微创直接前方与后外侧入路在初次全髋关节置换中的早期疗效分析

目的:比较分析微创直接前方(Direct anterior approach,DAA)与传统后外侧(Direct lateral approach,DLA)入路在初次全髋关节置换术中的早期临床疗效。方法:选取2015年至2018年在我院骨科行初次人工髋关节置换的60例患者,将其随机分为微创DAA组与传统DLA组(n=30)。DAA组行微创直接前方入路全髋关节置换术,DLA组行传统后外侧入路全髋关节置换术,比较两组患者满意度、住院时间、切口长度、手术时间、术中出血量、手术前后Harris评分与VAS评分、并发症、髋臼外展角及前倾角等指标。结果:DAA组切口长度、术中出血量、住院时间均显著优于DLA组(P0.05)。术后DAA组患者1个月和3个月的Harris评分明显高于DLA组(P0.05)。DAA组综合满意度优于DLA组(P0.05)。DAA组与DLA组髋臼外展角、前倾角之间无统计学差异(P0.05)。结论:在髋置换术中,DAA与DLA相比具有术中出血少、住院时间短、关节恢复快、及患者满意度高等优势,值得在基层临床中推广实施。     

比基尼切口微创髋关节置换术治疗髋关节发育不良的临床疗效

目的 研究比基尼切口直接前方入路(DAA入路)微创人工髋关节置换术治疗先天性髋关节发育不良(DDH)伴骨关节炎的临床疗效和并发症.方法 回顾性研究2019年1月至2019年12月上海交通大学附属第一人民医院收治的78例DDH髋关节骨关节炎患者,38例行比基尼切口 DAA入路人工全髋关节置换术,40例行传统后外侧入路人工...     

髋关节前外侧入路的应用解剖及临床意义

目的 :为髋关节前外侧入路及易损伤结构提供解剖学依据。方法 :对 6 0侧成尸下肢标本 ,参照手术进路的层次对相关结构和神经血管进行解剖观测。结果 :(1)股外侧皮神经干 80 %斜跨切口线下部 ;第一分支阔筋膜浅层穿出点位于髂前上棘下方 (6 .2± 2 .5 )cm ,主干阔筋膜深层穿出点位于髂前上棘下方 (1.6± 1.2 )cm ,此段主干位于阔筋膜浅深两层之间 ,周围充满脂肪组织。 (2 )股直肌直头呈圆柱形 ,其前内侧是股三角 ,后外侧是髋关节囊 ,仅遮挡髋关节囊前内侧 1 6部分。 (3)股神经股外侧肌支从前内上行向下外斜跨切口延长线 ,分数支入股外侧肌 ,其最上支与切口延长线交点位于髂前上棘下方 (12 .4± 2 .6 )cm ,结论 :(1)此入路浅层分离时应先在髂前上棘下 5 .0cm以内的阔筋膜浅深两层之间脂肪组织中寻找并保护股外侧皮神经 ,然后再分离切口下部浅筋膜。 (2 )在深层分离时应沿股直肌直头外侧深入至髋关节囊 ,切匆误入其前内侧的股三角。股直肌直头如果没有挛缩 ,可不必切断 ,以便患者尽早进行功能锻炼。 (3)切口如需向下延长时 ,不宜超过髂前上棘下 9.0cm ;如果必须再延长应向外侧偏斜 ,以免伤及股神经股外侧肌支。     

