, sit, pain, the sex life and work in his recovery evaluation, the excellent-good is seventeen cases, pelvic did not appear shift, did not appear to take off the screw, screw breakage. Two cases of the saddle area left feeling decline, did not appear, the blood vessel damage nerve complications.
[Conclusion](1) the s1pedicle sacroiliac joint screws should choose long for75mm screws for appropriate:(2) the s1pedicle level sacroiliac joint screws into the needle is located in the point of sciatic cut trace40mm above, after coming under the front was25mm;(3) the direction perpendicular to the needle for the lateral aspect of the ilium after wing, then end to tilt (5～10)°, back to tilt (5～10)°;(4) the s2pedicle screws level sacroiliac joints of needle points out in15mm above sciatic cut trace, after coming under30mm ahead spines;(5) the S2pedicle sacroiliac joint screws should choose smaller diameter short screws;6in the middle of the perpendicular to the direction the needle sagittal and the lateral aspect of the wing and the high an Angle of60°(plane);7S2pedicle nail is smaller than the diameter s1pedicle.
引文
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[29]廖德发,陈民生,张明,覃智斌,罗敏,赵绍伟.带锁髓内钉与加压钢板内固定治疗髂骨骨折的对比研究.广西医学,2005年第09期
[30]章飞,王林.交锁髓内钉内固定和AO外固定支架治疗骼骨开放骨折的疗效对比.中国全科医学,2010,17.
[1]S. R. I. Duff Avian, Intra-articular and para-articular defects in the pelvic limb and spine of adult male breeding Turkeys[J], Pathology 1988,30:80.
[2]PT Simonian, ML Jr Routt,RM Harrington, et al. Anterior versus posterior provisional fixation in the unstable pelvis, A biomeehanical comparison;Clin Orthop,1995, (301),245-250.
[3]K Yinger, SA Olson, J Scalise, et al, Biomechanical comparison of posterior pelvic ring fixation. J orthop,2003,17(7),481-487.
[4]EF Ward, J Tomasin, Pelvic pain Andrew Hodgkiss Journal of Reproductive and Infant Psychology 1990-10-01:79
[5]W Kraemer, M Tile, T Hcam, et al. The effect of thread length and location on extraction strengths ofiliosacral lag screws. Injury,1994,25(1),4-9.
[6]Santanu Majumder;Amit Roychowdhury; Three-dimensional finite element simulation of pelvic fracture during side impact with pelvis-femur-soft tissue complex[J] Subrata Pal International Journal of Crashworthiness 2008-06
[7]张奉琪,潘进社,张英泽,等.骨盆骨折骶髂关节分离前路钢板固定的应用解剖[J].中国临床解剖学杂志,2004,22(2)：120-121.
[8]张景僚,顾立强,谢颍涛.L4、5神经前支和腰骶干与骶髂关节毗邻关系及其临床意义[J].中国临床解剖学杂志,2004,22(2)：148-149.□
[9]Saucedo Majumder;Amit Roychowdhury; Three-dimensional finite element simulation of pelvic fracture during side impact with pelvis-femur-soft tissue complex[J] Subrata Pal International Journal of Crashworthiness 2008-04.
[10]NIL RouR, PJ Kregor, PT Simonian, et al;Earlyresults of percutaneous iliosacral screws placed with the patient in the supine position;J Trauma,1995, 9(3),207.214.
[11]C Untch, QI Liu, R Hart. Segmental motion adiacent to all instrmnented lumbar Fusin;the effect of fusion to the sacrum miscellaneous. Spine 2004; 29,2378-238 0.
[12]PT Simonian, ML JR Routt. Biomechanics of pelvic fixation. Orthop Clin NorthAm 1997,28 (3),351
[13]BR Moed. DE Kaxges,Technigues for reduction and fixation of pelvic ring disruptions through the posterior approach. Cl in Orthop,1996,329,103-114.
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[27]TA Schildhauer, CH Josten, G Muhr. Triangular ostcosynthesis of vertically unstable sacrum fractures--annew concept allowing early weight--aeating;J Trauma, 1998.12(5),308-314.
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[27]苏小桃,张卫,肖飞,吴家宝.交锁髓内钉治疗骼骨骨折、骨不连.南华大学学报(医学版),2004年第02期
[28]田文博,王广钱.外固定支架治疗髂骨骨折85例临床分析.第十三届全国中西医结合骨伤科学术研讨会论文集,发表时间：2005-09-01
[29]廖德发,陈民生,张明,覃智斌,罗敏,赵绍伟.带锁髓内钉与加压钢板内固定治疗髂骨骨折的对比研究.广西医学,2005年第09期
[30]章飞,王林.交锁髓内钉内固定和AO外固定支架治疗骼骨开放骨折的疗效对比.中国全科医学,2010,17.
[1]S. R. I. Duff Avian, Intra-articular and para-articular defects in the pelvic limb and spine of adult male breeding Turkeys[J], Pathology 1988,30:80.
