陈旧性骨盆桶柄样Tilt骨折的手术治疗

Deformities correction of old bucket handle and tilt fractures of pelvis

目的探讨陈旧性骨盆桶柄样Tilt骨折的临床特征和治疗方法。方法自1998年10月～2002年10月,共收治6例由侧方挤压暴力所致的陈旧性TileB2型骨盆桶柄样Tilt骨折,伤后至手术时间为2～15个月,平均6.5个月。术前损伤骨盆的桶柄侧内旋畸形均大于30°,下肢短缩2～3.5cm,平均2.5cm;骨盆前环Tilt畸形的骨折近端均向后下方旋转移位,耻骨联合陷入会阴。所有患者均采用髂腹股沟入路行手术治疗,耻骨上支畸形均沿骨折处原位截骨;骨盆后环畸形经髂骨截骨3例,骶骨外缘截骨1例,骶髂关节切开翻转并植骨融合2例。术中使用重建钢板固定3例,重建钢板联合拉力螺钉固定1例,重建钢板辅以支架固定2例。结果术后随访3～45个月,平均15.6个月。骨折愈合,肢体短缩纠正满意。根据Mears的影像评价标准,本组骨盆解剖复位5例,复位满意1例。根据Majeed的疗效评定标准,优5例,良1例。术后出现迟发性坐骨神经损伤1例,未行特殊处理,6周后症状自行缓解。结论骨盆前后环的联合截骨矫形及手术重建,是提高复位质量、纠正桶柄侧下肢短缩及防治远期并发症的有效方法。

Objective To explore the clinical features and outcomes of defo rm ities correction of old bucket handle and tilt fractures of pelvis. Methods From October 1998 to October 2002, six patients treated with open reduction, osteoto my and internal fixation for old bucket handle and tilt fractures of pelvis were analyzed. There were 3 males and 3 females aging from 18 to 51 years (mean, 27. 5 years). According to Tile’s classification, all fractures were diagnosed as t ype B2 with longitudinal stability and rotational instability, which were caused by traumatic violence of lateral compression, and associated with anterior ring injuries of ipsilateral inferior and superior rami of pubis combined symphysis separation as well as contralateral posterior ring injury of innominate fracture , dislocation of sacraoiliac joint, or sacral fracture. The incidence of associa ted injury was 100% in the patients as injured. The mean interval from the prima ry injury to the operation was an average of 6.5 months ranging from 2 to 15 mon ths. The limb shortening of buckle handle side of pelvis ranged from 2 to 3.5 cm (mean, 2.5 cm), and the rotational deformity of pelvis was more than 30° in al l patients. The tilting proximal fragment of the superior ramus and disrupted sy mphysis projected inferiorly and posteriorly into the perineum. The surgical pro cedures consisted of: 1) osteotomy through the superior pubic ramus malunion in 6 cases to correct anterior ring deformity, and through innominate osteotomy in 3 cases, direct osteotomy of sacral malunion in 1 case , and sacraoiliac fusion in 2 cases to correct the posterior ring deformity; 2) reduction by manipulati on or assisted with instrumentation; 3) fixation with reconstruction plate in 3 , reconstruction plate combined with anterior pelvic frame in 2, and reconstruct ion plate combined with lag screws in 1. Results All the patients were followed up on an average of 15.6 months (range, 3 to 45 months). The limb discrepancy ha d been completely corrected following satisfactory fracture reduction and union. According to Mears’s evaluation, the anatomical reduction of the pelvis was fo und in 5 cases and satisfactory in 1 patient. According to Majeed’s radiography evaluation, 5 patients were classified as excellent, and 1 good. One patient wi th delayed sacral nerve injury recovered without any treatment after operation. Conclusion The combination of osteotomy through anterior and posterior pelvic ri ng to correct the entire deformities in one stage is an useful technique for imp rovement of the affected limb shortening and prevention of the related complicat ions.