直接前侧入路与后外侧入路人工全髋关节置换术的临床效果比较研究

目的 探讨直接前侧入路（direct anterior approach, DAA）与后外侧入路（posterolateral approach, PLA）进行人工全髋关节置换手术（total hip arthroplasty, THA）的临床效果。方法 选取2016年3月至2017年1月在我科进行THA手术的病人60例,根据手术方法不同分为两组：DAA组30例,男16例、女14例,平均年龄为（66.88±12.13）岁,身体质量指数（body mass index, BMI）为（23.67±3.10） kg/m²;PLA组30例,男14例、女16例,平均年龄为（65.18±14.72）岁,BMI为（26.47±2.83） kg/m²。两组病人一般资料比较,差异均无统计学意义（均P>0.05）。观察并记录手术切口长度、手术时间、术中出血量、术中输血量、手术前后血红蛋白变化,手术前后采用西安大略和麦克马斯特大学（Western Ontario and McMaster Universities, WOMAC）骨关节炎指数、美国麻醉医师协会（American Society of Anesthesiology, ASA）评分、牛津髋关节功能量表（Oxford hip scale, OHS）评分和10 m步行测试进行关节功能评分。结果 DAA组在切口长度方面优于PLA组,而PLA组的手术时间、术中出血量、手术后血红蛋白减少量少于DAA组,差异均有统计学意义（均P＜0.05）;术后第2、4、6周,对两组病人的WOMAC评分（包括疼痛、关节僵硬、躯体功能和总分）、OHS评分和10 m步行测试进行比较,差异均无统计学意义（均P＞0.05）;两组病人住院时间比较,差异无统计学意义（P＞0.05）。术后第6、12周对病人进行WOMAC评分（包括床上坐起、弯腰拾物、穿鞋袜、脱鞋袜）,两组髋关节活动度比较,差异无统计学意义（P＞0.05）。DAA组发生1例无症状性大粗隆撕脱性骨折,经过保守观察6周后自愈;PLA组出现1例后脱位,经手法复位后不再脱位。术后12周,均未发现异位骨化形成。结论 采用两种入路均可获得良好的短期效果,DAA行THA病人可获得更好的术后ROM;对于年轻有髋关节高屈曲活动度病人,倾向采用DAA入路;针对复杂初次及翻修病例,建议采用后入路手术。     

Cemented primary total hip arthroplasty using a direct anterior approach

Total hip arthroplasty is one of the most successful surgeries used in medicine today. A major complication associated with significant comorbidity for THA is periprosthetic fracture. A number of risk factors associated with periprosthetic fracture have been identified, including the use of uncemented femoral fixation. In patients with significant risk factors, we use a collarless, composite beam cemented stem in order to mitigate the risk of periprosthetic fractures. This article describes the surgical technique utilized to obtain a safe and effective cemented fixation through the direct anterior approach of the hip.     

直接前入路与后入路初次全髋关节置换术的疗效比较

目的比较直接前入路与后入路行初次全髋关节置换术(THA)的临床疗效与并发症。方法回顾性分析自2010-01—2013-01符合选择标准的171例初次全髋关节置换术患者的临床资料。根据手术入路不同,将患者分为前入路组(采用直接前入路行TKA)和后入路组(采用后入路行THA)。比较2组手术时间、出血量、切口长度、住院天数、臼杯外展角及前倾角、股骨柄中置率、疼痛视觉模拟VAS评分、UCLA评分及Harris髋关节评分及术后并发症。结果所有患者获得平均48.9(24~60)个月随访。2组手术时间、失血量、切口长度、臼杯外展角、臼杯前倾角、股骨柄中置率、及术后并发症发生率等比较,差异均无统计学意义(P0.05)。与后入路组相比,前入路组住院时间较短(P0.05)、术后第1天VAS评分较低(P0.05)、术后6周时UCLA评分及HHS评分较高(P0.05),但在之后随访中2组VAS、UCLA评分及HHS评分相似,差异无统计学意义(P0.05)。结论直接前入路行THA术后早期疗效优于后入路,但术后晚期2种入路具有相似的临床疗效。     

微创直接前入路全髋关节置换术

2010年5月19日至22日,上海交通大学附属第一人民医院主办的第一届全国微创直接前方入路人工髋关节置换学习班顺利举行。受马金忠教授的邀请,国际著名微创关节置换专家——来自奥地利Innsbruck大学附属医院的Michael Nolger教授专程前来为全体学员作了关于微创前入路人工髋关节置换的精彩报告。此次有幸征得Nolger教授同意,将报告内容翻译整理如下,与广大读者分享。     

