钝头弹性敲击技术建立髋臼前柱逆行螺钉通道的应用研究

Hammering reverse guide wire technique for safe placement of anterior column retrograde in-tramedullary screw in pelvic and acetabular surgery

目的探讨应用钝头弹性敲击技术建立髋臼前柱逆行螺钉通道、微创螺钉固定治疗骨盆与髋臼骨折的临床疗效。方法回顾性分析2015年9月至2018年3月期间丽水市中心医院创伤骨科采用微创螺钉固定治疗的46例涉及前环或前柱的骨盆、髋臼骨折患者资料。男28例,女18例;年龄为21~85岁,平均55.6岁。骨盆环骨折34例,髋臼骨折9例,骨盆环合并髋臼骨折3例。术中应用钝头弹性敲击技术建立髋臼前柱逆行螺钉通道。记录患者髋臼前柱螺钉操作手术时间、术中X线透视次数、导针建立螺钉通道的次数、骨折愈合时间、并发症的发生情况及末次随访时患髋功能等。结果46例患者髋臼前柱螺钉操作手术时间平均为28.9min(16~55min),术中X线透视次数平均为16.3次(9~35次)。43例(93.5%)患者的导针一次性通过前柱成功建立通道,3例患者调整导针重新建立通道。40例患者术后获平均15.2个月(6~36个月)随访。1例患者发生内固定物松动、骨折移位,1例患者发生下肢深静脉血栓形成。随访期间无一例患者发生断钉、骨折不愈合、切口感染坏死、血管神经损伤及股骨头缺血性坏死等并发症。40例患者的骨折愈合时间为12~18周,平均14.7周。末次随访时根据Majeed骨盆功能评分系统评定疗效:优29例,良9例,可2例,优良率为95.0%。结论钝头弹性敲击技术建立髋臼前柱逆行螺钉通道可提高螺钉置入的精确度,具有操作简单、实用且安全、可减少术中X线辐射量和手术时间及并发症少等优点。

Objective To evaluate the efficacy and accuracy of hammering reverse guide wire technique for safe placement of anterior column retrograde intramedullary screw in pelvic and acetabular surgery. Methods From September 2015 to March 2018, 46 patients with pelvic or/and acetabular fracture involving the anterior column were treated with hammering reverse guide wire technique for safe placement of anterior column retrograde intramedullary screw at Department of Orthopaedics, Lishui Municipal Central Hospital. They were 28 men and 18 women, aged from 21 to 85 years (mean, 55.6 years). There were 34 pelvic ring fractures, 9 acetabular fractures and 3 combined pelvic ring and acetabular fractures. After the anterior lateral spine of pubic tuberosity was drilled by a guide pin and drill bit as the entry point, a reverse guide wire was knocked into the bone lightly by a hammer. For each retrograde intramedullary screwing into the acetabular anterior column, we recorded operation time, fluoroscopic frequency, and attempts to establish an acceptable screw pathway by the guide pin. The accuracy of screwing and the quality of fracture reduction were evaluated by imaging examination. For each patient, we recorded fracture union time and complications. Functional recovery of the pelvis and acetabulum was assessed by postoperative physical examination at the last follow-ups. Results The operation time of retrograde intramedullary screwing for the 46 patients averaged 28.9 minutes (from 16 to 55 minutes);the fluoroscopy frequency averaged 16.3 times (from 9 to 35 times);an acceptable screw pathway was established by the first attempt in 43 of the 46 patients (93.5%) and re-established after adjustment of the guide pin in the other 3. Forty patients were followed up for an average of 15.2 months(from 6 to 36 months). Postoperative CT scan and three-dimensional reconstruction showed that all the screws had been placed safely and accurately in the acetabular anterior column. Implant loosening and fracture displacement occurred in one case and lower limb thrombosis in another. No nail breakage, fracture nonunion, incision necrosis or infection, neurovascular injury or femoral head necrosis was observed. All fractures united after an average of 14.7 weeks (from 12 to 18 weeks). According to the Majeed scoring at the last follow-ups, the pelvic and acetabular function was evaluated as excellent in 29 cases, as good in 9, and as fair in 2, giving an excellent and good rate of 95.0%. Conclusion Hammering reverse guide wire technique is an effective method for safe placement of anterior column retrograde intramedullary screw in pelvic and acetabular surgery, because it can increase accuracy of screwing and reduce intraoperative radiation, operation time and incidence of complications though it is simple.