發(fā)布時(shí)間：2018-12-31 14:47

【摘要】：第一部分：經(jīng)臀中肌前緣間隙入路至股骨近端的解剖學(xué)基礎(chǔ) 目的：探討在改良股骨外側(cè)入路的基礎(chǔ)上經(jīng)臀中肌前緣間隙入路顯露股骨頸及股骨大、小轉(zhuǎn)子的解剖特點(diǎn)，明確該手術(shù)入路的重要解剖標(biāo)志并對(duì)其進(jìn)行解剖學(xué)測(cè)量，為臀中肌前緣間隙手術(shù)入路治療股骨轉(zhuǎn)子間骨折提供解剖學(xué)基礎(chǔ)。 方法：8例(16側(cè))成人尸體下肢標(biāo)本，模擬臀中肌前緣間隙入路對(duì)重要骨性解剖標(biāo)志和神經(jīng)血管進(jìn)行解剖觀測(cè)。 結(jié)果：經(jīng)臀中肌前緣間隙可充分顯露股骨頸及股骨大、小轉(zhuǎn)子。臀中肌前緣間隙髂嵴附著處距髂前上棘距離（5.08±0.59）cm(4.06～6.33cm），在該間隙內(nèi)常見(jiàn)臀上神經(jīng)最下支以及旋股外側(cè)動(dòng)脈升支臀中肌支穿過(guò)。臀上神經(jīng)最下支穿臀中肌前緣間隙處至股骨大轉(zhuǎn)子外側(cè)最凸點(diǎn)距離為（7.29±0.72）cm(6.35～9.56cm）；旋股外側(cè)動(dòng)脈升支臀中肌支走行至該間隙處距離股骨大轉(zhuǎn)子外側(cè)最凸點(diǎn)距離為（5.66±0.42）cm(5.05～6.87cm）。 結(jié)論：臀中肌前緣間隙入路在改良股骨外側(cè)入路的基礎(chǔ)上可充分顯露股骨近端結(jié)構(gòu)如股骨頸、股骨大、小轉(zhuǎn)子以及股骨干上段等，具有安全、軟組織損傷小等特點(diǎn)，為股骨轉(zhuǎn)子間骨折的手術(shù)治療提供了新思路和新方法。 第二部分：經(jīng)臀中肌前緣間隙入路治療老年股骨轉(zhuǎn)子間骨折的臨床應(yīng)用研究 目的：與傳統(tǒng)股骨外側(cè)入路相比較，探索經(jīng)臀中肌前緣間隙入路治療股骨轉(zhuǎn)子間骨折的臨床療效。 方法：回顧分析2011年2月-2013年2月67例采用動(dòng)力髖螺釘（DHS）治療的股骨轉(zhuǎn)子間骨折患者的臨床資料，其中經(jīng)臀中肌前緣間隙入路35例（試驗(yàn)組），經(jīng)傳統(tǒng)股骨外側(cè)入路32例（對(duì)照組）。兩組患者性別、年齡、Singh指數(shù)、側(cè)別、骨折分型、致傷原因及合并癥比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。記錄兩組患者手術(shù)時(shí)間、手術(shù)出血量、透視次數(shù)、術(shù)后引流量、住院時(shí)間及術(shù)后并發(fā)癥等，并于術(shù)后6,12月根據(jù)自定療效評(píng)定標(biāo)準(zhǔn)評(píng)估患者髖關(guān)節(jié)功能。 結(jié)果：兩組均順利完成手術(shù)，術(shù)中無(wú)神經(jīng)、大血管損傷發(fā)生�；颊吖钦劬�3-5月內(nèi)達(dá)到骨性愈合，愈合時(shí)間為3-5個(gè)月，平均3.7個(gè)月。61例患者獲得隨訪，平均隨訪時(shí)間18.2個(gè)月（14-24個(gè)月）。試驗(yàn)組患者在手術(shù)時(shí)間、術(shù)中出血量和透視次數(shù)、術(shù)后引流量以及住院時(shí)間方面顯著少于對(duì)照組（P0.05）；根據(jù)自定評(píng)價(jià)標(biāo)準(zhǔn)，術(shù)后6、12個(gè)月髖關(guān)節(jié)恢復(fù)程度及功能評(píng)定結(jié)果表明試驗(yàn)組優(yōu)于對(duì)照組，，差異有統(tǒng)計(jì)學(xué)意義（P0.05）；兩組患者在術(shù)后髖內(nèi)翻畸形愈合及總并發(fā)癥等方面明顯少于對(duì)照組（P0.05）；兩組患者在切口感染、下肢短縮畸形、內(nèi)固定松動(dòng)以及主螺釘切出股骨頭等方面比較，差異無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。 結(jié)論：與傳統(tǒng)股骨外側(cè)入路比較，經(jīng)臀中肌前緣間隙入路治療股骨轉(zhuǎn)子間骨折具有骨折暴露充分、手術(shù)時(shí)間短、創(chuàng)傷小等優(yōu)點(diǎn)，達(dá)到術(shù)后近期及遠(yuǎn)期并發(fā)癥減少和早期功能康復(fù)的目的，促進(jìn)髖關(guān)節(jié)功能恢復(fù)。
[Abstract]:Part one: anatomical basis from the anterior space approach of the middle gluteal muscle to the proximal end of the femur objective: to explore the anatomical characteristics of the femoral neck and the large and small trochanter of the femur through the anterior space approach of the middle gluteal muscle on the basis of the modified lateral approach of the femur. The important anatomic markers of the approach were identified and measured, which provided anatomic basis for the treatment of intertrochanteric fracture of femur by the anterior space approach of gluteus medius. Methods: eight adult cadavers (16 sides) with lower extremities were studied by simulating the anterior space approach of gluteus medius muscle to observe the important bone anatomical markers and nerve and blood vessels. Results: the femoral neck and the large and small trochanter of femur could be fully exposed through the anterior space of gluteal middle muscle. The distance from the anterior iliac crest to the anterior superior iliac spine was 5.08 鹵0.59) cm (4.06~6.33cm. The inferior branch of the superior gluteal nerve and the middle gluteus muscle branch of the ascending branch of lateral femoral circumflex artery were found in this space. The distance between the inferior branch of superior gluteal nerve and the protruding point of the lateral