直接前方入路全髋置换术近期疗效与学习曲线

[目的]探讨微创直接前方入路(direct anterior approach,DAA)的学习曲线,比较其不同时期与前外侧入路进行初次全髋关节置换术(total hip arthroplasty,THA)的早期临床疗效。[方法]回顾2015年6月~2017年6月,本院76例初次THA患者,分为DAA前期组25例、后期组26例以及前外侧入路(anterior lateral approach,ALA)组25例,比较3组在手术切口长度、手术时间及出血量、术前及术后6、12、24周Harris评分、髋臼假体外展角及前倾角的区别。[结果]DAA前期组手术切口长度、手术时间及出血量明显大于DAA后期组(P0.05),术后6、12周Harris评分DAA前期组明显不及后期组(P0.05),髋臼假体外展角及前倾角DAA前期组大于后期组(P0.05);两个DAA组较ALA组手术切口长度小、出血量少,但手术时间长(P0.05),术后6、12周Harris评分两个DAA组均优于ALA组(P0.05),但术后24周Harris评分3组差异无统计学意义(P0.05)。两个DAA组的髋臼假体外展角及前倾角较ALA组偏大(P0.05),但均在正常范围内。[结论]DDA学习曲线在25例左右,之后手术技术更趋于成熟与稳定,能有效缩短手术时间,减少出血量及并发症,与ALA手术相比提高患者早期疗效。     

Instability in primary total hip arthroplasty with the direct lateral approach.

Instability after a total hip arthroplasty is a serious complication. Dislocation rates as much as 6.5% after posterior approaches have been reported within the past decade. For this reason, the authors use the direct lateral approach for primary and revision total hip arthroplasties. A review of the arthroplasty database yielded 1515 primary total hip arthroplasties done via a direct lateral approach in 1333 patients. These arthroplasties were done within a 10-year period and patients with followup data less than 12 months were excluded. At the most recent examination, 11.6% of the patients had a moderate or severe limp and 2.5% had severe heterotopic ossification. Only six hips (0.4%) had a dislocation or episode of instability. Three patients had more than one dislocation and required revision surgery. The results of the current study show that dislocation after primary total hip arthroplasty almost can be eliminated using the direct lateral approach. The associated risks of heterotopic ossification or limp are acceptable.     

A modified direct lateral approach for total hip arthroplasty]

Literature based review of lateral hip approach (MacFarland, Osborne) modifications offered by Bauer, Harding, Mills, Moscal and Mann is presented. Surgical technique for the Moscal and Mann approach is described. The approach allows easy access to the proximal femur for reaming, cementing, prosthesis orientation and leg-length discrepancy correction. It offers visualization of the joint superior to all non transtrochanteric approaches and is successfully used for both primary and revision THR.     

A modified direct lateral approach in total hip arthroplasty

A modified lateral approach of Hardinge allows adequate access for orientation of the implant was described. Although this approach is more difficult than the posterior approach, there is a learning curve, when mastered, it ll definitely reduce the incidence of dislocation. In the Author s opinion, this approach should be used routinely for total hip arthroplasty for fractured neck of femur where the incidence of dislocation is unacceptably high using the posterior approach.     

侧卧位直接前路全髋关节置换手术技术

直接前路是理想的髋关节微创手术入路,特征是通过神经肌肉间隙显露髋关节。与其他入路相比,直接前路髋关节置换术具有术后疼痛轻、功能恢复快和患者满意度高等优势。然而,直接前路髋关节置换存在明显的学习曲线和较高的围手术期并发症。将患者体位由经典的仰卧位转换为侧卧位,旨在秉承直接前路的优点且克服仰卧位直接前路髋关节置换术中股骨侧显露困难的难题。侧卧位时髋关节后伸、外旋和内收程度较仰卧位明显增加,可以更加安全有效地完成股骨髓腔扩髓和股骨假体的精确植入。侧卧位直接前路髋关节置换术中髋臼视角与熟知的后方入路一样,术者无需改变髋臼侧操作习惯。熟悉直接前路解剖和理解技术难点是直接前路髋关节置换手术成功的关键。     

Minimally invasive total hip arthroplasty via direct anterior approach

BACKGROUND: Minimally invasive total hip arthroplasty (THA) aims at reduction of tissue damage to accelerate recovery. The anterior approach promises optimal soft tissue preservation. PATIENTS AND METHOD: Safety and feasibility of minimally invasive THA via an anterior approach without the use of an orthopedic table was tested in a prospective cohort study on 100 consecutive patients. There were no exclusion criteria, and cementless and cemented techniques were employed. RESULTS: No second incision was needed and neither nerve palsy nor dislocation was observed. The inclination angle of the cup was a median of 44.1 degrees and the position of the stem a median of 0 degrees varus/valgus. Short, satisfactory scars, little blood loss and postoperative pain, accelerated rehabilitation, and early discharge were noted. There were six cases of a permanent lesion of the lateral femoral cutaneous nerve. CONCLUSION: The proposed technique is safe and allows correct positioning of the cup and stem. It can be performed in a reasonable amount of time and blood loss is little.     

