髂嵴骨(iliac crest bone)是最常见的供骨部位,髂嵴前部提供了一个可靠的供区(donor site),可进行单皮质(monocortical)、双皮质(bicortical)或三皮质(tricortical)血管或无血管(vascular or avascular)移植。
但是,髂嵴前方供体部位的并发症高于后方。主要并发症有髂骨环骨折和疝,较为常见的并发症包括血肿、浅表感染、美学效果差、供区慢性疼痛、股外侧皮神经损伤(LFCN)等小问题。 (Major complications include iliac ring fracture and hernias, but commoner ones consist of less severe problems such as haematoma, superficial infection, poor aesthetic result, chronic donor site pain and injury to the lateral femoral cutaneous nerve (LFCN).) 据报道,当试图识别LFCN时,其损伤高达21%。可引起感觉障碍、暂时性或永久性感觉丧失和痛觉异常(dysesthaesia, temporary or permanent sensation loss and meralgia paraesthetica.)。几项解剖学研究已解释认为这是由于神经走行的不同而导致的高并发症发生率。与髂前上棘(ASIS)相对的外侧位置增加了髂嵴取骨过程中潜在神经损伤的风险。这个位置在三皮质骨移植物获取过程中,由于其靠近髂脊,使LFCN处于危险之中。 当需要较大块髂骨移植物时,则需要更大手术入路,这将增加取髂骨的并发症。Mahato等研究认为髂嵴内皮质、外皮质和松质骨的平均厚度≥0.5cm是有效的移植物,根据这项研究,最小1厘米宽的大结构骨移植可以被认为是足够的,但是从髂嵴前获取的这种骨块的最大长度和高度仍然太小. 作者强调了进行充分和安全的髂嵴前骨获取的四个要点:
解剖研究: 解剖的骨盆内观。个体化:LFCN(1)、股神经(2)和髂动脉(3)。图中显示了用于测量的五个髂嵴骨点(绿色和蓝色别针)。注意髂嵴和LFCN在骨盆内行走线之间的距离变化(Endopelvic view of a dissection. LFCN (1), femoral nerve (2) and iliac artery (3) are individualized. Five iliac crest bone points used for measurements (green and blue pins) are shown. Notice the variation of the distance between the iliac crest and LFCN along the endopelvic route) CT重建研究: 在髂前上棘水平测量髂骨厚度(1),髂前结节最厚点(4),距髂前上棘(ASIS,anterior superior iliac spine)中心2、3 cm的3个起点(2、3),髂前结节(anterior iliac tubercle ,AIT)最厚点后方2 cm(5)。髂嵴厚度与髂嵴方向垂直测量。最小半厘米厚的峰值测量值被定义为一种有用的移植物。在解剖过程中还测量了LFCN(黄线)在骨盆内与这五个点之间的距离(a,b,c,d,e)。(The thickness of the ilium was measured at the level of the anterior superior iliac spine (1), the thickest point of the anterior iliac tubercle (4) and three starting points situated 2 and 3 cm posterior to the centre of the ASIS (2, 3) and 2 cm posterior to the thickest point of the AIT (5). The thickness of the iliac crest was measured orthogonally to the direction of the iliac crest. A minimal halfcentimetre-width crest measurement was defined as being a useful graft. Distances between the LFCN in its endopelvic portion and those five points were also measured during dissection (a, b, c, d, and e) 测量这五点与LFCN的距离:为避免LFCN损伤提供了数据,也为有效厚度[5mm]的骨移植保留了有用的骨标志物。(This provided data to avoid LFCN injury and useful bony landmarks for harvesting a bone graft of useful thickness >5 mm.) CT重建研究: 一种安全、实用的移植物的CT重建。它从位于ASIS后2厘米处开始,最后到达AIT最厚的部分。平均长度为47毫米,平均深度为35毫米。(CT scan reconstruction of a safe and useful graft. It starts from a point situated 2 cm posterior to the ASIS and ends up at the level of the thickest part of the AIT. Its mean length was 47 mm and its mean depth was 35 mm) 解剖后切除的左前侧髂嵴的CT扫面的后面观,注意髂脊的厚度薄弱区在其后部和下部,在这个例子中25mm宽处厚度<5mm.(Posterior CT scan view of a left side anterior iliac crest removed after dissection. Notice the weak thickness of the iliac crest at the posterior and inferior part of the anterior iliac crest,<5 mm for a 25-mm width in this case) 与LFCN相关的手术切口的位置:
从ASIS到移植物前缘的安全距离:
最佳的移植骨长度:
最佳移植物高度:
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