利用融合器进行骶髂关节融合的研究
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摘要
目的：一、设计应用于骶髂关节(SIJ)融合的融合器及与之相配套的工具；测量SIJ不同平面与L4神经前支外缘间的水平距离；测量SIJ的长度和SIJ中点偏下部位可用于植入内固定物的深度；观察SIJ周围血管和神经。二、利用自行设计的融合器在尸体标本上进行SIJ融合手术；对融合器进行生物力学测试,对比并分析SIJ融合器和椎体间融合器以及本研究的融合方法与传统的SIJ融合方法的优点和缺点。
方法：一、选取防腐保存的正常成人骨盆标本18具(男14具,女4具),年龄25-55岁,排除标本畸形、肿瘤、外伤及解剖变异等情况。在SIJ线上确定五个点,A点(SIJ线最上缘),E点(SIJ线最下缘),C点(A、E两点沿SIJ连线的中点),B点(A、C间的中点),D点(C、E两点间的中点)。用游标卡尺测量B、C、D点与L4神经前支外缘间的水平距离。以游标卡尺测量SIJ的长度。用直径2 cm的环钻,以C、D连线中点为中心钻孔,环钻的长轴与SIJ关节面方向一致,与矢状面成18°-23°的角。环钻钻入38.0 mm后,根据骨盆标本大小,每钻入0.5圈或1圈,目测和测深器相结合,观察环钻是否钻破(钻出)了骨洞侧壁或底壁的骨皮质,并以游标卡尺测量骨洞深度,若环钻未钻出骨皮质,继续钻入,直至骨洞侧壁或底壁的骨皮质被突破,以出现骨皮质突破前一次的骨洞深度作为此处最大可钻孔深度。上述指标的测量,每一步骤均测量3次,取平均值。
二、另外选取死亡后半年至1年甲醛固定湿润成人骨盆标本(包括L5椎体和股骨上1/3)14具(男10具,女4具),年龄25-55岁,X线片证实无肿瘤、炎症、外伤引起的骨质破坏和解剖学变异。分为融合器组和对照组,每组7例标本(融合器组标本编号1-7,对照组编号1-7)。实验前用生理盐水浸泡标本24 h。剔除标本所附着的肌肉等软组织。融合器组和对照组先进行双侧SIJ完整状态下的生物力学测试。测试完成后,融合器组、对照组均切断右侧SIJ全部韧带,左侧SIJ全部韧带完整保留。融合器组和对照组均保持耻骨联合、双侧髋关节囊和韧带的完整性。用线锯沿关节面锯开SIJ,建立SIJ脱位模型。刮除关节软骨,将3孔的重建钢板2块塑形后横跨SIJ进行固定,其中一块要置于弓状线上缘附近,另一块置于骶髂关节的中上部。钢板的骶骨侧用一枚松质骨螺钉固定,髂骨侧用2枚松质骨螺钉固定。在左侧髂嵴上取松质骨植入SIJ间隙。用配套工具中的绞刀在SIJ处以C、D连线中点为中心绞入SIJ,然后攻丝,以配套工具中的植入器旋入融合器,取松质骨装入融合器。对照组同样用二枚3孔钢板固定,以三面有骨皮质的髂骨骨块代替融合器植入SIJ,在SIJ其余部位亦植入松质骨,此组取骨处亦在左侧。将已完成融合术标本放在特制夹具上,灌注自凝牙托粉,包埋固定L5椎体和两侧股骨。每具标本右侧SIJ的周围取9个应变测量位点。SIJ的位移,采用高精度光栅位移传感器测量。标本固定在实验机器上后,骶骨前面与实验台面保持60°倾斜角。应变片和位移计就位后,标本接受3个循环的0-900 N轴向压缩(垂直载荷)和-7-7 N·m轴向扭转的连续载荷。垂直载荷达到900 N后,在该负荷基础上施加逆时针、顺时针方向扭转力,扭矩为7 N·m,记录标本的应变值、位移值。生理载荷作用下的力学参数测量完毕之后,对不同内固定系统的标本进行极限载荷测试。
数据输入计算机,以SPSS15.0统计软件分析处理,P<0.05表示差异有统计学意义。
结果：一、B点到L4神经前支外缘的距离(mm,下同)为：19.10±2.36；C点到L4神经前支外缘的距离为：16.63±2.39；D点到L4神经前支外缘的距离为：14.29±1.97。SIJ长度为(cm)：5.54±0.39,可用于植入融合器的深度为：4.60±0.30。L4神经在上半部行程中与骨面之间有腰大肌纤维存在,神经离开腰大肌后为大量脂肪组织包裹,有一定的活动度；L5神经根紧贴骶骨翼骨面行走,神经周围有致密的纤维结缔组织包裹,较紧张,活动度小。髂腰动脉是位于SIJ前方的主要血管。本研究中,11具标本其髂腰动脉发自髂内动脉干,7具发自臀上动脉。
二、设计出8种尺寸融合器,以圆锥体底面圆形的直径和圆锥体的棱长来表示,单位为mm。底面圆直径为20 mm和18 mm的融合器,其上截面圆直径为10 mm;底面圆直径为16和14 mm的融合器,其上部截面圆直径为9 mm。计有20×40,20×30,18×40,18×30,16×40,16×30,14×40,14×308种。有一套与融合器相配套操作工具,共8种规格。
三、所有内固定物均准确植入,未发现内固定物移出骶骨和髂骨和/或内固物进入骶孔,生理载荷下生物力学测试完成后未见内固定松动。在一定范围内,随着载荷增加,应变值也增加。融合器组和对照组的应变和位移的差别有统计学意义(P<0.05)。同一标本在完整状态下,逆时针和顺时针方向扭转,SIJ水平位移差别无统计学意义(P＞0.05)。内固定后的二组标本在顺时针扭转时,每组标本均有SIJ后下方间隙增大,最大间隙达5.32 mm,具体见表7,8。逆时针扭转时SIJ前方间隙亦有增大,融合器组数值为(mm)：0.85±0.14,对照组为1.02±0.16；缝隙较小,二组比较,差别无统计学意义(P＞0.05)。融合器组极限载荷大于对照组(P<0.05)。
结论：一、SIJ从后上至前下的不同平面到L4神经前支的距离逐渐减小,所测B、C、D点中,B点距神经最远,C点次之。第一块钢板应放置在骶骨翼的下部,第2块钢板可放置骶骨翼的中上部。骶骨翼侧安放钢板的1孔,另外2孔置于髂骨侧。骶骨侧螺丝钉应选择长度在3.5cm以上的松质骨螺丝钉,螺丝钉头部向内成20°左右的角度。在放植了2枚钢板后,SIJ只能容纳一枚融合器。
二、融合器放在SIJ的中间稍偏下部位,置于二块钢板中间位置。钢板螺丝钉加融合器的内固定方式,其生物力学性能优于钢板螺丝钉加植骨的内固定方式,在抗垂直载荷时,有显著性差异。抗扭转时,钢板螺丝钉加融合器的内固定组合,其生物力学性能优于钢板螺丝钉加植骨块的组合。但是,融合器组与SIJ完整组相比,有显著性差异。此结果提示,术后早期应限制患者转身运动。融合器在尚未达到其极限载荷前,钢板螺丝钉已达到其极限载荷,融合器能满足和钢板螺丝钉组合应用的设计要求。本实验仅进行内固定器械稳定性研究,器械的耐疲劳性能还需经过临床长期观察验证,我们将在进一步的动物实验和临床研究中对内固定器械作出更全面、客观的评价。
Objective:To design cage applied to the sacroiliac joint (SIJ) fusion and design the supporting tools; measure the distance between different point of the sacroiliac joint and the L4 nerve; measure the length of the sacroiliac joint and the depth of the sacroiliac joint that could be used for the internal fixation implant; observe blood vessels and nerves. To do the biomechanical test of cage; observe the process of the surgery whether may exist problems and observe whether the interbody fusion cage's known advantages and disadvantages would be occur in the sacroiliac joint fusion cage we designed.
