改良Stoppa入路死亡冠血管的解剖学研究

目的研究改良Stoppa入路髂外和腹壁下血管与闭孔血管在耻骨上支区的吻合支（死亡冠）解剖学特点,为提高骨盆髋臼前路手术操作安全性提供解剖学基础。方法模拟改良Stoppa入路对12具国人成人尸体标本共24侧半骨盆进行解剖学研究。观测死亡冠血管的出现率、直径大小、长度及其至耻骨联合和髂耻隆起的距离。结果87．5％（21侧）耻骨上支表面存在死亡冠血管,其中62．5％（15侧）为静脉型,8．3％（2侧）为动脉型,16．7％（4侧）为混合动静脉型。死亡冠血管的长度平均32．1（24．1～40．6）mm,直径平均2．5（2．0～3．7）mm。死亡冠血管至耻骨联合距离平均54．9（47．8～63．8）mm,至髂耻隆起距离平均20.3（6．2～35．0）mm。死亡冠血管紧贴耻骨上支,移动度小。结论死亡冠血管出现率高,变异度大,以静脉型为主。移位骨盆前环髋臼骨折及前入路手术时易损伤死亡冠血管,应注意其存在并妥善处理,推荐骨膜下剥离。     

逆行髋臼前柱拉力螺钉内固定的应用解剖学研究

[目的]为逆行髋臼前柱拉力螺钉内固定提供应用解剖学基础。[方法]取半骨盆标本20个,自髋臼切迹至髋臼上缘每隔5.0 mm作系列截骨面,找到最小截骨面,用圆盘法确定其圆心及直径,用斯氏针由该截面的圆心逆行打入,在髂骨后外侧穿出。将该截面下方的系列截面解剖复位,再将斯氏针顺行打入前柱,由耻骨上支前外侧穿出,该穿出点为P,P即为逆行髋臼前柱拉力螺钉入钉点。测量其在髋臼前柱骨皮质内的长度,将耻骨结节命名为A,将髂耻隆起命名为B,测量AB及PA的距离,并观察该斯氏针的方向。[结果]最小截骨面位于髋臼切迹上方15.0 mm处,该截面平均直径为(4.9±1.7)mm,髋臼前柱骨皮质内斯氏针长度为(86.8±7.2)mm,P位于耻骨上支前缘闭孔嵴上,P距耻骨结节(A)的距离PA为(2.3±0.4)mm,耻骨结节(A)距髂耻隆起(B)的距离AB为(4.7±0.3)mm,P约为AB的中点,该斯氏针与弓状线平行。[结论]逆行髋臼前柱拉力螺钉入钉点P位于耻骨上支耻骨结节与髂耻隆起中点处的闭孔嵴上,P距耻骨结节(2.3±0.4)mm,该螺钉最大直径为(4.9±1.7)mm,最大长度为(86.8±7.2)mm,该螺钉与弓状线平行。     

基于CT血管造影三维重建的Corona Mortis动脉解剖学研究及其临床意义

目的 在CT血管造影(CTA)三维重建图像上观察Corona Mortis动脉的存在率及位置,以期为骨盆、髋臼骨折的手术入路提供解剖学基础.方法 回顾性分析2010年12月至2012年5月期间行腹主动脉CTA检查的80例(160个半骨盆)患者资料,男34例,女46例；年龄19 ～ 84岁,平均47.2岁.利用Mimics 10.01软件对患者骨盆CTA.dicom格式原始数据进行三维重建,在三维图像上观察Corona Mortis动脉,记录该血管的支数及起源,并测量该血管与耻骨联合的距离.比较左右两侧半骨盆、男女性及年龄≤50岁组与年龄＞ 50岁组之间Corona Mortis动脉存在率的差异. 结果 共发现29条Corona Mortis动脉,存在率为18.1％ (29/160).左侧和右侧Corona Mortis动脉存在率分别为17.5％ (14/80)、18.8％ (15/80);男性与女性Corona Mortis动脉存在率分别为19.1％ (13/68)、17.4％ (16/92),年龄≤50岁组与年龄＞50岁组Corona Mortis动脉存在率分别为14.3％ (14/98)、24.2％ (15/62),以上组别之间比较差异均无统计学意义(P＞0.05).Corona Mortis动脉经过耻骨上支的交点至耻骨联合上边缘的距离平均为(53.70 ±4.00) mm. 结论 CTA三维重建可清晰观察到Corona Mortis动脉.采用髂腹股沟入路和Stoppa入路行骨盆髋臼骨折手术前建议先行腹主动脉CTA检查,以明确是否存在该血管.术中剥离至距离耻骨联合上边缘(53.70±4.00) mm处的耻骨上支表面时,应高度警惕该变异血管的存在.     

