经皮骶髂螺钉技术治疗不稳定性骨盆骨折的效果及系统评价研究
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摘要
第一部分不稳定性骨盆骨折手术治疗的meta分析
目的：通过对目前已发表的关于不稳定性骨盆骨折手术治疗的随访研究进行meta分析，以找出最佳证据来综合评价不稳定性骨盆手术治疗的效果，手术并发症等问题，为临床治疗决策和下一步的研究提供一定的依据。
材料与方法：计算机检索Medline(ovid搜索引擎1950—2007．2)等数据库，通过ovid搜索引擎手工检索《clinical orthopaedics & related research》，《Injury》等杂志。收集相关长期随访报道，逐个进行质量评价，对手术方法，复位质量，手术早期和晚期并发症，功能评价等使用spss软件进行统计分析。
结果：不稳定性骨盆骨折平均ISS分数24.0分，神经损伤发生率16.2％，各系统损伤发生率9.4％到15.1％，合并各部位骨折，13.4％到40.0％。在骨盆后环稳定性重建手术方法中，使用经皮骶髂螺钉固定已占到41.5％，其他固定方式百分比从5.1％到22.6％。在手术并发症中，单独外固定架固定时针道感染及固定失败的发生率极高，均在20％左右，远高于内固定的相关并发症；而其他并发症的发生率均低于5％。在治疗效果方面，总体术后影像学评价解剖复位仅55.7％，疼痛发生率45.2％，功能评分量表优良率仅61.1％。
结论：不稳定性骨盆骨折总体损伤情况严重，而经皮固定技术已成为骨盆骨折内固定的首选方法，较高的针道感染及复位失败率使骨盆外支架不适合作为骨盆骨折的最终固定方法。虽然骨盆骨折总体手术并发症发生率低，但骨盆骨折的长期功能恢复仍然不令人满意。
第二部分经皮骶髂螺钉N定技术治疗不稳定性骨盆骨折中的效果评价
目的：手术治疗是不稳定性骨盆骨折稳定性重建的主要方法，骨盆稳定性重建的重点在后环，目前骨盆后环的固定方法有，前后路钢板，骶骨棒，椎弓根固定系统等，而骶髂螺钉联合经皮固定技术，因其良好的生物力学效应和较少的手术创伤及感染风险，已成为骨盆后环固定的首选方法。因此，通过对15例病人的病案回顾及随访，评价经皮骶髂螺钉技术在不稳定性骨盆骨折治疗中的安全性及治疗效果。
材料与方法：通过对2003年到2007年，四川大学华西医院收治的15例TileC型骨盆骨折患者，采用经皮骶髂螺钉技术固定骨盆后环，合并的前环损伤中7例采用外支架固定，3例采用钢板固定，5例采用钢板联合外支架固定。回顾术中出血，手术时间，并发症，应用Matta标准评价术后影像学资料，应用Majeed随访功能表随访功能。
结果：通过回顾病例我们发现无神经损伤感染等手术并发症，术后评价matta标准优14例，良1例．15例均获得随访，随访时间6月到2年，平均18月，骨折均愈合，1例螺钉松动移位(6.7％)但骨折复位愈合情况良好，其中12例(80.0％)完全无痛，1例轻度跛行，9例恢复原工作或学习(60％)，3例改换工作(15％)，3例随访时未工作(15％)，Majeed功能评分，优11例(73.3％)，良4例(36.7％)。
结论：经皮骶髂螺钉固定技术可以很好的重建骨盆后环的稳定性，使患者获得很好的功能康复，同时手术并发症发生率低及对患者创伤小，是不稳定性骨盆骨折后环稳定性重建的良好方法。但本研究病例数较少，随访时间较短，本文所获结果仅供参考，经皮骶髂螺钉的临床价值仍需进一步评价。
Objective: We have carried out a comprehensive review of the literature concerning the surgical management of unstable pelvic fractures and subjected it to a meta-analysis in order to assess the method of the fracture fixation ,the incidence of post-operative complications ,the quality of reduction and the functional outcome.
