改良髂腹股沟下入路的解剖学基础与临床应用

发布时间：2018-04-25 21:34

本文选题：髋臼骨折 + 外科手术　；参考：《郑州大学》2016年博士论文

【摘要】：髋臼骨折属于关节内骨折,后期髋关节功能的恢复和患者的满意度均与关节面的复位质量密切相关。经典的髂腹股沟入路虽然可以应用于除后壁骨折、后柱骨折、后柱合并后壁骨折、横行合并后壁骨折外的其他六种类型骨折,但由于腹股沟韧带的限制,采用该入路时无法显露髋关节,只能通过间接复位;而在植入螺钉时因无法直视关节面,即使借助术中透视,仍有可能误入到关节内,因此对术者的手术经验和复位技巧要求非常高。另外,术中对髂动静脉及其周围淋巴组织的牵拉、剥离等易引起血管损伤、术后深静脉血栓形成或术后淋巴漏;术中需要切开腹股沟管,如重建不佳可能导致术后腹股沟疝。针对以上不足之处,2008年Farid提出了髂腹股沟下入路,相比较传统的髂腹股沟入路具有如下优势:(1)该入路通过髂嵴截骨的方式可以显著扩大外侧窗,通过切断缝匠肌和股直肌可以实现髋臼关节面的直视下复位;(2)在腹股沟韧带下方分离结扎腹壁下动脉和旋髂深动脉,理论上可以避免死亡冠的损伤和减少术中出血;(3)无需切开腹股沟管,可以避免腹股沟直疝和斜疝的发生;(4)无需重建腹股沟管壁,因此闭合切口时间明显缩短。然而我们在临床实践中发现该入路存在以下问题:(1)因需要切断股外侧皮神经会引起术后灼性神经痛或其支配区的感觉障碍;(2)缝匠肌和股直肌采用直接切断于术毕进行缝合重建,因术后制动时间较长会影响术后康复及功能锻炼;(3)采取在腹股沟韧带下分离髂股血管进行三窗显露的方式并未减少对大血管的牵拉损伤;(4)对Fruchard孔下区完整性的破坏可能会诱发术后股疝的发生。因此,如何来减少或避免这些损伤以及由此导致的并发症仍需要进一步探讨。第一部分:改良髂腹股沟下入路的解剖学研究目的总结髂腹股沟下入路所涉及的解剖结构容易受损伤的原因,探讨预防损伤的具体手术技巧及对该入路的改良方法。方法应用20具成人尸体标本,首先按照髂腹股沟下入路步骤切开、分离,然后针对临床手术“三窗”显露时涉及到的解剖结构进行上下延伸逐层解剖,观察、测量、记录相关解剖结构走行、厚度、长度、角度及毗邻关系,结合临床操作分析其易损伤的原因及预防方法。结果髂腹股沟下入路三窗显露时涉及到的结构易受损伤的解剖特点:1.髂腹下神经和髂腹股沟神经的外侧段位于髂嵴上缘及髂结节内侧,如切口外侧段位置偏高易损伤;2.股外侧皮神经在髂前上棘内侧(22.35±1.65)mm穿腹股沟韧带出骨盆,呈(80.56±10.53)°角入股部,距髂前上棘(43.45±2.26)mm自阔筋膜浅出,因走行角度、穿出骨盆和阔筋膜部位存在较多变异,如不能直视下分离则易受损伤;3.旋髂深动脉31侧(77.5%)起始于髂外动脉,因此直接在腹股沟韧带下寻找并结扎旋髂深动脉较困难;4.缝匠肌与腹股沟韧带下缘呈(40.23±5.35)°向内下方斜行,覆盖于股神经和股动静脉前方,与股神经外侧边分支交汇点到腹股沟韧带下缘垂直距离约(20.13±6.02)mm,与股动脉交汇点到腹股沟韧带下缘的距离约(60.03±10.12)mm。缝匠肌、腹股沟韧带和髂耻弓三者对股神经和髂股血管起到保护和约束作用,术闭需要良好重建;5.腹壁下动脉23侧(57.5%)起自于髂外动脉,发出点到腹股沟韧带上缘的距离约为(8.81±3.02)mm,术中直接结扎该血管时易导致损伤;6.髂股血管前方与腹股沟韧带后壁结合较紧密,在腹股沟韧带下分离髂股血管并不能减少损伤;7.闭孔神经入小骨盆口处距离骨壁(10.18±2.44)mm,中点处距离骨壁(12.23±0.84)mm,骨折移位或显露四边体时易受损伤;8.Fruchard孔下区为近似四边形结构,存在多个薄弱部位,髂腹股沟下入路对其造成的广泛破坏因难以重建而易诱发多种股疝发生;9.腹壁下动脉与闭孔动脉的吻合支距离陷窝韧带约(10.65±3.22)mm,直接切开陷窝韧带显露内侧窗时易导致损伤。入路改良的解剖基础:1.髂耻弓总长约(31.25±1.42)mm,与髂耻隆起连接处致密,不易完整剥离。与腹股沟韧带内侧半呈(22.83±5.79)°夹角,仅有疏松的结缔组织充填,容易剥离分开;而夹角顶点距离股动脉外侧缘约(18.66±2.35)mm,左右侧比较无显著性差异(P0.05),在此处切开不易损伤股动脉。2.整体观髂筋膜在整个髂窝内呈一凹陷的近似四边体结构,近侧端较薄弱,向远端则逐渐增厚。髂筋膜深面及表面有髂肌、腰大肌、股神经和股外侧皮神经;生殖股神经和闭孔神经穿髂筋膜处较高,在髂窝处位于髂筋膜前方;髂血管及其周围淋巴组织、旋髂深动脉腹股沟段位于髂筋膜前方。只要保持髂筋膜完整,在其下方分离不会伤及上述结构。3.陷窝韧带游离缘厚度仅为(0.23±0.11)mm,结构薄弱,但其与耻骨肌筋膜一同附着于耻骨上支上方,附着点筋膜厚度为(2.23±1.35)mm,结构致密,可于此处完整剥离骨膜及筋膜后放置钢板。结论1、采用髂腹股沟下入路治疗髋臼骨折,手术切口及三窗显露时易对髂腹下神经、髂腹股沟神经、股外侧皮神经、股神经、闭孔神经、生殖股神经、旋髂深动脉、腹壁下动脉及其吻合支造成损伤;并不能减少髂股血管及周围淋巴组织的牵拉伤;易对Fruchard孔下区造成损伤,诱发术后股疝等并发症。2、髂筋膜与周围解剖结构关系密切,对于髂腹股沟下入路,可以通过髂前上棘截骨,于髂筋膜下显露外侧窗,辅以内侧小切口显露耻骨上支的方法进行改良,减少或避免相关的并发症。第二部分:应用髂腹股沟下入路与改良入路治疗髋臼前部简单骨折的疗效比较目的比较应用髂腹股沟下入路与改良入路治疗髋臼前部骨折的疗效。方法回顾性分析13例应用改良的髂腹股沟下入路(A组)和21例应用髂腹股沟下入路(B组)治疗的髋臼前部骨折(前壁、前柱和横行骨折)的临床资料。对两组的手术时间、术中出血量、Matta放射学评分的优良率及骨折的愈合时间进行比较。比较两组最后随访时的改良d’Aubigné-Postel功能评分和髋关节的活动度。结果两组患者的性别、年龄、骨折分型、自受伤到手术的间隔时间差别均无统计学意义,具有可比性(P0.05)。A组的手术时间平均为90min(60~160min),B组为110min(90~210min),两组之间差异有统计学意义(P㩳0.05);A组的平均失血量为530m L(400~1050m L),B组平均为830m L(600~1250m L),两组差异有统计学意义(P㩳0.05)。A组和B组的骨折愈合时间分别为20w(14~23w)和22w(15~25w);Matta放射学评分优良率分别为84.61%和90.48%;改良d’Aubigné-Postel评分优良率分别为92.30%和90.48%;关节活动度A组前屈(103.34±10.27)°后伸(10.23±5.12)°,B组前屈(106.13±12.33)°后伸(11.01±3.12)°。两组Matta放射学评分优良率、骨折愈合时间、改良d’Aubigné-Postel功能评分和髋关节活动度无显著性差异(P㧐0.05)。A组1例脂肪液化、3例腿肌间静脉血栓,无切口感染、神经损伤或麻痹、术后淋巴漏、内固定松动等并发症,B组21例均出现股外侧皮神经麻痹症状,另有2例脂肪液化、2例深静脉血栓、3例小腿肌间静脉血栓、3例术后淋巴漏和5例隐性股疝。结论与髂腹股沟下入路相比,应用改良髂腹股沟下入路治疗髋臼前部骨折可以避免股外侧皮神经损伤,减少并发症,并在缩短手术时间,减少出血量方面具有优势。第三部分:应用改良髂腹股沟下入路治疗髋臼复杂骨折的临床研究目的探讨应用改良髂腹股沟下入路即髂筋膜下显露外侧窗联合内侧小切口显露耻骨上支的方法治疗髋臼复杂骨折的可行性及临床疗效。方法2012年1月到2015年6月采用改良髂腹股沟下入路治疗22例髋臼复杂骨折,男12例,女10例,年龄22~56岁,平均37.0岁。根据Judet-Letournel分类:T形骨折4例,前柱合并后半横形骨折5例,双柱骨折13例。采用单一改良髂腹股沟下入路19例,联合Kocher-Langenbeck入路3例。应用Matta放射学标准评价术后复位情况;改良d’Aubigné-Postel评分系统评价髋关节功能。结果22例患者手术时间平均110min(80~210min);出血量平均770m L(650~1250m L)。术后出现3例脂肪液化,5例小腿肌间静脉血栓,5例深静脉血栓。无切口感染、坐骨神经、股神经及股外侧皮神经损伤表现及术后淋巴漏。22例患者获得平均18个月(8~22个月)随访,骨折平均愈合时间为22周(14~26周)。术后骨折复位质量根据Matta放射学标准评定:优11例,良5例,可3例,差3例,优良率(72.73%)。最后随访时间无内固定松动、断裂及腹股沟区疝,根据改良的d’Aubigné-Postel评分系统:优13例,良5例,可3例,差1例,优良率(81.82%)。评价为差的1例患者于术后9个月出现FicatⅣ期股骨头坏死,行全髋关节置换术。结论改良髂腹股沟下入路广泛的显露不但保障了前柱及前壁的直视下复位和固定,也利于后柱螺钉的准确置入,可以应用于髋臼复杂骨折的一些亚型。结合完善的术前准备,术后感染、血肿、深静脉血栓等并发症的预防以及正确的康复训练可以取得理想的疗效。