通过数字化分析对髋臼下螺钉最大通道参数的测量和置钉可行性的评估

目的 :通过对髋臼结构的数字化分析,测量髋臼下螺钉最大通道的参数,并评估髋臼下螺钉置入的可行性。方法:回顾性分析2013年4月至2015年6月行骨盆CT平扫100例患者的骨盆CT数据,男50例,年龄20～84(48.42±17.48)岁,女50例,年龄18～87(55.02±19.54)岁,髋臼骨折、髋关节发育不良和髋臼有金属植入物的患者除外。将CT数据以DICOM格式导入Mimics软件中,生成三维模型,在骨盆入口位找到髋臼下通道在耻骨中段的轴向投影区,在投影区置入虚拟螺钉,分别测出髋臼下最大通道的直径、髋臼下最大通道的长度、入钉点到耻骨联合的距离、入钉点到髂前上棘的距离以及入钉点到骨盆内侧边缘的距离。再将骨盆模型导入3-matic软件中,建立骨盆模型的骨盆前平面及正中矢状面,测量螺钉轴线与2个平面的角度。以5 mm作为置入3.5 mm螺钉的标准,计算螺钉的置入率。结果:在100例病例中,有49%的患者存在直径≥5 mm的髋臼下通道,其中男性置钉率明显高于女性。髋臼下最大通道的平均直径(4.86±1.72) mm,平均长度(94.04±8.29) mm,入钉点到耻骨联合平均距离(60.92±4.84) mm,到髂前上棘平均距离(85.15±6.85) mm,到骨盆内缘平均距离(6.12±3.32) mm。螺钉轴线与正中矢状面的平均角度(-1.38±4.74)°,与骨盆前平面的平均角度(56.77±7.93)°。男女性测量参数除螺钉轴线与骨盆前平面夹角差异无统计学意义外,其余测量结果差异均有统计学意义。骨盆双侧髋臼下最大通道参数差异无统计学意义。结论:所测患者中髋臼下螺钉置入率较低,术前应充分评估置钉可行性。     

关节外科人体解剖学系列讲解（八）髋臼骨折的髂腹股沟人路

一、适应证与禁忌证 髂腹股沟入路是由Letournel开展的显示髋臼前柱和髂骨体的内侧面的入路.它可由骶髂前面至耻骨联合范围内显露内髂骨的全部和骨盆入口.也可进入髂骨体部的四边形面和上下支.也可进入髂骨外侧面.所有骨盆前面和前柱的骨折均可采用髂腹股沟入路.     

经髂腹股沟入路内侧窗内固定治疗髋臼前柱或耻骨支骨折CSCD

目的：探讨经髂腹股沟入路内侧窗切开复位内固定治疗髋臼前柱或耻骨支骨折的手术技巧及临床疗效。方法：回顾性分析2017年1月至2022年1月采用髂腹股沟入路内侧窗切开复位内固定治疗的32例髋臼前柱或耻骨支骨折还在,其中髋臼前柱骨折14例,耻骨支骨折18例。术中均采用髂腹股沟入路内侧窗,即于耻骨结节上方沿耻骨支作3～5 cm横行切口,骨膜下剥离显露髋臼前柱或耻骨支骨折,骨折复位后沿骨盆界线放置重建钛板。将螺钉斜向置入髋臼顶部上方固定重建板的近端,将螺钉置入骨性耻骨联合和耻骨支固定重建板的远端。结果：术后骨折复位质量按Matta评分为：优24例,良6例,差2例,优良率为93.8%。32例患者均获得随访,随访时间为6～24个月,平均（10.9±4.8）个月,所有患者骨折均愈合。末次随访时髋关节功能按改良的D’Aubigne-Postel评分系统：优21例,良6例,可5例,优良率为84.4%。骨盆术后功能按照Majeed评分：优22例,良7例,可3例,优良率为90.6%。1例患者术后出现切口脂肪液化,经延迟拆线并换药后愈合。其余患者随访期间均无血管神经损伤、感染、异位骨化、股骨头坏死、腹股沟疝、切口疝等并发症发生。结论：经髂腹股沟入路内侧窗可有效复位固定髋臼前柱或耻骨支骨折,手术时间短,固定可靠,术中出血量少,创伤小,并发症少,可取得良好的临床疗效。     

