中国修复重建外科杂志

中国修复重建外科杂志

3D 打印技术辅助不稳定性骨盆骨折手术的疗效分析

查看全文

目的评估 3D 打印技术辅助不稳定性骨盆骨折内固定手术的临床疗效。方法回顾分析 2015 年 3 月—2017 年 12 月收治的符合选择标准的 28 例不稳定性骨盆骨折患者临床资料。根据手术方式不同将患者分为两组,对照组 18 例应用传统前、后环切开复位钢板内固定;观察组 10 例应用 3D 打印技术制作骨盆模型辅助前环皮下钢板塑形,设计并打印骶髂螺钉导航模板辅助后环骶髂螺钉固定。两组患者性别构成、年龄、致伤原因、骨折分型、受伤至手术时间等一般资料比较差异均无统计学意义(P>0.05),具有可比性。记录并比较两组患者手术时间、术中出血量、术中透视次数、切口总长度、负重锻炼等待时间、骨折愈合时间,末次随访时采用 Majeed 评分评价功能。术后即刻根据 Matta 影像学评分标准评价复位情况,并评价观察组骶髂关节螺钉植钉成功情况,以及比较观察组术后即刻实际植入螺钉的进钉点和进钉方向与术前模拟植钉距离和角度的偏差。结果两组患者均顺利完成手术,术后均获随访,随访时间 6~18 个月,平均 14.4 个月。对照组发生伤口感染 1 例,下肢深静脉血栓形成 2 例;两组其余患者均未发生重要血管神经损伤、肺栓塞等较严重并发症,也未发生螺钉退出、钢板断裂等内固定物相关并发症。对照组手术时间、术中出血量、术中透视次数、切口总长度及负重锻炼等待时间均显著大于观察组(P<0.05);两组骨折愈合时间比较差异无统计学意义(t=0.12,P=0.90)。术后即刻两组骨折复位质量比较差异无统计学意义(Z=–1.05,P=0.30);末次随访时采用 Majeed 评分评价功能,观察组显著优于对照组(Z=–2.42,P=0.02)。术后即刻观察组植钉成功率均达 Ⅰ 类。观察组术后即刻实际植入螺钉与术前模拟植钉的钉道方向角度偏移量为(0.09±0.22)°,进钉点在 X、Y、Z 轴上的偏差值分别为(0.13±0.63)、(0.14±0.58)、(0.15±0.53)mm,与术前(各值均为 0)比较差异均无统计学意义(P>0.05)。结论计算机辅助设计结合 3D 打印技术制作的个性化骨盆模型及手术导航模板应用于不稳定性骨盆骨折手术,有助于骶髂螺钉的精确植入,减少手术时间、术中出血量和透视次数,有较好的术后功能,是不稳定性骨盆骨折的可选手术治疗方式。

ObjectiveTo evaluate the effectiveness of three-dimensional (3D) printing assisted internal fixation for unstable pelvic fractures.MethodsThe clinical data of 28 patients with unstable pelvic fractures admitted between March 2015 and December 2017 were retrospectively analyzed. The patients were divided into two groups according to different surgical methods. Eighteen cases in the control group were treated with traditional anterior and posterior open reduction and internal fixation with plate; 10 cases in the observation group were treated with 3D printing technology to make pelvic models and assist in shaping the subcutaneous steel plates of the anterior ring. Sacroiliac screw navigation template was designed and printed to assist posterior ring sacroiliac screw fixation. There was no significant difference between the two groups in gender composition, age, cause of injury, fracture type, and time interval from injury to surgery (P>0.05). The operation time, intraoperative blood loss, intraoperative fluoroscopy times, incision length, waiting time for weight-bearing exercise, and fracture healing time were recorded and compared between the two groups. Majeed score was used to evaluate the function at last follow-up. At immediate after operation, the reduction was evaluated according to Matta imaging scoring criteria, and the success of sacroiliac joint screw implantation in the observation group was evaluated. The deviation of screw entry point and direction between postoperative screws and preoperative simulated screws were compared in the observation group.ResultsAll the operation was successfully completed, and all patients were followed up 6-18 months (mean, 14.4 months). In the control group, 1 case had wound infection and 2 cases had deep vein thrombosis. No serious complication such as important blood vessels, and nerve injury and pulmonary embolism occurred in other patients in the two groups. No screw pulling out or steel plate breaking occurred. The operation time, intraoperative blood loss, fluoroscopy times, incision length, and waiting time for weight-bearing exercise of the control group were significantly longer than those of the observation group (P<0.05); there was no significant difference in fracture healing time between the two groups (t=0.12, P=0.90). There was no significant difference in reduction quality between the two groups at immediate after operation (Z=–1.05, P=0.30); using Majeed score to evaluate the function, the observation group was significantly better than the control group at last follow-up (Z=–2.42, P=0.02). The success rate of sacroiliac joint screw implantation in the observation group reached category Ⅰ. In the observation group, the deviation angle of the direction of the screw path between the postoperative screw and the preoperative simulated screw implant was (0.09±0.22)°, and the deviation values of the entry points on the X, Y, and Z axes were (0.13±0.63), (0.14±0.58), (0.15±0.53) mm, respectively. There was no significant difference when compared with those before the operation (all values were 0) (P>0.05).ConclusionComputer design combine with 3D printing technology to make personalized pelvic model and navigation template applied to unstable pelvic fractures, is helpful to accurate placement of sacroiliac screw, reduce the operation time, intraoperative blood loss, and the fluoroscopy times, has good waiting time for weight-bearing exercise and function, and it is an optional surgical treatment for unstable fractures.

