保留关节囊的后侧入路人工全髋关节置换术

目的探讨保留关节囊的后侧入路人工全髋置换术(total hip arthroplasty,THA)临床意义和手术方法。方法对2006年1~12月的29例股骨颈骨折患者(保留组),行后路THA,术中行关节囊保留修复,并与2005年全年施行的32例行后路常规关节囊切除的THA病人(常规组)在手术时间、术中出血量以及术后脱位发生率进行回顾性比较。结果保留组平均手术时间和术中出血量分别为(96±14)min和(240±50)ml,少于常规组的(132±16)min,(410±100)ml(P<0.05)。保留组术后未发生脱位,常规组术后2例发生脱位。结论THA术中保留修复关节囊,可以减少手术时间和术中出血,不增加手术风险,可以重建髋关节后侧软组织平衡,对预防术后髋关节脱位的发生有一定临床意义。     

Mini-Incision Posterior Approach for Hip Arthroplasty

Objective To reduce the trauma to soft tissues through a shortened incision for a posterior approach for hip replacement. Indications Patients requiring primary hip replacement or revision. Contraindications Open wounds in area of incision. Planned femoral osteotomy. Surgical Technique Incision of 10-15 cm, splitting of the gluteus maximus, and division of the piriformis insertion allow exposure of the posterior capsule which is opened. The femoral neck is divided and the femoral head removed to expose the acetabulum and proximal femur. An anterior capsulectomy and retraction allow appropriate visualization of the acetabulum. Insertion of blunt Hohmann, Müller, and modified Müller retractors facilitates exposure of the proximal femur. Results Between 1993 and 1995, 102 consecutive unilateral elective hip replacements were performed using the described approach (patients' age range 48-96 years). The mean blood loss was 347 ml, 13% of patients received a transfusion. Mean surgical time was 37 min, mean hospital stay 3.5 days. One patient suffered a dislocation postoperatively. There were no infections, loosening, intraoperative fractures, pulmonary embolisms, deep vein thromboses or nerve injuries detected.     

改良直接外侧入路在初次全髋关节置换术中的应用

目的评价改良直接外侧入路在全髋关节置换术中的应用价值。方法自2004年4月～2005年6月，采用改良直接外侧入路行初次全髋关节置换术共84例86髋，以2003年4月～2004年4月后外侧入路行全髋关节置换术89例89髋为对照组，观察项目包括手术时间、术中失血量、Harris评分、术后脱位发生率、术后跛行情况。结果术后平均随访17．5个月，两组间手术时间、术中失血量、Harris评分优良率、术后脱位发生率、术后中重度跛行发生率差别均无统计学意义。结论改良直接外侧进路有助于提高全髋关节的稳定性，帮助患者尽快恢复日常生活，但相比后外侧入路尚无绝对的优势。     

Early Recovery Outcomes in Patients Undergoing Total Hip Arthroplasty Through a Posterior Approach With Modified Postoperative Precautions

BackgroundRecent data suggest that a modified, more lenient set of precautions after total hip arthroplasty (THA) performed through the posterolateral approach may safely allow more patient movement and exercise in the immediate postoperative period. We hypothesize that 1) patients undergoing THA given modified precautions will demonstrate a fast-track return to functional activity and 2) wrist-based activity trackers will provide valuable information on postoperative activity levels.MethodsWe prospectively enrolled patients undergoing THA. Patients were given a wrist-based, commercially available activity tracker to wear 1 week preoperatively and 6 weeks postoperatively. Postoperative hip precautions included only the avoidance of the “leg-shaving” position of combined hip flexion, adduction, and internal rotation. Linear mixed models were used to analyze the change in steps and Hip Disability and Osteoarthritis Outcome Score-Junior (HOOS)-JR data. Pearson correlation coefficients were used to describe the relationship between average steps and HOOS-JR scores over time.ResultsEighty-two patients were enrolled. Seventy-four percent returned to work by week 4. Seventy-six percent of left THA patients returned to driving by week 4. At 6 weeks, 23% of survey respondents were taking pain medication and 26% were using assistive devices. Average daily steps were 1098 at week 1, 2491 at week 2, 4130 at week 3, 4850 at week 4, 5712 at week 5, and 6069 at week 6. A significant correlation (R: ?0.981) was found between increased weekly steps and improved HOOS-JR scores after THA (P < .001).ConclusionDefining expected recovery timelines for patients undergoing THA helps surgeons counsel their patients preoperatively. Our study demonstrates an expected pathway for recovery after THA by using modified precautions that will be more clearly outlined with ongoing clinical data analysis.     

An Arthroscopic Technique to Enhance Visualization During Total Hip Arthroplasty

This technical note describes the use of an arthroscope or endoscope to enhance visualization during minimally invasive total hip arthroplasty. The arthroscope/endoscope is used to verify seating of the components and to look for potential impingements, loose bodies, or fractures. This technique was successfully used to identify and address 2 bony or soft tissue impingements as well as a calcar fracture that might otherwise have been missed. Although further study is necessary, we believe that this technique might reduce postoperative complications and improve clinical outcomes of total hip arthroplasty.     