直接前侧入路(DAA)与后外侧入路全髋关节置换治疗股骨颈骨折的早期临床疗效对比

目的探讨微创直接前侧入路(direct anterior approach,DAA)与传统后外侧入路行全髋关节置换术治疗股骨颈骨折的早期临床疗效情况。方法将我院2015年6月至2017年3月65例股骨颈骨折行全髋关节置换术患者分为2组:DAA组35例,男21例,女14例,平均年龄(65.6±9.7)岁;后外侧入路组30例,男19例,女11例,平均年龄(63.8±12.3)岁。比较两组患者的手术切口的长度、手术时间、术中出血量、卧床时间、住院时间及术后并发症情况,评估术前术后Harris评分及VAS评分情况。结果 2组患者切口长度、手术时间、术后卧床时间及住院时间比较,差异有统计学意义(0.05);术中出血量2组患者比较无统计学意义(0.05)。2组患者术后1个月、3个月Harris评分比较,差异有统计学意义(0.05);术前及术后6个月Harris评分比较无统计学意义(0.05)。2组患者术后第1天、第3天、第7天VAS评分比较,差异有统计学意义(0.05);术前及术后1个月VAS评分比较无统计学意义(0.05)。DAA组有2例大转子骨折,1例股外侧皮神经损伤发生;后外侧入路组有2例髋关节后脱位发生。结论 DAA入路具有切口短、损伤小、术后疼痛轻的优点,可以实现快速康复,短期内优势明显,但长期效果与后外侧入路相比优势不明显。另外,DAA手术技术要求高,早期并发症多,学习曲线较长。     

中国华南地区髋关节的测量参数及临床意义

目的:为改进和设计适合中国华南地区人的人工髋关节假体提供参数值。方法:随机取100例中国华南地区成人髋关节(200髋)拍髋关节X线正侧位片,在X线片上测量股骨头的直径、股骨颈长度、小转子及其上、下2 cm平面处髓腔的宽度、狭窄平面处的髓腔宽度、股骨长度及髋臼前倾角,外展角。选取10例(20髋)正常华南地区人尸体的髋关节直接和摄标准X线正侧位片测量上述参数。结果:中国南方人股骨头直径为(45.9±4.2)mm,转子处髓腔的宽度为(25.7±2.7)mm,其上2 cm处为(43.0±4.7)mm,其下2 cm处为(20.1±2.7)mm,狭窄处髓腔宽度为(10.1 1.1)mm,股骨长度为(43.4±2.6)cm,髋臼前倾角14.4°±5.3°,外展角为43.6°±3.3°。结论:(1)中国华南地区人髋关节解剖的各种参数与国人无明显差异,与欧美人则有显著不同,有必要设计符合中国华南地区人解剖特点的人工关节;(2)本组数据可为设计适合华南地区人解剖特点的人工髋关节提供依据。     

额窦及前中筛窦口l引流的临床应用解剖

目的 :为临床开展鼻窦内窥镜手术提供外科手术解剖学依据。方法 :在 2 0具 40侧经防腐处理的完整成人尸头标本上观测筛泡气化发育的情况 ,观察额窦及前中筛气房窦口引流情况。结果 :额窦向中鼻道引流占 87.5 % (3 5侧 ) ;向筛漏斗引流占 10 .0 % (4侧 ) ;鼻丘向中鼻道引流占 90 .0 % (3 6侧 ) ;向筛漏斗引流占 10 .0 % (4侧 ) ;额隐窝向中鼻道引流占 15 .0 % (6侧 ) ;向筛漏斗引流占 10 .0 % (4侧 ) ;向侧窦引流占75 % (3 0侧 ) ;筛泡向筛漏斗引流占 2 5 .0 % (10侧 ) ;向侧窦引流占 75 .0 % (3 0侧 )。结论 :钩突和筛泡的解剖异常直接影响前组鼻窦的通气引流 ,从而导致前组鼻窦的炎症发生和加重。     

钩突的临床解剖学研究及其意义

目的 :为临床开展鼻窦内窥镜手术提供外科手术解剖学依据。方法 :在 2 0具 40侧经防腐处理的完整成人尸头标本上观测钩突骨的形状大小及其相关临床数据。结果 :测得钩突骨的长度为 (19.6±3 .1)mm(14 .0～ 2 5 .0mm) ;宽度为 (4 .3± 1.2 )mm(2 .0～ 7.0mm) ;厚度为 (1.4± 0 .5 )mm(1.0～ 4.0mm ) ;其长轴与鼻底平面间的夹角为 (5 0 .6°± 5 .3°) (4 2 .0°～ 60 .0°)。结论 :筛漏斗及钩突的解剖形态是慢性鼻窦炎发病的重要解剖因素。     

