Department of Orthopaedic Surgery, George Washington University, Washington, DC 20037, USA.
J Bone Joint Surg Am. 2011 Aug 3;93(15):1392-8. doi: 10.2106/JBJS.J.00557.
A number of surgical approaches are utilized in total hip arthroplasty. It has been hypothesized that the anterior approach results in less muscle damage than the posterior approach. We prospectively analyzed biochemical markers of muscle damage and inflammation in patients treated with minimally invasive total hip arthroplasty with an anterior or posterior approach to provide objective evidence of the local soft-tissue injury at the time of arthroplasty.
Twenty-nine patients treated with minimally invasive total hip arthroplasty through a direct anterior approach and twenty-eight patients treated with the same procedure through a posterior approach were prospectively analyzed. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum creatine kinase (CK), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-1 beta (IL-1ß), and tumor necrosis factor-alpha (TNF-a) levels were measured preoperatively, in the post-anesthesia-care unit (except for the CRP level), and on postoperative days 1 and 2. The Student t test and Fisher exact test were used to make comparisons between the two groups. Independent predictors of elevation in levels of markers of inflammation and muscle damage were determined with use of multivariate logistic regression analysis.
The levels of the markers of inflammation were slightly decreased in the direct-anterior-approach group as compared with those in the posterior-approach group. The rise in the CK level in the posterior-approach group was 5.5 times higher than that in the anterior-approach group in the post-anesthesia-care unit (mean difference, 150.3 units/L [95% CI, 70.4 to 230.2]; p < 0.05) and nearly twice as high cumulatively (mean difference, 305.0 units/L [95% CI, -46.7 to 656.8]; p < 0.05).
We believe that the anterior total hip arthroplasty approach used in this study caused significantly less muscle damage than did the posterior surgical approach, as indicated by serum CK levels. The clinical importance of the rise in the CK level needs to be delineated by additional clinical studies. The overall physiologic burden, as demonstrated by measurement of inflammation marker levels, appears to be similar between the anterior and posterior approaches. Objective measurement of muscle damage and inflammation markers provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.
全髋关节置换术中采用了多种手术入路。有假说认为，前入路导致的肌肉损伤小于后入路。我们前瞻性分析了微创前路和后路全髋关节置换术患者的肌肉损伤和炎症的生化标志物，为关节置换时局部软组织损伤提供客观证据。
前瞻性分析 29 例微创前路全髋关节置换术和 28 例后路全髋关节置换术患者。收集围手术期和影像学资料，确保两组具有相似特征。术前、麻醉后监护室（CRP 水平除外）及术后第 1、2 天测量血清肌酸激酶（CK）、C 反应蛋白（CRP）、白细胞介素 6（IL-6）、白细胞介素 1β（IL-1β）和肿瘤坏死因子-α（TNF-α）水平。采用 Student t 检验和 Fisher 确切概率法对两组进行比较。采用多因素 logistic 回归分析确定炎症和肌肉损伤标志物升高的独立预测因素。
与后路组相比，直接前路组的炎症标志物水平略有下降。后路组 CK 水平在麻醉后监护室升高了 5.5 倍（平均差值，150.3 U/L [95%CI，70.4 至 230.2]；p <0.05），累计升高近 2 倍（平均差值，305.0 U/L [95%CI，-46.7 至 656.8]；p <0.05）。
我们认为，与后路手术入路相比，本研究中使用的前路全髋关节置换术导致的肌肉损伤明显更小，血清 CK 水平可证实这一点。CK 水平升高的临床重要性需要通过进一步的临床研究来阐明。前路和后路在炎症标志物水平上的总体生理负担相似。肌肉损伤和炎症标志物的客观测量为评估全髋关节置换术患者手术干预的即时效果提供了一种客观的方法。
