1、Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolOCM入路小切口全髋关节置换(MIS-THA)手术介绍及与传统外侧入路比较蒋 青Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolDisclosures No financial disclosuresBone&Joint Center,The Affiliated Drum Tower Ho
2、spital of Nanjing University Medical SchoolMinimally invasive surgery for THA(MIS-THA)代表性的为微创直接前入路，微创前外侧入路，微创后侧入路及后外侧入路，以及双切口入路。前外侧（OCM）入路和前侧入路及双切口均不损伤肌肉，为真正意义的微创切口。前侧入路和双切口的应用很少，报道至今但目前仍很少医院采用。OCM目前在德国应用很广，国内少数医院应用。Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical S
3、chool前侧入路 前外侧入路及后侧入路解剖Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School前侧入路 是一个改良的Smith-Peterson入路。以股骨大转子为界(2/3在上方,1/3 在下方),平行于髂前上棘与腓骨头的连线后方2 cm 为切口方向,切口长度限于5 10 cm。不伤肌肉，且在神经肌肉界面进行，缺点：股骨操作困难。Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing Unive
4、rsity Medical School后侧微创小切口 后侧切口是一个改良Gibson切口。患者侧卧位,骨盆固定,以大转子后侧顶点为中心,自后上向前下,做一长约8 10 cm 的切口。缺点：伤臀肌及外旋肌肉，并非真正意义微创，后脱位风险高。Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School两切口入路two-incision approachBerger于2019年首先报道了两切口入路法,这种手术方式需要一定的特制手术工具。第一个切口是长约5 cm 的前外侧切口,用来切
5、除股骨头和安放髋臼假体;第二个切口是后路切口,用来进行股骨准备,切口位置与股骨髓内钉的切口类似。该手术方式不需切断臀中肌和臀后外旋肌,手术从肌肉间隙进入,组织损伤小，能保留关节囊，是真正意义上的微创THA 手术。缺点：麻烦，常需要透视。Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolMinimal-invasiver anterolateraler Zugang in der HftendoprothetikReported in 2019OCM approach-
6、The modified Watson-JonesBone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical Schoollateral aspect of the hip jointBone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolWatson-Jones入路介绍Watson-Jones 入路OCM入路入路Watson-Jones 切口暴露髋关节方法切口暴露髋关
7、节方法Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolThe OCM approach using in our department-Bone grafting in AVNSurgery for femoral acetabular impingement(FAI)Open surgery for synovial chondromatosis THABone&Joint Center,The Affiliated Drum Tower Hospital of
8、Nanjing University Medical SchoolMIS-THA in China 微创的定义不清，真正微创应该是不损伤肌肉，并非仅仅切口小，目前较为公认的为前侧、OCM及双切口 国内应用较少的原因 learning curve Lack of knowledge and tools Inconvinient on the early stage of learning The long-term follow up showed similar results in prothesis surviving despite of the better function achi
9、eved Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolThe aim for THA Well fixed components Stable joint Impingement free ROM Equal leg lengthBone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolPlan for MIS-THA BMI 髋关节活动度评估
10、 有无固定畸形 原手术切口评估 功能评分：Harris评分 假体准备：臼杯无特殊 股骨柄：选择解剖柄(SL-Plus MIA，Acorade Stem，短柄，etc)髋臼及股骨柄大小型号评估 模板估计！模板估计！Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School适应症 Fracture AVN OA DDH？AS?Revision？手术技术成熟手术技术成熟Low BMI？High BMI？Bone&Joint Center,The Affiliated Drum To
11、wer Hospital of Nanjing University Medical School小切口手术专用工具Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School手术步骤介绍Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School体位 侧卧位，手术床保持水平，避免影响外展角 注意床水平不等于骨盆为侧位，可触摸髂前上棘大致判断 也可以透视定位标准
12、侧位 侧卧位手术经验很关键！Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School入路标记1/43/4Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolOCM入路髋关节暴露 间隙要找对皮肤切开暴露髂胫束暴露髂胫束Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing Univ
13、ersity Medical SchoolOCM入路髋关节暴露髂胫束切开暴露关节囊Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School关节囊切除 也可U形切开后翻瓣，术后予以修补，Really necessary？Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School脱位一步截骨法 对于部分先髋或股骨头坏死病例（股骨头较小）可以采用，小心臀中肌损伤
14、。45Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School两步截骨法 第一刀紧贴股骨头下，截完后外旋后伸内收下肢，触摸小粗隆后行第二刀截骨，截骨位置与传统手术位置相同，取头器取出，股骨头直径较大时需要注意12Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School髋臼拉钩暴露处理 髋臼处理与传统方式无差异，切除前外侧关节囊，去除盂唇、骨赘等Bone&
15、Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School髋臼磨锉 Be careful of the glutei 弯头锉进行髋臼处理，大头的髋臼处理可以用专用锉。注意外展角度可能和外侧入路感觉会不一样。Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School安装试模Bone&Joint Center,The Affiliated Drum Tower Hospi
16、tal of Nanjing University Medical School可能的撞击骨赘清除Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School安装臼杯 犬腿式安装器进行臼杯安装，再放入内衬Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School股骨侧处理Bone&Joint Center,The Affiliated Drum Tower H
