臂后侧手术入路的应用解剖

目的 :为臂后侧手术入路提供解剖学基础。方法 :在 2 0具尸体标本上对臂后侧手术入路有关的血管、神经进行解剖观察。结果 :桡神经在肱骨内上髁上方 (18.2± 0 .4)cm ,臂后中线鹰嘴上方 (13 .9± 1.3)cm ,肱骨外上髁上方 (8.4± 1.4)cm跨过肱骨后面。桡神经在桡神经沟以上发出肱三头肌长头支、肱三头肌内侧头—肘肌支、内侧头支和前臂后皮神经 ,在桡神经沟内发出肱三头肌外侧头支。肱三头肌内侧头—肘肌支走行于臂后中线的稍外侧 ,于臂后中线的稍内侧切开肱三头肌内侧头可避免损伤该神经。结论 :①肱骨后面中下部骨面宽阔而平坦 ,可放置各种类型的钢板 ;②肱骨下段后面无重要的血管、神经 ,手术较安全 ;③臂后侧手术入路适合于肱骨中下段骨折等手术处理。     

经颅开眶球后入路的应用解剖

目的：给眶内手术入路提供详细的形态学依据和显微解剖参数，分析经颅手术入路的优势及其易损伤结构。方法：用32例(64侧)成人头颅湿性标本，通过模拟额颞眶颧手术入路，在放大5—25倍手术显微镜下，运用显微解剖方法，通过颅前窝眶板开眶，观测开眶后球后结构在不同手术视野下的位置、毗邻、走行、变异、分支、分布等关系。结果：上内侧入路是经上斜肌与上睑提肌之间的问隙入路，暴露从球后到视神经管之让的视神经。上中央入路是经上直肌与上睑提肌之间的间隙入路，根据不同情况向内侧或外侧牵开额神经，暴露视神经眶内段的中部。上外侧入路是通过上直肌与外直肌之让的肌间膜入路，对眶尖深部上外侧区的暴露效果与经眼眶外侧壁的外上方入路基本相同，但前者能兼顾眶上裂与海绵窦，而后者则不能。经外下方入路可暴露肌锥间隙的下外侧区。结论：对于眶内肿瘤应根据病变在眶内的具体位置选择相应的最佳手术入路，有助于克服盲目的破坏性手术。     

三脑室区肿瘤手术入路及经胼胝体-穹隆间人路的显微解剖

三脑室区肿瘤的手术入路根据病变部位有适用于前部病变的经额叶皮质入路、经胼胝体前部入路、经终板入路，主要适用于中部病变的脉络丛下入路、经脉络裂入路和脉络裂下经中央帆入路，主要适用于后部病变的枕部经小脑幕入路、幕下小脑上入路、经胼胝体后部入路及经侧脑室三角区入路。解剖和临床研究表明经胼胝体穹隆间入路到达三脑室最近、术后并发症少，掌握该入路路径中扣带回、胼周动脉、胼胝体、穹隆、前连合等重要神经结构的显微解剖学知识，有利于术前手术计划的制定和实施手术。     

肩胛骨骨折三种手术入路的应用解剖比较

肩胛骨骨折（scapular fracture，SF）临床上相对少见，多由高能直接暴力所致，绝大多数为粉碎性骨折。既往观点认为大部分SF可通过功能康复治疗而获得满意疗效，仅少数移位严重或累及肩关节盂的骨折才需手术治疗。随着临床研究的深入，发现手术病例肩关节功能恢复要优于非手术病例。因此，手术机率逐渐升高。目前临床上大多数肩胛骨骨折采用Judet入路和肩胛骨外侧缘入路，部分骨折采用肩前方三角肌一胸大肌入路。本文通过对三种手术入路的局部解剖分析，探讨三种手术入路的优缺点及其各自的临床应用。     

甲状腺次全切除手术入路的改进及意义

目的：探讨甲状腺次全切除手术入路的改进，提高手术治疗水平。方法：回顾及总结300例甲状腺次全切除术不切断舌骨下肌群、保留颈前静脉。250例经颈白线，50例经胸锁乳突肌内侧筋膜间隙新的手术入路。结果：全组病例术中无血管、神经损伤，术后无甲状腺危象，抽搐，甲低等并发症。新的手术切口工期愈合，随访4月至5年无复发，术后切口平整，颈部活动无牵扯感。结论：(1)甲状腺次全切除术径路的改进减少了手术创伤与出血，且术野显露满意，术后颈部活动无障碍，切口愈合好。(2)颈白线入路适应双侧甲状腺次全切除术，胸锁乳突肌内侧筋膜间隙入路适宜单侧甲状腺次全切除术。     

