改良Stoppa入路联合髂棘入路髋臼周围截骨术

Modified Stoppa approach combined with iliac spine approach for periacetabular osteotomy

摘要:

[目的]介绍改良 Stoppa 入路联合髂棘入路行髋臼周围截骨术的手术技术。[方法]手术治疗 2018-2019 年本科收治的成人发育性髋关节发育不良患者共 3 例，1 例单髋，2 例双髋。术前 3D 打印骨盆及双髋关节，并测量 LCE 角、ACE 角及 Tonnis 角。取腹正中 Stoppa 切口，显露腹直肌鞘，沿腹白线分开腹直肌，沿腹膜外间隙暴露耻骨上支及四边体，导针定位髋臼，行耻骨、四边体截骨。再取髂棘入路，显露髂前上棘及髂板，并向坐骨大切迹方向行臼顶髂骨截骨，再旋转截骨块，4 枚皮质骨螺钉固定。[结果] 3 例患者均顺利完成手术，无血管、神经损伤表现。术后 LCE 角、ACE 角较术前显著增加，Tonnis 角较术前显著减少 (P＜0.05)。术后 6 周，患者可扶单拐行走，术后 3 个月，X 线片示截骨处已完全愈合后，所有患者均弃拐，完全负重行走。[结论]此种手术技术，可在直视下行耻骨支、髋臼后柱和四边体截骨，避免了术中骨刀凿穿关节的风险。

Abstract:

[Objective] To introduce the surgical technique of modified Stoppa approach combined with iliac spine approach for periac- etabular osteotomy. [Methods] Periacetabular osteotomy through modified Stoppa approach combined with iliac spine approach was per- formed in 3 patients for adult developmental hip dysplasia, including 1 case with unilateral involved and 2 cases with bilateral affected, in our department from 2018 to 2019. Before operation a 3D printed pelvic model was made to measure the lateral center edge angle (LCE) , anterior center edge angle (ACE) and Tonnis angle, additionally, mimic the osteotomies preoperatively. In the real operation, a Stoppa inci- sion on the middle of the abdomen was made to expose the rectus abdominis sheath, separate the rectus abdominis along the white line, ex- pose the suprapubic branch and the quadrilateral along the extraperitoneal space. Locating the acetabulum with guide pins, the pubis and quadrilateral osteotomies were conducted. After that, an iliac spine approach was made to expose the anterior superior iliac spine and the ili- ac plate, iliac osteotomy in the direction of the ischial notch was done, and then rotate the osteotomy block, fix it with 4 cortical screws. [Results] All the 3 patients had osteotomies performed successfully without complications, such as vascular and nerve injuries. The LCE and ACE increased significantly, whereas the Tonnis angle decreased significantly postoperatively compared with those preoperatively (P＜ 0.05) . At 6 weeks after the operation, all the 3 patients resumed walking with a single crutch. By the time 12 weeks after surgery, the Xrays showed the osteotomy completely healed, and all the patients returned to walking with full weight bearing without crutches. [Conclusion] This surgical technique can perform osteotomy of the pubic ramus, posterior acetabular column and quadrilateral under direct vision, avoiding the risk of intraoperative osteotomy penetrating the joint.