侧位直接前方入路髋关节置换治疗偏瘫肢体股骨颈骨折

doi:10.3877/cma.j.issn.1674-134X.2023.06.016

目的

探讨侧卧位直接前方入路(DAA)髋关节置换治疗偏瘫患者偏瘫肢体GardenⅢ型、Ⅳ型股骨颈骨折术后的稳定性及其临床效果。

方法

选自蚌埠医学院第一附属医院2018年2月至2022年1月收治的股骨颈骨折(GardenⅢ型、Ⅳ型)合并偏瘫患者43名，根据髋关节置换手术入路分为DAA组22例(男13例，女9例)和后外侧入路组21例(男11例，女10例)，随访时间为12~26个月，记录并采用t检验、卡方检验对比DAA组与后外侧入路组基线资料差异、术中出血量、手术时间、住院时间、术后第一次下地活动时间、术后并发症、活动能力恢复情况、视觉模拟疼痛评分(VAS)、生活质量评分(改良Barthel评定量表)、Harris髋关节功能评分、偏瘫肢体功能恢复情况(Brunnstrom偏瘫功能分期)，评定侧卧DAA入路髋关节置换治疗偏瘫患者股骨颈骨折的安全性及稳定性。

结果

两组患者均顺利完成手术。DAA组患者术后第一次下地活动时间较后外侧入路组短、术中出血量较后外侧入路组少、住院时间较后外侧入路组短(t＝7.756、6.925、3.479，均为P<0.05)。两组疼痛(VAS评分)较术前明显减轻、髋关节功能(Harris评分)较术前改善、生活质量较术前提升，DAA组改善情况较后外侧入路组显著(t＝11.200、－8.429、－11.034、均为P<0.05)；两组术后下肢Brunnstrom偏瘫功能分期较术前得到明显改善，DAA组改善较后外侧入路组更明显(Z＝6.747，P＝0.009)。DAA组16例(72.7%)恢复至术前，后外侧入路组9例(42.9%)恢复至术前(χ²＝3.939，P＝0.047)；两组患者早期并发症差异无统计学意义(χ²＝0.009，P >0.05)。

结论

合并偏瘫的Garden Ⅲ、Ⅳ型股骨颈骨折行侧卧DAA入路髋关节置换是一种积极的安全有效的手术方式，具有较好的临床效果。

关键词: 偏瘫, 股骨颈骨折, 关节成形术，置换，髋

Objective

To evaluate the stability and clinical effect of lateral decubitus direct anterior approach (DAA) hip replacement in patients with hemiplegia after treatment of Garden type Ⅲ and Ⅳ femoral neck fracture.

Methods

A total of 43 patients with femoral neck fracture (Garden type III and IV) combined with hemiplegia admitted to the First Affiliated Hospital of Bengbu Medical College from February 2018 to January 2022 were selected, and divided into 22 patients (13 males and nine females) in DAA group and 21 patients (11 males and 10 females) in posterolateral approach group according to hip replacement surgical approach. The follow-up period was 12 to 26 months. T test, chi square test and rank sum test were used to compare baseline data variance, intraoperative blood loss, operation time, hospital stay, first postoperative movement time, postoperative complications, mobility recovery, visual analoguepain scale (VAS), quality of life score (modified Barthel rating scale) and Harris hip between DAA group and posterolateral approach group Joint function scores and functional recovery of hemiplegic limbs (Brunnstrom stage of hemiplegic function) were used to evaluate the safety and stability of hip replacement with lateral DAA approach in the treatment of femoral neck fractures in hemiplegic patients.

Results

All the patients accpeted completed surgery successfully. DAA group had shorter time for first postoperative exercise, less intraoperative blood loss and shorter length of hospital stay than the posterolateral approach group (t=7.756、6.925、3.479, all P<0.05). Pain (VAS score) was significantly relieved, hip function (Harris score) was improved and quality of life was improved in both groups. The improvement in DAA group was more remarkable than that the posterolateral approach group (t=11.200、-8.429、-11.034、P<0.05, all P<0.05). The stage of Brunnstrom hemiplegia function of lower limbs was significantly improved in both groups after surgery, and the improvement in DAA group was more obvious than the posterolateral approach group (Z=6.747, P=0.009). In the DAA group, 16 cases (72.7%) recovered to the status before surgery, and in the posterolateral approach group, nine cases (42.9%) recovered to the status before surgery (χ²=3.939, P=0.047). There was no significant difference in early complications between the two groups (χ²=0.009, P>0.05).

Conclusion

Lateral DAA approach for hip replacement of Garden Ⅲ and Ⅳ femoral neck fractures with hemiplegia is a safe and effective surgical method with good clinical results.

