直接前入路与前外侧入路在人工全髋关节置换术后临床疗效的Meta分析

Meta-analysis of clinical efficacy of direct anterior approach and anterolateral approach after total hip arthroplasty

目的系统地比较直接前入路(DAA)与前外侧入路(ALA)在人工全髋关节置换术的临床疗效。方法计算机检索PubMed、Embase、Cochrane、知网、万方、维普等数据库(自建库以来到2019年7月)关于DAA与ALA髋关节置换术后临床疗效对照研究文献,按照纳入与排除标准进行筛选文献提取数据,并对文献质量进行评估。采用Review manager 5.2进行Meta分析,比较DAA与ALA临床疗效的差异,主要分析指标包括并发症(股外侧神经损伤、周围骨折)、影像学表现(前倾角、髋臼杯外展角)、术后髋关节功能Harris评分,次要指标为术中出血量、手术时间、住院时间。结果共有8篇文献、730例患者纳入研究。研究结果显示两组患者周围骨折[RR=2.02,95%CI(0.45~9.10),P=0.36]、前倾角[WMD=2.22,95%CI(-0.06~4.51),P=0.06]、髋臼杯外展角[WMD=0.66,95%CI(-0.38~1.71),P=0.21]、术后髋关节Harris评分[WMD=0.47,95%CI(-2.71~3.66),P=0.77]、手术时间[WMD=-0.44,95%CI(-1.14~0.26),P=0.22]、手术切口[WMD=-1.18,95%CI(-2.89~0.51),P=0.17]等方面差异无统计学意义;DAA入路股外侧神经损伤发生率高于ALA入路[RR=3.79,95%CI(1.43~10.01),P=0.007],但术中出血量少于ALA入路[WMD=-75.15,95%CI(-107.30^-43.00),P<0.001],患者住院时间短于ALA入路[WMD=-2.30,95%CI(-4.24^-0.36),P=0.02]。结论两种入路在影像学表现、术后髋关节功能Harris评分、手术时间、术口长度等方面无显著差异,但DAA入路术中出血量少,住院时间短,两者在并发症方面DAA入路股外侧神经损伤发生率高,但周围骨折发生率两者均较低,差异不明显。纳入研究异质性较大,结果需要更高质量对照研究进一步验证。

Objective To systematically compare the clinical outcomes of direct anterior approach(DAA)and anterior lateral approach(ALA)in total hip arthroplasty.Methods Controlled research literatures on the clinical effects of DAA and ALA hip arthroplasty were searched from PubMed,Embase,Cochrane,CNKI,Wanfang,Weipu and other databases(since the establishment of the databases until July,2019).According to inclusion and exclusion criteria,the literatures were screened and extracted,and the quality of them were evaluated.Meta-analysis was conducted by Review Manager 5.2,and the difference of clinical efficacy between DAA and ALA was compared.The main analysis indexes were complications(lateral femoral nerve injury and peripheral fracture),imaging findings(anterior dip angle,acetabular cup abduction angle)and postoperative Hip function Harris score.Secondary analysis indexes were intraoperative blood loss,operation time and hospital stay.Results A total of 8 articles and 730 patients were included in the study.The results of the study showed that there were no statistically significant differences in peripheral fractures[RR=2.02,95% CI(0.45~9.10),P=0.36],anteversion angles[WMD=2.22,95% CI(-0.06~4.51),P=0.06],hip cup abduction angles[WMD=0.66,95%CI(-0.38~1.71),P=0.21],postoperative hip joint Harris scores[WMD=0.47,95% CI(-2.71~3.66),P=0.77],operation time[WMD=-0.44,95% CI(-1.14~0.26),P=0.22],and surgical incisions[WMD=-1.18,95% CI(-2.89~0.51),P=0.17]between the two groups.The incidence of lateral nerve injury in the DAA approach was higher than that in the ALA approach[RR=3.79,95% CI(1.43~10.01),P=0.007],but the intraoperative blood loss was less than that in the ALA approach[WMD=-75.15,95% CI(-107.30^-43.00),P<0.001],patient hospitalization time was shorter than that in the ALA approach[WMD=-2.30,95%CI(-4.24^-0.36),P=0.02].Conclusion There are no significant differences between the two approaches in imaging findings,postoperative hip function Harris score,operation time and the length of the operation opening.However,the DAA approach has less bleeding and shorter hospital stay.The incidence of lateral nerve injury in the DAA approach is high,but the incidence of peripheral fractures in both approaches is low,difference is not significant.The heterogeneity of the inclusion study is large,and the results need to be further verified by higher quality control studies.