智能骨盆骨折复位机器人联合天玑机器人治疗不稳定型骨盆骨折的临床疗效

doi:10.3969/j.issn.1006-7795.2024.05.004

摘要/Abstract

摘要： 目的探讨智能骨盆骨折复位机器人（Rossum Robot）联合天玑骨科手术机器人（TiRobot）治疗不稳定型骨盆骨折的早期疗效，并分析其临床优势与局限性。方法回顾性分析2022年5月至2023年11月于佛山市中医院创伤骨科利用Rossum Robot联合TiRobot治疗的19例不稳定型骨盆骨折患者的病历资料。骨盆骨折Tile分型：B型5例、C型14例。从受伤到手术的中位时间为12(10，14)(6～34)d。在Rossum Robot和TiRobot的联合介入下完成骨盆骨折微创闭合复位内固定术。手术前后均进行骨盆电子计算机断层扫描（computed tomography，CT）并拍摄前后位、出口位、入口位X线片，根据X线及CT影像测量骨盆复位后的最大残余位移，采用Matta标准评估骨折复位质量。记录透视频率、透视时间、手术时间、术中出血量、术中导针调整次数、置入螺钉的数量及质量、复位后的最大残余位移。根据术后CT三维重建图像对螺钉位置进行分级。记录术后随访时间、骨折愈合时间及术后并发症发生率，并利用Majeed评分系统进行功能评价。结果在Rossum Robot和TiRobot的联合介入下，19例患者都成功完成了骨盆骨折微创闭合复位内固定术。中位透视次数为28(18，55)(10～120)次，透视时间为25.2(16.2，33.0)(6.0～72.6)s，手术时间为206(203，212)(125～231)min，术中失血量为100(100，200)(50～400)mL，术中19例患者的导针调整次数一共为4次，平均每例患者调整0.21次。共置入67枚螺钉，螺钉置入位置的质量为优65枚，良0枚，差2枚。螺钉位置优良率为97.01%。复位后的最大残余位移为(6.59±3.68)(1.21～13.00)mm。根据 Matta标准，骨盆的复位质量：优7例、良9例、可3例，优良率为84.21%。18例患者获得17.00（12.75，20.00）（6.00～21.00）个月随访，骨折愈合时间为3.55（3.35，4.18）（2.80～6.40）个月，随访期间并发症发生率为0%，末次随访时Majeed功能评分为（86.00±6.65）（74.00～98.00）分，其中优8例，良10例，优良率为100%。结论 Rossum Robot联合TiRobot可以为大多数不稳定型骨盆骨折患者完成智能、安全、精准、微创、均质的闭合复位内固定，可以获得良好的早期疗效。

