经臀中肌前缘间隙入路治疗股骨转子间骨折的解剖学基础及临床应用研究

发布时间：2018-12-31 14:47

【摘要】：第一部分：经臀中肌前缘间隙入路至股骨近端的解剖学基础目的：探讨在改良股骨外侧入路的基础上经臀中肌前缘间隙入路显露股骨颈及股骨大、小转子的解剖特点，明确该手术入路的重要解剖标志并对其进行解剖学测量，为臀中肌前缘间隙手术入路治疗股骨转子间骨折提供解剖学基础。方法：8例(16侧)成人尸体下肢标本，模拟臀中肌前缘间隙入路对重要骨性解剖标志和神经血管进行解剖观测。结果：经臀中肌前缘间隙可充分显露股骨颈及股骨大、小转子。臀中肌前缘间隙髂嵴附着处距髂前上棘距离（5.08±0.59）cm(4.06～6.33cm），在该间隙内常见臀上神经最下支以及旋股外侧动脉升支臀中肌支穿过。臀上神经最下支穿臀中肌前缘间隙处至股骨大转子外侧最凸点距离为（7.29±0.72）cm(6.35～9.56cm）；旋股外侧动脉升支臀中肌支走行至该间隙处距离股骨大转子外侧最凸点距离为（5.66±0.42）cm(5.05～6.87cm）。结论：臀中肌前缘间隙入路在改良股骨外侧入路的基础上可充分显露股骨近端结构如股骨颈、股骨大、小转子以及股骨干上段等，具有安全、软组织损伤小等特点，为股骨转子间骨折的手术治疗提供了新思路和新方法。第二部分：经臀中肌前缘间隙入路治疗老年股骨转子间骨折的临床应用研究目的：与传统股骨外侧入路相比较，探索经臀中肌前缘间隙入路治疗股骨转子间骨折的临床疗效。方法：回顾分析2011年2月-2013年2月67例采用动力髋螺钉（DHS）治疗的股骨转子间骨折患者的临床资料，其中经臀中肌前缘间隙入路35例（试验组），经传统股骨外侧入路32例（对照组）。两组患者性别、年龄、Singh指数、侧别、骨折分型、致伤原因及合并症比较，差异均无统计学意义（P0.05）。记录两组患者手术时间、手术出血量、透视次数、术后引流量、住院时间及术后并发症等，并于术后6,12月根据自定疗效评定标准评估患者髋关节功能。结果：两组均顺利完成手术，术中无神经、大血管损伤发生。患者骨折均在3-5月内达到骨性愈合，愈合时间为3-5个月，平均3.7个月。61例患者获得随访，平均随访时间18.2个月（14-24个月）。试验组患者在手术时间、术中出血量和透视次数、术后引流量以及住院时间方面显著少于对照组（P0.05）；根据自定评价标准，术后6、12个月髋关节恢复程度及功能评定结果表明试验组优于对照组，，差异有统计学意义（P0.05）；两组患者在术后髋内翻畸形愈合及总并发症等方面明显少于对照组（P0.05）；两组患者在切口感染、下肢短缩畸形、内固定松动以及主螺钉切出股骨头等方面比较，差异无统计学意义（P0.05）。结论：与传统股骨外侧入路比较，经臀中肌前缘间隙入路治疗股骨转子间骨折具有骨折暴露充分、手术时间短、创伤小等优点，达到术后近期及远期并发症减少和早期功能康复的目的，促进髋关节功能恢复。
[Abstract]:Part one: anatomical basis from the anterior space approach of the middle gluteal muscle to the proximal end of the femur objective: to explore the anatomical characteristics of the femoral neck and the large and small trochanter of the femur through the anterior space approach of the middle gluteal muscle on the basis of the modified lateral approach of the femur. The important anatomic markers of the approach were identified and measured, which provided anatomic basis for the treatment of intertrochanteric fracture of femur by the anterior space approach of gluteus medius. Methods: eight adult cadavers (16 sides) with lower extremities were studied by simulating the anterior space approach of gluteus medius muscle to observe the important bone anatomical markers and nerve and blood vessels. Results: the femoral neck and the large and small trochanter of femur could be fully exposed through the anterior space of gluteal middle muscle. The distance from the anterior iliac crest to the anterior superior iliac spine was 5.08 卤0.59) cm (4.06~6.33cm. The inferior branch of the superior gluteal nerve and the middle gluteus muscle branch of the ascending branch of lateral femoral circumflex artery were found in this space. The distance between the inferior branch of superior gluteal nerve and the protruding point of the lateral greater trochanter of femur was (7.29 卤0.72) cm (6.35~9.56cm). The distance between the middle gluteal muscle branch of the ascending branch of lateral femoral circumflex artery and the protruding point of the greater trochanter was (5.66 卤0.42) cm (5.05~6.87cm). Conclusion: the anterior margin approach of the middle gluteal muscle can fully reveal the proximal femoral structures such as the femoral neck, the large, the small trochanter and the upper segment of the femoral shaft on the basis of the modified lateral approach of the femur, which has the characteristics of safety and little soft tissue injury. It provides a new idea and method for the surgical treatment of intertrochanteric fracture of femur. Part two: clinical study on the treatment of intertrochanteric fracture of femur through the anterior margin approach of the middle gluteal muscle objective: to compare with the traditional approach of lateral approach of femur. Objective: to explore the clinical effect of intertrochanteric fracture of femur through anterior space approach of gluteus medius muscle. Methods: the clinical data of 67 patients with intertrochanteric fracture treated with dynamic hip screw (DHS) from February 2011 to February 2013 were retrospectively analyzed. 32 cases were treated by traditional lateral femoral approach (control group). Gender, age, Singh index, lateral sex, fracture classification, injury causes and complications were not significantly different between the two groups (P0.05). The operation time, blood loss, fluoroscopy times, postoperative drainage, hospital stay and postoperative complications were recorded in the two groups. The hip function was evaluated according to the standard of self-determined curative effect 6 and 12 months after operation. Results: the operation was completed successfully in both groups. There was no nerve and major vascular injury occurred during the operation. The fracture healing time was 3-5 months (mean 3.7 months). 61 patients were followed up for an average of 18.2 months (14-24 months). The time of operation, the amount of blood loss during operation, the times of fluoroscopy, postoperative drainage and hospital stay in the trial group were significantly less than those in the control group (P0.05). According to the self-evaluation criteria, the degree and function of hip joint recovery were evaluated at 6,12 months after operation. The results showed that the test group was superior to the control group, the difference was statistically significant (P0.05). The patients in the two groups were significantly less than the control group in the healing of coxa varus deformity and total complications (P0.05). There was no significant difference between the two groups in incision infection lower extremity shortening deformity internal fixation loosening and main screw cutting out of femoral head (P0.05). Conclusion: compared with the traditional approach of lateral femoral approach, the treatment of intertrochanteric fracture through the anterior margin of gluteal muscle approach has the advantages of full exposure, short operative time and less trauma. The short-term and long-term postoperative complications were reduced and early functional rehabilitation was achieved, and the hip function recovery was promoted.
【学位授予单位】：南昌大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R683;R322.7

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