坐股韧带的解剖与全髋置换术

目的研究坐股韧带的形态学特征,探讨全髋置换后路软组织的修补策略。方法采用10例福尔马林固定的成人尸体右髋标本,逐层解剖,将髋后关节囊分为3个扇区(Ⅰ～Ⅲ),寻找和观察坐股韧带。结果髋后方关节囊Ⅰ、Ⅱ区较厚,Ⅲ区较薄。坐股韧带走行于Ⅰ、Ⅱ区,在囊内面透照下呈增厚的弱透光带。结论坐股韧带是髋后方关节囊上的优势纤维。在后路全髋置换软组织修补中,应保护坐股韧带以发挥其固有的生物力学功能,这样以坐股韧带为主架的髋后方囊瓣才能发挥最大的抵挡作用。     

全髋关节置换后外侧结构重建前后的生物力学变化

目的分析后外侧入路行全髋关节置换（THA）后外侧结构重建前后的髋关节生物力学变化。方法 2012年11月至2013年3月期间,行人工THA手术患者9例10髋,其中股骨头坏死患者3例4髋,发育性髋关节发育不良并骨关节炎患者侧3例3髋（CroweⅠ型2例,CroweⅡ型1例）,股骨颈骨折3例3髋;男4例,女5例;年龄41-75岁,平均59.67岁。常规采用后外侧入路、生物型假体。所有患者均行关节囊及外旋肌群修复,于关节囊及外旋肌群修复前后分别测定髋关节内收、外展0°,屈曲45°和屈曲90°内旋时,关节即将脱位时扭矩的大小,观察股骨大转子后方有无骨折、关节囊及外旋肌群有无撕裂、缝线有无开结及断线、坐骨神经损伤。结果关节囊及外旋肌群缝合前后扭矩有显著增加,屈髋45°时,缝合前扭矩测量为（7.88±5.87）N·m,缝合后扭矩为（14.03±6.81）N·m,差异有统计学意义（P〈0.01）;屈髋90°时,缝合前扭矩测量为（12.22±3.58）N·m,缝合后扭矩为（17.15±5.81）N·m,差异有统计学意义（P〈0.01）。术中出现1例大粗隆后缘骨折,1例后外侧结构缝合打结后,线结松动,1例缝线断裂情况,术后随访3个月,无关节脱位发生,无坐骨神经损伤。结论 THA术中后方关节囊及外旋肌群的修复可显著改善THA术后关节即刻稳定性。     

后方关节囊修补预防全髋关节置换术后早期脱位

[目的]探讨加强修补后方软组织预防行后外侧切口首次人工全髋关节置换术后早期脱位的临床疗效和机理。[方法]回顾分析212例首次THA术中缝合后方关节囊与外旋短肌至臀中肌腱性部分的病例术中假体旋转活动度及术后早期脱位率，并与前期行关节囊完全切除的486例作对照分析。[结果]随访6个月～5a（平均3．7a），修补关节囊组仅2髋（0．9％）发生术后早期脱位；对照组发生脱位27髋（5．6％）。两组差异有显著意义（x^2=8．51，P〈0．005）。术中观察显示修补关节囊能够限制髋关节过度内旋20％～50％，阻止股骨头假体在髋臼内衬内的初始滑动。[结论]在假体安放正确基础上，加强修补后方关节囊能够有效预防行后外侧切口首次THA术后早期脱位，机理为关节囊修补后能限制髋关节过度内旋、阻止股骨头假体在髋臼内衬内的初始滑动，并提供了形成致密的假关节囊的生物学基础。     

修复关节囊及外旋肌群对预防全髋关节置换术后关节脱位的作用

目的 探讨采用髋关节后外侧切口进行初次全髋关节置换术(THA)时修复关节囊及外旋肌的作用.方法 2002年1月至2006年6月,初次采用后外侧切口行THA 116例122髋,术中保留后方关节囊及外旋肌群,并且分别将其用疝缝线"8"字直接缝合至股骨大转子(修复组).将修复组THA术后脱位率与同期常规行THA(未修复关节囊及外旋肌,对照组)的255例266髋THA做比较分析. 结果术后6个月内,修复组仅1髋(1/122,0.8%)发生术后早期脱位;对照组则有15髋发生早期脱位(15/266,5.6%),早期脱位率差异有统计学意义(X2=4.914,P=0.027);两组术后6个月均无冉脱位. 结论采用后外侧切口进行THA时修复关节囊及外旋肌群技术能够有效预防术后早期脱位.     

