侯靖釗，包洪衛(wèi)，程彥曉

·臨床論著·

應(yīng)用SuperPATH技術(shù)行全髖關(guān)節(jié)置換的早期療效觀察

侯靖釗，包洪衛(wèi)，程彥曉

目的 探討應(yīng)用SuperPATH技術(shù)行全髖關(guān)節(jié)置換的早期臨床效果。 方法 將40例行單側(cè)全髖置換患者分為SuperPATH組及常規(guī)置換組,每組20例,比較兩組切口長(zhǎng)度、手術(shù)時(shí)間、手術(shù)出血量、輸血率、VAS評(píng)分、Harris髖關(guān)節(jié)功能評(píng)分及影像學(xué)測(cè)量結(jié)果。結(jié)果 患者均獲得隨訪,時(shí)間10～13個(gè)月。手術(shù)切口長(zhǎng)度:SuperPATH組(7.2±0.5) cm,常規(guī)置換組(15.0±1.6)cm;手術(shù)出血量:SuperPATH組(315±116.0)ml,常規(guī)置換組(470±127.1)ml;兩項(xiàng)比較SuperPATH組均優(yōu)于常規(guī)置換組(P<0.001)。手術(shù)時(shí)間:SuperPATH組(115±10.9) min,常規(guī)置換組(105±15.4)min,兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。SuperPATH組輸血率低于常規(guī)置換組,但差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后1、3、7 d VAS評(píng)分:SuperPATH組分別為(3.1±1.3)分、(1.5±1.4)分、(1.3±1.1)分,常規(guī)置換組分別為(4.9±1.7)分、(2.9±1.3)分、(1.7±1.1)分,SuperPATH術(shù)后1、3 d疼痛輕于常規(guī)置換組(P<0.05);術(shù)后7 d兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后6周及末次隨訪Harris髖關(guān)節(jié)功能評(píng)分:SuperPATH組分別為(76.1±4.8)分、(93.5±2.9)分,常規(guī)置換組分別為(65.2±5.9)分、(91.6±4.8)分;術(shù)后6周SuperPATH組髖關(guān)節(jié)功能恢復(fù)快且優(yōu)于常規(guī)置換組(P<0.05),但末次隨訪時(shí)兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 應(yīng)用SuperPATH技術(shù)行全髖關(guān)節(jié)置換可以減少組織損傷,術(shù)后患者康復(fù)快,髖關(guān)節(jié)功能良好,是安全有效的手術(shù)方式。

SuperPATH技術(shù)；全髖關(guān)節(jié)置換術(shù)

2011年Chow et al報(bào)道了保留關(guān)節(jié)囊經(jīng)皮穿刺輔助的全髖關(guān)節(jié)置換術(shù),即SuperPATH技術(shù),該技術(shù)具有組織損傷小、脫位發(fā)生率低、術(shù)后康復(fù)快等優(yōu)點(diǎn)[1-2]。為了探究不同手術(shù)入路對(duì)患者術(shù)中及術(shù)后康復(fù)的影響,2014年6月～2015年6月,我科分別應(yīng)用SuperPATH技術(shù)及常規(guī)后外側(cè)入路行全髖關(guān)節(jié)置換術(shù)治療40例患者,筆者比較兩種方法的治療效果,報(bào)道如下。

1 材料與方法

1.1 病例資料 納入標(biāo)準(zhǔn):診斷為退變性髖關(guān)節(jié)炎、股骨頭壞死,經(jīng)保守治療無(wú)效的初次全髖關(guān)節(jié)置換患者。排除標(biāo)準(zhǔn):嚴(yán)重的骨質(zhì)疏松、股骨頸骨折、骨腫瘤、髖臼嚴(yán)重缺損、翻修、小兒麻痹癥、伴有神經(jīng)系統(tǒng)疾病、肌肉系統(tǒng)疾病、需行雙側(cè)全髖關(guān)節(jié)置換、不能配合隨訪的患者。本研究納入40例患者,按入院時(shí)間順序分為SuperPATH組(20例)和常規(guī)置換組(20例)?；颊呷朐汉?由手術(shù)醫(yī)師如實(shí)告知患者:SuperPATH為本院新開(kāi)展技術(shù),手術(shù)操作熟練度有待提高;常規(guī)后外側(cè)入路手術(shù)方式比較成熟,但術(shù)中對(duì)組織損傷相對(duì)較大。根據(jù)患者意愿簽署手術(shù)知情同意書(shū)。該研究經(jīng)過(guò)靖江市人民醫(yī)院倫理委員會(huì)審批。兩組性別、年齡、BMI、術(shù)前Harris評(píng)分比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),見(jiàn)表1。

