直接上方入路与外侧入路行全髋关节置换术的临床疗效比较

Clinical comparison of direct superior approach and lateral hardinge approach in total hip arthroplasty

目的 比较直接上方入路(DSA)和外侧(Hardinge)入路行全髋关节置换术(THA)的临床疗效。方法 回顾性分析2018年1月—2020年10月新乡医学院第一附属医院骨外科行THA患者112例。男性58例,女性54例;年龄35~78岁,平均64.2岁。股骨头坏死60例,股骨颈骨折32例,骨关节炎20例。根据采用手术入路不同分为DSA组(48例)与Hardinge组(64例),DSA入路从大粗隆中后1/3交界处往后上方45°延伸切口,Hardinge入路沿股骨大粗隆向近端行倒J形切口。比较两组患者手术时间、切口长度、术中失血量、起始下地时间、住院时间、手术并发症发生情况等围术期指标;比较术后1、3d视觉模拟评分(VAS)以及术后3、6、12个月Harris评分等髋关节疼痛及功能指标;测算双下肢长度差异(LLP)、髋臼假体前倾角度及股骨偏心距等影像学指标。结果 两组患者均顺利手术,获得随访,随访时间12~25个月,平均16.1个月。与Hardinge组比较,DSA组切口长度更短(8.6±0.6)cm vs.(11.5±0.7)cm,起始下地时间更早(15.4±1.2)h vs.(18.2±1.7)h,住院时间更短(4.4±1.2)d vs.(7.2±1.7)d,术后并发症发生率也更低(14.6%vs.20.3%),但手术时间更长(97.5±15.1)min vs.(79.9±14.3)min,P<0.05。两组患者术中失血量和隐性失血量无显著差异(288.3±17.4)mL、(435±32.6)mL vs.(297.8±18.1)mL、(429±30.4)mL,P>0.05。DSA组术后1d VAS(3.56±0.47)分vs.(4.68±0.78)分、术后3个月Harris评分(82.63±5.83)分vs.(77.34±5.71)分均优于Hardinge组(P<0.05)。与Hardinge组比较,DSA组髋臼外展角更小(41.53±6.13)°vs.(44.24±5.87)°,但差异无统计学意义(P>0.05)。结论 DSA入路THA在减少手术创伤、降低并发症发生率以及早期减轻疼痛、快速功能恢复具有一定的优势。但更长期的效果差异还需要进一步观察和更全面的评估。

Objective To compare the clinical efficacy of direct superior approach(DSA)and lateral Hardingee approach for total hip arthroplasty(THA).Methods From Jan.2018 to Oct.2020,112 patients with THA in the Department of Orthopaedic Surgery of the First Affiliated Hospital of Xinxiang Medical College were retrospectively analyzed.There were 58 males and 54 females,with an average age of 64.2 years(range,35-78 years).There were 60 cases of femoral head necrosis,32 cases of femoral neck fracture,and 20 cases of osteoarthritis.They were divided into DSA group(48 cases)and Hardingee group(64 cases)according to different surgical approaches.The Hardingee approach was along the greater trochanter of the femur,an inverted J-shaped incision was made at the proximal end.And the DSA approach extended the incision 45°posteriorly and superiorly from the junction of the middle and posterior 1/3 of the greater trochanter.The perioperative indicators such as operation time,incision length,intraoperative blood loss,initial landing time,hospitalization time,and operative complications were compared between the two groups.Hip pain and function indicators such as Harris score at 6 and 12 months were compared,imaging indicators such as the length difference of the lower limbs,the anteversion angle of the acetabular prosthesis and the femoral eccentricity were calculated.Results All patients in the two groups underwent successful operations and were followed up for 12 to 25 months,with an average of 16.1 months.Compared with the Hardingee group,the DSA group had shorter incision length[(8.6±0.6)cm vs.(11.5±0.7)cm],earlier starting time to the ground[(15.4±1.2)hours vs.(18.2±1.7)hours],shorter hospital stay[(4.4±1.2)days vs.(7.2±1.7)days],and lower postoperative complication rate(14.6%vs.20.3%),but longer operative time[(97.5±15.1)minutes vs.(79.9±14.3)minutes],P<0.05.There was no significant difference in intraoperative blood loss and hidden blood loss between the two groups[(288.3±17.4),(435±32.6)mL vs.(297.8±18.1),(429±30.4)mL],P>0.05.VAS[(3.56±0.47)points vs.(4.68±0.78)points]and Harris score[(82.63±5.83)points vs.(77.34±5.71)points]in DSA group were better than Hardingee group at 1 day postoperatively(P<0.05).Compared with the Hardingee group,the acetabular abduction angle was smaller in the DSA group[(41.53±6.13)°vs.(44.24±5.87)°].Conclusion The DSA approach for THA has certain advantages in reducing THA surgical trauma and the incidence of complications,with early pain reduction,and rapid functional recovery.But longer-term differences in effects require further observation and a more comprehensive assessment.