| Abstract | Cilj ovoga istraživanja bio je utvrditi razlike u funkcionalnom oporavku i kvaliteti života osam godina nakon ugradnje umjetnog zgloba kuka između skupine bolesnika operiranih klasičnim pristupom i skupine operirane minimalno invazivnim pristupom na zglob kuka te ulogu tjelesne aktivnosti, kao i indeksa tjelesne mase kao medijatora tog procesa. Klasični, lateralni pristup na zglob kuka je tehnika koju čine longitudinalna incizija te djelomično dezinseriranje m. gluteus mediusa i m. gluteus minimusa (Bauer-Hardinge tehnika). Od klasičnog anterolateralnog pristupa (Watson-Jones) razvio se anterolateralni minimalno invazivni operacijski pristup na zglob kuka. Ključna karakteristika je da se na zglob kuka pristupa između m. gluteus mediusa i m. tensor fasciae latae bez odvajanja mišićnog hvatišta.
Istraživanje je provedeno u Klinici za ortopediju Lovran 2019. godine. Ovaj dio istraživanja je bio transverzalni, ali je ujedno i treći, završni dio prospektivne longitudinalne studije čiji je inicijalni uzorak bio 130 ispitanika podijeljenih u dvije skupine. U konačnu obradu osam godina nakon operacije u istraživanje je uključeno 68 ispitanika, tj. 32 u klasično operiranoj skupini i 36 u minimalno invazivnoj skupini, uz podjednaki postotak odaziva u obje skupine. Uzorak varijabli se sastojao od morfološke varijable (indeks tjelesne mase), podataka o tjelesnoj aktivnosti IPAQ (engl. International Physical Activity Questionnaire), podataka o kvaliteti života SF-36 (engl. Short Form 36), HHS indeksa (engl. Harris hip score), podataka iz specifičnog upitnika o tjelesnoj aktivnosti i provedenoj rehabilitaciji (upitnik sastavljen isključivo za ovo istraživanje), opsega pokreta fleksije i abdukcije zgloba kuka, jakosti abduktorne muskulature mjerene dinamometrom, brzine hodanja na hodnoj pruzi na 50 metara, stručne procjene stupnja šepanja i vizualne skale boli (VAS). Uzimali su se podaci o komorbiditetima i bilježila ugradnja novih endoproteza ne samo na isti ili suprotni zglob kuka, već i na druge zglobove. Podaci su obrađeni pomoću programa za statističku obradu podataka STATISTICA verzija 13.5.0.17, 1984–2018 TIBCO Software Inc. Pri obradi podataka bile su korištene deskriptivne i odgovarajuće analitičke metode.
Bolesnici operirani minimalno invazivnim pristupom imali su nešto bolji funkcionalni oporavak čak i osam godina nakon operacijskog zahvata. To se očitovalo u manjoj prisutnosti šepanja u odnosu na bolesnike operirane klasičnim pristupom (p = 0,032) te također u određenim aspektima kvalitete života: ograničenje zbog tjelesnih poteškoća (p = 0,01), razina energije (p = 0,02), socijalno funkcioniranje (p = 0,02), bol (p = 0,02) i percepcija općeg zdravlja (p = 0,00). Harris hip score bio je bolji u bolesnika operiranih minimalno invazivnim
pristupom u odnosu na klasični pristup (p = 0,03). Veća razina tjelesne aktivnosti u obje skupine statistički je značajno bila povezana s boljim funkcionalnim oporavkom dok indeks tjelesne mase u obje skupine nije statistički značajno utjecao na ishod operacije. U dodatnoj analizi rezultata gdje su promatrane varijable opseg pokreta fleksije i abdukcije zgloba kuka, jakost abduktorne muskulature, bol i hodna pruga na 50 m, rezultati pokazuju da nema statistički značajne razlike između skupina u promatranim varijablama osim za varijablu opsega pokreta abdukcije (p < 0,001).
