前侧与后外侧入路全髋关节置换联合股骨近端截骨治疗化脓性髋关节炎后遗高位脱位的临床疗效

Comparison of clinical efficacy between anterior and posterolateral approaches for total hip arthroplasty combined with proximal femoral reconstruction osteotomy in the treatment of residual high dislocation after pyogenic hip arthritis

目的比较前侧入路和后外侧入路全髋关节置换联合股骨近端截骨治疗化脓性髋关节炎后遗高位脱位的临床疗效。方法回顾性分析2017年1月至2022年9月在中国科学技术大学附属第一医院(安徽省立医院)接受全髋关节置换联合股骨近端截骨治疗化脓性髋关节炎后遗高位脱位患者45例,依据手术入路分为前侧入路组14例和后外侧入路组31例。分析两组患者手术时间、术中出血量、术后在膝关节伸直后膝外侧视觉模拟评分(visual analogue scale,VAS)、肢体延长、髋关节Harris评分和并发症等,术后影像学评估髋臼前倾角和外展角、髋外展肌力臂、患侧髋-膝-踝角(hip-knee-ankle angle,HKA)、截骨部位骨愈合率和假体松动情况。结果所有患者均获得随访,随访时间(3.6±1.8)年(范围1.0~6.7年)。前侧入路组的手术时间为(141.4±21.0)min,长于后外侧入路组的(121.3±23.1)min;术中出血量为(425.2±80.2)ml,少于后外侧入路组的(535.1±96.3)ml,差异均有统计学意义(P<0.05)。前侧入路组患者在膝关节伸直后膝外侧疼痛的VAS评分为(3.2±0.8)分,低于后外侧入路组的(5.7±1.1)分,差异有统计学意义(t=7.300,P<0.001)。前侧和后外侧入路患者术后肢体延长分别为(5.0±1.5)cm和(4.5±1.4)cm,差异无统计学意义(t=1.075,P=0.289)。末次随访时,前侧和后外侧入路髋关节Harris评分分别为(86.2±5.0)分和(82.5±6.8)分,差异无统计学意义(t=1.839,P=0.073);前侧入路组髋臼前倾角、外展角和HKA角分别为12.9°±5.8°、42.6°±6.2°和179.8°±1.4°,后外侧入路组分别为14.5°±7.0°、44.2°±3.1°和178.8°±2.1°,差异均无统计学意义(P>0.05)。所有患者手术侧髋外展肌力臂为(5.6±0.7)cm,与健侧(5.9±0.6)cm比较差异无统计学意义(t=1.916,P=0.059)。末次随访时所有患者股骨近端重建截骨部位均骨性愈合。前侧入路1例患者出现股骨假体下沉,未进行股骨侧翻修;后外侧入路组2例发生髋关节后脱位,均在静脉麻醉下行闭合复位术。结论前侧入路较后外侧入路全髋关节置换联合股骨近端截骨治疗化脓性髋关节炎后遗高位脱位术中出血少、术后早期同侧膝关节外侧疼痛轻和脱位率低;股骨近端截骨可有效恢复髋外展肌力臂,截骨部位愈合率高。

ObjectiveTo compare the clinical efficacy of the anterior approach versus the posterolateral approach for total hip arthroplasty(THA)in treating residual high dislocation secondary to pyogenic hip arthritis,and to investigate the benefits of proximal femoral reconstruction osteotomy.MethodsA retrospective study was conducted on 45 patients who underwent THA combined with proximal femoral reconstruction osteotomy for high dislocation secondary to pyogenic hip arthritis at the First Affiliated Hospital of the University of Science and Technology of China from January 2017 to September 2022.Patients were categorized into two groups based on the surgical approach:14 in the anterior approach group and 31 in the posterolateral approach group.We analyzed surgical duration,intraoperative blood loss,postoperative visual analogue scale(VAS)scores for lateral knee pain after knee extension,postoperative limb lengthening,Harris hip scores,and complications.Radiographic assessments included anteversion and abduction angles of the acetabular cup,hip abductor muscle lever arm,hip-knee-ankle(HKA)angle of the affected side,osteotomy site bone healing rate,and prosthesis loosening.ResultsThe average follow-up period was 3.6±1.8 years(range,1.0-6.7 years).The anterior approach group had a significantly longer surgical duration(141.4±21.0 min)compared to the posterolateral approach group(121.3±23.1 min).Intraoperative blood loss was significantly less in the anterior approach group(425.2±80.2 ml)compared to the posterolateral approach group(535.1±96.3 ml).The difference was statistically significant(P<0.05).The VAS score for lateral knee pain after knee extension was significantly lower in the anterior approach group(3.2±0.8)than in the posterolateral approach group(5.7±1.1),the difference was statistically significant(t=7.300,P<0.001).Postoperative limb lengthening was 5.0±1.5 cm in the anterior approach group and 4.5±1.4 cm in the posterolateral approach group,with no significant difference(t=1.075,P=0.289).At the final follow-up,the Harris hip score was 86.2±5.0 in the anterior approach group and 82.5±6.8 in the posterolateral approach group,with no significant difference(t=1.839,P=0.073).The acetabular anteversion angle,abduction angle,and HKA angle in the anterior approach group were 12.9°±5.8°,42.6°±6.2°,and 179.8°±1.4°,respectively,while in the posterolateral approach group they were 14.5°±7.0°,44.2°±3.1°,and 178.8°±2.1°,respectively.The differences between the groups were not statistically significant(P>0.05).The hip abductor muscle lever arm was 5.6±0.7 cm on the surgical side compared to 5.9±0.6 cm on the healthy side,with no significant difference(t=1.916,P=0.059).All patients achieved bone healing at the osteotomy site by the final follow-up.One patient in the anterior approach group experienced femoral prosthesis subsidence but did not require femoral revision.Two patients in the posterolateral approach group experienced hip dislocation,both of which were managed with intravenous anesthesia and closed reduction.ConclusionThe anterior approach for THA combined with proximal femoral reconstruction osteotomy yields better clinical outcomes compared to the posterolateral approach,including reduced intraoperative blood loss,decreased lateral knee pain,and a lower rate of dislocation.Proximal femoral reconstruction osteotomy effectively restores the hip abductor muscle lever arm with a high rate of osteotomy site healing.