微创全膝关节置换术

随着微创技术的发展,微创全膝关节置换(MIS-TKA)愈来愈被骨科界所重视.正确理解MIS-TKA手术的概念,对手术成功与否及术后能否达到预期效果至关重要.该文对MIS-TKA的概念、发展历史、手术操作原则、常见手术入路、早期临床结果,以及进一步发展方向作一综述.     

Minimally invasive total knee arthroplasty

Currently, minimally invasive total knee arthroplasty is defined as an incision length of < 14 cm. However, the length of the incision is not the primary influence on potential postoperative benefits to the patient and should not be the only characteristic of the minimally invasive approach for knee arthroplasty. Some other factors that should also be included in this definition are: 1. The amount of soft-tissue dissection (including muscle, ligament, and capsular damage). 2. Patellar retraction or eversion. 3. Tibiofemoral dislocation. Minimally invasive surgery should not be considered to be a cosmetic procedure but rather one that addresses patients' concerns with regard to postoperative pain and slow rehabilitation. Standard total knee arthroplasties provide pain relief, but returning to activities of daily living remains a challenge for some individuals, who may take several weeks to recover. Several studies have demonstrated long-term success (at more than ten years) of standard total knee arthroplasties. However, many patients remain unsatisfied with the results of the surgery. In a study of functional limitations of patients with a Knee Society score of > or = 90 points after total knee arthroplasty, only 35% of patients stated that they had no limitations. This finding was highlighted in a study by Dickstein et al., in which one-third of the elderly patients who underwent knee replacement were unhappy with the outcome at six and twelve months postoperatively. Although many surgeons utilize objective functional scoring systems to evaluate outcome, it is likely that the criteria for a successful result of total knee arthroplasty differ between the patient and the surgeon. This was evident in a report by Bullens et al., who concluded that surgeons are more satisfied with the results of total knee arthroplasty than are their patients. Trousdale et al. showed that, in addition to concerns about long-term functional outcome, patients' major concerns were postoperative pain and the time required for recovery. Patients undergoing total knee arthroplasty have specific functional goals, such as climbing stairs, squatting, kneeling, and returning to some level of low-impact sports after surgery. Our clinical investigations demonstrated that the minimally invasive surgical approach reduces hospital stays, decreases postoperative pain, and decreases rehabilitation needs as well as enables patients to return to normal function more quickly. It is important for surgeons to take an evolutionary, rather than a revolutionary, approach when performing minimally invasive total knee arthroplasty. The surgeon should downsize incisions progressively to prevent severe damage to the quadriceps mechanism. Extensive open exposure, prolonged patellar eversion, and dislocation of the tibiofemoral joint should evolve into a vastus medialis muscle split with patellar subluxation, retraction but not dislocation of the patella, and avoidance of gross dislocation of the tibiofemoral joint. Developing the techniques of minimally invasive total knee arthroplasty may be difficult and time-consuming, but patient benefits and satisfaction should outweigh the extra effort required. These changes require well-designed clinical studies to further document their effectiveness.     

Minimally invasive total knee arthroplasty: pitfalls and complications

Despite reports of complications, there has been tremendous interest in using minimally invasive surgery (MIS) for total knee arthroplasty (TKA). Over the past 10 years, we have used an MIS approach for all TKAs. In the study described here, we examined the complications of the first 1000 of these TKAs. These cases involved a minimal incision (mean, 10 cm), a quadriceps muscle-sparing approach, and a non-patellar-everting technique. The complications assessed included manipulations, reoperations, and component revisions. We also analyzed for deviations in radiographic alignment or radiographic failures. There were 45 clinical complications-25 manipulations under anesthesia, 12 arthroscopic procedures for painful patellofemoral crepitus (mostly for an initially nonvisualized retained lateral band), and 8 operative explorations for various component problems. Radiographically, there were 3 impending component failures-2 tibial and 1 femoral. Excluding manipulations, there was a significant decrease in operative complication rate from the first 200 cases (6.0%) to the next 800 cases (1.0%), with overall complication rates similar to those of a control cohort treated with traditional surgical techniques. From this analysis, the major concern was potential tibial component loosening, which may be related to decreased exposure and possibly poor cement pressurization. Despite the low complication rate, this study yielded insights into further potential improvements in using this MIS technique for TKAs.     

