侧卧位直接前方入路全髋关节置换治疗强直性髋关节的早期疗效

Total hip arthroplasty by direct anterior approach in the lateral position in the treatment of ankylosed hips: early therapeutic effects

背景:全髋关节置换治疗晚期髋关节强直可恢复髋关节的运动功能,缓解疼痛,提高患者的生活质量。但由于强直性髋关节特殊的解剖和病理生理异常,髋臼侧显露和假体正确安装尤为困难。为了获得良好的髋臼侧显露,既往主要采用外侧入路结合大转子截骨、前后联合入路等入路来获得充分暴露,但上述入路都不可避免的损伤了强直性髋关节患者长期失用性萎缩的髋关节周围肌肉。而直接前方入路是通过阔筋膜张肌与缝匠肌间隙进入,最符合微创手术标准的全髋置换入路,髋臼侧显露充分,同时具有软组织损伤小、置换治疗后恢复快等优点。目的:探讨侧卧位下直接前方入路全髋关节置换治疗强直性髋关节的早期临床效果。方法:回顾性分析 2016 年 11 月至 2018 年 5 月在安徽医科大学第二附属医院骨科采用侧卧体位下直接前方入路全髋关节置换治疗 12 例(17 髋)强直性髋关节患者,记录切口长度、手术时间、术中出血量、假体位置、直腿抬高时间并随访关节活动度、Harris 评分、疼痛目测类比评分以及不良反应情况。试验获安徽医科大学第二附属医院伦理委员会批准,批准号为院医字(2018)7 号。结果与结论:①12 例患者(17 髋)平均的切口的长度、手术时间、术中失血量、直腿抬高时间分别为(11.12±1.69)cm、(122.47±25.40)min、(279.41±135.85)mL 和(9.59±4.62)d;②假体位置良好:平均前倾角度为(15.76±2.84)°,平均外展角为(40.00±3.45)°;③与置换前相比,置换后髋关节屈曲活动度及 Harris评分明显增加,疼痛目测类比评分明显降低,且随时间的延长,进一步改善;④置换治疗中发生 1 例股骨Cheng Wendan, MD,近端骨折,予以钢丝捆扎固定,3 个月后骨折愈合,髋关节功能良好。未发生感染、深静脉血栓、脂肪栓Associate chief physician,塞、假体松动、肢体长度不等和关节脱位等并发症;⑤结果提示侧卧位下直接前方入路全髋关节置换治疗Associate professor,强直性髋关节能直视下松解髋关节前方挛缩的软组织,髋臼暴露充分,利于假体正确安装,同时创伤小, Master’s supervisor,髋关节功能恢复快,早期疗效满意,是强直性髋关节全髋关节置换的安全有效入路。

BACKGROUND: Total hip arthroplasty in the treatment of advanced hip ankylosis can restore the motion function of hip joint, relieve pain and improve the quality of life of patients. However, due to the special anatomical and pathophysiological abnormalities of ankylosing hip joint, it is particularly difficult to expose the acetabular side and install the prosthesis correctly. To obtain good acetabular exposure, lateral approach combined with greater trochanter osteotomy and anterior-posterior combined approach were used to obtain full exposure. However, these approaches inevitably damaged the long-term disused atrophic peri-hip muscles of ankylosing hip patients. The direct anterior approach is through the gap between tensor fasciae latae and sartorius muscle. It is the most minimally invasive approach for total hip arthroplasty. The acetabular side is fully exposed. At the same time, it has the advantages of less soft tissue injury and fast recovery after replacement. OBJECTIVE: To investigate the clinical efficacy of total hip arthroplasty with direct anterior approach in the lateral position in the treatment of ankylosis hip. METHODS: A retrospective analysis was performed on the clinical data of 12 patients (17 hips) who underwent total hip arthroplasty with direct anterior approach in the lateral position for the treatment of hip ankylosis from November 2016 to May 2018. Length of incisions, operation time, intraoperative blood loss, prosthesis position, straight leg-raising time, visual analogue scale score, range of motion, Harris hip score and adverse reactions were recorded. This study was approved by the Ethics Committee of the Second Affiliated Hospital of Anhui Medical University (approval number:(2018)7). RESULTS AND CONCLUSION:(1) The average incision length, operative time, intraoperative blood loss and straight leg-raising time of 12 patients (17 hips) were (11.12±1.69) cm,(122.47±25.40) minutes,(279.41±135.85) mL and (9.59±4.62) days, respectively.(2) The prosthesis was in good position. The average forward angle was (15.76±2.84)°;average abducent angle was (40.00±3.45)°.(3) Compared with that before replacement, Harris score and range of motion remarkably increased, but visual analogue scale score obviously decreased, after replacement, and gradually improved with prolonged time.(4) One case of proximal femur fracture occurred and was fixed with wire binding intraoperatively;the fracture healed and the hip function recovered well 3 months later. No complications occurred such as infection, deep vein thrombosis, fat embolism, prosthesis loosening, limb length inequality and joint dislocation.(5) Total hip arthroplasty with direct anterior approach in the treatment of hip ankylosis in the lateral position is safe and effective, which has the advantages of small trauma, quick recovery of hip function, and can expose acetabulum fully and installed prosthesis properly, and the early clinical efficacy is satisfied.