直接前路髋关节入路中Heuter间隙术中识别的解剖学标志

IF 0.2 Q4 ORTHOPEDICS Techniques in Orthopaedics Pub Date : 2023-10-02 DOI:10.1097/bto.0000000000000648
Ross Condell, Martin Kelly, Paul Mckenna
{"title":"直接前路髋关节入路中Heuter间隙术中识别的解剖学标志","authors":"Ross Condell, Martin Kelly, Paul Mckenna","doi":"10.1097/bto.0000000000000648","DOIUrl":null,"url":null,"abstract":"Direct anterior approach (DAA) has been shown to have many benefits for patients undergoing total hip replacement. These include less soft tissue damage, a low dislocation rate, and earlier postoperative recovery compared with other approaches.1,2 The accurate identification of the Smith-Peterson interval is vital to minimize unnecessary soft tissue dissection, as well as to avoid injury to nearby structures. It also allows for an internervous approach, between the sartorius muscle (femoral nerve) and the tensor fascia latae muscle (superior gluteal nerve). This has been shown to lead to improved postoperative pain control and decreased length of hospital stay.3 The interval is accessed by incising the fascia over the tensor fascia lata muscle. It is the identification of this muscle that is the key element in ensuring safe exposure of the hip. A comprehensive understanding of the anterior hip anatomy is essential when acquiring exposure to the joint. Anterior mobilization of the femur is necessary for exposure for reaming, broaching, and femoral implant positioning. Specific releases are described in detail by Rodriguez et al,4 which allow the proximal part of the femur and the greater trochanter to be elevated anteriorly in front of the acetabulum with minimal force applied to the femur. The senior author has used the DAA in over 2500 cases to date and has identified 4 constant markers that aid in identifying the Smith-Peterson interval. TECHNIQUE After incision through the skin and subcutaneous fat, the tensor fascia muscle can be identified using the following markers (Figs. 1–3): Lateral to a line drawn from the anterior superior iliac spine to the head of the fibula. Oblique orientation of the muscle fibers running from the anterior superior iliac spine proximally in an inferolateral direction distally. Presence of perforating vessels in the fascia of the tensor fascia lata. Fat streak between tensor and sartorius medially. FIGURE 1: Right hip direct anterior approach. Anatomic landmarks for identifying the Heuter interval. ASIS indictes anterior superior iliac spine; TFL, Tensor fascia lata.FIGURE 2: Once the plane is identified, the fascia overlying the bulk of the tensor fascia muscle is incised and retracted to allow for access to the Heuter Interval.FIGURE 3: Anatomical landmarks for identifying the Heuter interval. The patient consented to clinical photography, available on request. ASIS indictes anterior superior iliac spine; TFL, Tensor fascia lata.Expected Outcomes The Heuter interval can be difficult to identify. However, using these 4 markers can allow surgeons to be confident with their approach. Once identified, the fascia overlying the bulk of the tensor fascia muscle is incised and retracted to allow for access to the Heuter interval and the hip capsule with minimal soft tissue disruption. The steep learning curve to the DAA can be aided by the identification of these markers. COMPLICATIONS The lateral femoral cutaneous nerve (LFCN) is at risk during a DAA. It is a purely sensory nerve. Careful dissection and identification are important to reduce the risk of damage. Incision of the fascia overlying the tensor fascia muscle limits the risk to the LFCN. The incidence of LFCN lesions varies in the literature.5 Despite the risk, the long-term effects of LFCN damage do