关键词: 骨盆骨折, 三维导航, 弹性牵引, 骨折复位, 骨折内固定术, 机器人手术

Abstract: Objective To discuss the early efficacy of Rossum Robot combined with TiRobot in the treatment of unstable pelvic fractures, thereby analyzing its clinical advantages and limitations. Methods A retrospective evaluation of 19 patients with unstable pelvic fractures treated with Rossum Robot combined with TiRobot at the Department of Orthopedic Trauma, Foshan Hospital of Traditional Chinese Medicine between May 2022 and November 2023 was conducted. The cohort included 10 males and 9 females according to the Tile classification, there were 14 type C and 5 type B fractures.The median interval from injury to surgery was 12(6-34)d. Minimally invasive closed reduction and internal fixation of pelvic fracture was completed with the joint intervention of the Rossum Robot and TiRobot. Pelvic computed tomography (CT) scans and anteroposterior, outlet, and inlet X-rays were taken before and after surgery. The maximum residual displacement of pelvic rings after reduction were measured according to X-ray and CT images, and the quality of fracture reduction was evaluated by Matta criteria.The fluoroscopy frequency, fluoroscopy time, surgery time, intraoperative blood loss, number of intraoperative guide pin adjustments, quantity and quality of inserted screws, and maximum residual displacement of pelvic rings after reduction were documented.The screw positions were graded according to the postoperative three-dimensional CT reconstruction images.The postoperative monitoring period, fracture healing time and postoperative complications incidence were recorded, and the Majeed scoring system was used for functional evaluation. Results With the joint intervention of the Rossum Robot and TiRobot, all 19 patients successfully completed minimally invasive closed reduction and internal fixation of pelvic fractures.The median intraoperative fluoroscopy frequency was 28 （10-120)times. The median fluoroscopy time was 25.2 (6.0-72.6)s. The median surgery time was 206 (125-231)min.The median intraoperative blood loss was 100(50-400)mL. During the surgery, the guide pin adjustment was performed a total of 4 times among 19 patients, with an average of 0.21 adjustments per patient.A total of 67 screws were inserted, with 65 screws being of excellent quality, 0 screws good quality, and 2 screws poor quality. The overall excellent and good rate for the screws' placement quality was 97.01%.The maximum residual displacement after reduction of pelvic ring was (6.59±3.68) (1.21-13.00)mm.According to Matta criteria, the reduction quality of the pelvic ring was excellent in 7 cases, good in 9 cases, and fair in 3 cases, with a good-to-excellent rate of 84.21%.Follow-up for the 18 cases lasted for 17 months (6-21)months, with the Majeed functional score averaging （86.00±6.65） (74.00-98.00)points and a good-to-excellent rate of 100%, with 8 cases scored excellent, and 10 good. Conclusions In our study, the Rossum Robot combined with TiRobot can complete intelligent, safe, accurate, minimally invasive, and homogeneous closed reduction and internal fixation for most patients with unstable pelvic fractures, and it can achieve good early efficacy.

Key words: pelvic fractures, three-dimensional navigation, elastic traction, fracture reduction, fracture internal fixation surgery, robot-assisted surgery

中图分类号:

R681.6

代永鸿, 曾焰辉, 吴征杰, 赵春鹏, 王军强, 吴新宝. 智能骨盆骨折复位机器人联合天玑机器人治疗不稳定型骨盆骨折的临床疗效[J]. 首都医科大学学报, 2024, 45(5): 763-772.

Dai Yonghong, Zeng Yanhui, Wu Zhengjie, Zhao Chunpeng, Wang Junqiang, Wu Xinbao. Clinical efficacy of intelligent pelvic fracture reduction robot combined with TiRobot in treating unstable pelvic fractures[J]. Journal of Capital Medical University, 2024, 45(5): 763-772.

