保留肌-关节囊组织瓣的改良后侧入路全髋关节置换术治疗老年GardenⅣ型股骨颈骨折的早期疗效观察

Early efficacy of total hip arthroplasty by modified posterior approach with muscle-capsule flap for elderly with Garden Ⅳ femoral neck fracture

目的探讨保留肌-关节囊组织瓣的改良后侧入路全髋关节置换术治疗老年GardenⅣ型股骨颈骨折的早期临床疗效。方法前瞻性随机对照研究。选取2017年10月—2018年10月山东省文登整骨医院老年GardenⅣ型股骨颈骨折患者60例,其中男33例、女27例,年龄60~75岁。随机分为常规组和改良组,每组30例。常规组行传统后侧入路全髋关节置换术,改良组行保留肌-关节囊组织瓣的改良后侧入路全髋关节置换术。记录并对比两组手术时间、出血量及并发症发生情况;术后第2天行患髋正侧位X线摄片,测量髋关节假体髋臼外展角、前倾角。术后1、3、12个月采用Harris髋关节功能评分评价髋关节功能,采用疼痛视觉模拟评分法(VAS)评估髋关节疼痛。术后12个月采用健康调查简表(SF-36)评估患者生活质量。结果两组患者性别构成、年龄、手术侧别、致伤原因以及受伤至手术时间等基线资料比较,差异均无统计学意义(P值均>0.05)。改良组手术时间、出血量分别为(42.37±4.94)min、(94.83±9.78)mL,常规组分别为(45.53±3.43)min、(107.4±14.60)mL,与常规组比较,改良组术中出血量少、手术时间短,差异均有统计学意义(t=2.882、3.792,P值均<0.05)。术后第2天复查骨盆正侧位X线片,改良组髋臼前倾角、外展角分别为16.47°±1.74°、45.53°±1.57°,常规组分别为16.10°±1.18°、46.13°±1.11°,两组间差异均无统计学意义(P值均>0.05)。常规组术中发生股骨大转子骨折1例,术后发生髋关节脱位1例、深静脉血栓形成1例;改良组术后发生深静脉血栓形成1例、坐骨神经麻痹(踝背伸无力)1例:两组患者术中、术后并发症发生率比较,差异无统计学意义(P>0.05)。60例患者均获得随访,随访时间12~15个月。改良组患者术后1、3、12个月的髋关节功能Harris评分分别为(81.80±2.87)、(90.00±2.00)、(96.23±0.82)分,高于常规组的(79.40±1.96)、(87.67±1.67)、(93.67±1.18)分,差异均有统计学意义(t=3.784、4.908、9.771,P值均<0.01)。术后1、3、12个月,两组VAS评分差异均无统计学意义(P值均>0.05)。改良组术后12个月SF-36量表中生理机能、生理职能评分分别为(93.43±0.89)、(77.83±0.91)分,高于常规组的(91.43±1.40)、(74.90±1.47)分,差异均有统计学意义(t=7.261、8.837,P值均<0.05),其余项目评分两组差异均无统计学意义(P值均>0.05)。结论与常规后侧入路相比,采用保留肌-关节囊组织瓣的改良后侧入路全髋关节置换术治疗老年GardenⅣ型股骨颈骨折,在准确置入假体的情况下,手术创伤更小,术后恢复更快,生活质量更高。

Objective To investigate the early clinical efficacy of total hip arthroplasty by modified posterior approach with muscle-capsule flap in the treatment of elderly with GardenⅣfemoral neck fracture.Methods Prospective randomized controlled trial was conducted between October 2017 and October 2018 among 60 eligible elderly patients with GardenⅣfemoral neck fracture in Wendeng Orthopedic Hospital,including 33 males and 27 females aged 60-75 years old.The patients were randomly divided into conventional and modified groups with 30 cases in each group.The conventional group underwent traditional posterior-approach total hip arthroplasty,and the modified group underwent modified posterior-approach total hip arthroplasty with preservation of muscle-capsule flap.The operation time,blood loss,and complications between the two groups were recorded and compared.The anteroposterior and lateral X-ray films of the affected hip were taken on the second day after operation,and the abduction angle and anteversion angle of the hip prosthesis were measured.Harris score was used to evaluate hip function,and visual analogue scale(VAS)was used to evaluate pain on the 1st,3rd,and 12th months after surgery.The Medical Outcomes Study 36-item short-form health survey(SF-36)was used to evaluate the quality of life at the 12th month after surgery.Results The two groups had no significant differences in gender,age,operation side,cause of injury,and time from injury to operation(all P values>0.05).The operation time and blood loss of the improved group were(42.37±4.94)min and(94.83±9.78)mL respectively,and those of the conventional group were(45.53±3.43)min and(107.4±14.60)mL,respectively.Compared with the conventional group,the improved group had less intraoperative blood loss and shorter operation time(t=2.882,3.792;all P values<0.05).The anteroposterior and lateral X-ray films of the pelvis were taken on the 2nd day after the operation.The anteversion and abduction angles of the acetabulum in the improved group were 16.47°±1.74°and 45.53°±1.57°,respectively,whereas those in the conventional group were 16.10°±1.18°and 46.13°±1.11°,respectively,but no significant difference was found between the two groups(all P values>0.05).The conventional group has one case of femoral trochanter fracture,one case of hip dislocation,and one case of deep vein thrombosis,whereas the improved group has one case of deep vein thrombosis and one case of sciatic nerve paralysis(ankle dorsiflexion weakness).The incidence of intraoperative and postoperative complications between the two groups had no significant difference(P>0.05).The Harris scores of hip joint function in the improved group at the 1st,3rd,and 12th months after operation were(81.80±2.87),(90.00±2.00)and(96.23±0.82)points,respectively,which were higher than those in the conventional group(79.40±1.96),(87.67±1.67)and(93.67±1.18)points,respectively),and the differences were statistically significant(t=3.784,4.908,9.771;all P values<0.01).The VAS score of the two groups at the 1st、3rd and 12th months after operation had no significant difference(all P values>0.05).At the 12th month after operation,the improved group had physiological function and physiological function of SF-36 scores of(93.43±0.89)and(77.83±0.91)points,respectively,which were higher than those in the conventional group(91.43±1.40)and(74.90±1.47)points,respectively,and the differences were statistically significant(t=7.261,8.837;all P values<0.05).The two groups had no statistically significant differences in the scores of other items(all P values>0.05).Conclusions Compared with conventional posterior approach,the modified posterior approach of total hip arthroplasty with muscle-capsule flap for the treatment of GardenⅣfemoral neck fracture in the elderly can reduce surgical trauma,make the postoperative recovery faster,and improve the quality of life without affecting the accurate placement of the prosthesis.