直接前方入路全髋关节置换术治疗高脱位型髋关节发育不良的临床应用

目的 探讨直接前方入路 (DAA ) 全髋关节置换术 (THA ) 治疗高脱位型髋关节发育不良 (DDH ) 的临床疗效和安全性。方法 回顾性分析2016 年 6 月— 2019 年 10 月蚌埠医学院第一附属医院8例采用DAA入路行 THA 治疗的DDH 患者的临床资料。其中男1例、女7例,年龄(61.86±8.49)岁,Crowe Ⅲ型 7例7髋、Crowe Ⅳ 型1例1髋。观察患者手术切口长度、手术时间、术中出血量、术后下床时间、住院时间,以及手术并发症情况;术后1周测量患者髋臼杯外展角及前倾角;对比观察术前、术后1周及末次随访时患者双下肢长度差异、髋关节 Harris评分以及中心边缘(CE)角的变化。结果 手术切口长度为(7.56±0.62)cm,手术时间为(108±17.65) min,术中出血量为(205±47.20) mL,术后下床时间为(3.25±0.88)d,住院时间为(5.50±0.76)d。术后1周髋臼杯外展角和前倾角测量值分别为41.40°±4.03°和17.90°±3.27°,均处于安全范围。术前、术后1周和末次随访时,患者双下肢长度差值、Harris 评分和CE角测量值分别为(3.98±0.47)cm、(43.38±9.65) 分、15.86 °± 2.20°,(0.85±0.25)cm、(80.63±4.37)分、37.29°± 2.21°,(0.81±0.20)cm、(80.50±4.75)分、37.17°± 2.07°:术前、术后1周、末次随访时3组数据比较差异均有统计学意义(F=597.814、40.866、150.145, P值均＜0.01),术后1周与末次随访时比较差异均无统计学意义(P值均＞0.05)。1例术后出现股外侧皮神经损伤症状,未见术中股骨骨折、髋脱位、坐骨神经损伤、下肢深静脉血栓形成等并发症。结论 采用DAA入路治疗高脱位型DDH患者,手术安全,可以取得良好的临床疗效。     

不同入路人工全髋关节置换术对患者术后恢复的影响

目的探讨人工全髋关节置换术(THA)后外侧入路(PLA)和直接前方入路(DAA)的安全性及对患者术后恢复的影响。方法选取经PLA行THA的患者145例(PLA组),再选取同期经DAA行THA的患者153例(DAA组)。比较2组围术期指标、髋臼假体影像学结果、并发症及术后Harris评分等。结果与PLA组相比,DAA组手术时间更长(P 0.05),而术中出血量、切口长度、住院时间及住院费用均更优(P 0.05)。术后1 d,2组髋臼前倾角、外展角的角度及安全率比较,差异均无统计学意义(P 0.05)。2组并发症总发生率比较差异无统计学意义(P 0.05)。DAA组术后6个月Harris评分高于PLA组(P 0.05),而2组术前及术后1年Harris评分比较,差异无统计学意义(P 0.05)。结论与PLA比较,经DAA行THA具有创伤小、美观度高、费用低的优点,且安全性较好,短期内对THA患者术后恢复的促进作用更显著。     

上颈性眩晕发生的颈交感神经及第2颈神经的解剖学因素观察

目的 明确颈上神经节（superior cervical ganglion,SCG）与第2颈神经及椎动脉的解剖关系,为临床诊治上颈性眩晕提供形态学基础。 方法 解剖15具（30侧）成人尸体标本,观察颈上神经节与C2的交通支及至椎动脉的分支。 结果 5侧未见SCG与C2之间存在神经连接;25侧存在神经连接,其中18侧存在迷走神经参与,7侧可见SCG分支支配椎动脉。SCG分支与C2前支汇合后,交感神经纤维分别至C2前、后支及椎动脉。 结论 SCG与C2的交通支及其对椎动脉的支配关系,可为阐明上颈性眩晕发病机理及建立有效治疗方案提供重要解剖学依据。     

