| Background The holistic view is the philosophical thought of the ancients studying the relationship between the mystery of the human body and the natural environment,and it is also one of the main ideas in the theoretical system of traditional Chinese medicine(TCM).In understanding human body,we should pay attention to the integrity of human body,the unity of human and nature,and the unity of human and social environment.The hip bone as a whole is composed of the ilium,ischium and pubis,which is coincides with the holistic view.It connects the trunk and lower limbs through sacroiliac joint and hip joint to maintain the normal physiological activities of humanbody.The method of image comparison is to make it easier to know and understand the research object with the help of some intuitive thing or phenomenon.The holistic view and the image comparison are both methods of understanding things in Chinese medicine,and provide methods for studying human physiology and pathology.The acetabulum is the fusion of the ilium,ischium and pubis,which is an important structure to contain the femoral head.The medial side of the acetabulum is the quadrilateral area of the ischium body,which is the bony plane of the lateral edge of the true pelvis and the medial wall of the acetabulum.It has the function of preventing the central dislocation of the femoral head.Scholars call this area the quadrilateral area.However,anatomical studies have found that the thin area of bone in the quadrilateral area is not only limited to the quadrilateral area,but also includes the bone between the boundary with the pelvis,and the scope of clinical acetabular fractures often corresponds to it.Therefore,Wang Zhengkun expanded the definition of quadrilateral area on the basis of previous studies,and collectively called the relatively flat area composed of ilium,ischium and pubis in the medial wall of acetabulum as the generalized quadrilateral area(the quadrilateral area in this study),including the arcuate line of pelvis(ALP)and above the level of ischial spine(referring to the line parallel to the top of ischial spine and the boundary),anterior to the posterior edge of obturator formamen(OF),and posterior to ischial notch.On this basis,the hemipelvis is divided into pubic region,quadrilateral region and iliac region. With the continuous development of transportation and construction industries,acetabular fractures involvingquadrilateral area caused by high-energy injuries have also increased.Because the fracture is mostly comminuted,and the acetabulum is adjacent to the important blood vessels,nerves and other tissues around,it is very difficult to fix the acetabulum directly.A little carelessness can easily lead to the screw entering the joint cavity by mistake,causing serious consequences.In order to solve the treatment of this type of the complex acetabular fracture involving quadrilateral area,Professor Cai Xianhua of our department found on the basis of previous clinical experience that it can be effectively treated by starting to project along the upper part of pubic symphysis,along the lateral margin of pubic comb,through the arcuate line to the large ischial notch,slightly laterally on the arcuate line,and then passing through the 10 mm outside the sacroiliac joint front edge,until the whole section of the iliac spine is in the shape of "S" arc and placing the internal fixator complex acetabular fractures involving a quadrilateral area.On this basis,the first generation of dynamic anterior plate-screw system for quardrilateral area(DAPSQ)was developed,and 3 to 5 screws were applied to directly fix the surface of the quardrilateral area through a single ilioinguinal approach.The trans-bone surface fixation changes the traditional internal fixation system that is pressurized and fixed along the long axis of the steel plate,and changes the traditional longitudinal dynamic design between screws and nail holes into the continuous lateral dynamic pressure generated by the linkage between the titanium plate molding complex and nail hole screw,and also creatively realizes the dream of using a single ilioinguinal approach to the internal fixation to solve thetraditional often required anterior-posterior combined fixation for the treatment of complex acetabular fractures.The first generation DAPSQ titanium plate has been improved on the basis of the reconstruction titanium plate.According to the semi pelvic division,the trajectory of DAPSQ titanium plate is also divided into three parts: pubic region,quardrilateral region and iliac region.The clinical application has also achieved satisfactory results,but there are still some problems in the clinical application of the first generation DAPSQ titanium plate.Because the first generation DAPSQ titanium plate is not anatomic plate,the pubic region,quardrilateral region and iliac region are too long or too short in practical application,and it still needs to consume time in special shaping.This kind of manual operation is not consistent with the increasing