直接前入路和前外侧入路全髋关节置换术后的早期功能恢复对比
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摘要
目的:对比直接前入路(direct anterior approach,DAA)与前外侧入路(anterolateral approach,ALA)行全髋关节置换术的早期临床疗效,了解两种手术方式的安全性及术后功能恢复情况。方法:选择2015年1月至2016年5月贵州省人民医院骨科行人工髋关节置换术(total hip arthroplasty,THA)治疗的50例患者,随机分成2组,25例25髋行直接前入路人工全髋关节置换术(DAA-THA),其中男16例16髋,女9例9髋,平均年龄(62±2)岁(48~76岁),疾病组成为髋关节骨关节炎11例11髋、股骨头缺血性坏死(Ⅲ~Ⅳ期)10例10髋和髋臼发育不良(Crowe2型)4例4髋,体重指数(body mass index,BMI)(23.26±4.95)kg/m2(19.6~29.5 kg/m2),术前Harris评分(33.4±15.5)分(17.9~48.9分);同期25例25髋行前外侧入路人工全髋关节置换术(ALA-THA),其中男18例18髋,女7例7髋,平均年龄(59±3)岁(43~72岁),疾病组成为髋关节骨关节炎10例10髋、股骨头缺血性坏死(Ⅲ~Ⅳ期)12例12髋和髋臼发育不良(Crowe 2型)3例3髋,BMI为(25.35±5.8)kg/m2(18.2~29.8 kg/m2),术前Harris评分(38.6±16.7)分(23.1~56.5分)。分别对两组的手术时间、切口长度、术中出血量、术后关节功能恢复情况进行评估。结果:手术时间:DAA组(108.33±18.5)min(98~135 min),ALA组(103.26±15.5)min,(85~116 min),两组之间差异无统计学意义(P>0.05);手术切口:DAA组平均手术切口长度(10.3±1.75)cm(8.7~12.2 cm),ALA组平均切口长度(9.6±1.65)cm(7.9~11.2 cm),两组之间差异无统计学意义(P>0.05);出血量:DAA组(210±135)m L(130~400 m L),ALA组(230±145)m L(160~450 m L),两组之间差异无统计学意义(P>0.05);两组患者随访平均时间6个月(6~12个月),术后3个月Harris评分,DAA组(88.7±9.05)分(79.1~97.2)分,ALA组(86.5±7.75)分(77.9~93.4分),两组之间差异无统计学意义(P>0.05),术后6个月,Harris评分,DAA组(93.5±5.85)分(87.4~99.1分),ALA组(90.9±5.15)分(86.9~97.2分),两组之间差异无统计学意义(P>0.05);ALA组术后早期随访患者髋关节的外展肌力、步态较DAA组差。结论:直接前入路髋关节置换术与前外侧常规入路髋关节置换术均可取得较好的早期疗效,但直接前入路早期步态更优于前外侧常规入路。
Objective: To evaluate the early clinical effects of direct anterior approach( DAA) versus anterolateral approach( ALA) on safety and functional recovery following total hip arthroplasty( THA).Methods: Between January 2015 and May 2016,a randomized clinical trial was performed at Guizhou Provincial People's Hospital. A total of 50 patients who underwent THA were allocated for either the DAA( n = 25) or ALA( n = 25). DDA group had 25 patients( 25 hips),including 16 males and 9 females,with the mean age of( 62 ± 2) years,BMI of( 23. 26 ± 4. 95) kg/m2( range: 19. 6 to 29. 5),and preoperative Harris score of( 33. 4 ± 15. 5)( range: 17. 9 to 48. 9). Eleven cases were diagnosed as primarily hip osteoarthritis,4 were developmental dysplasia of the hip( DDH,Crowe 2) and 10 were hip avascular necrosis( AVN,Stages 3 to 4). ALA group had 25 patients( 25 hips),including 18 males and 7 females,with the mean age of( 59 ± 3) years,BMI of( 25. 35 ± 5. 8) kg/m2( range: 18. 2 to29. 8),and preoperative Harris score of( 38. 6 ± 16. 7)( range: 23. 1 to 56. 5). Ten cases were diagnosed as primarily hip osteoarthritis,3 were developmental dysplasia of the hip( DDH,Crowe 2) and 12 were hip avascular necrosis( AVN,Stages 3 to 4). Operation time,incision length,intra-operative blood loss and functional recovery of hip postoperatively were compared between the two groups. Results: The surgical incision of both groups were stage Ⅰhealing. The mean follow-up was 6 months. There was no significant difference regarding operation time,incision length,and intra-operative blood loss between the two groups. However,we also found that there was no significant difference in the Harris score 3 months and 6 months postoperatively. In addition,two patients in ALA group suffered claudication( physical examination: abduction dysfunction of hip). We also found that DAA group resulted in better recovery of abductor strength and gait than ALA group during early follow-up. Conclusion: Both DAA and ALA could obtain good results of early curative effect following THA. Moreover,DAA resulted in better gait than ALA during early follow-up.
