本文選題：髖關(guān)節(jié)置換 + 前外側(cè)入路　； 參考：《河北醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的:隨著生物力學(xué)研究的不斷深入、假體設(shè)計(jì)的不斷更新、使用壽命的延長(zhǎng)以及手術(shù)技術(shù)的日趨成熟,人工髖關(guān)節(jié)置換術(shù)的適應(yīng)范圍也在不斷擴(kuò)大。它不僅能減少患者的臥床時(shí)間,提高患者術(shù)后功能恢復(fù)進(jìn)度,還能有效減少由股骨頸骨折所帶來(lái)的多種并發(fā)癥。因此人工髖關(guān)節(jié)置換治療股骨頸骨折為越來(lái)越多的患者所接受。本文通過(guò)回顧性分析臨床不同手術(shù)入路進(jìn)行的人工髖關(guān)節(jié)置換,量性比較改良前外側(cè)入路與后側(cè)入路的手術(shù)時(shí)間與術(shù)中出血量,探討兩種手術(shù)入路在髖關(guān)節(jié)置換術(shù)中的風(fēng)險(xiǎn)。方法:回顧性分析2011年3月至2015年1月河北醫(yī)科大學(xué)第三醫(yī)院所收治的股骨頸骨折并接受髖關(guān)節(jié)置換的患者,從中隨機(jī)抽取120例病例,排除發(fā)育不良、缺血性壞死、關(guān)節(jié)炎、陳舊性骨折、多發(fā)性骨折、術(shù)后翻修等情況,其中男性69例,女性51例,年齡45歲-91歲。按手術(shù)入路將患者分為觀察組和對(duì)照組,以髖關(guān)節(jié)置換改良前外側(cè)入路作為觀察組,髖關(guān)節(jié)置換后側(cè)入路作為對(duì)照組,分別每組選取60例,兩組患者在性別、年齡、致傷原因、合并疾病等方面比較,差異無(wú)顯著性。比較兩組患者的手術(shù)時(shí)間和術(shù)中出血量。觀察組:采用改良前外側(cè)入路,患者健側(cè)臥位,以大轉(zhuǎn)子尖端為中心做弧形切口,切開皮膚及皮下組織后至闊筋膜,切開闊筋膜后進(jìn)入其下的滑囊,沿闊筋膜張肌肌纖維方向分開闊筋膜張肌及髂脛束,鈍性分離臀中肌、臀小肌以及股外側(cè)肌,使用三把髖臼拉勾呈三點(diǎn)狀分別放在股骨頸內(nèi)外側(cè)及髖臼上緣,沿股骨頸基底部前面將關(guān)節(jié)囊U型切開,這樣可以用手指觸及并顯露股骨頭和股骨頸。切開關(guān)節(jié)囊后,剝離股骨頸,此時(shí)股骨頭及其骨折面即可充分顯露,用取頭器取出殘頭,將髖關(guān)節(jié)屈曲、內(nèi)收、外旋,并同時(shí)屈膝,將股骨頸基底部的截骨面朝向術(shù)野前方,至此,髖臼及股骨頸基底部的截骨面已達(dá)到充分的顯露,即可進(jìn)行人工髖關(guān)節(jié)的安裝操作。對(duì)照組:采用后側(cè)入路,以大轉(zhuǎn)子頂點(diǎn)為中心,沿股骨干向遠(yuǎn)端延伸切口,近端向髂后上棘前方延伸,切開皮膚及皮下組織后,切開闊筋膜,鈍性分離臀大肌與闊筋膜張肌,顯露股外側(cè)肌,鈍性分離臀大肌及深筋膜,屈膝、內(nèi)旋髖關(guān)節(jié),顯露梨狀肌、上[V肌、閉孔內(nèi)肌、下[V肌。留置縫線牽引諸肌群,在以上諸肌轉(zhuǎn)子尖、轉(zhuǎn)子窩止點(diǎn)處切斷,切開關(guān)節(jié)囊顯露股骨頸。手指觸摸小轉(zhuǎn)子確定股骨頸截骨長(zhǎng)度,旋轉(zhuǎn)截?cái)嗟墓晒穷i,顯露圓韌帶,組織剪剪斷圓韌帶,拔出股骨頭,顯露髖臼底,此時(shí)即可進(jìn)行人工髖關(guān)節(jié)的安裝操作。結(jié)果:根據(jù)兩組的手術(shù)時(shí)間和出血量的方差齊性檢驗(yàn)結(jié)果可知,兩組的手術(shù)時(shí)間檢驗(yàn)結(jié)果t=-0.699,P=0.4860.05,因此改良前外側(cè)入路與后側(cè)入路在手術(shù)時(shí)間上相比沒(méi)有明顯差異(t檢驗(yàn),P0.05)。兩組的術(shù)中出血量檢驗(yàn)結(jié)果t=-2.322,P=0.0220.05,因此改良前外側(cè)入路與后側(cè)入路在術(shù)中出血量上相比具有顯著差異(t檢驗(yàn),P0.05),且由均值可得知具體表現(xiàn)為改良前外側(cè)入路的術(shù)中出血量顯著小于后側(cè)入路。結(jié)論:對(duì)于人工髖關(guān)節(jié)置換治療股骨頸骨折時(shí),前外側(cè)入路與后側(cè)入路是最常用的手術(shù)入路方式。在手術(shù)過(guò)程中,手術(shù)時(shí)間與出血量的控制,決定著手術(shù)的風(fēng)險(xiǎn),對(duì)患者能否順利度過(guò)圍手術(shù)期相當(dāng)重要。因此在保證人工髖關(guān)節(jié)置換術(shù)成功的基礎(chǔ)上,用更短的手術(shù)時(shí)間、控制更少的出血量、更小的手術(shù)創(chuàng)傷,為患者的手術(shù)安全性提供更好的選擇,是骨科醫(yī)生共同追求的方向。在手術(shù)時(shí)間方面,改良前外側(cè)入路與后側(cè)入路無(wú)明顯差異,沒(méi)有統(tǒng)計(jì)學(xué)意義;但是在出血量方面,統(tǒng)計(jì)學(xué)差異還是很顯著的,由均值可知改良前外側(cè)入路的出血量明顯小于后側(cè)入路,這反映了在人工髖關(guān)節(jié)置換術(shù)中后側(cè)入路比改良前外側(cè)入路的手術(shù)風(fēng)險(xiǎn)要高。因此,對(duì)于自身身體條件、耐受性較差的患者,可以選擇應(yīng)用改良前外側(cè)入路術(shù)式進(jìn)行人工髖關(guān)節(jié)置換。
[Abstract]:Objective: with the continuous deepening of biomechanics research, continuous renewal of prosthesis design, prolongation of life span and the maturity of surgical technique, the adaptation range of artificial hip arthroplasty is also expanding. It can not only reduce the patient's bed time, improve the patient's postoperative functional recovery, but also reduce the femoral neck bone effectively. Therefore, artificial hip arthroplasty for the treatment of femoral neck fractures is accepted by more and more patients. In this paper, a retrospective analysis of artificial hip arthroplasty with different surgical approaches was reviewed, and the operative time and amount of intraoperative bleeding were compared between the anterior lateral approach and the posterior approach, and two kinds of surgical procedures were discussed. Methods: the risk of hip arthroplasty. Methods: a retrospective analysis was made of patients with femoral neck fracture and hip replacement in Third Hospital of Hebei Medical University from March 2011 to January 2015. 120 cases were randomly selected to remove dysplasia, ischemic necrosis, arthrosis, obsolete fractures, multiple fractures, post-operative refurbishment, etc. Cases were 69 male, 51 female, 45 years old -91 years old. The patients were divided into the observation group and the control group according to the surgical approach. The modified anterolateral approach was used as the observation group and the hip replacement lateral approach was used as the control group. 