原创马明医生  2019-07-29

来自专辑

下肢解剖

The anterolateral approach to the lateral tibial plateau offers safe access to the lateral tibial plateau for:

1. Open reduction and internal fixation of fractures of the lateral tibial plateau

2. Bone grafting for delayed union and nonunion of fractures

3. Treatment of osteomyelitis

4. Excision and biopsy of tumors

5. Harvesting of bone graft

外侧胫骨平台前外侧入路可以安全地显露外侧胫骨平台，主要用于:

1. 胫骨外侧平台骨折切开复位内固定

2. 植骨治疗骨折延迟愈合和不愈合

3. 治疗骨髓炎

4. 肿瘤的切除和活检

5. 骨移植的取骨

The soft tissue covering of the proximal tibia is thin and delicate consisting of skin and underlying fascia only. Soft tissue problems are common in this area and massive swelling or blistering can occur, particularly following high-velocity trauma. Careful assessment of the soft tissues is critical before surgery, and definitive treatment of fractures in this area is frequently delayed to allow swelling to subside and the soft tissues to recover. The anterolateral approach is preferred to a direct anterior approach to the tibia because the skin incised in the anterolateral approach does not directly overlay the bone and because less skin retraction is necessary to access the middle third of the lateral aspect of the lateral tibial plateau.

胫骨近端软组织覆盖薄而纤细，仅由皮肤和下筋膜组成。软组织问题在这一区域很常见，肿胀或起泡时有发生，尤其是在高速创伤后。手术前对软组织的仔细评估是至关重要的，该区域骨折的治疗常常被推迟，以使肿胀消退，软组织恢复。前外侧入路优于胫骨前入路，因为前外侧入路皮肤不是直接覆盖在骨面上，而且进入胫骨外侧平台外侧三分之一处不需要牵拉太多的皮肤。

Position of the Patient  患者体位

Place the patient supine on a radiolucent table. Place a firm wedge beneath the knee to flex the joint to approximately 60 degrees (Fig. 11-2). Place a small bag underneath the buttock to correct the normal external rotation of the lower limb. This will ensure that the patella is facing directly anteriorly. Exsanguinate the limb either by elevating it for 3 to 5 minutes or by applying a soft rubber bandage. Then inflate a tourniquet.

将患者仰卧在射线可透过的桌子上。在膝盖下方放置一个坚固的楔形物，使关节弯曲约60度。在臀部下方垫一个小袋子，以纠正下肢的正常外旋。这将确保髌骨直接面向前方。通过将肢体抬高3至5分钟或使用软橡皮绷带将肢体驱血。然后给止血带充气。

Landmarks and Incision  体表标志和切口

Landmarks 体表标志

Palpate the shaft of the proximal tibia along its anterior border. Identify the position of the lateral joint line of the knee by flexing and extending the joint. Palpate Gerdy tubercle just lateral to the patella tendon. All these landmarks are easily palpable, even in an obese patient.

沿胫骨前缘触诊胫骨近端。通过弯曲和伸展膝关节来确定膝关节外侧关节线的位置。触诊髌腱外侧的Gerdy结节。所有这些标志都很明显，即使是肥胖患者。

Incision 切口

Make an inverted L-shaped incision. Start approximately 1 to 3 cm distal

to the joint line, staying just lateral to the border of the patella tendon. Curve the incision anteriorly over Gerdy tubercle and then extend it distally, staying about 1 cm lateral to the anterior border of the tibia (Fig. 11-3). The exact length of the incision depends on the pathology to be treated and the implant to be used.

做一个倒L形切口。从关节线远端约1 - 3cm开始，沿髌腱的外侧，将切口向前弯曲越过Gerdy结节，然后向远处延伸，在胫骨前缘外侧约1厘米处。切口的确切长度取决于要治疗的病理和要使用的植入物。

Internervous Plane 神经界面

There is no internervous plane in this approach. The dissection is essentially epiperiosteal and does not disturb the nerve supply to the extensor compartment.

