微创小切口与传统切口在全髋关节置换术中应用的系统评价

目的 评价全髋关节置换术应用小切口是否优于传统长切口.方法 收集所有关于微创小切口与传统切口在全髋关节置换术中应用比较的随机对照试验(RCT),按Cochrane协作网标准逐个进行质量评价和Meta分析.结果 共纳入3篇RCT,包括339例患者.3个研究显示微创小切口组在术中失血量、总失血量、手术用时方面少于传统长切口,术中、术后并发症发生率无统计学意义,而对于术后镇痛药物用量、患肢功能恢复、术后影像学评价及远期手术效果由于各试验采用了不同的评价指标,不能进行合并分析.结论 微创小切口和传统长切口都可以用于全髋关节置换术,采用微创小切口在术中失血量、总失血量、手术用时方面少于传统长切口.在术中及术后并发症方面,两种切口的差异无统计学意义.因本研究的样本量较小,纳入的研究数量少,缺乏足够的证据,尚需更多设计严格的研究以增加证据的强度.     

动力髋和股骨近端髓内钉手术治疗股骨粗隆间骨折的系统评价

[目的]对动力髋和股骨近端髓内钉手术治疗股骨粗隆间骨折的疗效和安全性进行系统评价.[方法]在Pubmed、Cochrane Library、EMBASE、Science Direct以及CNKI、CBM、中国医学学术会议论文数据库等网站进行检索.文献检索起止时间为2000年1月～2010年9月.再对入选文献的参考文献进行手工检索.系统收集动力髋和股骨近端髓内钉手术治疗股骨粗隆间骨折的相关文献,并按临床科研方法的国际通用原则进行阅读和评价.采用Cochrane协作网提供的软件Revman 4.2进行Meta-分析,以获得动力髋和股骨近端髓内钉手术治疗股骨粗隆间骨折的疗效及其安全性指标的相关证据.[结果]共检索到183篇原始文献,有7篇符合最终的入选标准,总计随访患者919例.分析研究表明,股骨近端髓内钉平均手术时间短但术中接受X线的次数多于动力髋.股骨近端髓内钉组术后内固定移位发生多于动力髋.[结论]两种手术治疗术中失血量并无统计学差异,股骨近端髓内钉平均手术时间短但术中接受X线的次数多于动力髋;而术后切口感染率、再次手术率两者并无统计学差异,股骨近端髓内钉组术后内固定移位发生多于动力髋.     

老年新鲜移位股骨颈骨折的手术治疗分析

[目的]探讨内固定、人工股骨头置换和全髋置换在治疗老年人移位性股骨颈骨折中的价值.[方法]对2003年6月-2008年5月收治的95例65岁以上新鲜移位性股骨颈骨折患者进行随访研究,比较闭合复位内固定、人工股骨头置换和全髋置换术在手术时间、出血量、住院时间、术后1年和3年的功能评价、并发症以及二次手术率方面的差异.[结果]随访时间12～36个月,平均26个月.闭合复位内固定组的手术时间、失血量、住院时间均为最低(P<0.05),但卧床时间最长,并发症和手术翻修率最高,术后3年随访功能最差.全髋置换术卧床时间短,并发症和手术翻修率低,术后髋关节功能最好,但手术创伤较大,对患者身体一般状况要求较高.人工股骨头置换的手术创伤比全髋置换稍小,但并发症发生率、手术翻修率较高,术后功能比全髋置换差.[结论]关节置换是治疗老年移位性股骨颈骨折的有效手术方法.     

