微创人工关节置换治疗髋关节强直

目的 探讨微创全人工关节置换治疗髋关节强直的疗效.方法 2006年6月至2009年7月,13例(21髋)髋关节强直患者在微创入路下行人工全髋关节置换,年龄20～66岁(平均46岁),病因为:强直性脊柱炎5例(10髋),类风湿性关节炎4例(6髋),股骨头无菌性坏死继发严重骨性关节炎2例(3髋),髋关节感染后遗强直畸形2例...     

直接前侧微创入路全髋关节置换术临床应用研究

目的探讨直接前侧微创入路全髋关节置换术(THA)的临床应用效果。方法回顾性分析53例行直接前侧微创入路THA患者的临床资料,观察患者并发症发生情况,采用Harris评分评价患者的髋关节功能;通过骨盆正位X线片观察患者的假体位置及假体松动等情况。结果本组病例的平均手术时间为(114.3±38.9)min,平均术中失血量为(496.1±322.4)mL。术前Harris髋关节评分平均为38.9±11.9,术后12个月为93.2±14.6,术后Harris髋关节评分显著高于术前(t=-2.689,P=0.008)。臼杯前倾角平均为18.0°±7.6°,外展角平均为46.1°±8.5°。体质量指数与术中失血量及臼杯前倾角之间无显著相关性(r=0.102,P=0.089;r=0.112,P=0.075),但与手术时间(r=0.178,P=0.036)及臼杯外展角(r=0.154,P=0.028)呈弱正相关关系;手术时间随着手术例数的增加有减少趋势。术中发生手术切口周围神经损伤2例(3.8%),股骨近端骨折2例(3.8%);术后发生深静脉血栓形成3例(5.6%),髋关节脱位3例(5.6%);并发症发生率为20.8%。结论直接前侧微创入路THA创伤小,手术时间短,患者术后恢复快,有利于保留髋关节周围肌群正常张力,维持髋关节稳定。采用直接前侧微创入路THA,应熟练掌握手术技术,避免并发症的发生,以保证获得良好的手术效果。     

Comparison of minimally invasive surgery and mini-incision technique for total hip arthroplasty: a sub-group meta-analysis

Background  It is well accepted that the minimally invasive surgery (MIS) for total hip arthroplasty (THA) should combine with less or no muscle damage and is different from mini-incision technique and MIS should have better outcomes than mini-incision surgery. The aim of current analysis was to apply an explicitly defined sub-group analysis to confirm whether this hypothesis is true.

Methods  A computerized literature search was applied to find any data concerning MIS or mini-incision THAs. A multistage screening was then performed to identify randomized studies fulfilling the inclusive criteria for the analysis. The data were extracted, and sub-group analyses of MIS or mini-incision surgery for different kinds of outcomes were carried out. The P(sub) value for difference between MIS sub-group and mini-incision sub-group was also calculated.

Results  Eleven studies that fulfilling the inclusion criteria were included, with 472 cases in the study group (MIS or mini-incision) and 492 cases in the conventional group. The overall analysis showed the study group would achieve less surgical duration (P=0.037), intraoperative blood (P <0.001) and incision length (P <0.001) than conventional group. The difference between sub-groups showed, the MIS would achieve shorter incision length (P(sub) <0.05) and bigger cup abduction angle (P(sub) <0.05), and cause more blood loss (P (sub) <0.05) than mini-incision technique. Other indexes were comparable between the two sub-groups.

Conclusions  Though further high quality studies are still needed, the result of current analysis offered an initial conclusion that MIS THA failed to achieve a better clinical outcome than mini-incision technique. The exact definition of MIS still needs to be improved.

     

COA: Comparison of minimally invasive surgery(MIS) and mini-incision technique for total hip arthroplasty: a sub-group meta-analysis

Abstract: Background: It is well accepted that the minimally invasive surgery(MIS) for total hip arthroplasty(THA) should combine with less or no muscle damage and is different from mini-incision technique and MIS should have better outcomes than mini-incision surgery. The object of current analysis was to apply an explicitly defined sub-group analysis to confirm whether this hypothesis is true. Methods: A computerized literature was applied to find any data concerning MIS or mini-incision THAs. A multistage screening was then performed to identify randomized studies fulfilling the inclusive criteria for the analysis. The data were extracted, and sub-group analyses of MIS or mini-incision surgery for different kinds of outcomes were carried out. The p(sub) value for difference between MIS sub-group and mini-incision sub-group was also calculated. Results: 11 studies that fulfilling the inclusive criteria were included, with 472 cases in the study group(MIS or mini-incision) and 492 cases in the conventional group. The overall analysis showed the study group would achieve less surgical duration(p=0.037), intraoperative blood(p<0.001) and incision length(p<0.001) than conventional group. The difference between sub-groups showed, the MIS would achieve shorter incision length[p(sub)<0.05] and bigger cup abduction angle [p(sub)<0.05] and cause more blood loss[p(sub)<0.05] than mini-incision technique. Other indexes were comparable between the two sub-groups. Conclusions： Though further high quality studies are still needed, the result of current analysis offered an initial conclusion that MIS THA failed to achieve a better clinical outcome than mini-incision technique. The exact definition of MIS still needs to be improved     

