两种手术入路在髋关节置换术中的风险评估

发布时间：2018-07-10 20:12

本文选题：髋关节置换 + 前外侧入路　；参考：《河北医科大学》2015年硕士论文

【摘要】：目的:随着生物力学研究的不断深入、假体设计的不断更新、使用寿命的延长以及手术技术的日趋成熟,人工髋关节置换术的适应范围也在不断扩大。它不仅能减少患者的卧床时间,提高患者术后功能恢复进度,还能有效减少由股骨颈骨折所带来的多种并发症。因此人工髋关节置换治疗股骨颈骨折为越来越多的患者所接受。本文通过回顾性分析临床不同手术入路进行的人工髋关节置换,量性比较改良前外侧入路与后侧入路的手术时间与术中出血量,探讨两种手术入路在髋关节置换术中的风险。方法:回顾性分析2011年3月至2015年1月河北医科大学第三医院所收治的股骨颈骨折并接受髋关节置换的患者,从中随机抽取120例病例,排除发育不良、缺血性坏死、关节炎、陈旧性骨折、多发性骨折、术后翻修等情况,其中男性69例,女性51例,年龄45岁-91岁。按手术入路将患者分为观察组和对照组,以髋关节置换改良前外侧入路作为观察组,髋关节置换后侧入路作为对照组,分别每组选取60例,两组患者在性别、年龄、致伤原因、合并疾病等方面比较,差异无显著性。比较两组患者的手术时间和术中出血量。观察组:采用改良前外侧入路,患者健侧卧位,以大转子尖端为中心做弧形切口,切开皮肤及皮下组织后至阔筋膜,切开阔筋膜后进入其下的滑囊,沿阔筋膜张肌肌纤维方向分开阔筋膜张肌及髂胫束,钝性分离臀中肌、臀小肌以及股外侧肌,使用三把髋臼拉勾呈三点状分别放在股骨颈内外侧及髋臼上缘,沿股骨颈基底部前面将关节囊U型切开,这样可以用手指触及并显露股骨头和股骨颈。切开关节囊后,剥离股骨颈,此时股骨头及其骨折面即可充分显露,用取头器取出残头,将髋关节屈曲、内收、外旋,并同时屈膝,将股骨颈基底部的截骨面朝向术野前方,至此,髋臼及股骨颈基底部的截骨面已达到充分的显露,即可进行人工髋关节的安装操作。对照组:采用后侧入路,以大转子顶点为中心,沿股骨干向远端延伸切口,近端向髂后上棘前方延伸,切开皮肤及皮下组织后,切开阔筋膜,钝性分离臀大肌与阔筋膜张肌,显露股外侧肌,钝性分离臀大肌及深筋膜,屈膝、内旋髋关节,显露梨状肌、上[V肌、闭孔内肌、下[V肌。留置缝线牵引诸肌群,在以上诸肌转子尖、转子窝止点处切断,切开关节囊显露股骨颈。手指触摸小转子确定股骨颈截骨长度,旋转截断的股骨颈,显露圆韧带,组织剪剪断圆韧带,拔出股骨头,显露髋臼底,此时即可进行人工髋关节的安装操作。结果:根据两组的手术时间和出血量的方差齐性检验结果可知,两组的手术时间检验结果t=-0.699,P=0.4860.05,因此改良前外侧入路与后侧入路在手术时间上相比没有明显差异(t检验,P0.05)。两组的术中出血量检验结果t=-2.322,P=0.0220.05,因此改良前外侧入路与后侧入路在术中出血量上相比具有显著差异(t检验,P0.05),且由均值可得知具体表现为改良前外侧入路的术中出血量显著小于后侧入路。结论:对于人工髋关节置换治疗股骨颈骨折时,前外侧入路与后侧入路是最常用的手术入路方式。在手术过程中,手术时间与出血量的控制,决定着手术的风险,对患者能否顺利度过围手术期相当重要。因此在保证人工髋关节置换术成功的基础上,用更短的手术时间、控制更少的出血量、更小的手术创伤,为患者的手术安全性提供更好的选择,是骨科医生共同追求的方向。在手术时间方面,改良前外侧入路与后侧入路无明显差异,没有统计学意义;但是在出血量方面,统计学差异还是很显著的,由均值可知改良前外侧入路的出血量明显小于后侧入路,这反映了在人工髋关节置换术中后侧入路比改良前外侧入路的手术风险要高。因此,对于自身身体条件、耐受性较差的患者,可以选择应用改良前外侧入路术式进行人工髋关节置换。
[Abstract]:Objective: with the continuous deepening of biomechanics research, continuous renewal of prosthesis design, prolongation of life span and the maturity of surgical technique, the adaptation range of artificial hip arthroplasty is also expanding. It can not only reduce the patient's bed time, improve the patient's postoperative functional recovery, but also reduce the femoral neck bone effectively. Therefore, artificial hip arthroplasty for the treatment of femoral neck fractures is accepted by more and more patients. In this paper, a retrospective analysis of artificial hip arthroplasty with different surgical approaches was reviewed, and the operative time and amount of intraoperative bleeding were compared between the anterior lateral approach and the posterior approach, and two kinds of surgical procedures were discussed. Methods: the risk of hip arthroplasty. Methods: a retrospective analysis was made of patients with femoral neck fracture and hip replacement in Third Hospital of Hebei Medical University from March 2011 to January 2015. 120 cases were randomly selected to remove dysplasia, ischemic necrosis, arthrosis, obsolete fractures, multiple fractures, post-operative refurbishment, etc. Cases were 69 male, 51 female, 45 years old -91 years old. The patients were divided into the observation group and the control group according to the surgical approach. The modified anterolateral approach was used as the observation group and the hip replacement lateral approach was used as the control group. 