【作者】 杨军；

【导师】 尚希福；

【作者基本信息】 安徽医科大学 ， 外科学（骨外）， 2018， 硕士

【摘要】 背景人工全髋置换术(THA)是髋关节疾患终末期有效的治疗手段,传统手术入路有后外侧入路、外侧入路、前外侧入路、大粗隆截骨入路以及Super-path入路,髋关节置换经过经过一百多年来的发展,技术日趋成熟和手术操作的微创化。直接前方入路(DAA)符合国际快速康复理念,通过神经、肌肉解剖间隙进入,不切断任何神经及肌肉组织,减少了软组织的损伤,手术操控性好,创伤小,出血量少,术后疼痛轻,在院时间短以及能够满足快速康复的需要,是一种较为理想的微创术式。近年来,仰卧位DAA-THA发展迅速,但需要昂贵的手术牵引床和特殊的医疗器械,限制了这一微创技术在临床的应用,因此许多学者寻求DAA-THA更佳的手术方式。目的评价侧卧位直接前入路(DAA)微创全髋关节置换术(THA)的近期临床疗效,探讨侧卧位DAA-THA的临床应用价值。方法2014年7月至2016年3月安徽医科大学附属省立医院骨科由同一术者完成,且应用侧卧位DAA进行初次THA 309例(367髋)患者资料进行随访研究,均使用普通手术床和髋关节普通手术器械进行DAA-THA,分别从手术时间、术中及术后总失血量、相关并发症、疼痛视觉模拟评分(VAS)、Harris评分系统以及髋关节的正位片进行临床和影像学方面进行评价。结果281例(334髋)患者获得随访,随访率90.9%。随访时间:12~21月,平均15.3月。手术时间为58±8.2 min。失血量320±82.0 mL。手术发生股骨骨折4例(5髋),血肿1例(1髋),浅表切口感染3例(3髋),股外侧皮神经损伤6例(6髋),深静脉血栓1例(1髋),肌间静脉血栓形成1例,术后早期脱位2例(2髋),阔筋膜张肌损伤2例(2髋)。影像学检查髋臼假体位置:前倾角16.6°±4.8°,外展角43.5°±3.2°。与术前比较,术后随访时VAS评分和髋关节Harris评分改善显著。结论运用侧卧位DAA-THA治疗终末期髋关节疾患具有良好的近期临床疗效,无需特殊手术床及牵引设备,运用传统手术器械,降低了对手术床及手术器械的要求,通过神经、肌肉解剖间隙进入,不切断任何肌肉及神经组织,创伤小手术操控性好,出血量少,术后疼痛轻,在院时间短以及能够快速康复,是一种安全有效的微创术式。但是该术式技术操作难度较高,学习曲线较长,要掌握好手术适应症和禁忌症,减少并发症的发生。DAA术后早期有LFCN损伤与股骨假体周围骨折等并发症发生率较高的不足,随着术者经验的积累,手术方式以及医疗器械的改进,对DAA-THA患者能够减少并发症提高手术疗效。由于此组病例随访时间较短,长期疗效需有待进一步研究。基于该手术入路的微创特点和有一个满意的临床近期疗效,术后能有效减轻早期疼痛,缩短患者在院时间,早期恢复日常活动,减少住院费用,是目前十分有优势的手术入路,值得临床推广。更多还原

【Abstract】 Background Total hip arthroplasty(THA)is an effective treatment for the end stage of hip disease.Traditional surgical approaches include the posterolateral approach,lateral approach,anterolateral approach,greater trochanteric osteotomy and super-path approach.With the development of more than 100 years,the technology of hip arthroplasty has become increasingly mature and minimally invasive surgical operations have been conducted.Direct anterior approach(DAA)conforms to the international rapid rehabilitation concept,and with the nerve and muscle anatomy clearance,DAA doesn’t cut any nerve and muscle tissue.It is an ideal kind of minimally invasive surgery because of the less soft tissue damage,operational ease,small trauma,less blood loss,light postoperative pain,short hospital time and rapid recovery.In recent years,the supine DAA-THA has been developed rapidly,but those expensive surgical traction beds and special medical instruments limits its clinical application,so many scholars are looking for better surgical methods for DAA-THA.Objective This thesis is to evaluate the early clinical efficacy and to explore the clinical application value of minimally invasive for total hip arthroplasty(THA)by direct anterior approach(DAA)in the lateral decubitus position.Methods From July 2014 to March 2016,309 patients(367hips)underwent primary THAs,and they were performed by using a common surgical bed and a common surgical instrument for hip joint by the same surgeon via minimally invasive DAA in thelateral decubitus position in the Department of Orthopaedics,the Affiliated Anhui Provincial Hospital of Anhui Medical University.It was recorded and evaluated from the operation time,intraoperative and postoperative blood loss,related complications,visual analogue scale(VAS)score,Harris score and anteroposterior radiographic outcomes.Result A total of 281 patients(334 hips)(90.9%)were followed up.Follow-up duration was 12-21(average,15.3)months.Operative time was 58±8.2 min,and blood loss was 320±82.0 mL.4 cases(5 hips)occurred the femoral fracture,1 case(1 hip)occurred the hematoma,and 3 cases(3 hips)of superficial incision were infected.The lateral femoral cutaneous nerve injury was noted in 6 patients(6 hips),and the intermuscular venous thrombosis was noted in 1 patient.Deep venous thrombosis occurred in 1 patient(1 hip).The early dislocation occurred in 2 patients(2 hips),the tensor fascia tensor injury in 2 patients(2 hips).The orientatioin of the component was16.6°±4.8°anteversion and 43.5°±3.2°abduction.Compared with those preoperative ones,VAS score and Harris score were improved significantly.Conclusion It is an effective surgical approach to primary THA in the lateral decubitus position by DAA without special operation bed and traction equipment.It uses the traditional surgical instruments,and reduces the requirement for operation bed and surgical instruments.Through the nerve and muscle anatomy clearance,direct anterior approach(DAA)doesn’t cut any nerve and muscle tissue.It is an ideal kind of minimally invasive surgery because of the less soft tissue damage,operational ease,small trauma,less blood loss,light postoperative pain,short hospital time and rapid recovery.However,it demands higher operation technology and the learning curve is longer.It is necessary to master the indications and contraindications of the operation and reduce the incidence of complications.Shortly after the DAA,there were relativelyhigh incidence of LFCN injury and fracture around the femoral prosthesis.With the accumulation of experience,and the improvement of the surgical methods and the medical instruments,the side effects of DAA-THA could be prevented by reducing complications.Because of the short follow-up time of this group,the long-term effect needs to be further studied.Based on the minimally invasive features of the surgical approach and a satisfactory short-term clinical effect,and the reduction of the postoperative pain,it is an advanced surgical approach at present and worthy of clinical promotion,as a result,the hospital stay time of the patients can be shortened,daily activities can be resumed early,and hospital costs can be reduced.更多还原