微创与常规全髋关节置换术临床疗效的比较

目的探讨微创与常规全髋关节置换术（total hip arthroplosty,THA）临床疗效。方法全髋关节置换术20例,按治疗方法不同分为髋关节前外侧小切口THA（微创组）10例和常规后外侧THA（常规组）10例;观察两组病例的手术时间、出血量、切口长度、并发症、术后疼痛程度、术后功能评价等。结果微创组优3例,良4例,中2例,差1例;常规组优2例,良3例,中3例,差2例。两组优良率比较差异有统计学意义（χ2=3．984,P〈0．05）;微创组术中出血量、引流量、输血量、切口长度[（315．5&#177;223．1）ml、（259．5&#177;170．1）ml、（88．5&#177;13．2）ml、（9．9&#177;0．4）cm]与常规组[（520．5&#177;219．7）ml、（517．9&#177;212．7）ml、（359．1&#177;31．5）ml、（15．8&#177;2．1）cm]有显著性差异（均P〈0．05）;微创组手术时间、术后3个月Harris评分与常规组无显著性差异（均P〉0．05）。结论微创全髋关节置换术,具有创伤小、出血少、安全、并发症少等优点。     

Anterolateral muscle sparing approach total hip arthroplasty:

Background Many kinds of approaches have been used for minimally invasive surgery of total hip arthroplasty （MIS-THA）. However, until now when considering the balance of efficacy and associated surgical injury there is no approach widely accepted for MIS-THA. In this study, a modified anterolateral muscle sparing approach was developed to optimize MIS-THA. Methods Twenty adult cadaver specimens （40 hips） were used for anatomic research. The distance from anterior origin of the gluteus medius on the iliac crest to the anterior superior iliac spine was measured; the course of the superior gluteal nerve and the distances from the nerve to the regional anatomic landmarks were recorded. Simulated surgeries were performed in three fresh cadaver specimens to evaluate the soft tissues injury around incisions. From October 2004 to June 2006, 57 patients （57 hips） were treated with anterolateral muscle sparing minimally invasive total hip arthroplasty, of which 17 were femoral neck fractures, 9 osteoarthritis, 16 developmental dysplasia of hip （DDH） and 15 avascular necrosis （AVN）. All the operations were performed by the same senior surgeon. Operation time, blood loss and drainage volume were recorded and the correlation between the local complications and the native anatomical characteristics was especially noted. All cases were followed for at least 12 months. Results The distance from the anterior origin of the gluteus medius to anterior superior iliac spine along the iliac crest was （61±4） mm （range, 55-68 mm）, and the distance from inferior branch of the superior gluteal nerve to the anterior tubercle of the greater trochanter was （74±6）mm （range, 60-88 mm）. In simulated surgeries, excessive distraction of tissue was found to be the main cause of the anterior border injury of the gluteus medius muscle. Of the 57 patients treated with anterolateral muscle sparing MIS-THA, the average incision length was 9 cm （range 7.5-13 cm）. Blood transfusions were performed in 11 patients.     

腰麻硬膜外联合麻醉和患者自控静脉镇痛在微创全髋置换术中的作用

目的:研究腰麻硬膜外联合麻醉(CSEA)、患者自控静脉镇痛(PCIA)在老年微创全髋关节置换术(MIS THA)中的作用. 方法: 将80名年龄在60～78岁的老年患者随机分为A,B组,每组40名,A组行CSEA,术后PCIA镇痛下行早期功能锻炼;B组(对照组)行连续硬膜外麻醉(CEA). 视觉模拟评分法(VAS)双盲记录A, B组患者早期功能锻炼时疼痛水平. 结果: CSEA麻醉步骤简便,起效快,近95%的患者肌松完善,与B组差异显著(P＜0.01);PCIA明显减轻A组患者早期功能锻炼时疼痛(VAS 2.02±1.3),而B组患者疼痛剧烈(VAS 7.86±1.5)(P＜0.01). 结论: 在充分扩容下CSEA应用于MIS THA较CEA简便、快捷、肌松完善,术后PCIA镇痛有助患者早期功能锻炼.     

