大腿远端前内侧入路在股骨骨折内固定术中应用的影像及解剖学研究

目的 探讨大腿远端前内侧入路在股骨远端骨折内固定术中应用的安全性和可行性。方法 (1)纳入2016年8月-2017年2月河北医科大学第三医院MRI室双侧大腿中下段MRI资料20例40侧进行回顾性研究,其中男12例、女8例,年龄22~59岁,MRI均未见明显异常。扫描范围:自股骨内侧髁水平线(0 cm处)起,至其上方18.5 cm;扫描层厚5 mm、层间距15 mm,共10个扫描层面(Ⅰ~Ⅹ层面)。应用我院影像存储与传输系统(PACS)测量各扫描层面上前内侧手术入路(预计手术的前进路线)与股动脉之间的最短距离。(2)在1具成年男性新鲜尸体标本上,模拟股骨远端骨折前内侧手术入路内固定物置入过程,同时对该入路涉及解剖层次与结构进行应用解剖观察。结果 (1)20例40侧受检者MRI测量:前内侧入路与股动脉之间最短距离测量值左右两侧差异无统计学意义,故合并统计。分析显示,该间距测量值在Ⅰ~Ⅹ层面的分布规律总体呈中间小两头大、上端小下端大的趋势,其最大处位于股骨内侧髁水平线0 cm处(Ⅰ层面)为46.72~49.47(48.02±0.84)mm,其最小处位于股骨内侧髁水平线上方10~10.50 cm范围内(Ⅵ层面)为23.34~25.05(24.35±0.52)mm,手术入路与股动脉间有足够的安全间距。(2)尸体标本模拟手术:股骨远端骨折前内侧手术入路内固定物模拟置入过程顺利,手术操作未侵扰到股血管和股神经及其分支;应用解剖观察证实,该手术入路可沿肌间隙进入,周围解剖层次及结构显露清楚。结论 大腿远端前内侧入路应用于股骨远端骨折内固定术安全可行,这是对传统外侧入路治疗股骨远端骨折的良好补充。

Imaging and anatomic study of distal anterior medial approach to the thigh in internal fixation of femoral fractures

Objective To investigate the safety and feasibility of the anterior medial approach of distal thigh in the treatment of distal femoral fractures.Methods (1) A retrospective study was conducted on the MRI data of 20 subjects with 40 sides who underwent bilateral middle and lower thigh MRI examination in the MRI room of the Third Hospital of Hebei Medical University from August 2016 to February 2017. Among the 20 cases, 12 were male and 8 were female, aged from 22 to 59 years, and no significant abnormality was found on MRI. Scanning range: from the horizontal line of the medial femoral condyle (at 0 cm) to 18.5 cm above it. Scanning layer thickness 5 mm, 15 mm spacing, a total of 10 slices (Ⅰ-Ⅹ level). The picture archiving and communication systems (PACS) were used to measure the shortest distance between the anterior medial surgical approach (the expected surgical route) and the femoral artery at each scanning level. (2) The internal fixation process of the anterior medial approach for distal femoral fractures was simulated in one fresh adult male cadaver specimen, and applied anatomical observation was made on the anatomical layers and structures involved in the approach.Results (1) MRI measurements of 20 subjects with 40 sides: there was no significant difference between the measured values of the shortest distance between the anterior medial approach and the femoral artery on the left and right sides, so the data were combined. The distribution of the measurement results at the Ⅰ-Ⅹ levels generally showed a trend of small middle and large two ends and large upper and small lower ends, the largest position was located at 0 cm (level Ⅰ) of the medial condyle of the femur and was 46.72-49.47 (48.02±0.84) mm, the smallest position was within the range of 10-10.50 cm above the horizontal line of the medial condyle of the femur (level Ⅵ) was 23.34-25.05 (24.35±0.52) mm; there was sufficient safe space between the surgical approach and the femoral artery. (2) Simulated operation in the cadaver specimens: the simulated implantation of internal fixation through the anterior medial approach to distal femoral fracture was smooth, and the operation did not disturb femoral vessels, femoral nerves and their branches. Anatomical observations confirmed that the surgical approach can be entered along the muscle space, and the surrounding anatomical levels and structures were clearly displayed.Conclusions The anterior medial approach of distal thigh in the treatment of distal femoral fractures is safe and feasible, and it is a good complement to the traditional lateral approach for the treatment of distal femoral fractures.