两种髋关节后方关节囊重建法的对比研究

目的探讨两种髋关节后方关节囊重建方法对于全髋关节置换(total hip arthroplasty,THA)术后脱位的预防作用。方法 703例THA术按照有无进行髋关节后方关节囊修复重建分组进行统计分析。A组:398例,不修复后方关节囊;B组:179例,将后方关节囊和短外旋肌群缝合至短外旋肌在股骨大转子附着处;C组:126例,将后方关节囊和短外旋肌群经骨道缝合至股骨大转子上。结果 A组、B组和C组术后脱位率分别为7.04%、3.35%和0。C组的术后脱位率低于B组(P0.05),而B组的术后脱位率低于A组(P0.05)。结论两种后方关节囊修复方法均能有效预防全髋关节置换术后髋关节脱位,而经骨道缝合的方法能更可靠地恢复髋关节后方稳定性。     

保留修复后方关节囊及韧带对防止人工髋关节置换术后脱位的作用

目的 探讨保留并修复后方关节囊及韧带对防止后方入路人工髋关节置换术后髋关节后脱位的作用。方法 将503例采用髋关节后方入路的初次人工髋关节置换的患者分为两组:A组298例保留并修复后方关节囊及韧带,B组205例切除关节囊及韧带。比较两组术后髋关节后脱位发生率。结果 A组发生髋关节后脱位2例,发生率0.67%,B组发生髋关节后脱位6例,发生率2.93%,A组比B组术后髋关节后脱位发生率明显降低(P<0.05)。结论 保留并修复后方关节囊及韧带用以加强人工髋关节后方软组织支撑力量,有助于恢复髋关节的软组织平衡,增加关节稳定性,对防止后方入路人工髋关节置换术后髋关节后脱位有较为重要的作用。     

不同髋臼杯前倾位置和球头假体大小对全髋关节置换术后后方稳定性的影响

目的探讨髋臼杯的前倾位置与球头大小对全髋关节置换（THA）术后后方稳定性的影响。方法利用计算机导航技术在假骨上模拟THA术后,不同髋臼杯前倾位置和不同球头大小在屈髋90°、内收0°和内收30°时髋关节内旋到引起脱位的角度进行测量和比较发生后脱位时的角度差异。结果在髋臼杯外展45°、前倾0°、5°、10°、15°时,28mm和36mm球头在屈髋90°内收0°和30°睛况下内旋至脱位的角度有明显差别（均为P〈0．05）,36mm球头可有更大的内旋角度,稳定性优于28mm球头。但当髋臼杯前倾20°时28mm与36mm球头内旋至脱位的角度间的差异无统计学意义（P〉0．05）,内收30°时比内收0°时髋关节内旋至脱位的角度减小。关节稳定性随髋臼杯前倾减小而下降。髋臼杯前倾0°和髋关节内收30°时,28mm球头在外旋位时就可发生脱位。结论髋臼杯前倾角度增加可增加THA术后关节的稳定性,大球头的稳定性优于小球头,前倾达到某一角度时,大球头和小球头间的后方稳定性无差别。     

髋关节置换修复关节囊的解剖和拉伸力学分析

目的:研究髋关节后关节囊的拉伸力学和解剖特点,为全髋置换术中修复关节囊提供生物力学和解剖学依据。方法:以骨-关节囊-骨方式采集6个冷冻髋关节后关节囊韧带复合体标本,装载于Instron万能材料试验机,测定标本的载荷-应变曲线、极限拉伸应变、极限拉伸载荷、弹性模量等拉伸力学特性。解剖12具尸体髋关节标本至关节囊,记录屈髋90°位,正常关节囊和经转子钻孔(传统法)修复关节囊的拉伸应变;将后关节囊可缝合区划分为9个区域,测量、比较不同分区的关节囊厚度;在尸体标本的两侧髋关节,分别采用传统法和经股骨颈解剖止点钻孔(解剖法)修复后方关节囊,并模拟早期康复活动,观察康复对修复后关节囊的影响。结果:关节囊韧带复合体标本载荷-应变曲线符合流变学和粘弹性特征,其极限拉伸应变为(39.21±5.23)%、极限拉伸载荷为(142.06±34.15) N,拉伸强度为(1.65±0.38) MPa,弹性模量为(14.23±5.62) MPa。屈髋90°位,传统修复关节囊拉伸应变大于正常关节囊(P0.05),正常关节囊拉伸应变为:上部(17.0±2.6)%,中部(24.1±1.4)%,下部(26.0±4.3)%;传统修复法拉伸应变为:上部(37.0±4.9)%,中部(53.3±1.1)%,下部(68.3±6.2)%。后关节囊不同分区的厚度差异有统计学意义(P0.05),股骨止点近端0.5 cm处各部厚度适合缝合,此处关节囊平均厚度为:上部(3.48±0.11) mm,中部(2.36±0.09) mm,下部(1.59±0.24) mm,后下关节囊距股骨止点(1.42±0.02) cm处最薄,应避免此处进针。模拟康复活动后,传统法修复的关节囊后下部分发生撕脱(10/12),解剖法修复的关节囊完整。结论:传统法修复关节囊后下部分拉伸应变过大,容易撕脱,解剖修复关节囊符合拉伸力学要求,有助于提高关节囊修复成功率。     