greater trochanter of femur was (7.29 鹵0.72) cm (6.35~9.56cm). The distance between the middle gluteal muscle branch of the ascending branch of lateral femoral circumflex artery and the protruding point of the greater trochanter was (5.66 鹵0.42) cm (5.05~6.87cm). Conclusion: the anterior margin approach of the middle gluteal muscle can fully reveal the proximal femoral structures such as the femoral neck, the large, the small trochanter and the upper segment of the femoral shaft on the basis of the modified lateral approach of the femur, which has the characteristics of safety and little soft tissue injury. It provides a new idea and method for the surgical treatment of intertrochanteric fracture of femur. Part two: clinical study on the treatment of intertrochanteric fracture of femur through the anterior margin approach of the middle gluteal muscle objective: to compare with the traditional approach of lateral approach of femur. Objective: to explore the clinical effect of intertrochanteric fracture of femur through anterior space approach of gluteus medius muscle. Methods: the clinical data of 67 patients with intertrochanteric fracture treated with dynamic hip screw (DHS) from February 2011 to February 2013 were retrospectively analyzed. 32 cases were treated by traditional lateral femoral approach (control group). Gender, age, Singh index, lateral sex, fracture classification, injury causes and complications were not significantly different between the two groups (P0.05). The operation time, blood loss, fluoroscopy times, postoperative drainage, hospital stay and postoperative complications were recorded in the two groups. The hip function was evaluated according to the standard of self-determined curative effect 6 and 12 months after operation. Results: the operation was completed successfully in both groups. There was no nerve and major vascular injury occurred during the operation. The fracture healing time was 3-5 months (mean 3.7 months). 61 patients were followed up for an average of 18.2 months (14-24 months). The time of operation, the amount of blood loss during operation, the times of fluoroscopy, postoperative drainage and hospital stay in the trial group were significantly less than those in the control group (P0.05). According to the self-evaluation criteria, the degree and function of hip joint recovery were evaluated at 6,12 months after operation. The results showed that the test group was superior to the control group, the difference was statistically significant (P0.05). The patients in the two groups were significantly less than the control group in the healing of coxa varus deformity and total complications (P0.05). There was no significant difference between the two groups in incision infection lower extremity shortening deformity internal fixation loosening and main screw cutting out of femoral head (P0.05). Conclusion: compared with the traditional approach of lateral femoral approach, the treatment of intertrochanteric fracture through the anterior margin of gluteal muscle approach has the advantages of full exposure, short operative time and less trauma. The short-term and long-term postoperative complications were reduced and early functional rehabilitation was achieved, and the hip function recovery was promoted.
【學(xué)位授予單位】：南昌大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R683;R322.7

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