改良髂腹股沟入路手术治疗髋臼前柱或耻骨支骨折的疗效观察

目的探讨改良髂腹股沟入路手术治疗髋臼前柱或耻骨支骨折的临床疗效。方法笔者自2011-06—2015-10采用改良髂腹股沟入路手术治疗髋臼前柱13例、耻骨支骨折10例,分别采用Matta标准、D'Aubigne评分和Majeed评分评定疗效。结果本组均获随访11~23个月,平均13.9个月,骨折均愈合,无感染、股神经损伤或股血管损伤等并发症发生。按照Matta标准,术后解剖复位11例,复位良好10例,复位较差2例;末次随访疗效按髋关节功能D'Aubigne评分评定:优11例,良8例,可4例;末次随访疗效依据骨盆功能Majeed评分:优10例,良11例,可2例。结论改良髂腹股沟入路手术治疗髋臼前柱或耻骨支骨折创伤小,手术时间短,可获得满意的复位和固定,且无需显露局部股神经和股动静脉。     

髂前下棘的解剖学研究及其在骨盆骨折中的应用

目的对髂前下棘及其体表投影进行应用解剖学研究,为骨盆骨折微创置入外固定钉提供参考依据。方法观察15具尸体30侧骨盆髂前下棘及体表投影,测量髂前下棘横径、矢状径和体表投影,按性别分组进行统计学处理。结果男性髂前下棘矢状径和横径分别为(26.51±2.86)mm和(11.64±1.15)mm;女性分别为(25.46±3.92)mm和(9.20±1.14)mm。男性髂前上棘到髂前下棘体表投影的距离对髂前上棘与耻骨结节间距离的回归系数为0.252;女性为0.262。结论髂前下棘的体表投影点位于髂前上棘与耻骨结节连线的外上1/4处,了解这一特点有助于准确置入骨盆外固定钉。     

髂腹股沟微创小切口内固定治疗髋臼前柱或耻骨支骨折

 目的 探讨经髂腹股沟微创小切口内固定治疗髋臼前柱或耻骨支骨折的临床效果。 方法 2008 年6 月至2011 年6 月, 对16 例髋臼前柱骨折、10 例耻骨支骨折患者采用髂腹股沟微创小切口内 固定治疗。所有患者均采用全麻, 于髂结节至髂前上棘做3~5 cm 斜行切口, 沿髂骨内侧骨膜下剥离至 髂前下棘、髂耻隆起、髋臼前柱, 再于耻骨结节向外2~3 cm 横行切口, 沿耻骨支前上方骨膜下剥离显露 耻骨支, 两个切口分别向中间潜行剥离后形成沿耻骨支髋臼前柱相贯通的骨膜下隧道, 复位骨折, 将重 建钛板预弯后导入隧道, 固定骨折。 结果 根据Matta标准, 术后解剖复位13 例, 复位良好11 例, 复位 较差2 例。23 例患者获得平均15.6 个月随访(6~30 个月)。髋关节功能按照D’Aubigne 评分:优13 例, 良6 例, 可4 例。骨盆功能按照Majeed评分:优12例, 良9 例, 可2 例。无感染、股神经或股血管损伤、静 脉血栓、异位骨化等并发症发生。 结论 经髂腹股沟微创小切口内固定治疗髋臼前柱或耻骨支骨折创 伤小, 手术时间短, 安全性相对较高。髂耻前柱放置钢板对钢板塑形的要求低, 固定可靠。     

