直接前侧入路与后外侧入路人工全髋关节置换术的临床效果比较研究

Clinical outcome difference between direct anterior approach and posterior lateral approach in total hip arthroplasty

目的探讨直接前侧入路(direct anterior approach,DAA)与后外侧入路(posterolateral approach,PLA)进行人工全髋关节置换手术(total hip arthroplasty,THA)的临床效果。方法选取2016年3月至2017年1月在我科进行THA手术的病人60例,根据手术方法不同分为两组:DAA组30例,男16例、女14例,平均年龄为(66.88±12.13)岁,身体质量指数(body mass index,BMI)为(23.67±3.10)kg/m^2;PLA组30例,男14例、女16例,平均年龄为(65.18±14.72)岁,BMI为(26.47±2.83)kg/m2。两组病人一般资料比较,差异均无统计学意义(均P>0.05)。观察并记录手术切口长度、手术时间、术中出血量、术中输血量、手术前后血红蛋白变化,手术前后采用西安大略和麦克马斯特大学(Western Ontario and Mc Master Universities,WOMAC)骨关节炎指数、美国麻醉医师协会(American Society of Anesthesiology,ASA)评分、牛津髋关节功能量表(Oxford hip scale,OHS)评分和10 m步行测试进行关节功能评分。结果 DAA组在切口长度方面优于PLA组,而PLA组的手术时间、术中出血量、手术后血红蛋白减少量少于DAA组,差异均有统计学意义(均P<0.05);术后第2、4、6周,对两组病人的WOMAC评分(包括疼痛、关节僵硬、躯体功能和总分)、OHS评分和10 m步行测试进行比较,差异均无统计学意义(均P>0.05);两组病人住院时间比较,差异无统计学意义(P>0.05)。术后第6、12周对病人进行WOMAC评分(包括床上坐起、弯腰拾物、穿鞋袜、脱鞋袜),两组髋关节活动度比较,差异无统计学意义(P>0.05)。DAA组发生1例无症状性大粗隆撕脱性骨折,经过保守观察6周后自愈;PLA组出现1例后脱位,经手法复位后不再脱位。术后12周,均未发现异位骨化形成。结论采用两种入路均可获得良好的短期效果,DAA行THA病人可获得更好的术后ROM;对于年轻有髋关节高屈曲活动度病人,倾向采用DAA入路;针对复杂初次及翻修病例,建议采用后入路手术。

Objective To compared the clinical effect of total hip arthroplasty(THA)between direct anterior approach(DAA)and posterolateral approach(PLA).Methods Sixty patients undergoing THA from March 2016 to January 2017 were randomly divided into DAA group(30 cases)and PLA group(30 cases).The surgical incision length,operation time,intraoperative bleeding,intraoperative blood transfusion,and preoperative and postoperative HGB changes were recorded.The postoperative Western Ontario Mcmasters Arthritis Index(WOMAC)score,American Society of Anesthesiologists(ASA)scores,Oxford Hip scale(OHS)score and 10-meter walking test were used for postoperative joint function score.Results There was no significant difference in preoperative ASA score,intraoperative blood transfusion volume,operation time,intraoperative blood loss,hemoglobin reduction and hospital stay between DAA group and PLA group(all P>0.05).The length of the incision in the DAA group was shorter than in the PLA group(10.22±0.51 cm vs.15.26±1.10 cm,P<0.05).There were no significant differences in WOMAC scores(including pain,limited activity,daily activity and total score),OHS scores,and 10-meter walking test results between two groups at 2nd,4th,and 6th week postoperatively(P>0.05).There was no significant difference in the degree of hip movement between the two groups(P<0.05).The WOMA scores(including sitting on the bed,bending up,wearing shoes and socks)at 6th and 12th week postoperation indicated that there was no significant difference in the range of movement(ROM)of hips between two groups(P>0.05).There was no significant difference in the incidence of major complications between the two groups.Asymptomatic large trochanteric avulsion fractures occurred in one case of the DAA group.After 6 weeks of conservative observation,the patient was cured.There was one case of dislocation in the PLA group,and after reduction by hand,there was no dislocation.No ossification was found in the two groups at 12th week of follow-up.Conclusion THA through DAA is equivalent to THA through PLA,and two kinds of approaches can obtain good short-term effect.The patients subject to THA through DAA had better postoperative ROM.For young patients with high hip flexion activity,the DAA approach is preferred,but for the complex initial and revision cases,we prefer the posterior approach.