Key words: Hemiplegia, Femoral neck fractures, Arthroplasty, replacement, hip

表1 DAA组与后外侧入路组一般资料

Table 1 General information of DAA group and posterolateral approach group

组别Groups	年龄[岁，(±s)]Age (years)	身体质量指数[kg/cm²，(±s)]Body mass index	性别(男/女)Gender(male/female)	髋周肌力Muscle strength of hip		骨折分型Fracture classification
组别Groups	年龄[岁，(±s)]Age (years)	身体质量指数[kg/cm²，(±s)]Body mass index	性别(男/女)Gender(male/female)	≥Ⅲ级	<Ⅲ级	Ⅲ型	Ⅳ型
DAA组DAA group	66.9±7.6	21.6±1.4	13/9	16	6	10	12
后外侧入路组Posterolateral approach group	66.7±5.9	21.7±1.6	11/10	11	10	15	6
统计值Statistical value	t＝－0.116	t＝0.229	χ²＝0.196	χ²＝1.904		χ²＝2.978
P值	>0.05	>0.05	>0.05	>0.05		>0.05

表1 DAA组与后外侧入路组一般资料

Table 1 General information of DAA group and posterolateral approach group

组别Groups	年龄[岁，(±s)]Age (years)	身体质量指数[kg/cm²，(±s)]Body mass index	性别(男/女)Gender(male/female)	髋周肌力Muscle strength of hip		骨折分型Fracture classification
组别Groups	年龄[岁，(±s)]Age (years)	身体质量指数[kg/cm²，(±s)]Body mass index	性别(男/女)Gender(male/female)	≥Ⅲ级	<Ⅲ级	Ⅲ型	Ⅳ型
DAA组DAA group	66.9±7.6	21.6±1.4	13/9	16	6	10	12
后外侧入路组Posterolateral approach group	66.7±5.9	21.7±1.6	11/10	11	10	15	6
统计值Statistical value	t＝－0.116	t＝0.229	χ²＝0.196	χ²＝1.904		χ²＝2.978
P值	>0.05	>0.05	>0.05	>0.05		>0.05

表2 两组围手术期情况对比(±s)

Table 2 Comparison of perioperative period data between the two groups

组别Groups	例数Case number	手术时间(min)Operation time	术后第一次下地时间(d)First ambulant time after surgery	术中出血量(ml)Intraoperative blood loss	住院时间(d)Length of stay
DAA组DAA group	22	69.1±6.8	6.3±1.1	90.0±10.2	9.7±2.2
后外侧入路组Posterolateral approach group	21	70.3±5.4	9.8±1.8	149.5±38.9	12.5±3.1
t值		0.658	7.756	6.925	3.479
P值		>0.05	0.045	<0.001	0.049

表2 两组围手术期情况对比(±s)

Table 2 Comparison of perioperative period data between the two groups

组别Groups	例数Case number	手术时间(min)Operation time	术后第一次下地时间(d)First ambulant time after surgery	术中出血量(ml)Intraoperative blood loss	住院时间(d)Length of stay
DAA组DAA group	22	69.1±6.8	6.3±1.1	90.0±10.2	9.7±2.2
后外侧入路组Posterolateral approach group	21	70.3±5.4	9.8±1.8	149.5±38.9	12.5±3.1
t值		0.658	7.756	6.925	3.479
P值		>0.05	0.045	<0.001	0.049

表3 两组术前及术后疼痛及功能情况(±s)

Table 3 Pain and function evaluation before and after operation of the two groups

分组Groups	例数Case number	Harris评分Harris score		VAS评分VAS score		改良Barthel生活评分Modified Barthel life score
分组Groups	例数Case number	术前Before operation	术后After operation	术前Before operation	术后After operation	术前Before operation	术后After operation
DAA组DAA group	22	25.6±3.2	86.5±3.5	6.8±0.8	1.1±0.4	41.6±2.9	77.8±2.7
后外侧入路组Posterolateral approach group	21	24.5±3.5	75.1±5.3	6.9±1.0	3.7±1.0	40.7±2.5	65.7±4.3
t值		1.886	－8.429	0.302	11.200	－1.052	－11.034
P值		>0.05	0.039	>0.05	0.003	>0.05	0.006

表3 两组术前及术后疼痛及功能情况(±s)

Table 3 Pain and function evaluation before and after operation of the two groups