下腰椎侧方入路中相关神经的临床解剖学研究

[目的]研究下腰椎侧方入路中相关神经的应用解剖学特点,为该手术人路提供解剖学依据.[方法]观测21具成人尸体标本L3～S1神经根前支、闭孔神经及腰交感干的走行及与周围结构的毗邻关系.[结果]L3～S1神经根前支位置及走行相对恒定;骶髂关节间隙最上缘至L4.5神经根前支外侧缘及闭孔神经外侧缘的水平距离分别为(18.96±2.59) mm,(23.29±2.48) mm,(15.49±3.01) mm;骨盆界线与骶髂关节间隙交点至腰骶于外侧缘的水平距离为(6.20±2.08)mm;骶骨岬前外侧缘到第1骶前孔上缘切线的垂直距离为(28.73±2.93) mm.[结论]下腰椎侧方神经的走行及解剖学形态具有一定规律性,在下腰椎侧方手术入路中,可有效避开或牵开这些结构,避免术中损伤.     

An anatomical study of corona mortis and its clinical significance

Objective: To provide detailed information of corona mortis for ilioinguinal approach as an anterior approach to the acetabulum and pelvis. Methods: The course, branches and distribution of the vascular connection between the obturator system and the external iliac or inferior epigastric systems located over the superior pubic ramus were observed on 50 hemipelvises with intact soft tissues. Results：During the dissections, 72 % of the cadavericsides had at least one communicating vessel between the obturator system and the external lilac or inferior epigastric systems on the superior pubic ramus. The average diameter of the connecting vessel was 2.6 nun (range, 2.0-4.2 mm). It coursed over the superior pubic ramus or iliopubic eminence vertically to enter the obturator foramen and exit the pelvis. The average distance from pubic symphysis to the vascular connections between the obturator and external iliac systems was 52 nun ( range, 38-68 ram). Conclusions: Vascular connections between the obturator system and the external iliac or inferior epigastric systems were found over the superior pubic ramus with a high incidence. They are prone to damage during the ilioinguinal approach as an anterior approach to the acetabulum and pelvis. Thus, corona mortis located over the superior pubic ramus deserves great attention during the ilioinguinal approach.     

The incidence and location of corona mortis: a study on 75 cadavers

We dissected 150 fresh cadaver halves by ilioinguinal exposure, and counted all vessels more than 2 mm in diameter, connecting the obturator system to the external iliac system. The distance between the symphysis pubis and the anastomotic vessels was measured. We found vascular anastomoses between the obturator and external iliac systems in 91 of 150 sides (61%), and anastomotic veins in 78 of 150 exposures (52%). Arterial connections were seen in 29 of the exposures (19%). The mean distance between the anastomotic arteries and the symphysis pubis was 64 (45-90) mm, and 56 (37-80) mm for the communicating veins. There seemed to be no significant difference between genders in the incidence of corona mortis and the distance between communicating vessels and the symphysis pubis.     

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??Applied anatomical studying on corona mortis in Chinese ZHOU Lu-ke??ZHAO Yu??SUN Shan-quan, et al. Department of Vascular Surgery??the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
Corresponding author: ZHAO Yu, E-mail: zhaoyu@cta.cq.cn
Abstract Objective To observe the incidence and adjacent to the corona mortis, so as to provide anatomic basis for the surgical of ilioinguinal approach. Methods One hundred and two hemipelvises were assessed in 51 embalmed cadavers??37 males and 14 females??between November 2011 and February 2012 in the First Affiliated Hospital of Chongqing Medical University. Bilateral dissection was performed in every case with a total of 102 sides. The relationship between the corona mortis and external iliac vessels system was indentified and the distance from the corona mortis to the symphysis pubis was measured. Results Fifty-one human adult cadavers were dissected bilaterally (102 hemipelvises), with evidences of the vascular elements at the level of the superior pubic branch in 39 cases (66 sides, 76.5%) of hemipelvises. Among them, the average of distance from the corona mortis to the symphysis pubis was (52.00±12.29) mm in male and (55.39±11.86) mm in female. There was no significant difference in the incidence and distance from communicating vessels to the symphysis pubis between male and female??P??0.05??. Conclusion The incidence of an anomalous obturator artery forming the arterial corona mortis among Chinese is 76.5%. The corona mortis crossing over the iliopubic rami should be taken attention during the ilioinguinal surgery.     

