髋关节镜术的入路选择

目的探讨髋关节镜手术不同入路的可见视野和操作安全性.方法使用三点入路,2个入路分别位于大粗隆的外侧上方,1个入路位于前方.使用30/70镜头并更换镜头入路,记录关节镜下视野.通过18例髋关节镜检查和手术操作过程及并发症分析,评价不同髋关节镜入路的有效性和安全性.结果本研究显示,以30°/70°标准关节镜经髋关节前方及侧方入路,可确切观察到的髋关节结构包括髋臼上部的负重区,陷窝及圆韧带,上、前、外侧的髋臼盂唇;通过手术中台下外旋和内旋髋关节,可以观察到大部分股骨头关节面.本组未出现神经血管并发症.结论经由3个入路相配合交替使用镜头和手术器械,可以完成关节镜的系统检查与手术操作.该入路的操作具有安全、有效和可重复性.     

髋关节囊肿压迫股静脉1例报道与文献综述

本文报道1例髋关节囊肿压迫股静脉导致下肢肿胀病例的诊疗过程。完善单侧髋关节核磁等检查后明确诊断,行髋关节镜检查,证实了术前诊断,通过髋关节镜微创手术部分切除囊肿行内引流,同时处理股骨髋臼撞击,盂唇损伤等关节内原发病因。术后患者腹股沟区包块消失,疼痛及下肢肿胀症状明显缓解,且术后随访未见复发。通过总结此病例诊治思路及治疗策略的选择并回顾文献,可见髋关节镜手术治疗此类疾病,在切除囊肿的同时可一期处理关节内原发病因,具有创伤小,安全,疗效显著,术后恢复快,不易复发等优点。     

本期继续教育测试题

1.最先报告髋关节镜的学者是谁?A.MasonB.BurmanC.SampsonD.Gray2.髋关节镜最先应用到临床是哪一年?A.1928年B.1930年C.1931年D.1935年3.以下哪种疾患适合用髋关节镜?A.关节强直B.异位骨形成C.游离体D.关节内陷4.关节镜用于髋关节骨性关节炎(OA)主要进行哪些治疗?A.关节冲洗B.骨赘清理C.游离体摘除D.以上全对5.髋关节镜检查的标准入路是:A.前侧入路B.前外侧入路C.后外侧入路D.以上全对★凡订阅本刊者,均为本刊“继教”栏目学员,可免费学习与答题,每期5道单选题,答题合格授予中华医学会Ⅱ类学分1学分,全年共24学分,答题卡每年(随…     

两种髋关节入路的THA术后髋关节本体感觉的分析

目的关节的不稳定大致可分为机械性不稳和功能性不稳。据报道全髋关节置换术后脱位常发生在后侧入路,可能是由于关节周围软组织损伤引起的功能性不稳所致。因此我们对比了采用不同入路进行髋关节置换手术患者的髋关节位置觉,用以了解不同手术入路是否对术后脱位产生影响。方法 58例(116个髋关节)于我院接受髋关节置换的患者纳入研究,健康的没有影像学改变的对侧髋关节作为对照组。男性10例,女性48例;年龄40~84岁,平均年龄63.1岁。后外侧入路39个髋关节,前外侧入路30个髋关节,对照组是37个髋关节。结果前外侧入路(anterolateral approach,AL)组中的主动外旋的绝对复位角度误差明显低于后外侧入路(posterolateral approach,PL)组中的绝对复位角度误差,在AL组和对照组中被动内旋、外旋和主动内旋的相对复位角度误差明显低于PL组。结论在前外侧入路置换中由于关节周围软组织的保留,髋关节具有更好的位置觉。     

由周围室至中央室髋关节镜修复髋臼盂唇损伤

[目的]介绍由周围室至中央室髋关节镜治疗髋臼盂唇损伤的手术技术和初步临床结果。[方法]患者全麻后平卧于牵引架上，患肢屈髋10°，外展25°，内旋位，C形臂X线机透视辅助下在髋部前、外侧方做体表标志。自前外侧入路插入钝头关节镜鞘套内芯，可感觉触及一坚韧组织，将鞘套内芯左右分离组织后拔出，将关节镜从前外侧入路置入，看见关节镜镜头位于髋关节囊前方。从前方入路插入等离子刀头，分离前方关节囊外组织，显露髋关节囊前方及前外侧。“Y”形切开髋关节囊前侧、外侧。将关节镜插入关节内，观察外侧间室。牵引患肢，显露并探查中央间室。探查盂唇损伤情况，并缝合修复盂唇。[结果]所有患者均顺利完成手术，术中均未出现严重并发症。随访24～96个月，与术前相比，末次随访时，患者疼痛VAS评分[(6.7±1.2),(2.1±0.7), P<0.001]、Harris评分[(52.8±6.4),(86.9±4.7), P<0.001]均显著改善，无患者需要翻修或者二次手术。[结论]由周围室至中央室髋关节镜治疗髋臼盂唇损伤的技术可行，缩短了术中牵引时间，初步临床效果满意。     