Methods: Search were applide to the following electronic database: Medline (1950—2007.2) use ovid search engine, etc.A manual search was done to the major orthopaedic journals ,such as《clinical orthopaedics & related research》etc.Data ectraction by hand and data statistics by spss on a personal computer.
Results: The average ISS scoring of unstable pelvic fracture was 24.0 point,the incidence of neurological injury was 16.2%,and the incidence of other injurys was 9.4% to 40.0% . In the posterior ring fixation, Percutaneous fixation with sacro-iliac screw was used in 41.5% of patients,and the percent of other method was 5.1% to 22.6%. The incidence of post-operative complications associated with external fixator was high(pin infection 22.6%, loosening of the pin 19.1%), and other complications were haphazard.The quality of reduction,55.7% of them got anatomical or nearly anatomical reduction.After the average follow-up time of 28.8 months, only 61.1% of the patients get satisfactory results according to the majeed fuctional score,and 45.2% of patient have pain.
Conclusion: The unstable pelvic fractures is very difficult to treatment as a severe trauma. Pure external fixator cannot be choose to denfinit treament of unstable pelvic fractures,and Percutaneous technique become the primary method of the fixation technique.Although satisfaction in the quality of reduction and the safety of operative treatment was got ,but the long term follow-up show that the functional outcome was still unsatisfactory.
Objectives: The operative treatment is the dominating treatment of unstable pelvic fractures,and the fixation of posterior ring is the keystone. There are a variety of methods available, including iliosacral screws, sacral bars, and anterior and posterior plating techniques. Percutaneous technique with iliosacral screws become the primary method of the fixation technique.so we evaluated the effectiveness of Percutaneous fixation with iliosacral screw in the management of the unstable pelvic fractures in Huaxi hospital..
Methods: In 2003-2007,there is 15 unstable pelvic fractures were treated using Percutaneous fixation with iliosacral screws in Huaxi hospital. Anterior fixation was by means of plating in 3 cases ,by external fixation in 7 cases,by both in 5 cases. Complications were recorded and radiographs were analyzed with Matta criterion to classify fractures and identify screw misplacement and malunion. All patients had a functional evaluation according to Majeed functional scoring.
Results: Neither nerve injury nor other perioperative complications was found ,the quality of the fracture reduction was graded as excellent in 14 cases and satisfactory in 1 according to Matta criterion. After the average follow-up time of 28.8 months ,all fracture union , Screw loosing occurred in one patients but there were no adverse sequelae ,12 (80 percent) had no pain, slight limp was found in one patient .9 (60 percent) returned to their pre-injury occupation, six patients (15 percent) changed occupation, and nine patients (15 percent) had not yet returned to work by last follow-up. There was 11 excellent(73.3 percent) and 4 good (36.7 percent)according to Majeed functional scoring.
Conclusions: Iliosacral screw fixation is a useful method of fixation in the unstable pelvic fracture.But the clinic value of percutaneous iliosacral screws need more clinic study since there is few cases and little follow-up time in our report.