incidence of acetabular fracture.Although the first generation DAPQS titanium plate is not anatomic,the trajectories "Cai’s line" after fixation are in anatomic contact with the surface of the semi pelvis,so it is possible to measure the trajectories.Pelvic specimens for anatomical measurement were collected,the bone condition of the DAPSQ titanium plate trajectory should be paied attention to especially,looking for relevant bony landmarks,and seeking a suitable measurement method.Based on this,pelvic acetabular CT and 3D reconstruction data of normal people from different regions in China were collected,anatomical parameters were obtained combined with digital orthopedic software analysis to provide anatomical basis for the preparation of a standardized dynamic anterior plate-screw system for quardrilateral area.Then the standardized DAPSQ titanium plate was used in clinical and follow-up,theclinical efficacy was compared with that of the first generation DAPSQ titanium plate to evaluate the difference in efficacy between the two generations of DAPSQ.Part one Study on Digitized Measurement Method of Titanium Plate Track Length of Dynamic Anterior Plate-screw System for Quardrilateral AreaObjective Based on holistic view,DAPSQ titanium plate trajectory is considered as a whole.Digitized measurement of DAPSQ titanium plate trajectory length is made after the plate trajectory is divided into three parts including pubic area,quardrilateral region and iliac region in order to explore the feasibility and its clinical significance of the digital measurement,and provide a big data measurement methodMethods14 adult pelvis specimens without deformity or bone defect were collected,of which 6 were semi pelvis.The trajectories of DAPSQ titanium plate after installation were drawn on the pelvis specimens,and then Polydioxanone suture was used and the length of DAPSQ titanium plate was measured in pubic region,quardrilateral region,iliac region and the whole track.After the measurement,CT scan and three-dimensional(3D)reconstruction of pelvis were performed to obtain DICOM format data,and then DICOM format data was imported into Mimics 20.0.The diameter of each circle and the corresponding chord length of each circle were measured,then the digitized measurement length of DAPSQ titanium plate track in pubic region,quardrilateral region and iliac region was calculated according to the formula,and the total length of DAPSQ titanium plate track is calculated according to the length of each region of each pelvis specimen.The measurement process adopts double random measurement method.The group correlation coefficient was used to analyze the consistency between the two methods,the paired t-test was used to compare the differences between the two methods,and the Bland-Altman test was used to analyze the consistency between the two measurement methods.Results The actual measured length of pubic region,quardrilateral region,iliac region and total length were(60.38±3.90)mm,(66.08±3.19)mm,(89.19±4.38)mm,(215.65±8.23)mm,respectively;and the digitized measured length of pubic region,quardrilateral region,iliac region and total length were(60.60±3.79)mm,(67.48±4.63)mm,(88.20±6.03)mm,(216.23±11.41)mm,respectively.The paired t-test showed that there was no significant difference in the length of pubic area,quardrilateral area,iliac area and total length between the two methods(P > 0.05).The correlation coefficient between the two groups was greater than 0.8.Bland-Altman test showed that except for the difference of 4.5%(1/ 22)between the two measurement methods in the iliac region,the other differences were within the 95% consistency limit,with good consistency(P>0.05).Conclusion Based on the holistic view,the digitized measurement of DAPSQ trajectory length is reliable,which can provide a feasible measurement method for large data measurement of DAPSQ titanium plate trajectory length,and then provide relevant anatomicalparameter support for the design and production of standardized DAPSQ titanium plate.Part two Digitized Measurement and Analysis of Chinese Titanium Plate Track Length of Dynamic Anterior Plate-screw System for Quardrilateral AreaObjective Under the holistic view,according to the measurement method in Chapter 1,the track length of dynamic anterior plate-screw system for quardrilateral area of normal adults was obtained through the digitized measurement of the complete pelvis CT scan and 3D reconstruction data of normal adults.The proportion of each region was also obtained,which provides data support for designing standard dynamic anterior plate-screw system for quardrilateral area of normal adults.Methods3D reconstruction DICOM format data of normal Chinese adult pelvis were collected from southern China(Foshan Sanshui District People’s Hospital),central China(General Hospital of Central Theater Command),Northwest China(The First Affiliated Hospital of Xinjiang Medical University),Northeast China(General Hospital of Northern Theater Command).A total of 504(834 sides)normal adult