Methods:First, select 18 normal cadaveric pelvic specimens (male 14, female 4), aged 25 to 55 years, excluding deformities, tumors, trauma, and anatomic variations of the specimen and so on. Measur the horizontal distance between the human sacroiliac joint line and the L4 nerve. We made five measurement points. They were point A (the toppest point of the sacroiliac joint line), point E (the lowest point of the sacroiliac joint line, point C (the midpoint of point A, E along the sacroiliac joint, point B (the midpoint of point A, C), point D (the midpoint between point C, E). Use Vernier caliper to measure the length of the sacroiliac joint. Measur with vernier caliper the horizontal distance between point B, C, D and L4 nerve. Each point was measured 3 times then took average. Drill with 2 cm diameter ring at the midpoint of point C and D;drill sacroiliac joint surface in the direction of 18°-23°of angulation. When drill depth arrived at 38.0 mm, varying according to the size of the pelvic specimen, stop at one circle or one half circle, then observed whether the ring break the bone; measured the depth by vernier caliper and record the depth. If there was no bone break, continue to drill until the bone break occur,then recorded the former depth as the maximum depth
Second, select the six months to 1 year after the death, wet formalin-fixed adult cadaveric pelvic specimens (including the L5 vertebrae and femur of the proximal 1/3),total 14 (the other cadaveric pelvic specimens, not the used-samples in the pre-study.).There were 10 male,4 female (aged 25 to 55 years, there were no tumor, inflammation, bone destruction caused by trauma and anatomical variation. All cadaveric pelvic specimens were divided into two groups, each contain seven pelvic samples (cage group were numbered 1-7;the control group numbered 1-7,too). Soaked with normal saline for 24 hours before the experiment. Exclud the muscle and soft tissue attached to specimen. Cage group and control group were tested first under the situation that all sacroiliac joint ligament were well preserved. When the first test had been completed, cut off all the sacroiliac joint ligaments of the right side in cage group; all of the left sacroiliac joint ligaments were intact. To control group, the same was did. Cage group and control group remain the pubic symphysis, bilateral hip joint capsule and ligaments intact. With a wire saw crossing the sacrum and iliac auricular surface,then saw the sacroiliac joint apart, by this way,we established the sacroiliac joint dislocation model. Scraple the cartilage of the sacroiliac joint. Fix the the sacroiliac joint by 3-hole reconstruction plate.2 holes were fixed to the ilium and one hole is fixed to the sacrum. Make sure that one of the two plates was placed near the vicinity of the arcuate line. Cancellous bone screws must be fixed in the side of the sacrum, and two cortical bone screws were fixed in the iliac side. Implant iliac crest cortical bone to sacroiliac joint space (graft-bone is obtained in the opposite side). Drill with a cutter knife below point C, and then tapping in order to support the cage implant, at last, place the cage with the supporting tool. Put cancellous bone into the cage. The control group were also fixed with two 3-hole-plate but no cage. The sample position simulated both leg standing straight. The srain gages were adhered to 7 sites distributing in the two sides of the sacroiliac joint,the other two strain gages were adhered to pubic symphsis. The srain gages were connected with WS3811 digital strainometer to record the stain during test. The displacement of the sacroiliac joint were recorded using high-precision linear scale. Specimen was fixed in the test machine with the the sacrum maintaining 60°tilt angle. After all strain gauges and the displacement meter were in place, each group were treated with 3 cycles of 0-900 N axial compression (vertical load) and then the-7-7 N·m rotation load under the continuous axial load.10 N/s speed of loading were applied. After the vertical load reaches 900 N, holding the 900 N load, apply torque of 7 N·m. Record the value of the strain and displacement. When variety of physiological mechanical parameters such as strain, displacement has been recorded, the different fixation of the pelvis were test with maximum (limit) load.
All data were test with SPSS 15.0. Differences were regarded as statistically significant when P values were less than 0.05.
Results:The distance between point B and the outer edge of L4 nerve was (mm) 19.10±2.36. The distance between point C and the outer edge of L4 nerve was 16.63±2.39. The distance between point D and the outer edge of L4 nerve was 14.29±1.97. Sacroiliac joint length was(cm) 5.54±0.35; the depth was 4.60±0.30. L4 nerve in the upper part of the trip was accompanied by the skeletal muscle fibers. When it left musculi psoas major, it was covered by fat tissue and could move to a certain extent. L5 nerve was close to the surface of the sacral wing, and was covered by the dense connective tissue, so it could active less. Iliolumbar artery was located in the sacroiliac joint in front of the main blood vessels. In this study, There were 11 samples whose Iliolumbar artery were from the bottom of the internal iliac artery, seven from the superior gluteal artery.8 kinds of cage were designed and made. They were of cone-like shape. Their size was (diameter and arris length,expressed in unit of mm) 20×40,20×30,18×40,18×30,16×40,16×30,14×40,14×30. To cages 20×40,20×30,18×40,18×30, their diameter of upper transect is 10 mm. To cages 16×40,16×30,14×40,14×30, their diameter of upper transect is 9 mm.There also had 8 kinds of supporting tools.
All implantant were accurately implanted. Internal fixation did not break the sacrum and the ilium and/or intrude into the sacral foramina, and loose of internal fixation was not found. Within a certain range, as the load increased, strain also increased. Compared with the strain and displacement, cage group and control group showed statistically significant difference (P<0.05). Turn counter clockwise or clockwise, the horizontal displacement of sacroiliac joint showed no significant difference in both groups. The posterior and lower part of the sacroiliac joint gap occured the maximum 5.32 mm severance when turn clockwise. When it were turned counter clockwise, the front of the sacroiliac joint gap also increased.To cage group, the value was (mm) 0.85±0.14;to the control group,the value was 1.02±0.16. The maximum (limit) load of cage group was higher than that of the control group(P<0.05).
Conclusion:First, the distance between the sacroiliac joint and the the different point of L4 nerve decreased from point A to E. Point B was the farthest point in terms of distance. point C followed. First piece of plate should be placed between the middle and lower sacral wing near arcuate line, and the second plate could be place between the upper part and middle part of the sacral wing. Place one hole at the sacrum flank, the other two holes were placed in the iliac side. The single screw of the sacral side should be more than 3.5 cm in length (using cancellous bone screw)and the screw must head into the bone with a tilt angle of about 20°. After two three-hole plates were fixed, the sacroiliac joint could only accommodate one cage.
Cage were placed in next to the middle of the sacroiliac joint,changing with the change of plate position, but make sure that each cage were placed in the middle of the two plates. When it was compared with vertical load situation, the biomechanical properties of plate and cage combination were superior to that of the plate and bone combination, especially in the resistance to vertical load. Although the biomechanical properties of plate and cage combination were superior to the plate and bone combination with regard to anti-torsion ability, the biomechanical performance of plate and cage combination was still worse than that of the the intact group;the difference was still significant. Based on this finding, patients should be limited in turn movement post operaion. When cage had not yet reached its limit load, the screw had reached its limit load, therefore,the cage could meet the design aid that used with plate screws together. This test only studied the internal fixation system's ability of stability; fatigue resistance ability needed long-term observation after a clinical validation.We will further exam the internal fixation system by animal experiments and clinical studies and then a more comprehensive and objective assessment could be given.
Objective: To design cage applied to the sacroiliac joint (SIJ) fusion and design the supporting tools; measure the distance between different point of the sacroiliac joint and the L4 nerve ; measure the length of the sacroiliac joint and the depth of the sacroiliac joint that could be used for the internal fixation implant; observe blood vessels and nerves. To do the biomechanical test of cage; observe the process of the surgery whether may exist problems and observe whether the interbody fusion cage's known advantages and disadvantages would be occur in the sacroiliac joint fusion cage we designed.
Methods: First, select 18 normal cadaveric pelvic specimens (male 14, female 4), aged 25 to 55 years, excluding deformities, tumors, trauma, and anatomic variations of the specimen and so on. Measur the horizontal distance between the human sacroiliac joint line and the L4 nerve . We made five measurement points. They were point A (the toppest point of the sacroiliac joint line), point E (the lowest point of the sacroiliac joint line, point C (the midpoint of point A, E along the sacroiliac joint , point B (the midpoint of point A, C ), point D (the midpoint between point C, E ). Use Vernier caliper to measure the length of the sacroiliac joint. Measur with vernier caliper the horizontal distance between point B, C, D and L4 nerve . Each point was measured 3 times then took average. Drill with 2 cm diameter ring at the midpoint of point C and D ;drill sacroiliac joint surface in the direction of 18°- 23°of angulation. When drill depth arrived at 38.0 mm, varying according to the size of the pelvic specimen, stop at one circle or one half circle , then observed whether the ring break the bone ; measured the depth by vernier caliper and record the depth. If there was no bone break, continue to drill until the bone break occur ,then recorded the former depth as the maximum depth .
Second, select the six months to 1 year after the death, wet formalin-fixed adult cadaveric pelvic specimens (including the L5 vertebrae and femur of the proximal l/3),total 14 (the other cadaveric pelvic specimens , not the used-samples in the pre-study. ).There were 10 male , 4 female ( aged 25 to 55 years, there were no tumor, inflammation, bone destruction caused by trauma and anatomical variation. All cadaveric pelvic specimens were divided into two groups, each contain seven pelvic samples (cage group were numbered l-7;the control group numbered 1-7 ,too). Soaked with normal saline for 24 hours before the experiment. Exclud the muscle and soft tissue attached to specimen. Cage group and control group were tested first under the situation that all sacroiliac joint ligament were well preserved. When the first test had been completed, cut off all the sacroiliac joint ligaments of the right side in cage group; all of the left sacroiliac joint ligaments were intact. To control group, the same was did. Cage group and control group remain the pubic symphysis, bilateral hip joint capsule and ligaments intact. With a wire saw crossing the sacrum and iliac auricular surface,then saw the sacroiliac joint apart , by this way ,we established the sacroiliac joint dislocation model. Scraple the cartilage of the sacroiliac joint . Fix the the sacroiliac joint by 3-hole reconstruction plate. 2 holes were fixed to the ilium and one hole is fixed to the sacrum . Make sure that one of the two plates was placed near the vicinity of the arcuate line. Cancellous bone screws must be fixed in the side of the sacrum, and two cortical bone screws were fixed in the iliac side. Implant iliac crest cortical bone to sacroiliac joint space (graft-bone is obtained in the opposite side ). Drill with a cutter knife below point C , and then tapping in order to support the cage implant, at last , place the cage with the supporting tool. Put cancellous bone into the cage . The control group were also fixed with two 3- hole-plate but no cage. The sample position simulated both leg standing straight. The srain gages were adhered to 7 sites distributing in the two sides of the sacroiliac joint,the other two strain gages were adhered to pubic symphsis. The srain gages were connected with WS3811 digital strainometer to record the stain during test. The displacement of the sacroiliac joint were recorded using high-precision linear scale. Specimen was fixed in the test machine with the the sacrum maintaining 60°tilt angle. After all strain gauges and the displacement meter were in place, each group were treated with 3 cycles of 0 - 900 N axial compression (vertical load) and then the -7 - 7 N ? m rotation load under the continuous axial load. 10 N / s speed of loading were applied. After the vertical load reaches 900 N, holding the 900 N load , apply torque of 7 N ? m. Record the value of the strain and displacement . When variety of physiological mechanical parameters such as strain, displacement has been recorded, the different fixation of the pelvis were test with maximum ( limit ) load.