Patient-reported outcome after total hip arthroplasty: comparison between lateral and posterior approach

Background and purpose — Criticism of the lateral approach (LA) for hip arthroplasty is mainly based on the risk of poor patient-reported outcomes compared to the posterior approach (PA). However, there have been no controlled studies comparing patient-reported outcomes between them. In this randomized controlled trial, we tested the hypothesis that patient-reported outcomes are better in patients who have undergone total hip arthroplasty (THA) with PA than in those who have undergone THA with LA, 12 months postoperatively.

Patients and methods — 80 patients with hip osteoarthritis (mean age 61 years) were randomized to THA using PA or the modified direct LA. We recorded outcome measures preoperatively and 3, 6, and 12 months postoperatively using the Hip Disability and Osteoarthritis Outcome Score–Physical Function Short Form (HOOS-PS) as the primary outcome. Secondary outcomes were HOOS-Pain, HOOS-Quality-Of-Life, EQ-5D, UCLA Activity Score, and limping.

Results — We found no statistically significant difference in the improvements in HOOS-PS between the treatment groups at 12-month follow-up. All secondary outcomes showed similar results except for limping, where PA patients improved significantly more than LA patients.

Interpretation — Contrary to our hypothesis, patients treated with PA did not improve more than patients treated with LA regarding physical function, pain, physical activity, and quality of life 12 months postoperatively. However, limping was more pronounced in the LA patients.     

Worse patient-reported outcome after lateral approach than after anterior and posterolateral approach in primary hip arthroplasty

Background — The surgical approach in total hip arthroplasty (THA) is often based on surgeon preference and local traditions. The anterior muscle-sparing approach has recently gained popularity in Europe. We tested the hypothesis that patient satisfaction, pain, function, and health-related quality of life (HRQoL) after THA is not related to the surgical approach.

Patients — 1,476 patients identified through the Norwegian Arthroplasty Register were sent questionnaires 1–3 years after undergoing THA in the period from January 2008 to June 2010. Patient-reported outcome measures (PROMs) included the hip disability osteoarthritis outcome score (HOOS), the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), health-related quality of life (EQ-5D-3L), visual analog scales (VAS) addressing pain and satisfaction, and questions about complications. 1,273 patients completed the questionnaires and were included in the analysis.

Results — Adjusted HOOS scores for pain, other symptoms, activities of daily living (ADL), sport/recreation, and quality of life were significantly worse (p < 0.001 to p = 0.03) for the lateral approach than for the anterior approach and the posterolateral approach (mean differences: 3.2–5.0). These results were related to more patient-reported limping with the lateral approach than with the anterior and posterolateral approaches (25% vs. 12% and 13%, respectively; p < 0.001).

Interpretation — Patients operated with the lateral approach reported worse outcomes 1–3 years after THA surgery. Self-reported limping occurred twice as often in patients who underwent THA with a lateral approach than in those who underwent THA with an anterior or posterolateral approach. There were no significant differences in patient-reported outcomes after THA between those who underwent THA with a posterolateral approach and those who underwent THA with an anterior approach.     

Preservation of the articular capsule and short lateral rotator in direct anterior approach to total hip arthroplasty

Introduction

In total hip arthroplasty via a direct anterior approach, the femur must be elevated at the time of femoral implant placement. For adequate elevation, division of the posterior soft tissues is necessary. However, if we damage and separate the posterior muscle tissue, we lose the benefits of the intermuscular approach. Furthermore, damage to the posterior soft tissue can result in posterior dislocation. We investigate that protecting the posterior soft tissue increases the joint stability in the early postoperative period and results in a lower dislocation rate.

Methods

We evaluated muscle strength recovery by measuring the maximum width of the internal obturator muscle on CT images (GE-Healthcare Discovery CT 750HD). We compared the maximum width of the muscle belly preoperatively versus 10 days and 6 months postoperatively. As clinical evaluations, we also investigated the range of motion of the hip joint, hip joint function based on the Japanese Orthopaedic Association hip score (JOA score), and the dislocation rate 6 months after surgery.

