Internal fixation with different implants for the treatment of old pelvic fractures

doi:10.3969/j.issn.2095-4344.2013.09.027

Abstract

Abstract:

BACKGROUND: The treatment not in time after pelvic fracture is the main reason for old pelvic fracture malunion which with higher morbidity.
OBJECTIVE: To explore the effect of different implants internal fixation on old pelvic fracture malunion.
METHODS: Nine patients with old pelvic fracture malunion were selected from the Department of Orthopedics, General Hospital of Chinese PLA between January 2008 and January 2011; the nine patients were treated with internal fixation at 87-165 days after injury, averaged 116.7 days. The pelvic rotational deformity of nine patients was more than 30°. Pre-treatment walking persistent pain occurred in five patients, two patients had serious pain and could not walk, mild intermittent pain in two patients. Four patients had lower limbs discrepancy, and the average ipsilateral shortening was 2.25 cm. The treatment was performed when the iliac artery completely temporary blocked by balloon catheter with expanded ilioinguinal approach. For the treatment of posterior pelvic ring deformity, five patients received iliac osteotomy, one patient received outer edge sacrum osteotomy (in 1.5 cm) and three patients received sacroiliac joint incision flip and fusion.
RESULTS AND CONCLUSION: All the nine patients were followed-up for 12-48 months after implants internal fixation, and the average follow-up time was 24.8 months. The fracture healing time was 16-24 weeks, and the average healing time was 20.6 weeks. No sciatic nerve stretch injury occurred after treatment. According to the evaluation criteria reported by Mears DC after treatment, anatomic reduction was in six patients (6/9, 67%), satisfactory reduction in three patients (3/9, 33%). The follow-up of the nine patients showed that implants internal fracture combined with osteotomy for the treatment of old pelvic fracture through expanded ilioinguinal approach can effectively correct the deformity and reconstruct the pelvic stability.

Key words: bone and joint implants, academic discussion of bone and joint, pelvis, fracture, malunion, internal fixation, osteotomy, pain, sciatic nerve, deep vein thrombosis, lower limb discrepancy, the National Natural Science Foundation of China, photographs-containing paper of bone and joint implants

CLC Number:

R318

Zhang Li-cheng, Lan Xia, Zhang Li-hai, Tao Sheng, Zhang Qun, Liang Xiang-dang, Guo Yi-zhu, Tang Pei-fu. Internal fixation with different implants for the treatment of old pelvic fractures[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(9): 1703-1710.

Figures/Tables 6

2.4 治疗方法 9例患者内固定治疗均在球囊导管临时完全阻断髂总动脉下进行。治疗前先在数字减影血管造影机监控下行患侧髂总动脉造影，采用Seldinger技术行健侧股动脉穿刺，于患侧髂总动脉分叉处的近端安置双腔球囊导管，在开始行骨盆截骨操作时，准确地在预定部位充盈球囊，实施患侧髂总动脉阻断。治疗路径采用扩大的髂腹股沟入路。治疗过程主要包括：①截骨：首先显露骨盆前环，矫正前环畸形。9例患者中，8例患者耻骨上支骨折已畸形愈合，1例断端可见大量纤维骨痂形成。在原位截骨后，用髓核钳小心清除关节间隙的瘢痕组织，松解周围挛缩的软组织，用Cobb骨膜剥离器撬松关节后予纱布填塞，暂不固定，再显露骨盆后环，截骨复位固定后再固定前环。骨盆后环畸形的处理包括经髂骨截骨5例，骶骨外缘(1.5 cm内)截骨1例，骶髂关节切开3例。②复位：根据骨折和脱位的情况，通过患侧下肢牵引、复位钳提拉半骨盆、旋转耻骨联合及耻骨上支等使骨折获得复位。当骨折复位困难时，使用外固定支架等协助复位。在操作过程中，要注意保护坐骨神经，以免复位时过度牵拉。③内固定：耻骨联合、髂骨翼骨折均采用重建钢板固定5例，骶髂关节骨折和脱位采用重建钢板固定3例，合并骶骨骨折的骶髂复合体损伤采用重建钢板联合经皮骶髂空心拉力螺钉固定1例。④植骨：畸形矫正后，截骨断端会残留间隙，9例患者均于骨盆后环截骨处填充植骨，耻骨联合间植骨3例，骶髂关节切开翻转植骨融合3例。其中应用自体骨6例，同种异体骨2例，重组人骨形成蛋白复合骨替代材料1例。术后于髂窝和方形区以及耻骨后间隙放置两三根引流管，平卧，股动脉穿刺部位压迫24 h。术后第1天开始主动背伸和跖屈踝关节，股四头肌主动等长收缩，促进下肢静脉血液回流，预防深静脉血栓。术后两三天24 h切口引流量少于50 mL即可拔出引流管，常规行双下肢以及髂总动脉血管超声检查，排除髂总动脉和深静脉血栓形成。所有患者均于术后4周、12周、24周、1年进行临床和放射学随访评估。 2.5 治疗结果一般情况：手术时间为210-367 min，平均 290 min。球囊阻断持续时间45-90 min，平均 65 min。术中出血量700-2 800 mL，平均1 833 mL。切口引流量170-460 mL，平均260 mL，手术切口均甲级愈合。随访效果：全部患者均获得随访12-48个月，平均随访24.8个月。骨折愈合：骨折愈合时间为16-24周，平均20.6周，所有骨折都牢固愈合，无移位以及内固定的松动及断裂。并发症：9例患者术后均未发生迟发性神经损伤，均未发生髂总动脉、下肢深静脉血栓形成以及肢体远端缺血性坏死。内固定治疗后临床症状评估：治疗前行走时持续性疼痛5例，治疗后4例(4/5，80%)没有疼痛，1例(1/5，20%)残留轻度间歇疼痛，不需服用镇痛药物。治疗前严重疼痛不能行走的2例残留间歇疼痛，其中1例需服用镇痛药物。治疗前轻度间歇疼痛的2例，治疗后均没有疼痛。治疗前不能行走4例，治疗后2例(2/4，50%)正常行走，1例(1/4，25%)轻度跛行，无需扶拐，1例(1/4，25%)因坐骨神经嵌压时间长，损伤重，腓总神经麻痹部分恢复，遗留踝关节僵硬，足跟不能着地，步态异常。治疗前扶拐有限行走5例，治疗后2例(2/5，40%)正常行走，1例(1/5，20%)轻度跛行，无需扶拐，1例(1/5，20%)因合并粗隆间骨折，遗留髋关节僵硬，跛行但无需扶拐，1例(1/5，20%)因股骨髁间粉碎骨折，遗留膝关节部分僵硬，轻度跛行但无需扶拐。坐姿不平衡4例中3例完全矫正，1例残存轻度坐姿不平衡。因骨盆旋转畸形引起严重平卧困难的3例于术后均明显矫正。双下肢不等长4例矫正满意。内固定治疗后影像学评估：治疗后拍摄标准前后位骨盆平片、入口和出口位片，根据Mears DC[11]报道的标准，骨盆畸形矫正的程度分为：①解剖复位。在标准前后位骨盆平片、入口和出口位片上均无残存移位。②复位满意。骨折垂直或向后移位的残存畸形小于1 cm，或在任何平面的旋转畸形角度小于15°。③复位不满意。骨折垂直或向后移位的残存畸形大于1 cm，或在任何平面的旋转畸形角度大于15°。文章研究9例患者中6例C1型骨折(6/9，67%)解剖复位，2例C2.1型骨折(2/9，22%)和1例C1.3型骨折(1/9，11%)复位满意。典型病例见图3和图4。"

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