All data were test with SPSS 15.0. Differences were regarded as statistically significant when P values were less than 0.05.
Results: The distance between point B and the outer edge of L4 nerve was ( mm ) 19.10±2.36. The distance between point C and the outer edge of L4 nerve was 16.63±2.39. The distance between point D and the outer edge of L4 nerve was 14.29±1.97. Sacroiliac joint length was( cm ) 5.54±0.35; the depth was 4.60±0,30. L4 nerve in the upper part of the trip was accompanied by the skeletal muscle fibers. When it left musculi psoas major, it was covered by fat tissue and could move to a certain extent. L5 nerve was close to the surface of the sacral wing, and was covered by the dense connective tissue, so it could active less. Iliolumbar artery was located in the sacroiliac joint in front of the main blood vessels. In this study, There were 11 samples whose Iliolumbar artery were from the bottom of the internal iliac artery, seven from the superior gluteal artery. 8 kinds of cage were designed and made. They were of cone-like shape. Their size was (diameter and arris length .expressed in unit of mm) 20 x 40,20 x 30,18 x 40,18 x 30,16 x 40, 16 x 30,14 x 40,14 x 30. To cages 20 * 40,20 x 30,18 x 40,18 x 30 , their diameter of upper transect is 10 mm. To cages 16 x 40, 16 x 30,14 x 40,14 x 30, their diameter of upper transect is 9 mm .There also had 8 kinds of supporting tools.
All implantant were accurately implanted. Internal fixation did not break the sacrum and the ilium and / or intrude into the sacral foramina, and loose of internal fixation was not found. Within a certain range, as the load increased, strain also increased. Compared with the strain and displacement , cage group and control group showed statistically significant difference (P <0.05). Turn counter clockwise or clockwise , the horizontal displacement of sacroiliac ioint showed no significant difference in both groups. The posterior and lower part of the sacroiliac joint gap occured the maximum 5.32 mm severance when turn clockwise. When it were turned counter clockwise, the front of the sacroiliac joint gap also increased.To cage group, the value was (mm) 0.85±0.14;to the control group,the value was 1.02±0.16. The maximum (limit) load of cage group was higher than that of the control group(P<0.05).
Conclusion: First, the distance between the sacroiliac joint and the the different point of L4 nerve decreased from point A to E. Point B was the farthest point in terms of distance, point C followed. First piece of plate should be placed between the middle and lower sacral wing near arcuate line , and the second plate could be place between the upper part and middle part of the sacral wing. Place one hole at the sacrum flank, the other two holes were placed in the iliac side. The single screw of the sacral side should be more than 3.5 cm in length (using cancellous bone screw)and the screw must head into the bone with a tilt angle of about 20°. After two three-hole plates were fixed , the sacroiliac joint could only accommodate one cage.
Cage were placed in next to the middle of the sacroiliac joint ,changing with the change of plate position , but make sure that each cage were placed in the middle of the two plates. When it was compared with vertical load situation, the biomechanical properties of plate and cage combination were superior to that of the plate and bone combination, especially in the resistance to vertical load. Although the biomechanical properties of plate and cage combination were superior to the plate and bone combination with regard to anti-torsion ability, the biomechanical performance of plate and cage combination was still worse than that of the the intact group;the difference was still significant. Based on this finding , patients should be limited in turn movement post operaion. When cage had not yet reached its limit load,the screw had reached its limit load,therefore,the cage could meet the design aid that used with plate screws together. This test only studied the internal fixation system's ability of stability ; fatigue resistance ability needed long-term observation after a clinical validation.We will further exam the internal fixation system by animal experiments and clinical studies and then a more comprehensive and objective assessment could be given.
方法：一、选取防腐保存的正常成人骨盆标本18具(男14具,女4具),年龄25-55岁,排除标本畸形、肿瘤、外伤及解剖变异等情况。在SIJ线上确定五个点,A点(SIJ线最上缘),E点(SIJ线最下缘),C点(A、E两点沿SIJ连线的中点),B点(A、C间的中点),D点(C、E两点间的中点)。用游标卡尺测量B、C、D点与L4神经前支外缘间的水平距离。以游标卡尺测量SIJ的长度。用直径2 cm的环钻,以C、D连线中点为中心钻孔,环钻的长轴与SIJ关节面方向一致,与矢状面成18°-23°的角。环钻钻入38.0 mm后,根据骨盆标本大小,每钻入0.5圈或1圈,目测和测深器相结合,观察环钻是否钻破(钻出)了骨洞侧壁或底壁的骨皮质,并以游标卡尺测量骨洞深度,若环钻未钻出骨皮质,继续钻入,直至骨洞侧壁或底壁的骨皮质被突破,以出现骨皮质突破前一次的骨洞深度作为此处最大可钻孔深度。上述指标的测量,每一步骤均测量3次,取平均值。
二、另外选取死亡后半年至1年甲醛固定湿润成人骨盆标本(包括L5椎体和股骨上1/3)14具(男10具,女4具),年龄25-55岁,X线片证实无肿瘤、炎症、外伤引起的骨质破坏和解剖学变异。分为融合器组和对照组,每组7例标本(融合器组标本编号1-7,对照组编号1-7)。实验前用生理盐水浸泡标本24 h。剔除标本所附着的肌肉等软组织。融合器组和对照组先进行双侧SIJ完整状态下的生物力学测试。测试完成后,融合器组、对照组均切断右侧SIJ全部韧带,左侧SIJ全部韧带完整保留。融合器组和对照组均保持耻骨联合、双侧髋关节囊和韧带的完整性。用线锯沿关节面锯开SIJ,建立SIJ脱位模型。刮除关节软骨,将3孔的重建钢板2块塑形后横跨SIJ进行固定,其中一块要置于弓状线上缘附近,另一块置于骶髂关节的中上部。钢板的骶骨侧用一枚松质骨螺钉固定,髂骨侧用2枚松质骨螺钉固定。在左侧髂嵴上取松质骨植入SIJ间隙。用配套工具中的绞刀在SIJ处以C、D连线中点为中心绞入SIJ,然后攻丝,以配套工具中的植入器旋入融合器,取松质骨装入融合器。对照组同样用二枚3孔钢板固定,以三面有骨皮质的髂骨骨块代替融合器植入SIJ,在SIJ其余部位亦植入松质骨,此组取骨处亦在左侧。将已完成融合术标本放在特制夹具上,灌注自凝牙托粉,包埋固定L5椎体和两侧股骨。每具标本右侧SIJ的周围取9个应变测量位点。SIJ的位移,采用高精度光栅位移传感器测量。标本固定在实验机器上后,骶骨前面与实验台面保持60°倾斜角。应变片和位移计就位后,标本接受3个循环的0-900 N轴向压缩(垂直载荷)和-7-7 N·m轴向扭转的连续载荷。垂直载荷达到900 N后,在该负荷基础上施加逆时针、顺时针方向扭转力,扭矩为7 N·m,记录标本的应变值、位移值。生理载荷作用下的力学参数测量完毕之后,对不同内固定系统的标本进行极限载荷测试。
数据输入计算机,以SPSS15.0统计软件分析处理,P<0.05表示差异有统计学意义。
结果：一、B点到L4神经前支外缘的距离(mm,下同)为：19.10±2.36；C点到L4神经前支外缘的距离为：16.63±2.39；D点到L4神经前支外缘的距离为：14.29±1.97。SIJ长度为(cm)：5.54±0.39,可用于植入融合器的深度为：4.60±0.30。L4神经在上半部行程中与骨面之间有腰大肌纤维存在,神经离开腰大肌后为大量脂肪组织包裹,有一定的活动度；L5神经根紧贴骶骨翼骨面行走,神经周围有致密的纤维结缔组织包裹,较紧张,活动度小。髂腰动脉是位于SIJ前方的主要血管。本研究中,11具标本其髂腰动脉发自髂内动脉干,7具发自臀上动脉。
二、设计出8种尺寸融合器,以圆锥体底面圆形的直径和圆锥体的棱长来表示,单位为mm。底面圆直径为20 mm和18 mm的融合器,其上截面圆直径为10 mm;底面圆直径为16和14 mm的融合器,其上部截面圆直径为9 mm。计有20×40,20×30,18×40,18×30,16×40,16×30,14×40,14×308种。有一套与融合器相配套操作工具,共8种规格。
三、所有内固定物均准确植入,未发现内固定物移出骶骨和髂骨和/或内固物进入骶孔,生理载荷下生物力学测试完成后未见内固定松动。在一定范围内,随着载荷增加,应变值也增加。融合器组和对照组的应变和位移的差别有统计学意义(P<0.05)。同一标本在完整状态下,逆时针和顺时针方向扭转,SIJ水平位移差别无统计学意义(P＞0.05)。内固定后的二组标本在顺时针扭转时,每组标本均有SIJ后下方间隙增大,最大间隙达5.32 mm,具体见表7,8。逆时针扭转时SIJ前方间隙亦有增大,融合器组数值为(mm)：0.85±0.14,对照组为1.02±0.16；缝隙较小,二组比较,差别无统计学意义(P＞0.05)。融合器组极限载荷大于对照组(P<0.05)。
结论：一、SIJ从后上至前下的不同平面到L4神经前支的距离逐渐减小,所测B、C、D点中,B点距神经最远,C点次之。第一块钢板应放置在骶骨翼的下部,第2块钢板可放置骶骨翼的中上部。骶骨翼侧安放钢板的1孔,另外2孔置于髂骨侧。骶骨侧螺丝钉应选择长度在3.5cm以上的松质骨螺丝钉,螺丝钉头部向内成20°左右的角度。在放植了2枚钢板后,SIJ只能容纳一枚融合器。
二、融合器放在SIJ的中间稍偏下部位,置于二块钢板中间位置。钢板螺丝钉加融合器的内固定方式,其生物力学性能优于钢板螺丝钉加植骨的内固定方式,在抗垂直载荷时,有显著性差异。抗扭转时,钢板螺丝钉加融合器的内固定组合,其生物力学性能优于钢板螺丝钉加植骨块的组合。但是,融合器组与SIJ完整组相比,有显著性差异。此结果提示,术后早期应限制患者转身运动。融合器在尚未达到其极限载荷前,钢板螺丝钉已达到其极限载荷,融合器能满足和钢板螺丝钉组合应用的设计要求。本实验仅进行内固定器械稳定性研究,器械的耐疲劳性能还需经过临床长期观察验证,我们将在进一步的动物实验和临床研究中对内固定器械作出更全面、客观的评价。
Objective:To design cage applied to the sacroiliac joint (SIJ) fusion and design the supporting tools; measure the distance between different point of the sacroiliac joint and the L4 nerve; measure the length of the sacroiliac joint and the depth of the sacroiliac joint that could be used for the internal fixation implant; observe blood vessels and nerves. To do the biomechanical test of cage; observe the process of the surgery whether may exist problems and observe whether the interbody fusion cage's known advantages and disadvantages would be occur in the sacroiliac joint fusion cage we designed.
