虚拟现实技术联合电磁导航手术机器人辅助治疗复杂骨盆骨折一例

2020-07-28 胡鹏宇 王海涛 余志平 中国修复重建外科杂志

患者 女,50岁。因“交通事故致全身多处疼痛、活动受限2.5h”于2019年8月入院。入院查体:患者下颌部、双膝、左踝皮肤挫伤并少量渗血;腰椎叩击痛,骨盆挤压分离试验(+),双髋关节因疼痛不能活动;右

病例介绍

患者 女,50岁。因“交通事故致全身多处疼痛、活动受限2.5h”于2019年8月入院。入院查体:患者下颌部、双膝、左踝皮肤挫伤并少量渗血;腰椎叩击痛,骨盆挤压分离试验(+),双髋关节因疼痛不能活动;右小腿近端轻度肿胀,可触及骨擦感;双足活动良好,足背动脉搏动有力。骨盆CT平扫+三维重建显示骨盆粉碎性骨折(TileC3型),其中耻骨上、下支骨折,右侧骶髂关节脱位伴右髂骨骨折(图1a)。初步诊断为左侧耻骨上、下支骨折,左侧坐骨骨折,左髋臼骨折,骶椎多发骨折,右侧耻骨下支骨折,右骶髂关节脱位,右腓骨近端骨折,以及左膝前、下颌部皮肤裂伤。

入院后急诊行骨盆骨折闭合复位、外固定支架固定以及左股骨髁上牵引术。3d后患者病情稳定,复查骨盆CT平扫+三维重建,示耻骨上、下支骨折复位良好,右侧骶髂关节间隙恢复正常,髂骨骨折复位良好,骨盆骨折及分离部分恢复正常(图1b)。术后2周评估患者可耐受手术后,拟在3D虚拟现实技术(virtualreality,VR)眼镜(微软公司,美国)联合电磁导航手术机器人(山东威高集团有限公司)辅助定位下,行右骶髂关节脱位复位空心钉内固定术+骨盆骨折微创小切口桥接钢板内固定术。术前采用3D打印技术制备骨盆模型,根据模型选择合适的桥接钢板并预弯后消毒备用。


全麻下,患者取仰卧位,右臀部垫高,向对侧倾斜约25°。术者佩戴3DVR眼镜,选取骨性结构明显的3处(双侧髂前上棘以及右侧髂前上棘后方3cm处,尽量避开手术入路),穿入3枚细克氏针作为下一步配准选点的标志(图1c)。然后术中CT扫描骨盆,将数据导入电磁导航系统构建骨盆三维模型,采取5点配准法进行配准;用鼠标在骨盆三维模型的3枚克氏针上,按顺序选择5个分散点,完成图像选点。将电磁导航系统自配探针点放在患者骨盆上(位置与图像选点相同),并保持静止1s,该点自动被系统选中,完成5个分散点操作后软件自动进行粗配准;再用探针在患者骨盆划动,进行“患者点云选择”,最后完成精确配准。在电磁导航系统上设计右骶髂关节脱位空心钉固定最佳手术路径,并在路径上测量最适空心钉长度(图1d);电磁导航手术机器人的机械臂根据规划的手术路径进行精准定位,术者通过机械臂上套筒直接钻孔(图1e);经术中CT验证位置满意后,拧入选择的空心钉,再次CT验证螺钉位置满意。于左侧髂前上棘、耻骨联合上方约2cm处分别作长约3、4cm小切口,拆除骨盆外固定支架,在电磁导航系统辅助下实时复位骨盆骨折,安放预弯的桥接钢板,拧入6枚螺钉,再次透视复位固定效果满意。手术时间2h,术中出血量20mL。内固定术后3d复查X线片显示骨折复位良好、内固定位置满意(图1f)。术后切口Ⅰ期愈合,2周后拆线。术后5个月X线片示骨折位置良好,骨折线较前模糊(图1g)。患者恢复良好,可下地活动,无不良反应。

讨论

骨盆是人体结构中非常重要的部位,具有三维形状、深层构造及与重要结构毗邻的特点,多平面复合性损伤导致的不稳定型骨盆骨折是临床治疗难点。目前,已有3D打印技术、导航技术辅助治疗骨盆骨折的报道。电磁导航技术是通过发生器产生磁场,发射和接收电磁信号来确定靶目标的空间位置。该技术用于辅助骨折复位具有术中实时定位且准确性高,避免骨折反复复位导致的二次创伤,减少术者及患者X线暴露时间,以及有效避免光学导航术中遮挡问题等优势。

本例患者手术联合了电磁导航手术机器人、VR技术及3D打印技术。右骶髂关节脱位采用复位后空心钉内固定,术前于电磁导航系统完成手术路径规划,术中手术机器人机械臂自动定位,术者只需循机械臂路径直接钻孔。本例术中钻孔1次成功,CT透视确认位置满意,大大降低了手术难度,避免了术中反复穿刺与X线透视。耻骨及髋臼骨折采取微创桥接钢板内固定,在电磁导航系统辅助下实时复位骨折后,放置术前按照3D打印骨盆模型预弯的桥接钢板,有效避免了钢板反复折弯导致的强度降低,以及骨折移动对周围血管神经带来的二次损伤。本例手术在电磁导航手术机器人、VR技术以及3D打印技术辅助下顺利完成,术中仅透视4次(包括验证透视),出血少,手术时间短,与传统手术方式相比体现了绝对优势。但电磁导航辅助技术也存在一些局限性。首先,对术前配准要求高,配准准确性会直接影响术中骨折复位;其次,游离于整体的骨块不能在导航界面上显示。因此,VR技术联合电磁导航手术机器人辅助骨盆手术的疗效及应用价值,有待进一步临床应用验证。

原始出处:

胡鹏宇,王海涛,余志平,孙炳龙,丛海波.虚拟现实技术联合电磁导航手术机器人辅助治疗复杂骨盆骨折一例[J].中国修复重建外科杂志,2020,34(06):807-808.

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    2020-07-30 xue8602
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