3D打印技术辅助不稳定性骨盆骨折手术疗效分析

Effectiveness analysis of three-dimensional printing assisted surgery for unstable pelvic fracture

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。

Objective To evaluate the effectiveness of three-dimensional (3D) printing assisted internal fixation for unstable pelvic fractures.Methods The 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.Results All 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 more than those of the observation group (P<0.05);there was no significant difference in fracture healing time between the two groups (￠=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);Majeed score of the observation group was significantly better than that of 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土 0.53) mm,respectively.There was no significant difference when compared with those before the operation (all values were 0)(P>0.05).Conclusion Computer design combined with 3D printing technology to make personalized pelvic model and navigation template applied to unstable pelvic fractures,is helpful to accurately place sacroiliac screw,reduce the operation time,intraoperative blood loss,and the fluoroscopy times,has good waiting time for weight-bearing exercise and function,and 让 is an optional surgical treatment for unstable fractures.