直接前入路髋关节置换术及其早期临床疗效

Surgical technique and early clinical outcomes of direct anterior approach to total hip arthroplasty

目的:探讨直接前入路髋关节置换的手术技术和早期临床疗效。方法:对北京积水潭医院矫形骨科2015年3月11日至2016年6月21日,共100例患者116髋(双侧髋关节16例)进行了直接前入路髋关节置换术,其中男性50例,女性50例,平均年龄51岁,平均体重指数24.69 kg/m2。术前诊断包括股骨头缺血坏死、髋关节骨关节炎、髋臼发育不良继发骨关节炎、髋关节陈旧感染、强直性脊柱炎、类风湿性关节炎、股骨颈骨折空心钉术后股骨头坏死等,其中7例髋关节既往有手术史,3例为股骨头坏死既往采用Smith-Peterson入路进行植骨,2例为髋臼发育不良采用Smith-Peterson入路进行髋臼加盖术,2例为股骨颈骨折空心钉内固定(内固定残留)。所有髋关节假体均为非骨水泥型,其中67例股骨柄为Triloc(美国强生公司),45例Corail(美国强生公司),2例Accolade(美国史赛克医疗器械公司),1例Synergy(美国施乐辉公司),1例Polarstem(美国施乐辉公司)。结果:术后平均随访8.5个月,切口瘢痕长度平均10 cm,术后Harris评分平均93.62。95%患者术后双下肢长度差别在3 mm以内。术后平均外展角为38.7°,94.8%髋关节外展角在30°~50°,平均前倾角为14.3°,94.2%髋关节前倾角在5°~25°。共有15例(12.9%)发生术中和术后并发症,2例股骨穿孔(由原计划的Triloc柄改为Corail柄处理),3例股骨矩劈裂(采用钢丝环扎固定),4例大转子骨折(2例采用钢丝张力带固定,2例未移位骨折未处理),1例深部感染(清创处理并保留了假体),1例浅表软组织感染(清创处理),1例血肿和3例伤口愈合不良(清创处理),所有并发症病例至随访时均已痊愈。未见术后脱位和严重血管神经损伤病例,35例(30.2%)髋关节术后出现股外侧皮神经麻痹症状。结论:直接前入路髋关节置换能够更准确地控制髋臼假体安放角度和双下肢肢体长度,降低术后脱位风险,有利于术后早期快速康复。

Objective：To describe the surgical technique of direct anterior approach to total hip arthroplasty and to report the early clinical outcomes.Methods： A series of 100 consecutive,unselected patients who had 116 primary total hip arthroplasty surgeries （16 bilateral） done through direct anterior approach from March 11 2015 to June 21 2016 was reviewed.There were 50 male patients and 50 female patients.The average patient age was 51 years,and the average body mass index was 24.69 kg/m2.The preoperative diagnosis included avascular necrosis of femoral head,hip osteoarthritis,osteoarthritis se-condary to acetabular dysplasia,sequelae of hip old infection,ankylosing spondylitis,rheumatoid arthritis and avascular necrosis of femoral head after cannulated screws fixation of femoral neck fracture.There were 7 hips which had surgical history prior to the index hip arthroplasty,including 3 cases with bone graft treatment for avascular necrosis of femoral head through Smith-Peterson approach,2 cases with acetabular shelf procedures for acetabular dysplasia through Smith-Peterson approach,and 2 cases with cannulated screws fixation for femoral neck fracture （internal fixation residual）.All were uncemented hips.The stems used in this study included 67 Triloc stems （DePuy company,USA）,45 Corail stems （DePuy company,USA）,2 Accolade stems （Stryker company,USA）,1 Synergy stem （Smith-Nephew company,USA） and 1 Polarstem （Smith-Nephew company,USA）.Results： The average follow up period was 8.5 months,the average incision scar length was 10 cm,and the average postoperative Harris score was 93.62.There was 95% postoperative leg length discrepancy within 3 mm.The average cup inclination angle was 38.7°;with 94.8% in the range of 30°; to 50°;.The average cup anteversion angle was 14.3°; with 94.2% within the target range of 5; to 25°;.The were 15 （12.9%） operative complications,including two femoral perforations （changing stem from Triloc to Corail）,three calcar fractures （treated with cerclage wires）,four greater trochanter fractures （2 were treated wire tension band,and 2 nondisplaced fractures untreated）,one deep infection （debridement and retaining of the prothesis）,one superficial infection （debridement）,one hematoma and three wound healing complications （debridement）.All the complications were successfully treated without any sequelae at the end of the latest follow-up.There was no postoperative dislocation.There was no major nerve and vascular injuries.There were 35 cases （30.2%） reporting symptoms of lateral femoral cutaneous nerve palsy.Conclusion： Direct anterior approach to total hip arthroplasty allows accurate and reproducible cup orientation positioning and leg length restoration and decreases the risk of postoperative dislocation,which is helpful for early rapid postoperative recovery.