改良后外侧入路半髋置换治疗股骨颈骨折的早期疗效

doi:10.3877/cma.j.issn.1674-134X.2024.03.016

目的

探讨保留短外旋肌群的后外侧手术入路（CPP）人工股骨头置换治疗股骨颈骨折的临床疗效。

方法

回顾性分析上海交通大学医学院苏州九龙医院2019年1月至2022年1月共91例人工双极股骨头置换的患者。根据后外侧入路是否保留短外旋肌群分为常规组和CPP组，常规组常规切断短外旋肌群，CPP组为改良后外侧入路保留短外旋肌群。观察两组围手术期切口长度，手术时间，出血量，住院时间和疼痛等指标并进行卡方检验或t检验，随访术后并发症情况并对髋关节功能及疼痛进行评分。

结果

常规组50例患者，其中男15例，女35例，平均年龄（80±7）岁，CPP组41例患者，男15例，女26例，平均年龄（80±6）岁。常规组患者的手术时间、切口长度及住院时间更长，失血量较CPP组更多（t=3.192、4.553、2.968、5.835，均为P<0.05）。常规组患者术后1个月Harris评分明显低于CPP组（t=6.705，P<0.05），而术后3个月Harris评分差异则无统计学意义（t=1.484，P>0.05）。两组患者术前疼痛视觉模拟评分（VAS）差异无统计学意义（t=0.148，P>0.05），术后第1天VAS评分常规组高于CPP组（t=4.215，P<0.05）。术后总体并发症发生率两组差异无统计学意义（χ²=0.675，P>0.05）。

结论

采用CPP手术入路，不仅减少了手术创伤，缩短了患者回归正常生活时间，同时增加了髋关节的稳定性，理论上可降低术后脱位风险，更推荐用于高龄人工股骨头置换患者。

关键词: 股骨颈骨折, 关节成形术，置换，髋, 治疗结果

Objective

To investigate the clinical efficacy of hemiarthroplasty with conjoined tendon preserving posterior approach(CPP) in the treatment of femoral neck fractures.

Methods

A retrospective analysis was performed for a total of 91 patients undergone hemiarthroplasty in Suzhou Kowloon Hospital, Shanghai Jiao Tong University School of Medicine from January 2019 to January 2022. The patients were divided into the tradition group and the CPP group according to the different posterolatral approach types: the traditional group adopted cutting the conjoined tendon, while the CPP group adopted preserving the conjoined tendon. The incision length, operation time, blood loss, hospital stay and pain were compared in the two groups by chi square test or t test. The postoperative complications were followed up and the hip function and pain were scored.

Results

There were 50 patients in the tradition group and 41 patients in the CPP group, including 15 males and 35 females in the tradition group, with an average age of (80±7) years, and 15 males and 26 females in the CPP group, with an average age of (80±6) years. The operation time, incision length and hospital stay were longer in the tradition group, and the blood loss was more than that in the CPP group (t=3.192, 4.553, 2.968, 5.835, all P<0.05). The Harris score of the tradition group was significantly lower than that of the CPP group one month after surgery (t=6.705, P<0.05), but there was no statistically significant difference in Harris score three months after operation (t=1.484, P>0.05). There was no statistically significant difference in preoperative visual analogue scale (VAS) scores between the two groups (t=0.148, P>0.05), and the pain score of the tradition group were higher than those of the CPP group on the first postoperative day (t=4.215, P<0.05). There was no significant difference in the overall postoperative complication rate between the two groups (χ²=0.675, P>0.05).

Conclusion

The CPP approach not only reduces the surgical trauma, shortens the time for patients to return to normal life, but also increases the stability of the hip joint, which can theoretically reduce the risk of postoperative dislocation, and is more recommended for elderly patients with hemiarthroplasty.

