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中华关节外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (03) : 384 -390. doi: 10.3877/cma.j.issn.1674-134X.2022.03.022

微创关节技术

各式微创髋关节置换手术的入路解剖
徐永清1, 饶宇2, 蒙旭晗1, 唐志方3, 郭民政4, 浦路桥1, 陈旭升4, 李川4,†()   
  1. 1. 650032　昆明，解放军联勤保障部队第九二〇医院附属骨科医院
    2. 650500　昆明医科大学；657200　昭通，镇雄县人民医院
    3. 650032　昆明，解放军联勤保障部队第九二〇医院附属骨科医院；671000　大理大学医学院
    4. 650032　昆明，解放军联勤保障部队第九二〇医院附属骨科医院；650500　昆明医科大学
  • 收稿日期:2022-03-21 出版日期:2022-06-01
  • 通信作者: 李川
  • 基金资助:
    云南省重大科技专项-生物医药重大专项(2018ZF008); 云南省卫健委临床中心建设重大项目(ZX20191001)

Anatomy of various approaches for minimally invasive hip arthroplasty

Yongqing Xu1, Yu Rao2, Xuhan Meng1   

  • Received:2022-03-21 Published:2022-06-01
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徐永清, 饶宇, 蒙旭晗, 唐志方, 郭民政, 浦路桥, 陈旭升, 李川. 各式微创髋关节置换手术的入路解剖[J]. 中华关节外科杂志(电子版), 2022, 16(03): 384-390.

Yongqing Xu, Yu Rao, Xuhan Meng. Anatomy of various approaches for minimally invasive hip arthroplasty[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2022, 16(03): 384-390.

髋关节置换术(hip arthroplasty，HA)是一项历久而弥新的技术，因为传统的髋关节置换手术入路存在创伤大、失血多，术后康复慢等缺点[1]，自上世纪90年代开始，微创关节置换的入路研究成为了热点。微创既是外观微创，更是对深部组织结构严格保护的内在微创[2]，这给医生带来了要求更加严格的新挑战。选择传统入路还是微创入路一直众说纷纭，虽然有研究认为，更小的切口可以有效减少患者疼痛、出血，并且缩短康复和住院时间[1]，但微创髋关节置换(minimally hip arthroplasty，MHA)仍然没有受到广泛的认同。反对者认为，微创入路无法获得充分的术野来保护重要结构，以及在直视下截骨和安置假体，从而增加了术中透视，对医师操作技术要求也更高，使其并发症相对较多[3]，相对传统入路不具备明显的优势[1]。但随着对髋关节入路解剖研究的不断深入，微创入路辅助工具的不断改进以及新技术的运用，微创髋关节置换手术开始逐步克服这些不足，成为髋关节置换的主流术式[4]。

图1 髋臼周围重要结构解剖图及入路示意图。图A为髋关节周围重要结构解剖图；图B为常见MHA入路示意图注：1.髂胫束；2.阔筋膜张肌；3.髂骨；4.臀中肌；5.臀大肌；6.股外侧头肌；7.大收肌；8.坐骨神经；9.股二头肌长头；10.半腱肌；11.大收肌(对侧)；12.半膜肌(对侧)；13.半腱肌(对侧)；14.臀大肌(对侧)；15.股薄肌(对侧)；16.梨状肌；17.上孖肌；18.闭孔内肌；19.下孖肌；20.股方肌；红色(小切口后入路，MPA入路)；绿色(关节囊上方经皮辅助通道全髋关节置换术，SuperPATH)；紫色(前外侧入路，OCM)；蓝色(直接前侧入路，DAA)
图2 三种常见入路与肌群关系示意图注：MPA-小切口后入路；SuperPATH-关节囊上方经皮辅助通道全髋关节置换术；DSA-直接上方入路
图3 SuperPATH(关节囊上方经皮辅助通道全髋关节置换术)入路解剖示意图。图A为标准体位：屈髋、内收、内旋位；图B入路标记；图C红线处用以标记入路解剖间隙(梨状肌与臀小肌间隙)；图D建立PATH通道用以处理髋臼侧
图4 OCM切口及Watson Jones切口等两种切口示意图。图A为大体侧方切口投影，红色为OCM切口，绿色为Watson Jones切口[48]；图B为OCM切口肌间隙入路结构示意图
图5 OCM(前外侧入路)、DAA(直接前方入路)/Anterior Path(前侧经皮辅助通道全髋关节置换术)入路示意图
图6 DAA(直接前方入路)解剖示意图。图A为DAA入路浅层肌肉间隙见紫色标记线；图B为DAA入路切开关节囊显露股骨头颈
表1 各式微创THA入路归纳总结
入路名称 体位 入路解剖间隙 外旋肌群 操作顺序 备注
MPA   臀大肌与臀中肌间隙 切断孖肌和闭孔内肌 髋臼侧→股骨侧  
SuperPATH 侧卧位 臀大肌→梨状肌与臀小肌间隙 不断 股骨侧→髋臼侧 建立通道
DSA   髋臼侧→股骨侧 配套偏心工具    
OCM 臀中肌与阔筋膜间隙→臀小肌与股骨颈间隙 不断 髋臼侧→股骨侧 配套偏心工具  
DAA 仰卧位 阔筋膜张肌与缝匠肌间隙→阔筋膜张肌、臀中肌以及股直肌之间的间隔 常规松解或部分离断 股骨侧→髋臼侧 特殊体位床等
AnteriorPATH 阔筋膜张肌和缝匠肌、股直肌间隙 股骨侧→髋臼侧 建立通道    
表2 各式微创THA入路中外旋肌群松解情况总结
肌肉/入路 MPA SuperPATH DSA OCM DAA AnteriorPATH
梨状肌 根据需要松解 根据需要松解 根据需要松解 根据需要松解 根据需要松解 根据需要松解
上孖肌 松解 完整 完整 根据需要松解 根据需要松解 根据需要松解
闭孔内肌 松解 完整 完整 根据需要松解 根据需要松解 根据需要松解
下孖肌 松解 完整 完整 根据需要松解 根据需要松解 根据需要松解
闭孔外肌 根据需要松解 完整 完整 完整 完整 完整
股方肌 完整 完整 完整 完整 完整 完整
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