Establishment of hip arthroscopic portals: Application of acetabular sourcil midpoint calibration
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摘要:
背景 目前髋关节镜手术在建立入路时缺乏准确定位穿刺方向的方法。 目的 提出一种在建立髋关节镜手术入路时辅助定位穿刺方向的方法，验证其在建立前外侧(anterolateral，AL)入路、改良前方(modified anterior，MA)入路时定位穿刺方向的可行性和准确性。 方法 前瞻性招募2021年1月 - 2022年6月于我科接受髋关节镜手术的患者。术中在透视下采用实心钢珠定位髋臼眉弓中点体表标志点，以其尾侧5 mm处作为建立入路的穿刺定位点。建立AL、MA入路时按穿刺定位点方向穿刺，该方法称为髋臼眉弓中点标定法。计算此方法穿刺进入关节间隙的准确率。术中测量眉弓中点体表标志点与同侧髂前上棘最下缘之间的水平距离(X)和垂直距离(Y)，分析X和Y的离散程度。用多元线性回归方法分析X、Y与患者一般资料、骨盆正位X线片影像学参数的相关性。 结果 共招募53例髋关节镜手术病例，其中男34例，女19例；年龄(34.91 ± 12.26)岁；手术侧别左侧25例，右侧28例。髋臼眉弓中点标定法建立AL入路的穿刺准确率为94.3%；建立MA入路的穿刺准确率为90.6%。水平距离(X)为(2.94 ± 1.07) cm (95% CI：0.80 ~ 4.79 cm)，服从正态分布；垂直距离(Y)为(1.64 ± 1.02) cm (95% CI：0 ~ 3.76 cm)，服从正态分布。距离X和Y与患者一般资料、骨盆正位X线片影像学参数均不存在显著相关性(P＞0.05)。 结论 建立AL、MA入路时，髋臼眉弓中点标定法可准确定位穿刺方向。建立入路前可通过水平距离(X)、垂直距离(Y)的均值和95% CI初步确定眉弓中点体表标定点的位置，有助于快速定位标定点。 Abstract:Background Currently, there is a lack of methods to accurately determine the direction of puncture when establishing the hip arthroscopy portals. Objective To propose a method for assisting in determination of the direction of puncture for anterolateral (AL) and modified anterior (MA) portals for hip arthroscopy, and verify its feasibility and accuracy. Methods Patients who were proposed to undergo hip arthroscopy in our department from January 2021 to June 2022 were recruited prospectively. Intraoperatively, a solid steel ball was used under fluoroscopy to locate the acetabular sourcil midpoint body marker (SMBM), and a point 5 mm caudal to the SMBM was used as the puncture location point for establishing portals. When establishing the AL and MA portals, the puncture was performed in the direction of the puncture location point, and this method was called the acetabular sourcil midpoint calibration. The accuracy of the puncture into the joint space was calculated. The horizontal distance (X) and vertical distance (Y) between the SMBM and the inferior edge of the anterior superior iliac spine (ASIS) were measured intraoperatively, and the dispersion of these distances was analyzed. Multiple linear regression was used to analyze the correlation of the horizontal (X) and vertical (Y) distances in relation to the patient's general information and the imaging parameters of anteroposterior pelvis radiograph. Results A total of 53 hip arthroscopy cases were recruited, including 34 males and 19 females, with average age of 34.91 ± 12.26 years. Twenty-five cases were on the left side and 28 cases were on the right side. The puncture accuracy rate was 94.3% for the establishment of the AL portal and 90.6% for the establishment of the MA portal. The horizontal distance (X) was 2.94 ± 1.07 cm (95% CI: 0.80-4.79 cm), following a normal distribution; the vertical distance (Y) was 1.64 ± 1.02 cm (95% CI: 0.00-3.76 cm), following a normal distribution. The horizontal (X) and vertical (Y) distances were not significantly correlated with the patients' general information and the imaging parameters of anteroposterior pelvis radiograph (P > 0.05). Conclusion While establishing the AL and MA portals, the acetabular sourcil midpoint calibration can locate the exact puncture direction. The location of the SMBM can be initially determined by the mean and 95% confidence interval of the horizontal distance (X) and vertical distance (Y) before establishing portals. -