not limit function.6 The presence and number of the tensor fascia lata perforators can vary. Cadaveric studies show that it may be absent in 5% of cases, and the number of perforators can range from 0 to 5.7,8","PeriodicalId":45336,"journal":{"name":"Techniques in Orthopaedics","volume":null,"pages":null},"PeriodicalIF":0.2000,"publicationDate":"2023-10-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Anatomic Markers for Intraoperative Identification of the Heuter Interval in the Direct Anterior Approach to the Hip\",\"authors\":\"Ross Condell, Martin Kelly, Paul Mckenna\",\"doi\":\"10.1097/bto.0000000000000648\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"Direct anterior approach (DAA) has been shown to have many benefits for patients undergoing total hip replacement. These include less soft tissue damage, a low dislocation rate, and earlier postoperative recovery compared with other approaches.1,2 The accurate identification of the Smith-Peterson interval is vital to minimize unnecessary soft tissue dissection, as well as to avoid injury to nearby structures. It also allows for an internervous approach, between the sartorius muscle (femoral nerve) and the tensor fascia latae muscle (superior gluteal nerve). This has been shown to lead to improved postoperative pain control and decreased length of hospital stay.3 The interval is accessed by incising the fascia over the tensor fascia lata muscle. It is the identification of this muscle that is the key element in ensuring safe exposure of the hip. A comprehensive understanding of the anterior hip anatomy is essential when acquiring exposure to the joint. Anterior mobilization of the femur is necessary for exposure for reaming, broaching, and femoral implant positioning. Specific releases are described in detail by Rodriguez et al,4 which allow the proximal part of the femur and the greater trochanter to be elevated anteriorly in front of the acetabulum with minimal force applied to the femur. The senior author has used the DAA in over 2500 cases to date and has identified 4 constant markers that aid in identifying the Smith-Peterson interval. TECHNIQUE After incision through the skin and subcutaneous fat, the tensor fascia muscle can be identified using the following markers (Figs. 1–3): Lateral to a line drawn from the anterior superior iliac spine to the head of the fibula. Oblique orientation of the muscle fibers running from the anterior superior iliac spine proximally in an inferolateral direction distally. Presence of perforating vessels in the fascia of the tensor fascia lata. Fat streak between tensor and sartorius medially. FIGURE 1: Right hip direct anterior approach. Anatomic landmarks for identifying the Heuter interval. ASIS indictes anterior superior iliac spine; TFL, Tensor fascia lata.FIGURE 2: Once the plane is identified, the fascia overlying the bulk of the tensor fascia muscle is incised and retracted to allow for access to the Heuter Interval.FIGURE 3: Anatomical landmarks for identifying the Heuter interval. The patient consented to clinical photography, available on request. ASIS indictes anterior superior iliac spine; TFL, Tensor fascia lata.Expected Outcomes The Heuter interval can be difficult to identify. However, using these 4 markers can allow surgeons to be confident with their approach. Once identified, the fascia overlying the bulk of the tensor fascia muscle is incised and retracted to allow for access to the Heuter interval and the hip capsule with minimal soft tissue disruption. The steep learning curve to the DAA can be aided by the identification of these markers. COMPLICATIONS The lateral femoral cutaneous nerve (LFCN) is