pelvis 3D reconstruction images were obtained.In the General Hospital of Northern Theater Command there were 34 male(55 sides),21 complete pelvis,6 left pelvis,7 right pelvis,age 18-87 years old,average 45.9 years old,24 female(38 sides),12 complete pelvis,6 left pelvis,6 right pelvis,age 18-77 years old,average53.5 years old;In the Foshan Sanshui District People’s Hospital,there were 48 male(95 sides),47 complete pelvis,1 right pelvis,age 20-56 years old,average 30.3 years old,42 female(82sides),40 complete pelvis,1 left pelvis,1 right pelvis,age 20-64 years old,average 38.7 years old;in the First Affiliated Hospital of Xinjiang Medical University,there were 10 male(11 sides),1complete pelvis,4 left pelvis,5 right pelvis,age 18-69 years,average 37.8 years old.There were 4 female(4 sides),2 left pelvis,2 right pelvis,average 43.3 years old,age 27-54 years old;in the General Hospital of Central Theater Command there were 208 male(329sides),121 complete pelvis,45 left pelvis,42 right pelvis,age18-89 years old,average 43.4 years old,134 female(220 sides),86 complete pelvis,23 left pelvis,25 right pelvis,age 19-90 years old,average 48.6 years old.The above data were imported into Mimics20.0 software and 3D reconstruction of pelvis was performed.Based on the measurement method in the Chapter 1,the total length of titanium plate track and the length of each section of dynamic anterior plate-screw system for quardrilateral area of each region in Chinese were measured digitally.According to the measurement of the total length of DAPSQ titanium plate in pelvis and the proportion of each section,the standardized DAPSQ titanium plate in accordance with the normal Chinese adult were calculated,and the anatomical differences among the pubic region,quardrilateral region,iliac region and the total length of DAPSQ titanium plate in the Northeast,South and Central were compared.Results The length of pubic region,quardrilateral region,iliac region and total length of DAPSQ titanium plate in northeast China were(61.89±4.55)mm,(71.19±5.48)mm,(84.94±6.55)mm,(218.03±10.14)mm;the length of pubic region,quardrilateral region,iliac region and total length of DAPSQ titanium plate in central China were(61.18±5.29)mm,(69.12±5.25)mm,(84.77±6.62)mm,(215.07±9.86)mm;The length of pubic region,quardrilateral region,iliac region and total length of DAPSQ titanium plate in southern China were(60.03±5.78)mm,(67.94±4.98)mm,(83.10±5.56)mm,(211.07±9.93)mm.And the length of pubic region,quardrilateral region,iliac region and total length of DAPSQ titanium plate track in normal Chinese adult were(60.96±5.39)mm、(69.11±5.28)mm、(84.40± 6.41mm)mm 、(214.46 ± 10.15)mm.There was no significant difference among the three regions(P > 0.05);there was no significant difference in the length of iliac among the three regions(P>0.05);there was significant difference in the total length of DAPSQ locus among the three regions(P<0.05).According to the total length of DAPSQ and the error acceptance range of titanium plate(±10 mm),titanium plate can be divided into three types: small size 194 mm,medium size 214 mm and large size 234 mm.Then according to the different proportion of each section,it can be divided into two types under small,medium and large size,i.e.A and B under small size,C and D under medium size,E and F under large size.The length of pubic region,quardrilateral region and iliac region of type A titanium plate was 55 mm,61mm and 78 mm;type B titanium plate was 51 mm,66mm and 77mm;type C titanium plate was 61mm,67 mm and 86 mm in length in pubic region,quardrilateral region and iliac region;type D titanium plate was 56 mm,73mm and 84mm;type E titanium plate was 66 mm,74mm and 94 mm in length in pubic region,quardrilateral region and iliac region;type F titanium plate is 62 mm,80mm and 92 mm.Of the 834 samples,the numbers of titanium plates of type A,B,C,D,E and F were 112,104,501,424,102 and 79 respectively.Among them,87 cases were common type A and B,129(15.47%)could be included in small size;378 cases were common type C and D,546(65.47%)could be included in medium size;69 cases were common type E and F,112(13.43%)could be included in large size.A total of 787 cases of A,B,C,D,E,F titanium plates could be used,accounting for 94.36% of the total cases.Conclusion1.The holistic view provides the theoretical basis for anatomical measurement,simplifies the measurement method,and digitized orthopaedic software has the advantages of repeatability,time-saving and high accuracy.It provides a new method for anatomical measurement,which is worth popularizing;2.By measuring the length of DAPSQ titanium plate track,the length of DAPSQ track in normal Chinese adult was(214.46±10.15)mm,which made up for the anatomical parameters of this part of pelvis;3.In the comparison of the length of pubic region and iliac region in different regions of China,there is no statistical significance among the three regions.The track length and total length of quardrilateral region in different regions have statistical significance,and the overall