微创全髋关节置换治疗髋部疾病的疗效系统评价

Systematic review on the curative effect of total hip arthroplasty through direct anterior approach versus posterolateral Approach

目的系统性评价直接前入路和后外侧入路全髋关节置换术(THA)治疗髋部疾病的临床疗效。方法选取Cochrane Library、Pubmed、Web of Science、CBM、CNKI等数据库,计算机检索建库至2017年12月国内外公开发表的直接前入路(DAA入路组)与后外侧入路(PSA入路组) THA疗效比较的随机对照研究文献或观察性研究文献。由2名研究者独立对纳入的文献进行质量评价及数据提取,采用Rev Man 5. 3软件进行Meta分析。结果最初检索出249篇相关文献,经筛选最终纳入9篇文献,其中中文7篇,英文2篇;随机对照研究8篇,回顾性研究1篇;共纳入病例942例,DAA入路组463例、后外侧入路组479例。Meta分析结果显示:两组在切口长度[标准均数差(SMD)=-2. 51,95%CI:-4. 84,-0. 19,P=0. 03]、手术时间(SMD=0. 84,95%CI:0. 10,1. 59,P=0. 03)、术中出血量(SMD=-1. 52,95%CI:-2. 98,-0. 05,P=0. 04)、术后1个月Harris髋关节功能评分(SMD=2. 58,95%CI:0. 65,4. 51,P=0. 008)、术后24 h VAS评分(SMD=-0. 65,95%CI:-0. 91,-0. 38,P <0. 01)、术后卧床时间(SMD=-1. 85,95%CI:-3. 00,-0. 70,P=0. 002)、住院时间(SMD=-1. 12,95%CI:-1. 62,-0. 61,P <0. 01)等方面比较,差异有统计学意义;两组在引流量(SMD=-1. 45,95%CI:-3. 40,0. 49,P=0. 14)、末次随访时Harris髋关节功能评分(SMD=0. 91,95%CI:-0. 31,2. 14,P=0. 15)、术后48 h VAS评分(SMD=-1. 21,95%CI:-3. 03,0. 61,P=0. 19)、髋臼前倾角(SMD=-0. 50,95%CI:-1. 06,0. 05,P=0. 07)、外展角(SMD=-0. 01,95%CI:-0. 32,0. 30,P=0. 97)及并发症发生率(OR=1. 10,95%CI:0. 59,2. 07,P=0. 77)等方面比较,差异无统计学意义。利用末次随访时Harris髋关节功能评分及术后并发症发生率漏斗图来分析是否存在发表偏倚,漏斗图显示两侧基本对称。结论与后外侧入路THA相比,DAA入路THA对软组织损伤更小,术后恢复更快,符合当前微创治疗理念,推荐临床应用。

Objective To systematic evaluate the curative effect of total hip arthroplasty(THA)through direct anterior approach versus(DAA)posterolateral approach(PSA).Methods All the randomized controlled trial(RCT)articles and observational research articles about the curative effect of THA through direct anterior approach(DAA group)versus posterolateral approach(PSA group)for treatment of hip disease that published at home and abroad included from database establishing to December 2017 were retrieved from Cochrane Library,Pubmed,Web of Science,CBM and China national knowledge internet(CNKI)through computer.The articles were screened and the infonnation was extracted independently by two authors.A Meta-analvsis was performed utilizing the RevMan 5.3 software.Results Two hundred and forty-nine articles were searched out in the initial stage.After screening,7 Chinese articles and 2 English articles(942 cases)were included in the final analysis,including 8 RCT articles and I observational research article,and 463 patients in direct anterior approach and 479 patients in posterolateral approach.The results of Meta-analysis demonstrated that the incision length,operation time,intraoperative blood less,Harris hip function scores at I month after surgery,visual analogue scale(VAS)scores at 24 hours after surgery,postoperative bed rest time and the hospital stay were better in DAA group compared to PSA group(SMD=-2.51,95%CI:-4.84,-0.19,P=0.03);(SMD=0.84,95%CI:0.10,1.59,F=0.03);(SMD=-1.52,95%67:-2.98,-0.05,P=0.04);(SMD=2.58,95%Cl:0.65,4.51,P=0.009);(SMD=-0.65,95%CI:-0.91,-0.38,P<0.01);(SMD=-1.85,95%CI:-3.00,-0.70,P=0.002);(SMD=-1.12,95%CI:-1.62,-0.61,P<0.01).There were no statistical difference in drainage(SMD=-1.45,95%CI:-3.40,0.49,P=0.14),Harris hip function scores at last follow-up(SMD=0.91,95%CI:-0.31,2.14,P=0.15),VAS scores at 48 hours after surgery(SMD=-1.21,95%CI:-3.03,0.61,P=0.19),acetabular anteversion angles(SMD=-0.50,95%CI:-1.06,0.05,P=0.07),acetabular abduction angles(SMD=-0.01,95%CI:-0.32,0.30,P=0.97)and incidence of complications(OR=1.10,95%CI:0.59,2.07,P=0.77)between the 2 groups.The result of analysis of publication bias according to Harris hip function scores at last follow-up and incidence of complications showed that the funnel-plot was essentially bilateral symmetry.Conclusions FHA through DAA can significantly reduce the soft-tissue damage,and it is beneficial for patients quick recovery,also it conforms to the current concept of minimally invasive treatment that worthy of promotion.