Objective: To evaluate the early clinical effects of direct anterior approach( DAA) versus anterolateral approach( ALA) on safety and functional recovery following total hip arthroplasty( THA).Methods: Between January 2015 and May 2016,a randomized clinical trial was performed at Guizhou Provincial People's Hospital. A total of 50 patients who underwent THA were allocated for either the DAA( n = 25) or ALA( n = 25). DDA group had 25 patients( 25 hips),including 16 males and 9 females,with the mean age of( 62 ± 2) years,BMI of( 23. 26 ± 4. 95) kg/m2( range: 19. 6 to 29. 5),and preoperative Harris score of( 33. 4 ± 15. 5)( range: 17. 9 to 48. 9). Eleven cases were diagnosed as primarily hip osteoarthritis,4 were developmental dysplasia of the hip( DDH,Crowe 2) and 10 were hip avascular necrosis( AVN,Stages 3 to 4). ALA group had 25 patients( 25 hips),including 18 males and 7 females,with the mean age of( 59 ± 3) years,BMI of( 25. 35 ± 5. 8) kg/m2( range: 18. 2 to29. 8),and preoperative Harris score of( 38. 6 ± 16. 7)( range: 23. 1 to 56. 5). Ten cases were diagnosed as primarily hip osteoarthritis,3 were developmental dysplasia of the hip( DDH,Crowe 2) and 12 were hip avascular necrosis( AVN,Stages 3 to 4). Operation time,incision length,intra-operative blood loss and functional recovery of hip postoperatively were compared between the two groups. Results: The surgical incision of both groups were stage Ⅰhealing. The mean follow-up was 6 months. There was no significant difference regarding operation time,incision length,and intra-operative blood loss between the two groups. However,we also found that there was no significant difference in the Harris score 3 months and 6 months postoperatively. In addition,two patients in ALA group suffered claudication( physical examination: abduction dysfunction of hip). We also found that DAA group resulted in better recovery of abductor strength and gait than ALA group during early follow-up. Conclusion: Both DAA and ALA could obtain good results of early curative effect following THA. Moreover,DAA resulted in better gait than ALA during early follow-up.
引文
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[13]Restrepo C,Parvizi J,Pour AE,et al.Prospective randomized study of two surgical approaches for total hip arthroplasty[J].J Arthroplasty,2010,25(5):671-679.
[14]沈军,邹天明,王东来,等.改良外侧小切口全髋关节置换术的疗效分析[J].中国骨与关节损伤杂志,2012,27(10):876-878.
[15]Lachiewicz PF.Abductor tendon tears of the hip:evaluation and management[J].J Am Acad Orthop Surg,2011,19(7):385-391.
[16]Van Oldenrijk J,Hoogervorst P,Schaap GR,et al.Two-incision minimally invasive total hip arthroplasty-results and complications[J].Hip Int,2011,21(1):81-86.
[17]桑伟林,朱力波,马金忠,等.微创直接前入路全髋关节置换术[J].国际骨科学杂志,2010,31(5):266-267.
[2]Morrey BF.Difficult complications after hip joint replacement.Dislocation[J].Clin Orthop Relat Res,1997(344):179.
[3]Brennan SA,Khan F,Kiernan C,et al.Dislocation of primary total hip arthroplasty and the risk of redislocation[J].Hip Int,2012,22(5):500-504.
[4]Van Warmerdam JM,Mcgann WA,Donnelly JR,et al.Achilles allograft reconstruction for recurrent dislocation in total hip arthroplasty[J].J Arthroplasty,2011,26(6):941-948.
[5]White RE,Forness TJ,Allman JK,et al.Effect of posterior capsular repair on early dislocation in primary total hip replacement[J].Clin Orthop Relat Res,2001(393):163-167.
[6]Goldstein WM,Gleason TF,Kopplin M,et al.Prevalence of dislocation after total hip arthroplasty through a posterolateral approach with partial capsulotomy and capsulorrhaphy[J].J Bone Joint Surg Am,2001,83(A Suppl):2-7.
[7]Pellicci PM,Bostrom M,Poss R.Posterior approach to total hip replacement using enhanced posterior soft tissue repair[J].Clin Orthop Relat Res,1998(355):224-228.
[8]张先龙,蒋垚,陈云苏.人工髋关节外科学[M].北京:人民军医出版社,2009:431-432.
[9]吕厚山.现代人工关节外科学[M].北京:人民卫生出版社,2006:520.
[10]Siguier T,Siguier M,Brumpt B.Mini-incision anterior approach does not increase dislocation rate:a study of 1037 total hip replacements[J].Clin Orthop Relat Res,2004(426):164-173.
[11]Matta JM,Shahrdar C,Ferguson T.Single-incision anterior approach for total hip arthroplasty on an orthopaedic table[J].Clin Orthop Relat Res,2005(441):115-124.
[12]Nakata K,Nishikawa M,Yamamoto K,et al.A Clinical comparative study of the direct anterior with mini-posterior approach:two consecutive series[J].J Arthroplasty,2009,24(5):698-704.
[13]Restrepo C,Parvizi J,Pour AE,et al.Prospective randomized study of two surgical approaches for total hip arthroplasty[J].J Arthroplasty,2010,25(5):671-679.
[14]沈军,邹天明,王东来,等.改良外侧小切口全髋关节置换术的疗效分析[J].中国骨与关节损伤杂志,2012,27(10):876-878.
[15]Lachiewicz PF.Abductor tendon tears of the hip:evaluation and management[J].J Am Acad Orthop Surg,2011,19(7):385-391.
[16]Van Oldenrijk J,Hoogervorst P,Schaap GR,et al.Two-incision minimally invasive total hip arthroplasty-results and complications[J].Hip Int,2011,21(1):81-86.
[17]桑伟林,朱力波,马金忠,等.微创直接前入路全髋关节置换术[J].国际骨科学杂志,2010,31(5):266-267.