骨盆损伤后骶髂关节稳定性的生物力学研究
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摘要
目的：骶髂关节位处骨盆环的后环，是支撑人体躯干负载并完成力学传导的重要结构，其解剖及功能的完整性对骨盆环的稳定至关重要。其在骨盆骨折中经常受到损伤，但骨盆骨折的手术治疗中，对恢复骶髂关节稳定性的重要作用,尚没有引起足够的重视，因此,临床上骶髂关节损伤的长期功能预后经常是不能令人满意的。本实验仅就骶髂关节周围韧带损伤以及耻骨联合分离后对骶髂关节稳定性的影响进行了生物力学研究，试图进一步了解骶髂关节的解剖与功能，为骨盆骨折的临床治疗提供依据。
方法：取成年男性短期（1年内）防腐尸体20具, 自第3、4腰椎交界处及双大腿中下1/3交界处将尸体横断，得骨盆标本20个。将20个骨盆标本仔细剔除附着的肌肉,完整保留髋关节囊,骶棘韧带,骶结节韧带,耻骨联合及骶髂关节诸韧带结构,肉眼观察及X线摄片均无风湿、结核、肿瘤、骨折等病变及解剖学变异。将20具标本随机分为A、B两组，每组10具。A组又分为左右侧分别进行实验。将标本放于夹具上，模拟人体单足站立位,给予轴向加载500N(模拟人体自重)，测量并记录每步处理后的骶骨垂直位移及骶骨矢状面旋转角度（角移位）。A组左侧：第一步：完整骨盆 ；第二步：切断耻骨联合 ；第三步：在第二步基础上切断左侧骶棘韧带；第四步：切断左侧骶结节韧带；第五步：继续切断左侧骶髂前韧带；第六步：最后切断左侧骶
髂骨间韧带。A组右侧：按照顺序逐步切断骶髂后长韧带、骶髂后短韧带、髂腰韧带及骶髂骨间韧带，分别测量指标。B组10具骨盆按如下顺序进行实验： 第一步：完整骨盆；第二步：切断耻骨联合；第三步：逐步分离耻骨联合，0.5cm，1.0 cm，1.5 cm，2.0 cm，2.5 cm，每一阶段均测量指标；第四步：首先切断骶棘韧带、骶髂前韧带，然后将耻骨联合逐级开大3 .0cm，3.5 cm，4.0 cm，分别测量指标。实验数据用SPSS10.0统计软件的单因素方差分析，进行分析，进行组与组之间比较， P<0.05为差异有显著性意义。
结果：A组左侧：在实验顺次进行过程中，骶骨的垂直位移数值由完整骨盆测量的4.144±0.538mm增至5.853±0.368mm，骶骨的旋转角度由0.226±0.061°增至0.616±0.086°，均有了显著性增加。其中当仅切断耻骨联合周围韧带时，两指标均无显著性改变；进一步切断骶结节韧带，对骶骨垂直位移无明显影响，骶骨矢状面旋转角度有所增加，但无统计学意义；而当骶棘韧带切断时，骶骨矢状面旋转角度有了显著性增大；实验继续切断骶髂前韧带时，两个统计指标均无显著性变化；当切断骶髂骨间韧带时，上述指标均有显著性增加(P<0.05)。A组右侧：实验中逐次切断骶髂关节后部韧带。在实验顺次进行过程中，骶骨的垂直位移数值由完整骨盆测量的3.610±0.696mm增至6.825±0.565mm，有了明显增加。骶骨的旋转角度由骨盆完整时的0.271±0.094°增至0.746±0.192°，亦有了明显增加。以上两种指标的总体变化均有显著的统计学意义(P<0.05)。首先在耻骨联合已被切断的基础上切断骶髂后长
韧带，骶骨旋转角度出现显著性增加(P<0.05)，垂直位移无明显影响；进一步切断后短韧带，垂直位移及旋转角度均有了显著性增加(P<0.05)；切断髂腰韧带后，骶髂关节的稳定性明显降低，垂直位移及旋转角度均有显著性增大(P<0.05)；最后切断骶髂骨间韧带，上述指标进一步显著性加大，骶髂关节极度不稳。B组：实验表明，当耻骨联合分开0.5 cm至1.5cm阶段，骶骨的垂直位移由切断耻骨联合时的4.367±0.495mm增大到8.209±0.603mm，与此同时骶骨的角位移由0.307±0.097°增加到1.139±0.210°均有显著性统计学意义(P<0.05)；而当开大至2.0cm时两测量指标较前时又明显下降(P<0.05)，分别降至7.260±0.895mm，0.820±0.120°，但与单纯切断耻骨联合时相比，有显著性增大。2.5cm~4.0cm阶段仍呈下降趋势，由6.911±0.436mm，0.758±0.100°降至5.827±0.486 mm，0.557±0.122°，其组间比较无统计学意义，但两指标与单纯切断耻骨联合时相比，有显著性增大。
结论：耻骨联合及其周围韧带的损伤对骶髂关节的稳定性没有显著性影响；骶结节韧带、骶棘韧带对限制骶骨的角位移有很大的作用，临床上对其损伤应给予重视；骨间韧带对骶髂关节稳定性的作用是最为重要的；骶髂后韧带中后短韧带作用更加强大；后韧带与骨间韧带共同组成了骶髂关节后部韧带复合体，是骶髂关节周围韧带中最关键的部分。实验中耻骨联合的分离给骶髂关节造成显著不稳，从分离0.5cm至1.5cm阶段的逐步不稳到2.0cm至4.0cm阶段稳定性有所恢复，这里体现了一个内锁机制的破坏与伴随分离加剧的韧带张力之间的平衡。因此临床上对
于不伴有骶髂关节韧带损伤的耻骨联合分离(<25mm)也应同样重视，避免引起骶髂关节晚期的功能障碍。
Objective：Sacroiliac joint is located on the posterior ring of pelvis and it is the important structure to support the weight of the upper part of human body and complete the mechanics conducting. Its integrity of anatomy and function is most important to the pelvic ring. SI joint usually suffer the injury in the pelvic fracture, but it still did not cause enough recognition in surgical operation under medical treatment of the pelvic fracture to recover stability of SI joint .So its prognosis of long-term function is poor in clinic. So we carry out this biomechanical experiment to study the effect on pelvic stability with the disruption of SI ligaments and Separation of pubic symphysis, trying to gain the further understanding to the anatomy and function and providing the basis for the clinical treatment of the pelvic disruption.
