Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, United Kingdom.
National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, United Kingdom.
J Bone Joint Surg Am. 2020 Jan 2;102(1):21-28. doi: 10.2106/JBJS.19.00195.
Studies have suggested that the anterolateral approach is preferable to the posterior approach when performing total hip arthroplasty (THA) for a displaced intracapsular hip fracture, because of a perceived reduced risk of reoperations and dislocations. However, this suggestion comes from small studies with short follow-up. We determined whether surgical approach in THAs performed for hip fracture affects revision-free hip survival, patient survival, and intraoperative complications.
We retrospectively analyzed all stemmed primary THAs for hip fracture that were recorded in the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man that were performed between 2003 and 2015. The 2 surgical approach groups, posterior and anterolateral, were matched for patient and surgical confounding factors using propensity scores, with outcomes compared using regression modeling (with regression model ratios of <1 representing a reduced risk of the specified outcome in the posterior group). Outcomes were 5-year hip survival free from revision (all-cause revision, revision for dislocation and/or subluxation, and revision for periprosthetic fracture), patient survival (30 days, 1 year, and 5 years postoperatively), and intraoperative complications.
After matching, 14,536 THAs (7,268 per group) were studied. Five-year cumulative revision-free survival rates were similar (posterior group, 97.3%, and anterolateral group, 97.4%; subhazard ratio [SHR], 1.15 [95% confidence interval (CI), 0.93 to 1.42]). Five-year survival rates free from revision for dislocation (SHR, 1.28 [95% CI, 0.89 to 1.84]) and for periprosthetic fracture (SHR, 1.03 [95% CI, 0.68 to 1.56]) were also comparable between the 2 approach groups. Thirty-day patient survival was significantly higher following a posterior approach (99.5% compared with 98.8%; hazard ratio [HR], 0.44 [95% CI, 0.30 to 0.64]), which persisted at 1 year (HR, 0.73 [95% CI, 0.64 to 0.84]) and 5 years (HR, 0.87 [95% CI, 0.81 to 0.94]) postoperatively. The posterior approach was associated with a lower risk of intraoperative complications (odds ratio [OR], 0.59 [95% CI, 0.45 to 0.78]).
In THA for hip fracture, the posterior approach was associated with a similar risk of revision and a lower risk of both patient mortality and intraoperative complications compared with the anterolateral approach. We propose that the posterior approach is as safe as the anterolateral approach when performing THA for hip fracture and that either approach may be used according to surgeon preference.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
研究表明，对于囊内移位性髋关节骨折患者，行全髋关节置换术（THA）时，前路比后路更具优势，因为后路再手术和脱位的风险较低。然而，这种说法来自于随访时间较短的小型研究。我们旨在确定髋关节骨折行 THA 时的手术入路是否会影响无翻修髋关节生存率、患者生存率和术中并发症。
我们回顾性分析了英格兰、威尔士、北爱尔兰和马恩岛国家关节登记处记录的 2003 年至 2015 年期间行的所有带柄的初次 THA。后路和前路 2 个手术入路组，通过倾向评分匹配患者和手术混杂因素，使用回归模型比较结果（回归模型比值<1 表示后路组特定结局的风险降低）。结果包括 5 年无翻修髋关节生存率（所有原因翻修、脱位和/或半脱位翻修以及假体周围骨折翻修）、患者生存率（术后 30 天、1 年和 5 年）和术中并发症。
匹配后，共纳入 14536 例 THA（每组 7268 例）。5 年累积无翻修生存率相似（后路组为 97.3%，前路组为 97.4%；亚危险比[SHR]，1.15[95%可信区间（CI），0.93 至 1.42]）。后路组和前路组在脱位（SHR，1.28[95%CI，0.89 至 1.84]）和假体周围骨折（SHR，1.03[95%CI，0.68 至 1.56]）无翻修率方面也相似。后路组术后 30 天患者生存率显著较高（99.5%比 98.8%；风险比[HR]，0.44[95%CI，0.30 至 0.64]），1 年（HR，0.73[95%CI，0.64 至 0.84]）和 5 年（HR，0.87[95%CI，0.81 至 0.94]）时仍保持较高水平。后路组术中并发症风险较低（比值比[OR]，0.59[95%CI，0.45 至 0.78]）。
在髋关节骨折行 THA 中，后路与前路相比，翻修风险相似，患者死亡率和术中并发症风险较低。我们提出，后路在髋关节骨折行 THA 时与前路一样安全，可根据术者偏好选择使用。
治疗性 III 级。请参阅作者说明以获取完整的证据水平描述。