参考文献

［1］Zhao C P, Wang Y, Wu X B, et al. Design and evaluation of an intelligent reduction robot system for the minimally invasive reduction in pelvic fractures［Ｊ］. J Orthop Surg Res, 2022, 17(1): 205.
［2］曹奇勇, 赵春鹏, 卑明健, 等. 智能化骨盆骨折复位手术导航定位系统在骨盆骨折治疗中的初步应用［Ｊ］. 中华骨科杂志, 2023, 43(19): 1293－1299.
［3］饶福涛, 曾诗晨. 损伤控制理论在骨盆骨折患者中的应用进展［Ｊ］. 医学综述, 2021, 27(3): 550－554.
［4］Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures［Ｊ］. J Orthop Trauma, 2007, 21(1): 31－37.
［5］肖鸿鹄, 赵春鹏, 曹奇勇, 等. 智能化骨折微创复位手术机器人系统治疗不稳定型骨盆骨折的随机对照研究［Ｊ］. 中华创伤骨科杂志, 2023, 25(4): 341－350.
［6］Zhao C P, Cao Q Y, Sun X, et al. Intelligent robot-assisted minimally invasive reduction system for reduction of unstable pelvic fractures［Ｊ］. Injury, 2023, 54(2): 604－614.
［7］Mosheiff R, Weil Y, Peleg E, et al. Computerised navigation for closed reduction during femoral intramedullary nailing［Ｊ］. Injury, 2005, 36(7): 866－870.
［8］Liodakis E, Krettek C, Hawi N. Suitability of computer-assisted femoral intramedullary nailing for control of torsion and length: systematic review of clinical studies［Ｊ］. Unfallchirurg, 2018, 121(3): 182－190.
［9］Kim W Y, Ko S Y. Hands-on robot-assisted fracture reduction system guided by a linear guidance constraints controller using a pre-operatively planned goal pose［Ｊ］. Int J Med Robot, 2019, 15(2): e1967.
［10］Li C, Wang T, Hu L, et al. A visual servo-based teleoperation robot system for closed diaphyseal fracture reduction［Ｊ］. Proc Inst Mech Eng H, 2015, 229(9): 629－637.
［11］Jiménez-Delgado J J, Paulano-Godino F, PulidoRam-Ramírez R, et al. Computer assisted preoperative planning of bone fracture reduction: Simulation techniques and new trends［Ｊ］. Med Image Anal, 2016, 30: 30－45.
［12］贾鹏, 吴新宝. 骨科机器人辅助手术在创伤骨科的临床应用现状与发展［Ｊ］. 中华创伤骨科杂志, 2023, 25(5): 433－439.
［13］费晨, 庄岩, 张堃, 等. 机器人结合“O”型臂辅助闭合复位经皮螺钉固定术治疗不稳定性骨盆骨折［Ｊ］. 中华骨科杂志, 2022, 42(13): 815－822.
［14］杨成志, 黄站珠, 唐经励, 等. 骨科手术机器人与“O”型臂X线导航辅助骨盆骨折经皮内固定术的比较［Ｊ］. 中华骨科杂志, 2021, 41(19): 1387－1395.
［15］Long T, Li K N, Gao J H, et al. Comparative study of percutaneous sacroiliac screw with or without TiRobot assistance for treating pelvic posterior ring fractures［Ｊ］. Orthop Surg, 2019, 11(3): 386－396.
［16］李昊泽. 经皮骶髂螺钉置入：机器人辅助与传统技术的比较［D］. 太原: 山西医科大学, 2022.
［17］Kim W Y, Hearn T C, Seleem O, et al. Effect of pin location on stability of pelvic external fixation［Ｊ］. Clin Orthop Relat Res, 1999(361): 237－244.
［18］Yu Y H, Liu C H, Hsu Y H, et al. Matta's criteria May be useful for evaluating and predicting the reduction quality of simultaneous acetabular and ipsilateral pelvic ring fractures［Ｊ］. BMC Musculoskelet Disord, 2021, 22(1): 544.
［19］Pastor T, Tiziani S, Kasper C D, et al. Quality of reduction correlates with clinical outcome in pelvic ring fractures［Ｊ］. Injury, 2019, 50(6): 1223－1226.
［20］Lefaivre K A, Blachut P A, Starr A J, et al. Radiographic displacement in pelvic ring disruption: reliability of 3 previously described measurement techniques［Ｊ］. J Orthop Trauma, 2014, 28(3): 160－166.
［21］Mataliotakis G I, Giannoudis P V. Radiological measurements for postoperative evaluation of quality of reduction of unstable pelvic ring fractures: Advantages and limitations［Ｊ］. Injury, 2011, 42(12): 1395－1401.