Temeljem dobivenih rezultata zaključuje se da postoje određene prednosti za bolesnike operirane MIS pristupom. U slučaju da su operirani tim pristupom, stariji će bolesnici očekivano imati veću jakost muskulature i bolju posturalnu kontrolu te posljedično manji rizik od pada i potencijalnog ozljeđivanja. Veliki broj bolesnika, i starijih i mlađih, vrlo će se vjerojatno moći vratiti svim aktivnostima kojima su se bavili i prije; čak i sportovima uz preduvjet odgovarajućih motoričkih i funkcionalnih sposobnosti za navedenu aktivnost. Stoga se ovakav pristup liječenju može preporučiti i široj populaciji, a ne samo radno aktivnoj, zbog poboljšanja kvalitete života. Minimalno invazivni pristup je u nekim zdravstvenim sustavima često rezerviran za mlađu životnu dob iako je ovim istraživanjem utvrđeno da, neovisno o dobi, on ima pozitivan utjecaj čak i nakon osam godina, ne samo tijekom rane rehabilitacije, što je dokazano ranije. Dugoročno gledano, na ovaj način bi se umanjilo izdvajanje sredstava za zdravstveno i socijalno zbrinjavanje starijih osoba te trajanje bolovanja mlađih osoba koje je vrlo skupo. |
| Abstract (english) | The aim of this study was to determine differences in functional recovery and in quality of life eight years after total hip arthroplasty between a group of patients operated using classical approach and minimally invasive approach to the hip joint, as well as the role of physical activity, and body mass index as a mediator of this process. The classic, lateral approach to the hip joint is performed by a longitudinal incision followed by partial desinsertion of the gluteus medius and gluteus minimus (Bauer-Hardinge technique). Anterolateral minimally invasive operative approach to the hip is developed from a classic anterolateral approach (Watson-Jones). The key feature of the anterolateral operative approach is the technique using a muscular interval between m. gluteus medius, m. gluteus minimus and m. tensor fasciae latae.
The research was conducted at the University of Orthopaedic Clinic Lovran in 2019. This part of research was transversal, but at the same time and third final part of the prospective longitudinal study whose initial sample was 130 subjects divided into two groups. In the final process, eight years after surgery 68 subjects were included in the study, i.e. 32 subjects in the classical approach and 36 in minimally invasive approach, with an equal response rate in both groups. The sample variables were consisted of: morphological variables (body mass index), physical activity data, IPAQ (International Physical Activity Questionnaire), quality of life data, SF-36 (Short Form 36), HHS (Harris hip score), a specific questionnaire about physical activity and conducted rehabilitation (questionnaire designed exclusively for this research), active range of motion in terms of flexion and abduction of the hip joint, strength of the abductor muscles measured with a dynamometer, 50 m distance walking ability, expert assessment of the degree of limping and visual pain scale (VAS). Comorbidity data were taken and the implantation of new endoprostheses was recorded not only on the same or opposite hip joint but also on other joints. The data were analyzed by the software package STATISTICA, version 13.5.0.17, 1984-2018 TIBCO Software Inc. Descriptive and appropriate analytical methods were used in data analyzing.
Patients operated with a minimally invasive approach have slightly better functional recovery even 8 years after surgery. This is manifested by the lower presence of limping compared to patients operated with a classical approach (p = 0.032) and also in certain domains of quality of life (limitation due to physical problems (p = 0.01), energy level (p = 0.02), social functioning (p = 0.02), pain (p = 0.02) and general health perception (p = 0.00). The Harris
hip score was better in patients operated with a minimally invasive approach compared to the classical approach (p = 0.03). The higher level of physical activity in both groups was statistically significantly associated with better functional recovery while body mass index in both groups did not statistically significantly affect the outcome of the surgery. In an additional analysis of the results where the other variables (range of motion of flexion and abduction of the hip joint, strength of abductor's muscle, pain and 50 m distance walking ability) were observed, the results show no statistically significant difference between groups in the most of the variables, except for the range of motion of abduction (p = 0.001).
Based on the obtained results, it is concluded that there are certain advantages for patients operated by the MIS approach. In the case of older patients who underwent MIS approach, they will have as expected greater muscle strength and better postural control, and consequently less chance of falling and potential injury. In the case of both older and younger patients, a large number will very likely be able to return to all activities they have been involved in before, even in sports, with a precondition they have appropriate motor and functional abilities for that specific activity. Therefore, it can be recommended that this approach for the treatment of total hip replacement is recommended for the general population, not just for the working population to improve quality of life. In some health systems a minimally invasive approach is often reserved for younger age patients, although this study found that regardless of age, it has a positive impact even after 8 years, not just during early rehabilitation as previously proven. In the long follow-up, this would reduce the allocation of public funds for health and social care of the elderly and the duration of sick leave for young people, which is very expensive. |