[2]PT Simonian, ML Jr Routt,RM Harrington, et al. Anterior versus posterior provisional fixation in the unstable pelvis, A biomeehanical comparison;Clin Orthop,1995, (301),245-250.
[3]K Yinger, SA Olson, J Scalise, et al, Biomechanical comparison of posterior pelvic ring fixation. J orthop,2003,17(7),481-487.
[4]EF Ward, J Tomasin, Pelvic pain Andrew Hodgkiss Journal of Reproductive and Infant Psychology 1990-10-01:79
[5]W Kraemer, M Tile, T Hcam, et al. The effect of thread length and location on extraction strengths ofiliosacral lag screws. Injury,1994,25(1),4-9.
[6]Santanu Majumder;Amit Roychowdhury; Three-dimensional finite element simulation of pelvic fracture during side impact with pelvis-femur-soft tissue complex[J] Subrata Pal International Journal of Crashworthiness 2008-06
[7]张奉琪,潘进社,张英泽,等.骨盆骨折骶髂关节分离前路钢板固定的应用解剖[J].中国临床解剖学杂志,2004,22(2)：120-121.
[8]张景僚,顾立强,谢颍涛.L4、5神经前支和腰骶干与骶髂关节毗邻关系及其临床意义[J].中国临床解剖学杂志,2004,22(2)：148-149.□
[9]Saucedo Majumder;Amit Roychowdhury; Three-dimensional finite element simulation of pelvic fracture during side impact with pelvis-femur-soft tissue complex[J] Subrata Pal International Journal of Crashworthiness 2008-04.
[10]NIL RouR, PJ Kregor, PT Simonian, et al;Earlyresults of percutaneous iliosacral screws placed with the patient in the supine position;J Trauma,1995, 9(3),207.214.
[11]C Untch, QI Liu, R Hart. Segmental motion adiacent to all instrmnented lumbar Fusin;the effect of fusion to the sacrum miscellaneous. Spine 2004; 29,2378-238 0.
[12]PT Simonian, ML JR Routt. Biomechanics of pelvic fixation. Orthop Clin NorthAm 1997,28 (3),351
[13]BR Moed. DE Kaxges,Technigues for reduction and fixation of pelvic ring disruptions through the posterior approach. Cl in Orthop,1996,329,103-114.
[14]3M Matta, T Saucedo. Internal fixation of pelvic ring fracture; Clin Orthop; 1989.242,83-97.
[15]CP Comstock, Sexual Counseling of Patients Undergoing Radical Surgery for Pelvic or Genital Cancer Leslie [J], Michael Fife Journal of Psychosocial Oncology 1986-03-10
[16]T Shuler, D Boone, G Gruen, et al. Biomechanical comparison of posterior internal fixation techniques for unstable pelvic fracture;J Orthop Trauma.1995,38 (3), 453-458.
[17]ML Routt, PT Simonian, WJ Mills, Iliosacral SCrew fixation-early complication of the percutaneous technique. J Trauma.1997,11(8),584-589.
[18]BR Duwelius, BK Ahmad, JG Craig, et al. Sexual Abuse and Sexual Functioning in a Chronic Pelvic Pain Sample[J], Reddy Journal of Child Sexual Abuse 2006-09-26。
[19]JA Shaw, DP Mino, FW Werner, et al;Posterior stabilization of pelvic fracture by use of threaded compression rods-cases reports and mechanical testing;Clin Orthop,1985,192,242-253.
[20]LA Keating, JP Waddell, RK Leighton;Anterior approach and stabilization of the disrupted sacroiliac joint;J Trauma,1987,27(12),1333-1338
[21]PT keallam, ML JR Routt, RM Harrington. et al Thonnard; Influence of structural pelvic disorders during standing and walking in adolescents with idiopathic scoliosis. Clin Orthop,1994,309,245-256.
[22]Chyi-Shiun Wu;Research on pelvic angle variation when using a pelvic support Hiroyuki Miyamoto[J];Kageyu Noro Ergonomics 1998-03-01
[23]R. S. Salzar;D. Genovese;C. R. Bass;J. R. Bolton;H. Guillemot;A. M. Damon;J. R.,Load path distribution within the pelvic structure under lateral loading[J], Crandall International Journal of Crashworthiness 2009-02:79
[24]BR Moed, BK Ahmad, JG Craig, et al;Intraoperative monitoring with, stimulus:evoked eleetromyography during placement iliosacral screws. J Bone Joint Surg(Am),1998. (4),539-546.
[25]LA Simpson, JP Waddell, ILK Leighton;Anterior approach and stabilization of the disrupted sacroiliacjoint. J Trauma,1987.27(12),1334-1339.
[26]JA Shaw, DF Mino, L. Thonnard;Influence of structural pelvic disorders during standing and walking in adolescents with idiopathic scoliosis[J], C. Detrembleur Computer Methods in Biomechanics and Biomedical Engineering 2005-09
[27]TA Schildhauer, CH Josten, G Muhr. Triangular ostcosynthesis of vertically unstable sacrum fractures--annew concept allowing early weight--aeating;J Trauma, 1998.12(5),308-314.