枕下极外侧手术入路的解剖学研究

目的：为枕下极外侧手术入路提供解剖学基础。方法：10例成人尸体头湿标本按手术入路在手术显微镜下进行解剖和观测。结果：枕下三角是枕下极外侧入路中重要的解剖学标志，在分离移位椎动脉后，切除枕骨髁后部1／3以辨别和暴露舌下神经管，枕骨髁的磨除可显著扩大枕骨大孔前缘的暴露范围，磨除颈静脉结节对扩大斜坡中下部的暴露有重要的作用。椎动脉硬膜内段及其分支与后组脑神经有复杂的毗邻和穿行关系。结论：枕下极外侧入路尽管解剖复杂，但可在不牵拉延髓的基础上充分暴露颈延髓交界部腹侧面和外侧面的区域，达到充分暴露的枕骨髁磨除范围限于其后1／3即可.     

直外侧入路与后侧入路人工全髋关节置换术回顾性队列研究

目的 比较采用经直外侧入路与后侧入路行人工全髋关节置换术的临床效果.方法 回顾性分析了80名行人工全髋关节置换术患者,其中直外侧入路组40名,后侧入路组40名,对两组之间的手术切口长度、手术时间、术中出血量、术后髋关节Harris评分、髋关节Harris评分优良率、髋臼外展角、髋臼前倾角、偏心距恢复率、外展肌力恢复情况及并发症进行评估.结果 两组在手术切口长度、手术时间、术中出血量、术后髋关节Harris评分、髋关节Harris评分优良率、髋臼外展角、髋臼前倾角、偏心距恢复率、外展肌力恢复方面均无统计学差异.结论 直外侧入路与后侧入路行人工全髋关节置换术的临床效果并无明显差异,选取术者熟悉的手术方式更能保证手术质量.     

人肌腱袖肌群的构筑学研究

本的目的是了解肌腱袖肌群的构筑特点，功能及其临床意义，对10侧人肌腱袖诸肌进行了构筑学研究，结果表明，冈上肌是环羽肌，其生理横切面积与肌重的比率显大于其余三肌（P＜0．05），作推测冈上肌在人类是一块处于进化状态的上肢带肌，肩胛下肌是由5－7个羽构成的多羽肌，冈下肌与小圆肌为羽肌，以上三肌的生理横切面积之和比冈上肌和三角肌的生理横切面积之和更大，这充分说明人类肩关节运动中协同肌群的重要性，本讨论了肌腿袖肌群的临床意义。     

经盆腔、会阴及臀部会师入路切除EnnekingⅡⅢ型骨盆肿瘤1例并文献复习

目的：报道盆腔、会阴及臀部会师入路在EnnekingⅡⅢ型骨盆肿瘤切除中的应用与临床体会。方法：复习相关文献,成功采用盆腔、会阴及臀部会师入路切除EnnekingⅡⅢ型骨盆肿瘤,钛板、骨水泥重建髋臼1例。结果：切口一期愈合,无感染、死腔、漏与疝,无任何神经血管及脏器副损伤,无大小便障碍及会阴部感觉障碍等并发症。术后随访2．5a,X线片内固定无松动,行走、下蹲、盘腿正常,髋关节存在不适,无疼痛。结论：会师入路避免了髂腹股沟入路辅助会阴入路在操作至臀区、会阴区及坐骨直肠窝后部的盲目性,对避免重要结构的副损伤及完整切除肿瘤更有意义。     

肩袖损伤的病因,病理和发病机理

在肩关节病变中 ,肩袖损伤约占 17%～ 41%。其主要表现为肩关节疼痛和严重的肩关节功能障碍。最早在 1834年由 Sm ith发现并命名 ,当时未被引起重视 ,直到 1931年Codman和 Akerson〔1〕指出本病是引起肩疼的一个重要原因 ,并对其诊断和治疗作了初步的研究之后 ,许多作者开始探讨有关本病的病因、病理和发病机理。笔者现就近年来有关文献对此加以概述。1　肩袖功能解剖和生物力学肩袖起于肩胛骨 ,附着于肱骨头周围的冈上肌、冈下肌、肩胛下肌和小圆肌组成的一组具有相似功能的肌群。四块肌肉的肌腱部分在肱骨头解剖颈处形成袖套状结构 ,肩…     