Anatomical study of the lateral femoral cutaneous nerve with special reference to minimally invasive anterior approach for total hip replacement

Background  Lesion of the lateral femoral cutaneous nerve (LFCN) represents the main complication during minimally invasive anterior approach dissection to the hip joint. The aim of this anatomical study was to describe the different presentation features of the LFCN at the thigh and particularly to determine the potential location of damage during minimally invasive anterior approach for total hip replacement. Methods  The LFCN was dissected bilaterally at the thigh under the inguinal ligament in 17 formalin-preserved cadavers. Branching patterns of the nerve were recorded and distances from the LFCN to the anterior superior iliac spine (ASIS) and the anterior margin of the tensor fascia lata (TFL) were measured to clarify skin incision positioning during minimally invasive anterior approach for total hip replacement. Results  The LFCN divided proximal to the inguinal ligament in 13 cases and distal to it in 21 cases. In the distal group the mean distance from the ASIS to the nerve division was 34.5 mm (10–72 mm). The gluteal branch crossed the anterior margin of the TFL 44.5 mm (24–92 mm) distally to the ASIS. In 18 cases the femoral branch did not cross the TFL and was located in the intermuscular space between TFL and sartorius. In the remaining 16 cases, this branch crossed the anterior margin of the TFL 46 mm (27–92 mm) distally to the ASIS. During minimally invasive anterior approach along the anterior border of the TFL, the LFCN was found to be potentially at risk between 27 and 92 mm below the ASIS. We used those informations to describe a map of “danger zones” for the LFCN or its two main branches. Conclusion  According to this study, numerous anatomical variations of the LFCN at the thigh should be considered when performing anterior approach to the hip joint. Different mechanisms of injury during surgery should be considered especially during minimally invasive total hip replacement, such as section of the gluteal or the femoral branch where it crosses the anterior margin of the TFL or stretching of the femoral branch due to retractors positioned into the intermuscular space between sartorius and TFL. According to the map of “danger zones” reported, the author policy consists of positioning the skin incision as lateral and distal to the ASIS as possible.     

骨盆骨折髂腹股沟入路避免神经血管损伤的临床解剖学

目的　为髂腹股沟入路在骨盆骨折手术中避免神经血管损伤提供解剖学依据。  方法    在15具(男9具,女6具)30侧成尸标本上选择髂前上棘、耻骨结节和腹股沟韧带为标志观测股外侧皮神经(Lateral femoral cutaneous nerve,LFCN)、髂腹股沟神经(Ilioinguinal nerve,IN)、股神经耻骨肌支和闭孔动脉(Obturator artery,OA)的走形特点,所测数据统计学处理。  结果     ① LFCN在髂前上棘内侧穿出腹股沟韧带占96.67% (29/30侧),距髂前上棘中心点(20.01±0.32)mm;被腹股沟韧带纵横纤维所包裹的占33.33% (10/30侧);在阔筋膜形成的筋膜鞘中走行占46.67%(14/30侧)。② IN穿出腹内斜肌部位距离髂前上棘中心点为(5.41±0.50)mm,穿出腹外斜肌腱膜部位距离耻骨结节中心点为(18.04±0.21)mm。  结论　在显露髂骨翼内侧面和骶髂关节时,应在LFCN走行的阔筋膜和腹股沟韧带部位进行显露和预防性松解,以免牵拉损伤;切开腹外斜肌腱膜时应从腹股沟韧带两端上方5 mm处开始,防止损伤深面的IN。在显露髂耻隆起时先寻找和结扎闭孔血管耻骨支,以免引起不可控制的出血。     

Anatomical variability of the lateral femoral cutaneous nerve: Findings from a surgical series

