关节囊手术操作指南（含英文）VIP免费

1、术前准备Theanterolateralapproach(Watson-Jones)totheproximalfemur,throughtheintervalbetweengluteiandtensorfascialataprovidessomewhatlimitedaccesstothehipjointalongwiththelateralproximalfemur.Withwell-positionedretractorsandadequatesoft-tissuereleases,itispossibletoperformopenreductionofdisplacedfemoralneckfractures(31-B),andsomefemoralheadfractures(31-C).Amoremedialapproachtothehipjoint(IliofemoralorSmith-Peterson),medialtothetensorfascialata,mayimproveaccesstothefemoralheadandneck,butforfixationoftheneckwithaslidinghipscrew,aseparatelateralincisionwillberequired.前外侧入路即W-J入路显露股骨近端，通过臀肌与阔筋膜张肌之间有限显露髋关节及股骨近端。在牵开器帮助和充分的软组织松解的情况下，可以用来复位股骨颈骨折（31-b），有时也可以复位些股骨头骨折（31-C）。一个更靠内侧显露髋关节的切口如Iliofemoral切口或S-P切口，在阔筋膜张肌内侧，可以提供显露股骨头和股骨颈，但是如果用DHS固定股骨颈骨折，则需要一个独立的外侧切口。2、皮肤切口Starttheslightlyanteriorlycurvedskinincisionabout7-10cmproximalofthelateralpartofthegreatertrochanter(directedtowardsthetuberculeoftheiliaccrest–theposteriorlandmarkoftensorfascialataorigin).Distally,theincisionextendsalongthefemurabout10cmbelowthegreatertrochanter.在股骨大转子上约7-10cm外侧略前方处行轻微弯曲皮肤切口（方向从髂结节到阔筋膜张肌起始部），向远端延伸至股骨干（大粗隆下10cm处）。3、显露阔筋膜张肌Exposethefascialatasharply.Incisethefascialataoverthefemurandextendthisincisionproximallyalongtheposteriorborderofthetensorfascialata.锐性显露阔筋膜张肌。在股骨处切开阔筋膜张肌并向近端沿着阔筋膜张肌后侧边界锐性分离。4、深层分离Withthegreatertrochanterandthegluteusmediusmuscleexposed,retractthetensorfascialataanteriorlyandthegluteusmediusmuscleposteriorly.Exposetheintervalbetweenthegluteusmediusandthetensorfascialataandextenditproximallyoverthehipjoint.Thiscanbebestdonebybluntdissection.Beawareofvesselsrunningacrossthisinterval.Theyrequireligationorcautery.显露大粗隆及臀中肌，将阔筋膜张肌向前方牵开，臀中肌向后方牵开。钝性分离臀中肌与阔筋膜张肌之间间隙向近端延伸至髋关节。注意此间隙的血管术，可以结扎或电凝止血。5、显露髋关节囊PlaceaHohmannretractorintotheboneproximaltothehipcapsule.Additionalretractorsanteriorlyandposteriorlywillopenthedissectedinterval.Externalrotationofthelegimprovesaccesstothehipcapsule.在髋关节股骨头部放置Hohmann拉钩，另外在前和后方各放置一个拉钩，可以显露解剖间隙。外旋大腿将有助于显露髋关节囊。6、松解股外侧肌Theoriginofthevastuslateralismuscleshouldbereleasedfromtheanteriorinferiortrochantericregiontoexposetheunderlyinghipcapsule.Retractthemuscleinferiorly.Adjusttheretractorsasnecessary,anddebrideperiarticularfattoexposethehipcapsule.从大转子前下方剥离股外侧肌起点显露潜在的关节囊，向下牵拉肌肉。视需要调整拉钩，清除关节周围的脂肪。7、打开关节囊MakeanT-shapedincisioninthecapsule,…关节囊做一个T型切口8、打开关节囊…andplacetworetractionsutures,anteriorlyandposteriorly.Protecttheacetabularlabrum.Thiscapsulotomyshowstheanteriorfemoralheadandneck.Lateraltractionandrepositioningofthelegcanimprovevisualization.TheincisoncanbeprolongeddistallyovertheproximalvastuslateralistoallowinsertionofscrewsorDHSforfemoralneckfracturefixation.在关节囊前方和后方置入两根缝合线，以保护髋臼。此关节囊切开术可以显露股骨头和颈前面，外侧牵开或旋转大腿可以增加显露。此切口可以沿股外侧肌延长，以便拧入股骨颈螺钉或DHS来固定股骨颈骨折。9、闭合伤口Performameticulousdebridementofallsofttissuesbeforestartingwoundclosure.Removenecrotictissueandirrigatetheentirewoundtodecreasetheriskofperiarticularossification.Insertsuctiondrainsifdesired.Closethefascialataincisionwithinterruptedsutures.Closethesubcutaneoustissueandskinasdesired.闭合伤口前仔细清除所有软组织。清除坏死组织并冲洗整个伤口以减少关节周围骨化形成，如果必要可以下负压吸引装置。间断缝合阔筋膜，缝合皮肤及皮下组织。