关键词: 骨盆骨折; 内固定; 3D 打印技术

Key words: Pelvic fracture; internal fixation; three-dimensional printing technology

登录后 ,请手动点击刷新查看全文内容。 没有账号,
登录后 ,请手动点击刷新查看图表内容。 没有账号,
1. 李山珠, 袁锋, 张世民, 等. 不稳定型骨盆骨折的救治及手术治疗. 中国矫形外科杂志, 2012, 20(6): 485-489.
2. 黄涛, 庞清江, 张前法, 等. 不稳定型骨盆骨折的手术重建. 中国修复重建外科杂志, 2005, 19(7): 554-557.
3. 孙玉强. 微创内固定治疗骨盆损伤新进展. 中华创伤杂志, 2013, 29(8): 736-738.
4. 冯华明, 叶书熙, 杨成亮, 等. 骨盆骨折后环不稳的治疗策略. 创伤外科杂志, 2013, 15(1): 28-31.
5. 邹菁, 武明鑫, 陈敏. MIPPO 技术治疗骨盆前环不稳定型骨折患者的临床观察. 广西医科大学学报, 2016, 33(3): 455-459.
6. 张楠威, 于滨生. 经 S2 骶髂螺钉技术在脊柱骨盆稳定性重建中应用的研究进展. 中国修复重建外科杂志, 2018, 32(6): 764-768.
7. Zeng C, Xiao J, Wu Z, et al. Evaluation of three-dimensional printing for internal fixation of unstable pelvic fracture from minimal invasive para-rectus abdominis approach: a preliminary report. Int J Clin Exp Med, 2015, 8(8): 13039-13044.
8. Mariscalco MW, Yamashita T, Steinmetz MP, et al. Radiation exposure to the surgeon during open lumbar microdiscectomy and minimally invasive microdiscectomy: a prospective, controlled trial. Spine (Phila Pa 1976), 2011, 36(3):255-260.
9. Wong JM, Bewsher S, Yew J, et al. Fluoroscopically assisted computer navigation enables accurate percutaneous screw placement for pelvic and acetabular fracture fixation. Injury, 2015, 46(6): 1064-1068.
10. 王小阵, 汪国栋, 孟乘飞, 等. ISO-C3D导航下经皮骶髂关节螺钉内固定治疗骨盆后环损伤的临床研究. 中国修复重建外科杂志, 2016, 30(11): 1338-1343.
11. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg (Br), 1988, 70(1): 1-12.
12. 项舟, 段鑫, 王洪. 骨盆骨折三轴移位方式及复位原则. 中国修复重建外科杂志, 2017, 31(10): 1153-1160.
13. Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg (Br), 1989, 71(2): 304-306.
14. Matta JM, Tornetta P 3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res, 1996, (329): 129-140.
15. Schep NW, Haverlag R, van Vugt AB. Computer-assisted versus conventional surgery for insertion of 96 cannulated iliosacral screws in patients with postpartum pelvic pain. J Trauma, 2004, 57(6): 1299-1302.
16. 傅维德, 米东, 张旭, 等. 骨盆骨折患者死亡相关危险因素分析. 实用骨科杂志, 2018, 24(11): 979-981, 990.
17. 刘树平, 周庆, 刘跃洪, 等. Colorado 2TM 骶髂板治疗 Tile C 型骨盆骨折中骶髂关节骨折脱位的临床研究. 中国修复重建外科杂志, 2011, 25(12): 1426-1429.
18. 陈明, 韩智敏, 李志云, 等. 微创经皮钢板内固定术重建骨盆前环的近期疗效. 中国修复重建外科杂志, 2014, 28(9): 1082-1085.
19. 陈华, 齐红哲, 王彬彬, 等. 机器人体外通道螺钉定位系统联合骨盆随意外架辅助复位微创治疗复杂骨盆骨折一例. 中国修复重建外科杂志, 2016, 30(7): 915-917.
20. 谭振, 方跃, 张晖, 等. 计算机导航辅助下经皮骶髂螺钉与骶髂关节前路钢板内固定治疗骨盆 Tile C1 型骨折疗效对比分析. 四川大学学报 (医学版), 2017, 48(5): 668-672.
21. 穆卫庐, 常军英, 贾东昭, 等. 3D 打印手术导板引导骶髂螺钉置入的手术技术介绍. 中华骨科杂志, 2015, 35(7): 767-773.
22. 阳宏奇, 雷青, 蔡立宏, 等. 3D 打印导板辅助空心螺钉内固定治疗不稳定性骨盆骨折. 中国修复重建外科杂志, 2018, 32(2): 145-151.