Results

The width of the internal obturator muscle increased significantly from 15.1?±?3.1 mm before surgery to 16.4?±?2.8 mm 6 months after surgery. The JOA score improved significantly from 50.8?±?15.1 points to 95.6?±?7.6 points. No dislocations occurred in this study.

Conclusions

We cut only the posterosuperior articular capsule and protected the internal obturator muscle to preserve muscle strength. We repaired the entire posterosuperior and anterior articular capsule. These treatments increase joint stability in the early postoperative period, thus reducing the dislocation rate.

Level of evidence

Therapeutic, Level IV.

     

侧卧位直接前入路与后外侧入路在单侧全髋中的疗效对比

目的比较侧卧位直接前方入路(L-DAA)与后外侧入路(PLA)在单侧全髋关节置换术中的临床疗效。 方法回顾性分析2016年8月至2017年12月于重庆医科大学附属遂宁市中心医院关节外科行单侧全髋关节置换术患者共93例,纳入初次单侧置换患者,排除双侧或不能耐受手术的患者。按照手术入路不同分为L-DAA组(45例)及PLA组(48例)。所有手术均由同一组医师完成。对两组患者的身体质量指数(BMI)、围手术期各项指标(手术时间、失血量、术前血红蛋白值、术后第1天及第7天血红蛋白值、切口长度、平均住院日)、术前及术后Harris髋关节评分、术前及术后疼痛视觉模拟评分(VAS)等计数资料采用t检验分析;术后影像学评价、术中及术后并发症等计数资料采用卡方检验进行统计学分析。 结果两组患者均获得有效随访,随访时间6～16个月,平均(11.7±1.6)个月。所有患者术后均未出现深静脉血栓、感染等严重并发症。两组在BMI值、术前Harris评分、术前血红蛋白值、手术时间、切口长度、术后影像学评价、术前及术后VAS评分以及平均住院日上差异无统计学意义(P > 0.05);两组的失血量、术后第1天及第7天血红蛋白值差异具有统计学意义,后外侧入路组的失血量更多,而术后第1天和第7天的血红蛋白值更低(t ＝0.361、0.484,均为P < 0.05);同时术后3个月患侧Harris髋关节评分L-DAA组高于PLA组(t ＝0.572,P < 0.05);术后6个月Harris髋关节评分两组差异无统计学意义(P > 0.05)。L-DAA组术后均未发生人工关节脱位,PLA组术后出现2例人工关节后脱位,差异具有统计学意义(χ²＝0.465,P < 0.05)。L-DAA组术中发生2例股骨近端骨折,PLA组术中未发生股骨近端骨折,差异具有统计学意义(X² ＝0.587,P < 0.05)。 结论两种THA手术入路均能取得良好的近期临床疗效,其中L-DAA相较于PLA而言能减少手术创伤,更快恢复日常生活能力,有利于术后早期康复,符合快速康复(ERAS)理念。     

侧卧位直接前方入路全髋关节置换的可行性和效果

目的探讨侧卧位直接前方入路(DAA)全髋关节置换术的可行性和临床效果。方法对307例患者(332髋)行侧卧位DAA全髋关节置换术,评估临床功能,观察影像学结果和并发症。结果单侧髋关节置换手术时间41~73(52.0±5.6)min,术中失血量60~210(94.0±37.4)ml。患者均随访1年。髋关节Harris评分术后1、3、12个月均较术前明显改善(F=237.2,P<0.001)。术后第2天,髋臼假体前倾角为7°~22°(14.4°±6.0°),外展角为26°~57°(43.8°±4.4°)。双下肢长度的差异由术前0~2.5 cm纠正为术后0~1.5 cm(Z=-14.71,P<0.001)。18髋发生股外侧皮神经损伤,3髋发生术中股骨近端骨折,2髋术后早期出现髋关节脱位,1髋髋臼杯未完全打入臼窝,该24例经对症治疗后均愈合、复位良好。术后1年未发生假体周围骨折,无菌性假体松动。结论侧卧位DAA全髋关节置换术安全可行,临床效果良好。     