The lateral femoral cutaneous nerve (LFCN) is a branch of the lumbar plexus and supplies the skin of the lateral thigh region. This entrapment‐compressive syndrome is named meralgia paresthetica or Roth's meralgia and depends, on a vast majority of cases, on the entrapment of the nerve in proximity of the inguinal ligament. Surgical decompression of the nerve is an option when conservative treatments fail and is usually performed through a 3‐cm infrainguinal skin incision. Available data on anatomical variations of the LFCN derive from extensive cadaver dissections and lack many features relevant to the surgeon. This study was conducted to investigate anatomical details of the LFCN at the site of surgery for meralgia paresthetica. We reviewed retrospective data regarding the anatomical features of LFCN from 148 consecutive patients operated on for Roth's meralgia. In the majority of the cases the LFCN was a single trunk, deep to the thigh superficial fascia and to the inguinal ligament and coursing inferior‐lateral to the anterior superior iliac spine. Less frequent findings were early nerve bifurcation, epifascial position, inferior‐medial direction, and exit from the pelvis through an iliac bone canal. In 13 cases (8.8%) the nerve was not found at surgery. Anatomical variations of the LFCN must be considered at the time of surgery to maximize success rates and avoid nerve damage during surgical dissection. Clin. Anat. 22:365–370, 2009. © 2009 Wiley‐Liss, Inc.     

Variations in the course and microanatomical study of the lateral femoral cutaneous nerve and its clinical importance

The lateral femoral cutaneous nerve (LFCN), a branch from the lumbar plexus, may come to the clinician's or surgeon's attention. We studied this nerve to determine its location and its relationship with neighboring structures around the anterior superior iliac spine (ASIS) and the inguinal ligament (IL). Additionally, cross‐sectional microanatomy of the LFCN at the IL was studied. The LFCN was dissected in 47 lower limbs from formalin‐fixed cadavers. The distances from the ASIS to the point where the LFCN crossed the IL and the lateral border of the sartorius were measured. The distance between the ASIS and the point it pierced the deep fascia was also measured. Twelve nerve specimens at the IL were collected for histological sectioning and were stained with hematoxylin and eosin. On examination of the cross‐sectional area, the nonfascicular area was wider than the fascicular area because of an increased amount of thick collagen fibers. This study may be of help to clinicians managing meralgia paresthetica and may also assist in defining a safe area for surgical intervention on the anterolateral aspect of the thigh. Clin. Anat. 23:978–984, 2010. © 2010 Wiley‐Liss, Inc.     

股外侧皮神经在髂前上棘附近的解剖学和超声观察

目的 感觉异常性股痛(MP)常由股外侧皮神经(LFCN)的机械嵌压引起,通常发生在股外侧皮神经走行至髂前上棘的部位。MP最佳手术治疗方法有待确定,部分原因是LFCN周围筋膜平面的精细结构尚未阐明。本研究的目的是利用生物塑化和超声确定LFCN在髂前上棘附近的筋膜结构。方法 选择11具尸体（6名女性,5名男性, 38～97岁）制作薄层生物塑化切片。对34名健康志愿者（19名女性,15名男性,20～62岁）进行LFCN超声评估。结果 LFCN在腹内斜肌筋膜纤维和髂筋膜之间出骨盆,然后在缝匠肌表面和位于髂前上棘（ASIS）下方的阔筋膜张肌之间走行。在缝匠肌和阔筋膜张肌之间,LFCN走行在独立封闭的筋膜鞘中。结论 LFCN在髂前上棘处位于腹内斜肌腱膜内。LFCN在缝匠肌表面及外侧走行至大腿前外侧区域。超声定位LFCN有助于外科手术。     

股外侧皮神经骨盆出口处的应用解剖与神经卡压综合征

目的：研究股外侧皮神经骨盆出口处的位置及变异情况.方法：取20例成年国人尸体,男13例,女7例.大体解剖出双侧股外侧皮神经的骨盆出口处的骨纤维管道,测量股外侧皮神经的横径,以髂前上棘为基点,测量股外侧皮神经及其纤维管道的位置.结果：股外侧皮神经骨盆出口位点介于髂前上棘后2 cm以远与腹股沟韧带外1/3之间.结论：股外侧皮神经骨盆出口位点存在变异,55.0%经髂前上棘前（内）侧、腹股沟韧带（外1/3）的深面出骨盆.     

