摘要
目的探讨经会阴旁入路治疗骨盆耻骨下支-坐骨支骨折的解剖学基础及临床应用效果。方法在5具10侧完整湿性成人尸体标本上模拟会阴旁入路, 明确入路体表设计标志及显露范围, 观察股后皮神经会阴支与手术入路切口的解剖特点;于入路切口上选取5个测量点, 测量每个点与股后皮神经会阴支体表投影的距离(L1~L5)。临床应用经会阴旁入路耻骨下支-坐骨支骨折复位固定11例, 男5例、女6例;年龄(41.55±14.32)岁(范围18~62岁)。记录手术时间、手术切口长度、术中出血量、手术并发症;按照Matta影像学标准评价骨折复位质量, 末次随访时测量内收肌群肌力, 并根据Majeed评分评价功能。结果解剖研究表明, 耻骨联合角顶点水平外侧旁开4 cm与坐骨结节以近4 cm的连线为会阴旁入路轴线, 经此入路可显露耻骨联合至坐骨结节范围, 入路切口测量点与股后皮神经会阴支的距离L1为(19.40±1.17)mm(范围18~21 mm)、L2为(16.60±2.76)mm(范围10~20 mm)、L3为(18.30±1.89)mm(范围16~21 mm)、L4为(19.20±1.93)mm(范围16~22 mm)、L5为(14.70±1.83)mm(范围13~18 mm)。11例患者均获得随访, 随访时间为(17.91±4.09)个月(范围13~26个月)。手术切口长度为(8.18±0.98)cm(范围7~10 cm), 手术时间为(59.64±12.17)min(范围43~85 min), 术中出血量为100(50, 130)ml。患者骨折均愈合, 愈合时间为(13.36±2.06)周(范围10~16周)。Matta评分为优6例、良4例、可1例。末次随访时内收肌群肌力4级4例、5级7例;Majeed评分为(86.55±9.59)分(范围66~100分), 其中优8例、良3例。术后出现性交痛2例、异位骨化2例, 所有患者均无会阴区感觉障碍及疼痛。结论会阴旁入路与股后皮神经会阴支有一定的安全距离, 股后皮神经会阴支损伤的风险小。采用会阴旁入路治疗耻骨下支-坐骨支骨折切口隐蔽、手术时间短、出血少, 是治疗耻骨下支-坐骨支骨折的安全入路, 可获得较满意的近期临床疗效。
Objective To explore the anatomical and clinical effects of lateral-perineal approach in treating the fracture of inferior ramus of pubis-ischium ramus.Methods The lateral approach of the perineum was simulated on 10 side of 5 intact wet adult cadavers to determine the surface symbols of incision design and to expose the operative field of the approach and to observe the anatomical characteristics of the perineal branch of the posterior femoral cutaneous nerve and the incision of the surgical approach.Five points were selected at the incision of the approach.The distance(L1-L5)between each point and the body surface projection of the perineal branch of the posterior femoral cutaneous nerve was measured.A total of 11 patients,including 5 males and 6 females with an average age of 41.55±14.32 years,ranging from 18 to 62 years,were treated by this approach in clinical practice.All patients had a reduction and fixation to the fracture of inferior ramus of pubis-ischium ramus.The operation duration,incision length,intraoperative blood loss and surgical complications were recorded.The quality of fracture reduction was evaluated according to Matta radiographic criteria.The strength of the adductor was measured.The pelvic function was evaluated according to Majeed Pelvic Score at the last follow-up.Results Anatomical studies shown that the line between the two points.One point was 4 cm lateral to the level of the apex of the pubic arch.Another point was 4 cm from the ischial tubercle on the line from the ischial tuberosity to the point that 4 cm lateral to the level of the apex of the pubic arch was the axis of the approach lateral of the perineum.Anatomical studies showed that the lateral-perineal approach could expose the range from pubic symphysis to sciatic tuberculum.The distance between the points selected at the incision of the approach and the body surface projection of the perineal branch of the posterior femoral cutaneous nerve:L1 was 19.40±1.17 mm,ranging from 18 to 21 mm;L2 was 16.60±2.76 mm,ranging from 10 to 20 mm;L3 was 18.30±1.89 mm,ranging from 16 to 21 mm;L4 was 19.20±1.93 mm,ranging from 16 to 22 mm;L5 was 14.70±1.83 mm,ranging from 13 to 18 mm.All patients were followed up for 17.91±4.09 months,ranging from 13 to 26 months.The incision length was 8.18±0.98 cm,ranging from 7 to 10 cm.The operation duration was 59.64±12.17 min,ranging from 43 to 85 min.The intraoperative blood loss was 100 ml,ranging from 50 to 130 ml.All incisions were healed in all patients.The fractures were healed in 13.36±2.06 weeks,ranging from 10 to 16 weeks.According to Matta radiographic criteria,the quality of fracture reduction was excellent in 6 cases,good in 4 cases and fair in 1 case.At the last follow-up,the adductor muscle strength reached grade 4 in 4 patients and grade 5 in 7 patients.Furthermore,according to the Majeed Pelvic Score,the score of every patient was 86.55±9.59,ranging from 66 to 100,and 8 cases were excellent,3 cases were good at the last follow-up.The heterotopic ossification occurred in 2 patients,the pain during intercourse occurred in 2 patients.No patient had sensory disturbance or pain in the perineal area.Conclusion A certain safe distance is between the lateral to the perineum and the perineal branch of the posterior femoral cutaneous nerve with limited risk of injuring posterior femoral cutaneous nerve via the lateral approach of the perineum.The advantages in treating the fracture of inferior ramus of pubis-ischium ramus by this approach have concealed incision,short operation duration and less bleeding with satisfied short-term clinical effects.
作者
刘伟
程建文
唐士婷
赵劲民
杨志
胡峰
李木文
刘鹏
玉洪荣
谭桢
Liu Wei;Cheng Jianwen;Tang Shiting;Zhao Jinmin;Yang Zhi;Hu Feng;Li Muwen;Liu Peng;Yu Hongrong;Tan Zhen(Department of Orthopaedics,Second Affiliated Hospital of Guangxi Medical University,Nanning 530007,China;Department of Orthopaedic Trauma and Hand Surgery,First Affiliated Hospital of Guangxi Medical University,Nanning 530021,China;Department of Neurology,Second Affiliated Hospital of Guangxi Medical University,Nanning 530007,China;Department of Anatomy,Basic Medical College of Guangxi Medical University,Nanning 530021,China)
出处
《中华骨科杂志》
CAS
CSCD
北大核心
2022年第13期823-830,共8页
Chinese Journal of Orthopaedics
基金
国家自然科学基金(地区项目81960400)
广西自然科学基金(2019GXNSFBA185024)
广西壮族自治区重点临床专科(创伤外科)研发专项资助课题(GXKTS202203305)。
关键词
耻骨
坐骨
骨折固定术
内
解剖学
会阴
Pubic bone
Ischium
Fracture fixation,internal
Anatomy
Perineum