经皮加压钢板微创治疗老年性股骨粗隆间骨折的系统评价

[目的]对经皮加压钢板(PCCP)微创治疗老年性股骨粗隆间骨折的疗效和安全性进行系统评价.[方法]在Pubmed、Cochrane Library、EMBASE、Science Direct以及CNKI、CBM、中国医学学术会议论文数据库等网站进行检索.文献检索起止时间为2000年1月～2009年3月.再对入选文献的参考文献进行手工检索.系统收集PCCP微创治疗老年性股骨粗隆问骨折的相关文献,并按临床科研方法的国际通用原则进行阅读和评价.采用Cochrane协作网提供的软件Revman 4.2进行Meta-分析,以获得PCCP微创治疗老年性股骨粗隆间骨折的疗效及其安全性指标的相关证据.[结果]共检索到216篇原始文献,有7篇符合最终的入选标准,总计随访患者839例.分析研究表明,PCCP的平均输血需要量低于DHS、GN(P<0.05).[结论](1)PCCP具有减少平均输血需要量的优势;(2)PCCP的术中内固定失败率、切口感染率、额外二次手术率、深静脉血栓形成发生率、呼吸系统并发症发生率、心脑血管并发症发生率、恢复行走百分率和病死率等指标与常规手术无显著差异.     

外侧入路小切口技术在全髋关节置换术中的应用

[目的] 探讨髋外侧小切口全髋关节置换术的可行性、操作方法及优缺点.[方法] 2008年2月～2008年8月,采用外侧入路小切口进行单侧全髋人工关节置换手术28例.分析术中出血量、术后引流量、下床活动时间及髋关节Harris评分.[结果] 切口长度8～10 cm.术中出血量为280～710 ml,平均410 ml;术后引流量为250～600 ml,平均420 ml.患者平均下床时间6.5 d(3～9 d).Harris评分从术前的41.2分提高到术后6个月的91.5分.[结论] 外侧入路小切口具有创伤小、患者术后恢复快、易接受、术后关节功能好等优点,但应注意其适应证及容易发生的并发症.     

全膝关节置换术中不同时机释放止血带比较的Meta分析

[目的]应用Meta分析的方法,评价全膝关节置换术(totalkneearthroplasty,TKA)中关闭伤口前松开止血带电凝止血和关闭伤口并敷料包扎后松开止血带对失血量及手术并发症的影响.[方法]计算机检索Pubmed、EM-BASE、Ovid和Cochrane图书馆关于TKA术中对不同时机释放止血带进行比较的随机对照试验,按照文中所述纳入标准收集后进行比较,利用RevMan5.0软件进行异质性分析及Meta分析,绘制森林图.[结果]作者检索了1979～2010年间发表的198篇关于TKA术中应用止血带的文献,经过筛选和评价,最后收集到已发表的9篇(共526例患者)随机对照试验,符合本次Meta分析所纳入的试验标准.结果发现关闭伤口并敷料包扎后松开止血带组患者围手术期失血量和手术时间显著少于关闭伤口前松开止血带组,但后者可以显著减少术后相关并发症发生率.[结论]关闭伤口前松开止血带电凝止血方法可以减少TKA术中止血带应用时间而降低术后并发症发生率,但增加围手术期失血量.     

快捷小切口与常规切口人工髋关节置换术治疗老年股骨颈骨折的疗效对比

目的 对比快捷小切口与常规切口行人工髋关节置换治疗老年股骨颈骨折的临床疗效.方法 将240例老年移位股骨颈骨折随机分为全髋置换小切口组、全髋置换常规切口组、半髋置换小切口组、半髋置换常规切口组(各60例).对每组切口长度、手术时间、出血量、术后引流量、下地活动时间、术后Harris评分方面进行统计学分析.结果 全髋置换、半髋置换组中小切口与常规切口组在切口长度、手术时间、出血量、术后引流量、下地活动时间方面差异有统计学意义(P＜0.05);术后6周Harris评分差异无统计学意义(P＞0.05).小切口组术后疗效优于常规切口组.结论 快捷小切口人工髋关节置换术具有切口小、手术时间短、创伤小、出血少、瘢痕小、术后功能恢复快等优点,是治疗老年移位股骨颈骨折的理想方法.     