目的：通过对目前已发表的关于不稳定性骨盆骨折手术治疗的随访研究进行meta分析，以找出最佳证据来综合评价不稳定性骨盆手术治疗的效果，手术并发症等问题，为临床治疗决策和下一步的研究提供一定的依据。
材料与方法：计算机检索Medline(ovid搜索引擎1950—2007．2)等数据库，通过ovid搜索引擎手工检索《clinical orthopaedics & related research》，《Injury》等杂志。收集相关长期随访报道，逐个进行质量评价，对手术方法，复位质量，手术早期和晚期并发症，功能评价等使用spss软件进行统计分析。
结果：不稳定性骨盆骨折平均ISS分数24.0分，神经损伤发生率16.2％，各系统损伤发生率9.4％到15.1％，合并各部位骨折，13.4％到40.0％。在骨盆后环稳定性重建手术方法中，使用经皮骶髂螺钉固定已占到41.5％，其他固定方式百分比从5.1％到22.6％。在手术并发症中，单独外固定架固定时针道感染及固定失败的发生率极高，均在20％左右，远高于内固定的相关并发症；而其他并发症的发生率均低于5％。在治疗效果方面，总体术后影像学评价解剖复位仅55.7％，疼痛发生率45.2％，功能评分量表优良率仅61.1％。
结论：不稳定性骨盆骨折总体损伤情况严重，而经皮固定技术已成为骨盆骨折内固定的首选方法，较高的针道感染及复位失败率使骨盆外支架不适合作为骨盆骨折的最终固定方法。虽然骨盆骨折总体手术并发症发生率低，但骨盆骨折的长期功能恢复仍然不令人满意。
第二部分经皮骶髂螺钉N定技术治疗不稳定性骨盆骨折中的效果评价
目的：手术治疗是不稳定性骨盆骨折稳定性重建的主要方法，骨盆稳定性重建的重点在后环，目前骨盆后环的固定方法有，前后路钢板，骶骨棒，椎弓根固定系统等，而骶髂螺钉联合经皮固定技术，因其良好的生物力学效应和较少的手术创伤及感染风险，已成为骨盆后环固定的首选方法。因此，通过对15例病人的病案回顾及随访，评价经皮骶髂螺钉技术在不稳定性骨盆骨折治疗中的安全性及治疗效果。
材料与方法：通过对2003年到2007年，四川大学华西医院收治的15例TileC型骨盆骨折患者，采用经皮骶髂螺钉技术固定骨盆后环，合并的前环损伤中7例采用外支架固定，3例采用钢板固定，5例采用钢板联合外支架固定。回顾术中出血，手术时间，并发症，应用Matta标准评价术后影像学资料，应用Majeed随访功能表随访功能。
结果：通过回顾病例我们发现无神经损伤感染等手术并发症，术后评价matta标准优14例，良1例．15例均获得随访，随访时间6月到2年，平均18月，骨折均愈合，1例螺钉松动移位(6.7％)但骨折复位愈合情况良好，其中12例(80.0％)完全无痛，1例轻度跛行，9例恢复原工作或学习(60％)，3例改换工作(15％)，3例随访时未工作(15％)，Majeed功能评分，优11例(73.3％)，良4例(36.7％)。
结论：经皮骶髂螺钉固定技术可以很好的重建骨盆后环的稳定性，使患者获得很好的功能康复，同时手术并发症发生率低及对患者创伤小，是不稳定性骨盆骨折后环稳定性重建的良好方法。但本研究病例数较少，随访时间较短，本文所获结果仅供参考，经皮骶髂螺钉的临床价值仍需进一步评价。
Objective: We have carried out a comprehensive review of the literature concerning the surgical management of unstable pelvic fractures and subjected it to a meta-analysis in order to assess the method of the fracture fixation ,the incidence of post-operative complications ,the quality of reduction and the functional outcome.
Methods: Search were applide to the following electronic database: Medline (1950—2007.2) use ovid search engine, etc.A manual search was done to the major orthopaedic journals ,such as《clinical orthopaedics & related research》etc.Data ectraction by hand and data statistics by spss on a personal computer.
Results: The average ISS scoring of unstable pelvic fracture was 24.0 point,the incidence of neurological injury was 16.2%,and the incidence of other injurys was 9.4% to 40.0% . In the posterior ring fixation, Percutaneous fixation with sacro-iliac screw was used in 41.5% of patients,and the percent of other method was 5.1% to 22.6%. The incidence of post-operative complications associated with external fixator was high(pin infection 22.6%, loosening of the pin 19.1%), and other complications were haphazard.The quality of reduction,55.7% of them got anatomical or nearly anatomical reduction.After the average follow-up time of 28.8 months, only 61.1% of the patients get satisfactory results according to the majeed fuctional score,and 45.2% of patient have pain.
Conclusion: The unstable pelvic fractures is very difficult to treatment as a severe trauma. Pure external fixator cannot be choose to denfinit treament of unstable pelvic fractures,and Percutaneous technique become the primary method of the fixation technique.Although satisfaction in the quality of reduction and the safety of operative treatment was got ,but the long term follow-up show that the functional outcome was still unsatisfactory.