Minimally invasive knee arthroplasty

Interest in minimal-incision surgery among physicians and patients has led to the investigation of whether minimal-incision concepts have a role in knee arthroplasty. Successful outcomes in knee arthroplasty have been traditionally measured by long-term implant performance and low revision rates, with less emphasis on the size of the incision or the length of time to complete recovery. There are two evolving lines of development in minimal-incision knee arthroplasty: the small-incision approach and the new technology approach. The small incision approach seeks to minimize the length of the incision required to implant standard total knee components by altering the approach and instrumentation. The new technology approach seeks to develop lower profile implants and computer-assisted techniques to fundamentally change the way knee arthroplasty is done. The burden of proof as to whether these new approaches will stand the test of time remains with the investigators.     

Minimally invasive total knee arthroplasty: a 10-feature evolutionary approach

There should not be a revolution to MIS-TKA but rather an evolutionary approach. This includes progressively downsizing incisions and causing less damage to the quadriceps mechanism. Previously,there was an extensive open exposure prolonged patella eversion and dislocation of the tibio-femoral joint. This should be evolved into a VMO muscle split with patella subluxation, retraction but not dislocation, and no gross dislocation of the tibio-femoral joint. Although the present MIS-TKA technique can be difficult and time-consuming, the resulting patient benefits should outweigh the extra effort required. In the future, we may use bone cuts and implantation with computer navigation. Each advance, however, will require new techniques, instrumentation, implants, and careful clinical studies. Caution should be taken by surgeons to avoid revolutionary approaches with existing implants, because they harbor a risk of catastrophic failure.     

Minimally invasive unicompartmental knee arthroplasty

The exact indication for a unicompartmental knee arthroplasty (UKA) remains debated. Minimally invasive techniques have been developed to decrease the surgical trauma related to the prosthesis implantation, and this technique is well fitted to UKA. However, there are concerns about loss of accuracy with minimally invasive techniques. Furthermore, rapid recovery techniques have been developed in order to reduce the length of hospital stay. Again, UKA is well fitted to these new developments of postoperative care. We combine routinely a minimal invasive operative technique with navigation assistance to ensure proper positioning of the implants as well as an optimal ligamentous balance. Instruments have been adapted for use with a typical 6-cm skin incision with little change from the conventional navigated operating technique. A multimodal pain treatment is implemented immediately after the implantation, with special attention to a routine saphenous nerve blockade. Patients are instructed to stand up on the day of surgery with full weight bearing and to mobilize the knee joint without restriction. They may be discharged at least on the day following surgery, and the most favorable patients may be operated in our day-case surgery unit. These conclusions should be confirmed on a larger scale.     

Minimally invasive knee arthroplasty: An overview

Minimally invasive surgery (MIS) for arthroplasty of the knee began with surgery for unicondylar knee arthroplasty (UKA). Partial knee replacements were designed in the 1970s and were amenable to a more limited exposure. In the 1990s Repicci popularized the MIS for UKA. Surgeons began to apply his concepts to total knee arthroplasty. Four MIS surgical techniques were developed: quadriceps sparing, mini-mid vastus, mini-subvastus, and mini-medial parapatellar. The quadriceps sparing technique is the most limited one and is also the most difficult. However, it is the least invasive and allows rapid recovery. The mini-midvastus is the most common technique because it affords slightly better exposure and can be extended. The mini-subvastus technique entirely avoids incising the quadriceps extensor mechanism but is time consuming and difficult in the obese and in the muscular male patient. The mini-parapatellar technique is most familiar to surgeons and represents a good starting point for surgeons who are learning the techniques. The surgeries are easier with smaller instruments but can be performed with standard ones. The techniques are accurate and do lead to a more rapid recovery, with less pain, less blood loss, and greater motion if they are appropriately performed.     

