THÔNG TIN TÀI LIỆU
1 BACKGROUND Pelvic fracture is a serious injury and are common in clinical practice [1] Melton (1981) statistics in 10 years (1968-1977) in Minnesota, found the frequency of pelvic fractures: 37 patients/100,000 people/1 year [2] In Vietnam, according to statistics of Ngo Bao Khang (1995), pelvic fracture accounts for 3-5% of the total fractures [3] The pelvic fractures are often caussing shock and has a high mortality rate The cause of pelvic fractures is mainly due to traffic accidents The conservative treatment of pelvic fracture is to let the patient stay motionless on the Braun′ frame This method is simple and easy to do, but the results of anatomical reduction are not good, uncertain, and the patient must stay immobile for a long time The method of internal pelvic fixation, although have a good result of reduction of the anatomical recovery, the pelvic fracture is fixed firmly and the patient mobilizes early but it is a big surgery so it could not be assigned in the emergency phase and it is very limited with open pelvic fracture The compressed reverse threaded rods (CRTR) of Nguyen Van Nhan were studied and applied in the treatment of fractures in the limbs from the 60s of the last century Some reports on the application of the CRTR to treat unstable pelvic fractures at 103 Military Hospital and 108 Central Military Hospital in recent years have shown that this framework could be used in emergencies and fixed the pelvic fracture firmly, pain relief, hemostasis and it is convenient of care or management of combined lesions However, during implementation, we have also seen many additional research points Specifically, for each type of fracture frame (type B and type C - according to the classification of the Tile), after piercing the Schanz pins into the iliac crests and assemble the CRTR, how to turn the rods to stretch or compress and combine traction is essential From this idea we have designed the unstable pelvic fracture models of type B and C and construct the technical process of external pelvic fixation with the CRTR on experiment, basis on it, continue to improve the effectiveness of the CRTR in treating unstable pelvic fractures From this reasons, we conduct the research topic: "Study on application of the compressed reverse threaded rods to treat unstable pelvic fractures" for two purposes: To construct the technical process of reduction and external pelvic fixation by the compressed reverse threaded rods on experimentation To evaluate the results of treatment of unstable pelvic fracture with the compressed reverse threaded rods * New contributions from thesis - This is a new study in the country, the construction of the technical process of external pelvic fixation by CRTR on unstable pelvic fractures models B1, B2 and C1 (according to Tile) is the basis for application of external pelvic fixation in clinic is more corected and effective The study demonstrates that the CRTR is capable of good treatment of some types of pelvic fractures, and each type of pelvic fracture have a difference of technical reduction - Method of external pelvic fixation by CRTR helps doctors have more options in treating pelvic fracture, because in the current conditions of our country, to have a foreign frame of external pelvic fixation is very difficult, it is a topical practice and although there are many advantages of internal fixation, it is not always possible have an indication of internal fixation * Thesis outline The dissertation covers 125 pages, inclucding: preamble (2 pages), literature review (33 pages), materials and method (26 pages), outcomes (30 pages), discussion (32 pages), conclusion (2 pages) It consists of 37 tables, 58 figures There are 143 references in Vietnamese and English CHAPTER 1: LITERATURE REVIEW 1 MECHANISM OF INJURY * Anterior-posterior compression: pelvic fratures of the open book * Lateral compression: pelvic fratures of the closed book * Vertical shear force: This force often makes the half of pelvis had upward displacement, the pelvis is unstable in the direction of rotation and verticality 3 1.2 CLASSIFICATION OF PELVIC FRACTURE ACCORDING TO TILE M (2003) + Type A: Stable pelvic fracture (A1, A2, A3) -Type B: Not total unstable pelvic fracture (Unstable rotation, Stable verticality): + B1: Open book pelvic fracture + B2: Closed book pelvic fracture + B3: Usually open book pelvic fractures - Type C: Total unstable pelvic fracture (Unstable rotation + vertical): - C1:unstable