微创小切口人工全髋关节置换术治疗晚期股骨头坏死

目的探讨微创小切口人工全髋关节置换术(THA)治疗成人晚期股骨头坏死的适应证与疗效。方法本组45例50髋,平均年龄57.8(41~70)岁。根据世界骨循环研究学会(ARCO)分期,Ⅲ-C期20髋,IV期30髋。采用后外侧单个小切口,骨水泥型假体15髋,非骨水泥型假体35髋。结果平均随访时间1.8(0.5~3.8)年。平均切口长度8.5(6~10)cm,平均出血量300(100~600)m l,平均输血量110(0~400)m l,平均引流量200(100~400)m l,平均手术时间82(60~110)m in。髋臼杯外展角44.2°(40°~55°),股骨偏心距由术前42.5(31.2~50.5)mm增加到45.2(35.2~55.5)mm。X线片上髋臼杯外展角平均44.2°(40°~55°),股骨偏心距由术前平均42.5(31.2~50.5)mm增加到45.2(35.2~55.5)mm。平均术后6(4~12)周弃拐行走。髋关节Harris评分由术前的44分改善为92分。无假体松动、下沉。结论成人晚期股骨头坏死(ARCOⅢ-C期与IV期)可采用微创小切口THA治疗,创伤小,出血少,康复快,效果好,适合于体格胖瘦适中者。     

经后方传统及微创全髋关节置换切口的比较研究

目的 比较经后方传统及微创全髋关节置换入路的临床疗效.方法 由同一组手术医生行传统切口全髋关节置换50例,微创切口全髋关节置换36例.比较两种不同入路的手术时间、出血量、术后并发症、术后12周Harris评分及假体的位置、血沉及c-反应蛋白.结果 所有病例均获得随访,出血量、术后并发症、术后12周Harris评分及假体的位置、术后疼痛评分经统计学处理差异无统计学意义(P＞0.05).在传统入路血沉及C-反应蛋白较高(P＜0.05).结论 传统及外侧微创全髋关节入路均体现了满意的临床疗效,微创入路创伤较小.     

Use of mid-vastus approach in less invasive primary total knee arthroplasty

Background Total knee arthroplasties （TKR） combined with the concept of reduced trauma to tissue has been performed by many doctors. The aim of this study was to retrospectively assess the early results of a group of TKR with a mid-vastus approach, which was characterized as no patellar eversion, no disruption of suprapatellar pouch and extensor mechanism, and to compare the outcome with conventional operative techniques. Methods A total of 59 patients （67 knees） were followed. All patients received the same prosthesis of Genesis II posterior-stabilized total knees. Of them, 29 consecutive patients （34 knees） had a mid-vastus approach and were operated on with less invasive instruments and techniques. The mean follow-up duration was 11.6 months. Clinical evaluations were performed according to the Hospital for Special Surgery scores; radiographic assessment followed the guidelines of the Knee Society. Postoperative recovery of quadriceps strength and the extensor mechanism was also evaluated. Results No prosthetic loosening or anterior knee pain was found at the latest follow-up; 1 patient had a superficial infection and postoperative stiffness of the knee who undertook a debridement and manipulation several months later. The angulations of tibial osteotomy were within normal range. The average preoperative and postoperative Hospital for Special Surgery scores were 57.9 points and 86.1 points respectively. The mean postoperative range of motion was 113.5~-. Most patients regained their quadriceps strength at the third or fourth month postoperatively. Conclusions The overall early results from using the mid-vastus approach were comparable with that of using a standard approach, and the exposure did not affect the accuracy of the tibial cut. The muscle maximal contraction strenath recovered araduallv after oDeration. The aDDroach was safe and Datients of this aroup obtained satisfactorv outcomes.     

两种外展枕用于人工全髋关节置换术后的疗效观察

目的 比较两种外展枕用于人工全髋关节置换术(THA)后的效果.方法 选择2007年1月至2010年10月行THA的患者160例随机分为实验组和对照组,每组80例,实验组使用引进的新技术梯形外展枕,对照组为改良后的外展枕.比较两组外展枕用于THA后的效果.结果 实验组患者翻身时间(5～10)min、侧卧耐受时间(10.0±1.3)min,舒适度(31.2%)和满意度(65.0%),与对照组[分别为(3～5)、(30.0±2.1)min、56.2%和90.0%]比较,差异有统计学意义(P＜0.05).结论 改良后的外展枕更利于THA后的患者.     

