三维导航模板辅助儿童肱骨外髁骨折畸形愈合的截骨矫形

Three-dimensiona navigation template assisted osteotomy for fracture malunion of lateral condyle of humerus in children

目的探讨三维导航模板辅助儿童肱骨外髁骨折畸形愈合截骨矫形的有效性和安全性。方法回顾性分析2012年8月至2019年12月南方医科大学第三附属医院收治的18例儿童肱骨外髁骨折畸形愈合患儿的病历资料。其中12例采用常规手术方案治疗(常规组),即根据CT重建分析畸形位置、术中凭经验截骨治疗;6例采用导航模板辅助截骨矫形治疗(导航模板组),即根据双侧肘关节CT数据建立三维骨骼模型,通过患侧肱骨远端与健侧肱骨远端的镜像进行比较来评估肱骨远端冠状面、矢状面的畸形,从而确定最佳截骨平面及复位的目标位置,在计算机上进行术前模拟,设计截骨导航模板及复位导航模板,用3D打印机打印出导航模板。术中在导航模板辅助下截骨矫形,空心螺钉固定截骨断端,屈曲80°石膏固定。2组术后定期复查X线片。观察2组术中出血量、手术时间、术后并发症发生率(肱骨小头及滑车坏死、迟发性尺神经麻痹、骨不愈合)、术后肘关节屈伸功能恢复情况。结果所有患儿肘关节活动基本恢复正常,截骨矫形部位均获得骨性愈合,矫形效果满意。18例均获得随访,随访6~24个月,平均15个月。术后Dhillon评分,导航模板组:优1例,良5例;常规组:良11例,一般1例,2组比较差异无统计学意义(P>0.05)。2组术后肘关节活动度比较差异无统计学意义(P>0.05)。导航模板组手术时间[(200.0±24.2)min]、术中出血量[(85.0±10.9)mL]优于常规组[(232.0±20.1)min,(139.1±18.3)mL],差异均有统计学意义(均P<0.001)。结论应用肱骨三维重建、镜像对比评估患侧肱骨远端畸形,设计截骨及复位导航模板辅助手术,可以最大程度地恢复肘关节正常解剖结构,精准矫形,术后肘关节功能恢复良好,优化了手术程序,提高了手术的安全性和有效性。

Objective To investigate the efficacy and safety of three-dimensional navigation template assisted osteotomy for fracture malunion of lateral condyle of humerus in children.Methods Eighteen children with ma-lunion of fracture of lateral condyle of humerus were treated in Southern Medical University Third Affiliated Hospital from August 2012 to December 2019 and analyzed retrospectively.Among them,12 cases were treated with routine ope-ration:according to CT reconstruction and empirical osteotomy during the operation,the location of deformity was analyzed.Six cases were treated with navigation template assisted osteotomy:according to the CT data of bilateral elbow joints,a three-dimensional bone model was established,and the coronal and sagittal deformities of the distal humerus were evaluated by comparing the images of the distal humerus of the affected side with the distal humerus of the healthy side,so as to determine the best plane of osteotomy and the target position of reduction.The preoperative simulation was carried out on the computer,and the osteotomy navigation template and reduction navigation template were designed.The navigation template was printed out with a 3D printer.During the operation,the osteotomy was corrected with the assistance of navigation template,and the broken end of osteotomy was fixed with hollow screw and fixed with 80 degree flexion plaster.The X-ray films of the two groups were reexamined regularly after operation.The amount of intraoperative blood loss,operation time,incidence of postoperative complications(necrosis of humeral head and trochlea,delayed ulnar nerve paralysis,and bone nonunion)and the recovery of flexion and the extension function of elbow joint were observed in the 2 groups.Results The elbow joint activity of all children basically returned to normal,the orthopedic site of osteotomy achieved bony healing,and the orthopedic effects were satisfactory.All the 18 cases were followed up for 6-24 months(mean 15 months).According to the postoperative Dhillon score,the navigation template group was excellent in 1 case and better in 5 cases,while in the routine group,11 cases were batter and 1 case was fair.There were no significant differences in Dhillon score between the 2 groups after operation(P>0.05).There were no significant differences in the range of the motion of elbow joint between the 2 groups(P>0.05).In the comparison of operation time and intraoperative blood loss,the navigation template group[(200.0±24.2)min,(85.0±10.9)mL]was better than the routine group[(232.0±20.1)min,(139.1±18.3)mL](all P<0.001).Conclusions The application of three-dimensional humerus reconstruction and mirror image contrast to evaluate the distal humerus deformity of the affected side,and the design of osteotomy and reduction navigation template auxiliary operation can restore the normal anatomical structure of elbow joint to the greatest extent.Accurate correction,and the function of elbow joint recover well after operation,which optimizes the operation procedure,improves the safety and effectiveness of the operation.