fracture side (both rotation and vertical) - C2: unstable fracture of both sides (1 side of type B, side of type C) - C3: unstable fracture both sides of type C 1.3 DIAGNOSTIC IMAGE - Pelvic X-ray straight images, observe the whole pelvic view - CT-scaner: we can see the images of discreet lesions in the posterior pelvic ring that difficult to observe on X-ray images 1.4 TREATMENT OF PELVIC FRACTURE WITH COMPRESSED REVERSE THREDED RODS 1.4.1 Structure of compressed reverse threaded rods * The CRTR consists two main components: -The first component: stainless steel rods with a diameter of 10 mm, and 350 mm length (35cm), in the middle of each rods, there is a hexagonal section of 2cm length to allow the 10 wrench to turn (1), two sides with threads are reverse The threaded step of the pressed rods is according to Vietnam Standard 2248: 1977 Metric thread, threaded step = 1, when turning each round, clamping nuts holding pins at ends of CRTR will move in the middle or stretch away with distance = 2mm Figure 1.22 the compressed reverse threaded rods * Source: photo of experimental instrument - number 01 - The second component: The pin holders to connect the CRTR and the Schanz pins or Steinmann pins (2) 4 * In addition to the two main components mentioned above, there are also some things: - Two pin holders located on either side of each rods are used to connect two rods together through Steinmann pins (3) - Schanz pins Ø 4,5mm, 180 mm long to insert in the iliac crest - Steinmann pins Ø 4.5mm, 100mm long (10cm) are used to connect CRTR 1.4.2 Some applications of the compressed reverse threaded rods in the treatment of bone fractures and sequelae in motor organs In 1998 at the 108 Military Hospital, Nguyen Van Tin treated 27 patients with closed fractures and sequelae by CRTR, of which patients broke the pelvis Pham Dang Ninh (2000) reported the treatment results of 48 open fractured patients with leg fractures and infected open fractures by one-side external fixation method with the CRTR, the results were good and very good 96.42% 1.4.3 Treatment of unstable pelvic fracture by methods of external fixation in the world Pennal used methods of external fixation in treating pelvic fractures from World War II in Canada, until the early 1970s of the last century, the external pelvic fixation was used in the world widely In recent years Lindahl J., et al (1999), Rommens P M et al (2003) , Michelangelo S., et al (2010), Burkhardt M., et al (2014), Apostolov P., et al (2011), Vécsei V., et al (2010) , reporting on the treatment of unstable pelvic fractures by methods of external fixation, the results were very positive 1.5.5 Treatment of unstable pelvic fracture by methods of external fixation in Vietnam + Since 1992, Cho Ray Hospital in Ho Chi Minh City has started to use the external fixation frame to treat unstable pelvic fractures + Nguyen Ngoc Toan (2014), reported 94 unstable pelvic fracture patients treated with external fixation frame at Cho Ray Hospital with self-created frame according to Muller's frame, the results were very good and good 64.2% + At the 103 Military Hospital, in the early 1990s the CRTR was applied to treat unstable pelvic fractures, the results were very positive 1.5.6 Assigning for treatment of pelvic fractures with external fixation - Assigning in the emergency phase, the purpose is to fix the pelvic fracture, stop bleeding, reduce pain and prevent shock - Assigning for real treatment for pelvic fractures type B1, B2, C1 (according to Tile); indications for open pelvic fractures or associated lesions in the perineum at high risk of infection CHAPTER 2: MATERIALS AND METHOD 2.1 EXPERIMENTAL RESEARCH 2.1.1 Research subjects - 16 models of synthetic pelvis (Sawbone) manufactured in the Federal Republic of Germany, the size is the same the pelvic size of adults, upper waist diameter: combined diameter = 12cm, horizontal diameter = 13cm, 12.5cm diagonal diameter - On each pelvic model, draw and saw to create typical types of injuries including: + models of pelvic fracture type B1 (open book): dislocation of pubic joint (20mm wide dislocation), dislocation of left sacroiliac joints (10mm wide dislocation) + models of pelvic fracture type B2.1 (closed book): fracture of Superior anh Inferior pubic rami (20mm of disruption), dislocation of left sacroiliac joints (10mm wide dislocation) + models of pelvic fracture type B2.2 (closed book): fracture of Superior anh Inferior pubic rami (20mm of disruption), vertical