1.2 術(shù)前準(zhǔn)備 常規(guī)置換組:常規(guī)攝骨盆平片及髖關(guān)節(jié)側(cè)位片。SuperPATH組:① 常規(guī)拍攝骨盆標(biāo)準(zhǔn)正位片,根據(jù)X線(xiàn)片進(jìn)行模板測(cè)量,預(yù)計(jì)假體大小、截骨位置及股骨頸的長(zhǎng)度。② 器械準(zhǔn)備:Cobb剝離器、Homan拉鉤、自動(dòng)撐開(kāi)器、羊角拉鉤、髖臼定位器、Trocar及套管等。

1.3 手術(shù)方法 硬膜外麻醉,患者側(cè)臥位。

1.3.1 常規(guī)置換組 切開(kāi)皮膚皮下組織、闊肌膜張肌,切斷后方外旋肌群,顯露后方關(guān)節(jié)囊。切除后方關(guān)節(jié)囊,顯露股骨頸部,股骨頸小轉(zhuǎn)子上方1～1.5 cm處標(biāo)準(zhǔn)截骨,取出股骨頭后顯露髖臼,常規(guī)打磨髖臼后根據(jù)股骨頭大小置入合適的髖臼杯。再行股骨近端擴(kuò)髓,置入合適的股骨柄,試模后置入人工股骨頭,活動(dòng)人工關(guān)節(jié),穩(wěn)定后修復(fù)外旋肌群,逐層關(guān)閉切口。切口常規(guī)放置負(fù)壓引流管24 h。