Methods:First, select 18 normal cadaveric pelvic specimens (male 14, female 4), aged 25 to 55 years, excluding deformities, tumors, trauma, and anatomic variations of the specimen and so on. Measur the horizontal distance between the human sacroiliac joint line and the L4 nerve. We made five measurement points. They were point A (the toppest point of the sacroiliac joint line), point E (the lowest point of the sacroiliac joint line, point C (the midpoint of point A, E along the sacroiliac joint, point B (the midpoint of point A, C), point D (the midpoint between point C, E). Use Vernier caliper to measure the length of the sacroiliac joint. Measur with vernier caliper the horizontal distance between point B, C, D and L4 nerve. Each point was measured 3 times then took average. Drill with 2 cm diameter ring at the midpoint of point C and D;drill sacroiliac joint surface in the direction of 18°-23°of angulation. When drill depth arrived at 38.0 mm, varying according to the size of the pelvic specimen, stop at one circle or one half circle, then observed whether the ring break the bone; measured the depth by vernier caliper and record the depth. If there was no bone break, continue to drill until the bone break occur,then recorded the former depth as the maximum depth
Second, select the six months to 1 year after the death, wet formalin-fixed adult cadaveric pelvic specimens (including the L5 vertebrae and femur of the proximal 1/3),total 14 (the other cadaveric pelvic specimens, not the used-samples in the pre-study.).There were 10 male,4 female (aged 25 to 55 years, there were no tumor, inflammation, bone destruction caused by trauma and anatomical variation. All cadaveric pelvic specimens were divided into two groups, each contain seven pelvic samples (cage group were numbered 1-7;the control group numbered 1-7,too). Soaked with normal saline for 24 hours before the experiment. Exclud the muscle and soft tissue attached to specimen. Cage group and control group were tested first under the situation that all sacroiliac joint ligament were well preserved. When the first test had been completed, cut off all the sacroiliac joint ligaments of the right side in cage group; all of the left sacroiliac joint ligaments were intact. To control group, the same was did. Cage group and control group remain the pubic symphysis, bilateral hip joint capsule and ligaments intact. With a wire saw crossing the sacrum and iliac auricular surface,then saw the sacroiliac joint apart, by this way,we established the sacroiliac joint dislocation model. Scraple the cartilage of the sacroiliac joint. Fix the the sacroiliac joint by 3-hole reconstruction plate.2 holes were fixed to the ilium and one hole is fixed to the sacrum. Make sure that one of the two plates was placed near the vicinity of the arcuate line. Cancellous bone screws must be fixed in the side of the sacrum, and two cortical bone screws were fixed in the iliac side. Implant iliac crest cortical bone to sacroiliac joint space (graft-bone is obtained in the opposite side). Drill with a cutter knife below point C, and then tapping in order to support the cage implant, at last, place the cage with the supporting tool. Put cancellous bone into the cage. The control group were also fixed with two 3-hole-plate but no cage. The sample position simulated both leg standing straight. The srain gages were adhered to 7 sites distributing in the two sides of the sacroiliac joint,the other two strain gages were adhered to pubic symphsis. The srain gages were connected with WS3811 digital strainometer to record the stain during test. The displacement of the sacroiliac joint were recorded using high-precision linear scale. Specimen was fixed in the test machine with the the sacrum maintaining 60°tilt angle. After all strain gauges and the displacement meter were in place, each group were treated with 3 cycles of 0-900 N axial compression (vertical load) and then the-7-7 N·m rotation load under the continuous axial load.10 N/s speed of loading were applied. After the vertical load reaches 900 N, holding the 900 N load, apply torque of 7 N·m. Record the value of the strain and displacement. When variety of physiological mechanical parameters such as strain, displacement has been recorded, the different fixation of the pelvis were test with maximum (limit) load.
All data were test with SPSS 15.0. Differences were regarded as statistically significant when P values were less than 0.05.
Results:The distance between point B and the outer edge of L4 nerve was (mm) 19.10±2.36. The distance between point C and the outer edge of L4 nerve was 16.63±2.39. The distance between point D and the outer edge of L4 nerve was 14.29±1.97. Sacroiliac joint length was(cm) 5.54±0.35; the depth was 4.60±0.30. L4 nerve in the upper part of the trip was accompanied by the skeletal muscle fibers. When it left musculi psoas major, it was covered by fat tissue and could move to a certain extent. L5 nerve was close to the surface of the sacral wing, and was covered by the dense connective tissue, so it could active less. Iliolumbar artery was located in the sacroiliac joint in front of the main blood vessels. In this study, There were 11 samples whose Iliolumbar artery were from the bottom of the internal iliac artery, seven from the superior gluteal artery.8 kinds of cage were designed and made. They were of cone-like shape. Their size was (diameter and arris length,expressed in unit of mm) 20×40,20×30,18×40,18×30,16×40,16×30,14×40,14×30. To cages 20×40,20×30,18×40,18×30, their diameter of upper transect is 10 mm. To cages 16×40,16×30,14×40,14×30, their diameter of upper transect is 9 mm.There also had 8 kinds of supporting tools.
All implantant were accurately implanted. Internal fixation did not break the sacrum and the ilium and/or intrude into the sacral foramina, and loose of internal fixation was not found. Within a certain range, as the load increased, strain also increased. Compared with the strain and displacement, cage group and control group showed statistically significant difference (P<0.05). Turn counter clockwise or clockwise, the horizontal displacement of sacroiliac joint showed no significant difference in both groups. The posterior and lower part of the sacroiliac joint gap occured the maximum 5.32 mm severance when turn clockwise. When it were turned counter clockwise, the front of the sacroiliac joint gap also increased.To cage group, the value was (mm) 0.85±0.14;to the control group,the value was 1.02±0.16. The maximum (limit) load of cage group was higher than that of the control group(P<0.05).
Conclusion:First, the distance between the sacroiliac joint and the the different point of L4 nerve decreased from point A to E. Point B was the farthest point in terms of distance. point C followed. First piece of plate should be placed between the middle and lower sacral wing near arcuate line, and the second plate could be place between the upper part and middle part of the sacral wing. Place one hole at the sacrum flank, the other two holes were placed in the iliac side. The single screw of the sacral side should be more than 3.5 cm in length (using cancellous bone screw)and the screw must head into the bone with a tilt angle of about 20°. After two three-hole plates were fixed, the sacroiliac joint could only accommodate one cage.