[Abstract]:The fracture of the acetabulum belongs to the intra-articular fracture. The recovery of the posterior hip function and the satisfaction of the patients are closely related to the quality of the articular surface reduction. The classic iliac inguinal approach can be applied to the posterior wall fracture, posterior column fracture, posterior wall fracture, and other six types of fractures outside the posterior wall fracture, but the abdomen is due to the abdomen. The limitation of the groin ligament is that the hip joint can not be exposed at the time of the approach, only by indirect reduction, but the inability to look at the articular surface when the screw is implanted, even with the help of intraoperative fluoroscopy, is still possible to enter the joint. Therefore, the operation experience and the reduction skills are not often high. In addition, the iliac vein and its peripheral lymph nodes are used in the operation. Retraction, divestiture, etc. easily cause vascular damage, deep venous thrombosis or postoperative lymphatic leakage; intraoperative incision of the groin tube, such as poor reconstruction, may lead to postoperative inguinal hernia. For the above deficiencies, the lower iliac inguinal approach was proposed by Farid in 2008 compared with the traditional iliac approach: (1) the following advantages The lateral window can be significantly expanded through the osteotomy of the iliac crest. The reduction of the articular surface of the acetabulum can be achieved by cutting the sartorius and the rectus femoris. (2) the ligation of the lower abdominal artery and the deep iliac artery under the inguinal ligament can theoretically avoid the injury of the dead crown and reduce the intraoperative bleeding; (3) no inguinal canal is not needed. It is possible to avoid direct inguinal hernia and oblique hernia; (4) there is no need to reconstruct the wall of the inguinal canal, so the closure of the incision is obviously shortened. However, we found the following problems in clinical practice: (1) the need to cut the lateral femoral cutaneous nerve to cause postoperative burning nerve pain or the sensory disturbance in its dominating area; (2) the sartorius and rectus femoris The postoperative rehabilitation and functional exercise can be affected by a long period of closure with a longer period of brakes. (3) the way to separate the iliac femoral vessels under the inguinal ligament for the three window exposure does not reduce the traction damage to the large vessels; (4) the damage to the integrity of the suborifice of the Fruchard may induce the post operative hernia. Therefore, how to reduce or avoid these injuries and the resulting complications still need to be further explored. Part 1: to improve the anatomical study of the inferior inguinal approach, to summarize the causes of the anatomical structures involved in the inferior inguinal approach, and to explore the specific surgical techniques for the prevention of injury and the approach to this approach. Methods 20 adult cadavers were used to cut and separate the specimens according to the procedure of the iliac inguinal approach. Then the anatomical structures involved in the clinical operation "three windows" were dissected, observed, measured, and recorded the related anatomical