先天性髋脱位髂股韧带重建

目的 探索先天性髋脱位股骨头复位后增加髋关节稳定的新加方法。方法 选择３２例４３例髋关节囊肥大患儿，利用多余关节囊瓣重建髂股韧带。结果 经１￣５年随访，股骨头复位后稳定，髋关节活动范围正常。讨论 髂股韧带重建有效地预防了股骨头再脱位，增加了髋关节的稳定性，是先天性髋脱位手术治疗中较理想的辅助方法。     

关节囊修补对老年初次全髋关节置换术后早期脱位的影响

目的探讨后路老年初次全髋关节置换术中关节囊修补及其对术后早期脱位的影响。方法分析1996年11月至2007年5月行K—L入路治疗老年初次全髋关节置换的股骨颈骨折患者120例,均为单髋病例。根据术中是否进行关节囊的修补及外旋肌群的修复分为两组：A组术中切除后关节囊,行外旋肌群的修补;B组术中“T”形切开关节囊进行修补,并将关节囊与外旋肌群共同缝合于大转子及臀中肌止点。结果A组80例,16例失随访,术后早期脱位2例2髋（2．5％）。B组40例,1例失随访,无一例出现术后早期脱位。结论后路关节囊及软组织袖修补方法简单,不增加手术创伤,可以有效发挥阻挡作用,降低术后早期脱位率。     

全髋关节置换扩大后路软组织修补关节囊切开线的解剖学研究

OBJECTIVE: To investigate the anatomic feature of the posterior hip joint capsule and its distributional difference of collagen fibers and to probe the optimization of the capsulotomy which can reserve the best strength part. METHODS: Ten adult cadaver pelvises (6 males and 4 females, aged 28-64 years) fixed with formalin were used. Ten right hips were used for anatomical experiment of hip joint capsule. The posterior hip joint capsules were divided into 3 sectors (I-III sectors) and 9 parts (I(A-C), II(D-F), III(G-I). The average thickness of each part was measured and the ischiofemorale ligaments were observed. Five capsules selected from ten left hips were used for histological experiment. The content of collagen fibers in sector I and sector II was analyzed by Masson's staining. Two fresh frozen specimens which were voluntary contributions were contrasted with the fixed specimens. The optimal incision line of the posterior capsule was designed and used. RESULTS: The thickness in the posterior hip joint capsule [I(A) (2.30 +/- 0.40), I(B) (4.68 +/- 0.81), I(C) (2.83 +/- 0.69), II(D) (2.80 +/- 0.79), II(E) (4.22 +/- 1.33), II(F) (2.50 +/- 0.54), III(G) (1.57 +/- 0.40), III(H) (2.60 +/- 0.63), III(I) (1.31 +/- 0.28) mm] had no uniformity (P < 0.01). The III(G) part and the III(I) part were thinner than the I(B) part and the II(E) part (P < 0.01). Two weaker parts located at obturator externus sector (sector III), the ischiofemorale ligament trunk went through two thicker parts (I(B) and II(E)). The distribution of the collagen fibers in sector I and sector II(I(A) 20.34% +/- 5.14%, I(B) 48.79% +/- 12.67%, I(C) 19.87% +/- 5.21%, II(D) 17.57% +/- 3.56%, II(E) 46.76% +/- 11.47%, II(F) 28.65% +/- 15.79%) had no uniformity (P < 0.01). The content of collagen fibers in I(B) part and II(E) part were more than that of other parts (P < 0.01). There were no statistically significant difference in the distribution feature of the thickness and the ischiofemorale ligaments between the fresh frozen specimens and the fixed specimens. The optimal incision line C-A-B-D-E of the posterior capsule was designed and put into clinical application. The remaining capsular flap comprise the most of the ischiofemorale ligament trunk and the part of gluteus minimus. CONCLUSION: Although enhanced posterior soft tissue repair in total hip arthroplasty was investigated deeply and obtained great development, but the postoperative dislocation rate was not eliminated. It is significant for optimizing the capsulotomy to reserve the best strength part of the posterior capsule and to bring into full play the function of the ischiofemorale ligaments.     

