Chinese Journal of Tissue Engineering Research ›› 2020, Vol. 24 ›› Issue (12): 1957-1961.doi: 10.3969/j.issn.2095-4344.2518
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Wang Haonan1, Wen Shuzheng2, Wang Jihong2, Hao Zengtao2, Fan Dongsheng2, Jing Shangfei2, Han Chaoqian2, Wang Yongfei2, Wang Xiaolong2, Yin Chao2, Jiang Dong2
Received:
2019-07-27
Revised:
2019-07-31
Accepted:
2019-10-15
Online:
2020-04-28
Published:
2020-03-03
Contact:
Wen Shuzheng, Professor, Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010030, Inner Mongolia Autonomous Region, China
About author:
Wang Haonan, Inner Mongolia Medical University, Hohhot 010030, Inner Mongolia Autonomous Region, China
CLC Number:
Wang Haonan, Wen Shuzheng, Wang Jihong, Hao Zengtao, Fan Dongsheng, Jing Shangfei, Han Chaoqian, Wang Yongfei, Wang Xiaolong, Yin Chao, Jiang Dong. Research and development of fluoroscopy for the detection of dorsal screw penetration in the fixation of distal radius fracture with volar locking plate[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(12): 1957-1961.
2.1 标准正、侧位方法 正位透视采用后前位;侧位透视采用纯侧位,即第三掌骨的长轴与桡骨远端的长轴共轴平行,此时豌豆骨叠加于舟骨远极。 2.2 腕管位透视法 MARSLAND等[18]描述了一种腕关节在完全背屈下进行透视的方法,并称之为腕管位透视。在其报道的42例患者中,与标准侧位透视图像相比,腕管位透视可以更准确地评估螺钉穿出长度,从而使术中螺钉更换率达到17%(7/42)。事实上术中进行背侧螺钉穿出长度的精确测量是非常困难的[19]。MARSLAND等[18]进行的试验表明,对于穿出长度>2 mm的螺钉,腕管位透视方法能够有效发现其是否穿出背侧骨皮质。 遗憾的是这种透视方法往往需要多次调整患肢位置及术中透视角度才能取得满意的图像,这不仅增加了手术时间,同时也增加了医护人员放射线暴露的机会。因此,作者认为这种方法对于这一类型骨折患者有一定的帮助,但是也为患者及医护人员带来一些健康问题。 2.3 改良腕管位透视法 刘涛等[20]在最近的一项临床试验中应用了改良腕管位透视法来检测桡骨远端骨折时掌侧锁定钢板内固定后背侧螺钉穿出长度,见图2。试验结果表明,标准正、侧位透视发现5例患者螺钉穿出背侧皮质(10.4%,5/48),改良腕管位透视法发现包括上述5例在内的16例患者螺钉穿出背侧皮质(33.3%,16/48),2种透视方法检出率的差异有显著性意义;另外有2例患者螺钉进入下尺桡关节,且仅在改良腕管位透视法中发现。刘涛等[20]认为与标准正、侧位透视方法相比较,改良腕管位透视法能可靠的探测到螺钉的背侧皮质穿出,并能对下尺桡关节提供良好的术中透视,从而尽可能减少背侧穿出螺钉过长导致背侧肌腱的激惹、磨损及断裂等的发生概率[20]。 "