17、ospital of Nanjing University Medical School要点 极度后伸内收外旋体位，助手很重要 拉钩位置重要 切口选择的重要性 偏后会暴露不够，偏前则容易挫伤皮肤 并非所有病例均能顺利暴露，可松解：关节囊、臀小肌止点 肢体严重短缩病人松解髂胫束、髂腰肌 髋关节强直病例屈髋功能受限可松解髂胫束、臀大肌等 陈旧性骨折、骨性关节炎的骨赘松解 内收畸形患者内收肌松解 必要时可延长切口Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School体位摆放Bo
18、ne&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School拉钩暴露Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School关节囊松解Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School标记扩髓方向 要点：肢体标准外旋中立位Bone&Jo
19、int Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School开槽Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School髓腔铰刀探明方向并扩髓 注意勿损伤皮肤，尽可能内收、后伸Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School髓腔锉扩髓 偏距髓腔
20、锉自小到大进行扩髓 注意：由于为解剖柄，且偏距扩髓，受力可能会出问题，有可能出现内外翻的情况，且有可能会导致股骨距劈裂Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School假体安装Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School试头安装并复位 复位一般比较容易，屈伸、内外旋、后伸状态下不脱位，由于保留臀肌，对于长度判断容易Bone&Joint
21、Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School术后处理Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School术后当天-3天 手术当天即可屈髋锻炼，拔除引流，无需中立鞋，复查X线后即可下地行走Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical Schoo
22、l术后当天-术后3天Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School术后3-5天I want to leave！Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School 48 yr双侧股骨头坏死一期置换术后术后4天天VedioBone&Joint Center,The Affiliated Drum Tower Hospital of Nanji
23、ng University Medical School 49 yr股骨颈骨折术后术后术后3天天VedioBone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School 54 yr双侧股骨头坏死分次置换术后术后4天天VedioBone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolAS first case Male 29 yr术后3天Vedio术后3个月ve
24、dioWhich side is operated？Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolBone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School股骨颈骨折 The first case Male 78 yr术后3个月Which side is operated？Bone&Joint Center,The Affiliated Drum
25、 Tower Hospital of Nanjing University Medical School术后半年术后Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolDDH 76yrWhich side is operated？术后3个月vedioBone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School术前术后术后3个月Bone&Joint Cen
26、ter,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolDDH 50 yr术后3个月Which side is operated？Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolBone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolOCM与传统外侧入路
27、初步病例比较Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School临床资料 2019年9月-2019年6月 本组共55例连续初次单侧全髋关节置换病例 由同一主刀医师完成 入选标准：股骨头坏死、股骨颈骨折、CrowelI/II/III型发育性髋关节发育不良，排除高位先髋病例。A组OCM组、B组改良Hardinger入路组 选择OCM入路的原因：目前仅部分假体可使用相应的小切口工具，假体费用相对较高，而无法选择小切口适合假体的均使用常规Hardinger入路。Bone&Joi
28、nt Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School临床资料 A组病例25例，股骨头坏死9例、陈旧性/新鲜股骨颈骨折7例、CrowelI/II/III型发育性髋关节发育不良6例、髋关节骨性关节炎2例，强直性脊柱炎1例。其中男性12例，女性13例。B组病例30例，股骨头坏死6例、陈旧性/新鲜股骨颈骨折11例、CrowelI/II/III型发育性髋关节发育不良10例、髋关节骨性关节炎3例。其中男性 例，女性 例。，A组BMI平均24.32.43kg/m2，B组 BMI平均23.4 2.47
29、kg/m2（P0.05）。Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School结果Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School切口、疼痛、出血量及跛行情况 A组切口长度平均8.3cm，B组切口长度平均12.6cm（P0.05）A组术后1、3天平均VAS评分2.3分，1.3分。B组术后1、3天平均VAS评分4.4分，3.1分。差异显著（P0
30、.05）两组出血量无明显差异 A组满3个月的19例无1例跛行，臀中肌肌力均为5级。B组3例仍有跛行表现，臀中肌肌力4级。Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School假体安装情况比较 A组与B组所有病例假体安装均无明显内外翻表现，髋臼外展角度介于40-50度之间 A组所有病例的肢体短缩在1cm以内，B组有2例患者短缩在1cm-2cm之间Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing U
31、niversity Medical School A组1例术后对侧发生DVT，B组4例发生周围型DVT深静脉血栓（DVT）发生情况Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School总结Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical SchoolOCM入路的优入路的优缺缺点点创伤小、不伤肌肉对于下肢长度判断有优势术后疼痛度明显有所减轻血栓发生率减少输血率低关节功能可能更好。患者近期满意度高疤痕小，可能利于二期翻修暴露欠佳，技术要求较高初学时手术时间反而会延长有一定的臀上神经损伤概率骨质疏松患者可能增加骨折发生率解剖柄价格高需要特殊工具BalanceYour Choice？Bone&Joint Center,The Affiliated Drum Tower Hospital of Nanjing University Medical School致谢！感谢Pro.Michael Schultem and Diakoniekrankenhaus Rotenburg Hospital！