1.3.2 SuperPATH組 髖部稍后傾,術(shù)側(cè)髖關(guān)節(jié)屈曲45°,下肢內(nèi)旋10°～15°,使大轉(zhuǎn)子朝向上方,患側(cè)足部放置于帶襯墊的托盤(pán)車(chē)上,下肢稍?xún)?nèi)收。① 切口與暴露:自大轉(zhuǎn)子順股骨軸線(xiàn)向身體近端做6～8 cm 切口,逐層切開(kāi)分離,使用自動(dòng)撐開(kāi)器輔助暴露臀大肌筋膜,沿皮膚切口方向切開(kāi)臀大肌筋膜,鈍性分離臀大肌,暴露臀中肌后緣滑囊組織。切開(kāi)滑囊后,將Cobb剝離器置于臀中肌下,使用Homan拉鉤替換Cobb剝離器維持臀中肌位置。助手將髖關(guān)節(jié)外展、外旋,減小外旋肌的張力,再將Cobb剝離器置于臀小肌和梨狀肌間隙,然后用Homan拉鉤替換;助手恢復(fù)下肢體位并輕壓拉鉤以維持外旋肌于關(guān)節(jié)囊的位置。如果梨狀肌產(chǎn)生的張力過(guò)大,可以直視下予以松解。使用Cobb剝離器從前方輕推臀小肌后緣,顯露深層關(guān)節(jié)囊,沿切口方向切開(kāi)關(guān)節(jié)囊,使用長(zhǎng)頭電刀切開(kāi)大轉(zhuǎn)子筋膜,以預(yù)防股骨頸基底部周?chē)鲅４颂幏抵а茌^多,關(guān)節(jié)囊從股骨頸的鞍部切開(kāi)向近端至髖臼近端1 cm處,剝離髖臼邊緣關(guān)節(jié)囊附著點(diǎn)并向前、向后延伸1 cm。抬高膝關(guān)節(jié)以降低外旋肌張力,將Cobb剝離器置于后關(guān)節(jié)囊和股骨頸后方之間,使用后關(guān)節(jié)囊處的Homan拉鉤替換Cobb剝離器后放下膝關(guān)節(jié)。以同樣方法重置前方Homan拉鉤。② 股骨準(zhǔn)備:輕微用力,使膝關(guān)節(jié)內(nèi)收,在保留股骨頭完整的狀態(tài)下行股骨準(zhǔn)備,進(jìn)行擴(kuò)髓和髓腔形成,并使用干骺端絞刀擴(kuò)展近端髓腔,使用圓形股骨距銼從絞刀開(kāi)口處行股骨頸開(kāi)槽,用刮匙處理股骨中段髓腔,以確保假體在髓腔良好的皮質(zhì)接觸。根據(jù)選用的假體進(jìn)行擴(kuò)髓,將最終髓腔銼留置髓腔,去除手柄,在髓腔銼頂部行股骨頸截骨并取出股骨頭。③ 髖臼準(zhǔn)備:將患肢恢復(fù)到初始體位準(zhǔn)備髖臼,將兩個(gè)尖Homan拉鉤放置于關(guān)節(jié)囊和髖臼唇間的髖臼窩中,按常規(guī)手術(shù)切除臼唇及殘余組織,在髖臼近遠(yuǎn)端骨膜下放置配套撐開(kāi)器,此為髖臼挫及植入物提供操作空間,此時(shí)去除Homan拉鉤。使用骨鉤插入股骨髓腔銼,將股骨拉向前方以進(jìn)一步顯露髖臼。安裝配套定位套管,定位后做輔助皮膚切口,通過(guò)此切口置入套管及Trocar,取出定位器留置套管,通過(guò)套管插入髖臼銼的桿,在主切口內(nèi)安裝相應(yīng)型號(hào)髖臼銼打磨髖臼,再使用配套手柄通過(guò)主切口放置髖臼杯,通過(guò)瞄準(zhǔn)手柄控制臼杯位置,臼杯撞擊器連接瞄準(zhǔn)器打擊臼杯直至固定。④ 試模復(fù)位與拆除:根據(jù)術(shù)前模板測(cè)量及截骨情況選擇合適股骨頭和頸,將股骨頸試模安裝在股骨髓腔銼上,股骨頭試模安放于髖臼杯,開(kāi)口朝上,調(diào)節(jié)肢體復(fù)位試模。試模脫位通過(guò)骨鉤鉤住髓腔銼,Trocar尖端置入試模頸上孔,相互對(duì)抗分離,將股骨頸試模從髓腔銼上拆除。⑤ 假體植入關(guān)閉切口:髓腔銼移除后,將髖臼假體及股骨柄打入,按試模安裝方法放置股骨頭假體,安裝股骨柄假體并固定牢靠,配合活動(dòng)下肢,復(fù)位股骨頭和頸。假體安裝完成后逐層縫合。典型病例見(jiàn)圖1。

表1 兩組一般資料比較

圖1 患者,女,65歲,因右髖部疼痛4年、加重1年入院 A.術(shù)前骨盆X線(xiàn)片,顯示右髖關(guān)節(jié)骨性關(guān)節(jié)炎;B.體位及手術(shù)切口設(shè)計(jì);C.術(shù)中手術(shù)操作;D.手術(shù)結(jié)束時(shí)測(cè)量切口長(zhǎng)度,約6.5 cm;E.術(shù)后第2天骨盆X線(xiàn)片,顯示假體在位;F.術(shù)后第2天髖關(guān)節(jié)X線(xiàn)片,顯示假體在位

1.4 術(shù)后處理 兩組術(shù)后處理相同。常規(guī)口服塞來(lái)昔布0.1 g早晚各一次以緩解疼痛。術(shù)后穿丁字鞋放置于外展中立位,麻醉清醒后即行股四頭肌舒縮及髖關(guān)節(jié)屈伸活動(dòng),術(shù)后2～3 d在康復(fù)師指導(dǎo)下下床活動(dòng),逐漸負(fù)重,4～6周棄拐行走。