小切口单髁置换术治疗膝关节内侧间室骨关节炎94膝的中短期疗效研究

[目的]探讨小切口单髁置换术治疗膝关节内侧间室骨性关节炎的中短期疗效与手术技术。[方法]回顾性分析本院2003年1月～2010年6月收治的87例(94膝)经小切口单髁置换术治疗的膝关节内侧间室骨性关节炎患者的资料。对患者膝关节疼痛VAS评分、关节活动度、膝关节HSS评分、关节力线等进行评估分析,分析单髁关节置换临床效果、遇到的问题及应对方法。[结果]术后平均随访3.4年(6个月～7年),返修2例,无感染、深静脉血栓、假体脱位等,HSS评分由术前61.05分增至92.67分,优良率达92%。VAS评分由术前6.46分降至2.80分。术后疼痛缓解率94%。膝屈曲度平均达127.53°。术后力线平均内翻2°。[结论]小切口单髁置换术治疗膝关节内侧间室骨性关节炎中短期疗效满意,具有创伤小、恢复快、症状改善明显、术后功能良好等特点。     

Minimally invasive total knee arthroplasty using the contralateral knee as a control group: a case-control study

The primary purpose of this study was to compare clinical and functional results of bilateral total knee arthroplasties in which a conventional total knee replacement was initially performed on one knee and a minimally invasive total knee replacement was later performed on the contralateral side. Operative factors, clinical and radiographic outcomes, and quadriceps muscle strength were evaluated in twenty-five patients (50 total knee arthroplasties). Twenty-one of the 25 patients preferred the minimally invasive approach. Knee society objective scores and range-of-motion were significantly greater in the minimally invasive group. Isokinetic testing demonstrated statistically improved quadriceps muscle strength in the minimally invasive technique group compared to the standard approach at both 12 weeks and one year postoperatively. Radiographic analysis did not reveal differences in alignment variables between the two approaches. The results of this study suggest that minimally invasive total knee arthroplasty offers superior short-term as well as possible long-term results.     

Minimally invasive total knee arthroplasty compared with traditional total knee arthroplasty. Assessment of the learning curve and the postoperative recuperative period

BACKGROUND: There is disagreement about whether so-called minimally invasive approaches result in faster recovery following total knee arthroplasty. It is also unknown whether patients are exposed to excess risk during the surgeon's learning curve. We hypothesized that a minimally invasive quadriceps-sparing approach to total knee arthroplasty would allow earlier clinical recovery but would require longer operative times and compromise component alignment during the learning period compared with a traditional medial parapatellar approach. METHODS: The first 100 minimally invasive total knee arthroplasties done by a single high-volume arthroplasty surgeon were compared with his previous fifty procedures performed through a medial parapatellar approach, with respect to operative times, implant alignment, and clinical outcomes. Radiographic end points and operative times for the minimally invasive group were evaluated against increasing surgical experience, in order to characterize the learning curve. RESULTS: Overall, the minimally invasive approach took significantly longer to perform, on the average, than a medial parapatellar approach (86.3 and 78.9 minutes, respectively; p=0.01); this was the result of especially long operative times in the first twenty-five patients in the minimally invasive group (mean, 102.5 minutes). After the first twenty-five minimally invasive operations, no significant difference in the operative times was detected between the groups. The first twenty-five minimally invasive procedures had significantly less patellar resection accuracy (p<0.001) and significantly more patellar tilt than the last twenty-five (p=0.006). Other end points for implant alignment, including the frequency of radiographic outliers, were not different between the minimally invasive and traditional groups. The patients who had the minimally invasive approach demonstrated significantly better clinical outcomes with respect to the length of hospital stay (p<0.0001), need for inpatient rehabilitation after discharge (p<0.001), narcotic usage at two and six weeks postoperatively (p=0.001 and p=0.01, respectively), and the need for assistive devices to walk at two weeks postoperatively (p=0.025). CONCLUSIONS: A quadriceps-sparing minimally invasive approach seems to facilitate recovery, but a substantial learning curve (fifty procedures in the hands of a high-volume arthroplasty surgeon) may be required. If this experience is typical, the learning curve may be unacceptably long for a low-volume arthroplasty surgeon.     

