【作者】 张斌；

【导师】 戴闽；

【作者基本信息】 南昌大学医学院 ， 外科学（专业学位）， 2013， 博士

【摘要】 研究背景和目的：股骨远端骨折是骨科常见骨折,由于其解剖形态较为特殊且与膝关节关系密切,骨折后形态较为复杂,缺乏合适的内固定器械,使得股骨远端骨折治疗颇为困难,易出现畸形愈合及膝关节僵硬。目前股骨远端骨折建议积极行手术治疗,切开复位内固定术是其常用的治疗方法,但目前常规外侧入路损伤髂胫束且显露不充分,常规前外侧入路对股中间肌损伤较大,从而影响了股骨远端骨折的手术疗效,因此股骨远端骨折目前临床尚无理想的手术入路。康复医学是近年来在国内外日益受到重视且发展迅速的一门新兴学科,它是以功能障碍为治疗对象,贯穿了骨科疾病治疗的全过程。现代骨科康复观认为股骨远端骨折,尤其是C型骨折切开复位内固定术的理想入路应该满足三个条件,首先是能达到理想的显露,便于手术操作；其次是要尽可能减少软组织损伤,便于修复；再次是便于术后早期功能锻炼,尽早康复。本研究在现代骨科康复观指导下,根据大腿中下段及膝关节解剖结构结合临床经验设计了新型股骨远端前外侧入路,该入路切口呈“S”型,沿股外侧肌与股直肌间隙进入,深面从股中间肌远段外侧缘顺肌纤维方向切开至股四头肌扩张部后弧形向下、外切开外侧支持带和膝关节囊,充分显露股骨下端及髁部关节面。为验证该新型入路治疗股骨远端骨折的安全性、有效性及实用性,本研究还进行了相关的尸体解剖学研究及临床对照研究。研究内容和方法：1.新型股骨远端前外侧入路的解剖学研究福尔马林防腐成人下肢标本6例,男性4例,女性2例,设计新型股骨远端前外侧入路,观察入路周围软组织结构,观测腓总神经、胭动脉及髌骨周围血管与入路的关系。2.新型股骨远端前外侧入路治疗股骨远端骨折的临床前瞻性研究将2010年1月至2012年6月在我院骨科手术治疗的60例股骨远端骨折患者随机分成新型股骨远端前外侧入路组和常规入路组,记录两组患者手术时间、术中出血量、术中透视次数、住院时间、住院期间并发症发生情况及术前1小时、术后6小时、术后12小时、术后24小时血液C反应蛋白和肌酸激酶水平。3.新型股骨远端前外侧入路治疗股骨远端骨折的临床回顾性研究回顾分析2007年7月至2009年12月在我院骨科手术治疗的58例股骨远端骨折患者,分成新型股骨远端前外侧入路组和常规入路组,记录两组患者手术时间、术中出血量、术中透视次数、住院时间及最后一次随访膝关节HSS评分。结果：1.新型股骨远端前外侧入路的解剖学研究(1)新型股骨远端前外侧入路对股外侧肌与股直肌损伤小,并尽可能减少了对股中间肌的损伤,股四头肌扩张部、外侧支持带呈弧形切开,张力小；(2)新型入路不损伤胭动脉和腓总神经,但膝上外侧动脉于股骨外上髁上方平面横过该入路；(3)按新型股骨远端前外侧入路切开,将髌骨翻向内侧,股骨下端及髁部关节面显露充分2.新型股骨远端前外侧入路治疗股骨远端骨折的临床前瞻性研究(1)新型入路组手术时间、术中出血量、术中透视次数均显著少于常规入路组,差异有统计学意义(P<0.05),住院时间、并发症发生率差异无统计学意义(P>0.05)：(2)新型入路组、常规入路组患者C反应蛋白水平术后各时间点与术前相比差异均有统计学意义(P<0.05),两组病例在术后各时间点组间比较差异无统计学意义(P>0.05)。两组肌酸激酶水平术后各时间点与术前相比差异均有统计学意义(P<0.05),新型入路组在术后各时间点肌酸激酶水平小于常规入路组,差异有统计学意义(P<0.05)。3.新型股骨远端前外侧入路治疗股骨远端骨折的临床回顾性研究(1)新型入路组与常规入路组手术时间、术中透视次数比较差异有统计学意义(P<0.05),新型入路组优于常规入路组；术中出血量、住院时间比较无统计学意义(P>0.05)；(2)两组患者最后一次随访膝关节HSS评分,新型入路组为94.4±4.2,常规入路组为89.2士6.0,差异有统计学意义(P0.05),新型入路组优于常规入路组。结论：现代骨科康复观指导下设计的新型股骨远端前外侧入路对股直肌、股外侧肌损伤小,并尽可能减少了对股中间肌的损伤；骨折显露充分,便于术中操作；股四头肌扩张部、外侧支持带呈弧形切开,缝合张力小,便于术后早期功能康复,从而促进膝关节功能的恢复。更多还原

