不同手术入路全髋关节置换术后并发症对比:单中心大样本回顾性病例对照研究

Comparison of complications between different surgical approach after total hip arthroplasty:a single high-volume center,retrospective case-control study

背景:近年来,直接前入路(DAA)全髋关节置换术(THA)逐渐成为关节外科领域的研究热点。临床中DAA入路是否真正优于传统后外侧入路(PLA)尚不清楚。目的:探讨加速康复外科(ERAS)背景下采用DAA入路和传统PLA入路THA术后并发症是否存在区别。方法:回顾性分析单中心、大样本连续病例资料,纳入2012年6月至2017年6月期间由同一位高年资关节外科医师主刀完成的初次THA患者1546例(1780髋)。其中914例患者(1015髋)采用传统PLA入路(PLA组),632例(765髋)采用DAA入路(DAA组)。通过住院病历系统以及急诊病历系统查询患者并发症情况,通过电话随访患者术后并发症情况,通过术后影像学资料测量假体安放位置、双下肢长度等指标。结果:本组1546例患者随访12~60个月,平均随访(38.4±10.5)个月。随访期内PLA组患者髋关节脱位发生率高于DAA组患者[0.69%(7/1015)vs 0],且差异有统计学意义(χ^(2)=5.297,P=0.021)。但DAA组患者股骨柄内翻发生率高于PLA组患者[3.8%(29/765)vs 1.6%(16/1015)],且差异有统计学意义(χ^(2)=8.681,P=0.003)。两组患者术中假体周围骨折发生率差异无统计学意义,但DAA组患者术中骨折程度更重,处理更棘手,2例股骨骨折需要更换体位通过PLA入路完成手术,其余大转子尖部骨折选择保守治疗。此外,两组患者双下肢不等长发生率、髋臼假体安放位置不良发生率差异均无统计学意义。结论:在降低THA术后脱位并发症方面,DAA入路比传统PLA入路更具有优势,但是平均手术时间更长,股骨柄内翻发生率更高,术中如果发生骨折处理较困难,甚至需要更换为PLA入路完成手术,在伤口并发症、髋臼假体安放位置以及肢体长度调整等方面两种手术入路没有明显区别。

Background:Total hip arthroplasty(THA)through direct anterior approach(DAA)has caught great attention worldwide in recent years,but it is unclear whether the new technique is superior to traditional posterolateral approach(PLA)in clinic.Objective:To compare complications after THA through DAA versus PLA.Methods:A retrospective analysis was performed in a total of 1546 consecutive patients(1780 hips)who underwent primary THA by one experienced surgeon from June 2012 to June2017 at a high-volume center.THA was completed by PLA in 914 patients(1015 hips)and by DAA in 632 patients(765 hips).Complications were investigated by medical records and telephone follow-up.Prothesis position and length of both lower extremities were measured by postoperative imaging data.Results:The mean duration of follow-up was(38.4±10.5)months(range,12-60 months)in these patients.PLA group had higher incidence of dislocation than DAA group(0.69%vs 0,P=0.021),but the varus rate of femoral stem was significantly higher in DAA group than that in PLA group(3.8%vs 1.6%,P=0.003).Although there was no significant difference in the incidence of periprosthetic fracture between the two groups,the fracture in DAA group was more serious and more difficult to handle.Two patients with proximal femoral fracture in DAA group had to convert PLA for fracture fixation and femoral stem insertion,the other fractures of greater trochanter were treated by conservative therapy.No significant difference was detected in leg discrepancy or malposition of acetabular cup between the two groups.Conclusions:The DAA has lower risk of dislocation,higher incidence of femoral stem varus and longer operation time as compared with PLA in THAs.There are no significant differences in the incidence of incision problem,acetabular component malposition or leg discrepancy between the two surgical approaches.However,intraoperative fracture in DAA group is more serious and difficult to handle.