Minimally invasive versus conventional unicompartmental knee arthroplasty

Introduction  

Unicompartmental knee arthroplasty (UKA) has been proven to be a viable procedure in case of medial osteoarthritis of the knee joint. Minimally invasive surgery (MIS) techniques have been described to facilitate recovery after surgery. The aim of this study was to rule out major failure mechanisms and to obtain clinical data for comparison between a conventional and the MIS approach.     

Minimally invasive Oxford medial unicompartmental knee arthroplasty

We present the peak outcome results of the Oxford medial unicompartmental arthroplasty through a minimally invasive surgical incision. This prospective study included 78 Oxford medial unicompartmental knee replacements in 68 patients. At the 2 year review the patients achieved a mean Oxford Knee Score of 38.3. This was not significantly different to the 2 year results of the phase 2 Oxford knee carried out using a standard parapatellar approach when patients achieved a mean OKS of 36.0. Four unicompartmental knee replacements required revision for unexplained pain, deep infection, aseptic loosening and bearing dislocation. Minimally invasive joint replacement is attractive to both patients and surgeons, but is technically demanding with complications inherent to limited access.     

微创全膝关节置换术的早期临床疗效分析

目的比较不干扰股四头肌（QS）微创全膝置换术与标准全膝关节置换术的早期临床结果。方法2005年3月至2006年3月,采用QS微创全膝置换术完成26例单侧全膝关节置换术（QS组）,观察切口长度、手术时间、出血量、关节屈曲活动度,视觉模拟（VAS）疼痛评分、膝关节协会评分（KSS）、下肢胫股角和直腿抬高时间等,并与同期33例标准髌旁内侧入路TKA比较（标准组）。结果术后平均随访17个月（12～23个月）。平均切口长度QS组为（9．5±1．5）cm,标准组为（14．0±2．3）cm（P〈0．05）。止血带时间QS组为（83±16）min,标准组为（55±11）min（P〈0．05）。平均胫股角QS组为外翻（5．7±1．5）°,标准组为（6．0±1．4）°（P〉0．05）。VAS评分术后1、3和7dQS组明显低于标准组,术后6周VAS评分无差异。膝关节主动屈曲活动度术后1周QS组可达到（107±12）°,标准组为（95±11）°（P〈0．05）,术后6周和3个月组间差异有统计学意义（P〈0．05）,术后12个月平均屈曲度组间差异无统计学意义（P〉0．05）。直腿抬高术后1周QS组为23例（88％）,而标准组为21例（64％）（P〈0．05）。术后6周膝关节评分QS组为78±15,标准组为71±20（P〈0．05）。QS组1例出现有症状的深静脉血栓,标准组3例;QS组1例伤口愈合不良。所有病例未发现深部感染,神经血管损伤等并发症。结论采用QS微创全膝置换,术后疼痛轻,有利于早期伸膝功能和活动度的恢复,但手术技术要求高,应严格掌握手术适应证。     