Key words: Femoral neck fractures, Arthroplasty, replacement, hip, Treatment outcome

表1 两组患者一般资料比较

Table 1 General information of the two groups

组别 Groups	例数 Cases number	性别（男/女） Gender(male/female)	年龄［岁，（）］ Age (year)	身高［cm，（）］ Height	体重［kg，（）］ Weight
常规组 Tradition group	50	15/35	80±7	165±7	63±9
CPP组 CPP group	41	15/26	80±6	166±8	66±9
统计值 Statistical value		χ²=0.442	t=0.171	t=0.829	t=1.567
P值		>0.05	>0.05	>0.05	>0.05

表1 两组患者一般资料比较

Table 1 General information of the two groups

组别 Groups	例数 Cases number	性别（男/女） Gender(male/female)	年龄［岁，（）］ Age (year)	身高［cm，（）］ Height	体重［kg，（）］ Weight
常规组 Tradition group	50	15/35	80±7	165±7	63±9
CPP组 CPP group	41	15/26	80±6	166±8	66±9
统计值 Statistical value		χ²=0.442	t=0.171	t=0.829	t=1.567
P值		>0.05	>0.05	>0.05	>0.05

表2 两组围手术期相关指标（

）

Table 2 Perioperative data of the two groups

组别 Groups	例数 Cases number	手术时间（min） Operation time	切口长度（cm） Incision length	失血量（ml） Blood loss	住院时间（d） Length of hospital stay
常规组Tradition group	50	72.6±12.4	10.2±1.9	221.2±29.9	9.5±2.0
CPP组CPP group	41	64.9±10.3	8.5±1.7	187.1±24.9	8.2±2.1
t值		3.192	4.553	5.835	2.968
P值		0.002	<0.001	<0.001	0.004

表2 两组围手术期相关指标（

）

Table 2 Perioperative data of the two groups

组别 Groups	例数 Cases number	手术时间（min） Operation time	切口长度（cm） Incision length	失血量（ml） Blood loss	住院时间（d） Length of hospital stay
常规组Tradition group	50	72.6±12.4	10.2±1.9	221.2±29.9	9.5±2.0
CPP组CPP group	41	64.9±10.3	8.5±1.7	187.1±24.9	8.2±2.1
t值		3.192	4.553	5.835	2.968
P值		0.002	<0.001	<0.001	0.004

表3 两组髋关节功能Harris评分及VAS疼痛评分（

）

Table 3 Harris and VAS scoresin perioperative period

组别 Groups	例数 Case snumber	术后1个月Harris评分 Harris score one month after surgery	术后3个月Harris评分 Harris score three months after surgery	术前VAS评分 Preoperative VAS score	术后1 d VAS评分 VAS score one day after surgery
常规组 Tradition group	50	84.0±2.4	89.1±2.0	5.5±1.2	3.3±1.1
CPP组 CPP group	41	87.3±2.3	89.7±2.2	5.5±1.2	2.4±0.9
t值		6.705	1.484	0.148	4.215
P值		<0.001	>0.05	>0.05	<0.001

表3 两组髋关节功能Harris评分及VAS疼痛评分（

）

Table 3 Harris and VAS scoresin perioperative period

组别 Groups	例数 Case snumber	术后1个月Harris评分 Harris score one month after surgery	术后3个月Harris评分 Harris score three months after surgery	术前VAS评分 Preoperative VAS score	术后1 d VAS评分 VAS score one day after surgery
常规组 Tradition group	50	84.0±2.4	89.1±2.0	5.5±1.2	3.3±1.1
CPP组 CPP group	41	87.3±2.3	89.7±2.2	5.5±1.2	2.4±0.9
t值		6.705	1.484	0.148	4.215
P值		<0.001	>0.05	>0.05	<0.001

表4 两组相关并发症比较

Table 4 Comparison of related complications between the two groups

组别 Groups	例数 Cases number	骨折 Fracture	脱位 Dislocation	感染 Infection	脑梗死 Cerebral infarction	并发症率（%） Complication rate
常规组 Tradition group	50	1	2	1	2	12
CPP组 CPP group	41	1	0	0	1	4.88
χ²值						0.675
P值						>0.05