Key words:
- arthroscopy /
- hip /
- portals /
- acetabulum /
- sourcil
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图 1 左髋臼眉弓中点体表标志点的定位
A：将带有无菌贴膜(四边形虚线内)的实心钢珠(直径3 mm)贴于术区皮肤表面；B：在透视下调整实心钢珠至眉弓中点处，实心钢珠在皮肤表面的位置即为眉弓中点体表标志点
Figure 1. Location of the sourcil midpoint body marker in the left hip
A: Solid steel balls (diameter 3 mm) with a sterile sticker (inside the dashed line of the quadrilateral) were attached to the skin surface of the surgical area; B: The solid steel ball was adjusted to the sourcil midpoint under fluoroscopic guidance, and the position of the solid steel ball on the skin is the sourcil midpoint body marker
图 2 左侧髂前上棘最下缘和眉弓中点体表标志点间距的测量与穿刺定位点的确定
A：线1连接双侧髂前上棘最下缘(星号)，作为水平线，线2经过眉弓中点体表标志点(圆点)并垂直于线1；B：两线交点到眉弓中点体表标志点(圆点)的距离为垂直距离(Y)，两线交点到髂前上棘最下缘(星号)的距离为水平距离(X)，穿刺定位点(三角形)位于眉弓中点体表标志点尾侧5 mm处
Figure 2. Measurement of the distance between the inferior edge of the anterior superior iliac spine and the sourcil midpoint body marker, and determination of the puncture location point in the left hip
A: Line 1 is the horizontal reference connecting the inferior edge of the ASIS (asterisk) bilaterally, and line 2 passes through the sourcil midpoint body marker (dot) and is perpendicular to line 1; B: The distance between the sourcil midpoint body marker (dot) and the intersection of the two lines was the vertical distance (Y). The distance between the intersection of the two lines and the inferior edge of the ASIS (asterisk) was the horizontal distance (X). The puncture location point (triangle) was 0.5 cm caudal to the sourcil midpoint body marker
图 3 透视下确认穿刺针的位置。该病例穿刺针位于关节间隙内，说明穿刺定位点定位准确
Figure 3. The position of the spinal needle was confirmed under fluoroscopy. In this case, the spinal needle was in the articular space, indicating that the puncture location point was accurately located by the puncture direction
图 4 关节镜监视下确认穿刺针的位置
A：关节镜视角下的关节囊前三角；B：穿刺针经关节囊前三角顺利穿入关节内
Figure 4. Confirming the position of the spinal needle by arthroscopic surveillance
A: Arthroscopic view of the anterior triangle of the capsule; B: The spinal needle was successfully penetrated into the joint from the anterior triangle of the capsule
表 1 术中测量距离与一般资料、影像学参数的关系
Table 1. Intraoperative measurement of distances in relation to general information and imaging parameters
指标 水平距离(X) 垂直距离(Y) B值 t值 P值 B值 t值 P值 性别 ＜0.001 ＜0.001 1.000 -0.638 -1.249 0.218 手术侧别 -0.137 -0.417 0.679 0.103 0.336 0.739 年龄 0.012 0.819 0.417 -0.012 -0.887 0.380 身高 -0.012 -0.322 0.749 -0.004 -0.103 0.918 体质量 0.012 0.579 0.566 -0.025 -1.289 0.204 骨盆高度 - - - 0.063 0.671 0.506 骨盆宽度 0.042 0.645 0.522 - - - 股骨颈干角 -0.003 -0.125 0.901 -0.020 -0.938 0.353 LCEA 0.013 0.530 0.599 0.026 1.114 0.271 因变量为术中测量的水平距离(X)、垂直距离(Y)，自变量为患者的一般资料和术前影像学测量参数。 
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