髂骨钉棒固定治疗单侧不稳定性DenisⅠ、Ⅱ区骶骨骨折

Posterior iliac screw rod for the treatment of unilateral unstable Denis Ⅰ and Ⅱ sacral fractures

目的探讨后路髂骨钉棒固定治疗单侧不稳定性DenisⅠ、Ⅱ区骶骨骨折的临床疗效。方法回顾性分析2016年3月至2018年10月治疗50例单侧不稳定性DenisⅠ、Ⅱ区骶骨骨折患者资料。根据置钉及固定方式分为髂骨钉棒固定组(简称髂骨钉棒组)和机器人辅助骶髂螺钉置入组(简称骶髂螺钉组),其中髂骨钉棒组20例,男13例,女7例,年龄(41.10±14.07)岁(范围,22~76岁);骶骨骨折Denis分型,Ⅰ型5例,Ⅱ型15例;均合并骨盆前环损伤,骨盆Tile分型,B1型2例,B2型12例,C1型6例;3例合并骶神经损伤,Gibbons分级Ⅱ级。骶髂螺钉组30例,男18例,女12例;年龄(44.70±13.35)岁(范围,16~78岁);骶骨骨折Denis分型,Ⅰ型6例,Ⅱ型24例;均合并骨盆前环损伤,骨盆Tile分型,B1型2例,B2型20例,C1型8例;4例合并骶神经损伤,Gibbons分级,3例Ⅱ级,1例Ⅲ级。两组患者年龄、手术时间、术中出血量、透视次数、Majeed评分比较采用独立样本t检验;骨折复位质量比较采用卡方检验;骶神经损伤恢复Gibbons分级比较采用秩和检验。结果两组患者均获得随访,随访时间22.8个月(范围,12~40个月)。髂骨钉棒组手术时间(41.40±7.30)min;术中出血(105.00±61.94)ml;术中透视(19.10±7.33)次;根据Mears和Velyvis影像学评价标准,9例解剖复位,10例复位满意,1例复位不满意;Majeed评分(84.25±8.29)分;术前3例GibbonsⅡ级骶神经损伤,术后2例恢复为Ⅰ级。骶髂螺钉组手术时间(18.27±5.89)min;术中出血(33.00±17.54)ml;术中透视(14.93±4.49)次;术后15例解剖复位,13例复位满意,2例复位不满意;Majeed评分(86.43±7.43)分;术前3例GibbonsⅡ级骶神经损伤,其中2例术后恢复为Ⅰ级,术前1例Ⅲ级损伤,术后恢复为Ⅱ级。与骶髂螺钉组比较,髂骨钉棒组手术时间长(t=-12.36,P<0.001)、出血量多(t=-6.04,P<0.001)、透视次数多(t=-2.50,P=0.016),以上各指标比较差异均有统计学意义。术后髂骨钉棒组与骶髂螺钉组在骨折复位质量(χ^2=0.23,P=0.89)、Majeed评分(t=0.97,P=0.34)、Gibbons分级(Z=-0.224,P=0.82)比较,差异均无统计学意义。术后髂骨钉棒组1例发生单侧伤口表浅感染,1例诉钉尾部不适;骶髂螺钉组1例发生S1神经损伤。结论对于单侧不稳定性DenisⅠ、Ⅱ区骶骨骨折且不适合使用骶髂螺钉固定者,采用后路髂骨钉棒固定操作简单,术后疗效满意,与使用机器人辅助骶髂螺钉固定相似。

Objective To explore the efficacy of posterior iliac screw rod for unilateral unstable Denis Ⅰ and Ⅱ sacral fractures.Methods Data of 50 patients with unilateral unstable Denis Ⅰ,Ⅱ sacral fractures treated from March 2016 to October 2018 were retrospectively analyzed.According to fixation methods,the patients were divided into posterior iliac screw rod group(Iliac screw rod group)and robot-assisted iliosacral screw group(Iliosacral screw group).There were 20 patients in the Iliac screw rod group,13 males and 7 females,with an average age of 41.10±14.07 years(range,22-76 years),and there were 5 cases of Denis type Ⅰ and 15 cases of type Ⅱ sacral fractures.All of them had anterior pelvic ring injuries,and according to pelvic Tile classification,there were 2 B1 type,12 B2 type,6 C1 type,and 3 cases of Gibbons grade Ⅱ sacral nerve injuries.There were 30 patients in the Iliosacral screw group,18 males and 12 females,with an average age of 44.70±13.35 years(range,16-78 years),and there were 6 cases of type Ⅰ and 24 cases oftype Ⅱ sacral fractures.There were 2 cases of type B1,20 cases of B2,8 cases of C1 pelvic fractures,4 cases combined with sacral nerve injuries including 3 cases of Gibbons grade Ⅱ and 1 case of grade Ⅲ.The patients’age,operation time,amount of bleeding,times of fluoroscopy,postoperative Majeed score were compared by the independent t test.The quality of fracture reduction was compared by Chi-square test,and the postoperative Gibbons grade was compared by the rank sum test.Results All patients were followed up for 22.8 months(range,12-40 months).In the Iliac screw rod group,the operation time was 41.40±7.30 min,intraoperative blood loss 105.00±61.94 ml,intraoperative times of fluoroscopy 19.10±7.33,and according to Mears and Velyvis valuation criterion,there were 9 cases of anatomical reduction,10 cases of satisfactory reduction,and 1 case of unsatisfactory reduction,with the Majeed score of 84.25±8.29.There were 3 cases with Gibbons grade II sacral nerve injury,and 2 of them recovered to grade I.In the Iliosacral screw group,the operation time was 18.27±5.89 min,intraoperative blood loss 33.00±17.54 ml,intraoperative times of fluoroscopy 14.93±4.49,and according to Mears and Velyvis valuation criterion,there were 15 cases of anatomical reduction,13 cases of satisfactory reduction and 2 cases of unsatisfactory reduction,with the Majeed score of 86.43±7.43.There were 3 cases with Gibbons grade Ⅱ sacral nerve injury,and 2 of them recovered to grade Ⅰ,and 1 case with grade Ⅲ recovered to grade II postoperation.Compared to Iliosacral screw group,the Iliac screw rod group has longer operation time(t=-12.36,P<0.001),more blood loss(t=-6.04,P<0.001)and more intraoperative times of fluoroscopy(t=-2.50,P=0.016).There were no statistical differences for quality of fracture reduction(χ^2=0.23,P=0.89),Majeed score(t=0.97,P=0.34),and the Gibbons grade(Z=-0.224,P=0.82)between the two groups.In the Iliac screw rod group,1 patient had a unilateral superficial wound infection and 1 patient complained of discomfort because of the nail.In the Iliosacral screw group 1 patient had iatrogenic S1 neurological injury.Conclusion For the unstable sacral fractures,who are not suitable for iliosacral screw fixation,posterior iliac screw rod fixation is an effective alternative with similar clinical effect as robot assisted iliosacral screw fixation.