EMG of scapulohumeral muscles in the chimpanzee during reaching and “arboreal” locomotion

Current views on the function of the deltoid and rotator cuff muscles emphasize their roles in arm-raising as participants in a scapulohumeral force “couple.” The acceptance of such a mechanism is based primarily on a 1944 EMG study of human shoulder muscle action. More recently, it has been suggested that shoulder joint stabilization constitutes a second and equally important function of the cuff musculature, especially in nonhuman primates which habitually use their forelimbs in overhead postural and locomotor activities. Few comparative data exist, however, on the actual recruitment patterns of these muscles in different species. In order to assess the general applicability of a scapulohumeral force couple model, and the functional significance of the differential development of the scapulohumeral musculature among primate species, we have undertaken a detailed study of shoulder muscle activity patterns in nonhuman primates employing telemetered electromyography, which permits examination of unfettered natural behaviors and locomotion. The results of our research on the chimpanzee, Pan troglodytes, on voluntary reaching and two forms of “arboreal” locomotion reveal four ways in which previous perceptions of the function of the scapulohumeral muscles must be revised: (1) the posterior deltoid is completely different in function from the middle and anterior regions of this muscle; (2) the integrity of the glenohumeral joint during suspensory postures is not maintained solely by osseoligamentous structures; (3) the function of teres minor is entirely different from that of the other rotator cuff muscles and is more similar to the posterior deltoid and teres major; and (4) each remaining member of the rotator cuff plays a distinct, and often unique, role during natural behaviors. These results clearly refute the view that the muscles of the rotator cuff act as a single functional unit in any way, and an alternative to the force couple model is proposed.     

The moment arms of the muscles spanning the glenohumeral joint: a systematic review

The moment arm of a muscle represents its leverage or torque‐producing capacity, and is indicative of the role of the muscle in joint actuation. The objective of this study was to undertake a systematic review of the moment arms of the major muscles spanning the glenohumeral joint during abduction, flexion and axial rotation. Moment arm data for the deltoid, pectoralis major, latissimus dorsi, teres major, supraspinatus, infraspinatus, subscapularis and teres minor were reported when measured using the geometric and tendon excursion methods. The anterior and middle sub‐regions of the deltoid had the largest humeral elevator moment arm values of all muscles during coronal‐ and scapular‐plane abduction, as well as during flexion. The pectoralis major, latissimus dorsi and teres major had the largest depressor moment arms, with each of these muscles exhibiting prominent leverage in shoulder adduction, and the latissimus dorsi and teres major also in extension. The rotator cuff muscles had the largest axial rotation moment arms regardless of the axial position of the humerus. The supraspinatus had the most prominent elevator moment arms during early abduction in both the coronal and scapular planes as well as in flexion. This systematic review shows that the rotator cuff muscles function as humeral rotators and weak humeral depressors or elevators, while the three sub‐regions of the deltoid behave as substantial humeral elevators throughout the range of humeral motion. The pectoralis major, latissimus dorsi and teres major are significant shoulder depressors, particularly during abduction. This study provides muscle moment arm data on functionally relevant shoulder movements that are involved in tasks of daily living, including lifting and pushing. The results may be useful in quantifying shoulder muscle function during specific planes of movement, in designing and validating computational models of the shoulder, and in planning surgical procedures such as tendon transfer surgery.     

Towards the development of a novel experimental shoulder simulator with rotating scapula and individually controlled muscle forces simulating the rotator cuff

A preclinical analysis of novel implants used in shoulder surgery requires biomechanical testing conditions close to physiology. Existing shoulder experiments may only partially apply multiple cycles to simulate postoperative, repetitive loading tasks. The aim of the present study was therefore the development of an experimental shoulder simulator with rotating scapula able to perform multiple humeral movement cycles by simulating individual muscles attached to the rotator cuff. A free-hanging, metallic humerus pivoted in a polyethylene glenoid is activated by tension forces of linear electroactuators to simulate muscles of the deltoideus (DELT), supraspinatus (SSP), infraspinatus/teres minor and subscapularis. The abductors DELT and SSP apply forces with a ratio of 3:1 up to an abduction angle of 85°. The rotating scapular part driven by a rotative electro actuator provides one-third to the overall arm abduction. Resulting joint forces and moments are measured by a 6-axis load cell. A linear increase in the DELT and SSP motors is shown up to a maximum of 150 and 50 N for the DELT and SSP, respectively. The force vector in the glenoid resulted in 253 N at the maximum abduction. The present investigation shows the contribution of individual muscle forces attached to the moving humerus to perform active abduction in order to reproducibly test shoulder implants.     

