Starr复位架联合"O"型臂导航系统治疗骨盆骨折的近期疗效

Preliminary application of Starr reduction framecombined with O-arm navigation systemin the treatment ofcomplex pelvic fractures

目的探讨Starr复位架联合"O"型臂导航系统微创治疗复杂骨盆骨折的近期疗效。方法回顾性分析2017年6月至2018年12月手术治疗32例Tile C型骨盆骨折患者资料。其中17例采用切开复位内固定治疗[切开治疗组,男10例,女7例;年龄24~60岁,平均(37±6.5)岁;骨盆骨折Tile分型,C1型8例,C2型8例,C3型1例;骶骨骨折根据Denis分区:Ⅰ区9例,Ⅱ区6例,Ⅲ区2例],15例采用Starr复位架联合"O"型臂导航系统治疗组[联合治疗组,男8例,女7例;年龄32~57岁,平均(40±5.2)岁;骨盆骨折Tile分型,C1型8例,C2型6例,C3型1例;骶骨骨折Denis分区:Ⅰ区8例,Ⅱ区5例,Ⅲ区2例]。切开治疗组采用髂腹股沟及Stoppa入路,使用重建钢板螺钉、空心螺钉分别固定前、后环损伤。联合治疗组使用Starr架辅助复位后,联合"O"型臂导航技术采用经皮骶髂关节螺钉、耻骨上支螺钉及INFIX内固定架固定前、后环损伤。采用Matta影像学标准评价骨盆骨折复位质量,Majeed评分评价临床疗效。结果32例患者均获得6~12个月的随访。切开治疗组住院时间[(45±11)d]、手术时间[(220.0±49.4)min]、骨折愈合时间[(24.0±5.6)周]均较联合治疗组[(21±9)d、(180.0±24.2)min、(16.1±3.8)周]长,术中出血量[(820.0±140.4)ml]较联合治疗组[(24.0±10.4)ml]多,两组以上各指标比较,差异均有统计学意义(t值分别为6.651、2.772、6.128、22.874;均P<0.05)。根据Matta影像学标准,切开治疗组优8例、良6例、可2例、差1例,优良率82.4%(14/17);联合治疗组优9例、良5例、可1例,优良率93.3%(14/15)。末次随访时Majeed评分,切开治疗组51~85分,其中优8例、良6例、可2例、差1例,优良率82.4%(14/17);联合治疗组75~95分,其中优9例、良5例、可1例,优良率93.3%(14/15)。两组Matta影像学评价和Majeed评分优良率比较差异均有统计学意义(χ2=0.034和0.040;均P<0.05)。术后切开治疗组4例出现切口感染,经清创换药和使用敏感抗生素治疗后术口愈合;并发症发生率23.5%(4/17)。联合治疗组术后2例出现大腿前外侧皮肤感觉减退,经甘露醇、甲钴胺治疗及内固定取出后症状缓解;1例患者术后出现臀大肌血肿,经血管造影发现为INFIX螺钉过长,在坐骨大孔附近穿出,损伤臀上动脉所致,经停用抗凝药、氨甲环酸静滴、输血等治疗后痊愈;并发症发生率20.0%(3/15)。两组并发症发生率比较差异无统计学意义。结论借助Starr复位架可以实现骨盆骨折的早期复位及微创治疗,减少患者术中出血量;联合应用"O"型臂导航技术更能提高术中骶髂关节螺钉、前柱螺钉置入的准确性和安全性,同时降低了术者和患者的辐射剂量和次数,缩短了手术时间,提高疗效。

Objective To investigate the feasibility and short term clinical efficacy of early minimally invasive treatment of complex pelvic trauma with Starr reduction frame combined with O-arm navigation system. Methods From June 2017 to December 2018, thirty two patients with Tile C complex pelvic fractures were prospectively divided into two groups according to the random number table. The open treatment group included 17 cases (open reduction and internal fixation group;10 males and 7 females, age 24-60 years, average 37±6.5 years;according to Tile classification, 8 cases of C1 type, 8 cases of C2 type and 1 case of C3 type;according to the Denis classification of sacral fractures, 9 cases in zone I, 6 cases in zone II and 2 cases in zone III). The combined treatment group included 15 cases (Starr reduction frame group combined with O-arm navigation system, 8 males and 7 females, age 32-57 years, average 40±5.2 years;according to Tile classification, 8 cases of C1 type, 6 cases of C2 type and 1 case of C3 type;according to the Denis classification of sacral fractures, 8 cases in zone I, 5 cases in zone II and 2 cases in zone III). The ilioinguinal and Stoppa approaches were used in the open treatment group, and the anterior and posterior ring injuries were fixed with reconstruction plate screws and hollow screws, respectively. In the combined treatment group, starr frame was used to assist reduction, combined with "O" arm navigation technique, infix internal fixation frame, superior pubic branch screw, sacroilium screw were used to fix the anterior and posterior ring injury. The quality of pelvic fracture reduction was evaluated by the Matta scoring system, and the Majeed score was used to evaluate the clinical efficacy. Results All patients were followed up for 6 to 12 months. The hospitalization time (45±11 d), operation time (220.0±49.4 min) and fracture healing time (24.0±5.6 weeks) in the open treatment group were longer than those in the combined treatment group (21±9 d, 180.0±24.2 min, 16.1±3.8 weeks), and the intraoperative blood loss (820.0±140.4 ml) was significantly higher than that in the combined treatment group (24.0±10.4 ml)(t=6.651, 2.772, 6.128, 22.874;all P< 0.05). According to Matta scoring system, in the open treatment group, there are 8 excellent cases, 6 good cases, 2 fair cases, 1 poor case, thus the excellent and good rate was 82.4%(14/17). While 9 cases were excellent, 5 good, 1 fair, and the excellent and good rate was 93.3%(14/15) in the combined treatment group. At the latest follow-up, Majeed score was 51-85 points in the open treatment group, including excellent in 8 cases, good in 6 cases, fair in 2 cases, poor in 1 case, thus the excellent and good rate 82.4%(14/17), and the Majeed score was 75-95 points in the combined treatment group, including excellent in 9 cases, good in 5 cases, fair in 1 case, thus excellent and good rate 93.3%(14/15). There was a statistically significant difference between the two groups of Matta score and Majeed score (χ2=0.034, 0.040;P< 0.05). Surgical infection occurred in 4 cases in the open treatment group and healed after debridement and treatment with sensitive antibiotics. The incidence of complications was 23.5%(4/17). In the combined treatment group, 2 cases had anterolateral thigh skin sensory loss after operation, and the symptoms were relieved after mannitol, mecobalamine treatment and removal of internal fixations. One patient had hematoma of the gluteus maximus muscle after operation. The result of angiography showed that the INFIX screw was too long and perforated near the foramen of the ischium, resulting from the injury of the superior gluteal artery. After stopping the use of anticoagulant, intravenous infusion of tranexamic acid, blood transfusion, etc., the patient was cured and discharged from hospital. The incidence of complications was 20.0%(3/15). There was no significant difference in the incidence of complications between the two groups. Conclusion With the help of starr reduction frame, the early reduction and minimally invasive treatment of pelvic fracture can be realized, and the amount of intraoperative bleeding can be reduced. The combined application of "o" arm navigation can improve the accuracy and safety of sacroiliac screw and anterior column screw placement, reduce the radiation dose and frequency of operators and patients, shorten the operation time and improve the curative effect.