Anatomy of the medial femoral circumflex artery and its surgical implications

The primary source for the blood supply of the head of the femur is the deep branch of the medial femoral circumflex artery (MFCA). In posterior approaches to the hip and pelvis the short external rotators are often divided. This can damage the deep branch and interfere with perfusion of the head. We describe the anatomy of the MFCA and its branches based on dissections of 24 cadaver hips after injection of neoprene-latex into the femoral or internal iliac arteries. The course of the deep branch of the MFCA was constant in its extracapsular segment. In all cases there was a trochanteric branch at the proximal border of quadratus femoris spreading on to the lateral aspect of the greater trochanter. This branch marks the level of the tendon of obturator externus, which is crossed posteriorly by the deep branch of the MFCA. As the deep branch travels superiorly, it crosses anterior to the conjoint tendon of gemellus inferior, obturator internus and gemellus superior. It then perforates the joint capsule at the level of gemellus superior. In its intracapsular segment it runs along the posterosuperior aspect of the neck of the femur dividing into two to four subsynovial retinacular vessels. We demonstrated that obturator externus protected the deep branch of the MFCA from being disrupted or stretched during dislocation of the hip in any direction after serial release of all other soft-tissue attachments of the proximal femur, including a complete circumferential capsulotomy. Precise knowledge of the extracapsular anatomy of the MFCA and its surrounding structures will help to avoid iatrogenic avascular necrosis of the head of the femur in reconstructive surgery of the hip and fixation of acetabular fractures through the posterior approach.     

Evaluation of the muscle morphology of the obturator externus and piriformis as the predictors of avascular necrosis of the femoral head in acetabular fractures

Avascular necrosis (AVN) of femoral head is a recognised complication of fracture dislocation of the hip joint but is not studied frequently in relation to acetabulum fractures. The aim was to establish the relationship between obturator externus and piriformis muscle morphology in acetabulum fractures and potenital development of AVN of the femoral head. Twenty-five fractures were included in this prospective study and were subjected to radiological assessment and computed tomography of the pelvis. Magnetic resonance imaging (MRI) of the hip was performed to assess the morphology of obturator externus and piriformis, and findings were compared intraoperatively (in 15 cases). Serial radiographs were taken at monthly intervals to assess the development of avascular necrosis. The patients with no evidence of AVN on radiographs at 6 months had additional MRI scans to look for such changes. Three patients developed AVN of femoral head and two had complete tears of piriformis and/or obturator externus muscles on the pre-operative MRI with the findings confirmed intraoperatively (p = 0.013). None of the patients without changes of AVN at 6-month follow-up had complete tears of either or both muscles. Of these patients, there was one case each of T-type fracture, isolated posterior wall fracture with hip dislocation, and posterior wall with transverse fracture of the acetabulum. Complete tears of obturator externus and/or piriformis muscles are a strong predictor of future development of AVN of the femoral head.     

The surgical anatomy of the blood supply to the femoral head: description of the anastomosis between the medial femoral circumflex and inferior gluteal arteries at the hip

The inferior gluteal artery is described in standard anatomy textbooks as contributing to the blood supply of the hip through an anastomosis with the medial femoral circumflex artery. The site(s) of the anastomosis has not been described previously. We undertook an injection study to define the anastomotic connections between these two arteries and to determine whether the inferior gluteal artery could supply the lateral epiphyseal arteries alone. From eight fresh-frozen cadaver pelvic specimens we were able to inject the vessels in 14 hips with latex moulding compound through either the medial femoral circumflex artery or the inferior gluteal artery. Injected vessels around the hip were then carefully exposed and documented photographically. In seven of the eight specimens a clear anastomosis was shown between the two arteries adjacent to the tendon of obturator externus. The terminal vessel arising from this anastomosis was noted to pass directly beneath the posterior capsule of the hip before ascending the superior aspect of the femoral neck and terminating in the lateral epiphyseal vessels. At no point was the terminal vessel found between the capsule and the conjoined tendon. The medial femoral circumflex artery receives a direct supply from the inferior gluteal artery immediately before passing beneath the capsule of the hip. Detailed knowledge of this anatomy may help to explain the development of avascular necrosis after hip trauma, as well as to allow additional safe surgical exposure of the femoral neck and head.     