体位对直接前方入路全髋关节置换术的影响

目的：探讨术中不同体位对直接前方入路（direct anterior approach,DAA）全髋关节置换术的影响。方法：回顾性分析2016年7月至2020年6月行DAA全髋关节置换术患者94例,根据术中不同体位分为2组,其中侧卧位45例,仰卧位（支架辅助下）49例。观察比较两组患者性别、患肢、身体质量指数（body mass index,BMI）等一般资料,切口长度、手术时间、术中出血量、术后24 h引流量、手术前后血红蛋白差值、术后首次下地时间、术后住院时间、术后并发症,术后1 d,1、2周,1、3、6个月的疼痛视觉模拟评分（visual analogue scale,VAS）,术后1、2周及1、3、6个月的Harris评分。结果：两组患者术后均获得随访,时间6~12（8.31±2.22）个月。两组患者的性别、手术部位、年龄、BMI、术前VAS、术前Harris评分比较差异无统计学意义（P>0.05）。仰卧位（支架辅助下）组患者切口长度、手术时间、术中出血量、术后24 h引流量、手术前后血红蛋白差值、术后首次下地时间和术后住院时间均优于侧卧位组（P<0.05）;术中、术后输血例数比较,差异无统计学意义（P=0.550）。仰卧位（支架辅助下）组术中和术后前倾角、外展角比较,差异无统计学意义（P=0.825,P=0.066）;侧卧位组术中和术后前倾角、外展角比较,差异有统计学意义（P<0.05）。仰卧位（支架辅助下）组患者术后1 d,1、2周,1个月VAS低于侧卧位组（P<0.05）,两组术后3、6个月VAS差异无统计学意义（P>0.05）。仰卧位（支架辅助下）组患者术后1周及1、3个月的Harris评分高于侧卧位组（P<0.05）,两组术后6个月的Harris评分比较,差异无统计学意义（P>0.05）。结论：仰卧位（支架辅助下） DAA全髋关节置换术与侧卧位术式相比,手术切口小、手术时间短、出血少、下地时间早、住院时间短,且术中髋臼杯位置判断误差小,具有术后恢复快的优势,但在6个月后患者的髋关节功能恢复是相同的。     

Biomechanical reconstruction parameters obtained after direct anterior approach total hip arthroplasty do not compromise clinical outcome

European Journal of Orthopaedic Surgery & Traumatology - Accurate reconstruction of biomechanical parameters following total hip arthroplasty (THA) is crucial for good joint function. We...     

Greater trochanter chip fractures in the direct anterior approach for total hip arthroplasty

Background

The direct anterior approach (DAA) for the treatment of total hip arthroplasty (THA) has gained popularity in recent years. Chip fractures of the greater trochanter are frequently seen, but the risk factors for such fractures are unknown. The study aimed to identify the risk factors for chip fractures in patients undergoing primary THA by the DAA during the surgeons’ learning curve.

Materials and methods

From November 2011 to April 2015, the first experiences of three surgeons who performed 120 THAs by the DAA (120 hips; 40 cases per beginner surgeon) were included. The incidence of chip fracture of the greater trochanter, the size of the greater trochanter as measured by computed tomography, and the patients’ characteristics were retrospectively investigated.

Results

After exclusion of 11 hips, the remaining 109 hips were investigated. Chip fracture of the greater trochanter was identified in 32 hips (29.4 %). Univariate analysis with and without fractures showed that the width and depth of the greater trochanter were statistically significant risk factors (p = 0.02 and p < 0.001, respectively). Multivariate analysis using a logistic regression model demonstrated that the depth of the greater trochanter was an independent risk factor for chip fracture of the greater trochanter (OR 1.725; 95 % CI 1.367–2.177; p < 0.001).

Conclusion

The size of the greater trochanter was identified as a risk factor for chip fracture of the greater trochanter. Novice surgeons should pay attention to the size of the greater trochanter when performing THA by the DAA.

     

直接前侧入路与后外侧入路全髋关节置换术的疗效比较

目的 比较直接前侧入路(DAA)与后外侧入路(PA)行全髋关节置换术(THA)的疗效.方法 将60例行THA患者按随机数字表法分为PA组和DAA组,每组30例.比较两组切口长度、术中出血量、手术时间、住院时间、下床时间、部分负重锻炼时间和术后并发症情况.术后6、12个月采用髋关节Harris评分标准评价髋关节功能.结果...     

Two-year experience using a limited-incision direct lateral approach in total hip arthroplasty

We evaluated clinical, radiographic, and short-term recovery outcomes in an 18-month 1 surgeon series of 102 unilateral primary total hip arthroplasties performed by direct lateral approach through standard size (15-20 cm) and limited (<10 cm) incisions. Patients were blinded to incision type. Observed measures related to hematological status, transfusions, operative time, hospitalization time, narcotic use, rehabilitation, and discharge disposition did not appear to differ by incision type. Components were well placed in both groups. Intraoperative femoral fractures occurred in 2 limited-incision cases. At 2 years' minimum follow-up, we did not observe evidence that minimally invasive surgical technique provided clinically significant benefit to these patients.