侧卧位直接前方入路与Hardinge入路行初次全髋关节置换在老年股骨颈骨折患者中的早期疗效比较

Comparison of early outcomes of primary total hip arthroplasty with a direct anterior approach in the lateral decubitus position versus Hardinge approach in elderly patients with femoral neck fracture

目的比较侧卧位直接前方入路(direct anterior approach,DAA)与Hardinge入路行初次全髋关节置换在老年股骨颈骨折患者中的早期疗效。方法回顾性分析2017年9月~2019年9月南京市第一医院运动关节科收治的行初次全髋关节置换的老年股骨颈骨折患者248例(年龄≥70岁),其中直接前方入路137例,Hardinge入路111例。排除严重基础疾病,经过术后随访14个月以上,共获得228例完整的临床和影像学资料,其中直接前方入路组(DAA组)126例,Hardinge入路组102例。通过比较围手术期的相关指标、手术相关数据、术后功能及影像学资料以及术后相关并发症分析两种不同手术入路对于老年股骨颈骨折患者早期临床疗效的差异。结果DAA组手术的平均手术时间为(79.8±7.5)min,与Hardinge入路组平均手术时间(74.3±6.3)min比较无明显差异(P>0.05),DAA组手术缝合时间(11.5±3.2)min较Hardinge入路组手术缝合时间(21.4±4.2)min明显缩短(P<0.001),术中出血量DAA组(155.1±9.7)mL较Hardinge入路组(249.4±16.2)mL明显降低(P=0.001)。髋关节Harris评分DAA组术后1个月(80.3±2.1 vs 72.7±4.2,P<0.05)、术后6个月(89.2±2.4 vs 82.1±3.6,P<0.05)较Hardinge入路组均有改善,但两组术后12个月时Harris评分无明显差异(93.2±2.5 vs 86.3±1.9,P>0.05)。术后1周的疼痛视觉模拟评分(VAS)DAA组优于Hardinge入路组(2.4±0.9 vs 3.1±1.3,P<0.05)。术后影像学结果显示:髋臼前倾角、外展角及双下肢长度差异在两种入路术式中不存在明显统计学差异(P>0.05)。未出现术中假体周围骨折等其他并发症,术后并发症出现11例股外侧皮神经损伤,以患肢外侧局部皮肤感觉减退为主要不适,长期随访均有一定程度恢复,余无其他术后并发症;所有病例术后12个月随访未发生术后假体周围骨折、无菌性假体松动以及感染等。结论对老年股骨颈骨折患者,侧卧位DAA优于传统Hardinge入路,该方法创伤更小,术后恢复更快,且手术效果及安全性都值得肯定。

Objective To compare the early clinical efficacy of the direct anterior approach(DAA)and the Hardinge approach in the lateral decubitus position for primary total hip arthroplasty(THA)of elderly patients with femoral neck fracture.Methods From September 2017 to September 2019,248 elderly patients with femoral neck fracture(age≥70 years old)who underwent primary THA in the Department of Sports Medicine and Joint Surgery,Nanjing First Hospital,were retrospectively analyzed,including 137 patients with direct anterior approach(DAA)and 111 patients with Hardinge approach.A total of 228 patients were followed up for more than 14 months,including 126 patients with DAA and 102 patients with Hardinge approach,excluding those patients with severe underlying diseases.The differences in the early clinical efficacy of two different surgical approaches for elderly patients with femoral neck fracture were analyzed by comparing the perioperative related index,surgery related data,postoperative function and imaging data,and postoperative related complications.Results The average operation time of DAA group was(79.8±7.5)min,which was not different from that of Hardinge approach group(74.3±6.3)min,P>0.05.The suture time of DAA group(11.5±3.2)min was significantly shorter than Hardinge group(21.4±4.2)min,P<0.001.The intraoperative blood loss in the DAA group(155.1±9.7)mL was significantly lower than that in the Hardinge approach group(249.4±16.2)mL,P=0.001.The Harris score of hip joint at 1 month after operation(80.3±2.1 vs 72.7±4.2,P<0.05)and 6 months after operation(89.2±2.4 vs 82.1±3.6,P<0.05)were improved compared with Hardinge approach group.However,at 12 months after the operation,there was no significant difference in score(93.2±2.5 vs 86.3±1.9,P>0.05)between the two groups.The visual analogue scale(VAS)of pain at 1 week after operation was also better than that in the Hardinge approach group(P<0.005).The postoperative imaging results showed that there were no significant differences in the acetabular anteversion angle,abduction angle and the length of the lower limbs between the two approaches(P>0.05).There was no periprosthetic fractures and other complications occurred.However,lateral cutaneous nerve injury occurred in 11 cases,and limb lateral local skin feel loss as the main discomfort.Fortunately,all patients recovered in a certain degree.All cases followed up for 12 months,there was no postoperative fractures around the prosthesis,aseptic prosthetic loosening and infection.Conclusion For elderly patients with femoral neck fractures,DAA in the lateral decubitus position is better than traditional Hardinge approach,which has less trauma,faster recovery after surgery,and the surgical effect and safety are worthy of recognition.