人工全髋关节置换术治疗18例强直性脊柱炎的临床观察

目的探讨人工全髋关节置换术治疗强直性脊柱炎的效果。方法对18例（22髋）强直性脊柱炎全髋关节置换术后患者进行了2～9年的随访。临床随访根据Harris评分系统进行评分，X线随访根据Gruen等和DeeleandCharnley分区法进行股骨柄和臼杯X线分析。结果髋关节屈曲、内收、外展、内旋、外旋总活动度由术前的平均35．6。提高到术后的平均185。。Harris评分由术前的平均32分提高到术后的83分，手术优良率为81．8％，其中优11髋，良7髋，中4髋。X线未见假体松动、脱位。异位骨化发生率为13．6％（3／22髋）。结论人工全髋关节置换术治疗强直性脊柱炎可以明显缓解髋关节疼痛，恢复关节功能。     

微创动力髋螺钉固定治疗股骨转子间骨折30例

目的通过与传统动力髋螺钉固定治疗股骨转子间骨折的疗效进行比较,探讨微创动力髋螺钉固定治疗股骨转子间骨折的优缺点。方法选择2009年1月～2010年1月在我院进行手术治疗的股骨转子间骨折患者60例纳入研究,随机分为研究组和对照组各30例,所有患者均知情同意。研究组采用微创动力髋螺钉内固定治疗,对照组采用传统动力髋螺钉内固定治疗。观察对比两组切口长度、术中失血量、手术时间、骨折愈合时间、Harris评分、并发症、髋关节功能分级等情况。结果研究组术口长度显著短于对照组,术中出血量明显少于对照组,手术时间明显短于对照组,骨折愈合时间明显短于对照组,差异均有统计学意义(P<0.05)。两组患者髋关节功能比较,差异无统计学意义(P>0.05)。结论微创动力髋螺钉固定治疗股骨转子间骨折具有术口小、失血量少、术后骨折愈合快等优点,同时髋关节功能恢复与传统动力髋螺钉固定术相似,值得临床推广使用。     

微创Wheat手术4例报道

 目的  介绍我院采用经胸骨上段“J”型切口行微创Wheat手术的临床经验。 方法  2011年11月,我院采用胸骨上段“J”型切口为4例主动脉瓣病变合并有升主动脉瘤样扩张患者行微创Wheat手术,其中男性3例,女性1例,年龄43~62岁,平均55.3岁。结果  无院内死亡,低心排血量综合征、脑血管意外、肾功能不全、伤口愈合不良等并发症。术后1年随访升主动脉人工血管和主动脉瓣瓣膜功能良好,心功能恢复至I~Ⅱ级。结论  经胸骨上段“J”型切口行微创Wheat手术可安全有效地应用于主动脉瓣病变合并升主动脉瘤样扩张的患者,值得临床选择性应用。     

保留股骨颈型人工全髋关节置换术92例

目的探讨保留股骨颈型人工全髋关节置换术的疗效。方法 2000年9月—2010年9月,我科开展保留股骨颈型人工全髋关节置换术92例（104髋）,其中男50例,女42例,年龄20～65岁。结果本组经过0.5～10年随访,92例人工全髋关节置换术后,髋关节功能良好。影像学检查显示人工髋关节位置良好,假体无松动和下沉。结论保留股骨颈型人工全髋关节置换符合股骨近端生理顺应性,能防止股骨近端骨质疏松引起假体松动和下沉。     

ERAS在全髋关节置换术后并发症预防中的效果评价

目的 研究快速康复外科（enhanced recovery after surgery,ERAS）方法在全髋关节置换术预防并发症的临床效果。 方法 选取河北医科大学第三医院行全髋关节置换术的患者作为研究对象,按照随机对照的原则分为研究组与对照组。研究组为实施ERAS护理方案组,对照组为常规护理组,评估并记录2 组患者术后1、3、7 d及1个月的疼痛评分、术后相关并发症（深静脉血栓、泌尿系感染、坠积性肺炎、压疮、便秘）、Harris髋关节功能评分;并对住院时间、住院费用和患者满意度进行比较。 结果 研究组的VAS评分与对照组比较,2组的VAS评分随时间的延长而降低,2组在组间、时点间、组间·时点间交互作用方面差异有统计学意义（P＜0.05）,术后并发症发生率均低于对照组,Harris评分高于对照组,差异均有统计学意义(P＜0.05)。研究组住院时间及住院平均费用均少于对照组,而患者满意度高于对照组 ,差异均有统计学意义(P＜0.05)。 结论 ERAS应用于全髋关节置换术后的患者中,可减少术后并发症的发生,促进患者髋关节功能恢复,增加患者及家属的满意度。     

