骨盆髋臼入路选择

1、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-Langenbeck Ilioinguinal（髂腹股沟入路） Extended iliofemoral(扩大髂股入路) 改良Stoppa入路

2、 Surgical hip dislocation（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: Ilioinguinal approach,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

3、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,1st wind,3rd window,2nd window,ow 三窗口 1st window,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

4、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 Corona Mortis 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

5、对后柱及后关节面 由两人提出 -Kocher (1874) -Langenbeck (1904),1958s,Judet and Lagrange:Kocher-Langenbeck Approaches,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

6、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,Cole JD,Bolhofner BR.Acetabular fracture fixation via a modi

7、fied stoppa limited intrapelvic approach:description of operative technique and preliminary treatment results.Clin Orthop 1994;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。,Rives J,Stoppa R.Dacron patches and their place in Surgery of groin hernia: 65 c

8、ases collected from a completeseries of 274 Hernia operations in French. Ann Chir. 1968;22:159171. Stoppa RE. The treatment of complicated groin and incisional hernias.World J Surg. 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,Hirvensalo E, Lindahl J, Bostman O. A new approach to

9、the internal fixation of unstable pelvic fractures. Clin Orthop Rel Res. 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,Cole JD, Bolhofner BR. Acetabular fracture fixation via modified Stoppa limited intrapelvic approach. Clin Orthop 1994;305:11223.,Stoppa Approach,2006年荷兰Kees-Jan使用下腹正中

10、切口Stoppa治疗骨盆 髋臼骨折。,Pieter Joosse, MD, Internal Fracture Fixation Using the Stoppa cetabular Fractures: Technical Aspectsand Operative Results. The Journal of TRAUMA.2006:662-667,2007年芬兰Hirvensalo采用下腹正中切口固 定骨盆骨折,Eero Hirvensalo . Modied and new approaches for pelvic and Acetabular surgery. Injury,Int

11、.J.Care Injured(2007) 38,431441,Stoppa Approach,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,Iliac fossa Stoppa Approach,髂窝入路：暴露范围,Stoppa Approach,四边体的复位,H. Claude Sagi,J Orthop Trauma Volume 24, Number 5, Ma

12、y 2010,Safe Zone,Pierre Guy,J Orthop Trauma Volume 24, Number 5, May 2010,Comparison of Acetabular Fracture Reduction Quality by the Ilioinguinal or the Anterior Intrapelvic (Modified RivesStoppa) Surgical Approaches Conclusions: The AIP approach is a safe alternative that offers better exposure and

13、 possibly improved reduction quality of acetabular fractures compared with the ilioinguinal approach. We believe that the major advantage of the AIP approach is that it enables reduction of the posterior column and the uadrilateral plate from the contralateral side and enables application of a buttr

14、ess plate below the pelvic brim. J Orthop Trauma 2014;28:313319,Randomized, Controlled Trial of the Modified Stoppa Versus the Ilioinguinal Approach for Acetabular Fractures,ORTHOPEDICS | H,OCTOBER 2013 | Volume 36 Number 10,The study showed no significant differences in all measured preoperative va

15、riables between the 2 groups (all P.05). In addition, no significant differences were found in the intraoperative complication rate, early operative complication rate, late operative complication rate, quality of reduction, radiological results, and clinical outcomes (all P.05). However, compared wi

16、th the ilioinguinal approach, the modified Stoppa approach reduced intraoperative blood lossand in doing so decreased wound drainage and the need for blood transfusionand shortened operative time (all P,.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 European Journal of Trauma 2002 No. 4 . U

17、rban 21:25169 DOI 10.1007/s00064-009-1803-7,OperativeTreatment of T-Type Fractures of the Acetabulum via Surgical Hip Dislocation or Stoppa Approach .Moritz Tannast, Klaus-Arno,Siebenrock1,A-P and Judet anterior column posterior hemitransverse acetabular fracture.,典型病例,CT and 3D films,B3 前柱后半横,ORIF :an ilioinguinal approach,Anteroposterior and Judet films,Type C2,典型病例,CT and 3D,an extensile approach.,spur sign,AP an