全髋关节置换扩大后路软组织修补关节囊切开线的解剖学研究

OPTIMIZATION OF CAPSULOTOMY OF ENHANCED POSTERIOR SOFT TISSUE REPAIR IN TOTAL HIP ARTHROPLASTY

目的研究髋后方关节囊的解剖特点及胶原纤维的分布差异,探讨能保留最佳力学强度的髋后方关节囊切开线。方法采用10个(20侧)福尔马林固定的成人尸体髋标本,男6个,女4个;年龄28～64岁。右侧10髋解剖出髋后方关节囊,将其划分为3区(Ⅰ～Ⅲ区)9部(ⅠA～C、ⅡD～F、ⅢG～I),测量髋后方关节囊各部厚度,观察坐股韧带走行。左侧10髋选取5髋对其较厚的Ⅰ区和Ⅱ区进行Masson染色观察和胶原纤维含量分析。采用自愿捐赠的冰冻新鲜尸体标本2髋与固定标本比较,设计最佳的切口线并临床应用。结果各部髋后方关节囊厚度分别为:ⅠA(2.30±0.40)、ⅠB(4.68±0.81)、ⅠC(2.83±0.69)、ⅡD(2.80±0.79)、ⅡE(4.22±1.33)、ⅡF(2.50±0.54)、ⅢG(1.57±0.40)、ⅢH(2.60±0.63)、ⅢI(1.31±0.28)mm,具有不均一性,差异有统计学意义(P<0.01),ⅢG部和ⅢI部的平均厚度较ⅠB部和ⅡE部薄,差异有统计学意义(P<0.01)。较薄弱的两部在Ⅲ区,坐股韧带主干经过较厚的ⅠB部和ⅡE部。Masson染色可见ⅠB和ⅡE部的绿色面积明显较Ⅰ、Ⅱ区其余4部大。各部胶原纤维含量分别为:ⅠA20.34%±5.14%,ⅠB48.79%±12.67%,ⅠC19.87%±5.21%,ⅡD17.57%±3.56%,ⅡE46.76%±11.47%,ⅡF28.65%±15.79%;各部胶原含量亦具有不均一性(P<0.01),ⅠB部和ⅡE部与其余4部比较差异有统计学意义(P<0.01)。新鲜冰冻标本的厚度和坐股韧带分布特点经观察与固定标本无明显差别。在标本上设计并应用包括大部坐股韧带主干且连带部分臀小肌束的髋后方关节囊切开线。结论全髋关节置换扩大后路软组织修补虽不断深入研究和发展,但术后脱位率仍未完全消除;优化关节囊切开线,保留最佳力学强度部分,使坐股韧带发挥其固有生物力学功能,具有较大意义。

Objective To investigate the anatomic feature of the posterior hip joint capsule and its distributional difference of collagen fibers and to probe the optimization of the capsulotomy which can reserve the best strength part. Methods Ten adult cadaver pelvises （6 males and 4 females, aged 28-64 years） fixed with formalin were used. Ten right hips were used for anatomical experiment of hip joint capsule. The posterior hip joint capsules were divided into 3 sectors （Ⅰ-Ⅲ sectors ） and 9 parts （IA-C, ⅡD-F,ⅢG-J）. The average thickness of each part was measured and the ischiofemorale ligaments were observed. Five capsules selected from ten left hips were used for histological experiment. The content of collagen fibers in sector I and sector II was analyzed by Masson＇s staining. Two fresh frozen specimens which were voluntary contributions were contrasted with the fixed specimens. The optimal incision line of the posterior capsule was designed and used. Results The thickness in the posterior hip joint capsule [ⅠA（2.30±0.40）、ⅠB（4.68±0.81）、ⅠC（2.83±0.69）、ⅡD（2.80±0.79）、ⅡE（4.22±1.33）、ⅡF（2.50±0.54）、ⅢG （1.57±0.40）、ⅢH（2.60±0.63）、ⅢI（1.31±0.28）mm] had no uniformity （P 〈 0.01）. The ⅢG part and the ⅢJ part were thinner than the ⅠB part and the ⅡE part （P 〈 0.01）. Two weaker parts located at obturator externus sector （sector Ⅲ）, the ischiofemorale ligament trunk went through two thicker parts （ⅠB and ⅡE）. The distribution of the collagen fibers in sector Ⅰ and sector Ⅱ（ⅠA20.34%±5.14%,Ⅰ B48.79%±12.67%,ⅠC 19.87%±5.21%,ⅡD 17.57%±3.56%,ⅡE46.76%±11.47%,ⅡF28.65%±15.79%） had no uniformity （P 〈 0.01）. The content of collagen fibers in ⅠB part and ⅡE part were more than that of other parts （P 〈 0.01）. There were no statistically significant difference in the distribution feature of the thickness and the ischiofemorale ligaments between the fresh frozen specimens and the fixed specimens. The optimal incision line C-A-B-D-E of the posterior capsule was designed and put into clinical application. The remaining capsular flap comprise the most of the ischiofemorale ligament trunk and the part ofgluteus minimus. Conclusion Although enhanced posterior soft tissue repair in total hip arthroplasty was investigated deeply and obtained great development, but the postoperative dislocation rate was not eliminated. It is significant for optimizing the capsulotomy to reserve the best strength part of the posterior capsule and to bring into full play the function of the ischiofemorale ligaments.