骨盆髋臼入路选择ppt课件

骨盆髋臼骨折,入路选择纪方上海第二军医大学长海医院创伤骨科,目的,骨盆髋臼的解剖特点及影像学评估骨盆髋臼骨折损伤机制及分类髋臼骨折处理策略髋臼骨折的手术入路髋臼骨折的复位固定技术典型病例介绍,部分资料图片源于AO及OTC讲师和网络教育,关于髋臼骨折至今有三个重要观点,Pennal:疗效与复位满意度密切相关;Judet:复位满意度与手术暴露密切相关;Letournel:没有一个切口能暴露全部骨折。,髋臼骨折常用手术入路,Korcher-LangenbeckIlioinguinal（髂腹股沟入路）Extendediliofemoral(扩大髂股入路)改良Stoppa入路Surgicalhipdislocation（GANZ）联合入路,髂腹股沟入路,由Letournel提出针对前柱和前关节面的入路,1960s,Letournel:Ilioinguinalapproach,髂腹股沟入路：显露,无法直接显露关节,髂腹股沟入路：适应症,前壁骨折前柱骨折横行骨折并前方移位后方移位前柱后半横行骨折双柱骨折,髂腹股沟入路：体位和切口,仰卧(0-30)能穿透射线的骨折床切口：耻骨联合上12横指顺延向髂前上棘平行于髂嵴至髂嵴前2/3,手术步骤,切开腹外斜肌腱膜从髂前上棘到中线腹股沟韧带近端1cm打开腹股沟管的上顶暴露腹股沟管的底分辨精索或圆韧带沿髂嵴剥离腹部肌肉及髂骨沿内侧髂窝剥离髂骨,手术步骤,从耻骨到髂前上棘沿腹股沟韧带切开腹内斜肌筋膜在髂前上棘远端找到股外侧皮神经用橡皮条保护好股外侧皮神经在腰大肌鞘中找到股神经确认股动静脉寻找“死亡之冠”,手术步骤,切开髂耻筋膜：-将血管腔隙与肌腔隙分离开,切开髂耻筋膜,窗口操作,1stwind,3rdwindow,2ndwindow,ow三窗口1stwindow,窗口操作,优点:,(1)与Langer氏皮纹平行,手术疤痕小美观(2)臀肌未剥离,术后功能恢复快(3)几乎无HO,关节活动满意(4)不切开关节囊,手术创伤小(5)易于显露和固定作为髋臼延伸段的髂骨骨折,有利于髋臼的解剖复位,缺点,入路不熟悉不能直接显露关节-尤其在骨折复位时达不到后壁无法直接达到后柱,关于死亡之冠,游离并切开髂耻梳筋膜，暴露出第二个窗口，显露前壁在暴露过程中一定要注意髂外与闭孔之间的血管吻合支CoronaMortis通过第二个窗口可进入真骨盆检查后柱的复位情况,如何避免损伤?,熟悉解剖特点，术中能够分辨，了解处理原则骨膜下剥离，不必刻意寻找如有损伤，立即压住，结扎,并发症,50%1%,股外侧皮神经损伤其他损伤髂/股动静脉髂/股静脉血栓形成,股神经损伤感染异位骨化疝气形成,Kocher-Langenbeck入路,针对后柱及后关节面由两人提出-Kocher(1874)-Langenbeck(1904),1958s,JudetandLagrange:Kocher-LangenbeckApproaches,KocherLangenbeck入路:显露,整个后柱坐骨大切迹、坐骨小切迹坐骨棘反髋臼面坐骨结节,适应症,后壁骨折-合并股骨头后脱位,后柱骨折横行骨折横行+后壁骨折T形骨折,体位与切口,俯卧或侧卧位骨科床类似髋关节后入路切口：平行于股骨干过大转子尖弧形转向髂后上嵴,手术步骤,切开髂胫束钝性分离臀大肌纤维-上1/3：臀上动脉-下2/3：臀下动脉分离至臀下神经分支,手术步骤,在股方肌上找出坐骨神经注意：不要用橡皮条固定，保持肌肉覆盖松弛梨状肌和联合腱离大转子1cm以上（保护旋股内侧动脉，并固定）无需切除方肌（保护旋股内侧动脉）,手术步骤,探查外旋肌群与关节囊之间的间隙骨膜下剥离：坐骨大切迹四边形臀小肌，以暴露关节囊和反髋臼面保护关节囊在骨折块上的附着防止周围血管离断清理骨折缘,Kocher-Langenbeck入路:并发症,8-25%3-5%,异位骨化坐骨神经麻痹（神经失用）感染,改良Stoppa入路,ColeJD,BolhofnerBR.Acetabularfracturefixationviaamodifiedstoppalimitedintrapelvicapproach:descriptionofoperativetechniqueandpreliminarytreatmentresults.ClinOrthop1994;305:2030.,体位：仰卧位/漂浮体位皮肤切口：下腹正中耻骨联合上2厘米处横切口,历史回顾,1968-1989年法国Stoppa使用该入路修补复杂的腹股沟疝、切口疝。,RivesJ,StoppaR.DacronpatchesandtheirplaceinSurgeryofgroinhernia:65casescollectedfromacompleteseriesof274HerniaoperationsinFrench.AnnChir.1968;22:159171.StoppaRE.Thetreatmentofcomplicatedgroinandincisionalhernias.WorldJSurg.1989Sep-Oct;13(5):545-54.,历史回顾,1993年芬兰Hirvensalo采用下腹正中切口固定骨盆骨折,HirvensaloE,LindahlJ,BostmanO.Anewapproachtotheinternalfixationofunstablepelvicfractures.ClinOrthopRelRes.1993;297.2832.,历史回顾,1994年美国南佛罗里达大学的Cole利用改良Stoppa复位固定髋臼骨折,ColeJD,BolhofnerBR.AcetabularfracturefixationviamodifiedStoppalimitedintrapelvicapproach.ClinOrthop1994;305:11223.,StoppaApproach,2006年荷兰Kees-Jan使用下腹正中切口Stoppa治疗骨盆髋臼骨折。