膝关节镜下膝后侧腔室联合手术入路的探讨

[目的]探讨在关节镜下膝关节后侧腔室联合手术入路的重要性和可操作性。[方法]经过前内侧、前外侧和股骨髁切迹以及后内侧、后外侧和后纵隔内切口联合入路分别入镜、入器械，进行膝关节后侧腔室的探查和手术操作。[结果]216例（239膝）应用联合入路探查和治疗，其中5例膝因关节僵硬操作失败；175例膝用于治疗后侧腔室疾病，膝关节后侧腔室手术视野显著改善，探查和手术操作完善，均达到手术目的。1例膝内侧隐神经不全损伤，没有腘后神经、腓总神经、腘后血管、交叉韧带等重要组织损伤。[结论]膝关节后侧腔室病变较多，是检查和治疗的重要部位，并非“技术盲区”。这种联合手术入路，手术风险低，具备可操作性，可以提高手术效率和质量，可作为膝关节镜下常规手术入路。     

外侧入路全髋关节置换手术后的并发症与分析

目的探讨外侧入路全髋关节置换术后的并发症，给出目前可采用的预防措施。方法对2000年1月至2006年1月本组360例采用外侧入路行全髋关节置换术的患者进行回顾性分析，术后随访时间为1．5～7年。结果外侧入路与后侧入路全髋关节置换术后的并发症主要有：感染，假体松动，髋臼磨损，髋关节脱位，双下肢不等长，下肢深静脉血栓，骨折，异位骨化等。外侧入路全髋关节置换术的术后髋关节脱位及坐骨神经损伤发生率均低于后侧入路。结论外侧入路全髋关节置换术后并发症的发生与围手术期处理、手术操作、假体设计及选择、患者个体差异等因素有关。     

关节外科人体解剖学系列讲解（二）髋关节后外侧入路

髋关节后外侧入路是髋关节人工假体置换术最常采用的入路，也称为K-L入路、Gibson入路。该入路由Kocher—Langenbeck首先介绍推荐，并由Gibson进行了推广，因其入路操作简捷，显露充分且不损伤髋关节部臀中肌等外展装置，有利于术后功能的迅速恢复，因此是一个十分理想且实用的手术入路。     

微创全髋关节置换术手术入路的现状

全髋关节置换术(total hip arthroplasty,THA)临床已广泛应用于治疗各种晚期髋关节疾病.THA入路主要包括前侧入路、外侧入路及后侧入路等.传统的手术入路具有显露充分、操作方便的优点,但需要切断梨状肌、外旋肌群、臀中肌,影响术后关节稳定性.手术创伤大,围手术期出血较多,从而导致术后康复时间相对较长[...     

后外侧与外侧入路翻修Vancouver B2型股骨假体周围骨折

[目的]比较后外侧入路和外侧入路翻修治疗髋关节置换术后Vancouver B2型股骨假体周围骨折的治疗效果。[方法] 2010年6月～2018年1月,翻修治疗髋关节置换术后Vancouver B2型股骨假体周围骨折患者38例。其中,采用后外侧入路18例(后外侧组),外侧入路20例(外侧组),对两组手术时间、切口长度、术中出血量、术后引流量、首次下地时间、术后并发症,以及术后Harris评分和影像检查进行比较。[结果] 38例患者顺利完成手术,术中未发生骨折及重要神经血管损伤等严重并发症。两组患者手术时间、手术切口长度、术中出血量、术后引流量差异无统计学意义(P0.05),后外侧组的术后首次下地时间明显早于外侧组,差异有统计学意义(P0.05)。后外侧入路组术后1个月Harris评分优于外侧入路组(P0.05),之后两组间Harris评分差异无统计学意义(P0.05)。两组患者术后骨折均愈合,愈合时间差异无统计学意义(P0.05)。至末次随访时,未发生关节脱位、假体松动下沉、深静脉血栓及感染等并发症。[结论]髋关节后外侧入路和外侧入路翻修治疗Vancouver B2型股骨假体周围骨折各有其特点,后外侧入路术后早期康复效果优于外侧入路。     

Editorial Commentary: Axial Stress Examination Under Anesthesia Provides a Highly Reliable Test for Measurement of Hip Distraction