Teres minor innervation in the context of isolated muscle atrophy

Purpose  

Teres minor atrophy occurs either in isolation, associated with other rotator cuff muscle pathologies or in quadrilateral space syndrome. In the latter condition, compression of the axillary nerve is the likely cause; however, the anatomy of the nerve to teres minor and how this may relate to isolated teres minor atrophy have not been extensively investigated. In light of the significance of teres minor atrophy in shoulder pathology, we performed a combined radiological and anatomical study of teres minor and its nerve supply.     

Bilateral absence of the quadrangular space of the axilla]

In the 1988 student course on gross anatomy dissection of cadavers at Iwate Medical University School of Medicine, two cases of the absence of the quadrangular space of the axilla were found bilaterally in a 92-year-old female who had died of heart failure. The cases were investigated anatomically. The tendons of insertion of the latissimus dorsi and the teres major muscles and the tendon of origin of the long head of the triceps brachii muscle were united, forming a conjoint tendon that attached to the infraglenoid tubercle of the scapula and the lower part of the anatomical neck of the humerus adhering to the articular capsule of the shoulder joint. The subscapularis muscle was normal except that a muscular bundle arose from the conjoint tendon and inserted to the lesser tubercle of the humerus and the crest continuing down from the tubercle. A part of the conjoint tendon was covered by the insertion of the subscapularis muscle, and there was no space between the conjoint tendon and the insertion of the subscapularis muscle. The teres major muscle was poorly developed, but the area of origin was rather wide and arose from both the dorsal and costal surfaces of the scapula. The anatomical features of the latissimus dorsi and the long head of the triceps brachii muscles were normal except for the insertion of the former and the origin of the latter. The triangular space of the axilla was found to be surrounded by the conjoint tendon, teres major muscle, and the lateral border of the scapula covered by the subscapularis and the teres minor muscles.(ABSTRACT TRUNCATED AT 250 WORDS)     

Density of muscle spindles in prosimian shoulder muscles reflects locomotor adaptation

We examined the correlation between the density of muscle spindles in shoulder muscles and the locomotor mode in three species of prosimian primates: the slow loris (Nycticebus coucang), Garnett's galago (Otolemur garnettii), and the ring-tailed lemur (Lemur catta). The shoulder muscles (supraspinatus, infraspinatus, teres major, teres minor, and subscapularis) were embedded in celloidin and cut into transverse serial thin sections (40 microm); then, every tenth section was stained using the Azan staining technique. The relative muscle weights and the density of the muscle spindles were determined. The slow loris muscles were heavier and had sparser muscle spindles, as compared to Garnett's galago. These features suggest that the shoulder muscles of the slow loris are more adapted to generating propulsive force and stabilizing the shoulder joint during locomotion and play a less controlling role in forelimb movements. In contrast, Garnett's galago possessed smaller shoulder muscles with denser spindles that are suitable for the control of more rapid locomotor movements. The mean relative weight and the mean spindle density in the shoulder muscles of the ring-tailed lemur were between those of the other primates, suggesting that the spindle density is not simply a consequence of taxonomic status.     

Innervation of the scapular muscles and its morphological significance in man

The origin, course and distribution of the nerves supplying the supraspinatus, infraspinatus, subscapularis, teres minor, deltoid, teres major and latissimus dorsi were examined in 40 human body-halves. All the nerves supplying these 7 muscles derive from the brachial plexus between the upper trunk and the posterior cord. Within the plexus the nerves originate in the following order: the suprascapular nerve in the most cranial and ventral position followed caudally and dorsally the superior subscapular nerve, the axillary nerve, the inferior subscapular nerve and the thoracodorsal nerve. The superior subscapular nerve tends to innervate the upper and middle (thoracic) portions of the subscapularis. Both the axillary and inferior subscapular nerves tend to innervate the lower (axillary) portion of the subscapularis as well as the teres minor and deltoid, and the teres major, respectively. The subscapularis can be regarded as the compound muscle deriving from the components supplied by these nerves, 4 segmental nerves from C5 to C8 innervate the 7 muscles: C5, and (C6) innervate the supraspinatus; C5, and C6 the infraspinatus, the thoracic portion of the subscapularis, and the teres minor; C5, C6, and (C7) the deltoid; (C5), C6, and (C7) the axillary portion of the subscapularis; (C5), C6, and C7 the teres major; and (C6), C7, and C8 the latissimus dorsi. The relationships between the nerves and muscles suggest that these 7 muscles morphologically belong to the same group, the second group of the dorsal musculature attached to the shoulder girdle and limb. The probable process of formation of these muscles from the cervical myotoms is proposed.     