Methods: 20 short-term (in one year) embalmed pelves along with their spines intact from L4 to the sacrum, and hip joints with the 2/3 proximal of both femora were harvested for this study. All of these specimens were visually examined and then X-rayed to exclude the presence of pelvic bone or soft tissue disease. Care was taken to preserve the hip capsules, symphysis pubis, sacroiliac joint, sacrotuberous and
sacrospinons ligaments. 20 specimens were divided into two groups randomly, 10 specimens per group. The group A was divided into two sides again, left and right, to start experiment respectively. In preparation for mechanical testing, one denuded femur were secured in the fixturn designed for test. Biomechanical testing was performed in model. Each specimen was loaded by vertical compression through the lumbar spine in a single-leg-stance model. The loads were applied at the speed of 5mm/min. It was increased in a continuous fashion until it reached 500N. In every step, the following data were recorded: the sacral rotation around the transversal axis(sacroiliac joint angulation) and its vertical displacement. For each pelvis, the micromotion of each SI joint was study separately in various states one after the other. Left side of group A: (1) intact pelvis; (2) section of the pubic symphysis ligament; (3) section of the sacrotuberous ligament; (4) section of the sacrospinous ligament; (5) section of the anterior SI ligament; (6) section of the interosseous SI ligament; Right side of group A: A gradual section in a order as follows: (1) long posterior SI ligament; (2) short posterior SI ligament; (3) iliolumbar ligament; (4) interosseous SI ligament. In every step, datum were recorded. Group B: (1) intact pelvis; (2) section of the pubic symphysis ligament; (3) To performant experiment with the pubic diastasis in sequence following : 0.5cm，1.0 cm，1.5 cm，2.0 cm，2.5 cm，and datum were recorded. (4) After the section of unilateral sacrospinous and sacrotuberous ligaments, pubic
symphysis was separated to 3 .0cm，3.5 cm，4.0 cm，step by step. The experimental datum were analyzed by the one-way ANOVA in SPSS10.0 statistic software. The statistical significance for the test was set at P<0.05.