The iliohypogastric and ilioinguinal nerves

The courses of the iliohypogastric and ilioinguinal nerves were studied in 44 adult human cadavers, in order to clarify their relations to incisions in the abdominal wall in appendectomy, inguinal hernial repair, caesarean section and lumbar nephrectomy. If either of these nerves is trapped during suturing of the abdominal layers, especially after inguinal hernia repair and appendectomy typical nerve irritation in the inguinal region is observed. To avoid cutting the anterior branches of the iliohypogastric and ilioinguinal nerves in appendectomy, incisions should be placed at a distance of not less than 3 cm from the anterior superior iliac spine. In inguinal hernial repair, after the external oblique aponeurosis has been opened, the ilioinguinal nerve should be displaced from the spermatic cord cranially. In performing a lower paramedian incision (Lennander) and Pfannenstiel's suprapubic incision, the iliohypogastric nerve will be spared if the incision passes at least 5 cm cranial to the inguinal ligament. During oblique lumbar incision for nephrectomy (Bergmann-Israel) the iliohypogastric nerve can easily be found in the middle third of the lateral margin of the quadratus lumborum muscle. The nerve should be displaced carefully downwards. Positional changes of the kidney or ureter, perinephric inflammation, etc. are often referred to the skin areas (Head, Mackenzie) of the iliohypogastric and ilioinguinal nerves.     

骶结节韧带和骶棘韧带的解剖定位研究

目的通过测量骶结节和骶棘韧带附着处附近的骨性标志间的距离,获得两条韧带的解剖定位方法及其体表投影位置,为临床相关应用提供解剖学依据。方法 20例(男、女性各10例20侧)正常成人防腐骨盆标本,用游标卡尺测量同侧髂后上棘至坐骨结节、髂后上棘至坐骨棘、髂后上棘至第4骶椎横突结节、髂后上棘至骶角、坐骨结节至坐骨棘、坐骨棘至骶角、坐骨结节至骶角的距离,并进行性别比较。结果男、女性骨盆髂后上棘至坐骨结节距离分别为(12.19±0.49)cm和(11.20±0.39)cm(P0.05);髂后上棘至骶角距离(7.62±0.50)cm和(6.70±0.92)cm(P0.05)。骶结节韧带的体表投影线为同侧髂后上棘至骶角连线中点与坐骨结节的连线;骶棘韧带的体表投影线为同侧髂后上棘至坐骨结节连线的上3/4与下1/4交点(坐骨棘位置,约距髂后上棘8.5cm)与骶角的连线。结论本研究不仅丰富了人类学数据,且提供的体表定位方法,为临床相关应用和康复治疗提供解剖学参考。     

优化髋臼后柱螺钉内固定的计算机辅助设计

目的研究专门的最优化计算机辅助解剖测量技术,为髋臼后柱拉力螺钉内固定提供解剖学基础。方法取骨盆CT数据40份,进行精确的三维重建得到80个半骨盆模型。根据临床手术需要,对螺钉到骨边界的加权距离进行动态采样作为最优化目标函数,在约束条件下自动迭代修改螺钉2个端点位置,达到最佳位置。对测量结果进行统计分析,并设计新的解剖测量参考体系。结果髋臼后柱拉力螺钉的入钉点在骶髂关节最前缘与髂前上下棘之间切迹连线的上方(18.90±1.19)mm处,垂足点在骶髂关节最前缘与髂前上下棘之间切迹连线上的比例位置为2:3;其进针方向与入钉点-髂前上下棘之间切迹连线呈(85.99±2.04)°,进针方向与入钉点-垂足点连线的夹角呈(37.54±1.55)°;螺钉骨内段长度为(133.07±3.22)mm。结论最优化计算机辅助解剖测量是一种非常有效的新测量技术,克服了传统手工实物解剖测量的缺点,并且方便设计新的解剖测量参考体系和临床手术方案,有利于提高临床工作质量和效率。