臀肌挛缩症术式改良的基础与临床研究
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摘要
目的：根据臀大肌及其周围组织的局部解剖，结合臀肌挛缩症病理改变及临床实践，探讨臀肌挛缩症术式改良及其注意事项。方法：①．局部解剖6例12侧尸体臀部标本，观察臀大肌的起始点、滋养血管出入肌点、支配神经分布以及臀大肌与坐骨神经之相互位置关系。②．术中观测67例臀肌挛缩症患者病变侵犯肌肉情况，测量病变范围。③．根据以上观测结果设计大粗隆后上方前上后下方向斜S形切口(以下简称改良S形切口)治疗56例臀肌挛缩症，与42例选用其它切口者在术中出血、手术用时、切口裂开、窦道形成及预后等方面进行比较。结果：①．臀大肌肌起广泛，止点范围大，而臀肌挛缩症病例的局部可见臀部筋膜挛缩，臀大肌以中部肌纤维硬化为主，病变范围局限于臀筋膜以及臀大肌纤维，其走行方向与臀大肌纤维走行一致，挛缩带宽度1.50-8.30cm、厚度0.51-2.56cm不等；②．臀大肌的血供主要来自臀上、下动脉的浅支，臀大肌的神经支配来自臀下神经，与臀下血管伴行，两者的入肌点多在该肌的3/4-4/4部之间和1/4-2/4部之间；③．坐骨神经位于股骨大粗隆与坐骨结节之间且贴附于坐骨背面的骨纤维通道内，与臀大肌之间有蜂窝组织间隔。④．改良S形切口治疗的病例在手术用时、术中出血、切口裂开、窦道形成及预后等方面较前显著减少。结论：①．改良S形切口具有手术用时少、不需输血、无切口裂开、切口感染及窦道形成等诸多优点，不失为臀肌挛缩症手术的一个良好选择。②．手术松解挛缩组织时应在臀大肌中下部偏外沿肌纤维方向进行以尽量避免血管神经的不必要损伤。③。手术时宜靠近股骨大粗隆同时注意臀大肌下蜂窝组织间隔可避免坐骨神经损伤。
Objective: According to the local dissection of gluteus maximus and the pathological dissection of gluteal muscle contracture to discuss the modified operational mode and attention" s proceeding of the operation. Methods: ㏕o anatomize 6 cases 12 sides buttocks specimen and to observe the original spot, nourishing vessel, innervation of gluteus maximus and relations with sciatic nerve; ㏕o observe the local pathological changes of 67 cases gluteal muscle contracture. 〢ccording to the above results, to design syncline S-shaped incision on the posterior and upper part of the big tuberosity of femur to treat 56 cases gluteal muscle contracture which compared with those selected other incisions. Results: ㏕he start point and the stop point of gluteus maximus are far-ranging while the cases" pathological changes only restrained in gluteus fascia and gluteus maximus fibre. (2)The enter points of the nourishing vessels and nerves of gluteus maximus are between the upper and the below quarter. (3)There is clearance between gluteus maximus and deep muscles which full of fat. connective tissue, blood vessels and nerves, the sciatic nerve is situated the groove which between thighbone's big tuberosity and ischial tuberosity and has honeycomb tissue with gluteus maximus. ㏕he operational time, bleeding, the fissions of incision and sinuses formation which used modified S-shaped incision are reduced than before remarkably. Conclusion: (D.The modified S-shaped incision will be a better choice in the operation of gluteal muscle contracture. (D.In order to avoid the injury of blood vessels and nerves, the incision should be located to the middle muscle and along with the fiber's way. (3).If close with thighbone's big tuberosity and attended it's groove at the same time could avoid the injury of sciatic nerve.