Symptomatic hip microinstability is now recognized as one of the most common surgical indications for revision hip arthroscopy. Hip microinstability can be difficult to diagnose, particularly because of the multifactorial etiology and limited physical examination maneuvers that provide objective testing of gross hip stability. One measure of hip stability is axial stability evaluated under traction intraoperatively. Recent research has suggested that average axial stability of the hip is decreased after primary hip arthroscopy—although not in all cases. Recognizing that there are many additional factors that may contribute to hip microinstability, as well as the fact that axial stability is only one assessment of overall stability of the hip, is important in the evaluation of microinstability in the setting of prior hip arthroscopy.     

Editorial Commentary: Is Back Pain Killing Your Hip Arthroscopy Outcomes?

The identification of factors associated with inferior postoperative outcomes after hip arthroscopy is critical as we try to further clarify indications for hip arthroscopy. Recent arthroplasty studies have shown worse outcomes after hip and knee replacement in patients with comorbid joint and spine pain. Recent evidence has shown this to be true in patients undergoing hip arthroscopy as well. This evidence helps surgeons counsel patients better preoperatively and manage their expectations postoperatively. Patients with comorbid joint and spine pain should expect improvements in pain and function after hip arthroscopy; however, the overall functional outcomes are worse than those in patients without these comorbid conditions.     

The 23-Point Arthroscopic Examination of the Hip: Basic Setup,Portal Placement,and Surgical Technique

The 23-point arthroscopic examination of the hip has been used for more than 400 arthroscopic hip procedures. It ensures that all components of the hip are carefully inspected and allows for proper documentation. It is vital that a precise knowledge of hip anatomy and common portal placement is coupled with proper patient selection, sound preoperative planning, and a consistent arthroscopic technique in order to maximize clinical outcomes. The 23-point arthroscopic examination of the hip uses 3 standard portals (anterior, anterolateral, and posterolateral) that provide a systematic method of examination of the key structures of the central and peripheral hip joint. The points are divided up into groups based on the portal through which they are viewed. The 23-point arthroscopic examination of the hip is reproducible, and offers some standardization within the evolving field of hip arthroscopy. It provides a consistent routine for hip arthroscopy that has yet to be published. Using this standardized examination can assist with the diagnostic accuracy of hip arthroscopy.     

Editorial Commentary: Myth Buster—Is Femoral Retroversion a Contraindication to Hip Arthroscopy in Femoroacetabular Impingement?

Hip arthroscopy can effectively address cam and pincer impingement by reshaping bone prominences or bone edges. However, hip arthroscopy cannot be used to correct severe bone torsion abnormalities such as acetabular or femoral retroversion. As a result, some surgeons contraindicate hip arthroscopy in patients with femoral retroversion absent correction of the torsion abnormalities. However, recent research has suggested that hip arthroscopy absent osteotomy, with a focus on labral preservation and thorough correction of underlying cam and pincer bony abnormalities, achieves positive outcomes. Still, although femoral retroversion should not be considered a contraindication for hip arthroscopy, patients should be carefully counseled about residual symptoms.     

Editorial Commentary: The Hip-Spine Connection in Patients Undergoing Hip Arthroscopy: Should We Learn From Total Hip Replacement and Counsel Patients Differently If They Have Had Previous Back Surgery?

Disorders of the adult hip and spine are common, and there is evidence that there is a hip-spine connection in patients with hip femoroacetabular impingement (FAI). Many reports have shown that patients undergoing lumbar fusion and subsequent total hip arthroplasty have a higher risk of complications and worse outcomes following total hip arthroplasty. However, there has been a paucity of research on the effect of a history of lumbar spine surgery in patients undergoing hip arthroscopy for the treatment of FAI. Variations in lumbar lordosis, pelvic incidence, tilt, and sacral slope may modify the degree of FAI, symptoms, and patient-reported outcomes following hip arthroscopy. In the future, we should continue our efforts to better understand the impact that limited range of motion in the spine has in joint mechanics of the hip and the possibility of affecting patient-reported outcomes after hip arthroscopy. Future studies incorporating novel imaging technology, such as EOS, may be an objective way of assessing the effect of abnormal spine-pelvic function in patients with hip FAI.     