分组Groups	例数Case number	Harris评分Harris score		VAS评分VAS score		改良Barthel生活评分Modified Barthel life score
分组Groups	例数Case number	术前Before operation	术后After operation	术前Before operation	术后After operation	术前Before operation	术后After operation
DAA组DAA group	22	25.6±3.2	86.5±3.5	6.8±0.8	1.1±0.4	41.6±2.9	77.8±2.7
后外侧入路组Posterolateral approach group	21	24.5±3.5	75.1±5.3	6.9±1.0	3.7±1.0	40.7±2.5	65.7±4.3
t值		1.886	－8.429	0.302	11.200	－1.052	－11.034
P值		>0.05	0.039	>0.05	0.003	>0.05	0.006

表4 两组术前及术后下肢Brunnstrom偏瘫功能分期

Table 4 Pre- and postoperative Brunnstrom hemiplegic function stage of lower limbs

组别Groups	例数Case number	术前1周One week before surgery
组别Groups	例数Case number	1期First phase	2期Second phase	3期Third phase	4期Fourth phase	5期Fifth phase	5期率(%)Ratio of fifth phase
DAA组DAA group	22	3	7	7	4	1	4.5
后外侧入路组Posterolateral approach group	21	3	8	4	4	2	9.5
P值							0.607^*
组别Groups	例数Case number	术后1年One year after surgery
组别Groups	例数Case number	1期First phase	2期Second phase	3期Third phase	4期Fourth phase	5期Fifth phase	5期率(%)Ratio of fifth phase
DAA组DAA group	22	0	1	3	3	15	68.2
后外侧入路组Posterolateral approach group	21	0	1	4	10	6	28.6
χ²值							6.747
P值							0.009

表4 两组术前及术后下肢Brunnstrom偏瘫功能分期

Table 4 Pre- and postoperative Brunnstrom hemiplegic function stage of lower limbs

组别Groups	例数Case number	术前1周One week before surgery
组别Groups	例数Case number	1期First phase	2期Second phase	3期Third phase	4期Fourth phase	5期Fifth phase	5期率(%)Ratio of fifth phase
DAA组DAA group	22	3	7	7	4	1	4.5
后外侧入路组Posterolateral approach group	21	3	8	4	4	2	9.5
P值							0.607^*
组别Groups	例数Case number	术后1年One year after surgery
组别Groups	例数Case number	1期First phase	2期Second phase	3期Third phase	4期Fourth phase	5期Fifth phase	5期率(%)Ratio of fifth phase
DAA组DAA group	22	0	1	3	3	15	68.2
后外侧入路组Posterolateral approach group	21	0	1	4	10	6	28.6
χ²值							6.747
P值							0.009

表5 两组患者术后随访情况对比[例(%)]

Table 5 Comparison of postoperative follow-up between the two groups

分组Groups	例数Case number	活动恢复状态Activity recovery		早期并发症Early complication
分组Groups	例数Case number	恢复至术前状态Same as pre-operative status	未达到术前状态Not acheive preoperative status	有Yes	无No
DAA组DAA group	22	16(72.7)	6(27.3)	6(27.3)	16(72.7)
后外侧入路组Posterolateral approach group	21	9(42.9)	12(57.1)	6(28.6)	15(71.4)
χ²值		3.939		0.009
P值		0.047		>0.05

表5 两组患者术后随访情况对比[例(%)]

Table 5 Comparison of postoperative follow-up between the two groups

分组Groups	例数Case number	活动恢复状态Activity recovery		早期并发症Early complication
分组Groups	例数Case number	恢复至术前状态Same as pre-operative status	未达到术前状态Not acheive preoperative status	有Yes	无No
DAA组DAA group	22	16(72.7)	6(27.3)	6(27.3)	16(72.7)
后外侧入路组Posterolateral approach group	21	9(42.9)	12(57.1)	6(28.6)	15(71.4)
χ²值		3.939		0.009
P值		0.047		>0.05

图1 小儿麻痹后遗症偏瘫患者右股骨颈骨折治疗前后情况。图A为术前双下肢对比，示右腿肌肉明显萎缩；图B为治疗前骨盆正位X线片，示右股骨颈骨折Garden Ⅳ型，骨折周围骨溶解；图C为行DAA(直接前方入路)人工股骨头置换术后复查骨盆X线片，示假体稳定在位，无松动脱位现象

Figure 1 Images of hemiplegia following poliomyelitis with right femoral neck fractures. A is comparison of lower limbs before surgery, showing muscular atrophy of right leg; B is X ray image of pelvis at anteroposterior view before surgery, showing right femoral neck fractures of Garden Ⅳ and osteolysis around the fracture; C is X ray image of pelvis at anteroposterior view after femoral head replacement by DDA, showing the prosthesis was stable at position without loosening

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Direct anterior approach in lateral hip replacement for hemiplegic limb femoral neck fracture

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Direct anterior approach in lateral hip replacement for hemiplegic limb femoral neck fracture