Sheth Dhiren, Cafri Guy, Inacio Maria C S, Paxton Elizabeth W, Namba Robert S
Department of Orthopaedic Surgery, Orange County, Southern California Permanente Medical Group, Irvine, CA, USA.
Surgical Outcomes and Analysis, Kaiser Permanente, 8954 Rio San Diego Drive, Suite 406, San Diego, CA, 92108, USA.
Clin Orthop Relat Res. 2015 Nov;473(11):3401-8. doi: 10.1007/s11999-015-4230-0.
Lack of consensus continues regarding the benefit of anteriorly based surgical approaches for primary total hip arthroplasty (THA). The purpose of this study was to evaluate the risk of aseptic revision, septic revision, and dislocations for various approaches used in primary THAs from a community-based healthcare organization.
QUESTIONS/PURPOSES: (1) What is the incidence of aseptic revision, septic revision, and dislocation for primary THA in a large community-based healthcare organization? (2) Does the risk of aseptic revision, septic revision, and dislocation vary by THA surgical approach?
The Kaiser Permanente Total Joint Replacement Registry was used to identify primary THAs performed between April 1, 2001 and December 31, 2011. Endpoints were septic revisions, aseptic revisions, and dislocations. The exposure of interest was surgical approach (posterior, anterolateral, direct lateral, direct anterior). Patient, implant, surgeon, and hospital factors were evaluated as possible confounders. Survival analysis was performed with marginal multivariate Cox models. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. A total of 42,438 primary THAs were available for analysis of revision outcomes and 22,237 for dislocation. Median followup was 3 years (interquartile range, 1-5 years). The registry's voluntary participation is 95%. The most commonly used approach was posterior (75%, N = 31,747) followed by anterolateral (10%, N = 4226), direct anterior (4%, N = 1851), and direct lateral (2%, N = 667).
During the study period 785 hips (2%) were revised for aseptic reasons, 213 (0.5%) for septic reasons, and 276 (1%) experienced a dislocation. The revision rate per 100 years of observation was 0.54 for aseptic revisions, 0.15 for septic revisions, and 0.58 for dislocations. There were no differences in adjusted risk of revision (either septic or aseptic) across the different THA approaches. However, the anterolateral approach (adjusted HR, 0.29; 95% CI, 0.13-0.63, p = 0.002) and direct anterior approach (adjusted HR, 0.44; 95% CI, 0.22-0.87, p = 0.017) had a lower risk of dislocation relative to the posterior approach. There were no differences in any of the outcomes when comparing the direct anterior approach with the anterolateral approach.
Anterior and anterolateral surgical approaches had the advantage of a lower risk of dislocation without increasing the risk of early revision.
Level III, therapeutic study.
对于初次全髋关节置换术（THA）采用前方入路手术的益处，目前仍未达成共识。本研究的目的是评估一家社区医疗保健机构在初次全髋关节置换术中使用不同入路的无菌性翻修、感染性翻修及脱位风险。
问题/目的：（1）在一家大型社区医疗保健机构中，初次全髋关节置换术的无菌性翻修、感染性翻修及脱位的发生率是多少？（2）无菌性翻修、感染性翻修及脱位的风险是否因全髋关节置换术的手术入路不同而有所差异？
利用凯撒医疗集团全关节置换登记系统，确定2001年4月1日至2011年12月31日期间实施的初次全髋关节置换术。观察终点为感染性翻修、无菌性翻修及脱位。感兴趣的暴露因素为手术入路（后方、前外侧、直接外侧、直接前方）。对患者、植入物、外科医生及医院因素进行评估，作为可能的混杂因素。采用边际多变量Cox模型进行生存分析。报告风险比（HRs）及95%置信区间（CIs）。共有42438例初次全髋关节置换术可用于翻修结果分析，22237例可用于脱位分析。中位随访时间为3年（四分位间距，1 - 5年）。该登记系统的自愿参与率为95%。最常用的入路是后方（75%，N = 31747），其次是前外侧（10%，N = 4226）、直接前方（4%，N = 1851）及直接外侧（2%，N = 667）。
在研究期间，785髋（2%）因无菌性原因进行了翻修，213髋（0.5%）因感染性原因进行了翻修，276髋（1%）发生了脱位。每100年观察期的翻修率，无菌性翻修为0.54，感染性翻修为0.15，脱位为0.58。不同全髋关节置换术入路的调整后翻修风险（感染性或无菌性）无差异。然而，相对于后方入路，前外侧入路（调整后HR，0.29；95% CI，0.13 - 0.63，p = 0.002）和直接前方入路（调整后HR，0.44；95% CI，0.22 - 0.87，p = 0.017）脱位风险较低。直接前方入路与前外侧入路相比，在任何结局方面均无差异。
前方及前外侧手术入路具有脱位风险较低的优势，且不增加早期翻修风险。
III级，治疗性研究。