60 cases were selected in each group. The two groups were compared with the sex, age, cause of injury, and the combination of diseases. The operation time and intraoperative bleeding amount of the two groups were compared. In the observation group, a modified anterolateral approach, the patient's lateral position, a curved incision with the center of the great trochanter, incision of the skin and subcutaneous tissue to the fascia lata, the fascia lata, and the broad tendons along the tensor fascia lata muscle fibers. The membrane tensor muscle and ilibiin bundle, the blunt separation of the gluteus medius, the gluteus gluteus and the lateral femoral muscle, and the three points of the acetabulum draw on the upper and outer side of the neck of the femur and the upper margin of the acetabulum, and the U of the joint capsule in front of the basal part of the neck of the femur, so that the femoral head and the neck of the femur can be exposed with the finger and the joint capsule and peel off the neck of the femur. At this time, the femoral head and its fracture surface can be fully revealed, using the head device to remove the residual head, flexing the hip joint, adduction, external rotation, and bending the knee to the front of the operation field. At this point, the osteotomy surface of the base of the acetabulum and the neck of the femur has reached full exposure, and the artificial hip joint can be installed. Control group: The posterior approach was used to extend the apex of the great trochanter, extending the incision along the femoral shaft to the distal end, extending the proximal end to the posterior superior iliac spine, incision of the skin and subcutaneous tissue, opening the fascia lata, separating the gluteus maximus and the tensor fascia, revealing the lateral femoral muscle, separating the gluteus maximus and the deep fascia, flexing the knee, the internal rotation hip joint and exposing the piriform muscle, [V Muscles, obturator muscles, and lower [V muscles. The muscle groups are tracted by the indwelling suture, cut off at the tip of the muscle of the muscles and the point of the rotor, and opening the joint capsule to expose the neck of the femur. Results: according to the results of the two groups of operation time and blood volume variance homogeneity test, the results of the two groups were t=-0.699, P=0.4860.05, so there was no significant difference between the improved anterolateral approach and the posterior approach (t test, P0.05). The intraoperative bleeding test of the two groups Results t=-2.322, P=0.0220.05, so the improved anterolateral approach and posterior approach had significant differences in the amount of intraoperative bleeding (t test, P0.05), and the mean value of the modified anterolateral approach was significantly smaller than the posterior approach. Conclusion: the anterolateral approach to the treatment of femoral neck fractures by artificial hip replacement The most common surgical approach is the approach and the posterior approach. During the operation, the operation time and the amount of bleeding are controlled, the risk of the operation is determined, and it is important for the patient to pass through the perioperative period. Therefore, on the basis of the success of the artificial hip replacement, the shorter operation time is used to control less bleeding and smaller. There is no significant difference between the anterolateral approach and the posterior approach, but there is no statistical difference between the improved anterolateral approach and the posterior approach. However, the statistical difference is significant in the amount of bleeding, and the improvement of the anterolateral approach is known from the mean value. The blood volume is significantly less than the posterior approach, which reflects the higher risk of the posterior approach in the hip replacement than the modified anterolateral approach. Therefore, the modified anterolateral approach can be selected for the hip replacement for the patients with poor tolerance to their own physical conditions.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R687.4

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