Objective: According to the local dissection of gluteus maximus and the pathological dissection of gluteal muscle contracture to discuss the modified operational mode and attention" s proceeding of the operation. Methods: ㏕o anatomize 6 cases 12 sides buttocks specimen and to observe the original spot, nourishing vessel, innervation of gluteus maximus and relations with sciatic nerve; ㏕o observe the local pathological changes of 67 cases gluteal muscle contracture. 〢ccording to the above results, to design syncline S-shaped incision on the posterior and upper part of the big tuberosity of femur to treat 56 cases gluteal muscle contracture which compared with those selected other incisions. Results: ㏕he start point and the stop point of gluteus maximus are far-ranging while the cases" pathological changes only restrained in gluteus fascia and gluteus maximus fibre. (2)The enter points of the nourishing vessels and nerves of gluteus maximus are between the upper and the below quarter. (3)There is clearance between gluteus maximus and deep muscles which full of fat. connective tissue, blood vessels and nerves, the sciatic nerve is situated the groove which between thighbone's big tuberosity and ischial tuberosity and has honeycomb tissue with gluteus maximus. ㏕he operational time, bleeding, the fissions of incision and sinuses formation which used modified S-shaped incision are reduced than before remarkably. Conclusion: (D.The modified S-shaped incision will be a better choice in the operation of gluteal muscle contracture. (D.In order to avoid the injury of blood vessels and nerves, the incision should be located to the middle muscle and along with the fiber's way. (3).If close with thighbone's big tuberosity and attended it's groove at the same time could avoid the injury of sciatic nerve.
引文
1. Wolbrink AJ, Hsu Z, Bianco AJ. abduction contracture of the shoulders and hip secondary to fibrous band. J Bone Joint Surg(Am),1973,55:844.
2．马承宣，房伦光，刘贵林，等．注射性臀大肌挛缩症．中华小儿外科杂志，1978，16：345．
3．彭明惺，周素华，周裼华，等．四川地区儿童臀肌挛缩症调查报告．中华小儿外科杂志，1989，10：356-358．
4．周素华，彭明惺，刘利君，等．儿童注射性臀肌挛缩症与易感因素的探讨．中华小儿外科杂志，1992，13：30-31．
5．顾洁夫，陈振光，余荣国，等．儿童臀肌挛缩症的诊治及病因学研究，中华小儿外科杂志，1989，10：353-355。
6．吉士俊，潘少川，王继孟．主编．小儿骨科学．济南．山东科学技术出版社．1999：377．
7．郭世绂著．临床骨科解剖学．天津：天津科学技术出版社，1988．696-700
8．王启华，孙博主编．临床解剖丛书(四肢分册)．北京：人民卫生出版社，1991．238-242
9．王龙胜，张红亮．臀肌挛缩症的CT诊断．中国临床医学影象杂志，2000，3：218．
10．刘国辉，宋九宏，杜靖远，等．臀肌挛缩症治疗的回顾性分析兼论相关问题．中国矫形外科杂志，2001，4：317-318．
11．史占军，夏霆，杨玲利，等．臀肌挛缩对小儿身体发育的影响．中华小儿外科杂志，1996，4：235-236．
12．马承宣，许瑞江，房论光，等，注射性臀大肌挛缩症的临床病理变化．中华小儿外科杂志，1990，1：39
13. Shen YS. Gluteus maximus contracture. Clin Orthop 1982, 162: 185.
14．张光铂，任玉珠．臀大肌挛缩症的诊断与治疗．中华骨科杂志，1988，8：423．
15．杨忠汉，黄承达，徐锦森，等，臀肌筋膜挛缩症．中华骨科杂志．1993．3：187-188
16．韩镜明，代品华，李达泉，等．儿童臀肌挛缩症的骨关节X线变化．中华小儿外科杂志．1997，18：111-112．
17．冯宗权，曾湘穗，林庆光，等．臀肌挛缩症并骨盆倾斜的病因分析及疗效观察．中华骨科杂志，2000，20：649-651．
18．徐新六．小儿注射性臀肌挛缩症的手术治疗．中华小儿外科杂志，1989，4：213．
19．王维才，王以进，陈枫文，等．臀肌筋膜挛缩症的生物力学机制及其临床意义．中国矫形外科杂志，1999，10：755．
20．肖进，冯宗权，原林，等．挛缩臀肌的生物力学变化．中国临床解剖学杂志，2001，2：182-184．
21. Peiro A. Fernandez CI, Gomar F. Gluteal fibrosis. J Bone Joint Surg Am, 1975: 57(7): 987-990.
22．陈辉，乔新生，立永刚，等．双“Z”形切断并延长挛缩束带治疗臀肌挛缩症．中国矫形外科杂志，2002，9：146-148．
23. Hang YS. Contracture of the hip secondary tO fibrosis of the gluteus maximus muscle. J Bone Joint Surg(Am). 1979, 61: 52.
