股骨远端外侧髌旁入路

1、原则 1.1

显露股骨远端关节面 Exposure of the articular surface

The lateral parapatellar approach provides a good view of the articular surface of the distal femur. With a longitudinal division of the quadriceps tendon and extensor mechanism, the patella can be dislocated medially.股骨远端外侧髌旁入路提供良好地关节面视野，需要纵向劈开股四头肌和伸肌装置，髌骨可以向内侧脱位，以增加显露。

1.2 神经血管特征 Neurovascular structures

In general, there are no neurovascular structures at risk. The common peroneal nerve is safe posterior and distal to the approach.There is only the lateral superior genicular artery to avoid, or ligate.此处没有神经血管束，腓总神经位于其后方，此处仅有膝上外侧动脉经过，注意保护或结扎。

1.3 神经血管风险 Neurovascular risks

The surgical approach exploits only the extensor mechanism. No significant neurovascular risks are present.下图显示横行血管为膝上外侧动脉

2、髌旁外侧入路的扩展 Extensions of the lateral parapatellar approach 图中（1）为髌旁外侧入路，可通过（2）来显露股骨干，（3）中间微创显露

.

3、使用止血带 Tourniquet usage

4、皮肤切口 Skin incision

Place a rolled towel under the knee to produce 20° to 30° of knee flexion.Mark the tibial tubercle and the patella. The incision can be either directly midline, or preferably, slightly lateral to midline (as shown).A common mistake is to make the incision too short, which will later on not permit medial patellar dislocation. The incision is generally 15–18 cm in length.在膝下方放置“布卷”以便使膝关节屈曲20-30°，标记胫骨结节和髌骨，切口可以选正中切口，也可稍向外侧直切口，如下图示。经常犯错误为切口不够长，髌骨不能向内侧脱位，一般切口要长约15-18cm 。

5、深层分离 Deep dissection

A deep dissection exposes the lateral aspect of the patella.The extensor retinaculum is preserved over front of the patella.The skin incision is long

enough for the surgeon to define both the medial and the lateral aspects of the quadriceps tendon.Make a full thickness, longitudinal incision through the lateral parapatellar retinaculum and the quadriceps tendon. It begins slightly lateral to midline (40% lateral; 60% medial) and curves to the lateral aspect of the patella. It should leave an 8–10 mm cuff of parapatellar retinaculum on the lateral aspect of the patella.The split in the quadriceps tendon extends approximately 10 cm above the superior pole of the patella. If an adequate release is not performed, the surgeon risks patellar tendon avulsion during

patellar dislocation.显露髌骨外侧面及伸肌装置，在膝上，完全显露股四头肌腱，在4：

6比例处全厚层劈开股四头肌腱，弯向下方，在髌骨外侧面保留8-10mm 伸肌装置，以便修复缝合，切口继续向下方延伸约10cm ，如果手术中未充分切开游离髌腱，则在髌骨脱位的时候有造成髌腱撕脱的风险。

6、扩展切口深层分离 Distal extension of the deep dissection

Carry the division down distally to the lateral aspect of the patellar tendon and then, by flexion of the knee and medial traction on the extensor mechanism, the patella is dislocated medially.屈膝，向内侧牵开伸膝装置，髌骨向内侧脱位。

7、胫骨结节截骨 Tibial tubercle osteotomy

知道有就行了，什么时候也不能用.

8、闭合创口 Wound closure

Close the quadriceps tendon and cuff of tissue along the lateral aspect of the patella with interrupted #2, or larger, sutures. Suction drain usage may be considered. Close the skin and subcutaneous tissue in a routine manner.修复伸肌装置，放置负压引流管，缝合皮下组织和皮肤