钢板内固定和髓内钉固定治疗肱骨干骨折的系统评价

[目的]对钢板内固定与髓内钉固定治疗成人肱骨干骨折的疗效进行系统评价.[方法]在Pubmed、Co-chrane Library、EMBASE、Science Direct以及CNKI、CBM、中国医学学术会议论文数据库等网站进行检索.文献检索起止时间为1995年1月～2010年9月.再对入选文献的参考文献进行手工检索.系统收集钢板内固定和髓内钉固定治疗肱骨干骨折的相关文献,并按临床科研方法的国际通用原则进行阅读和评价.采用Cochrane协作网提供的软件Revman 4.2进行Meta-分析,以获得钢板内固定和髓内钉固定治疗肱骨干骨折的疗效及其安全性指标的相关证据.[结果]共检索到192篇原始文献,有6篇符合最终的入选标准,总计随访患者335例.Meta分析结果表明,钢板内固定与髓内钉固定比较,可显著降低再次手术发生率但是增加术后感染率.[结论]钢板内固定可显著降低再次手术发生率但是增加术后感染率.在骨折不愈合率、医源性神经损伤等方面,两者差异无统计学意义.因本次系统评价纳入病例数较少,尚需要更多设计严谨的大样本随机对照研究来增加证据的论证强度.     

小切口全髋关节置换的手术体会

[目的]探讨小切口人工全髋关节置换手术的优缺点。[方法]比较32例37髋小切口人工全髋关节置换术与普通切口人工全髋关节置换术在切口长度、手术时间、术中出血量、术后引流量、住院时间及并发症等方面的异同。[结果]小切口组平均切口长度为7．7cm，普通切口组为11．5cm（P〈0．05）；小切口组平均手术时间为95min，普通切口组为51min（P〈0．05）；小切口组术中平均出血量为380ml，普通切口组为299ml（P〈0．05）；小切口组及普通切口组在术后引流量及住院时间方面无显著性差异（P〉0．05）；小切口组1例术中出现大转子尖骨折、股骨颈截骨过多、髋臼内凸，1例因髋臼安放角度异常于术后第3d出现髋关节脱位，行扩大切口调整髋臼假体角度后恢复正常；普通切口组术中、术后无1例出现并发症。[结论]与普通长度切口全髋关节置换手术相比，小切口手术在出血量、组织损伤程度、手术时间方面并无明显优势；由于切口小，术野受限，手术操作比较困难，易出现假体安装位置异常等问题。在熟练做好普通切口全髋置换手术、不增加手术损伤的前提下，可尽量减小手术切口长度，没有必要刻意追求小切口全髋置换手术。     

微创前外侧与常规后外侧入路对全髋置换术的系统评价

目的系统评价微创前外侧与常规后外侧入路对全髋置换术的临床效果。方法计算机检索Cochrane Central Register of Controlled Trials,MEDLINE,EMBASE,CINAHL,CNKI,VIP,万方数据库和中国生物医学文献数据库,辅以手工检索其他杂志,全面检索关于前外侧微创与常规后外侧入路对全髋置换术效果的随机对照试验,检索时限均为从建库至2015年8月。按照Cochrane系统评价手册5.1.0版本偏倚风险评估标准评估文献质量,采用Review Manager 5.2软件对数据进行Meta分析。结果共纳入6篇文献。包括376例患者,结果显示:前外侧微创较常规后外侧入路的切口长度小、出血少、术后各随访时期Harris评分高,并发症发生率较少,而手术时间及髋臼外展角度无差异。结论前外侧微创较常规后外侧入路的临床效果更有优势,可作为髋关节置换术的首选切口之一。     