trend is northeastern region >central region > southern region.4.According to the digitized measurement results,DAPSQ titanium plate can be divided into six types: A,B,C,D,E and F,which can basically meet the clinical needs.The standardized design of DAPSQ titanium plate can provide new ideas and methods for the treatment of complex acetabular fractures involving quardrilateral region.Part three Clinical Study on the Treatment of Acetabulum Fractures Involving Quardrilateral Region with Standardized Dynamic Anterior Plate-screw System for Quardrilateral AreaObjective Based on the holistic view,the whole pelvis or hemipelvis plays an important role in maintaining the stability of acetabular fracture.According to the track data of titanium plate in the second chapter,a standardized dynamic anterior plate-screw system for quardrilateral area was designed and applied to the treatment of acetabulum fracture involving quardrilateral area for the comparison with the clinical effect of the first generation DAPSQ.The difference of clinical effect between the standardized DAPSQ and the first generation DAPSQ in the treatment of complex acetabulum fracture involving quardrilateral area was preliminarily discussed.Methods From October 2013 to October 2019,54 cases of acetabular fracture involving quardrilateral region were analyzed retrospectively,including 43 males and 13 females,aged from 23 to 65,with an average age of 46.2 years old.Causes of injury: 18 cases of traffic accident injury,34 cases of high-altitude falling injury and 2 cases of falling injury.The average time from injury to operation was 12.5 days(3-26 days).There were 30 cases of both column fracture,6 cases of T-type fracture,7 cases of transverse fracture,11 cases of anterior column with posterior half transverse fracture.All patients were treated with single ilioinguinal approach with standard DAPSQ internal fixation,27 patients were treated with first generation DAPSQ titanium plate,27 patients were treated with standard DAPSQ.27 patients were followed up for 4-26 months,with an average of 18 months.At the last follow-up,the hip function was evaluated based on the modified Merle d’Aubigné-Postel score,and the excellent rate of fracture reduction was evaluated based on the Matta imaging standard.Results In this paper,operation incisions of 54 cases healed in stage one.The operation time and intraoperative bleeding volume of the standardized DAPSQ group were(237.1±50.3)min,(1102.3±480.7)ml,respectively;the operation time and intraoperative bleeding volume of the first generation DAPSQ group were(295.8±56.6)min,(1420.5±504.8)ml,respectively.The difference of operation time and intraoperative hemorrhage between the two groups was statistically significant(P<0.05).According to the evaluation results of Matta imaging standard,the first generation DAPSQ group:15 excellent cases,8 good cases,4 poor cases;standardized DAPSQ group: 17 excellent cases,7 good cases,3 poor cases.There was no significant difference between the two groups at the last follow-up(P > 0.05).During the follow-up period,no loosening,displacement or fracture of internal fixation was found.According to the modified Merle d’Aubigné-Postel score,hip joint function was evaluated at the last follow-up.The results showed that 16 cases of fracture reduction in the first generation DAPSQ group were excellent,6 cases were good,3 cases were fair,2 cases were poor,and the excellent and good rate was 81.5%;of fracture reduction in the standardized DAPSQ group,18 cases were excellent,5 cases were good,3 cases were fair,1 case was poor,and the excellent and good rate was 85.2%.There was no significant difference between the two groups(P > 0.05).In the standard DAPSQ group,1 patient had obvious hip pain,limp with limited activity,was unable to participate in daily life and activities,and later underwent total hip arthroplasty;in the first generation DAPSQ group,2 patients had necrosis of the femoral head one year after operation and underwent total hip arthroplasty.Conclusion The pubic region,quardrilateral region and iliac region of pelvis are connected and coordinated in structure and function.When treating complex acetabular fracture involving quardrilateral region,we should know the relationship between different areas,which can guide the reduction;when treating complex acetabular fracture involving quardrilateral region,standardized DAPSQ makes up the deficiency of the first generation DASPQ,defines the classification of titanium plate,and optimizes it the proportion of each partition of DAPSQ titanium plate and avoids the operation process of internal fixation and molding.In clinical application,the standardized DASPQ maintains the advantages of stability and reliability of the first generation DAPSQ.Meanwhile,compared with the first generation DASPQ,the standardized DAPSQ has the advantages of shortening the operation time and reducing the complications,which creates conditions for widespread use. |
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