| With the rapid development of the society and the economy,The incidence of falling injuries,crush injuries and traffic accidents was on the rise,followed by the incidence,the pelvic fractures was also showed an upward trend,and accounting for 1%-3% in the all fractures.The displacement and deformity of pelvic fractures caused by high-energy trauma were often accompanied by the damage of blood vessels,digestive system,urinary system and nervous system.Pelvic fractures lead to high mortality and disability rate because of the complex injury,especially the death caused by bleeding was up to 20%.In view of high mortality and teratogenic rates of the pelvic fractures,Pelvic ring injuries present a therapeutic challenge to the orthopedic surgeon and attracted the attention of orthopedist because of its high research value.The pelvic ring is composed of the pubis,the ischium,the ilium,the sacrum,the coccyx,and connected together by the ligaments.The pubic ramus is the thinnest in the pelvic ring,and most prone to fracture.The study showed that the posterior element was the main bearing structure in pelvic ring,and experts advocated that the treatment of posterior pelvic ring fracture was more important,and the anterior element could be cured by conservative treatment.with the development of the society,more patients choose surgery when their pelvis is fracture because of their high expectations.now experts and scholars have reached a consensus that the fixed pubic ramus fracture did well in reducing the stress levels of the pelvic bone and fixation system and the displacement difference in the pubic symphysis and could change the unstable situation back to a certain extent.While patients can exercise as soon as possible after surgery,significantly reduce the disability and various complications.There are several surgeries to fix anterior ring fracture such as external fixation treatment,internal fixation surgery,and the most popular minimally invasive surgery with the development of imaging,anatomy,orthopedic surgery.There are more and more articles reporting that minimally invasive internal fixation fixed anterior ring fracture,such as minimally invasive percutaneous screw internal fixation,percutaneous plates interal fixation,percutaneous nail-stick system interal fixation.Minimally invasive surgery has the advantage of smaller surgical incision,smaller tissue destruction,less intraoperative risk,better fuction.It has attracted the attention of orthopedist.But the incision fixation surgery is still the most widely used surgical approach,because of the less indications of minimally invasive surgical,such as a wide range of comminuted fractures in anterior ring is not suitable for minimally invasive surgery,but minimally invasive surgery is still in the development stage,I believe that it will become the main method to fixing pelvic fracture as development.The incisions of several minimally invasive surgeries were similar,they all took the pubic tubercle or anterior inferior iliac spine as the center,the main difference is the choice of surgical instruments and surgical approach.The essence of minimally invasive percutaneous screw internal fixation is the pubic internal fixation,which the screw walking in the pubic bone.Percutaneous bridge plate internal fixation and percutaneous fixation all build the approach under the skin.We propose a new minimally invasive approach for the treatment of anterior pelvic ring fracture-parosteal approach in the first part of our study.And it also called minimally invasive parosteal plate internal fixation.We confirmed the feasibility of the approach by using the specimens of human corpse.In the second part we cleared that the effect of minimally invasive parosteal plate internal fixation for the treatment of anterior pelvic fracture by reporting the treatment process of40 patients who suffered from pelvic fracture.Part one Anatomical research of the anterior pelvic ring region and the construction of parosteal pathway Objective: To provide the anatomical dates for the construction of minimally invasive parosteal approach by the anatomical measurement of anterior pelvic ring and adjacent organs,which confirm that the feasibility of minimally invasive parosteal plate internal fixation.Methods: By taking and dissecting 12 human body specimens according to the human anatomy.We would measure the bone markers anatomical parameters of pubic symphysis,pubic branch and ilium.Also measured the anatomical data that the surrounding tissue structure of the pelvic ring such as spermatic cord,uterine round ligament,femoral artery,femoral vein,femoral nerve,death crown and lateral femoral cutaneous nerve.For another,we would measure the distance of pubic nodules on the same side.Then we simulated the construction of parosteal pathway,and observed the feasibility and safety of constructing parosteal pathway.Results: The anatomical research found that the narrowest branch of the pubis was10.137 ± 1.364 mm,the distance between the pubic tubercles was 50.148 ± 4.562 mm,the thickness of upper pubic symphysis was 14.420 ± 1.814 mm,the altitude of pubic symphysis was 42.630 ± 2.024 mm,the thickness of anterior inferior spine12.731 ±0.762 mm,the distance between the pubis tubercle and the anterior inferior spine was12.583 ± 2.031 cm,the distance between the spermatic cord and the pubic tubercle was10.408 ± 1.325 mm,the distance between the uterine round ligament and the pubic tubercle was 9.256 ± 1.085 mm,the distance between the femoral vein and the pubic tubercle was 26.887 ± 2.356 mm,the distance between the femoral artery and the pubic tubercle was 34.233 ± 3.642 mm.Corona Mortis has a high degree of variability,we found the Corona Mortis in only one specimen,the distance between Corona Mortis and pubic tubercle is 44.82 mm.We used vascular clamp to construct the parosteal approach walking under the iliopsoas and pubis muscle,start from the lateral side of the iliopsoas to the pubic tubercle,then Vascular clamp pierced out between the spermatic cord(uterine round ligament)and pubic tubercle,the approach was constructed smoothly and not hurt the important nerve,blood vessels.Conclusion: By the anatomical measurement of the anterior pelvic ring region and the research of the parosteal approach,we found that the surgical approach passes smoothly through the gap under the muscle which under the important nerves and vessels,the surgical approach is feasible and security.Part two Clinical research of minimally invasive parosteal plate internal fixation for the treatment of anterior pelvic ring fracture Objective: To introduce the method and curative effect of minimally invasive parosteal plate osteosynthesis internal fixation in treatment of anterior pelvic ring fractures by reporting 40 patients’ clinical treatment.Methods: Collected the data of 40 patients from September 2014 to June 2016 who experienced the operation,and summarized the operation points,including surgical indications,precautions,prognosis,to evaluate the safety and efficacy of this surgical method.Result: The average time of 40 patients with the minimally invasive surgery was 30-40 min,the amount of bleeding was 50-80 ml.All the data refer to unilateral pubic branch fracture surgery.No vascular injury occurred in these surgeries,and only one patient developed a sensory abnormality in the lateral thigh skin,but it disappeared after 3months.All of the 26 male patients had no symptoms of scrotal swelling and pain.The surgical incision of 40 patients with minimally invasive surgery was primary healing.Two patient developed deep vein thrombosis due to multiple fractures.Then we followed-up the 40 patients,X-ray showed a firm fixation,the fracture healed well and fracture line disappeared in these patients after 3 months of surgery.According to Majeed assesment we evaluated the outcome of the fracture,and the result showed that 34 cases were excellent,6 cases were good.Conclusion: Minimally invasive parosteal plate osteosynthesis internal fixation for unstable anterior ring injury is a safe,easy operation,effective,less complications surgical approach. |
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