但是这种方法对于螺钉穿出桡骨远端背侧骨皮质<2 mm的螺钉的检出率仍效果不佳,因此作者认为该方法对于将螺钉穿出长度控制在<2 mm方面有一定的作用,但是尚不能非常有效的将螺钉长度完全控制在背侧骨皮质内。 2.5 天际线透视法 PICHLER等[22]最近描述了一种术中检测背侧皮质穿出长度的方法,并称为天际线透视图像。在试验中通过对30个标本的前臂进行三维计算后,进行扫描矢状面CT切片检测到Lister结节的最高峰值。为了量化最高峰值,其在垂直于轴的方向上测量结节尖端和桡骨掌侧表面之间的距离。事实证明,Lister结节的存在和变异会引起术中X射线透视的差异。 RIDDICK等[23]在最近的一项研究中证实检测螺钉是否穿出背侧皮质时,天际线透视比标准侧位更灵敏和准确,见图4。RIDDICK等[23]文献报道中表明,天际线视图在探测到仅1 mm长的背侧皮质螺钉时的灵敏度为83%。因此,如果螺钉较长,则其灵敏度可能更高。同时他们发现,使用天际线透视检测放置在桡骨远端尺侧的螺钉是否穿出骨皮质时,灵敏度高达90%。而标准侧位显示放置到尺侧区域螺钉的穿透性,其敏感性为75%[19]。 "
尽管SOONG等[24]的研究结果表明,桡骨远端骨折时掌侧锁定钢板内固定后背侧伸肌腱的激惹、磨损及断裂等是现代掌侧钢板治疗时不常见的并发症。但是如果发生,将会严重影响患者的腕部功能,同时为患者的生活及经济等方面带来一定的困扰。因此,在桡骨远端骨折掌侧钢板内固定过程中,天际线透视应作为检测背侧皮质螺钉穿出的一种方法[22]。 2.6 背侧切线视图法 HAUG等[25]报道了一项关于背侧切线透视方法的实验,见图5。实验中采用6具尸体的前臂,进行掌侧锁定钢板内固定后,使用背侧切线透视方法图像采集,同时在直视下观测背侧螺钉是否穿出并测量穿出螺钉的长度。结果表明,直视下测量的实际背侧螺钉穿出长度与背侧切线透视图像中测量的螺钉长度之间具有统计学意义的相关性。对于穿透背侧骨皮质2 mm的螺钉,两者相关性的统计显著性显示为肘部半径从5°-20°的倾斜角度。在倾斜度为15°时发现了最高的相关性,并且检测到除了1个螺钉以外的所有螺钉都太长。 "
在掌侧锁定钢板内固定过程中,从背侧应用背侧切线透视方法检测桡骨远端螺钉时,可以使螺钉穿出背侧骨皮质的长度最小。HAUG等[25]得出的结论:理想的肘关节弯曲半径倾角为15°,可以获得最好的透视图像,有助于预防腕背侧伸肌腱激惹、磨损及断裂等并发症的发生。但作者发现该研究是基于尸体标本,还需要进一步的临床研究来验证这种放射技术的可行性。而且在临床实践中,准确地确定15°倾角是一个难题。 JOSEPH等[26]近期进行了一项临床试验,对15例桡骨远端骨折患者使用掌侧锁定钢板进行骨折固定,在手术中通过使用背侧切线透视作为最后检查背侧皮质螺钉突出的长度。为了获得背侧视野,手腕过度弯曲,透视装置的光束沿桡骨纵轴方向移动。术中通过该透视方法有4例患者共有4枚螺钉穿出,并在术中进行更换。被发现的4枚螺钉平均突出长度为2.25 mm,且仅在该透视图像上被发现。JOSEPH等[26]认为背侧切线透视方法提供了确定桡骨远端骨折掌侧锁定钢板内固定中确定螺钉穿出背侧皮质的新方法。因此在桡骨远端骨折时进行骨内固定时,利用背侧切线透视是一种有效的辅助手段,可预防螺钉穿出于背侧皮质之外。OZER等[27]在最近的一项报道中也证实了背侧切线视图是一种能够提高透视诊断准确率的简单方法。 作者认为,由于JOSEPH等[26]在临床试验中不能对15例患者的桡骨远端背侧进行直视下观测,所以在这组患者中,螺钉穿出的真实发生率可能更高。同时作者也发现该报道中未指出腕关节屈曲角度,因此在临床实践中可能需要手术医师多次调整腕关节才能获得较为可靠的图像,这同样增加了医护人员放射线暴露的机会。 2.7 径向凹槽视图法 LEE等[28]在最近的文献报道中提出了一种新的术中透视方法,他们将其命名为“径向凹槽视图”,见图6。文献报道中指出,LEE等[28]使用径向凹槽视图法在93例骨折患者中检测到13例(14%)腕背侧螺钉突出到凹槽中。在术中更换较短的螺钉后,未发现螺钉在X射线片上突出。统计学评估得出术中使用径向沟槽视图在桡骨远端骨折的掌侧锁定钢板内固定治疗后检测拇长伸肌腱沟槽中的突出螺钉的灵敏度为92.8%(95%CI:91.3-98.4),因此他们建议术中使用该透视技术,避免桡骨远端骨折时掌侧锁定钢板内固定后螺钉穿出背侧骨皮质,预防腕背侧伸肌腱的激惹、磨损及断裂等并发症的发生。 "
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