Results: Left side of group A: In the successive loading test, the average vertical displacement increased from 4.144±0.538mm which measured in intact pelves to 5.853±0.368mm, the sacroiliac joint angulation varied from 0.226±0.061 to 0.616±0.086 degrees.Each index showed the significant increase. We found no further increase in the pubic symphysis joint motion; Further section of sacrotuberous ligament showed no evident change in vertical diaplacement while the average of angulation increasing, but had no statistical significance; When cutting off the sacrospinous ligament, sacroiliac joint angulation showed significant aggrandizement; When continuously cutting off the anterior SI ligament, two indexes showed no variety; When sectioned the interosseous SI ligament, the above indexes showed the significant increase (P<0.05). Right side of group A: In the successive loading test, the average vertical displacement increased from 3.610±0.696mm which measured in intact pelves to
方法：取成年男性短期（1年内）防腐尸体20具, 自第3、4腰椎交界处及双大腿中下1/3交界处将尸体横断，得骨盆标本20个。将20个骨盆标本仔细剔除附着的肌肉,完整保留髋关节囊,骶棘韧带,骶结节韧带,耻骨联合及骶髂关节诸韧带结构,肉眼观察及X线摄片均无风湿、结核、肿瘤、骨折等病变及解剖学变异。将20具标本随机分为A、B两组，每组10具。A组又分为左右侧分别进行实验。将标本放于夹具上，模拟人体单足站立位,给予轴向加载500N(模拟人体自重)，测量并记录每步处理后的骶骨垂直位移及骶骨矢状面旋转角度（角移位）。A组左侧：第一步：完整骨盆 ；第二步：切断耻骨联合 ；第三步：在第二步基础上切断左侧骶棘韧带；第四步：切断左侧骶结节韧带；第五步：继续切断左侧骶髂前韧带；第六步：最后切断左侧骶
髂骨间韧带。A组右侧：按照顺序逐步切断骶髂后长韧带、骶髂后短韧带、髂腰韧带及骶髂骨间韧带，分别测量指标。B组10具骨盆按如下顺序进行实验： 第一步：完整骨盆；第二步：切断耻骨联合；第三步：逐步分离耻骨联合，0.5cm，1.0 cm，1.5 cm，2.0 cm，2.5 cm，每一阶段均测量指标；第四步：首先切断骶棘韧带、骶髂前韧带，然后将耻骨联合逐级开大3 .0cm，3.5 cm，4.0 cm，分别测量指标。实验数据用SPSS10.0统计软件的单因素方差分析，进行分析，进行组与组之间比较， P<0.05为差异有显著性意义。
结果：A组左侧：在实验顺次进行过程中，骶骨的垂直位移数值由完整骨盆测量的4.144±0.538mm增至5.853±0.368mm，骶骨的旋转角度由0.226±0.061°增至0.616±0.086°，均有了显著性增加。其中当仅切断耻骨联合周围韧带时，两指标均无显著性改变；进一步切断骶结节韧带，对骶骨垂直位移无明显影响，骶骨矢状面旋转角度有所增加，但无统计学意义；而当骶棘韧带切断时，骶骨矢状面旋转角度有了显著性增大；实验继续切断骶髂前韧带时，两个统计指标均无显著性变化；当切断骶髂骨间韧带时，上述指标均有显著性增加(P<0.05)。A组右侧：实验中逐次切断骶髂关节后部韧带。在实验顺次进行过程中，骶骨的垂直位移数值由完整骨盆测量的3.610±0.696mm增至6.825±0.565mm，有了明显增加。骶骨的旋转角度由骨盆完整时的0.271±0.094°增至0.746±0.192°，亦有了明显增加。以上两种指标的总体变化均有显著的统计学意义(P<0.05)。首先在耻骨联合已被切断的基础上切断骶髂后长