at risk during a DAA. It is a purely sensory nerve. Careful dissection and identification are important to reduce the risk of damage. Incision of the fascia overlying the tensor fascia muscle limits the risk to the LFCN. The incidence of LFCN lesions varies in the literature.5 Despite the risk, the long-term effects of LFCN damage do not limit function.6 The presence and number of the tensor fascia lata perforators can vary. Cadaveric studies show that it may be absent in 5% of cases, and the number of perforators can range from 0 to 5.7,8\",\"PeriodicalId\":45336,\"journal\":{\"name\":\"Techniques in Orthopaedics\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":0.2000,\"publicationDate\":\"2023-10-02\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Techniques in Orthopaedics\",\"FirstCategoryId\":\"1085\",\"ListUrlMain\":\"https://doi.org/10.1097/bto.0000000000000648\",\"RegionNum\":0,\"RegionCategory\":null,\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q4\",\"JCRName\":\"ORTHOPEDICS\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Techniques in Orthopaedics","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1097/bto.0000000000000648","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q4","JCRName":"ORTHOPEDICS","Score":null,"Total":0}
引用次数: 0

摘要

直接前路(DAA)已被证明对全髋关节置换术患者有许多好处。这些优点包括软组织损伤少,脱位率低,与其他入路相比,术后恢复早。1,2准确识别Smith-Peterson间隙对于减少不必要的软组织剥离以及避免损伤附近结构至关重要。它也允许神经间入路,在缝匠肌(股神经)和阔筋膜张肌(臀上神经)之间。这已被证明可改善术后疼痛控制并缩短住院时间这个间隙是通过切开阔筋膜张肌上的筋膜进入的。识别这块肌肉是确保安全暴露臀部的关键因素。在获得关节暴露时,对髋关节前解剖结构的全面了解是必不可少的。股骨前移位对于扩孔、拉削和股骨植入物定位是必要的。Rodriguez等人对具体的松解术进行了详细的描述4,它允许股骨近端和大转子在髋臼前方向前提升,对股骨施加的力最小。迄今为止,该资深作者已在2500多例病例中使用DAA,并确定了4个有助于识别Smith-Peterson间期的恒定标记。切开皮肤和皮下脂肪后,可以通过以下标记来识别筋膜张肌(图1-3):从髂前上棘到腓骨头的一条线的外侧。从髂前上棘近端沿外侧方向远端延伸的肌纤维斜向。阔筋膜张肌筋膜上存在穿孔血管。张肌和缝匠肌中间的脂肪条纹。图1:右髋关节直接前路入路。鉴别休伊特间隙的解剖标志。ASIS指髂前上棘;阔筋膜张肌。图2:一旦确定了平面,就切开并收缩覆盖在大部分筋膜张肌上的筋膜,以便进入Heuter间隙。图3:用于识别Heuter间期的解剖学标志。患者同意临床摄影,可根据要求提供。ASIS指髂前上棘;阔筋膜张肌。预期结果Heuter区间可能难以确定。然而,使用这4种标记可以让外科医生对他们的方法充满信心。一旦确定,就切开并收缩覆盖在大部分筋膜张肌上的筋膜,以便在最小程度破坏软组织的情况下进入Heuter间隙和髋关节囊。通过识别这些标记,可以帮助了解DAA的陡峭学习曲线。在DAA中,股外侧皮神经(LFCN)处于危险之中。这是一种纯粹的感觉神经。仔细的解剖和鉴定对于减少损伤的风险是很重要的。切开筋膜张肌上的筋膜限制了LFCN的风险。LFCN病变的发生率在文献中有所不同尽管存在风险,但LFCN损伤的长期影响并不会限制功能阔筋膜张肌穿支的存在和数量可以变化。尸体研究表明,5%的病例可能没有穿孔,穿孔的数量可以从0到5.7,8不等
本文章由计算机程序翻译,如有差异,请以英文原文为准。
查看原文
分享 分享
微信好友 朋友圈 QQ好友 复制链接
本刊更多论文
Anatomic Markers for Intraoperative Identification of the Heuter Interval in the Direct Anterior Approach to the Hip
Direct anterior approach (DAA) has been shown to have many benefits for patients undergoing total hip replacement. These include less soft tissue damage, a low dislocation rate, and earlier postoperative recovery compared with other approaches.1,2 The accurate identification of the Smith-Peterson interval is vital to minimize unnecessary soft tissue dissection, as well as to avoid injury to nearby structures. It also allows for an internervous approach, between the sartorius muscle (femoral nerve) and the tensor fascia latae muscle (superior gluteal nerve). This has been shown to lead to improved postoperative pain control and decreased length of hospital stay.3 The interval is accessed by incising the fascia over the tensor fascia lata muscle. It is the identification of this muscle that is the key element in ensuring safe exposure of the hip. A comprehensive understanding of the anterior hip anatomy is essential when acquiring exposure to the joint. Anterior mobilization of the femur is necessary for exposure for reaming, broaching, and femoral implant positioning. Specific releases are described in detail by Rodriguez et al,4 which allow the proximal part of the femur and the greater trochanter to be elevated anteriorly in front of the acetabulum