经皮辅助关节囊入路微创人工全髋关节置换术

doi:10.3877/cma.j.issn.1674-134X.2018.01.001

目的

分析经皮辅助关节囊(SuperPATH)入路微创人工全髋关节置换术的短期随访结果和可行性。

方法

纳入自2014年12月至2015年7月在上海市第六人民医院骨科关节外科，诊断为髋关节骨关节炎、无菌性股骨头坏死或轻度先天性髋关节发育不良的采用SuperPATH微创技术行初次人工全髋关节置换术病例，排除有髋关节感染史，创伤性髋关节炎史和结核性髋关节炎的病例，共纳入14例(14髋)，男6例，女8例，年龄62～81岁，平均(74±6)岁。记录本组病例手术时间、术中出血量、切口长度、住院天数、术后并发症、影像学评价，并采用单因素重复测量方差分析比较患髋疼痛改善、功能康复情况。

结果

14例病例均获得随访，平均随访时间(16±3)个月，手术时间、术中出血量、切口长度、住院天数分别为(101±25)min，(450±230)ml，(8.9±1.4)cm，(7.2±0.8)d。术后首次直腿抬高时间为(31±7)h；术后1、3月患侧单腿站立试验阴性率42.8%(6/14)、100%(14/14)；疼痛视觉模拟评分(VAS)评分术前、术后第1、3、5天、1月、3月分别平均为(8.0±1.3)、(4.3±1.1)、(2.5±0.9)、(2.0±0.8)、(1.6±0.8)、(1.1±0.6)(F＝62.8，P<0.01)；术前、术后1月、术后3月、末次随访髋关节Harris评分分别平均为(43.4±5)、(80.3±8.9)、(91.6±6.7)、(93.3±5.3)(F＝432.4，P<0.01)；术前、术后第3、5天、1月3月和末次随访Berg评分分别平均为(29.7±6.7)、(13.8±3.7)、(18.2±6.0)、(39.6±4.3)、(49.0±6.1)、(54.5±2.7)(F＝152.6，P<0.01)；术前、术后第3、5天、1月3月和末次随访Barthel指数分别平均为(57.9±8.4)、(32.1±8.5)、(48.9±10.6)、(81.5±5.9)、(94.2±6.5)、(97.5±5.2)(F＝217，P<0.01)。术后影像学检查，双下肢长度差值、双侧股骨偏心距差值、髋臼外展角和前倾角分别平均为(4.6±3.1)mm、(3.2±2.2)mm、(36.0±4.9)°、(17.4±7.5)°，术后未发生假体周围骨折，感染、深静脉血栓、肺栓塞及血管神经损伤并发症。

结论

Super-PATH全髋关节置换术切口小，创伤小，不切断髋关节周围肌肉，且不影响假体植入，改善术后疼痛及加快功能康复，是一个安全可行的微创全髋关节置换手术技术。

关键词: 关节成形术，置换，髋, 外科手术，微创性, 关节囊

Objective

To investigate and discuss the short-term clinical outcomes and feasibility of the minimally invasive supercapsular percutaneously assisted total hip (SuperPATH) arthroplasty.

Methods

From December 2014 to July 2015, 14 cases of the minimally invasive SuperPATH-approach total hip arthroplasty were performed. There were six males and eight females with an average age of (74±6) years. Preoperative diagnosis of the patients included four cases of osteoarthritis, five cases of osteonecrosis and five cases of developmental dysplasia hip. Preoperative scores of the visual analogue scale (VAS), Harris score, Berg scale and Barthel index were recorded; operation time, blood loss, length of incisions, average hospitalization, operation related complications, radiological outcomes and the degree of pain relief and function rehabilitation postoperatively were analyzed. Variance analysis was applied for statistical analysis.