【Abstract】 Research backround and objectiveDistal femoral fractures is a common fracture. Due to its special anatomical morphology, close to the knee joint, relatively complex fracture morphology and lack of proper internal fixation instruments, the treatment of distal femoral fracture is difficult and prone to malunion and anchylosis of knee. Distal femoral fractures suggest active surgical treatment. Open reduction and internal fixation is common treatment for distal femoral fracture. But the conventional lateral approach damages the iliotibial band and its surgical exposure is inadequate. The conventional anterolateral approach damages vastus intermedius seriously. So there is no ideal surgical approach for the distal femoral fracture at the moment. Rehabilitation medicine is an emerging discipline with growing attention and rapid development at home and abroad in recent years. It is based on the dysfunction of the treatment object, throughout the whole process of the orthopaedic disease treatment. With the modern orthopaedic rehabilitation theory,the ideal approach for the distal femoral fractures, especially for type C fractures, should meet three conditions.First of all is to expose fully; the second is to minimize tissue damage as soon as possible; again is to facilitate early postoperative functional exercise and rehabilitation.Therefore, this study intends to explore more ideal surgical approach for the distal femoral fractures. Guided by the modern concept of orthopaedic rehabilitation,the study designs the new anterolateral approach of the distal femur on the basis of the anatomic structure of the thigh and the knee combined with clinical experience.The new anterolateral approach of the distal femur is "S" type.The approach incises along the spatium intermusculare between the vastus lateralis and rectus femoris.At deep layer,the approach incises the lateral margin of the distal segment of vastus intermedius along the fiber direction to the pavilion of quadriceps femoris and curved downward to cut open the lateral retinaculum and knee joint capsule to expose the distal femur and the joint surface fully.The study also includes related anatomical study and clinical control study. Content and methods1.Anatomical study of the new anterolateral approach of the distal femur.With formalin preservative adult lower limb specimens of6cases, male in4cases, female in2cases, the study designed the new anterolateral approach of the distal femur and observed the soft tissue structures including common peroneal nerve, popliteal artery and blood vessels around the patellar.2. Prospective studies for the treatment of distal femoral fractures with the new anterolateral approach of the distal femurIn January2010to June2012,60patients with distal femoral fractures in our hospital were randomly divided into new anterolateral approach group and conventional approach group.The study record operation time, blood loss in operation, number of intraoperative fluoroscopy, length of hospital stay, complications and blood creatine kinase and c-reactive protein at preoperative1hour, postoperative6hours, postoperative12hours, postoperative24hours.3. Retrospective study for the treatment of distal femoral fractures with the new anterolateral approach of the distal femurIn July2007to December2009,58patients with distal femoral fractures in our hospital divided into new anterolateral approach group and conventional approach group. The operation time, intraoperative blood loss, number of intraoperative fluoroscopy. length of hospital stay and HSS score of knee were record.Results1.Anatomical study of the new anterolateral approach of the distal femur.(1) With the new anterolateral approach of the distal femur,the damage of the vastus lateralis and rectus femoris is small, and the injury of the vastus intermedius is reduced as far as possible. The pavilion of quadriceps femoris and the lateral retinaculum are An arc incision with small tension.(2) This approach does not damage the popliteal artery and common peroneal nerve, but lateral superior genicular artery across the approach; (3) With the new anterolateral approach of the distal femur, the patella can be turned inward and the distal femur and the joint surface are exposed fully.2.Prospective studies for the treatment of distal femoral fractures with the new anterolateral approach of the distal femur(1) The operation time, blood loss in operation, number of intraoperative fluoroscopy of new anterolateral approach group were significant less than conventional approach group, the differences were significant statistically (P<0.05).The differences of the length of hospital stay and complications in the two groups were not significant statistically (P>0.05);(2) The differences of c-reactive protein levels at each postoperative time point compared with preoperative time point in new anterolateral approach group and conventional approach group were significant statistically (P<0.05).The differences of c-reactive protein levels at each time point after surgery between the two groups are not significant statistically (P>0.05). The differences of creatine kinase levels at each postoperative time point compared with preoperative time point in new anterolateral approach group and conventional approach group were significant statistically (P<0.05). The creatine kinase level at each time point after surgery in the new anterolateral approach group were less than that in conventional approach group, and the differences were significant statistically (P<0.05).3.Retrospective study for the treatment of distal femoral fractures with the new anterolateral approach of the distal femur(1) The operation time and the number of intraoperative fluoroscopy of new anterolateral approach group were significant less than conventional approach group, the differences were significant statistically (P<0.05).But the Intraoperative blood loss and the length of hospital stay compared with no statistical significance between the two groups(P>0.05).(2) The knee HSS score of patients at the last follow-up of the new approach group was94.4±4.2, and the knee HSS score of patients of the conventional approach group was89.2±6.0.The difference between the two groups was significant statistically (P<0.05). ConclusionWith the new anterolateral approach of the distal femur guided by the modern concept of orthopaedic rehabilitation,the damage of the vastus lateralis and rectus femoris is small, and the injury of the vastus intermedius is reduced as far as possible. The exposure of distal femoral fractures is sufficient for the operation. The pavilion of quadriceps femoris and the lateral retinaculum are an arc incision with small tension and facilitate early postoperative functional rehabilitation so as to enhance the recovery of knee joint.更多还原