with minimal force applied to the femur. The senior author has used the DAA in over 2500 cases to date and has identified 4 constant markers that aid in identifying the Smith-Peterson interval. TECHNIQUE After incision through the skin and subcutaneous fat, the tensor fascia muscle can be identified using the following markers (Figs. 1–3): Lateral to a line drawn from the anterior superior iliac spine to the head of the fibula. Oblique orientation of the muscle fibers running from the anterior superior iliac spine proximally in an inferolateral direction distally. Presence of perforating vessels in the fascia of the tensor fascia lata. Fat streak between tensor and sartorius medially. FIGURE 1: Right hip direct anterior approach. Anatomic landmarks for identifying the Heuter interval. ASIS indictes anterior superior iliac spine; TFL, Tensor fascia lata.FIGURE 2: Once the plane is identified, the fascia overlying the bulk of the tensor fascia muscle is incised and retracted to allow for access to the Heuter Interval.FIGURE 3: Anatomical landmarks for identifying the Heuter interval. The patient consented to clinical photography, available on request. ASIS indictes anterior superior iliac spine; TFL, Tensor fascia lata.Expected Outcomes The Heuter interval can be difficult to identify. However, using these 4 markers can allow surgeons to be confident with their approach. Once identified, the fascia overlying the bulk of the tensor fascia muscle is incised and retracted to allow for access to the Heuter interval and the hip capsule with minimal soft tissue disruption. The steep learning curve to the DAA can be aided by the identification of these markers. COMPLICATIONS The lateral femoral cutaneous nerve (LFCN) is at risk during a DAA. It is a purely sensory nerve. Careful dissection and identification are important to reduce the risk of damage. Incision of the fascia overlying the tensor fascia muscle limits the risk to the LFCN. The incidence of LFCN lesions varies in the literature.5 Despite the risk, the long-term effects of LFCN damage do not limit function.6 The presence and number of the tensor fascia lata perforators can vary. Cadaveric studies show that it may be absent in 5% of cases, and the number of perforators can range from 0 to 5.7,8
求助全文
通过发布文献求助,成功后即可免费获取论文全文。 去求助
来源期刊
CiteScore
0.60
自引率
0.00%
发文量
31
期刊介绍: The purpose of Techniques in Orthopaedics is to provide information on the latest orthopaedic procedure as they are devised and used by top orthopaedic surgeons. The approach is technique-oriented, covering operations, manipulations, and instruments being developed and applied in such as arthroscopy, arthroplasty, and trauma. Each issue is guest-edited by an expert in the field and devoted to a single topic.
期刊最新文献
A Derotational Corrective Osteotomy in a Torsional Malaligned Femoral Shaft Fracture Around a Prior Stuck Intramedullary Nail Optimizing Femoral Tunnel Placement in ACL Reconstruction: Effect of a 70-degree Arthroscope and Portal Position Intraoperative O-arm Use for Physeal Bar Excision Rambam Hospital Protocol for Treatment of Early Stages of Legg-Calve-Perthes Disease Cup and Cage Reconstruction for Metastatic Acetabular Lesions Provides Functional Improvement and Cost-efficiency
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
现在去查看 取消
×
提示
确定
0
微信
客服QQ
Book学术公众号 扫码关注我们
反馈
×
意见反馈
请填写您的意见或建议
请填写您的手机或邮箱
已复制链接
已复制链接
快去分享给好友吧!
我知道了
×
扫码分享
扫码分享
Book学术官方微信
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术
文献互助 智能选刊 最新文献 互助须知 联系我们:info@booksci.cn
Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。
Copyright © 2023 Book学术 All rights reserved.
ghs 京公网安备 11010802042870号 京ICP备2023020795号-1