髋部手术入路

LESSERTUBEROSITYAPpelvisandAPhipofanelderlypatientwithathree-partintertrochanterichipfracture.LATERALRADIOGRAPHThesetuponthefracturetabledoesnotrequiretheuninjuredlegtobeplacedinhyperflexionandabduction.Thelegsmaybescissoredtoallowforgoodlateralradiographsoftheaffectedsidewithoutputtingtheoppositehipatrisk.ISCHIUMLESSERTROCHANTERFEMURThisimagedemonstratesthepositionofthefracturetablewiththepatient’saffectedarmoverthechestandwellpadded.SCDsONDURINGPROCEDUREThisimagedemonstratesthescissoringofthelegswiththeaffectedsideslightlyflexedandtheunaffectedsideslightlyextended.Noticethatsequentialcompressiondevicesremainonthelegsduringtheprocedure.Aviewfrombelowdemonstratesthepositionofthearm.TheC-armisbroughtinfromanangleapproximately30degreesdistaltothepatient.TheAPradiographistakenwiththeC-armslightlyoverrotatedtogiveamoreperfectAPviewwithrespecttotheanatomyoftheproximalfemurandthelateralview.Theincisionshouldbeginproximallyatthetrochanteric

ridgeandneedextendapproximately10centimetersdownthethigh.ITBTheincisionbroughtdowntotheleveloftheiliotibialbandandfascialata.ITBTheiliotibialbandisincisedwithaknife.AMetzenbaumscissorsisusedtodissectundertheband,whichisdividedinlinewiththeincision.Theiliotibialbandisincisedwithaknife.AMetzenbaumscissorsisusedtodissectundertheband,whichisdividedinlinewiththeincision.Withretractionoftheiliotibialband,thevastuslateralisfasciaisvisualized.VASTUSLATERALISITBAsharprakeisintroducedanteriorlyandisusedtoretractthevastuslateralisanteriorly.Anincisionisthenmadeinthefasciajustanteriortothemostposterioraspectofthefemur.Asharprakeisintroducedanteriorlyandisusedtoretractthevastuslateralisanteriorly.Anincisionisthenmadeinthefasciajustanteriortothemostposterioraspectofthefemur.Aperiostealelevatorcanbeusedtoelevatethelateralisoffthefemurwithcaretakentoavoidperforatingbranches.ABennettretractorcanbeplacedovertheanteriorsurfaceofthefemur,exposingthelateraledgeofthefemur.APx-raydemonstratingabductionoftheproximalfragmentanddisplacementoftheposteromedialfragment.Abonehookcanbeused,ascanaclamporothertechnique,toreducetheabductionintheproximalfragment.OnceareductionisobtainedandconfirmedontheAPandlateralradiographs,theangleguideisplacedagainstthelateralsurfaceofthefemurinordertoplacetheguidewireforthelagscrew.Thenaturalanteversionofthehiprequirescommensurateexternalrotationofthejiginordertodrivethewireintothecenterofthehead.X-raysdemonstratingthepositionoftheguidewirethroughthejigintheAPandlateralplanes.Aftertheappropriatemeasurementforthelagscrewismade,thefemurispreparedbyreaming.Inthiscase,alongbarrelwaschosenandtheappropriatereamerisselected.Iftheboneisofgoodquality,atapmaybeused.APradiographofthelagscrewbeingterminallyseated.Whenusingasmallincision,thesideplatemustbeslidfromproximaltodistalalongthefemoralshaft,thendrawnbackupproximallysuchthatitiswithinthewound.Inordertoseatthesideplate,itsdistalendmustbeheldgentlyoffbone,suchthatthesideplateisparallelwiththefemurinordertoengagethelagscrew.Oncetheplateisterminallyseatedandtappedinplace,itisaffixedtothecortexusingstandardscrewfixation.APradiographofthelagscrewandsideplateinposition.Inthisparticularsituation,theposteromedialfragmentwasratherlarge,thusitwaselectedtofixitwithalagscrew.Thismustbedonefromapositionanteriortothesideplate.Thisisthecasebecausethesideplatemustbeslightlyposteriortothemidlineinordertodirectthelagscrewintothecenterofthehead,giventhenormalanteversionoftheneck.Theposteromedialfragmentcannotbelaggedthroughtheplatebecausetheangleofthescrewthroughtheplatewouldbetoogreat.Thus,thescrewisplacedfromanteriortotheplateasseeninthisfigure.Lateralviewoftheposteromedialfragmentreductionwithaclamp.Theimageshowsthedrillthatisplacedintothelessertrochanter.FinalAPradiographdemonstratingexcellentfixationandcompressionacrosstheintertrochantericfractureaswellaslagscrew