髋部解剖体表投影分区对臀肌挛缩镜下松解术的临床价值

Clinical value of regional division based on surface projection in arthroscopic release of gluteal muscle contracture

[目的]探讨髋部解剖体表投影分区对镜下臀肌挛缩松解术的临床价值。[方法]2014年12月~2015年7月间,对96例臀肌挛缩症患者参考髋部解剖体表投影分区行关节镜下挛缩带松解手术,男41例,女55例,平均年龄(24.9±4.4)岁(18~36岁)。患者均有反复臀部肌肉注射药物史,术前查体均有下蹲及翘腿困难,髋部弹响,Ober’s征阳性。髋部解剖体表投影分区:依据髋部解剖学特征,将其划分为9个区,分区界线呈"井"字形网格,将界线及重要解剖结构在体表投影标记以供手术参考。术后对患者下蹲活动、髋部弹响、Ober’s征、神经血管有无损伤、伤口有无血肿、髋关节外展肌力及对生活工作影响情况进行综合评估。[结果]术中松解在第8区96例(100%),第5区68例(71%),第2区52例(54%),第4区31例(32%)。术后随访1年以上,患者均无下蹲及翘腿困难,Ober’s征、髋部弹响均为阴性,无神经血管损伤,无术后伤口血肿,1例髋关节外展肌力弱(肌力Ⅳ级)。臀肌挛缩功能评分术前为49.2(26~70)分,术后末次随访为91.2(81~100)分,两者差异有统计学意义(P<0.05)。[结论]手术安全区划分有助于判定局部解剖结构,避免神经血管肌肉等重要解剖结构的损伤风险,有助于描述记录病变情况和教学。

[Objective] To explore the clinical significance of regional division based on surface projection in arthroscopic release of gluteal muscle contracture. [Method] We retrospectively reviewed 96 patients with bilateral gluteal muscle con- tracture, including 41 males and 55 females aged from 18 years to 36 years with an anverage of 24.9＋4.4 years. All of the patients had the history of repeatitive intramuscular injections in childhood and presented signs before surgery as follows ： squat- ting and crouching disability, difficulty in crossing the leg, Ober＇ s sign, as well as click during rotation of the hip. After an- esthesia, the patient was placed in lateral position. With lateral greater trochanter as the center, a ＂tic tac toe＂ -shaped mark was made on the body surface, which would projected to deep fascia layer to divide the surgical field into 9 areas. During the arthroscopic surgery, the contractile band was released mostly in the division 5, 8 and 2. The divisions in which contractile band was released, neurovascular injury, muscular weakness, wound hematoma were recorded. The functional score of gluteal muscle contracture （FGMC） was evaluated before surgery and at the last follow-up. [Results] The division 8 was released in 100% of the patients （96 patients）, the division 5 in 71% patients （68 cases）, the division 2 in 54% patier, ts （52 cases）, and the division 4 in 32% patients （31 cases） . All the patients were followed up for more than 1 years ＂alter operation. All of them could Crouch with both knees close to each other, sit with their legs crossed, without positive Ober＇s sign and click during rotation of the hip. No neurovascular injury, wound hematoma, recurrent eontraeture of the hip abductor or residual hip pain were hotbed in any of the 96 patients. Only a patient had mild muscular weakness with muscle strength of grade 4. FGMC was significantly improved from 49.2 （26 to 70） before surgery to 91.2 （81 to 100） at last follow-up （P〈 0.05） . [Conclusion] In arthroseopic release of gluteal contracture, this regional division of the surgical field with surface projection is helpful to identify anatomical position, facili- tate release of the contracted lesion, reduce bleeding during operation, avoid neurovascular injury and save operation time. Specifically, it is useful skill for beginner to master this extraarticular arthroscopic technique.