Hip joint pressure after femoral neck fracture

The hip joint pressure in 40 patients with intracapsular femoral neck fractures was measured on the fracture table prior to surgery. All but 1 patient had pressures well below 20 mmHg with the hip unreduced. When the hip was extended and internally rotated, the pressure rose to values exceeding the normal arteriolar pressure in most patients, with a peak pressure of 135 mmHg. In nine of 22 Garden IV fractures, the pressure remained low despite extension and inward rotation. Injection of contrast medium in three of these hips indicated a rupture of the joint capsule. The pressure response to extension and internal rotation was less marked in fractures older than 72 hours.

The findings do not support the hypothesis that a hip-joint tamponade is a common etiologic factor for the development of femoral head necrosis following fracture. However, prolonged reduction maneuvers with the hip joint in extension and internal rotation can create intracapsular pressures high enough to temporarily jeopardize the circulation of the femoral head.     

Hip joint pressure after femoral neck fracture

The hip joint pressure in 40 patients with intracapsular femoral neck fractures was measured on the fracture table prior to surgery. All but 1 patient had pressures well below 20 mmHg with the hip unreduced. When the hip was extended and internally rotated, the pressure rose to values exceeding the normal arteriolar pressure in most patients, with a peak pressure of 135 mmHg. In nine of 22 Garden IV fractures, the pressure remained low despite extension and inward rotation. Injection of contrast medium in three of these hips indicated a rupture of the joint capsule. The pressure response to extension and internal rotation was less marked in fractures older than 72 hours. The findings do not support the hypothesis that a hip-joint tamponade is a common etiologic factor for the development of femoral head necrosis following fracture. However, prolonged reduction maneuvers with the hip joint in extension and internal rotation can create intracapsular pressures high enough to temporarily jeopardize the circulation of the femoral head.     

Hip joint pressure after femoral neck fracture

The hip joint pressure in 40 patients with intracapsular femoral neck fractures was measured on the fracture table prior to surgery. All but 1 patient had pressures well below 20 mmHg with the hip unreduced. When the hip was extended and internally rotated, the pressure rose to values exceeding the normal arteriolar pressure in most patients, with a peak pressure of 135 mmHg. In nine of 22 Garden IV fractures, the pressure remained low despite extension and inward rotation. Injection of contrast medium in three of these hips indicated a rupture of the joint capsule. The pressure response to extension and internal rotation was less marked in fractures older than 72 hours.

The findings do not support the hypothesis that a hip-joint tamponade is a common etiologic factor for the development of femoral head necrosis following fracture. However, prolonged reduction maneuvers with the hip joint in extension and internal rotation can create intracapsular pressures high enough to temporarily jeopardize the circulation of the femoral head.     

Hip mechanics after posterior structure repair in total hip arthroplasty

This study investigated the rotational response of the hip with different repairs of posterior structures after using the posterior approach in total hip replacement. Five groups were tested: (1) the normal hip without a replacement, (2) the normal hip with a vented capsule, (3) no repair of the capsule and external rotators after total hip replacement, (4) repair of only the piriformis tendon, and (5) repair of the capsule and external rotators as a flap of tissue (capsule, piriformis, obturator internus, gemellae, and quadratus) to the posterior aspect of the greater trochanter. Hemipelvis cadaveric specimens were attached to a joint testing device for testing at full extension, 30 degree, 60 degree and 90 degree hip flexion as internal and external rotation was applied to the femur and the load deflection curves were recorded. Specimens after total hip replacement were externally rotated in full extension until dislocation occurred and the maximum torque was recorded. Each specimen then was rotated internally at 90 degree flexion to the point of dislocation and the maximum torque was recorded for comparison as well. The posterior approach had significantly decreased internal rotational support with no repair or only piriformis repair. When the capsule and external rotators were repaired, a more normal load deflection curve resulted when comparing the full repair group with the normal hip. Significantly higher torque was needed to dislocate the hip in flexion when a full posterior repair was done, and most specimens dislocated in flexion without complete failure of the repair.     

Specific inferior dislocation of the hip： one case report

Hip joint dislocations are generally classified as anterior, posterior, and central dislocations. In 1970s, the anterior dislocation was divided into pubic type and obturator type.1 It is generally recognized that for anterior dislocation of the hip joint, the femoral head is located at anteriorinferior part of the acetabulum, characterized clinically as abduction, extorsion, slight flexion deformity, and longer limb than the opposite side. When posterior dislocation is present, the femoral head is located at posteriorsuperior part of the acetabulum and manifested clinically as flexion, adduction, intorsion, and shortening deformity.