微创人工全髋关节置换术疗效的系统评价

[目的]评价微创全髋关节置换术(total hip arthroplasty,THA)的疗效.[方法]电子检索Cochrane图书馆(2010年第8期)、PubMed(2001～2010年8月)、OVID数据库(2001～2010年8月)、万方数据库(2001～2010年8月)、中国期刊全文数据库(2001～2010年8月)、维普中文科技期刊全文数据库(2001～2010年8月),纳入有关人工全髋关节置换术的所有随机对照试验(RCT),评价其方法学质量并提取数据.比较微创全髋关节置换术(minimally invasive surgery to total hip arthroplasty,MIS-THA)和传统THA的切口长度、手术时间、术中出血量、住院时间、并发症及近期疗效.对数据进行异质性检验,用RevMan 5.0软件进行Meta分析.[结果]共纳入12个RCT,1 489例患者.Meta分析结果显示:与传统手术相比,MIS-THA有着术中出血量少(P=0.04)、住院时问短(P=0.000 5)等优点,但其缺陷是手术时间较传统THM略长(P=0.002).另外,MIS-THA术后总体并发症发生率与传统THA相当[RR=0.90,95%CI(0.62,1.32)P=0.59];MIS-THA术后患者的Harris总评分要高于传统THA(P=0.008).[结论]MIS-THA的整体近期疗效要优于传统手术,但由于手术开展初期,其手术时伤口暴露时间较长,有可能造成患者体液丢失总量的增多及对手术本身耐受力的下降,故应加强医师手术操作技能的培训及术中对伤口的保护意识.受纳入研究数量及质量限制,上述结论尚需大样本、高质量的RCT进一步证实.     

单切口微创与传统全髋置换术疗效比较的Meta分析

目的应用Meta分析系统总结评价单切口微创与传统全髋关节置换术的临床疗效。方法计算机检索2000年1月至2011年5月间PubMed、Embase、Cochrane图书馆、Elsevier、Springer、CNKI、万方、维普数据库,并手工补充检索相关领域的杂志,纳入单切口微创与传统全髋关节置换术的临床随机对照试验。根据改良Jadad评分量表评价纳入研究质量,并采用RevMan4.2软件进行Meta分析。结果共纳入16项随机对照研究,共计1415位患者,1490侧关节。其中,微创组为742侧,传统组为748侧。结果显示：单切口微创全髋关节置换术手术切口较传统全髋关节置换术短约6.61cm（WMD=-6.61,95%CI：-8.05～-5.16,P〈0.01）,而手术时间（WMD=-0.74,95%CI：-7.76～6.27,P=0.84）、术后3年内Harris评分（WMD=1.26,95%CI：-2.34～4.85,P〉0.05）、术后6周时WOMAC评分（WMD=-0.55,95%CI：-3.54～2.44,P〉0.05）及术后3年内并发症发生率（WMD=1.00,95%CI：0.70～1.44,P〉0.05）两组间差异均无统计学意义。结论单切口微创全髋关节置换术短期临床疗效与传统全髋关节置换术相似,其远期疗效是否优于后者仍有待观察、总结。     

Total Hip Arthroplasty: Is Small Incision Better?

Outcome data are eagerly awaited at present time to evaluate the role of minimally invasive surgery in orthopedic surgery. This matched-pair study reports the outcome of total hip arthroplasty (THA) performed through regular or small incision technique by a single surgeon. There were 120 patients in this cohort with a mean age of 66.8 years (range, 39-90 years). There was no detectable difference in outcome between the two groups with regard to blood loss, analgesia requirement, functional recovery, length of hospital stay, or disposition at discharge. One patient in the small incision group with undersized femoral component required revision of the femoral stem 8 months later. The recent extensive interest for minimally invasive THA has been attributed to market-driven and patient-driven demand for this procedure. We were not able to detect any difference in outcome parameters for THA performed through small incision compared with the conventional techniques.     

Minimally invasive versus conventional exposure for total hip arthroplasty: a systematic review and meta-analysis of clinical and radiological outcomes

Over the past decade, minimally invasive surgery has gained popularity as a means of optimising early postoperative rehabilitation and increasing patient satisfaction and cosmesis following total hip arthroplasty (THA). However, this surgical exposure has also been associated with increased risk of iatrogenic nerve injury and implant mal-positioning due to limited visibility compared to conventionally larger surgical incisions. The purpose of this meta-analysis was to compare the outcomes of these two surgical exposures. A systematic review of the published and unpublished literature was conducted to include all randomised and non-randomised controlled trials comparing the clinical and radiological outcomes of minimally invasive and conventional THA procedures. In total, 28 studies met the eligibility criteria and included 2,849 hips, i.e. 1,428 minimally invasive compared to 1,421 conventional THAs. The meta-analysis of the current evidence base showed that minimally invasive THA is associated with a significantly increased risk of transient lateral femoral cutaneous nerve palsy (p = 0.006) with no significantly better outcome.     

