   蔡鴻敏 | Miles Stone 河南省洛陽正骨醫(yī)院（河南省骨科醫(yī)院） 骨盆髖臼損傷微創(chuàng)診療研究組 E-mail：[email protected] 著作權(quán)聲明：本文圖文內(nèi)容均100%原創(chuàng)，享有著作權(quán),。 規(guī)范,、深入、精準,、高效：骨盆髂嵴外固定Schanz螺釘置入的知識框架 Standard, deep, accurate, efficient: A knowledge framework for pelvic external fixation Schanz screw insertion 我是蔡鴻敏,，一個喜愛骨盆髖臼微創(chuàng)診療的青年創(chuàng)傷骨科醫(yī)生，我來給您分享一個系統(tǒng)的,，可以規(guī)范,、深入,、精準且高效地置入骨盆髂嵴外固定Schanz螺釘?shù)闹R框架,。 I am Cai Hongmin (Miles Stone), a young surgeon who is fond of the minimally invasive diagnosis and treatment of pelvic and acetabular trauma. Now, what I am sharing is a knowledge framework for standard, deep, accurate and efficient insertion of the pelvic external fixation Schanz screw. 錯誤置釘，損害外固定效果,，誰都不想要,。 No one wants a misplaced Schanz screw to hazard the pelvic external fixation. 規(guī)范、深入,、精準且高效的置釘,，促進外固定效果，我們之所求,。 Standard, deep, accurate and efficient insertion enhancing the external fixation is the thing we are pursuing. 遵循以下知識框架,，則所欲隨心，所求信手,。 Following the knowledge framework recommended below, the excellent results inthe pelvic external fixation shall be acquired gradually. 知識框架之一：置釘區(qū)域髂骨翼的解剖學研究及解剖分區(qū),，用以規(guī)范化地規(guī)劃Schanz螺釘?shù)墓切酝ǖ?/span> Knowledge framework part one: anatomical analysis and zoning of the iliac crest for the insertion of the pelvic external fixation Schanz screw 四條平行線（基線連接髂前上下棘最前點，余者分別經(jīng)髂前上下棘間凹陷最后點,、髖臼最后點及臀中肌柱最后點）自前向后將置釘區(qū)域分成I,、II和III區(qū)。II和III區(qū)可用于置釘,。進釘點位于髂嵴內(nèi)外緣中內(nèi)1/3交界線上,，一個在髂前上棘后兩橫指（II區(qū)），另一個在髂結(jié)節(jié)（III區(qū)）,。螺釘均朝向髖臼置入,，III區(qū)螺釘亦可朝向坐骨大切跡。置釘深度在80~140mm之間,。 Four parallel lines (the index line connects the most anterior ends of the ASIS and AIIS, the rest three lines go through the most posterior end of the inter notch of the anterior iliac spines, the acetabulum and the gluteus medius pillar, respectively) divide the iliac crest into 3 zones (zone I, II and III) anteroposteriorly. The startpoints lie in the line of the middle-medial one third of the crest, one is two-finger breadth posterior to the ASIS (zone II), the other is just over the iliac tubercle (zone III). Schanz screws should be inserted into zone II and III towards the acetabulum, also the screw in zone III can point to the greater sciatic notch, with the insertion depth between 80 and 140 millimeters. 知識框架之二：基于觸診的透視非依賴的骨盆髂嵴外固定Schanz螺釘經(jīng)皮置入技術(shù),，用以深入且精準地置入螺釘 Knowledge framework part two: A palpation-basedand fluoroscopy-independent percutaneous insertion technique for the pelvic external fixation Schanz screw can place the screw deeply and intraosseously 目前所流行的其他置釘技術(shù)無一不存在置釘不夠深入且精準性差的缺陷。究其癥結(jié),，不在于髂骨翼解剖的不規(guī)則與單薄,，不在于術(shù)中透視的不可靠，而在于沒有預先在髂骨翼內(nèi)建立起螺釘?shù)墓切酝ǖ馈Ｏ胂笠幌录怪倒葆數(shù)闹萌爰夹g(shù)即可領悟此理,。 Any of the screw insertion techniques now in use is in lack of deepness and accuracy. The crucial reason lies neither in the anatomy of the ilium nor inthe intraoperative fluoroscopy, but rather in the failure of preparation and establishment of the screw’s osseous corridor in the iliac wing. Just imagine the insertion technique of the pedicle screw into the spine. 此項新技術(shù),，憑借克氏針和脊柱外科的球頭探子，可在髂骨翼內(nèi)建立起深入的螺釘骨性通道,，進而便于精準地置入螺釘,。 The technique recommended here, utilizing some simple tools such as the K-wire and ball-tipped probe, can build a deep and intraosseous corridor down into the iliac wing for the accurate and efficient insertion of the Schanz screw. 置釘步驟： Screw insertion procedures: 觸診確定進針點 Make the start-point under palpation 開辟軟組織窗口 Do a stab incision
開立骨窗 Open a pilot hole down the crest into the cancellous bone
建立骨性通道 Establish the osseous corridor by pushing the probe down in a blunt manner
置入螺釘 Insert the screw manually
可惜的是，以前,，沒有專用的手術(shù)器械來建立,，尤為關(guān)鍵的是，來維持建立好的螺釘?shù)墓切酝ǖ?，從而最大程度上保證置釘?shù)母咝?、深入性及精準性?/span> There was not any set of tools in specialty to build, and most importantly, to maintain the osseous corridor for the readily insertion of the screw. What a pity. 到此停駐不前就可惜了。 Even pity is the unreadiness to make any progress. 可喜的是,，專用器械研發(fā)并生產(chǎn)出來了,。
But there is now a delightfulness over the success in the design and manufacture of a patented set of tools. 經(jīng)過臨床使用證實其功能，更使其完善,。 Under the verification from clinical application, refinement is already made to the set of tools for better use.