Cage were placed in next to the middle of the sacroiliac joint,changing with the change of plate position, but make sure that each cage were placed in the middle of the two plates. When it was compared with vertical load situation, the biomechanical properties of plate and cage combination were superior to that of the plate and bone combination, especially in the resistance to vertical load. Although the biomechanical properties of plate and cage combination were superior to the plate and bone combination with regard to anti-torsion ability, the biomechanical performance of plate and cage combination was still worse than that of the the intact group;the difference was still significant. Based on this finding, patients should be limited in turn movement post operaion. When cage had not yet reached its limit load, the screw had reached its limit load, therefore,the cage could meet the design aid that used with plate screws together. This test only studied the internal fixation system's ability of stability; fatigue resistance ability needed long-term observation after a clinical validation.We will further exam the internal fixation system by animal experiments and clinical studies and then a more comprehensive and objective assessment could be given.
Objective: To design cage applied to the sacroiliac joint (SIJ) fusion and design the supporting tools; measure the distance between different point of the sacroiliac joint and the L4 nerve ; measure the length of the sacroiliac joint and the depth of the sacroiliac joint that could be used for the internal fixation implant; observe blood vessels and nerves. To do the biomechanical test of cage; observe the process of the surgery whether may exist problems and observe whether the interbody fusion cage's known advantages and disadvantages would be occur in the sacroiliac joint fusion cage we designed.
Methods: First, select 18 normal cadaveric pelvic specimens (male 14, female 4), aged 25 to 55 years, excluding deformities, tumors, trauma, and anatomic variations of the specimen and so on. Measur the horizontal distance between the human sacroiliac joint line and the L4 nerve . We made five measurement points. They were point A (the toppest point of the sacroiliac joint line), point E (the lowest point of the sacroiliac joint line, point C (the midpoint of point A, E along the sacroiliac joint , point B (the midpoint of point A, C ), point D (the midpoint between point C, E ). Use Vernier caliper to measure the length of the sacroiliac joint. Measur with vernier caliper the horizontal distance between point B, C, D and L4 nerve . Each point was measured 3 times then took average. Drill with 2 cm diameter ring at the midpoint of point C and D ;drill sacroiliac joint surface in the direction of 18°- 23°of angulation. When drill depth arrived at 38.0 mm, varying according to the size of the pelvic specimen, stop at one circle or one half circle , then observed whether the ring break the bone ; measured the depth by vernier caliper and record the depth. If there was no bone break, continue to drill until the bone break occur ,then recorded the former depth as the maximum depth .
Second, select the six months to 1 year after the death, wet formalin-fixed adult cadaveric pelvic specimens (including the L5 vertebrae and femur of the proximal l/3),total 14 (the other cadaveric pelvic specimens , not the used-samples in the pre-study. ).There were 10 male , 4 female ( aged 25 to 55 years, there were no tumor, inflammation, bone destruction caused by trauma and anatomical variation. All cadaveric pelvic specimens were divided into two groups, each contain seven pelvic samples (cage group were numbered l-7;the control group numbered 1-7 ,too). Soaked with normal saline for 24 hours before the experiment. Exclud the muscle and soft tissue attached to specimen. Cage group and control group were tested first under the situation that all sacroiliac joint ligament were well preserved. When the first test had been completed, cut off all the sacroiliac joint ligaments of the right side in cage group; all of the left sacroiliac joint ligaments were intact. To control group, the same was did. Cage group and control group remain the pubic symphysis, bilateral hip joint capsule and ligaments intact. With a wire saw crossing the sacrum and iliac auricular surface,then saw the sacroiliac joint apart , by this way ,we established the sacroiliac joint dislocation model. Scraple the cartilage of the sacroiliac joint . Fix the the sacroiliac joint by 3-hole reconstruction plate. 2 holes were fixed to the ilium and one hole is fixed to the sacrum . Make sure that one of the two plates was placed near the vicinity of the arcuate line. Cancellous bone screws must be fixed in the side of the sacrum, and two cortical bone screws were fixed in the iliac side. Implant iliac crest cortical bone to sacroiliac joint space (graft-bone is obtained in the opposite side ). Drill with a cutter knife below point C , and then tapping in order to support the cage implant, at last , place the cage with the supporting tool. Put cancellous bone into the cage . The control group were also fixed with two 3- hole-plate but no cage. The sample position simulated both leg standing straight. The srain gages were adhered to 7 sites distributing in the two sides of the sacroiliac joint,the other two strain gages were adhered to pubic symphsis. The srain gages were connected with WS3811 digital strainometer to record the stain during test. The displacement of the sacroiliac joint were recorded using high-precision linear scale. Specimen was fixed in the test machine with the the sacrum maintaining 60°tilt angle. After all strain gauges and the displacement meter were in place, each group were treated with 3 cycles of 0 - 900 N axial compression (vertical load) and then the -7 - 7 N ? m rotation load under the continuous axial load. 10 N / s speed of loading were applied. After the vertical load reaches 900 N, holding the 900 N load , apply torque of 7 N ? m. Record the value of the strain and displacement . When variety of physiological mechanical parameters such as strain, displacement has been recorded, the different fixation of the pelvis were test with maximum ( limit ) load.
All data were test with SPSS 15.0. Differences were regarded as statistically significant when P values were less than 0.05.
Results: The distance between point B and the outer edge of L4 nerve was ( mm ) 19.10±2.36. The distance between point C and the outer edge of L4 nerve was 16.63±2.39. The distance between point D and the outer edge of L4 nerve was 14.29±1.97. Sacroiliac joint length was( cm ) 5.54±0.35; the depth was 4.60±0,30. L4 nerve in the upper part of the trip was accompanied by the skeletal muscle fibers. When it left musculi psoas major, it was covered by fat tissue and could move to a certain extent. L5 nerve was close to the surface of the sacral wing, and was covered by the dense connective tissue, so it could active less. Iliolumbar artery was located in the sacroiliac joint in front of the main blood vessels. In this study, There were 11 samples whose Iliolumbar artery were from the bottom of the internal iliac artery, seven from the superior gluteal artery. 8 kinds of cage were designed and made. They were of cone-like shape. Their size was (diameter and arris length .expressed in unit of mm) 20 x 40,20 x 30,18 x 40,18 x 30,16 x 40, 16 x 30,14 x 40,14 x 30. To cages 20 * 40,20 x 30,18 x 40,18 x 30 , their diameter of upper transect is 10 mm. To cages 16 x 40, 16 x 30,14 x 40,14 x 30, their diameter of upper transect is 9 mm .There also had 8 kinds of supporting tools.
All implantant were accurately implanted. Internal fixation did not break the sacrum and the ilium and / or intrude into the sacral foramina, and loose of internal fixation was not found. Within a certain range, as the load increased, strain also increased. Compared with the strain and displacement , cage group and control group showed statistically significant difference (P <0.05). Turn counter clockwise or clockwise , the horizontal displacement of sacroiliac ioint showed no significant difference in both groups. The posterior and lower part of the sacroiliac joint gap occured the maximum 5.32 mm severance when turn clockwise. When it were turned counter clockwise, the front of the sacroiliac joint gap also increased.To cage group, the value was (mm) 0.85±0.14;to the control group,the value was 1.02±0.16. The maximum (limit) load of cage group was higher than that of the control group(P<0.05).
Conclusion: First, the distance between the sacroiliac joint and the the different point of L4 nerve decreased from point A to E. Point B was the farthest point in terms of distance, point C followed. First piece of plate should be placed between the middle and lower sacral wing near arcuate line , and the second plate could be place between the upper part and middle part of the sacral wing. Place one hole at the sacrum flank, the other two holes were placed in the iliac side. The single screw of the sacral side should be more than 3.5 cm in length (using cancellous bone screw)and the screw must head into the bone with a tilt angle of about 20°. After two three-hole plates were fixed , the sacroiliac joint could only accommodate one cage.
Cage were placed in next to the middle of the sacroiliac joint ,changing with the change of plate position , but make sure that each cage were placed in the middle of the two plates. When it was compared with vertical load situation, the biomechanical properties of plate and cage combination were superior to that of the plate and bone combination, especially in the resistance to vertical load. Although the biomechanical properties of plate and cage combination were superior to the plate and bone combination with regard to anti-torsion ability, the biomechanical performance of plate and cage combination was still worse than that of the the intact group;the difference was still significant. Based on this finding , patients should be limited in turn movement post operaion. When cage had not yet reached its limit load,the screw had reached its limit load,therefore,the cage could meet the design aid that used with plate screws together. This test only studied the internal fixation system's ability of stability ; fatigue resistance ability needed long-term observation after a clinical validation.We will further exam the internal fixation system by animal experiments and clinical studies and then a more comprehensive and objective assessment could be given.