微创全膝关节置换术中不干扰股四头肌和经股内侧肌入路的比较

目的比较不干扰股四头肌（QS）和经股内侧肌入路进行微创全膝置换术（MIS—TKA）的早期临床和影像学结果。方法从2005年9月至2006年9月，采用不干扰股四头肌和经股内侧肌入路分别完成33例和46例微创全膝置换术，观察手术时间、出血量、关节屈曲活动度、VAS（visual analog scale）疼痛评分，支持带松解率和直腿抬高时间；采用膝关节协会TKA放射线评估表评估假体位置和力线等。结果手术时间不干扰股四头肌组明显比经股内侧肌组长（P〈0．01）。而失血量，VAS评分，关节屈曲度和直腿抬高时间两组间的差异无统计学意义（P〉0．05）。影像学胫骨假体内移不干扰股四头肌组为5例，而经股内侧肌组为1例，两组间的差异有统计学意义（P〈0．01）。股骨外移两组分别为3例和4例，两组间的差异无统计学意义（P〉0．05）。术后胫股角和假体的对线指标两组间无差异。不干扰股四头肌组发生有症状的深静脉血栓为3例，经股内侧肌微创组为4例。两组都未发现皮肤坏死，深部感染，和神经血管损伤的并发症。结论不干扰股四头肌和经股内侧肌入路微创全膝置换早期功能恢复和早期结果没有差异。不干扰股四头肌入路要注意后外侧角的暴露，经股内侧肌入路要限制股内侧肌劈裂的长度和方向。     

微创全髋人工关节置换术及全髋关节表面置换术

髋关节成形术是应用一种手术的方法使一个强直或畸形、疼痛的髋关节转变为一个灵活的、无痛的、比较符合生物力学解剖结构和恢复接近较正常功能的髋关节。在开展髋关节成形术的早期，往往于修整了关节面以后，在股骨头与髋臼之间置入某种隔置物（如阔筋膜或皮肤等），以防止手术后两关节面之间重新粘连融合，但效果并不明显。     

自制组配式截骨工具行微创膝关节置换术的早期随访结果

目的评价自制组配式截骨工具行微创全膝关节置换术的临床及早期随访效果。 方法对95例中山大学附属第一医院关节外科行全膝关节置换的重度膝关节骨关节炎的患者随机分组,分别使用自制组配式截骨工具行微创全膝关节置换术或常规全膝关节置换术。对患者术前、术后的膝关节评分法(KSS)、视觉模拟评分法(VAS)、X线影像学(下肢力线、股骨角、胫骨角和胫骨平台后倾角)进行随访对比研究,微创组和传统组之间的差异采用独立样本t检验进行比较。 结果成功随访2年以上的手术患者87例,其中微创组42例,传统组45例。微创组手术时间比传统组长(t＝9.275,P<0.05),但两组在术中出血量、输血量、引流量的比较无统计学差异(P>0.05)。两组患者均未出现皮肤坏死,深部感染和神经血管损伤的并发症。下肢力线、股骨角、胫骨角和胫骨平台后倾角比较无统计学差异(P>0.05)。术后2周内,KSS评分、VAS评分微创组要优于传统组(t＝1.518,P<0.05)(除外术后第2周KSS临床评分),但术后3月后两组比较无统计学差异(P>0.05)。 结论自制组配式截骨工具行微创全膝关节置换手术早期的临床效果要优于常规人工全膝关节置换术,两组的影像学结果相当,但尚需更长时间的随访以全面评价其临床疗效。     

Minimally invasive total hip arthroplasty: a systematic review

The purpose of this study was to compare the operative outcome between mini and standard incisions in total hip arthroplasty (THA). We identified 12 randomised or quasi-randomised control trials (RCT or qRCT) published between 1996 and 2008. Subgroup and sensitivity analyses were performed to evaluate the differences in results for surgical approach, trial quality, and follow-up duration. Operative time and blood loss were significantly reduced in the mini-incision group for studies with the posterior or posterolateral approach. Concerning postoperative complications, there were no significant differences between the two groups with no significant heterogeneity. No differences were observed between the two groups for Harris hip score and radiographic results except for cup anterversion. Although mini-incision appeared to have similar outcomes compared to standard incision, the follow-up is short-term according to current standards in THA. High-quality studies are required to compare the outcomes of these two procedures.