1.5 觀察指標(biāo) ① 一般情況:記錄手術(shù)時(shí)間、輸血病例數(shù)(血紅蛋白<75 g/L行輸血治療),手術(shù)結(jié)束關(guān)閉切口后無(wú)菌鋼尺測(cè)量并記錄患者切口長(zhǎng)度,根據(jù)術(shù)中負(fù)壓吸引量及術(shù)后引流量?jī)煞矫娼y(tǒng)計(jì)手術(shù)出血量。② 術(shù)后第1～3天攝骨盆平片及髖關(guān)節(jié)側(cè)位片評(píng)估髖臼前傾角及外展角。③ 采用VAS評(píng)分評(píng)價(jià)術(shù)后1、3、7 d疼痛程度。④ 采用Harris髖關(guān)節(jié)評(píng)分標(biāo)準(zhǔn)評(píng)價(jià)術(shù)前、術(shù)后6周及末次隨訪時(shí)患髖關(guān)節(jié)的功能狀態(tài),≥90分為優(yōu)良,80～89分為較好,70～79分為尚可,<70分為差。

2 結(jié)果

患者均順利完成手術(shù),兩組圍手術(shù)期參數(shù)見(jiàn)表2。SuperPATH組切口長(zhǎng)度、術(shù)中出血量均優(yōu)于常規(guī)置換組(P<0.001),兩組手術(shù)時(shí)間、輸血率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)?；颊呔@得隨訪,時(shí)間10～13個(gè)月;平均隨訪時(shí)間:常規(guī)置換組為(11.8±0.64)個(gè)月,SuperPATH組為(11.5±0.83)個(gè)月。兩組術(shù)后1周髖臼前傾角及外展角比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。VAS評(píng)分:SuperPATH組術(shù)后1、3 d均優(yōu)于常規(guī)置換組(P<0.05),術(shù)后7 d兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。Harris髖關(guān)節(jié)評(píng)分:術(shù)后6周時(shí)SuperPATH組優(yōu)于常規(guī)置換組,末次隨訪時(shí)兩組差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),見(jiàn)表3。并發(fā)癥:SuperPATH組無(wú)切口感染、深靜脈血栓及髖關(guān)節(jié)脫位等發(fā)生;常規(guī)置換組1例切口淺表感染,經(jīng)積極切口換藥及選用敏感抗生素后治愈,無(wú)深靜脈血栓及髖關(guān)節(jié)脫位發(fā)生。

表2 兩組圍手術(shù)期參數(shù)比較

3 討論

3.1 SuperPATH技術(shù)的優(yōu)點(diǎn) SuperPATH技術(shù)是經(jīng)標(biāo)準(zhǔn)后外側(cè)入路改良而來(lái),保留了標(biāo)準(zhǔn)后外側(cè)入路的優(yōu)點(diǎn),能進(jìn)一步降低組織損傷,最大限度地恢復(fù)髖關(guān)節(jié)功能。有以下優(yōu)點(diǎn):① 手術(shù)切口小:手術(shù)切口經(jīng)大轉(zhuǎn)子頂點(diǎn),切口6～8 cm,本組全髖切口長(zhǎng)度僅在7 cm左右。② 肌肉損傷小:手術(shù)經(jīng)梨狀肌和臀小肌的間隙進(jìn)入髖關(guān)節(jié),術(shù)中最大限度的經(jīng)肌肉間隙分離顯露關(guān)節(jié)囊,不需要切斷周?chē)∪饣蚣‰?完整保留了外旋肌群和關(guān)節(jié)囊,減少臀肌損傷。③ 輸血率低:文獻(xiàn)報(bào)道[3]應(yīng)用SuperPATH技術(shù)圍手術(shù)期輸血率低,可能與組織損傷小、失血量少有關(guān)。本研究中SuperPATH組僅1例輸血,常規(guī)置換組4例輸血,但兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義,可能與樣本量少有關(guān)。④ 對(duì)假體類(lèi)型要求低:術(shù)中借助特殊器械及配合特殊體位,此入路可獲得良好的顯露及操作空間,對(duì)假體類(lèi)型無(wú)特殊要求。⑤ 術(shù)后假體脫位發(fā)生率低:手術(shù)過(guò)程中沒(méi)有切斷任何肌肉或肌腱,在減少手術(shù)創(chuàng)傷同時(shí),將手術(shù)后關(guān)節(jié)脫位等并發(fā)癥的可能性降到最低[4]。⑥ 術(shù)后康復(fù)快:由于切口小、肌肉損傷小,SuperPATH組術(shù)后1周內(nèi)患者VAS評(píng)分明顯優(yōu)于常規(guī)置換組,且術(shù)后2～3 d即可配合康復(fù)師指導(dǎo)下床活動(dòng),這為術(shù)后髖關(guān)節(jié)功能恢復(fù)創(chuàng)造條件。⑦ 術(shù)后功能恢復(fù)快:由于術(shù)中較好地保留了髖關(guān)節(jié)周?chē)P(guān)節(jié)囊韌帶復(fù)合體及臀肌的穩(wěn)定性,在術(shù)后快速康復(fù)訓(xùn)練的基礎(chǔ)上,患者髖關(guān)節(jié)功能可以得到更好恢復(fù)。Harris評(píng)分顯示,本研究中SuperPATH組術(shù)后6周屈髖與外展功能更滿(mǎn)意。