引文
1. Tile M. Fracture of the pelvic and acetabulum[M].2nd edition.Baltimore: Williams and Wilkins,1995.66-72.
2. Vleeming A, Pool-Goudzwaard AI, Hammudoghlu. The function of the long dorsal sacroiliac ligament:its implication for understanding low back pain[J]. Spine,1996,21(5):556-56.
3. Vleeming A, Stoeckart R, Volkers AC, et al. Relation between form and function in the sacroiliac joint. PartⅠ:Clinical anatomical aspects[J]. Spine, 1990,15(2):130-132.
4. Arand M, Kinzl I, Gebhard E. Computer—guidance in percutaneous screw stabilization of the iliosacrai ioint [j]. Clin Orthop Relat Res,2004, (422): 201-207.
5. Yinger K, Scaltse J, Olson SA, et al. Biomechanica comparison of posterior pelvic ring fixation[J]. J Orthop Truma,2003,17(7):481-487.
6. Swezey PL.The sacroiliac joint.Nothing is sacred. Phys Med Rehabil Clm N Am,1998.9(2):515-518.
7.郭世绂.临床骨科解剖学.第1版,天津：天津科学技术出版社。1986：303-307.
8. Brunner C, Kissling R, Jacob HAC. The efects of morphology histopathologic findings on the mobility of the sacroiliac joint J: Spine,1991; 16(9):1111-1114.
9. Freeman MD, Fox D, Richards T. The superior atmcapzutar ligament of the sacroiliac joint:priariptive evidence for confirmation of sacroiliac ligment[J].J PhysTher,1997:13(7):384-387.
10. Bagby GW.Arthrodesis by the distraction-compression method using a stainless implant. Orthopedics,1988,11:931-934.
11. Ray CD. Threaded titanium cages for lumbar interbody fusions. Spine,1997,22:667-680.
12. Kuslich SD, et al. Four year follow-up results of lumbar spine arthrodesis using the Bagby and Kuslich lumbar fusion cage. Spine, 2000,25:2656-2662.
13. Agazzi S. PLIF with cages:an independent review of 71 cases.J Neurosurg,1999,91:186-192.
14. Ebraheim NA, Haman ST, XU Rongming, et 41, The lumbosacral nerves inrelation to dorsal S1 screw placement and their locations on plain radiographs. Orthopedics,2000; 23(3):245-249.
15. Korovessis P Stamatakis M, Baikousis A. Posterior stabilization of unstable sacroiliac injuries with the Texas Scottish Rite Hospital spinal instrumentation. Orthopedics,2000; 23(4).320-323.
16. Tile M.Fractures of the pelvis.In Schatzker J, Tile M. The rationale of operative fracture care. Berlin, Springer Verlag,1987:133-213.
17 Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic Fractures. Clin Orthop,1993,279:28-32.
18. Leighton RK, waddell JP. Techniques for reduction and posterior fixation through the anterior approach Clin Orthop,1996,329:115-120.
19. Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic Fractures. Clin Orthop,1993,279:28-32.
20. Salsabili N,Valojerdy MR. Hogg DA.Variations in thickness of articular cartilage in the human sacrolilsc joint.Clin Anat.1995,8(6):388-391.
1. Leighton RK, Waddell JP. Techniques for reduction and posterior fixation through the anterior approach. Clin Orthop,1996,329:115-120.
2. Korovessis P, Baikousis A, Stamatakis M, et al. Medium and long termresults of open reduction and internal fixation for unstable pelvic ringfractures. Orthopedics,2000; 23(11):1165-1171.
3. Miller JA, Schultz AB, Andersson GB. Load-displacement behavior of sacroiliac joints[J].J Orthop Res,1987,5(1):92-101.
4. Egund N, Olsson TH, Schmid H, et al. Movements in the sacroiliac joints demonstrated with roentgen stereophoto-grammetry[J]. Acta Radiol Diagn,1978,19(5):833-846.
5. Ishii K, Chiba K, Watanabe M, et al. Local recurrence after S2-3 sacrectomy in sacral chordoma:report of four cases [J].J Neurosurg,2002,97(Suppl 1):98-101.
6. Hugate RR, Dickey ID, Phimolsarnti R, et al. Mechanical effects of partial sacrectomy [J].Clin Orthop Relat Res,2006,450:82-88.
7 Yu B, Zheng Z, Zhuang X, et al. Biomechanical effects of transverse partial sacrectomy on the sacroiliac joints:an in vitro human cadaveric pelvic specimens investigation of the borderline of sacroiliac joint instability. Spine(Phila Pa 1976),2009,34(13):1370-1375.
8 Zheng ZM, Yu BS, Chen H, et al. Effect of iliac screw insertion depth on the stability and strength of lumbo-Iliac fixation constructs:An anatomical and biomechanical study. Spine (Phila Pa 1976),2009, 34(16):E565-572.
9. Egund N, Olsson TH, Schmid H, et al. Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. [J].Acta Radiol Diagn,1978,19(5):833-846.
10. Sturesson B,Selvik G,Uden A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine,1989,14(2):162-165.
11.Smidt GL, Shun-hua Wei, Kevin M, et al.Sacroiliac motionfor extrementship positions:a fresh cadaver study. Spine.1997,22(18): 2073-2076.
12. Rapoff AJ et al. Biomechanical comparison of posterior lumbarinterbody fusion cages. Spine,1997,22:2375-2379.
13.Tsantrizos A et al. Segmental stability and compressive strength of posterior lumbarinterbody fusion implants. Spine,2000,25:1077-1084.
14. Brantigan JW et al. A carbon fiber implant to aid interbody lumbarfusion. Mechanical testing, Spine,1991,16:S277-282.
15. Steffen T, Tsantrizos A, Aebi M. Effect of implant design and endplate preparatation on the compressive strength of interbody fusion constructs. Spine,2000,25:1077-1084.
16. Ray CD. Threaded titanium cages for lumbar interbody fusions. Spine, 1997,22:667-680.
17. Kuslich SD, et al. Four year follow-up results of lumbar spine arthrodesis using the Bagby and Kuslich lumbar fusion cage. Spine, 2000,25:2656-2662.
18. Agazzi S. PLIF with cages:an independent review of 71 cases. J Neurosurg,1999,91:186-192.
19.Ebraheim NA,Madsen TD,Xu R,et al.Dynamic changes in the contact area of the sacroiliac joint. Orthopedics,2003,26:(7):711-714.
1. Henderson RC.The long-term results of nonoperatively treated major pelvicdisruptions.J Orthop Trauma,1989,3:41-47.
2. Harrison DE. Harrison DD, Troyanovich sJ. The sacroiliac joint:areview of anatomy and biomechanics with clinical implications. Manulative Physiol Ther,.1997,20(9):607-610.
3. Voom R. Case report:can sacroiliac joint dysfunction cause chronic Achilles tendonitis? J Orthop Sports Phys Thef.1998.27(6):436-439.
4. van Wingerde JP, Vleering A,Buyruk HM. et al. Stabilization of the sacroiliac joint in vivo:verification of muscular contributrion to force closure of the pelvis. Eur Spine J.2004,13(3):199-205.
5. Richardson CA,Snijders CJ.Hides JA.et al.The relation between the transversus abdominis muscles,sacroiliac joint mechanics,and low back pain.Spine.2002,27(4):399-406.
6. Vleeming A,Pool—Goudzwsard AL. Hammudoghlu D, al.The function of the long dorsal sacroiliac joint ligament:its implication for understanding low back pain. Spine.1996.21(5):556-560.
7. Simonian PT, Routt Jr MLC, Harrington RM, et al. Biomechanical simulation of the anteroposterior compression injury of the pelvis. An understanding of instablility and fixation. Clin Orthop.1994,309:245-256.
8. Vrahas M,Hern TC,Diangelo,D,et al.Experimental study of the sacroiliac micromotion in pelvic disruption.J Orthop Trauma.2002,16(2):99-103.
9. Vukicevic S,Marusic A,Stavljenic A,et al.Holographic analysis of the human pelvis.Spine 1991,16(2)209-214.
10.XuR. Ebraheim NA,Yeasting RA, et al Anatomic considerations, for posterior iliac bone harvesting. Spine,1996.21(9):1017-1020.
11.Pool-Goudzwaard AL,Kleinrensink GJ,Snijders CJ, et al.The sacrooliac part of the fliolumbar ligament. J Anat.2001,199(4):457-461.
12. Tile M. Acute pelvic fractures:I. Causation and classification [J]. JAAOS,1996,4:143-151.
13. Salsabili N,Valojerdy MR. Hogg DA. Variations in thickness of articular cartilage in the human sacrolilsc joint.Clin Anat.1995,8(6):388-391.
14.钱齐荣.贾连顺.周伟明等.不同体位骶髋关节面应力分布的三维有限元研究.中华骨科杂志.2000,20(3)：173-175.
15. Rosatelli AL,Agur AM,Chhaya S. Anatomy of the interosseous region of the sacroiliac joint.J Orthop Sports Phys Ther,2006,36(4):200-208.
16. Joseph A,Thomas A, Sheldon R. Orthopaedic basic science:biology and biomechanics of the musculskeletal system, second edition[M].American Academy of Orthopaedic Surgeons,2000, 152-156.