韧带，骶骨旋转角度出现显著性增加(P<0.05)，垂直位移无明显影响；进一步切断后短韧带，垂直位移及旋转角度均有了显著性增加(P<0.05)；切断髂腰韧带后，骶髂关节的稳定性明显降低，垂直位移及旋转角度均有显著性增大(P<0.05)；最后切断骶髂骨间韧带，上述指标进一步显著性加大，骶髂关节极度不稳。B组：实验表明，当耻骨联合分开0.5 cm至1.5cm阶段，骶骨的垂直位移由切断耻骨联合时的4.367±0.495mm增大到8.209±0.603mm，与此同时骶骨的角位移由0.307±0.097°增加到1.139±0.210°均有显著性统计学意义(P<0.05)；而当开大至2.0cm时两测量指标较前时又明显下降(P<0.05)，分别降至7.260±0.895mm，0.820±0.120°，但与单纯切断耻骨联合时相比，有显著性增大。2.5cm~4.0cm阶段仍呈下降趋势，由6.911±0.436mm，0.758±0.100°降至5.827±0.486 mm，0.557±0.122°，其组间比较无统计学意义，但两指标与单纯切断耻骨联合时相比，有显著性增大。
结论：耻骨联合及其周围韧带的损伤对骶髂关节的稳定性没有显著性影响；骶结节韧带、骶棘韧带对限制骶骨的角位移有很大的作用，临床上对其损伤应给予重视；骨间韧带对骶髂关节稳定性的作用是最为重要的；骶髂后韧带中后短韧带作用更加强大；后韧带与骨间韧带共同组成了骶髂关节后部韧带复合体，是骶髂关节周围韧带中最关键的部分。实验中耻骨联合的分离给骶髂关节造成显著不稳，从分离0.5cm至1.5cm阶段的逐步不稳到2.0cm至4.0cm阶段稳定性有所恢复，这里体现了一个内锁机制的破坏与伴随分离加剧的韧带张力之间的平衡。因此临床上对
于不伴有骶髂关节韧带损伤的耻骨联合分离(<25mm)也应同样重视，避免引起骶髂关节晚期的功能障碍。
Objective：Sacroiliac joint is located on the posterior ring of pelvis and it is the important structure to support the weight of the upper part of human body and complete the mechanics conducting. Its integrity of anatomy and function is most important to the pelvic ring. SI joint usually suffer the injury in the pelvic fracture, but it still did not cause enough recognition in surgical operation under medical treatment of the pelvic fracture to recover stability of SI joint .So its prognosis of long-term function is poor in clinic. So we carry out this biomechanical experiment to study the effect on pelvic stability with the disruption of SI ligaments and Separation of pubic symphysis, trying to gain the further understanding to the anatomy and function and providing the basis for the clinical treatment of the pelvic disruption.