Posterior Approach for Total Ankle Arthroplasty

Total ankle arthroplasty is a technically challenging reconstruction, with soft tissue complications posing potential significant morbidity, especially when the anterior ankle soft tissue envelope is not pristine. Alternate approaches to the ankle for arthroplasty may need to be sought in unique cases. The author describes a posterior surgical approach for total ankle arthroplasty.     

改良小切口技术在骨水泥型全髋关节置换术中的应用

目的　探讨改良小切口下骨水泥型全髋关节置换术的方法和手术效果。方法　自 2 0 0 2年 6月～ 2 0 0 3年 1月 ,采用改良小切口技术进行骨水泥型人工全髋关节置换术 ,临床应用 18例 19髋 ,男 11例 ,女 7例 ;体重指数 17 5～ 2 4 ,平均 2 1 2 ;年龄 5 5～ 78岁 ,平均 6 5 8岁 ;股骨颈骨折 7例 ,股骨头缺血性坏死 11例 (12髋 ) ;切口长度为 9～ 14cm ,平均 11 2± 0 8cm。结果　所有患者手术均在术前设计的切口下顺利进行 ,术中无需对周围组织过分牵拉 ;术后随访 2 0～ 2 7个月 ,平均 2 5 7个月 ,X线检查示假体位置良好 ;除 1例术后出现切口轻度脂肪液化经治疗痊愈外 ,其他患者无术后并发症出现。结论　在术前准备充分、解剖入路熟悉的前提下 ,采用改良小切口技术进行骨水泥型人工全髋关节置换确实可行 ,且具有创伤小、愈合快、瘢痕小、外形美观等优点 ,是值得提倡的一种手术方法。     

A Systematic Review and Meta-Analysis of the Standard Versus Mini-Incision Posterior Approach to Total Hip Arthroplasty

The mini-incision posterior approach may appeal to surgeons comfortable with the standard posterior approach to the hip. We present the first systematic review and meta-analysis of these two approaches. Twelve randomised controlled trials and four non-randomised trials comprising of 1498 total hip arthroplasties were included. The mini-incision posterior approach was associated with an early improvement in Harris hip score of 1.8 points (P < 0.001), reduced operating time (5 minutes, P < 0.001), length of hospital stay (14 hours, P < 0.001), intraoperative and total blood loss (63 ml, P < 0.001 and 119 ml, P < 0.001 respectively). There were no statistically significant differences in the incidence of dislocation, nerve injury, infection or venous thromboembolic events. The minimally invasive posterior approach appears to provide a safe and acceptable alternative to the standard incision posterior approach.     

Acetabular and Femoral Component Positioning Using Direct Anterior Approach Versus Posterior Approach in Total Hip Arthroplasty

PurposeDirect anterior approach (DAA) has recently become popular in total hip arthroplasty (THA). However, irrespective of the surgical approach used, component malposition is an important factor affecting function and complications after THA. This study aims to compare component positioning on the femoral and acetabular side between DAA and posterior approach (PA) to the hip joint. We hypothesized that the two approaches are similar in terms of component positioning.MethodsWe prospectively studied 50 patients, matched according to age, sex, and body mass index, undergoing THA, divided non-randomly into 2 groups. Group 1 comprised 25 patients (35 hips) undergoing THA using DAA and group 2 comprised 25 patients (25 hips) undergoing THA using PA. Ten patients from group 1 had simultaneous bilateral THA. Radiological parameters studied were acetabular inclination (AI), coronal femoral stem alignment (CFA), leg length difference (LLD), acetabular cup version (AV), and femoral stem version (FV).ResultsThere was no significant difference in AI, CFA, LLD, AV, and FV between the two groups. Excellent to good inter and intra-observer reliability expressed in terms of intraclass correlation coefficient (ICC) was noted for all the radiographic measurements.ConclusionBoth DAA and PA for THA achieve comparable radiological component positioning. DAA may not provide any advantage over PA in terms of positioning of the prosthesis.Level of EvidenceLevel II, non-randomized comparative study.     

Oblique Posterior Trochanteric Osteotomy in Revision Total Hip Arthroplasty

Modular polyethylene failure and attendant revision play an increasing role in hip arthroplasty. In spite of well-fixed, well-aligned components, bearing exchange has a high risk of chronic instability, which may be attributed to the resection of stabilizing soft tissue structures to gain exposure. This creates a difficult situation for the surgeon and an inexplicable one for the patient with a previously well-functioning implant. The senior author modified a technique previously described by Shaw that included an osteotomy of the posterior one third of the greater trochanter and preservation of posterior soft tissues. Thirty-five patients underwent 47 revision procedures utilizing this approach, including 16 modular component and 31 more extensive procedures. There were no dislocations or significant complications and no loss of reduction or nonunion. The approach offers excellent exposure while preserving stabilizing soft tissues.     

