前后关节囊入路对全髋关节置换术后早期外展肌影响的病例对照研究

Case control study on effect of anterolateral and posterolateral approaches on early postoperative hip abductor strength in total hip arthroplasty

目的 ：探讨前关节囊入路和后关节囊入路对全髋关节置换术后早期髋关节外展肌力及外展功能的影响。方法：自2009年5月至2011年4月共施行全髋置换术149例,随访130例,分为改良Gibson前外侧切口的前关节囊入路（A组）65例和常规Gibson后外侧切口的后关节囊入路（B组）65例。A组男26例,女39例;年龄（72.5±8.3）岁;体重指数（24.7±3.7）kg/m^2;健侧外展肌力（1.08±0.49）N·m/kg。B组男30例,女35例;年龄（71.6±7.1）岁;体重指数（25.5±3.9）kg/m^2;健侧外展肌力（1.05±0.51）N·m/kg。另外招募60名60~80岁志愿者作为年龄相关对照组,男33例,女32例;年龄（73.1±7.5）岁;体重指数（24.2±3.8）kg/m^2;股外侧肌力（1.17±0.53）N·m/kg。A组、B组及年龄相关对照组在年龄、体重指数及健侧外展肌力（骨折患者采取健侧测量）方面差异无统计学意义。分别测量和记录两组术后第1、2、3、6、12个月术髋股外侧肌肌力、髋关节外展活动角度及髋关节Harris评分。对两组手术路径进行解剖学比较,并对股外侧肌肌力、髋关节外展度及功能的恢复进行量化分析和比较。结果：术后1、2、3、6、12个月股外侧肌肌力A组分别为（0.53±0.13）、（0.66±0.21）、（0.85±0.15）、（0.95±0.19）、（1.03±0.13）N·m/kg,B组分别为（0.46±0.14）、（0.57±0.18）、（0.78±0.12）、（0.85±0.18）、（0.98±0.14）N·m/kg,术后前6个月A组患者股外侧肌肌力优于B组,术后12个月两组患者股外侧肌肌力差异无统计学意义;术后1、2、3、6、12个月髋关节外展角度A组分别为（25.35±4.31）°、（36.53±5.13）°、（48.07±1.62）°、（61.53±1.77）°、（68.62±3.16）°,B组分别为（23.47±2.41）°、（33.42±4.23）°、（46.64±2.51）°、（60.96±1.75）°、（67.47±4.36）°,前3个月A组患者髋关节外展角度大于B组。术后1、2、3、6、12个月Harris评分,A组分别为72.23±2.57、79.36±3.91、84.75±3.17、88.63±2.16和95.21±1.37,B组分别为71.58±3.62、78.96±2.21、83.97±3.57、87.92±2.94和94.83±1.62,两组差异无统计学意义。同时,A组手术入路肌肉累及和损伤少于B组,尤其是外展肌的损伤少于B组。结论：两种关节囊入路的全髋关节置换术,采用改良Gibson切口前关节囊入路术中对外展肌的手术干扰更少,术后早期外展肌肌力和外展活动度恢复更快。

Objective：To compare the difference of early postoperative hip abductor strength and function between improved Gibson anterolateral approach（group A） and conventional Gibson posterolateral approach（group B） in patients who had underwent total hip arthroplasty（THA）. Methods：Among 149 patients performing total hip arthroplasty,130 patients were followed up and were randomly divided into two groups（19 unqualified cases were excluded）. Group A included 65 cases who underwent anterolateral approach,and the other group included 65 cases who underwent posterolateral approach. In the group A,male：female =26 ∶39,with an average age of（72.5 ±8.3） years old,BMI of（24.7 ±3.7） kg / m^2,and hip abductor strength of（1.08±0.49） N·m / kg. In the group B,male：female=30∶35,with an average age of（71.6±7.1） years old,BMI of（25.5±3.9） kg / m^2,and hip abductor strength of（1.05±0.51） N·m / kg. In the age related control group,male：female=33：32,with an average age of（73.1±7.5） years old,BMI of（24.2±3.8） kg / m^2,and hip abductor strength of（1.17±0.53） N·m / kg.The age,BMI,hip abductor strength,anatomy of surgical approach,hip abduction angles and Harris score in all patients were evaluated at the day before surgery and at 1,2,3,6,and 12 months after surgery. All preoperative clinical data（age,BMI and abductor strength of the uninjured side limb） of these cases had no significant differences. Results：At 1,2,3,6,and 12 months after surgery,the hip abductor strength in group A were（0.53±0.13）,（0.66±0.21）,（0.85±0.15）,（0.95±0.19）,（1.03±0.13） N·m / kg respectively,while in group B were（0.46±0.14）,（0.57±0.18）,（0.78±0.12）,（0.85±0.18）,（0.98±0.14） N·m /kg respectively.The differences between the two groups at the 6th months after operation were significant;the hip abduction angles in group A were（25.35±4.31）°,（36.53±5.13）°,（48.07±1.62）°,（61.53±1.77）°,（68.62±3.16）°,while in group B were（23.47±2.41）°,（33.42±4.23）°,（46.64±2.51）°,（60.96±1.75）°,（67.47±4.36）°. The differences between the two groups at the3 rd month after operation were significant. Harris score in the group A were 72.23 ±2.57,79.36 ±3.91,84.75 ±3.17,88.63 ±2.16,95.21 ±1.37 repectively; while in the group B were 71.58 ±3.62,78.96 ±2.21,83.97 ±3.57,87.92 ±2.94,94.83 ±1.62 respectively. There were no significant differences between them. Conclusion：Owing to less muscles interrupted,the THA with improved Gibson anterolateral approach offers a better improvement in earlier hip abductor strength and abduction angle compared with the conventional surgery.