structure, thickness, length, angle and adjacent relationship, combined with clinical exercises. Results the causes and prevention methods of the injuries were analyzed. Results the anatomical features of the structures involved in the three window of the ilio inguinal approach were revealed: 1. the lateral segment of the iliac inferior nerve and the ilio inguinal nerve located at the upper iliac crest and the medial iliac nodules, such as the high location of the lateral incisional segment, and the 2. femoral lateral cutaneous nerve in the anterior superior iliac spine. The lateral (22.35 + 1.65) mm of the inguinal ligament was out of the pelvis, (80.56 + 10.53) angle into the femoral part, and from the anterior superior iliac spine (43.45 + 2.26) mm from the fascia. There were many variations in the position of the pelvis and the fascia lata because of the walking angle, for example, it was easy to be damaged in the part of the pelvis and the fascia lata; the 31 side of the 3. deep iliac artery (77.5%) started from the external iliac artery, so it was directly in the middle of the iliac artery. It is difficult to find and ligate the deep iliac artery under the inguinal ligament; the 4. sartorius muscle and the inferior inguinal ligament are (40.23 + 5.35) degrees inward, covering the femoral nerve and the femoral vein. The vertical distance from the lateral branch of the groin to the inferior edge of the inguinal ligament is about (20.13 + 6.02) mm, and the intersection of the femoral artery to the groin is toughened. The distance of the lower margin (60.03 + 10.12) mm. sartorius, inguinal ligaments and iliac iliac arches played a protective and binding role in the femoral and iliac femoral vessels, and the operation closed to a good reconstruction; the 5. abdominal inferior artery 23 (57.5%) from the external iliac artery, the distance from the point to the inguinal ligament was about (8.81 + 3.02) mm, and the blood was directly ligated during the operation. Guan Shiyi caused injury; 6. the front of the iliac ligament was closely associated with the posterior ligament of the inguinal ligament, and the separation of the iliac femoral vessels under the inguinal ligament could not reduce the damage; 7. the obturator nerve was located at the mouth of the bone (10.18 + 2.44) mm, and the middle point was distance from the bone wall (12.23 + 0.84) mm. The fracture was displaced or exposed to the quadrangular body, and the 8.Fruchard hole was easily damaged. The lower region is an approximate quadrilateral structure, and there are many weak parts. The extensive destruction caused by the inferior inguinal approach is easy to induce multiple inguinal hernia. The anastomosis branch of the inferior wall artery and the closed artery of the 9. abdomen is about (10.65 + 3.22) mm, and the direct incision of the lacunae ligament exposes the medial window to the injury. Good anatomical basis: 1. the total length of the 1. iliac arch is about (31.25 + 1.42), which is dense and not easy to peel off with the iliac hump. It is half (22.83 + 5.79) angle with the inside of the inguinal ligament, only loose connective tissue is filled and easily stripped and separated, but the angle of the apex is about (18.66 + 2.35) mm, and there is no significant difference between the left and right sides. P0.05, the incision is not easy to damage the femoral artery.2. as a whole, and the iliac fascia in the whole iliac fossa is an approximate quadrangular structure in the whole iliac fossa. The proximal end is weak, and gradually thickens to the distal end. The deep