fracture of left pelvic wing (20mm of disruption) + models of pelvic fracture type C1: dislocation of pubic joint (30mm wide dislocation), vertical fracture of sacrum (left pelvic bone displaced up 20mm) 2.1.2 Experimental research method 2.1.2.1 Technical process of External pelvic fixation by compressed reverse threaded rods on unstable pelvic fracture models * Prepare experimental pelvic models * Prepare surgical instruments - CRTR Ø 10 mm, 35cm long; Schanz pin Ø 4,5mm, 180 mm long; Steinmann pins Ø 4.5mm, 10cm long - hand drill, electrical drill, diameter of bit 3.5mm, wrench 10 6 * Technique of insering Schanz pins, assemble compressed reverse threaded rods and reduce pevic fractures First stage: Inserting the Schanz pins into the iliac crests + The first pin: it is behind the Anterior Superior Iliac Spine (ASIS) 10mm direction of inserting pins is from anterior to posterior, top to bottom, from outside to inside Firstly, use electrical drill to drill to guide, and then insert Schanz pins with hand drill + The second pins is also inserted into the iliac crest but is 3cm behind the first pins position Second stage: Assemble CRTR, and reduce pevic fractures * Assemble CRTR to connect Schanz pins and assemble Steinmann pins to connect the CRTR together, the distance between the CRTR and the abdominal wall is cm * Unstable pelvic reduction of type B1 To gradually turn the first rod (number 1) 10 rounds, and the second rod rounds, then the pubic joint and sacroiliac joint return anatomical position Figure 2.8 (A, B) the CRTR on experimental models * Source: photo of experimental model B – number 07 A * Unstable pelvic reduction of type B2 - Type B2.1: Use the wrench 10 turn to stretch the first bar (number 1) gradually, to reduce the outer rotation of the pelvis Then turn the second rod (number 2) to press the sacroiliac joints gradually After turning stretch 10 rounds in first rod, the pubic rami return to the anatomical position Next, turn to press rounds in second rod, then see the sacroiliac joint return to the anatomical position - Type B2.2: turn to stretch the first rod (number 1) gradually, to reduce the outer rotation of the pelvis, observe that the ramus pubis return to the anatomical position, then stretching the second rod (number 2) 10 rounds, the pelvic fracture in the posterior pelvic ring also returnto the anatomical position * Reduction of pelvic fracture type C1 7 To tract half of pelvic fracture through the femur with 7-8 kg weight until the pelvic return to the anatomical position Assemble the external fixation frame, turn to stretch the second rod (number 2) rounds and the fisrt rod (number 1) 10 rounds to make the pubic joint return to the anatomical position Turn to press CRTR rounds to see that the iliac joint return to anatomical position, but the pubic joint is still dislocated, turn to press the rod number one 10 rounds continuously, see that the pubic joint return to normal anatomical position Third stage: Complete experiment To take video of experimental process Record the order of reduction, the number of rounds, turn (stretch or press), the result of reduction of the pevic fractures and the position of the pubic joint, and the sacroiliac joint Record the results in the statistics table and record the experiment minutes 2.2 CLINICAL RESEARCH 2.2.1 Research subjects Including 71 patients with unstable pelvic fractures, external pelvic fixation by the CRTR, treatment at Military Hospital 103 and National Institute of Burn Including 41 male and 30 female patients, aged 13-71 (average: 36) Time: from May 2010 to February 2017 * Standard of choosing patients - Patients are diagnosed with unstable pelvic fracture B1, B2 and C1 according to the classification of Tile M (2003) External pelvic fixation by the CRTR - All patients have all files, clear addresses, X-ray films before and after surgery * Exclusion criteria: Unstable pelvic fractures on both sides; pelvic fractures with ASIS (where Schanz pins are pierced) 2.2.2 Methods of clinical research Clinical studies by observable description, follow-up, non- control group, include: prospective study of 49 patients; Retrospective study of 22 patients 2.2.3 The stages of research 2.2.3.1 prospective study * Clinical and subclinical examination: Take pelvic X-ray as a basis for diagnosis, classify and evaluate the level of pelvic lesion; Prepare patients and instruments; pierce Schanz pins, assemble the CRTR and reduction; to record the surgical minutes; follow