侧卧位直接前方入路与后外侧入路全髋关节置换术治疗高龄股骨颈骨折对照研究

Direct anterior approach versus posterolateral approach for total hip arthroplasty in the lateral decubitus position for the treatment of elderly femoral neck fracture: a comparative study

目的评价侧卧位直接前方入路（DAA）行初次全髋关节置换术（THA）治疗高龄股骨颈骨折的疗效。方法选取2014年9月至2016年1月沈阳军区总医院骨科行初次单侧人工THA的高龄股骨颈骨折患者62例,采用直接前方入路31例（A组）,后外侧入路31例（B组）。记录两组手术时间、切口长度、术中失血量、总失血量、术后引流量、下床行走时间、住院天数,术后1周、1、3、6个月髋关节Harris评分（HHS）,术后1、3、5、7 d的疼痛视觉模拟评分（VAS）,术后脱位率及其他并发症发生情况。结果所有患者均获得6~15个月随访,平均8.6个月。A组和B组的手术时间分别为（65.4±11.2）min和（63.0±9.8）min;A组和B组患者的切口长度分别为（9.8±3.2）cm和（10.3±3.4）cm,两组患者的手术时间及切口长度比较,差异无统计学意义（P〉0.05）。A组和B组术中失血量分别为（223.0±38.8）ml和（293.4±52.4）ml;术后引流量分别为（305.5±38.2）ml和（414.3±43.3）ml;总失血量分别为（686.3±160.7）ml和（876.4±176.8）ml;A组和B组下床行走的时间分别为（2.1±0.4）d和（3.6±0.8）d;A组和B组住院天数分别为（5.2±0.9）d和（8.1±1.6）d,两组术中失血量、总失血量、术后引流量、下床行走时间、住院天数比较,差异均有统计学意义（P〈0.05）。术后1周、1个月A组HHS评分高于B组,差异有统计学意义（P〈0.05）,术后3、6个月两组HHS评分比较,差异无统计学意义（P〉0.05）;A组术后1、3、5、7 d的VAS评分均低于B组,两组比较,差异有统计学意义（P〈0.05）。B组发生假体后脱位2例（6.5%）,A组未发生脱位。A组发生股外侧皮神经损伤1例（3.2%）,输血5例（16.1%）;B组输血9例（29.0%）,与A组比较,差异有统计学意义（P〈0.05）。结论直接前方入路与后外侧入路全髋关节置换比较,具有出血少、疼痛轻、防脱位能力强、术后恢复快等优势。

Objective To explore the evaluation of lateral decubitus position direct anterior approach（ DAA） for primary total hip arthroplasty（ THA） in the treatment of elderly femoral neck fracture. Methods A retrospective study was performed on 62 patients with elderly femoral neck fracture that underwent primary unilateral THA that received in the General Hospital of Shenyang Military Command from September 2014 to January 2016. There were 31 cases underwent DAA（ Group A） and 31 cases underwent posterolateral approach（ Group B）. The operation time,incision length,intraoperative blood loss,total blood loss,postoperative drainage,ambulation time,hospitalization time,postoperative 1 week,1 month,3 months and 6 months Harris hip score（ HHS）,postoperative 1 day,3 days,5 days and 7 days visual analogue score（ VAS）,the incidence of postoperative dislocation and other complications were recorded. Results All patients received follow-up for 6-15 months,with an average of 8. 6 months. The operation time in Group A and Group B was（ 65. 4 ± 11. 2） minutes and（ 63. 0 ± 9. 8） minutes,respectively; the incision length was（ 9. 8 ± 3. 2） cm and（ 10. 3 ± 3. 4） cm,respectively; there was no statistically significant difference in the operation time and incision length between the two groups（ P〉0. 05）. The intraoperative blood loss in Group A and Group B was（ 223. 0 ± 38. 8） ml and（ 293. 4 ± 52. 4） ml,respectively. The postoperative drainage was（ 305. 5 ± 38. 2） ml and（ 414. 3 ± 43. 3） ml,respectively. The total blood loss was（ 686. 3 ± 160. 7） ml and（ 876. 4 ±176. 8） ml,respectively; the ambulation time was（ 2. 1 ± 0. 4） days and（ 3. 6 ± 0. 8） days,respectively; the hospitalization time was（ 5. 2 ± 0. 9） days and（ 8. 1 ± 1. 6） days,respectively; there were statistically significant differences between the two groups in intraoperative blood loss,total blood loss,postoperative drainage,ambulation time and hospitalization time（ P〈0. 05）. HHS of Group A was higher than that of B group after 1 week and 1 month of operation,the difference was statistically significant（ P〈0. 05）. HHS between the two groups had no statistical significance in postoperative 3 months and 6 months（ P〈0. 05）. VAS of Group A was less than that of Group B after 1 day,3 days,5 days and 7 days of operation,the difference between the two groups was statistically significant（ P〈0. 05）. There were 2 cases（ 6. 5%） of postoperative dislocation in Group B and no dislocation in Group A. There was 1 case（ 3. 2%）of lateral femoral cutaneous nerve injury and 5 cases（ 16. 1%） of blood transfusion in Group A; 9 cases（ 29%） of blood transfusion in Group B,compared with Group A,the difference was statistically significant（ P〈0. 05）. Conclusion Compared with the posterolateral approach,the direct anterior approach in total hip arthroplasty had the advantages of less bleeding,less pain,anti dislocation ability and faster postoperative recovery.