此入路没有神经界面。解剖分离实际上是沿骨膜进行，不会影响伸肌群的神经支配。

Superficial Surgical Dissection 浅层手术分离

Deepen the incision proximally through subcutaneous tissue to expose the lateral aspect of the knee joint capsule. Incise the knee joint capsule transversely just below the lateral meniscus. Take care not to divide the lateral meniscus inadvertently. Below the joint line, deepen the incision through subcutaneous tissue and incise the fascia overlying the tibialis anterior muscle .

近端切开皮下组织，显露膝关节囊外侧。在外侧半月板下方横形切开膝关节囊。注意不要切开外侧半月板。在关节线以下，向深部切开皮下组织，切开覆盖胫骨前肌的筋膜。

Deep Surgical Dissection 深层手术分离

Proximally enter the knee joint by dividing the synovium. Carefully detach the lateral meniscus from its soft tissue attachments inferiorly and develop a plane between the undersurface of the lateral meniscus and the underlying tibial plateau. Insert stay sutures to the periphery of the meniscus to facilitate reattachment during closure. Ensure that the anterior attachment of the meniscus remains intact. Detach a sufficient amount of the meniscus to allow adequate visualization of the superior surface of the lateral tibial plateau. Using an elevator inferiorly detach some of the origin of tibialis anterior from the proximal tibia. Try to work in a plane between the periosteum and the muscle.

近端切开关节滑膜进入膝关节。小心地将外侧半月板从其下方的软组织附着中分离出来，显露位于外侧半月板下表面和胫骨平台之间的平面。在半月板边缘置定位线以便在关口合时重新缝合，确保半月板前附着软组织保持完整。充分剥离半月板，显露胫骨外侧平台上表面。用撑开器从胫骨近端向下分离胫骨前肌的部分起点。试着在骨膜和肌肉之间的平面进行操作。

Dang 风险

Nerves 神经

The deep branch of the peroneal nerve has a variable course. Normally, it lies well posterior to the area of dissection and it should not be injured.

The lateral meniscus has to be detached from some of its soft tissue attachments inferiorly to allow adequate visualization of the articular surface of the tibia. Take care not to completely detach it, preserving anterior and posterior attachments, however. It is at most risk during the incision of the knee joint synovium.

腓神经的深支走行多变异。正常情况下，它位于解剖区后方，不应损伤。

外侧半月板必须从下方的一些软组织中分离出来，以便充分显露胫骨关节面。但注意不要完全分离，要保留其前方和后方附着。在膝关节滑膜切开时，其危险性最大（易伤了半月板）。

How to Enlarge the Approach 如何扩大入路

Local Measures 局部措施

Application of a distractor or external fixator to the lateral aspect of the knee between the femur and the tibia allows a varus distraction force to be applied to the knee joint, thereby opening up the lateral compartment.

在股骨和胫骨之间的膝关节外侧应用牵张器或外固定器，可使膝关节内翻，从而打开外侧关节腔。

Extensile Measures 延伸措施

Proximal Extension. To extend the approach proximally, continue the skin incision along the lateral aspect of the patella, then curve posteriorly over the lateral aspect of the distal femur. Deepen the incision through the lateral joint capsule to gain access to the knee joint and the distal femur proximally.

近端延长：近端延长入路，沿髌骨外侧延长皮肤切口，然后在股骨远端外侧向后弯曲。通过外侧关节囊加深切口，显露膝关节和股骨远端。

Distal Extension. To extend the approach distally, continue the incision in a longitudinal fashion, remaining 1 cm lateral to the anterior border of the tibia. Extend it all the way down to the ankle proximally. Deep dissection, either by splitting the tibialis anterior muscle or by detaching it from the lateral aspect of the tibia, allows access to the tibial shaft down to its distal quarter.

远端扩长：沿胫骨前缘外侧1厘米处继续向远端纵向延长切口，一直延伸到踝关节近端。深层解剖，无论是通过劈开胫骨前肌，还是通过将其从胫骨外侧面剥离，都能显露胫骨干近端1/4。