髓内钉手术进针点的探讨--股骨近端解剖学测量

Anatomy of the proximal femur for intramedullary femoral nailing

目的旨在髓内钉手术进针点术语的标准化,探索股骨近端可靠的骨性标志与周围软组织的解剖学关系。方法查阅关于顺行髓内钉进针点的文献,重点关注"梨状窝"和"转子窝"两个术语。选取国人成人股骨干标本130例,分析转子窝与大转子的关系。选取国人成人尸体下肢标本20例,观察股骨近端软组织附着,测量梨状肌、闭孔内肌和闭孔外肌肌腱相关数据。结果 (1)如果没有梨状窝则转子窝是髓内钉标准的进针点。(2)样本中3.85%的大转子完全不遮挡转子窝,76.15%的大转子包绕转子窝但不遮挡,20.00%部分遮挡。(3)梨状肌纵径和横径的均值分别为(6.74±1.21)mm和(4.29±1.37)mm,闭孔内肌纵径和横径的均值分别为(6.36±1.74)mm和(5.74±1.61)mm,闭孔外肌纵径和横径的平均值分别为(6.26±1.13)mm和(4.57±1.26)mm。(4)梨状肌附着点前、后缘距大转子后缘的距离占大转子长度的百分比分别为(57.9±8.8)%和(43.8±8.7)%,闭孔内肌的分别为(65.6±7.3)%和(52.6±6.9)%。结论所谓的梨状窝应被称为转子窝;因为大转子与转子窝不同的关系,股骨钉的进针点是可变的,转子窝不能被视为通用的进针点;肌腱的定量数据有助于优化手术入路。

Objective To standardize the terminology related to the entry point and to explore the relationship between the proximal femoral bone markers and the surrounding soft tissues. Methods Previous publications about the suggested entry point for antegrade femoral nailing were reviewed and special attention was paid to ＂trochanteric fossa＂ and ＂piriform fossa＂. The relationship between the trochanteric fossa but the greater trochanter in 130 Chinese aduh dried femurs was analyzed. Twenty cadaveric lower limb specimens were dissected toobserve proximal femur soft tissue attachments and to measure data related with piriform muscle, internal and external obturator muscle. Results Firstly, the trochanteric fossa but not the piriform fossa was the standard entry point. Secondly, in 3.85% of the cases a shape with a free entry point was found, whereas 76.15% of the specimens were defined by a laterally projecting spine. In 20.00% cases the entry points was partially covered. Thirdly, the means of the vertical and horizontal widths of the piriformis tendon were （6.74 ± 1.21 ）mm and （4.29 ± 1.37 ） ram, respectively. The means of the vertical and horizontal widths of the obturator internus tendon were （6.36 ± 1.74） mm and（5.74 ± 1.61 ） ram, respectively. The means of the vertical and horizontal widths of the obturator external tendon were （6.26 ± 1.13 ） mm and （4.57 ± 1.26）mm, respectively. Fourthly, the mean distances of the anterior and posterior edges of the piriformis tendon attachment from the posterior limit of the greater trochanter, defined as a percentage of the anteroposterior length of the greater trochanter in this study, were （57.9 ± 8.8） % and（43.8 ± 8.7） % , respectively. Equivalent mean distances for the obturator internus attachment were （65.6 ± 7.3 ） % and （52.6 ± 6.9） % , respectively. Conclusion Piriform fossa should be named as Trochanteric fossa. Because of the various relationships between the trochanteric fossa and the greater trochanter, the entry point is variable, and the trochanteric fossa can not be considered as a general entry point. Quantitative data about tendons is helpful to optimize surgical approaches.