前外侧肌间隙入路微创全髋关节置换术的应用解剖与临床研究

Anatomic and clinical study of anterolaterai muscle sparing minimally invusive total hip arthroplusty

目的 研究国人臀中肌、臀上神经和微创全髋关节置换术前外侧肌间隙入路的解剖关系，探讨临床意义并观察临床效果。方法 解剖20具成年尸体标本（40髋），测量臀中肌前缘在髂嵴处起点距髂前上棘的距离，记录臀上神经的走向及与周围解剖标志的距离。对3具新鲜灌注尸体标本行模拟手术，观察切口周围软组织的损伤情况。57例患者（57髋）施行前外侧肌间隙入路微创全髋关节置换术。结果 臀中肌前缘沿髂嵴方向距髂前上棘距离为（61±4）mm（55-68mm）；臀上神经下支距大转子前结节的距离为（74±6）mm（60-88mm）。模拟手术显示臀中肌过度牵拉是造成臀中肌前缘挫伤的主要原因。手术切口平均长9cm（8～13cm），输血11例。9例术中发现臀中肌深层前缘肌纤维部分断裂，2例发生假体柄股骨侧内后方穿出，即刻行翻修术。随访12个月末发现Trendelenburg征阳性者。结论 前外侧肌间隙入路皮肤切口方向应从大转子前结节指向髂前上棘后方6cm；切口近端部分长度应控制在距离大转子前结节6cm以内，切口向远端延长较安全。前外侧肌间隙入路具有单一切口内完成髋臼和股骨假体安装、不需要透视、不剥离任何肌肉附着点的优点。

Objective To investigate the relationship between the incision approach of anterolateral muscle sparing minimally invasive total hip arthroplasty and anatomic structure of gluteus medius and superior gluteal nerve and to discuss clinical significance of this research. Methods 20 adult cadavers （40 hips） were used for anatomic research. The distance from the anterior border of gluteus medius muscle on the iliac crest to the anterior inferior iliac spine were measured. The. orientation and location of the superior gluteal nerves was recorded. Analogue operation was taken on three fresh cadavers to assess the injury extent of soft tissues around incisions. 57 hips of 57 patients were treated with minimally invasive total hip arthroplasty through anterolateral muscle sparing approach. All the operations were under general anaesthesia. Results The average distance from anterior border of the gluteus medius to anterosuperior iliac along crista iliaca was （61±4） mm （ranged 55-68 mm）, and the average distance between inferior branch of superior gluteal nerve and the anterior tubercle of greater trochanter was （74±6） mm （ranged 60-88 mm）. In the analogue operations, excess pulling was the main cause of anterior rim injury of gluteus medius muscle. The average incision length was 9 cm （ranged 7.5-13 cm）. Blood transfusion were given in 11 patients. During the operations, anterior border injury in deep portion of the gluteus medius muscle could be seen in 9 patients. Prosthesis stem protrusion via posteromedial side of the femur cavity, which were revised instantly, were found in 2 patients. No patient suffered from Trendelenburg sign during the 12 months follow-up. Conclusion Anterolateral muscle sparing approach should be located from the tubercle of greater trochanter to 6 cm posterior of anterosuperior iliac. Proximal portion of the incision should be within 6 cm and it is safer to extend distally. By using minimal invasive anterolateral muscle sparing approach, acetabular and fomeral stem are implanted in single small incision without fluorescence imaging and muscle attachment striping. Superordinary clinical outcome can be achieved.