Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,髋部手术入路课件,1,LESSER,TUBEROSITY,AP pelvis and AP hip of an elderly patient,with a three-part intertrochanteric hip fracture.,LESSERAP pelvis and AP hip of,2,LATERAL RADIOGRAPH,The set up on the fracture table does not require the uninjured leg to be placed in hyperflexion and abduction.The legs may be scissored to allow for good lateral radiographs of the affected side without putting the opposite hip at risk.,ISCHIUM,LESSER,TROCHANTER,FEMUR,LATERAL RADIOGRAPHThe set up o,3,This image demonstrates the position of the fracture,table with the patients affected arm over the chest,and well padded.,This image demonstrates the po,4,SCDs ON,DURING,PROCEDURE,This image demonstrates the scissoring of the legs with the,affected side slightly flexed and the unaffected side slightly,extended.Notice that sequential compression devices remain,on the legs during the procedure.,SCDs ONThis image demonstrates,5,A view from below demonstrates the position of the arm.,A view from below demonstrates,6,The C-arm is brought in from an angle approximately 30 degrees,distal to the patient.The AP radiograph is taken with the C-arm,slightly over rotated to give a more perfect AP view with respect,to the anatomy of the proximal femur and the lateral view.,The C-arm is brought in from a,7,The incision should begin proximally at the trochanteric,ridge and need extend approximately 10 centimeters down the thigh.,The incision should begin prox,8,ITB,The incision brought down to the level of the,iliotibial band and fascia lata.,ITBThe incision brought down t,9,ITB,The iliotibial band is incised with a knife.A Metzenbaum,scissors is used to dissect under the band,which is divided,in line with the incision.,ITBThe iliotibial band is inci,10,The iliotibial band is incised with a knife.A Metzenbaum,scissors is used to dissect under the band,which is divided,in line with the incision.,The iliotibial band is incised,11,With retraction of the iliotibial band,the vastus,lateralis fascia is visualized.,VASTUS,LATERALIS,ITB,With retraction of the iliotib,12,A sharp rake is introduced anteriorly and is used to retract the,vastus lateralis anteriorly.An incision is then made in the,fascia just anterior to the most posterior aspect of the femur.,A sharp rake is introduced ant,13,A sharp rake is introduced anteriorly and is used to retract the,vastus lateralis anteriorly.An incision is then made in the,fascia just anterior to the most posterior aspect of the femur.,A sharp rake is introduced ant,14,A periosteal elevator can be used to elevate the lateralis,off the femur with care taken to avoid perforating branches.,A periosteal elevator can be u,15,A Bennett retractor can be placed over the anterior,surface of the femur,exposing the lateral edge of,the femur.,A Bennett retractor can be pla,16,AP x-ray demonstrating abduction of the proximal fragment,and displacement of the posteromedial fragment.,AP x-ray demonstrating abducti,17,A bone hook can be used,as can a clamp or other,technique,to reduce the abduction in the proximal,fragment.,A bone hook can be used,as ca,18,Once a reduction is obtained and confirmed on the AP and lateral radiographs,the angle guide is placed against the,lateral surface of the femur in order to place the guidewire,for the lag screw.,Once a reduction is obtained a,19,The natural anteversion of the hip requires commensurate,external rotation of the jig in order to drive the wire into the,center of the head.,The natural anteversion of the,20,X-rays demonstrating the position of the guidewire,through the jig in the AP and lateral planes.,X-rays demonstrating the posit,21,After the appropriate measurement for the lag screw is made,the femur is prepared by reaming.In this case,a long barrel,was chosen and the appropriate reamer is selected.,After the appropriate measurem,22,If the bone is of good quality,a tap may be used.,If the bone is of good quality,23,AP radiograph of the lag screw being terminally seated.,AP radiograph of the lag screw,24,When using a small incision,the side plate must be slid from proximal,to distal along the femoral shaft,then drawn back up proximally such,that it is within the wound.,When using a small incision,t,25,In order to seat the side plate,its distal end must be held,gently off bone,such that the side plate is parallel with the femur in order to engage the lag screw.,In order to seat the side plat,26,Once the plate is terminally seated and tapped in place,it is affixed to the cortex using standard screw fixation.,Once the plate is terminally s,27,AP radiograph of the lag screw and side plate in position.,AP radiograph of the lag screw,28,In this particular situation,the posteromedial fragment was,rather large,thus it was elected to fix it with a lag screw.,This must be done from a position anterior to the side plate.,In this particular situation,29,This is the case because the side pl