空心钉经皮微创内固定技术治疗骨盆环损伤的疗效评价

目的：评价经皮微创空心钉固定骨盆环损伤的安全性及可靠性。方法：对48例不稳定骨盆环损伤患者，分别行闭合复位、经皮微创空心钉内固定术。按Tile分型：B1型4例，B2．1型8例，B2．2型10例，B3型4例，C1型11例，C2型7例，C3型4例。39例前后环损伤均固定，4例仅固定前环损伤，5例仅固定后环损伤。以术前骨盆的三位x线片（前后位、入口位及出口位）及CT片判断骨盆的稳定性及移位情况，术后以x线片及CT片评估复位情况及螺钉位置准确性。结果：手术时间15～95min，平均55min。术中出血量15～150ml，平均60ml，术中及术后无输血。48例患者共植入空心钉157枚，每人2～8枚，平均3．3枚。术后行骨盆CT检查42例（共植入135枚空心钉），发现123枚空心钉位置准确，占91．11％；7枚空心钉因偏向或超长而侵入盆腔或髋臼（但均〈0．5em）；5枚位置偏差干扰骶管或骶孔，但均未引起任何症状。随访8～49个月，平均13个月，45例患者骨盆环移位复位满意，所有骨折均Ⅰ期愈合。40例恢复原工作，4例末次随访时尚处康复期，其余4例因坐骨神经损伤或下肢截肢而不再工作。参照Lindahl改良的骨盆损伤后功能评定标准，优35例，良10例，可3例，平均得分78.7分。结论：在对骨盆环及其毗邻血管神经的解剖结构熟练掌握的基础上，结合良好的透视引导，闭合复位经皮微创空心钉内固定治疗不稳定骨盆环损伤安全可行，疗效满意。

Clinical outcome of minimally invasive internal fixation of pelvic ring injuries with cannulated screws

Objective: To evaluate the safety and reliability of percutaneous internal fixation for pelvic ring injuries with cannulated screws. Methods: Forty-eight patients(21 male and 27 female,aged from 17 to 61 years with an average age of 38 years)with unstable pelvic ring injuries were treated with closed reduction and percutaneous cannulated screws fixation under C-arm fluoroscopic guidance. According to Tile's classification,the patients were classified into type B1 in 4 cases,B2.1 in 8, B2.2 in 10,B3 in 4,C1 in11,C2 in 7 and C3 in 4. Among them,39 patients were treated with anterior and posterior fixation,4 were treated with anterior fixation,and 5 were treated with posterior fixation alone. Anteroposterior,inlet and outlet X-ray radiographs and CT scans of the pelvis were taken preoperatively to evaluate the stability and deformities,and after surgery the plain radiographs and CT scans were taken to evaluate the reduction and the location of screws. Results: The average operative time was 55 minutes(range,15 to 95 minutes),and the average intraoperative blood loss was 60 ml(range,15 to 150 ml),no patient accepted blood transfusion during or after operation. All 48 patients were inserted 157 cannulated screws(mean 3.3, range 2 to 8 per patient). Forty-two patients(135 screws) underwent postoperative pelvic CT scan and 91.11% (123 screws) of them was considered in optimal location;7 screws penetrated the wall of pelvis and acetabulam because of overlength(<0.5 cm) or deviation,5 screws interfered with the sacral canal or foramen. Fortunately,these 12 screws did not cause any symptom to the patients. The average follow-up period was 13 months(range,8 to 49 months),the displacement of injured pelvis was satisfactorily corrected in 45 patients(93.75%)and the fractures were healed at one stage. Among all patients,40 cases(83.33%) had returned to their original works, 4 were still in the process of recovery at the last follow-up and the other 4 were unemployed as sciatic nerve injury or amputation. According to Lindahl improved standard of functional assessment of pelvic injury,the result was excellent in 35 cases,good 10 and fair 3,the average score was 78.7. Conclusion: With better understanding of the pelvic anatomy,and under C-arm fluoroscopic guidance, treatment of closed reduction and percutaneous cannulated screw internal fixation for unstable pelvic ring injuries is a safe,reliable and feasible method. The clinical outcome is satisfactory.