Jabłoński Mirosław, Gorzelak Mieczysław, Kuczyński Paweł, Piasecki Jarosław, Turzańska Karolina
Klinika Ortopedii i Rehabilitacji AM, Lublin.
Ortop Traumatol Rehabil. 2007 Jan-Feb;9(1):25-30.
We attempted to analyse the difficulties and risk of complications associated with total hip replacement using a limited posterior approach and standard instrumentation.
A series of 85 consecutive cases (47 females and 38 males; age range 22-87 years; mean age: 65.6 +/- 10.4) of total hip replacement using a modified Gibson approach were analyzed prospectively. Bilateral surgery was performed in 7 patients. There were 44 non-cemented arthroplasties. Body mass index varied from 22 to 36 (body weight 78-104 kg) and the length of the operative wound varied from 6.5 to 14 cm (mean 9.8 +/- 1.3 cm). The wound was 14 centimeters long in six subjects with a BMI of 35-36. The procedure was performed in a lateral decubitus position using an appropriately limited posterior approach. After careful coagulation of blood vessels surrounding the base of the femoral head posteriorly, the obturator and gemelli tendons and the posterior part of the joint capsule were cut through as close to the femoral attachment (T) as possible. This made it possible to dislocate the joint posteriorly. Further stages of the procedure were performed in a typical manner, with special attention paid to the preservation of the tendon of the piriformis muscle. Continuity of the muscle was re-examined following the reposition of the artificial joint.
Two injuries to the piriform tendon were observed. Persistent bleeding from vessels surrounding the femoral neck base occurred in 5 patients while in four others there was transient paresis of the peroneal muscles and dorsal extensors of the ipsilateral foot, probably caused by extension of the sciatic nerve. There was one oblique fracture of the proximal femoral shaft. We did not observe significant errors in postoperative joint geometry. Mean intraoperative blood loss was 400 ml. We did not note postoperative dislocations or infections.
On the basis of our observations of a series of 85 patients, minimizing the extent of the posterior surgical approach for hip joint replacement seems an attractive alternative to the classical extensive technique. Our material reveals a relatively high incidence of transient paresis of the peroneal part of the sciatic nerve. The introduction of appropriate instrumentation and the accumulation of experience will certainly decrease the risk of extension of the sciatic nerve in the operative wound.
我们试图分析采用有限后入路和标准器械进行全髋关节置换术的困难及并发症风险。
前瞻性分析了连续85例采用改良吉布森入路进行全髋关节置换术的病例（47例女性，38例男性；年龄范围22 - 87岁；平均年龄：65.6±10.4岁）。7例患者接受了双侧手术。其中44例为非骨水泥型关节成形术。体重指数在22至36之间（体重78 - 104千克），手术切口长度在6.5至14厘米之间（平均9.8±1.3厘米）。6例体重指数为35 - 36的患者切口长度为14厘米。手术在侧卧位采用适当有限的后入路进行。在仔细凝血股骨头后方基部周围的血管后，尽可能靠近股骨附着点（T）切断闭孔肌腱、梨状肌腱和关节囊后部。这使得关节能够向后脱位。手术的后续步骤以典型方式进行，特别注意保留梨状肌肌腱。在人工关节复位后重新检查肌肉的连续性。
观察到2例梨状肌腱损伤。5例患者股骨颈基部周围血管持续出血，另外4例患者同侧足部腓骨肌和背伸肌出现短暂麻痹，可能是坐骨神经牵拉所致。发生1例股骨近端骨干斜形骨折。我们未观察到术后关节几何形状的明显误差。术中平均失血量为400毫升。我们未注意到术后脱位或感染。
基于我们对85例患者的观察，对于髋关节置换术，尽量减少后入路手术范围似乎是经典广泛技术的一个有吸引力的替代方案。我们的资料显示坐骨神经腓骨部分短暂麻痹的发生率相对较高。引入适当的器械并积累经验肯定会降低手术伤口中坐骨神经牵拉的风险。