［22］Tornetta P 3, Matta J M. Outcome of operatively treated unstable posterior pelvic ring disruptions［Ｊ］. Clin Orthop Relat Res, 1996(329): 186－193.
［23］Matta J M, Tornetta P 3 rd. Internal fixation of unstable pelvic ring injuries［Ｊ］. Clin Orthop Relat Res, 1996(329): 129－140.
［24］李涛. TiRobot机器人辅助下经皮螺钉内固定治疗骨盆骨折的临床效果分析［D］. 济南: 山东大学, 2021.
［25］贾健. 骨科定位机器人在骨盆髋臼骨折手术治疗中的应用［Ｊ］. 中华骨科杂志, 2023, 43(19): 1334－1342.
［26］赵春鹏, 王军强, 苏永刚, 等. 机器人辅助经皮螺钉内固定治疗骨盆和髋臼骨折［Ｊ］. 北京大学学报: 医学版, 2017, 49(2): 274－280.
［27］李鹏. 机器人辅助与传统透视辅助置入骶髂螺钉治疗骨盆后环骨折的Meta分析［D］. 太原: 山西医科大学, 2023.
［28］Majeed S A. Grading the outcome of pelvic fractures［Ｊ］. J Bone Joint Surg Br, 1989, 71(2): 304－306.
［29］李灿辉, 吴征杰, 曾焰辉, 等. 骨科机器人辅助微创手术治疗骨盆骨折的临床应用研究［Ｊ］. 北京生物医学工程, 2022, 41(2): 134－139.
［30］王永标, 冯小仍, 姚艺艺, 等. 天玑骨科手术机器人结合三维成像技术辅助微创治疗骨盆骨折的疗效分析［Ｊ］. 中华创伤骨科杂志, 2022, 24(10): 856－861.
［31］Ead M S, Westover L, Polege S, et al. Virtual reconstruction of unilateral pelvic fractures by using pelvic symmetry［Ｊ］. Int J Comput Assist Radiol Surg, 2020, 15(8): 1267－1277.
［32］Ead M S, Duke K K, Jaremko J L, et al. Investigation of pelvic symmetry using CAD software［Ｊ］. Med Biol Eng Comput, 2020, 58(1): 75－82.
［33］Chunpeng Z, Mingjun G, Chao S, et al. Automatic reduction planning of pelvic fracture based on symmetry［Ｊ］. Comput Methods Biomech Biomed Eng Imaging Vis, 2022, 10(6): 577－584.
［34］Kausch L, Thomas S, Kunze H, et al. Toward automatic C-arm positioning for standard projections in orthopedic surgery［Ｊ］. Int J Comput Assist Radiol Surg, 2020, 15(7): 1095－1105.
［35］Du D J, Liu Z, Omori S, et al. Computer-aided parachute guiding system for closed reduction of diaphyseal fractures［Ｊ］. Int J Med Robot, 2014, 10(3): 325－331.
［36］Koo T K K, Papuga M O. A computer aided method for closed reduction of diaphyseal tibial fracture using projection images: A feasibility study［Ｊ］. Comput Aided Surg, 2009, 14(1/3): 45－57.
［37］Nakajima Y S K, Tashiro T, Sugano N, et al. Fluoroscopic bone fragment tracking for surgical navigation in femur fracture reduction by incorporating optical tracking of hip joint rotation center［Ｊ］. IEEE Trans Biomed Eng, 2007, 54(9): 1703－1706.
［38］Ron O, Joskowicz L, Milgrom C, et al. Computer-based periaxial rotation measurement for aligning fractured femur fragments from CT: a feasibility study［Ｊ］. Comput Aided Surg, 2002, 7(6): 332－341.
［39］许珂, 朱罡, 王豫, 等. 辅助骨盆骨折复位的弹性牵引装置实验研究［Ｊ］. 北京生物医学工程, 2019, 38(2): 126－133.
［40］Liu J X, Xu K, Zhao C P, et al. Experimental and finite element analysis studies of a reduction-force reducing traction method for pelvic fracture surgeries［Ｊ］. Med Nov Technol Devices, 2022, 13: 100101.
［41］Tobolsky V A, Kurki H K, Stock J T. Patterns of directional asymmetry in the pelvis and pelvic canal［Ｊ］. Am J Hum Biol, 2016, 28(6): 804－810.
［42］Boulay C, Tardieu C, Bénaim C, et al. Three-dimensional study of pelvic asymmetry on anatomical specimens and its clinical perspectives［Ｊ］. J Anat, 2006, 208(1): 21－33.
［43］葛硕, 张雷, 周子斐, 等. 天玑骨科机器人联合O臂导航系统辅助经皮微创治疗骨盆后环损伤［Ｊ］. 中国修复重建外科杂志, 2022, 36(8): 934－939.