THA手术入路怎么选?最新研究进展来了
随着逐渐步入老年社会,髋关节置换术对股骨颈骨折或髋关节骨性关节炎患者有着非凡的意义,可有效改善患者功能、提高生活质量、降低死亡率等。手术入路方式也有多种,目前使用较为广泛的入路有后外侧Moore、Super-PATH;直接外侧Hardinge;直接前入路(DAA、Bikini)等,相对于传统的后外侧入路,近期美国AAHKS协会对996关节外科医师进行调查,发现56%医师在髋关节置换中优先选择前入路。针对全髋关节置换中前侧入路、后侧入路和后外侧入路方式利弊仍存在争议,本文纳入了近1年关于此问题高质量的最新研究,供大家参考。
来自美国犹他大学医学院的Finch教授通过一项多中心前瞻性研究(n=3018,48.1%后侧入路, 21.0%后外侧入路, 30.9%前侧入路)发现术后6月患者报告结局指标(patientreported outcome measures,PROM)评分均明显提高,但与手术入路方式无关,提示手术入路对早期临床预后无影响[1]。类似的,一项前瞻性随机对照研究(n=183)对比了前入路和后入路两者PROM方面的差异,发现术后1-5年内PROM评分无差异[2]。梅奥医疗中心通过对1967例全髋关节置换患者(56%后侧入路, 29%后外侧入路, 15%前侧入路)研究发现术后30天内大的或小的并发症与手术入路无关(表1)[3]。
图2,并发症的累积发生率曲线,(A)所有机械力学方面并发症总和,(B)再次手术,(C)不稳定/脱位,(D)假体周围骨折,(E)无菌松动
[1] Finch DJ, Martin BI, Franklin PD. Patient-reported outcomes following total hip arthroplasty: a multicenter comparison based on surgical approaches. J Arthroplasty. 2020 Apr;35(4).
[2]Sauder N, Vestergaard V, Siddiqui S, Galea VP. The AAHKS Clinical Research Award: no evidence for superior patient-reported outcome scores after total hip arthroplasty with the direct anterior approach at 1.5 months postoperatively, and through a 5-year follow-up. J Arthroplasty. 2020 Feb.
[3]Hart A, Wyles CC, Abdel MP, Perry KI,. Thirty-day major and minor complications following total hip arthroplasty-a comparison of the direct anterior, lateral, and posterior approaches. J Arthroplasty. 2019 Nov;34.
[4]Fleischman AN, Tarabichi M, Magner Z. Mechanical complications following total hip arthroplasty based on surgical approach: a large, single-institution cohort study. J Arthroplasty. 2019 Jun.
[5] Hoskins W, Bingham R, Lorimer M, Early Rate of Revision of Total Hip Arthroplasty Related to Surgical Approach: An Analysis of 122,345 Primary Total Hip Arthroplasties. J Bone Joint Surg Am. 2020 Nov 4.
[6] Li M, Glassman AH. What's New in Hip Replacement. J Bone Joint Surg Am. 2020;102(18):1572-1580.
本文内容仅代表作者个人观点,不代表骨今中外官方立场。希望大家理性判断,有针对性地应用。