全髋关节置换术的手术配合

目的保证手术顺利进行，缩短手术时间，减少感染机会，促进术后恢复，提高患者生存质量。方法用人造假关节置换全部髋关节，做好术前访视、术前准备、麻醉配合、手术配合。结果重庆市中医骨科医院2006年10月～2007年1月行全髋关节置换术6例，无一例感染，术后患者恢复良好，能自行行走。结论由于全髋关节置换手术难度大风险高，所以要求医护人员密切配合，技术操作必须熟练，护士必须有高度的责任心和紧迫感，确保手术顺利进行，为患者康复创造良好的条件。     

小切口全髋关节置换术78髋临床分析

目的:通过微创小切口技术进行人工全髋关节置换术,以达到保护组织、加快术后恢复的目的,同时初步探讨小切口全髋置换术的优越性。方法:对2004年9月￣2006年6月78髋小切口全髋置换术病人进行短期随访并做回顾性总结分析。结果:78髋随访12￣26周,平均16周,优62髋,良15髋,中1髋,总优良率为98.7%(77/78)。髋关节Harris评分由术前的平均39分提高到末次随访时的平均91分。结论:小切口全髋置换术,具有手术瘢痕较小,相对美观;失血量少,降低输血量;组织损伤少,术后疼痛轻,康复时间短,病人满意率高;短期并发症少等优点。     

后外侧小切口入路全髋关节置换术的近期疗效观察

目的探讨小切口全髋关节置换术的手术技术要点及临床近期疗效。方法髋关节疾病患者18例,男7例,女11例,年龄53-82岁,平均73.5岁,术前Harris评分39.6分。采用后外侧入路,行小切口人工全髋关节置换术。对病例的切口长度、术中髋关节囊处理、围手术期出血量、术后早期功能恢复情况及假体的位置进行评价。结果本组病例手术切口均小于10cm,手术过程中均未行关节囊切除,对关节囊行缝合修整,围手术期出血量312±113.6ml,假体的安放和固定较常规手术未因手术切口的改变而改变,术后扶拐下床时间5.3±2.2天,术后6周均脱拐行走,术后3个月Harris评分94.3分。术后1例出现下肢静脉血栓,经对症处理后缓解,无一例出现关节脱位、感染。结论后外侧小切口全髋关节置换术具有创伤小、围手术期出血少、术后并发症少及术后早期功能恢复快的优点,对于多数病例能替代传统手术,但手术要掌握好手术适应证,手术医师需具有丰富的关节置换经验,减少软组织的损伤和关节囊的保护至关重要。     

Comparative study on early period of recovery between minimally invasive surgery total knee arthroplasty and minimally invasive surgery-quadriceps sparing total knee arthroplasty in Chinese patients

Background Different kinds of minimally invasive surgery （MIS） procedures have now been used in total knee arthroplasty （TKA）. Compared with traditional TKA procedure with a long skin incision, clinical studies showed MIS procedures had some advantages. Quadriceps sparing （QS） procedures are the most minimally invasive MIS procedure until now. This study was aimed to find the insertion types for Chinese patients＇ vastus medialis and if the QS procedure had some advantages in patients＇ early recovery. Methods Between February 2006 and May 2007, 120 consecutive patients underwent unilateral primary TKA under general anesthesia, among whom 14 patients were lost to follow-up, the remaining 106 cases were enrolled in this study. Among the 106 cases there were 85 right knees, 21 left knees （15 men and 91 women, with a mean age of 65.1±7.4 years）; osteoarthritis in 97 patients （91.5%） and rheumatoid arthritis in 9 patients （8.5%）. MIS TKA was performed in 49 cases （MIS TKA group）, while MIS-QS TKA in 57 cases （MIS-QS TKA group）. During the operation, the type Ⅰ, Ⅱ and Ⅲ insertions of the vastus medialis for all patients were recorded. Each knee was rated post-operatively according to the Hospital of Special Surgery （HSS） scoring system. Clinical follow-up was undertaken at 1 week, 2, 6, 12 and 24 weeks. Operating time and complications were recorded. Results There was no statistically significant difference between the two groups for gender distribution, age, left or right knee incidence, pre-operative diagnosis, incidence of varus or valgus deformity. Of the 106 cases there was 1 （0.9%） case with a type Ⅰ insertion of the vastus medialis, 4 （3.8%） cases with type Ⅱ insertions, 101 （95.3%） cases with type Ⅲ insertions. The HSS scoring was significantly different between the MIS-QS TKA group and MIS TKA group within the first two weeks post operation. From 2 weeks later to 24 weeks, no significant difference was found. The average operating time was （53.3