Fibrous structure of the joint capsule in the human shoulder

The fibrous structure and arrangement of joint capsules of human shoulders [8 males (7 right, 6 left), 4 females (4 right, 3 left)] were observed under a low magnification microscope as well as a polarized microscope on film preparations (H?utchen-Pr?parat, Vogt 1935) with reference to stained sections (mainly with H, E and orcein). The joint capsule is composed of synovial and fibrous layers and is classified into three types according to tissue composition [areolar (loose connective tissue-Fawcett, 1986) type, fibrous (dense fibrous- Fawcett, 1986) type and adipose type- (Key 1932)]. In the joint capsule of the shoulder, the areolar type was found in the anterior region, and the fibrous type in the posterior, superior and inferior regions; the adipose type was not found. The author found that the fibrous layer of the fibrous type basically has a 3 layered structure; the composition and arrangement of fibers differ depending on the type of layer. These three layers were named in order from the synovial layer as "Internal fibrous layer (IFL)", "Intermediate fibrous layer (MFL)" and "External fibrous layer (EFL)". The external fibrous layer can normally be directly visualized by peeling off the muscles. The EFL consists of external fascia, tendons and their transitional regions, which compose the joint of the shoulder. IFL and MFL can only be observed under a low magnification microscope and are distinguishable on film preparations. The IFL, which is located immediately under the stratum synoviale, consists of fibrous bundles approximately 20 microns thick. The MFL, which is adjacent to the IFL, consists of 100-400 microns thick fibrous bundles. The IFL and the MFL have a differently fixed arrangement. The fibrous bundle of EFL is slightly thicker than that of IFL and the arrangement of the fibrous bundle is like that of supraspinatus m., infraspinatus m. and teres minor m. in the superior and posterior regions of the joint capsule. The local existence as well as the arrangement of the fibrous layer of these three different types is discussed from the standpoint of mechanical movement of the shoulder joint.     

Lines of action and stabilizing potential of the shoulder musculature

The objective of the present study was to measure the lines of action of 18 major muscles and muscle sub‐regions crossing the glenohumeral joint of the human shoulder, and to compute the potential contribution of these muscles to joint shear and compression during scapular‐plane abduction and sagittal‐plane flexion. The stabilizing potential of a muscle was found by assessing its contribution to superior/inferior and anterior/posterior joint shear in the scapular and transverse planes, respectively. A muscle with stabilizing potential was oriented to apply more compression than shear at the glenohumeral joint, whereas a muscle with destabilizing potential was oriented to apply more shear. Significant differences in lines of action and stabilizing capacities were measured across sub‐regions of the deltoid and rotator cuff in both planes of elevation (P < 0.05), and substantial differences were observed in the pectoralis major and latissimus dorsi. The results showed that, during abduction and flexion, the rotator cuff muscle sub‐regions were more favourably aligned to stabilize the glenohumeral joint in the transverse plane than in the scapular plane and that, overall, the anterior supraspinatus was most favourably oriented to apply glenohumeral joint compression. The superior pectoralis major and inferior latissimus dorsi were the chief potential scapular‐plane destabilizers, demonstrating the most significant capacity to impart superior and inferior shear to the glenohumeral joint, respectively. The middle and anterior deltoid were also significant potential contributors to superior shear, opposing the combined destabilizing inferior shear potential of the latissimus dorsi and inferior subscapularis. As potential stabilizers, the posterior deltoid and subscapularis had posteriorly‐directed muscle lines of action, whereas the teres minor and infraspinatus had anteriorly‐directed lines of action. Knowledge of the lines of action and stabilizing potential of individual sub‐regions of the shoulder musculature may assist clinicians in identifying muscle‐related joint instabilities, assist surgeons in planning tendon reconstructive surgery, aid in the development of rehabilitation procedures designed to improve joint stability, and facilitate development and validation of biomechanical computer models of the shoulder complex.