Comparison of Complications in Single-incision Minimally Invasive THA and Conventional THA

The purpose of this meta-analysis was to investigate whether single-incision minimally invasive total hip arthroplasty (THA) is superior to conventional incision THA by comparing postoperative complication rates, Harris Hip Scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores. Randomized, controlled trials comparing single-incision minimally invasive THA and conventional THA were reviewed. The methodological quality of each randomized, controlled trial was assessed using the Physiotherapy Evidence Database (PEDro) scale (Centre for Evidence-based Physiotherapy, The George Institute for Global Health, New South Wales, Australia). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of the evidence. Fourteen studies involving 1254 patients (1329 hips) were included in the meta-analysis, comprising 659 single-incision minimally invasive THAs (mean patient age, 63.9 years) and 670 conventional incision THAs (mean patient age, 65.0 years). A funnel plot of postoperative complication rates showed that a slight publication bias existed in the study.According to the meta-analysis, no significant statistical difference was observed in complication rates in no more than 3 postoperative years (odds ratio=1.06; 95% confidence interval, 0.69 to 1.63; P=.79), in Harris Hip Scores in no more than 2 postoperative years (weighted mean difference=0.71; 95% confidence interval, -3.09 to 4.51; P=.71), and in WOMAC scores at 6 weeks postoperatively (weighted mean difference=-0.55; 95% confidence interval, -3.54 to 2.44; P=.72) between single-incision minimally invasive THA and conventional THA. Therefore, single-incision minimally invasive THA is not superior to conventional THA in early postoperative recovery, hip function, and complication rate.     

Minimally Invasive Intermuscular Approaches Versus Conventional Approaches in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundTo date, the literature has not yet revealed superiority of Minimally Invasive (MI) approaches over conventional techniques. We performed a systematic review to determine whether minimally invasive approaches are superior to conventional approaches in total hip arthroplasty for clinical and functional outcomes. We performed a meta-analysis of level 1 evidence to determine whether minimally invasive approaches are superior to conventional approaches for clinical outcomes.MethodsAll studies comparing MI approaches to conventional approaches were eligible for analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to throughout this study. Registries were searched using the following MeSH terms: ‘minimally invasive’, ‘muscle-sparing’, ‘THA’, ‘THR’, ‘hip arthroplasty’ and ‘hip replacement’. Locations searched included PubMed, the Cochrane Library, ClinicalTrials.gov, the European Union (EU) clinical trials register and the International Clinical Trials Registry Platform (World Health Organisation).ResultsTwenty studies were identified. There were 1,282 MI total hip arthroplasty (THAs) and 1,351 conventional THAs performed. There was no difference between MI and conventional approaches for all clinical outcomes of relevance including all-cause revision (P = .959), aseptic revision (P = .894), instability (P = .894), infection (P = .669) and periprosthetic fracture (P = .940). There was also no difference in functional outcome at early or intermediate follow-up between the two groups (P = .38). In level I studies exclusively, random-effects meta-analysis demonstrated no difference in aseptic revision (P = .461) and all other outcomes between both groups.ConclusionIntermuscular MI approaches are equivalent to conventional THA approaches when considering all-cause revision, aseptic revision, infection, dislocation, fracture rates and functional outcomes. Meta-analysis of level 1 evidence supports this claim.     

Minimalinvasive H��ftendoprothetik �C nur Trend oder schon Standard?

