OCM入路小切口全髋关节置换

股骨侧处理
Bone&Joint Center, The Affiliated Drum Tower Hospital 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
OCM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 School
Disclosures
• No financial disclosures
OCM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
Plan for MIS-THA
• BMI • 髋关节活动度评估
– 有无固定畸形
– 原手术切口评估
• 功能评分：
– Harris评分
MIS-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 achieved
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
安装试模
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
THA
Open surgery for synovial chondromatosis
Bone grafting in AVN
Surgery for femoral acetabular impingement (FAI)
Bone&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
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Bone&Joint Center, The Affiliated Drum Tower 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
• 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！
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
• Reported in 2004
Orthopädische Chirurgie (OCM), München • OCM approach ---The modified Watson-Jones
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 University Medical School
入路标记
3/4 1/4
Βιβλιοθήκη Baidu
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
OCM入路髋关节暴露
• 间隙要找对
皮肤切开 暴露髂胫束
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
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。
45°
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
适应症
– Fracture – AVN – OA – DDH？ – AS? – Revision？ High BMI？
Low BMI？
手术技术成熟
Bone&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&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
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
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
The aim for THA
• • • • Well fixed components Stable joint Impingement free ROM Equal leg length
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
Minimally invasive surgery for THA (MISTHA)
• 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。
lateral aspect of the hip joint
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
Watson-Jones入路介绍
OCM入路 Watson-Jones 入路
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
Minimal-invasiver anterolateraler Zugang in der Hüftendoprothetik
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
两切口入路two-incision approach
• Berger于2004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。
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
Watson-Jones 切口暴露髋关节方法
Bone&Joint Center, The Affiliated Drum Tower Hospital of Nanjing University Medical School
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The OCM approach using in our department