Objectives: The operative treatment is the dominating treatment of unstable pelvic fractures,and the fixation of posterior ring is the keystone. There are a variety of methods available, including iliosacral screws, sacral bars, and anterior and posterior plating techniques. Percutaneous technique with iliosacral screws become the primary method of the fixation technique.so we evaluated the effectiveness of Percutaneous fixation with iliosacral screw in the management of the unstable pelvic fractures in Huaxi hospital..
Methods: In 2003-2007,there is 15 unstable pelvic fractures were treated using Percutaneous fixation with iliosacral screws in Huaxi hospital. Anterior fixation was by means of plating in 3 cases ,by external fixation in 7 cases,by both in 5 cases. Complications were recorded and radiographs were analyzed with Matta criterion to classify fractures and identify screw misplacement and malunion. All patients had a functional evaluation according to Majeed functional scoring.
Results: Neither nerve injury nor other perioperative complications was found ,the quality of the fracture reduction was graded as excellent in 14 cases and satisfactory in 1 according to Matta criterion. After the average follow-up time of 28.8 months ,all fracture union , Screw loosing occurred in one patients but there were no adverse sequelae ,12 (80 percent) had no pain, slight limp was found in one patient .9 (60 percent) returned to their pre-injury occupation, six patients (15 percent) changed occupation, and nine patients (15 percent) had not yet returned to work by last follow-up. There was 11 excellent(73.3 percent) and 4 good (36.7 percent)according to Majeed functional scoring.
Conclusions: Iliosacral screw fixation is a useful method of fixation in the unstable pelvic fracture.But the clinic value of percutaneous iliosacral screws need more clinic study since there is few cases and little follow-up time in our report.
引文
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1 Lindahl J, Hirvensalo E, Bostman O.Santavirta S.Failure of reduction with an external fixator in the management of injuries of the pelvic ring. J Bone Joint Surg [Br], 1999, 81-b:955-62.
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7 Gorczyca JT, Varga E, Woodside T, et al. The strength of iliosacral lag screws and transiliac bars in the fixation of vertically unstable pelvic injuries with sacral fractures. Injury, 1996,27:561-4.
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1 Lindahl J, Hirvensalo E, Bostman O.Santavirta S.Failure of reduction with an external fixator in the management of injuries of the pelvic ring. J Bone Joint Surg [Br], 1999, 81-b:955-62.
2 Tornetta P 3rd, Matta JM. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop, 1996,(329): 186-93
3 Dujardin FH, Hossenbaccus M, Dupare F, et al. Long-term functional prognosis of posterior injuries in high-energy pelvic disruption. J Orthop Trauma, 1998, 12:145-50.
4 Rubash HE, Brown TD, Nelson DD.Comparative mechanical performances of some new devices foe fixation of unstable pelvic ring fractures.Med.and Biol.Eng.and Comput., 1983,21:657-63,.
5 Comstock CP, van der Meulen MS, Goodman SB. Biomechanical comparison of posterior internal fixation techniques for unstable pelvic fractures.,J Orthop Trauma,1996,10:517-2
6 Simonian PT, Routt ML Jr. Biomechanics of pelvic fixation. Orthop Clin North Am, 1997,28:351-67.
7 Gorczyca JT, Varga E, Woodside T, et al. The strength of iliosacral lag screws and transiliac bars in the fixation of vertically unstable pelvic injuries with sacral fractures. Injury, 1996,27:561-4.
8 Yinger K, Scalise J, Olson SA, et al. Biomechanical comparison ofposterior pelvic ring fixation. J Orthop Trauma, 2003,17:481-7
9 S.A.Majeed.Grading The Outcome of Pelvic Fracture.J Bone Joint Surg[Br]. 1989,71 -B;304-6,
10 Shuler T, Boone DC, Gruen G. Percutaneous iliosacral screw fixation: optimal treatment for unstable posterior pelvic ring disruption.abstract. J Trauma, 1993;35:984
11 Blake-Toker AM, Hawkins L, Nadalo L, et al. CT guided percutaneous fixation of sacroiliac fractures in trauma patients. J Trauma ,2001,51:1117-21.
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