Minimally invasive approaches in total hip arthroplasty are being used worldwide and continue to grow in popularity. Despite early reports of catastrophic failures, both the number of scientific publications as well as the number of orthopaedic surgeons practicing minimally invasive techniques in total hip arthroplasty are steadily increasing. By means of a systematic review of the literature, the current article weighs the potential advantages and disadvantages of minimally invasive techniques. A shorter skin incision, potentially less muscle damage, a faster rehabilitation and a clinically irrelevant lower blood loss may support the use of minimally invasive techniques. However, the potential impairment of wound cosmetics, the increased risk of periprosthetic fractures, implant malpositioning and lack of long-term results contradict the use of minimally invasive total hip arthroplasty as a standard treatment.     

全髋关节表面置换术与传统全髋关节置换术围手术期总失血量的比较研究

目的比较全髋表面置换术（HRA）和传统全髋置换术（THA）围手术期的总失血量以及术后住院时间,探讨两种术式不同的失血机制及其对手术创伤的影响。方法 2009年1月至2009年12月,选择67例髋关节骨病患者,分为两组分别施行HRA和THA,HRA组34例（34髋）,THA组33例（33髋）THA,两组均为初次单侧关节置换。通过Gross方程,根据身高、体重和手术前后的红细胞压积（Hct）变化差值算出所有患者的总失血量,记录显性失血量（术中出血和术后引流量）,推算出隐性失血量。记录手术时间和术后住院时间,将以上数据进行比较。结果 HRA组总失血量、显性失血量和隐性失血量都与THA组有统计学差异。总失血量HRA组和THA组分别为（1048.0±134.2）ml和（1466.0±167.4）ml,两组间差异有统计学意义（t=11.3,P〈0.05）;术中出血量分别为（542.0±68.9）ml和（625.0±86.3）ml,两组间差异有统计学意义（t=4.4,P〈0.05）;术后引流量分别为（266.0±93.9）ml和（379.0±162.7）ml,两组间差异有统计学意义（t=3.5,P〈0.05）;平均隐性失血量分别为（240.0±43.4）ml和（462.0±71.5）ml,两组间差异有统计学意义（t=15.3,P〈0.05）;平均术后住院时间HRA组也明显缩短,HRA为（4.6±0.9）d,THA为（6.1±0.9）d,两组间差异有统计学意义（t=7.0,P〈0.05）;平均手术时间HRA组则比HA组延长,HRA组为（114±13.9）min,THA组为（87±18.5）min,两组间差异有统计学意义（t=-6.9,P〈0.01）。结论尽管HRA比THA手术时间和手术切口都有延长,但总出血量明显降低,尤其是隐形失血量,术后住院时间也缩短,说明HRA出血相对偏少,创伤相对较小。     

Comparison of total hip arthroplasty via a posterior mini-incision versus a classic anterolateral approach

Surgical approaches to the hip for total hip arthroplasty (THA) are termed minimally invasive when allowing for a skin incision length of 10 cm or less. The aim of this study was to explore if a minimally invasive posterior approach compared to a classic anterolateral approach negatively influenced surgical time, blood loss, implant position, or perioperative complications. Two groups of THA patients mainly differing with respect to the surgical approach were compared. Results of 76 consecutive THA via a posterior mini-incision approach were recorded prospectively and those of 76 controls operated via a classic anterolateral approach were recorded retrospectively. THA was performed by the same surgeon in every case. Surgical time or intraoperative blood loss were not different among the groups. Total 24-h blood loss was significantly less in patients undergoing THA via minimally invasive posterior approaches. Median cup inclination was 45 degrees in both groups. Cup anteversion was 15 degrees (classic anterolateral) and 12 degrees (minimally invasive posterior), respectively. Stem position was regarded as neutral in 80% of THA through classic anterolateral and in 76 % through minimally invasive dorsal incisions. Complications occurred in 8% (classic anterolateral) and 9% (minimally invasive posterior) of THA patients. Surgical time, blood loss, risk of malpositioned implants, or complications were not increased for THA patients operated through minimally invasive posterior incisions compared to those operated via classic anterolateral approaches.