表4 两组相关并发症比较

Table 4 Comparison of related complications between the two groups

组别 Groups	例数 Cases number	骨折 Fracture	脱位 Dislocation	感染 Infection	脑梗死 Cerebral infarction	并发症率（%） Complication rate
常规组 Tradition group	50	1	2	1	2	12
CPP组 CPP group	41	1	0	0	1	4.88
χ²值						0.675
P值						>0.05

图1 典型病例影像及手术情况。图A为术前右髋关节正侧位片，示右侧股骨颈骨折，骨折端移位明显；图B为术中处理，红色箭头示关节囊，蓝色箭头示髋臼；图C为术中安放假体，黄色箭头示短外旋肌群，绿色箭头示人工股骨头；图D为术后右髋关节正侧位片，示人工髋关节假体在位，位置良好

Figure 1 X ray and operation images of typical case. A is preoperative X-ray images of right hip joint at anteroposterior and lateral views, showing right femoral neck fracture with obvious displacement; B is image during operation, and red arrow shows joint capsule, blue arrow shows acetabular; C is image of putting prosthesis during operation, and the yellow arrow shows short external rotator muscles, green arrow shows artificial femoral head; D is postoperative X-ray images of right hip joint at anteroposterior and lateral views, showing hip prosthesis in good position

［1］	Li X，Ma L，Wang Q，et al. Comparison of total hip arthroplasty with minimally invasive SuperPath approach vs. conventional posterolateral approach in elderly patients: a one-year follow-up randomized controlled research［J］. Asian J Surg，2021,44(3): 531-536.
［2］	Jin Z，Wang L，Qin J，et al. Direct anterior approach versus posterolateral approach for total hip arthroplasty in the treatment of femoral neck fractures in elderly patients: a meta-analysis and systematic review［J］. Ann Med，2023,55(1): 1378-1392.
［3］	Nakamura T，Yamakawa T，Hori J，et al. Conjoined tendon preserving posterior approach in hemiarthroplasty for femoral neck fractures: a prospective multicenter clinical study of 322 patients［J/OL］. J Orthop Surg，2021,29(3): 23094990211063963. DOI: 10.1177/23094990211063963.
［4］	Page BJ，Parsons MS，Lee JH，et al. Surgical approach and dislocation risk after hemiarthroplasty in geriatric patients with femoral neck fracture with and without cognitive impairments-does cognitive impairment influence dislocation risk?［J］. J Orthop Trauma，2023,37(9): 450-455.
［5］	van der Sijp MPL，van Delft D，Krijnen P，et al. Surgical approaches and hemiarthroplasty outcomes for femoral neck fractures: ameta-analysis［J］. J Arthroplasty，2018,33(5): 1617-1627.e9.
［6］	Jobory A，Kärrholm J，Hansson S，et al. Dislocation of hemiarthroplasty after hip fracture is common and the risk is increased with posterior approach: result from a national cohort of 25，678 individuals in the Swedish Hip Arthroplasty Register［J］. Acta Orthop，2021,92(4): 413-418.
［7］	Liang S，Wu H，Deng S，et al. A comparison of different surgical approaches to hemiarthroplasty for the femoral neck fractures: a meta-analysis［J/OL］. Front Surg，2022,9: 1049534. DOI: 10.3389/fsurg.2022.1049534.
［8］	de Vries EN，Gardenbroek TJ，Ammerlaan H，et al. The optimal approach in hip hemiarthroplasty: a cohort of 1009 patients［J］. Eur J Orthop Surg Traumatol，2020,30(4): 569-573.
［9］	Ng KCG，Jeffers JRT，Beaulé PE. Hip joint capsular anatomy，mechanics，and surgical management［J］. J Bone Joint Surg Am，2019,101(23): 2141-2151.
［10］	Eilander W，van der Velden E，van Harten M，et al. The short external rotators in the anterior approach hip arthroplasty: do the tendons heal or not？A prospective MRI study［J］. Hip Int，2023,33(5): 819-827.
［11］	Yoo JH，Kwak D，Lee Y，et al. Clinical results of short external rotators preserving posterolateral approach for hemiarthroplasty after femoral neck fractures in elderly patients［J］. Injury，2022,53(3): 1164-1168.