surface and surface of the iliac fascia have iliac muscle, the psoas muscle, the femoral nerve and the lateral femoral cutaneous nerve; the genital and obturator nerve and the iliac fascia are higher. The iliac fossa is located in front of the iliac fascia; the iliac vessel and its peripheral lymphatic tissue and the inguinal segment of the deep iliac artery are located in front of the iliac fascia. As long as the iliac fascia is intact, the separation below it will not hurt the thickness of the free margin of the.3. lacunar ligament (0.23 + 0.11) mm and the structure is weak, but it is attached to the suprapubic branch with the pubis myofascial membrane. Above, the thickness of the attachment point was (2.23 + 1.35) mm, and the structure was dense, and the plate could be placed after the entire periosteum and fascia. Conclusion 1, the iliac inguinal approach was used to treat the acetabular fracture. The surgical incision and the three window were easily exposed to the iliofabastric nerve, the ilio inguinal nerve, the lateral femoral cutaneous nerve, the femoral nerve, the obturator nerve and the reproduction of the femoral nerve. The deep iliac artery, inferior epigastric artery and its anastomotic branch are damaged, and it can not reduce the traction of the iliac femoral vessels and peripheral lymphatic tissue; it is easy to cause damage to the suborifice of the Fruchard and induce postoperative complications such as.2, the iliac fascia is closely related to the surrounding anatomy, and the inferior iliac inguinal approach can be used for the iliac anterior upper spine osteotomy and iliac iliac. Subfascial exposure of the lateral window with a small medial incision to expose the superior branch of the pubic symphysis to reduce or avoid related complications. Second part: comparison of the efficacy of the inferior inguinal approach and improved approach for the treatment of simple fracture of the anterior acetabulum; the application of the iliac femoral subtrench approach and improved approach for the treatment of the anterior acetabular fracture Methods the clinical data of 13 cases of the modified iliac inferior inguinal approach (group A) and 21 cases of the anterior, anterior and transverse fractures of the acetabulum treated by the inferior inguinal approach (group B) were retrospectively analyzed. The operative time, the amount of intraoperative bleeding, the good rate of Matta radiological score and the healing time of the fracture were compared between the two groups. Compared with the improved d 'Aubign e -Postel function score and the hip joint activity at the last follow-up of the two groups. Results there were no significant differences in the sex, age, fracture type and interval between the two groups of patients and the interval between the injury to the operation, and the average operation time of the.A group was 90min (60~160min), and the B group was 110min (90~210min). The difference between the two groups was statistically significant (P? 0.05); the average blood loss in the group A was 530m L (400~1050m L), the average of the B group was 830m L (600~1250m L), and the two groups were statistically significant (P? 0.05) and the fracture healing time was 84.61% and 90.48% respectively. The excellent rate of -Postel score was 92.30% and 90.48%, joint activity A (103.34 + 10.27) degrees (10.23 + 5.12) degrees, B group forward flexion (106.13 + 12.33) degrees (11.01 + 3.12) degrees. The excellent rate of Matta radiology score, fracture healing time, improved d 'Aubign e -Postel function score and hip joint activity were no