The prevalence and morphology of the corona mortis (Crown of death): A meta-analysis with implications in abdominal wall and pelvic surgery

PurposeCorona mortis is a highly variable vascular connection between the obturator and external iliac or inferior epigastric arteries or veins located behind the superior pubic ramus in the retropubic space (space of Retzius). Due to the significant variation in this collateral circulation, detailed anatomical knowledge of the corona mortis is vital to enhance the prevention of possible iatrogenic errors in hernia repair and other pubic surgical procedures. The aim of our meta-analysis was to provide comprehensive data on the prevalence, anatomical characteristics, and ethnic variations of the corona mortis vessel.MethodsAn extensive search was conducted through the major electronic databases to identify eligible articles. Data extracted included investigative method, prevalence of the corona mortis vessels among hemi-pelvises (overall, arterial only, venous only, and combined), distance from the corona mortis to pubic symphysis, and assessment of gender, side, laterality, and ethnicity subgroups.ResultsA total of 21 studies (n = 2184 hemi-pelvises) were included in the meta-analysis. The overall prevalence of the corona mortis in hemi-pelvises is high (49.3%). A venous corona mortis is more prevalent than an arterial corona mortis (41.7% vs. 17.0%). The corona mortis is more common in Asia (59.3%) than in Europe (42.8%) and North America (44.3%).ConclusionsAs a corona mortis is present in an about half of all hemi-pelvises, it is important to consider the possibilities of its presence when undertaking surgical procedures and plan accordingly to avoid injuries. All surgeons operating in the retropubic region should have a thorough understanding of the anatomical characteristics and surgical implications of a corona mortis.     

Vascular anatomy for rotational acetabular osteotomy: cadaveric study

 Rotational acetabular osteotomies are performed to correct dysplastic hips in young adults. However, there is a potential risk of intrapelvic vascular injury. To define the relation of these vascular structures to the bone around the acetabulum, we measured the distance and direction from the anteroinferior iliac spine to the external iliac artery and from the base of the superior pubic ramus to the obturator artery in 34 cadaveric hemipelves (17 male, 17 female; 19 left, 15 right). The distance to the external iliac artery was significantly shorter in females (average 31.7 mm) than in males (average 38.2 mm); and the distance to the intrapelvic entry portal of the obturator canal, through which the obturator artery passes, was significantly shorter in females (average 27.2 mm) than in males (average 33.4 mm). In addition, the external iliac artery was located significantly more ventral and closer to the anteroinferior iliac spine in right hemipelves than in left hemipelves. The intrapelvic entry portal of the obturator canal was located more caudodorsal to the base of the superior pubic ramus in females than in males. Care should thus be taken during surgery in light of our findings. Received: May 17, 2002 / Accepted: December 12, 2002 RID="*"     

髂腹股沟下和髂腹股沟入路的解剖比较研究及在髋臼骨折中的应用

目的：比较治疗髋臼骨折的髂腹股沟下入路和髂腹股沟入路的解剖学差别,并探讨髂腹股沟下入路的临床疗效.方法：选取男女新鲜尸体标本7具,同一标本做左右两侧对比研究,左侧采用髂腹股沟入路,右侧采用髂腹股沟下入路,切口内侧均自耻骨联合上方2 cm开始横行,切口外侧沿髂骨嵴至髂前上棘后外5 cm处,对比测量切口第1窗暴露的长径、横径和髂腰肌游离度.并随访观察2010年5月至2012年8月采用单一髂腹股沟下入路治疗的15例髋臼骨折患者的手术疗效,其中男12例,女3例;年龄20～65岁,平均40.6岁,采用Matta标准进行疗效评价.结果：髂腹股沟下入路在切口第1窗暴露长径、横径和髂腰肌游离度均优于髂腹股沟入路（P＜0.01）.临床观察15例髋臼骨折患者,根据Mata复位标准,10例获得解剖复位,5例复位满意;所有患者X线片结果为优.结论：相比经典的髂腹股沟入路,髂腹股沟下入路可显著扩大第1窗口的暴露范围,同时手术步骤简单.此入路是暴露髋臼前柱、前内侧壁和髋关节前方的理想手术入路.     

