髋关节后外侧入路

1、概述The posterolateral approach to the hip may be done with the patient in lateral decubitus or prone positions. For arthroplasty, a lateral decubitus position is usually chosen.The approach is essentially the same as the Kocher-Langenbeck, but exposure is limited to the hip joint, respecting but not displaying the sciatic nerve. The femoral attachment of the short external rotators and hip capsule should be repaired to reduce the risk of postoperative dislocation. (Early descriptions of hip arthroplasty through a posterolateral approach suggested excision of the posterior hip capsule.)患者可以侧卧位或俯卧位，对于关节置换，通常选择侧卧位。这个切口和K-L切口相似，只是有限显露髋关节，不显露坐骨神经。股骨的外旋肌群需要修复以减少术后关节脱位的风险。2、概述After posterior capsulotomy, the hip is dislocated with internal rotation.后侧关节囊切开后，髋关节在内旋时脱位。3、体位PositioningThe patient is placed in the lateral decubitus position, with supports to prevent rotation away from true lateral, and appropriate padding to limit focal pressure.After sterile preparation of the hip region, the involved leg is draped free, to permit full mobility.患者侧卧位，用支架支撑放置选择，用棉垫踮起防止局部压迫。整个下肢都要无菌消毒，以便术中移动下肢。4、皮肤切口Skin incisionOutline all bony landmarks with a sterile marking pen:(1) posterior superior iliac spine (PSIS)(2) greater trochanter(3) shaft of femurStart the skin incision posterior to the lateral side of the greater trochanter and carry it distally about 6 cm along the femoral axis. Proximally, the incision runs slightly curved towards the PSIS to a point approximately 6 cm proximal to the greater trochanter.切口标志：1.髂后上棘 2.大转子 3. 股骨干起自大转子后方向下与股骨干长轴平行（6cm），向上指向掐后上棘(6cm)。5、分离深筋膜Dissection of fascia lataStraight sharp dissection of the fascia lata and gluteal muscle across the greater trochanter. Incise the fascia lata in line with the skin incision.锐性分离阔筋膜和臀大肌间隙，方向与切口方向一致。6、保护坐骨神经Protection of sciatic nerveRetraction of the gluteal muscle flap posteriorly shows short external rotators inserting on femur (at least partially obscured by fat). The sciatic nerve can be palpated posteriorly in the depths of the wound. Its exposure is not necessary for uncomplicated hip arthroplasty, but the surgeon should be aware of the nerves location, and avoid injuring it with retractors.向后方牵开臀大肌显露外旋肌群在股骨的止点（部分被脂肪垫掩盖）。坐骨神经可以在伤口深处的后方触及。在不复杂的髋关节时不必显露，但是外科医生应意识到神经的位置，应避免牵拉损伤。7、切开外旋肌Exposure of short rotator tendonsBluntly dissect the tendinous insertions of the short external rotators. Before dividing the tendons, place heavy, nonabsorbable stay sutures for retractionand subsequent repair. One suture can be placed in the piriformis tendon, and the other in the conjoined tendons of obturator internus and gemelli.钝性剥离外旋肌腱，在分离肌腱之前，在肌腱上用粗不可吸收线缝合以备牵拉或修复缝合用。梨状肌，闭孔肌，gemelli。8、牵开外旋肌Divide and reflect short rotatorsReflection of the short rotator muscles exposes the hip capsule. Next, enter the joint with a broad-based, 3-sided capsulotomy as shown. Preserve the acetabular labrum, unless total hip arthroplasty is intended.牵开外旋肌，显露关节囊，用宽拉钩保护髋臼，除非准备关节置换。9、显露ExposureExpose the hip joint by creating and reflecting a full thickness, broad-based flap of the posterior hip capsule. Heavy (e.g. #2) non-absorbable sutures in its free corners aid retraction and subsequent repair.同上10、闭合创口ClosureAt the completion of the procedure, the posterior capsular flap sutures, and then the tendon sutures, are tied to each other after being passed through drill holes in the posterior greater trochanter.Quadratus femoris, if divided, is repaired separately. A s