Joint Perception After Total Hip Arthroplasty and the Forgotten Joint

Background

Assessing patients’ functional outcomes following total hip arthroplasty with traditional scoring systems is limited by their ceiling effects. The Forgotten Joint Score (FJS) has been suggested as a more discriminating option. The actual score in the FJS which constitutes a “forgotten joint,” however, has not been defined. The emerging concept of joint perception led to the development of the Patient’s Joint Perception question (PJP) to assess the patient’s opinion of their prosthetic joint.

Similar Improvement in Gait Parameters Following Direct Anterior & Posterior Approach Total Hip Arthroplasty

We compared gait parameters prior to, at 6 months and 1 year following total hip arthroplasty (THA) performed via direct anterior approach (DAA) and posterior approach (PA) by a single surgeon in 22 patients. A gait analysis system involving reflective markers, infrared cameras and a multicomponent force plate was utilized. Postoperatively, the study cohort demonstrated improvement in flexion/extension range of motion (ROM) (P = 0.001), peak flexion (P = 0.005) and extension (P = 0.002) moments with no differences between groups. Internal/external ROM improved significantly in the DAA group (P = 0.04) with no change in the PA group. THA performed via DAA and PA offers similar improvement in gait parameters with the exception of internal/external ROM which might be related to the release and repair of external rotators during PA THA.     

改良小切口与常规全髋关节置换术的比较研究

目的比较改良小切口与常规全髋关节置换术的手术经验及短期临床随访结果。方法采用改良小切口对15例15髋进行全髋关节置换术（total hip arthroplosty，THA），男10例，女5例；年龄65～75岁，平均72岁，体重指数20．5～26．5kg／m^2，平均23．5kg／m^2。股骨颈骨折10例，股骨头缺血性坏死3例，骨关节炎2例。术前Harris评分平均33．5分。同期采用常规后外侧入路行THA15例15髋，男11例，女4例；年龄66～78岁，平均73岁，体重指数20．8～25．8kg／m^2，平均23．8kg／m^2。股骨颈骨折12例，股骨头缺血性坏死3例。术前Harris评分平均33．8分。两组年龄、性别及体重指数均衡（P〉0．05），疾病谱相似。对两组病例的术中出血量、手术时间、切口长度、术后早中期的功能锻炼情况及影像学评价进行比较。结果术后随访6～10个月，平均8．2个月。改良小切口THA组切口长度平均9．5cm，较常规THA组短（P〈0．05）；术中出血量（318±223．1）mL，引流量（252±169．1）mL，均较常规THA组少（P〈0．05）；平均手术时间两组并无统计学意义。小切口THA组术后早期功能恢复较常规THA组快，而中期结果相似。术后及随访时两组假体位置均良好。小切口THA组除有2例患者术中发生切口近端皮肤擦伤，无并发症，常规THA组有1例患者术后脱位。结论改良小切口技术可选择性用于部分病例的人工全髋关节置换术，创伤小，围手术期出血少，切口小且不影响假体位置，术后早期功能锻炼。但应严格选择手术适应证，由拥有相应设备条件的医院及有一定经验的医生开展。     

微创 SuperPath 入路全髋关节置换术后的关节功能及生命质量

目的：观察经微创 SuperPath 入路行全髋关节置换术后患者的关节功能及生命质量,并与传统后外侧入路做随机对照研究。方法：选取拟行全髋关节置换术的患者 54 例,按数字随机表法分为观察组和对照组各 27 例,分别行 SuperPath 和传统后外侧入路全髋关节置换术,记录两组手术前后的 Harris 髋关节功能评分、计时“起立 - 行走”测试时间、单腿站立测试时间、6 min 步行测试距离、术后下地负重行走时间、住院时间、健康调查简表 SF-36 评分及并发症,并进行对比。结果：观察组术后 1 周及 3 个月的 Harris 评分（70.5±5.6,83.1±5.5）分别高于对照组（63.8±6.1,78.0±5.6）（P<0.05）,6 个月及 12 个月两组间差异无统计学意义（P>0.05）。相较于对照组,观察组术后 1 个月及 3 个月的计时“起立 - 行走”时间 [(36.5±7.3) s,(24.4±4.9) s] 更短,术后 1 个月的单腿站立时间 [(14.4±3.6) s] 更长,术后 3 个月的 6 min 步行距离 [(395.1±27.7) m] 更远（P<0.05）。观察组术后下地时间及住院时间 [(20.0±3.6) h,(9.7±2.8) d] 分别短于对照组[(33.2±5.4) h,(13.2±3.7) d]（P<0.05）。SF-36 评分,术后 12 个月观察组心理健康及总体健康两个维度评分（78.1±9.3,82.0±8.8）分别高于对照组（73.1±8.7,76.3±10.2）（P<0.05）;躯体疼痛及社会功能两个维度评分无统计学差异（P>0.05）。对照组 2 例出现无症状下肢深静脉血栓。结论：相比较于传统后外侧入路,微创 SuperPath 入路的全髋关节置换术能更快、更有效地恢复髋关节功能,提高患者术后的生命质量,符合现代快速康复理念。