Hip arthroscopy: evolving frontiers

The basic principles of hip arthroscopy have been well developed and well accepted. Arthroscopy has been instrumental in understanding numerous aspects of hip joint disorders. Operative arthroscopy has met with successful results for a variety of conditions. The outcomes continue to improve and the indications continue to evolve. Arthroscopy has expanded from the intra-articular compartment to the peripheral aspect of the joint, allowing greater access to various lesions. Extracapsular and endoscopic techniques can now be employed in the hip region. These methods are beginning to evolve from resection to restorative procedures. Also, with a better understanding of the pathomechanics and natural disease process, arthroscopy may have a preventative role in the development of subsequent pathology. The basic technique and emerging technology are illustrated in this chapter.     

Editorial Commentary: Hip Arthroscopy—A Microcosm in the Evolution of Arthroscopy in Sports Medicine

Hip arthroscopy represents a microcosm in the evolution of arthroscopy within sports medicine. It has evolved right before our eyes over a condensed time frame with current-day techniques in arthroscopy and concepts in sports medicine. Early on, arthroscopy identified labral tears and other painful problems that had previously gone unrecognized and untreated because open procedures were rarely performed for these poorly defined conditions. The evolution of hip arthroscopy changed when femoroacetabular impingement was described and open surgical procedures were used for treatment. Open procedures for the hip, like the knee and shoulder before it, then evolved to less invasive arthroscopic methods. Techniques, technology, and understanding of hip disorders have all evolved simultaneously, resulting in a quickly changing landscape in the role of arthroscopy. And an improved focus has been gained on disorders other than femoroacetabular impingement that can lead to hip problems. This evolution is not novel because we have seen it in other joints, as well as among other general surgical procedures; most important, this evolution is not complete. Miles to go before we sleep.     

Complications following hip arthroscopy: a retrospective review of the McMaster experience (2009–2012)

Background

The use of hip arthroscopy has been steadily rising as technology, experience and surgical education continue to advance. Previous reports of the complication rate associated with hip arthroscopy have varied. The purpose of this study was to report our experience with hip arthroscopy complications at a single Canadian institution (McMaster University).

Methods

We performed a retrospective chart review of 2 hip arthroscopists at the same institution to identify patients who had undergone the index surgery and had been followed for a minimum of 6 months postoperatively. We used a standard data entry form to collect information on patient demographic and clinical characteristics, including age, sex, surgical indication and type of complication if any.

Results

A total of 211 patients underwent 236 hip arthroscopies. The mean age at time of surgery was 37 ± 13 years and mean follow-up was 394 ± 216.5 days. The overall complication rate associated with hip arthroscopy was 4.2% (95% confidence interval 2.3%–7.6%). We identified 4 major and 6 minor complications.

Conclusion

Overall, hip arthroscopy appears to be safe, with minor complications occurring more frequently than major ones. However, surgeons should recognize the possibility of serious complications associated with this procedure. Future research should focus on prospective designs looking for potential prognostic factors associated with hip arthroscopy complications.     

Stellenwert der Handgelenkarthroskopie

Wrist arthroscopy has been the gold standard in diagnosing ligament, cartilage, or triangular fibrocartilage complex (TFCC) lesions of the wrist joint. One advantage of arthroscopy is the ability not only to see, but also to palpate the lesions using a probe. A disadvantage of arthroscopy is the low interobserver reliability of digital images or videos made during arthroscopy. Magnetic resonance imaging (MRI) is an alternative to wrist arthroscopy in diagnosing wrist lesions. Its reliability is enhanced by a limited, specific use, which should be founded on a thorough hand surgical clinical examination. MR images should be transmitted to the surgeon in an adequate quality.     

Peri-acetabular rotational osteotomy with concomitant hip arthroscopy for treatment of hip dysplasia

Reconstructive acetabular osteotomy is a well established and effective procedure in the treatment of acetabular dysplasia. However, the dysplasia is frequently accompanied by intra-articular pathology such as labral tears. We intended to determine whether a concomitant hip arthroscopy with peri-acetabular rotational osteotomy could identify and treat intra-articular pathology associated with dysplasia and thereby produce a favourable outcome. We prospectively evaluated 43 consecutive hips treated by combined arthroscopy and acetabular osteotomy. Intra-operative arthroscopic examination revealed labral lesions in 38 hips. At a mean follow-up of 74 months (60 to 97) the mean Harris hip score improved from 72.4 to 94.0 (p < 0.001), as did all the radiological parameters (p < 0.001). Complications included penetration of the joint by the osteotome in one patient, a fracture of the posterior column in another and deep-vein thrombosis in one further patient. This combined surgical treatment gave good results in the medium term. We suggest that arthroscopy of the hip can be performed in conjunction with peri-acetabular osteotomy to provide good results in patients with symptomatic dysplasia of the hip, and the arthroscopic treatment of intra-articular pathology may alter the progression of osteoarthritis.