Results

All the patients were followed up from 12 to 19 months, (16±3) months on average. The average operation time, blood loss, length of incision and hospitalization were (101±25) min, (450±230) ml, (8.9±1.4) cm, (7.2±0.8) d. The average time of first straight leg raising postoperatively was (31±7) h. The negative rates of the Trendelenburg test at one month and three months postoperatively were 42.8% (6/14) and 100% (14/14), and the average Harris scores was (43.4±5) preoperatively, were(80.3±8.9) at postoperative 1^st month, (91.6±6.7)at postoperative 3^rd month, and(93.3±5.3) at the last follow-up(F=432.4, P<0.01). The average Berg scale scores was (29.7±6.7)before the surgery, and were postoperatively (13.8±3.7)on day 3, (18.2±6.0)on day 5, (39.6±4.3)at the 1^st month, (49.0±6.1)at the 3^rd month, and(54.5±2.7)at the last follow-up(F=152.6, P<0.01). The mean Barthel index was (57.9±8.4)before the surgery, and were postoperatively(32.1±8.5)on day 3, (48.9±10.6)on day 5, (81.5±5.9)at the 1^st month, (94.2±6.5)at the 3^rd month, (97.5±5.2)at the last follow-up(F=217, P<0.01). The average VAS scores was (8.0±1.3)before the surgery, and on 1 d, 3 d, 5 d, one month and three months postoperatively were (4.3±1.1)、(2.5±0.9)、(2.0±0.8)、(1.6±0.8)、(1.1±0.6)(F=62.8, P<0.01)respectively. As to the radiological outcomes, the average D-values of lower limb length and femoral offset and the average angles of acetabular abduction and anteversion were (4.6±3.1)mm, (3.2±2.2) mm, (36.0±4.9)°, (17.4±7.5)°. No periprosthetic fracture, infection, deep venous thrombosis, pulmonary embolism or nerve injury happened.

Conclusion

SuperPATH approach has the advantages of smaller incision, minimally invasive, muscle sparing, pain relief, fast recovery and good prosthesis location, which contributes the minimally invasive SuperPATH approach to be safe and feasible.

Key words: Arthroplasty, replacement, hip, Minimally invasive surgical procedures, Joint capsule

图2 经皮辅助关节囊(SuperPATH)入路全髋关节置换术后已缝合切口，小切口，约10 cm

图4 术后骨盆正位X线片，示假体位置良好

表1 髋关节功能评分(±s)

时间点	Berg评分	Barthel指数	Harris评分
术前	29.7±6.7	57.9±8.4	43.4±5
术后3 d	13.8±3.7^**	32.1±8.5^**	/
术后5 d	18.2±6.0^*	48.9±10.6^**	/
术后1月	39.6±4.3^**	81.5±5.9^**	80.3±8.9^**
术后3月	49.0±6.1^**	94.2±6.5^**	91.6±6.7^**
末次随访	54.5±2.7^*	97.5±5.2^*	93.3±5.3
F值	152.6	217	432.4
P值	<0.01	<0.01	<0.01

表1 髋关节功能评分(±s)

时间点	Berg评分	Barthel指数	Harris评分
术前	29.7±6.7	57.9±8.4	43.4±5
术后3 d	13.8±3.7^**	32.1±8.5^**	/
术后5 d	18.2±6.0^*	48.9±10.6^**	/
术后1月	39.6±4.3^**	81.5±5.9^**	80.3±8.9^**
术后3月	49.0±6.1^**	94.2±6.5^**	91.6±6.7^**
末次随访	54.5±2.7^*	97.5±5.2^*	93.3±5.3
F值	152.6	217	432.4
P值	<0.01	<0.01	<0.01

表2 VAS疼痛评分(±s)

时间点	VAS评分
术前	8.0±1.3
术后1 d	4.3±1.1^**
术后3 d	2.5±0.9^**
术后5 d	2.0±0.8
术后1月	1.6±0.8
术后3月	1.1±0.6^*
F值	62.8
P值	<0.01

表2 VAS疼痛评分(±s)

时间点	VAS评分
术前	8.0±1.3
术后1 d	4.3±1.1^**
术后3 d	2.5±0.9^**
术后5 d	2.0±0.8
术后1月	1.6±0.8
术后3月	1.1±0.6^*
F值	62.8
P值	<0.01

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Supercapsular percutaneously assisted total hip arthroplasty

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