表3 兩組術(shù)后髖臼前傾角和外展角、VAS評(píng)分、Harris髖關(guān)節(jié)評(píng)分比較

3.2 SuperPATH技術(shù)的不足 ① 學(xué)習(xí)曲線(xiàn)較長(zhǎng):對(duì)于一種新的手術(shù)方式,術(shù)者往往要有一學(xué)習(xí)過(guò)程才能熟練掌握,初期手術(shù)時(shí)間偏長(zhǎng),隨著手術(shù)經(jīng)驗(yàn)的積累,手術(shù)時(shí)間逐漸縮短,最終達(dá)到平臺(tái)期。Rasuli et al[3]報(bào)道SuperPATH組學(xué)習(xí)曲線(xiàn)稍偏長(zhǎng),在行50例患者手術(shù)后仍未達(dá)平臺(tái)期。② 手術(shù)時(shí)間略長(zhǎng):因視野相對(duì)較小,操作比常規(guī)手術(shù)略困難,一定程度上導(dǎo)致手術(shù)時(shí)間偏長(zhǎng)。Rasuli et al[3]的研究也證實(shí)SuperPATH技術(shù)行全髖置換手術(shù)平均時(shí)間比傳統(tǒng)手術(shù)長(zhǎng)約8.5 min,本研究結(jié)果與之大致相同。

3.3 SuperPATH技術(shù)要點(diǎn)及難點(diǎn) ① 術(shù)前制定詳細(xì)的手術(shù)計(jì)劃,精確測(cè)量關(guān)節(jié)周?chē)馄蕝?shù),選擇合適假體,熟悉解剖入路及特殊器械的應(yīng)用,有助于手術(shù)順利進(jìn)行。Rasuli et al[3]報(bào)道,應(yīng)用SuperPATH技術(shù),術(shù)后患者髖臼假體的外展角偏小,但并未增加脫位的發(fā)生,但髖臼假體的外展角異常會(huì)加重股骨頭和聚乙烯內(nèi)襯的磨損而影響遠(yuǎn)期效果。筆者在術(shù)中為預(yù)防髖臼外展角異常,采用髖臼定位器定位時(shí)結(jié)合髖臼橫韌帶輔助定位[5],在術(shù)后測(cè)量時(shí)與常規(guī)置換組比較未發(fā)現(xiàn)髖臼假體的位置有明顯異常。② 術(shù)中對(duì)部分梨狀肌張力較大患者應(yīng)行局部松解,否則可能影響切口顯露。Nobel et al[6]研究發(fā)現(xiàn),小切口手術(shù)時(shí)拉鉤對(duì)皮膚軟組織產(chǎn)生的壓力較標(biāo)準(zhǔn)切口大,容易造成脂肪液化及切口皮緣壞死,因此手術(shù)時(shí)張力若較大則不要強(qiáng)行實(shí)施。③ 使用“移動(dòng)視窗技術(shù)”,即顯露時(shí)需配合調(diào)整股骨位置來(lái)暴露術(shù)野,以便獲得最佳視角。

綜上所述,應(yīng)用SuperPATH技術(shù)行全髖關(guān)節(jié)置換手術(shù),可以減少手術(shù)創(chuàng)傷,降低術(shù)后疼痛評(píng)分,促進(jìn)患者術(shù)后快速康復(fù),獲得更滿(mǎn)意的關(guān)節(jié)功能,是實(shí)施全髖關(guān)節(jié)置換安全可行的術(shù)式。

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[2] Gofton W,Chow J,Olsen K D,et al.Thirty-day readmission rate and discharge status following total hip arthroplasty using the supercapsular percutaneously-assisted total hip surgical technique[J].Int Orthop,2015,39(5):847-851.

