髋关节置换课件

髋关节置换-Theseimagesdemonstrateadistalfemoralshaftfractureoccurringfromblunttrauma.髋关节置换-Beforeperformingantegradefemoralnailing,ahigh-qualityAPradiographofthehipisnecessarytoruleoutoccultfemoralneckfracture.髋关节置换-ManypatientswithfemoralshaftinjurieshaveCTscansperformedtoruleoutintraabdominalinjury.TheCTscancutsthroughthefemoralneckshouldalsobereviewedtoruleoutfracture.髋关节置换-Lateraldecubituspositionispreferredforantegradefemoralnailinginthepatientwithnormalpulmonarystatusandnospineorpelvicinjury.Theaffectedlegisflexed,exposingthepiriformisfossawithoutstericinterferencefromthepatient’storso.髋关节置换-Thedownsidelegiswellsupportedandpaddedtoavoidneuropraxia.Thesurgeonispointingtothestartingpointforthepiriformisentrypoint.髋关节置换-Viewoftheareathatispreppedoutforperformingthenailing.髋关节置换-PIRIFORMISFOSSAThepiriformisfossaentryportalisdirectlyinlinewiththecanaloftheshaft.However,itisslightlyposteriortothefemoralneck.Itiscurvilinearandangledposteriorly.髋关节置换-Becausethepiriformisentryportalisonaslopedsurface,astraightawlmustbeintroducedfirstatanangletothefemoralshaftdirectlyanteriorly…12髋关节置换-…andthenasit’sintroduced,thehandisraiseduptogoinlinewiththefemoralshaft.髋关节置换-1cmTheskinincision,whichcanbeapproximately1to1-1/2cminlength,shouldbemadeatadistanceawayfromthepiriformisfossatoallowfordirectentryintothefossa.Thiscanbebestestimatedbylooking髋关节置换-1cmattheAPradiographtodeterminehowproximaltheincisionneedstobewithrespecttothetrochanter.Theheavierthepatient,themoreproximalinthebuttockstheincisionneedstobeinordertobeinlinewiththefemoralshaft.髋关节置换-ThefasciaoftheTensorfasciaLatamuscleisdivided,exposingsomeofthemusculature.髋关节置换-Theperfectlateralradiographofthehipdemonstratesthenecktobecolinearwiththeshaftandslightlyanteriortoit.Thepiriformisfossaiseasiervisualized.髋关节置换-Thestraightawlisintroducedthroughtheincision,thengentlyplacedagainstthepiriformisfossadirectedanteriorly.髋关节置换-Theawlisintroducedintothefemoralcanal;asitentersthebone,theawlisadjustedtobeinlinewiththefemoralshaftbymovingthehandandawlanteriorly.髋关节置换-Theawlisintroducedintothefemoralcanal;asitentersthebone,theawlisadjustedtobeinlinewiththefemoralshaftbymovingthehandandawlanteriorly.髋关节置换-Oncetheawlhasbeenintroducedgently,itistappeddownpastthecalcartoallowforeasypassageoftheguidewire.髋关节置换-Oncetheawlhasbeenintroducedgently,itistappeddownpastthecalcartoallowforeasypassageoftheguidewire.髋关节置换-Theguidewireshouldhaveagentledistalbendtoalloweasypassageacrossthefracturesite.Theguidewireisintroduceddownthefemoralshaft..髋关节置换-Asofttissueprotectorcanbeusedtominimizemuscleinjuryproximally.髋关节置换-Theguidewireisadvanceddownthecanal.Notethecolinearityoftheentrypointwiththecenteroftheshaft.髋关节置换-Theguidewireisintroducedtothelevelofthefracture.髋关节置换-ThefractureisreducedandtheguidewireispassedacrossanddistallyuntilitisjustshyoftheepiphysealscarinthecenterofthefemurontheAPradiograph.Thisisparticularlyimportantfordistalfractures.髋关节置换-Oncetheguidewireisfullyintroduced,lengthmaybemeasuredinmanyways.Whilesomesystemshavejigstomeasurelength,afoolproofsystemistomeasurearesidualofaguidewireofthesamelength.髋关节置换-Theaboveimagedemonstratesasecondguidewireofthesamelengthintroducedtothelevelofthetrochanter.髋关节置换-AKocherclampisplacedontheguidewiresothattheresidualcanbedirectlymeasured.髋关节置换-Measuringtheresidualfromthisguidewirewillgiveanexactmeasurementofthelongestnailthatispossibleforthispatient.Aftermeasurementisobtained,thefemoralcanalisreamed.髋关节置换-Thereamerintroducedthroughthestabincisionandthesoft-tissueprotectorusedtoprotectthemusculature.髋关节置换-Afterreamingiscomplete,theappropriatesizenailischosen.Beforethenailisinserted,aswithanynailingprocedure,theproximaljigneedstobecheckedforappropriatealignmentofthelockingmechanism.髋关节置换-Anexchangetubeisplacedovertheball-tipguidewire,whichisthenremoved.Astraightguidewireisthenplacedthroughtheexchangetube,whichisthenremoved,allowingforplacementofthenailoverthestraightguidewire.髋关节置换-Thenailisgentlytappeddownthecanal.Anysignificantresistancewarrantsbiplanarradiographicconfirmationofappropriatepositionofboththeguidewireandthenail,aswellasareasofthefemoralneckforpossiblefracture.髋关节置换-Afterthenailisappropriatelyseated,withthejigatthelevelofthegreatertrochanter,theproximaljigisusedtolockthenail.Distallockingisgenerallyperformedusingafreehandtechniqueviaperfectcircles.髋关节置换-髋关节置换-髋关节置换-髋关节置换-TheaboveimagedemonstratestheC-arminapositiontoviewaperfectcircle.髋关节置换-Thisimageshowsthe