17. Garcia JM, Doblare M, Seral B, et al. Three-dimensional finite element analysis of several internal and external pelvis fixations[J]. Biomech Eng,2000,122:516-521.
18. Miura H.Biomechanical properties of the sacroiliac joint.ippon Seikeigeka Gakkai Zasshi,1987,61:1093-1105.
19. Sturesson B,Selvik G,Uden A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine,1989,14(2):162-165.
20. Smidt GL, Shun-hua Wei, Kevin M, et al.Sacroiliac motionfor extrementship positions:a fresh cadaver study. Spine.1997,22(18): 2073-2076.
21 Blake-Toker AM, Hawkins L, Nadalo L, et al. CT guided percutaneous fixation of sacroiliac fractures in trauma patients. J Trauma.2001,51:1117-1121.
22. Schwamcr A. Spine,1995:20(1):31-37.
23. Yinger K, Scalise J, Olsin SA, et al. Biomechanical comparison of posterior pelvic ring fixation [J]. Orthop Trauma,2003.17:481-487.
24. Comstock CP, Van der Meulen MC, Goodman SB. Biomechanical comparison of posterior internal fixation techniques for unstable pelvic fractures. J Orthop Trauma,.1996,10:517-522.
25. Schildhauer TA, Wliber JH, Patterson BM. Posterior locked lateral compression injury of the pelvis report of three cases[J]. Orthop Trauma.2000,14:107-111.
26.van Zwienen CM, vanden Bosch EW, Snijders CJ, et al. Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures [J]. Orthop Trauma,2004,18(9):589-595.
27.司卫兵,吴乃庆,嵇鹏等.骨盆骨折棒双重固定效应的生物力学研究[J].中国骨与关节损伤杂志.2005,20(4)：249-251.
28. van Zwienen CM, vanden Bosch EW, Hock van Dijke GA, et al. Cyclic loading of sacroiliac screws in Tile C pelvic fractures [J]. Trauma—Injury Infection,2005,8(5):1029-1034.
29. Ward EF,Tomasin J,Vander Griend RA. Open reduction and internal fixation of vertical shear pelvic fractures[J]. J Trauma,1987,27 (3):291-295.
30. Tile M. Pelvic ring fracture:should they be fixed[J]. J Bone Joing Surg Br.,1988,70(1):1-12.
31. Paul Tornetta, MD; K Dickson; Outcome of Rotationally Unstable Pelvic Ring injures:Treated operatively[J]. Clinical Orthopaedics and Related Research.1996; 329:147-151.
32. MacAvoy MC, Meclefan RT, Goodman SB, et al. Stability of open-book pelvic fractures using a new biomechanical model of single limb stance[J]. J Orthop Trauma.1997,11(8):590-593.
33. Simonian PT, Sehwappach JR, Routt ML JR, et al. Evaluation of new plate designs for symphysis pubis internal fixation[J]. Trauma Injury Infection.1996,41(3):498-502.
34. Gansslen A, Krettek C. Retrograde transpubic screw fixation of transpubic instabilities [J]. Oper Orthop Traumatol.2006,18(4):330-40.
35. Hinsche AF, Giannoudis PV, Smith RM, Fluoroscopy-based multiplanar image guidance for insertion of sacroiliac screws [J].Clin Orthop.2002,395:135-144.
36.胡勇,徐荣明,等.CT引导经皮置钉治疗病理性SIJ疼痛[J]. 中国骨伤.2005,18(11)：644-645.
37.周东生,黄涛,王鲁博.术中导航三维影像系统辅助置入骶骨钉微创治疗SIJ脱位[J].临床骨科杂志.2007,10(1)：1-3.
1. Tile M. Fracture of the pelvic and acetabulum[M].2nd edition.Baltimore: Williams and Wilkins,1995.66-72.
2. Vleeming A, Pool-Goudzwaard AI,Hammudoghlu. The function of the long dorsal sacroiliac ligament:its implication for understanding low back pain[J]. Spine,1996,21(5):556-56.
3. Vleeming A, Stoeckart R, Volkers AC, et al. Relation between form and function in the sacroiliac joint. Part Ⅰ:Clinical anatomical aspects[J]. Spine, 1990,15(2):130-132.
4. Arand M, Kinzl I, Gebhard E. Computer—guidance in percutaneous screw stabilization of the iliosacrai ioint [j]. Clin Orthop ReIat Res,2004, (422): 201-207.
5. Yinger K, Scaltse J, Olson S A, et al. Biomechanica comparison of posterior pelvic ring fixation[J]. J Orthop Truma,2003,17(7):481-487.
6. Swezey PL.The sacroiliac joint.Nothing is sacred. Phys Med Rehabil Clm N Am,1998.9(2):515-518.
7.郭世绂.临床骨科解剖学.第1版,天津：天津科学技术出版社。1986：303-307.
8. Brunner C, Kissling R, Jacob H AC. The efects of morphology histopathologic findings on the mobility of the sacroiliac joint J: Spine,1991; 16(9):1111-1114.
9. Freeman MD, Fox D, Richards T. The superior atmcapzutar ligament of the sacroiliac joint:priariptive evidence for confirmation of sacroiliac ligment[J].J PhysTher,1997:13(7):384-387.
10. Bagby GW.Arthrodesis by the distraction-compression method using a stainless implant. Orthopedics,1988,11:931-934.
11. Ray CD. Threaded titanium cages for lumbar interbody fusions. Spine,1997,22:667-680.
12. Kuslich SD, et al. Four year follow-up results of lumbar spine arthrodesis using the Bagby and Kuslich lumbar fusion cage. Spine, 2000,25:2656-2662.
13. Agazzi S. PLIF with cages:an independent review of 71 cases.J Neurosurg,1999,91:186-192.
14 Ebraheim NA, Haman ST, XU Rongming, et 41, The lumbosacral nerves inrelation to dorsal S1 screw placement and their locations on plain radiographs. Orthopedics,2000; 23(3):245-249.
15 Korovessis P Stamatakis M, Baikousis A. Posterior stabilization of unstable sacroiliac injuries with the Texas Scottish Rite Hospital spinal instrumentation. Orthopedics,2000; 23(4).320-323.
16. Tile M.Fractures of the pelvis.In Schatzker J, Tile M. The rationale of operative fracture care. Berlin, Springer Verlag,1987:133-213.
17 Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic Fractures. Clin Orthop,1993,279:28-32.
18. Leighton RK, waddell JP. Techniques for reduction and posterior fixation through the anterior approach Clin Orthop,1996,329:115-120.
19. Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic Fractures. Clin Orthop,1993,279:28-32.
1. Leighton RK, Waddell JP. Techniques for reduction and posterior fixation through the anterior approach. Clin Orthop,1996,329:115-120.
2. Korovessis P, Baikousis A, Stamatakis M, et al. Medium and long termresults of open reduction and internal fixation for unstable pelvic ringfractures. Orthopedics,2000; 23(11):1165-1171.
3. Miller JA, Schultz AB, Andersson GB. Load-displacement behavior of sacroiliac joints[J].J Orthop Res,1987,5(1):92-101.
4. Egund N, Olsson TH, Schmid H, et al. Movements in the sacroiliac joints demonstrated with roentgen stereophoto-grammetry[J]. Acta Radiol Diagn,1978,19(5):833-846.
5. Ishii K, Chiba K, Watanabe M, et al. Local recurrence after S2-3 sacrectomy in sacral chordoma:report of four cases [J].J Neurosurg,2002,97(Suppl 1):98-101.
6. Hugate RR, Dickey ID, Phimolsarnti R, et al. Mechanical effects of partial sacrectomy [J].Clin Orthop Relat Res,2006,450:82-88.
7 Yu B, Zheng Z, Zhuang X, et al. Biomechanical effects of transverse partial sacrectomy on the sacroiliac joints:an in vitro human cadaveric pelvic specimens investigation of the borderline of sacroiliac joint instability. Spine(Phila Pa 1976),2009,34(13):1370-1375.
8 Zheng ZM, Yu BS, Chen H, et al. Effect of iliac screw insertion depth on the stability and strength of lumbo-Iliac fixation constructs:An anatomical and biomechanical study. Spine (Phila Pa 1976),2009, 34(16):E565-572.
9. Egund N, Olsson TH, Schmid H, et al. Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. [J].Acta Radiol Diagn,1978,19(5):833-846.
10. Sturesson B,Selvik G,Uden A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine,1989,14(2):162-165.
11.Smidt GL, Shun-hua Wei, Kevin M, et al.Sacroiliac motionfor extrementship positions:a fresh cadaver study. Spine.1997,22(18): 2073-2076.
12. Rapoff AJ et al. Biomechanical comparison of posterior lumbarinterbody fusion cages. Spine,1997,22:2375-2379.
13.Tsantrizos A et al. Segmental stability and compressive strength of posterior lumbarinterbody fusion implants. Spine,2000,25:1077-1084.
14. Brantigan JW et al. A carbon fiber implant to aid interbody lumbarfusion. Mechanical testing, Spine,1991,16:S277-282.
15. Steffen T, Tsantrizos A, Aebi M. Effect of implant design and endplate preparatation on the compressive strength of interbody fusion constructs. Spine,2000,25:1077-1084.