知識框架之三：專利器械,，用以提升手術(shù)效率 Knowledge framework part three: a patented set of tools for a higher surgical effectiveness 基于上述基礎解剖研究和臨床置釘技術(shù)，著眼于高效建立并維持螺釘?shù)墓切酝ǖ?，專利器械應時勢而生了,。完善版的專利工具包括一個外套筒、一個內(nèi)套筒,、一把開口錐,、一組不同型號的子彈頭探子、一把套筒打入/拔出器,。組件之間可嚴密適配,，開口錐和探子尾端設有與通用快速拆裝手柄適配的連接機構(gòu)。 Basing on the basic anatomical research and the clinical insertion technique, with an eye to efficiently establish and maintain the osseous corridor, the patented set of tools is out. The refined version of the tools contains an outer sleeve, an inner sleeve, an owl, a group of bullet-tipped probes, and a sleeve knocker / extractor. The fit among the components is strict and precise. The owl and probe can attach to the universal quick assembling and disassembling handle.
組件間的不同適配情形提供了相應的功能狀態(tài),，配合置釘手術(shù)步驟,，簡便而高效地建立起螺釘?shù)墓切酝ǖ溃⒕S持好其開口及方向,，等待螺釘?shù)捻槃葜萌搿?/span> Different match status of the components offers different function. Following the screw insertion technique, simply the best, the tools can build the osseous corridor and maintain its opening and direction, awaiting the subsequent insertion of the screw.
專利器械使用說明： Instructions of the patented set of tools for pelvic external fixation Schanz screw insertion 將內(nèi)套筒插配到外套筒中,，經(jīng)軟組織窗口置入，抵在髂嵴骨皮質(zhì)表面,，套筒頭端對齊,，尾端則預留功能空間。 Put the inner sleeve into the outer one, then insert them through the stab incision till they touch the cortex of the iliac crest, with their tipped heads coplanar and their thickened ends separated for later insertion of the inner sleeve.
保持套筒插入狀態(tài),，經(jīng)內(nèi)套筒插入開口錐,，刺破髂嵴骨皮質(zhì)，進入板障后撤出而開立骨窗。注意避免刺破髂骨翼內(nèi)外板,。 Hold the sleeves steady, attach the owl to the handle and insert it through the inner sleeve to break the cortex of the iliac crest down into the cancellous bone in order to open an osseous window. Care should be taken not to penetrate the inner and outer iliac tables.
保持套筒插入狀態(tài),，經(jīng)內(nèi)套筒插入最細直徑的子彈頭探子至所開立的骨窗內(nèi)，鈍性下壓至明顯深度并遭遇明顯阻力后撤出而建立骨性通道,。探子體部刻度可提示插入深度,。 Hold the sleeves steady, insert the bullet-tipped probe of the smallest diameter through the inner sleeve and into the osseous window, then push itdown in a blunt fashion, until the insertion is deep enough or there encounters an obvious increase of resistance from the bone, to establish the osseous corridor for the external fixation Schanz screw. The calibration in the probe can indicate the depth for the osseous corridor. The probe is then retreated.
經(jīng)內(nèi)套筒逐級插入子彈頭探子至所建立的骨性通道內(nèi)并達前述深度而擴大骨性通道的孔徑。保持最大直徑子彈頭探子的插入狀態(tài),，撤除手柄,。 Hold the sleeves steady, enlarge the diameter of the osseous corridor incrementally by using the rest of the probes until the probe of the largest diameter is inserted. Keep the insertion in place and retract the handle.
應用套筒打入/拔出器，沿最大直徑子彈頭探子的體部,，向下錘擊內(nèi)套筒尾端,，使內(nèi)套筒頭端與外套筒相抵，尖端刺入髂嵴骨質(zhì)內(nèi),，此時,，套筒即可維持骨性通道的開口和方向,，拔出子彈頭探子,。 Over the probe, the sleeve knocker / extractor is used to knock the inner sleeve down, resulting its head touching that of the outer sleeve and its endstabbing into the crest, to hold the opening and direction of the osseous corridor, followed by the retrace of the probe.
自內(nèi)套筒，手動擰入外固定Schanz螺釘,，至所建立骨性通道深度,。 Insert the Schanz screw manually through the inner sleeve to the depth ofthe osseous corridor.
應用套筒打入/拔出器拔出套筒。外固定Schanz螺釘被深入且精準地置入髂骨翼內(nèi),。 Use the sleeve knocker / extractor to pull out the sleeves. The Schanz screw insertion is deep and intraosseous.
子彈頭探子在松質(zhì)骨內(nèi)的鈍性行進不會突破堅實的皮質(zhì)骨（包括髖臼軟骨下骨和坐骨大切跡）,，因而，只要置釘深度不超過所建立骨性通道的深度,，手術(shù)安全性有保障,。骨質(zhì)疏松的情況下的置釘操作則需謹慎。 The blunt progression of the probe in the cancellous bone precludes cortical violation, so, when the insertion of the Schanz screw is no deeper than theosseous corridor, the safety of the surgery is promising. However, screw insertion in the case of osteoporosis demands meticulous care. 蔡鴻敏 骨盆髖臼損傷微創(chuàng)診療研究組 河南省洛陽正骨醫(yī)院（河南省骨科醫(yī)院） 2020/03/28 |
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