Combined Anterior Pelvic (CAP) approach for fracture acetabulum fixation - Functional outcome evaluation and predictors of outcome

ObjectiveIlio-inguinal approach has been considered standard anterior approach for acetabulum fracture fixation. Different modifications of this approach have been described. This study analysed the patients treated using a Combined Anterior Pelvic (CAP) approach - minimal AIP (anterior intra-pelvic) with modified ilio-femoral along with ’anterior superior iliac spine’ osteotomy. This combined approach provides wide exposure of pelvis to direct visualise the entire anterior column from sacroiliac joint to pubic symphysis, medial side of quadrilateral plate and entire iliac wing with minimal retraction of soft tissues required.MethodsData of patients treated from July 2014 to June 2018 for acetabulum fracture using CAP approach was retrieved from hospital record system. Inclusion criteria were - acetabulum fractures treated surgically using CAP approach. Exclusion criteria were – age less than 18 years, associated pelvis ring injury and incomplete peri-operative radiological record (pre-operative/post-operative antero-posterior, 45° obturator and 45° iliac oblique radiographs and pre-operative computed tomographic (CT) scans. 62 patients who met inclusion exclusion criteria were called in out-patient-department for final functional evaluation using Matta modified Merle d’aubigne score.ResultsOut of 62 patients 47 patients who turned up for final functional evaluation were included in study. 19 patients had excellent, 15 had good, 2 had fair and 11 had poor results. Age less than 40 years, anterior column fracture pattern, Pre-operative fracture displacement >20 mm, fracture comminution and post-operative fracture reduction within 3 mm were the predictors of the functional outcome. When analysed using logistic regression model, post-operative fracture reduction was found to be the only significant predictor of functional outcome.ConclusionCAP approach is useful anterior approach to acetabulum. Fracture reduction is the independent predictor of functional outcome. Comparison of this approach with other anterior approaches to acetabulum can be area of further research.     

Combined Anterior Pelvic (CAP) approach for fracture acetabulum fixation - Functional outcome evaluation and predictors of outcome

ObjectiveIlio-inguinal approach has been considered standard anterior approach for acetabulum fracture fixation. Different modifications of this approach have been described. This study analysed the patients treated using a Combined Anterior Pelvic (CAP) approach - minimal AIP (anterior intra-pelvic) with modified ilio-femoral along with ’anterior superior iliac spine’ osteotomy. This combined approach provides wide exposure of pelvis to direct visualise the entire anterior column from sacroiliac joint to pubic symphysis, medial side of quadrilateral plate and entire iliac wing with minimal retraction of soft tissues required.MethodsData of patients treated from July 2014 to June 2018 for acetabulum fracture using CAP approach was retrieved from hospital record system. Inclusion criteria were - acetabulum fractures treated surgically using CAP approach. Exclusion criteria were – age less than 18 years, associated pelvis ring injury and incomplete peri-operative radiological record (pre-operative/post-operative antero-posterior, 45° obturator and 45° iliac oblique radiographs and pre-operative computed tomographic (CT) scans. 62 patients who met inclusion exclusion criteria were called in out-patient-department for final functional evaluation using Matta modified Merle d’aubigne score.ResultsOut of 62 patients 47 patients who turned up for final functional evaluation were included in study. 19 patients had excellent, 15 had good, 2 had fair and 11 had poor results. Age less than 40 years, anterior column fracture pattern, Pre-operative fracture displacement >20 mm, fracture comminution and post-operative fracture reduction within 3 mm were the predictors of the functional outcome. When analysed using logistic regression model, post-operative fracture reduction was found to be the only significant predictor of functional outcome.ConclusionCAP approach is useful anterior approach to acetabulum. Fracture reduction is the independent predictor of functional outcome. Comparison of this approach with other anterior approaches to acetabulum can be area of further research.