60 cases were selected in each group. The two groups were compared with the sex, age, cause of injury, and the combination of diseases. The operation time and intraoperative bleeding amount of the two groups were compared. In the observation group, a modified anterolateral approach, the patient's lateral position, a curved incision with the center of the great trochanter, incision of the skin and subcutaneous tissue to the fascia lata, the fascia lata, and the broad tendons along the tensor fascia lata muscle fibers. The membrane tensor muscle and ilibiin bundle, the blunt separation of the gluteus medius, the gluteus gluteus and the lateral femoral muscle, and the three points of the acetabulum draw on the upper and outer side of the neck of the femur and the upper margin of the acetabulum, and the U of the joint capsule in front of the basal part of the neck of the femur, so that the femoral head and the neck of the femur can be exposed with the finger and the joint capsule and peel off the neck of the femur. At this time, the femoral head and its fracture surface can be fully revealed, using the head device to remove the residual head, flexing the hip joint, adduction, external rotation, and bending the knee to the front of the operation field. At this point, the osteotomy surface of the base of the acetabulum and the neck of the femur has reached full exposure, and the artificial hip joint can be installed. Control group: The posterior approach was used to extend the apex of the great trochanter, extending the incision along the femoral shaft to the distal end, extending the proximal end to the posterior superior iliac spine, incision of the skin and subcutaneous tissue, opening the fascia lata, separating the gluteus maximus and the tensor fascia, revealing the lateral femoral muscle, separating the gluteus maximus and the deep fascia, flexing the knee, the internal rotation hip joint and exposing the piriform muscle, [V Muscles, obturator muscles, and lower [V muscles. The muscle groups are tracted by the indwelling suture, cut off at the tip of the muscle of the muscles and the point of the rotor, and opening the joint capsule to expose the neck of the femur. Results: according to the results of the two groups of operation time and blood volume variance homogeneity test, the results of the two groups were t=-0.699, P=0.4860.05, so there was no significant difference between the improved anterolateral approach and the posterior approach (t test, P0.05). The intraoperative bleeding test of the two groups Results t=-2.322, P=0.0220.05, so the improved anterolateral approach and posterior approach had significant differences in the amount of intraoperative bleeding (t test, P0.05), and the mean value of the modified anterolateral approach was significantly smaller than the posterior approach. Conclusion: the anterolateral approach to the treatment of femoral neck fractures by artificial hip replacement The most common surgical approach is the approach and the posterior approach. During the operation, the operation time and the amount of bleeding are controlled, the risk of the operation is determined, and it is important for the patient to pass through the perioperative period. Therefore, on the basis of the success of the artificial hip replacement, the shorter operation time is used to control less bleeding and smaller. There is no significant difference between the anterolateral approach and the posterior approach, but there is no statistical difference between the improved anterolateral approach and the posterior approach. However, the statistical difference is significant in the amount of bleeding, and the improvement of the anterolateral approach is known from the mean value. The blood volume is significantly less than the posterior approach, which reflects the higher risk of the posterior approach in the hip replacement than the modified anterolateral approach. Therefore, the modified anterolateral approach can be selected for the hip replacement for the patients with poor tolerance to their own physical conditions.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.4

【参考文献】