保留梨状肌的后路手术可降低股骨颈骨折患者半髋关节置换术的脱位率。

A piriformis-preserving posterior approach reduces dislocation rate of the hemiarthroplasty in patients with femoral neck fracture.

作者信息

Viberg Bjarke, Kristensen Erik Qvist, Gaarsdal Thomas, Petersen Charlotte Densing, Jensen Thomas Giver, Overgaard Søren, Palm Henrik

机构信息

Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital Kolding, University Hospital of Southern Denmark, Denmark.

出版信息

Injury. 2023 Apr 23. doi: 10.1016/j.injury.2023.04.040.

DOI:10.1016/j.injury.2023.04.040

PMID:37100693

Abstract

INTRODUCTION

The posterior approach (PA) for hemiarthroplasty (HA) in patients with femoral neck fracture (FFN) has a high risk of dislocation; however, by preserving the piriformis muscle, the dislocation rate could be lowered considerably. The aim of this study was to compare the surgical complications of the piriformis-preserving posterior approach (PPPA) and the PA in patients with FNF treated with HA.

METHODS

On 1 January 2019, the PPPA was introduced at two hospitals as the new treatment standard. The sample size was calculated based on a 5 percentage point dislocation reduction and 25% censoring; a sample of 264 patients per group was determined. An approximately 2-year inclusion period with 1-year follow-up was estimated, including a historical cohort from 2 years before the PPPA introduction. Data were retrieved from health care records and X-ray images from the hospitals' administrative databases. Relative risk (RR) and 95% confidence intervals were calculated using Cox regression and adjusted for age, sex, comorbidity, smoking, surgeon experience and implant type.

RESULTS

There were 527 patients included in the study, of which 72% were women and 43% were above 85 years old. There were no baseline differences between the PPPA and PA groups in sex, age, comorbidity, body mass index, smoking, alcohol, mobility, length of surgery, blood loss or implant positioning, but there were differences in 30-day mortality, surgeon experience and implant type. The dislocation rate reduced from 11.6% in the PA group to 4.7% in the PPPA group (p = 0.004), with an RR of 2.5 (1.2; 5.1). The reoperation rate reduced from 6.8% with the PA to 3.3% with the PPPA (p = 0.022), with an RR of 2.1 (0.9; 5.2), and total surgery-related complications reduced from 14.7% with the PA to 6.9% with the PPPA (p = 0.003), with an RR of 2.4 (1.3; 4.4).

INTERPRETATION

Changing from PA to PPPA in patients with FNF treated with HA resulted in a more than 50% reduction in dislocation and reoperation rates. This approach was easily introduced and may enable further lowering of dislocation rates through the sparing of all short external rotators.

摘要

引言

股骨颈骨折（FFN）患者半髋关节置换术（HA）采用后入路（PA）时脱位风险较高；然而，保留梨状肌可显著降低脱位率。本研究旨在比较保留梨状肌后入路（PPPA）与PA在接受HA治疗的FNF患者中的手术并发症。

方法

2019年1月1日，两家医院将PPPA作为新的治疗标准引入。样本量根据脱位率降低5个百分点和25%的删失率计算得出；每组确定264例患者样本。估计约2年的纳入期和1年的随访期，包括PPPA引入前2年的历史队列。数据从医院管理数据库中的医疗记录和X线图像中获取。使用Cox回归计算相对风险（RR）和95%置信区间，并对年龄、性别、合并症、吸烟、外科医生经验和植入物类型进行调整。

结果

本研究共纳入527例患者，其中72%为女性，43%年龄在85岁以上。PPPA组和PA组在性别、年龄、合并症、体重指数、吸烟、饮酒、活动能力、手术时长、失血量或植入物位置方面无基线差异，但在30天死亡率、外科医生经验和植入物类型方面存在差异。脱位率从PA组的11.6%降至PPPA组的4.7%（p = 0.004），RR为2.5（1.2；5.1）。再次手术率从PA组的6.8%降至PPPA组的3.3%（p = 0.022），RR为2.1（0.9；5.2），与手术相关的总并发症从PA组的14.7%降至PPPA组的6.9%（p = 0.003），RR为2.4（1.3；4.4）。