significant difference (P? 0) 5) in group.A, 1 cases of fat liquefaction, 3 cases of intermuscular venous thrombosis, no incision infection, nerve injury or paralysis, postoperative lymphatic leakage, internal fixation loosening and other complications, 21 cases in group B all had lateral femoral cutaneous nerve paralysis, 2 cases of fat liquefaction, 2 cases of deep venous thrombosis, 3 cases of intermuscular venous thrombosis, 3 cases of postoperative lymphatic leakage and 5 recessive hernia. Compared with the inferior inguinal approach, the modified iliac inguinal approach in the treatment of the anterior acetabular fracture can avoid the lateral femoral cutaneous nerve injury, reduce the complications, and have advantages in shortening the operation time and reducing the amount of bleeding. The third part: the clinical study of the modified iliac inferior groin approach for the treatment of the complex fracture of the acetabulum The feasibility and clinical efficacy of the modified iliac inferior inguinal subfascia under the external iliac fascia exposed to the lateral window and the small medial incision to reveal the superior branch of the pubis in the treatment of the complex fracture of the acetabulum. Methods from January 2012 to June 2015, the modified iliac inguinal approach was used to treat 22 cases of complex fracture of the acetabulum, 12 males and 10 females, with an average age of 37. years, averaging 37.. 0 years old. According to Judet-Letournel classification: 4 cases of T shaped fracture, 5 cases of anterior column with posterior semi transverse fracture and 13 cases of double column fracture. 19 cases with single improved iliac inferior inguinal approach and 3 cases with Kocher-Langenbeck approach were used to evaluate the postoperative reduction with Matta radiology standard; the modified D 'Aubign e -Postel scoring system was used to evaluate hip function. 22 results 22 The average operation time of the patients was 110min (80~210min), the average bleeding volume was 770m L (650~1250m L). 3 cases of fat liquefaction, 5 cases of intermuscular venous thrombosis, 5 cases of deep venous thrombosis, no incision infection, sciatic nerve, femoral nerve and lateral femoral cutaneous nerve injury, and postoperative lymphatic leakage of.22 cases were followed up for 18 months (8~22 months). The average healing time of fracture was 22 weeks (14~26 weeks). The quality of fracture reduction was evaluated according to Matta radiological criteria: excellent 11 cases, good 5 cases, 3 cases, 3 poor cases, excellent rate (72.73%). The final follow-up time had no internal fixation loosening, fracture and inguinal hernia, according to improved d 'Aubign e -Postel scoring system: excellent 13 cases, good 5 cases, 3 cases, 1 cases, poor 1 case, fine 1 cases, fine 1 cases, excellent and good Rate (81.82%). 1 patients with poor evaluation appeared Ficat IV necrosis of the femoral head and total hip replacement at 9 months after operation. Conclusion the extensive exposure of the improved inferior inguinal approach not only protects the immediate reduction and fixation of the anterior and anterior walls, but also facilitates the accurate placement of the posterior column screws, which can be applied to some of the complicated acetabular fractures. Combination of comprehensive preoperative preparation, postoperative infection, hematoma, deep vein thrombosis and other complications prevention and proper rehabilitation training can achieve satisfactory results.

【学位授予单位】：郑州大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R687.3;R322.7

【相似文献】