16. Ray CD. Threaded titanium cages for lumbar interbody fusions. Spine, 1997,22:667-680.
17. Kuslich SD, et al. Four year follow-up results of lumbar spine arthrodesis using the Bagby and Kuslich lumbar fusion cage. Spine, 2000,25:2656-2662.
18. Agazzi S. PLIF with cages:an independent review of 71 cases. J Neurosurg,1999,91:186-192.
19.Ebraheim NA,Madsen TD,Xu R,et al.Dynamic changes in the contact area of the sacroiliac joint. Orthopedics,2003,26:(7):711-714.
2. Vleeming A, Pool-Goudzwaard AI, Hammudoghlu. The function of the long dorsal sacroiliac ligament:its implication for understanding low back pain[J]. Spine,1996,21(5):556-56.
3. Vleeming A, Stoeckart R, Volkers AC, et al. Relation between form and function in the sacroiliac joint. PartⅠ:Clinical anatomical aspects[J]. Spine, 1990,15(2):130-132.
4. Arand M, Kinzl I, Gebhard E. Computer—guidance in percutaneous screw stabilization of the iliosacrai ioint [j]. Clin Orthop Relat Res,2004, (422): 201-207.
5. Yinger K, Scaltse J, Olson SA, et al. Biomechanica comparison of posterior pelvic ring fixation[J]. J Orthop Truma,2003,17(7):481-487.
6. Swezey PL.The sacroiliac joint.Nothing is sacred. Phys Med Rehabil Clm N Am,1998.9(2):515-518.
7.郭世绂.临床骨科解剖学.第1版,天津：天津科学技术出版社。1986：303-307.
8. Brunner C, Kissling R, Jacob HAC. The efects of morphology histopathologic findings on the mobility of the sacroiliac joint J: Spine,1991; 16(9):1111-1114.
9. Freeman MD, Fox D, Richards T. The superior atmcapzutar ligament of the sacroiliac joint:priariptive evidence for confirmation of sacroiliac ligment[J].J PhysTher,1997:13(7):384-387.
10. Bagby GW.Arthrodesis by the distraction-compression method using a stainless implant. Orthopedics,1988,11:931-934.
11. Ray CD. Threaded titanium cages for lumbar interbody fusions. Spine,1997,22:667-680.
12. Kuslich SD, et al. Four year follow-up results of lumbar spine arthrodesis using the Bagby and Kuslich lumbar fusion cage. Spine, 2000,25:2656-2662.
13. Agazzi S. PLIF with cages:an independent review of 71 cases.J Neurosurg,1999,91:186-192.
14. Ebraheim NA, Haman ST, XU Rongming, et 41, The lumbosacral nerves inrelation to dorsal S1 screw placement and their locations on plain radiographs. Orthopedics,2000; 23(3):245-249.
15. Korovessis P Stamatakis M, Baikousis A. Posterior stabilization of unstable sacroiliac injuries with the Texas Scottish Rite Hospital spinal instrumentation. Orthopedics,2000; 23(4).320-323.
16. Tile M.Fractures of the pelvis.In Schatzker J, Tile M. The rationale of operative fracture care. Berlin, Springer Verlag,1987:133-213.
17 Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic Fractures. Clin Orthop,1993,279:28-32.
18. Leighton RK, waddell JP. Techniques for reduction and posterior fixation through the anterior approach Clin Orthop,1996,329:115-120.
19. Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic Fractures. Clin Orthop,1993,279:28-32.
20. Salsabili N,Valojerdy MR. Hogg DA.Variations in thickness of articular cartilage in the human sacrolilsc joint.Clin Anat.1995,8(6):388-391.
1. Leighton RK, Waddell JP. Techniques for reduction and posterior fixation through the anterior approach. Clin Orthop,1996,329:115-120.
2. Korovessis P, Baikousis A, Stamatakis M, et al. Medium and long termresults of open reduction and internal fixation for unstable pelvic ringfractures. Orthopedics,2000; 23(11):1165-1171.
3. Miller JA, Schultz AB, Andersson GB. Load-displacement behavior of sacroiliac joints[J].J Orthop Res,1987,5(1):92-101.
4. Egund N, Olsson TH, Schmid H, et al. Movements in the sacroiliac joints demonstrated with roentgen stereophoto-grammetry[J]. Acta Radiol Diagn,1978,19(5):833-846.
5. Ishii K, Chiba K, Watanabe M, et al. Local recurrence after S2-3 sacrectomy in sacral chordoma:report of four cases [J].J Neurosurg,2002,97(Suppl 1):98-101.
6. Hugate RR, Dickey ID, Phimolsarnti R, et al. Mechanical effects of partial sacrectomy [J].Clin Orthop Relat Res,2006,450:82-88.
7 Yu B, Zheng Z, Zhuang X, et al. Biomechanical effects of transverse partial sacrectomy on the sacroiliac joints:an in vitro human cadaveric pelvic specimens investigation of the borderline of sacroiliac joint instability. Spine(Phila Pa 1976),2009,34(13):1370-1375.
8 Zheng ZM, Yu BS, Chen H, et al. Effect of iliac screw insertion depth on the stability and strength of lumbo-Iliac fixation constructs:An anatomical and biomechanical study. Spine (Phila Pa 1976),2009, 34(16):E565-572.
9. Egund N, Olsson TH, Schmid H, et al. Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. [J].Acta Radiol Diagn,1978,19(5):833-846.
10. Sturesson B,Selvik G,Uden A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine,1989,14(2):162-165.
11.Smidt GL, Shun-hua Wei, Kevin M, et al.Sacroiliac motionfor extrementship positions:a fresh cadaver study. Spine.1997,22(18): 2073-2076.
12. Rapoff AJ et al. Biomechanical comparison of posterior lumbarinterbody fusion cages. Spine,1997,22:2375-2379.
13.Tsantrizos A et al. Segmental stability and compressive strength of posterior lumbarinterbody fusion implants. Spine,2000,25:1077-1084.
14. Brantigan JW et al. A carbon fiber implant to aid interbody lumbarfusion. Mechanical testing, Spine,1991,16:S277-282.
15. Steffen T, Tsantrizos A, Aebi M. Effect of implant design and endplate preparatation on the compressive strength of interbody fusion constructs. Spine,2000,25:1077-1084.
16. Ray CD. Threaded titanium cages for lumbar interbody fusions. Spine, 1997,22:667-680.
17. Kuslich SD, et al. Four year follow-up results of lumbar spine arthrodesis using the Bagby and Kuslich lumbar fusion cage. Spine, 2000,25:2656-2662.
18. Agazzi S. PLIF with cages:an independent review of 71 cases. J Neurosurg,1999,91:186-192.
19.Ebraheim NA,Madsen TD,Xu R,et al.Dynamic changes in the contact area of the sacroiliac joint. Orthopedics,2003,26:(7):711-714.
1. Henderson RC.The long-term results of nonoperatively treated major pelvicdisruptions.J Orthop Trauma,1989,3:41-47.
2. Harrison DE. Harrison DD, Troyanovich sJ. The sacroiliac joint:areview of anatomy and biomechanics with clinical implications. Manulative Physiol Ther,.1997,20(9):607-610.
3. Voom R. Case report:can sacroiliac joint dysfunction cause chronic Achilles tendonitis? J Orthop Sports Phys Thef.1998.27(6):436-439.
4. van Wingerde JP, Vleering A,Buyruk HM. et al. Stabilization of the sacroiliac joint in vivo:verification of muscular contributrion to force closure of the pelvis. Eur Spine J.2004,13(3):199-205.
5. Richardson CA,Snijders CJ.Hides JA.et al.The relation between the transversus abdominis muscles,sacroiliac joint mechanics,and low back pain.Spine.2002,27(4):399-406.
6. Vleeming A,Pool—Goudzwsard AL. Hammudoghlu D, al.The function of the long dorsal sacroiliac joint ligament:its implication for understanding low back pain. Spine.1996.21(5):556-560.
7. Simonian PT, Routt Jr MLC, Harrington RM, et al. Biomechanical simulation of the anteroposterior compression injury of the pelvis. An understanding of instablility and fixation. Clin Orthop.1994,309:245-256.
8. Vrahas M,Hern TC,Diangelo,D,et al.Experimental study of the sacroiliac micromotion in pelvic disruption.J Orthop Trauma.2002,16(2):99-103.
9. Vukicevic S,Marusic A,Stavljenic A,et al.Holographic analysis of the human pelvis.Spine 1991,16(2)209-214.
10.XuR. Ebraheim NA,Yeasting RA, et al Anatomic considerations, for posterior iliac bone harvesting. Spine,1996.21(9):1017-1020.
11.Pool-Goudzwaard AL,Kleinrensink GJ,Snijders CJ, et al.The sacrooliac part of the fliolumbar ligament. J Anat.2001,199(4):457-461.
12. Tile M. Acute pelvic fractures:I. Causation and classification [J]. JAAOS,1996,4:143-151.
13. Salsabili N,Valojerdy MR. Hogg DA. Variations in thickness of articular cartilage in the human sacrolilsc joint.Clin Anat.1995,8(6):388-391.
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