髂腰固定治疗Tile C型垂直不稳定骨盆骨折伴复杂骶骨骨折

Lumbopelvic fixation of vertically unstable Tile type C pelvic fractures combined with complex sacral fractures

目的探讨髂腰固定治疗Tile C型垂直不稳定骨盆骨折伴复杂骶骨骨折的临床疗效。方法采用前瞻性研究分析2014年5月— 2015年12月行髂腰固定治疗C型垂直不稳定骨盆骨折伴复杂骶骨骨折患者21例，其中男10例，女11例；年龄14～59岁，平均35.9岁。骨盆骨折根据Tile分型：C1型5例，C2型4例，C3型12例。骶骨骨折根据Denis分型：Ⅰ区5例，Ⅱ区7例，Ⅲ区9例，其中合并神经损伤12例。记录手术时间、术中出血量、骨折愈合时间、术前术后骨盆垂直移位及复位情况。采用Matta评分标准评价复位质量、Majeed评分评价临床疗效，记录并发症发生情况。结果患者均获随访7～26个月[（12.5±5.4）个月]。手术时间64～225 min[（108.0±49.4）min]。术中出血量150～3 000 ml[400（225～500）ml]。骨折愈合时间15～32周[（19.0±4.6）周]。术前骨盆垂直移位2.54～21.80 mm[（8.76±5.46）mm]，术后垂直移位0～12.57mm[（4.20±3.22）mm]（P〈0.05），骨盆垂直移位复位－4.45～17.86 mm[4.09（1.74～5.58）mm]。根据Matta评分标准：优13例，良6例，可2例，差0例，优良率90%。末次随访Majeed评分51～98分，优9例，良9例，可2例，差1例，优良率86%。2例术后出现深部感染，通过清创和敏感抗生素的使用，感染得到控制，骨折愈合后取出内固定。术后螺钉明显松动5例，无内固定断裂。4例因髂后上棘的髂骨螺钉突出而出现骶部异物感或不适。4例腰椎活动度部分受限，主要表现为前屈受限，其中3例已取出内固定，腰椎活动度恢复至正常。结论髂腰固定可重建Tile C型骨盆骨折垂直方向的稳定性，固定确切。术后螺钉松动发生率高，需常规取出内固定。

Objective To evaluate the clinical outcomes of lumbopelvic fixation of vertically unstable Tile type C pelvic fractures combined with complex sacral fractures. Methods A prospective study was made on 21 cases of vertically unstable type C pelvic fractures combined with complex sacral fractures admitted between May 2014 and December 2015. There were 10 males and 11 females, with a mean age of 35.9 years （range, 14-59 years）. Tile classification of pelvic fractures was type C1 in five cases, type C2 in four and type C3 in 12. Denis classification of sacral fractures was zone Ⅰ in five cases, zone Ⅱ in seven and zone Ⅲ in nine. Twelve cases had neurological deficits. Operation time, intraoperative blood loss, bone healing time, pelvis vertical displacement and postoperative complications were recorded. Vertical displacement and functional outcome were assessed by Matta method and Majeed score respectively. Results All cases were followed up for （ 12.5 ± 5.4） months （ range, 7-26 months）. Operation time was （108.0 ±49.4） min （range, 64-225 min）. Intraoperative blood loss was 150-3 000 rnl [ 400 （225-500） ml ]. All fractures were healed at （ 19.0 ± 4.6） weeks （ range, 15-32 weeks）. Vertical displacement of the pelvis was （8.76 ± 5.46）mm （2.54-21.80 mm） before operation and （4.20 ± 3.22）mm （0-12.57 mm） after lumbopelvic fixation （P 〈 0.05 ）, showing the reduction distance of -4. 45-17.86 mm [4.09（1.74-5.58）mm]. According to the Matta method, the results were excellent in 13 cases, good in six, and fair in two, with the excellent and good rate of 90%. Majeed score evaluation at last follow-up was 51-98 points and the results were excellent in nine cases, good in nine, fair in two and poor in one, with the excellent and good rate of 86%. Deep infection occurred in two cases who were cured by debridement and antibiotics, and the internal instruments of the two cases were removed after fracture healing. Screw loosening occurred in five cases with no evidence of screw breakage. Four cases complained of foreign body sensation and discomfort in sacral area due to the prominence of the iliac hardware. Four cases had limited range of motion of the lumbar spine, especially in anterior flexion range, and lumbar range of motion was recovered in three of them after removal of the internal fixator. Conclusion Lumbopelvic fixation can restore vertical stability of the pelvis, but removal of the internal fixator is suggested after fracture healing due to the high rate of screw loosening.