,PieterJoosse,MD,InternalFractureFixationUsingtheStoppacetabularFractures:TechnicalAspectsandOperativeResults.TheJournalofTRAUMA.2006:662-667,2007年芬兰Hirvensalo采用下腹正中切口固定骨盆骨折,EeroHirvensalo.ModiedandnewapproachesforpelvicandAcetabularsurgery.Injury,Int.J.CareInjured(2007)38,431441,StoppaApproach,显露范围,体位大腿垫枕，患侧屈曲,术者位于患髋对侧,1、皮肤-腹直肌前鞘、腹白线,2、切开腹白线、腹直肌,2、切开腹白线、腹直肌,钝性分离,电刀切口韧带、骨膜、复位、固定,电刀切口韧带、骨膜,复位、固定,缝合,手术显露-简便、快捷,www.themegall,ery.c,IliacfossaStoppaApproach,髂窝入路：暴露范围,StoppaApproach,四边体的复位,H.ClaudeSagi,JOrthopTraumaVolume24,Number5,May2010,SafeZone,PierreGuy,JOrthopTraumaVolume24,Number5,May2010,ComparisonofAcetabularFractureReductionQualitybytheIlioinguinalortheAnteriorIntrapelvic(ModifiedRivesStoppa)SurgicalApproachesConclusions:TheAIPapproachisasafealternativethatoffersbetterexposureandpossiblyimprovedreductionqualityofacetabularfracturescomparedwiththeilioinguinalapproach.WebelievethatthemajoradvantageoftheAIPapproachisthatitenablesreductionoftheposteriorcolumnandtheuadrilateralplatefromthecontralateralsideandenablesapplicationofabuttressplatebelowthepelvicbrim.JOrthopTrauma2014;28:313319,Randomized,ControlledTrialoftheModifiedStoppaVersustheIlioinguinalApproachforAcetabularFractures,ORTHOPEDICS|H,OCTOBER2013|Volume36Number10,Thestudyshowednosignificantdifferencesinallmeasuredpreoperativevariablesbetweenthe2groups(allP.05).Inaddition,nosignificantdifferenceswerefoundintheintraoperativecomplicationrate,earlyoperativecomplicationrate,lateoperativecomplicationrate,qualityofreduction,radiologicalresults,andclinicaloutcomes(allP.05).However,comparedwiththeilioinguinalapproach,themodifiedStoppaapproachreducedintraoperativebloodlossandindoingsodecreasedwounddrainageandtheneedforbloodtransfusionandshortenedoperativetime(allP,.05).,截骨自大粗隆后上缘至股外侧肌后缘厚度不超过1.5cm在外旋肌群外侧，不影响肌群止点二附肌截骨EuropeanJournalofTrauma2002No.4.Urban21:25169DOI10.1007/s00064-009-1803-7,OperativeTreatmentofT-TypeFracturesoftheAcetabulumviaSurgicalHipDislocationorStoppaApproach.MoritzTannast,Klaus-Arno,Siebenrock1,A-PandJudetanteriorcolumnposteriorhemitransverseacetabularfracture.,典型病例,CTand3Dfilms,B3前柱后半横,ORIF:anilioinguinalapproach,AnteroposteriorandJudetfilms,TypeC2,典型病例,CTand3D,anextensileapproach.,spursign,