[3] Rasuli K J, Gofton W. Percutaneously assisted total hip (PATH) and Supercapsular percutaneously assisted total hip (SuperPATH) arthroplasty: learning curves and early outcomes[J]. Ann Transl Med, 2015, 3(13): 179.

[4] 冉學(xué)軍, 蒲川成, 胡 敏,等. 保留修復(fù)后方關(guān)節(jié)囊及韌帶對(duì)防止人工髖關(guān)節(jié)置換術(shù)后脫位的作用[J]. 臨床骨科雜志, 2015,18(3):314-317.

[5] Archbold H A,Mockford B,Molloy D,et al.The transverse acetabular ligament: an aid to orientation of the acetabular component during primary total hip replacement:a preliminary study of 1000 cases investigating postoperative stability[J].J Bone Joint Surg Br,2006,88(7):883-886.

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(接收日期:2016-12-03)

Early effect observation of total hip arthroplasty by using SuperPATH technique

HOUJing-zhao,BAOHong-wei,CHENGYan-xiao

(DeptofOrthpaedics,thePeople′sHospitalofJingjiang,Jingjiang,Jiangsu214500,China)

Objective To investigate the early clinical results of total hip arthroplasty(THA)by using SuperPATH technique. Methods Forty patients treated with THA were randomly divided into two groups,20 patients in each group. SuperPATH minimally invasive THA and conventional THA were performed in the two groups. The incision length, operation time, intraoperative blood loss, blood transfusion, postoperative pain, function recovery, and prosthetic prosthetic position were analyzed and compared between two groups. Results All patients were followed up for 10～13 months. Incision length of SuperPATH group was (7.2±0.5)cm, conventional group was (15.0±1.6)cm; the volume of bleeding of SuperPATH group was(315±116.0)ml and conventional group was (470±127.1)ml, SuperPATH group was superior to the conventional group in two comparisons, the differences between the two groups were statistically significant(P<0.001);the operation time of SuperPATH was (115±10.9) min, the operation time of conventional group was (105±15.4) min; there was no statistically significant difference between the two groups(P>0.05). The blood transfusion rate in the SuperPATH group was lower than that of the conventional group, but there were no statistical difference(P>0.05). The VAS on the postoperative 1st, 3rd and 7th day: SuperPATH group was 3.1±1.3，1.5±1.4，1.3±1.1 and conventional group was 4.9±1.7，2.9±1.3，1.7±1.1. On the 1st and 3rd day after SuperPATH operation, the pain of SuperPATH group was lighter than that of the conventional replacement group (P<0.05),there was no significant difference between the two groups after 7 days(P>0.05). Harris hip function scores at 6 weeks and at the end of follow-up: SuperPATH group was 76.1±4.8，93.5±2.9 and conventional group was 65.2±5.9，91.6±4.8. In 6 weeks after operation, the hip function recovered fasterly in SuperPATH group, which was better than the conventional replacement group (P<0.05). But there was no significant difference between the two groups at the last follow-up.(P>0.05). Conclusions These results show that the application of SuperPATH technology in THA has the advantages of minimally invasive,less tissue damage, fast recovery and satisfaction hip function, which is a safe and effective surgical method.

SuperPATH technique；total hip arthroplasty

10.3969/j.issn.1008-0287.2017.01.023

靖江市人民醫(yī)院骨科,江蘇 靖江 214500

侯靖釗,男,副主任醫(yī)師,主要從事關(guān)節(jié)外科研究,E-mail:hjzhcy@163.com; 包洪衛(wèi),男,主任醫(yī)師,通訊作者,主要從事關(guān)節(jié)外科研究,E-mail:jjbhw@126.com

R 687.4；R 684

A

1008-0287(2017)01-0050-04