up and take care of patients after surgery; the time to evaluate the last results at least months after surgery 2.2.3.2 Retrospective study - Make a list of patients, collect all medical files and pelvic X-ray films before and after surgery Prepare research medical files and follow-up result evaluation sheets Invite the patients to come back for clinical examination and take the pelvic X-ray 2.2.4 The treatment process of unstable pelvic fracture by compressed reverse threaded rods 2.2.4.1 Preparing patients 2.2.4.2 Preparing instruments 2.2.4.3 Anesthesia method If done at the patient's bed, just give a local anesthetic at the drilling and inserting positions of Schanz pins and combine with a full body pain reliever 2.2.4.4 The technique of inserting the Schanz pins and assembling the compressed reverse threaded rods Stage 1: inserting the Schanz pins into the iliac crest + The first pins position after ASIS 1.0 cm (direction of Schanz pins: from anterior to posterior, top to bottom, outside to inside) Use Kirschner pins to orient the drill First, use the electric drill, then pierce Schanz pins by hand drill, inserted Schanz pins to iliac crest cm + The second pin is also inserted into the iliac crest but is 3cm behind the position of the first pins Stage 2: Assemble the CRTR, reduce pevic fractures Assemble the CRTR into Schanz pins, assemble the connecting rods, tighten the screws that hold the pins The distance between two CRTR and the abdominal wall is 3-5 cm * Techniques of reduction * Unstable pelvic reduction of type B1 Turning the CRTR gradually, starting with the first rod On each rounds of CRTR to shorten the distance between two pins 2mm Compare the AB distance between two pins before and after turning Take X- ray film of pevis to check the correction results, if the pubic joint still dilates, continue to turn until it is tightened * Unstable pelvic reduction of type B2.1 Turn to stretch the rod number to the half of the pelvic ring on the outer rotation Then turn the rod number to press the iliac joint Take X-ray of pelvis, or take C-arm pelvic straight images to check the results of correction, if there is still displacement, continue to reduce with the two CRTR * Unstable pelvic reduction of type B2.2 Turn to stretch CRTR to reduce the half of pelvic ring on outer rotation Measure the distance from ASIS to the navel on both sides if equal Take X-ray, or take C-arm pelvic straight images to check the correction results, if it still displacement, turn the CRTR continuously * Reduction of pelvic fracture type C1 Tracting on Bohler′ rack is to reduce half of pevis, that is dislocated upward Examining the pelvic X-ray, to the external pelvic fixation like the type B1, B2 fractures Then turn to press to reduce the pevis of internal rotation Stage 3: Complete the operation Move legs and hip joints of patients to assess the condition of pelvic fracture If the patient have painful relief, the pelvic fracture has been fixed well Figure 2.16 photo of patient after external pelvic fixation * Source: photo of Nguyen Duc T, number 62 Turn to tighten the pin holders to ensure that the frame is fixed firmly With fracture type C1, after external pelvic fixation and reduce completely, remove the instruments of traction 10 2.2.4.5 After operating Prophylactic of antibiotics, analgesic, care of pins 2.2.4.6 Practice exercise after operating After operating, let the patient lie in bed and move his feet gently Take him gets up early from the second day After weeks, the patient srarts walking with crutches After weeks, he walks with only one crutch After 7-8 weeks, without crutches 2.2.4.7 Time to remove frame of external fixation The patient is re-examined in the 2nd month after operating Remove the frame after 10 weeks when the X - ray images shows that the pelvic fracture had bone healing of level III The patient can walk without crutches and there is not painful in the clinic 2.2.5 Evaluation 2.2.5.1 Evaluate the early results Evaluate the results of orthopedic reconstruction: according to the method of Richard C.H (1989); evaluate the bone healing and bone healing time; complications, and technical complications 2.2.5.1 Evaluate far results - Time to evaluate far results: at least months after operating - Evaluate the functional results according to Majeed (1989), total 100 points, divided into levels: Good ≥ 85 points; Fair: 70 - 84 points; Average: 55 - 69 points; Poor
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