24．马承宣，房伦关，刘贵林，等．注射性臀大肌挛缩症112例回顾性分析．中华小儿外科杂志，1988，9：169．
25．余希临，桂彤，刘海峰，等．影响儿童臀肌挛缩症手术效果的原因分析．中华小儿外科杂志，2001，6：372．
26．肖进，徐力鹏，原林，等．臀肌挛缩伴骨盆倾斜的发病机制及治疗．中国矫形外科杂志，2001，4：319-321．
27．黄耀添，李建文，雷伟，等．臀肌挛缩症的病因、类型及治疗．中华骨科杂志，1999，2：106-108．
2．马承宣，房伦光，刘贵林，等．注射性臀大肌挛缩症．中华小儿外科杂志，1978，16：345．
3．彭明惺，周素华，周裼华，等．四川地区儿童臀肌挛缩症调查报告．中华小儿外科杂志，1989，10：356-358．
4．周素华，彭明惺，刘利君，等．儿童注射性臀肌挛缩症与易感因素的探讨．中华小儿外科杂志，1992，13：30-31．
5．顾洁夫，陈振光，余荣国，等．儿童臀肌挛缩症的诊治及病因学研究，中华小儿外科杂志，1989，10：353-355。
6．吉士俊，潘少川，王继孟．主编．小儿骨科学．济南．山东科学技术出版社．1999：377．
7．郭世绂著．临床骨科解剖学．天津：天津科学技术出版社，1988．696-700
8．王启华，孙博主编．临床解剖丛书(四肢分册)．北京：人民卫生出版社，1991．238-242
9．王龙胜，张红亮．臀肌挛缩症的CT诊断．中国临床医学影象杂志，2000，3：218．
10．刘国辉，宋九宏，杜靖远，等．臀肌挛缩症治疗的回顾性分析兼论相关问题．中国矫形外科杂志，2001，4：317-318．
11．史占军，夏霆，杨玲利，等．臀肌挛缩对小儿身体发育的影响．中华小儿外科杂志，1996，4：235-236．
12．马承宣，许瑞江，房论光，等，注射性臀大肌挛缩症的临床病理变化．中华小儿外科杂志，1990，1：39
13. Shen YS. Gluteus maximus contracture. Clin Orthop 1982, 162: 185.
14．张光铂，任玉珠．臀大肌挛缩症的诊断与治疗．中华骨科杂志，1988，8：423．
15．杨忠汉，黄承达，徐锦森，等，臀肌筋膜挛缩症．中华骨科杂志．1993．3：187-188
16．韩镜明，代品华，李达泉，等．儿童臀肌挛缩症的骨关节X线变化．中华小儿外科杂志．1997，18：111-112．
17．冯宗权，曾湘穗，林庆光，等．臀肌挛缩症并骨盆倾斜的病因分析及疗效观察．中华骨科杂志，2000，20：649-651．
18．徐新六．小儿注射性臀肌挛缩症的手术治疗．中华小儿外科杂志，1989，4：213．
19．王维才，王以进，陈枫文，等．臀肌筋膜挛缩症的生物力学机制及其临床意义．中国矫形外科杂志，1999，10：755．
20．肖进，冯宗权，原林，等．挛缩臀肌的生物力学变化．中国临床解剖学杂志，2001，2：182-184．
21. Peiro A. Fernandez CI, Gomar F. Gluteal fibrosis. J Bone Joint Surg Am, 1975: 57(7): 987-990.
22．陈辉，乔新生，立永刚，等．双“Z”形切断并延长挛缩束带治疗臀肌挛缩症．中国矫形外科杂志，2002，9：146-148．
23. Hang YS. Contracture of the hip secondary tO fibrosis of the gluteus maximus muscle. J Bone Joint Surg(Am). 1979, 61: 52.
24．马承宣，房伦关，刘贵林，等．注射性臀大肌挛缩症112例回顾性分析．中华小儿外科杂志，1988，9：169．
25．余希临，桂彤，刘海峰，等．影响儿童臀肌挛缩症手术效果的原因分析．中华小儿外科杂志，2001，6：372．
26．肖进，徐力鹏，原林，等．臀肌挛缩伴骨盆倾斜的发病机制及治疗．中国矫形外科杂志，2001，4：319-321．
27．黄耀添，李建文，雷伟，等．臀肌挛缩症的病因、类型及治疗．中华骨科杂志，1999，2：106-108．