Methods: 20 short-term (in one year) embalmed pelves along with their spines intact from L4 to the sacrum, and hip joints with the 2/3 proximal of both femora were harvested for this study. All of these specimens were visually examined and then X-rayed to exclude the presence of pelvic bone or soft tissue disease. Care was taken to preserve the hip capsules, symphysis pubis, sacroiliac joint, sacrotuberous and
sacrospinons ligaments. 20 specimens were divided into two groups randomly, 10 specimens per group. The group A was divided into two sides again, left and right, to start experiment respectively. In preparation for mechanical testing, one denuded femur were secured in the fixturn designed for test. Biomechanical testing was performed in model. Each specimen was loaded by vertical compression through the lumbar spine in a single-leg-stance model. The loads were applied at the speed of 5mm/min. It was increased in a continuous fashion until it reached 500N. In every step, the following data were recorded: the sacral rotation around the transversal axis(sacroiliac joint angulation) and its vertical displacement. For each pelvis, the micromotion of each SI joint was study separately in various states one after the other. Left side of group A: (1) intact pelvis; (2) section of the pubic symphysis ligament; (3) section of the sacrotuberous ligament; (4) section of the sacrospinous ligament; (5) section of the anterior SI ligament; (6) section of the interosseous SI ligament; Right side of group A: A gradual section in a order as follows: (1) long posterior SI ligament; (2) short posterior SI ligament; (3) iliolumbar ligament; (4) interosseous SI ligament. In every step, datum were recorded. Group B: (1) intact pelvis; (2) section of the pubic symphysis ligament; (3) To performant experiment with the pubic diastasis in sequence following : 0.5cm，1.0 cm，1.5 cm，2.0 cm，2.5 cm，and datum were recorded. (4) After the section of unilateral sacrospinous and sacrotuberous ligaments, pubic
symphysis was separated to 3 .0cm，3.5 cm，4.0 cm，step by step. The experimental datum were analyzed by the one-way ANOVA in SPSS10.0 statistic software. The statistical significance for the test was set at P<0.05.
Results: Left side of group A: In the successive loading test, the average vertical displacement increased from 4.144±0.538mm which measured in intact pelves to 5.853±0.368mm, the sacroiliac joint angulation varied from 0.226±0.061 to 0.616±0.086 degrees.Each index showed the significant increase. We found no further increase in the pubic symphysis joint motion; Further section of sacrotuberous ligament showed no evident change in vertical diaplacement while the average of angulation increasing, but had no statistical significance; When cutting off the sacrospinous ligament, sacroiliac joint angulation showed significant aggrandizement; When continuously cutting off the anterior SI ligament, two indexes showed no variety; When sectioned the interosseous SI ligament, the above indexes showed the significant increase (P<0.05). Right side of group A: In the successive loading test, the average vertical displacement increased from 3.610±0.696mm which measured in intact pelves to
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张朝佑 主编. 人体解剖学. 第二版. 北京:人民卫生出版社,1998:155~157
钟世镇 主编. 临床应用解剖学. 第一版. 北京: 人民军医出版社,1998:550~551
Simonian PT, Chip Routt ML. Biomechanics of pelvic fixation. Orthopedic Clinics of North America,1997,28(3):352~353
Pennal GF, Tile M, Waddell JP, et al. Pelvic disruption: assessment and classification. Clin Orthop, 1980,151:12~15
Cryer HM, Miller FB, Evers BM, et al. Pelvic fracture classification: correlation with hemorrhage. J Trauma,1988, 28:973~977
Burgess AR: effective classification system and treatment , Eastridge BJ, Young JWR, et al. Pelvic ring disruptions protocols. J Trauma, 1990,30(7):848~851
Vukicevic S, Marusic A, Stavljenic, et al. Holographic analysis of the human pelvis. Spine,1991,16(2):209~221
Pool-Goudzwuard A.The iliolumbar ligament:its influence on stability of the sacroiliac joint. Clin Biomech, 2003,18 (2):99 ~105
Bucholz RW: The pahological anatomy of Malgaigne fracture-dislocations of the pelvis. J Bone Joint Surg,1981,63(A): 400 ~404
Hefzy Ms,Ebraheimn,Mekhail A,et al.Kinematics of the human
pelvis following open book injury.Med Eng
Phys,2003,25(4):259~274
Schildhauer TA,Ledoux WR,Chapman JR, et al.Triangular osteosynthesis ane iliosacral screw fixation for unstable sacral fractures:A cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma,2003,17(1):22~31
郭世绂 主编. 临床骨科解剖学. 第1版.天津:天津科学技术出版社,1997,310~311
荣国威,翟桂华,刘沂,等译.骨科内固定.第3版.北京:人民卫生出版社,1998,340~341
钱齐荣,贾连顺，高建新.骶髂关节面形态的测量及其生物力学意义.临床骨科杂志,2002,5(1):1~5