[1]	刘晓凡. 老年股骨头坏死髋关节置换术后康复应用多维度干预[J]. 中华关节外科杂志(电子版), 2024, 18(03): 314-319.
[2]	卢国良, 潘耀成. 比较不同类型假体用于骨质疏松症的老年股骨颈骨折[J]. 中华关节外科杂志(电子版), 2024, 18(02): 277-279.
[3]	刘昌盛, 江思, 童娟. 可视化超声引导下针刀治疗狭窄性腱鞘炎的疗效分析[J]. 中华关节外科杂志(电子版), 2024, 18(02): 160-166.
[4]	钟向娣, 任婷婷, 任丽, 刘梦碟, 周娅颖, 游月梅, 张琳玲. 全髋关节置换护理的可视化分析[J]. 中华关节外科杂志(电子版), 2024, 18(02): 256-263.
[5]	唐艳, 赵小虎, 栗玉姣, 顾向梅. 针刀治疗老年膝骨关节炎的肌骨超声特征与疗效相关性[J]. 中华关节外科杂志(电子版), 2024, 18(01): 48-53.
[6]	欧梁, 齐麒, 胡伟伟, 卢敏, 黄彦昌, 黄维琛, 匡建军. 股骨颈动力交叉钉系统与其它内固定治疗股骨颈骨折对比[J]. 中华关节外科杂志(电子版), 2024, 18(01): 92-105.
[7]	潘韩丽, 何静, 陈媛媛, 贾梦瑶, 赵兴, 杨佩. 机器人辅助全髋关节置换围手术期应用加速康复护理[J]. 中华关节外科杂志(电子版), 2024, 18(01): 142-146.
[8]	许正文, 李振, 侯振扬, 苏长征, 朱彪. 富血小板血浆联合植骨治疗早期非创伤性股骨头坏死[J]. 中华关节外科杂志(电子版), 2023, 17(06): 773-779.
[9]	金鑫, 谢卯, 刘芸, 杨操, 杨述华, 许伟华. 个性化股骨导向器辅助初次全髋关节置换的随机对照研究[J]. 中华关节外科杂志(电子版), 2023, 17(06): 780-787.
[10]	孟繁宇, 周新社, 赵志, 裴立家, 刘犇. 侧位直接前方入路髋关节置换治疗偏瘫肢体股骨颈骨折[J]. 中华关节外科杂志(电子版), 2023, 17(06): 865-870.
[11]	王宏宇. 固定与活动平台假体在全膝关节置换术中的应用价值[J]. 中华关节外科杂志(电子版), 2023, 17(06): 871-876.
[12]	高玲, 于哲, 范然, 臧银善. 外周血细胞计数比值评估类风湿关节炎疗效的价值[J]. 中华关节外科杂志(电子版), 2023, 17(05): 642-647.
[13]	张海涛, 康婵娟, 翟静洁. 胰管支架置入治疗急性胆源性胰腺炎效果观察[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 654-657.
[14]	陈垚, 徐伯群, 高志慧. 改良式中间上入路根治术治疗甲状腺癌的有效性安全性研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 619-622.
[15]	王峰杰, 王礼光, 廖珊, 刘颖, 符荣党, 陈焕伟. 腹腔镜右半肝切除术治疗肝癌的安全性与疗效[J]. 中华肝脏外科手术学电子杂志, 2023, 12(05): 517-522.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Early efficacy of hemiarthroplasty of conjoined tendon preserving posterior approach for femoral neck fractures

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Early efficacy of hemiarthroplasty of conjoined tendon preserving posterior approach for femoral neck fractures