微创全膝关节置换术研究进展

现代膝关节置换术(total knee arthroplasty,TKA)始于20世纪70年代,在过去三十多年的时间里,手术的方法与技术得到了长足的发展,且不断趋于精细与可靠.     

Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty

The objective of this study was to compare the radiologic outcomes of total knee arthroplasty using the conventional technique with those using minimally invasive surgery (MIS) techniques. Ninety patients were randomized to undergo conventional (control), MIS mini-incision mid-vastus (mini), or MIS side-cutting (side cut) techniques for their total knee arthroplasty. Long-leg radiographs were assessed postoperatively. The mean overall limb varus alignments were 1.03 degrees (SD, 2.58 degrees ) for the control group, 0.87 degrees (SD, 2.96 degrees ) for the mini group, and 0.37 degrees (SD 4.27 degrees ) for the side cut group. The mean overall limb alignments within +/-3.0 degrees varus/valgus were 83.3%, 83.3%, and 56.7%, respectively. Femoral implant placement (P = .028) and overall limb alignment (P = .024) in the side cut group were significantly poorer as compared with those in the control group. The side cut group also had more outliers in the coronal plane. Results were comparable between the mini and control groups. The side cut technique appears to affect the accuracy of implant placement.     

Advances in unicompartmental knee arthroplasty with minimally invasive techniques

Abstract Unicompartmental arthroplasty has proved to be a reliable option for monocompartmental arthritis in well selected patients. Unicompartmental knee arthroplasty (UKA) is not a temporary procedure and its ten year survival is comparable to TKA and better than High Tibial Osteotomy. The success of the procedure depends on strict patient selection, meticulous surgical technique and proper implant selection. The renewed interest in UKA is due to improved results, more conservative nature of the procedure, faster rehabilitation, decreased cost and the minimally invasive techniques. The sedentary patient with unicompartmental arthritis is currently the primary indication for UKA. The role of unicompartmental arthroplasty in younger patients needs more investigation. Revision of UKA has not found to be as complicated as reported in the early series. Minimally invasive UKA has shown short term promising results but more long term studies showing similar implant longevity compared with the standard approach are required to establish its role. Due to high level of patient satisfaction and low morbidity and complications compared with TKA, unicompartmental arthroplasty is an attractive option for patients with predominantly unicompartmental non inflammatory arthritis.     

微创人工全膝关节表面置换术治疗创伤性膝关节炎的疗效观察

目的对创伤性膝关节炎患者采用微创人工全膝关节表面置换术治疗,术后观察其临床疗效。方法自2006年4月～2009年3月采用微创人工全膝关节表面置换术治疗创伤性膝关节炎共22例22膝,根据KSS评分标准,对术后随访患者进行评分以观察临床疗效。结果 22例术后均获得随访,随访36.0～71.0个月,平均48.6个月,未出现手术切口感染、膝关节假体松动、下沉等相关并发症。在最终的随访中,膝关节评分82～99分,平均90分;功能评分78～94分,平均85分;膝关节屈曲度95°～130°,平均115°;膝关节伸直度0°～5°,平均3°。结论对于创伤性膝关节炎患者,采用微创人工全膝关节表面置换术治疗术后临床疗效令人满意。     

Comparison of computer-assisted navigation and conventional instrumentation for bilateral total knee arthroplasty

This prospective study analyzed computer-assisted surgery (CAS) navigation and conventional instrumentation in bilateral total knee arthroplasty. Sixty patients underwent CAS navigation in 1 knee and conventional instrumentation in the contralateral knee randomly. The target zone resided in the reconstructed mechanical axis within a range of 3 degrees varus or valgus. The reconstructed mechanical axes in the CAS navigation group were significantly closer to planned axes than those in the conventional group. Average blood loss in the CAS navigation group was lower, whereas mean tourniquet time was longer than in the conventional group. No surgery-related complications existed in either group. The results indicate that, despite longer operative time, CAS navigation total knee arthroplasty is a safe procedure and outperforms conventional technique in accuracy of leg axes.     

微创人工全髋关节置换术的临床研究

[目的]比较微创与常规全髋关节置换术(total hip arthroplasty THA)的短期临床随访结果.[方法]将2008年1月至2011年1月施行THA的200例患者随机分成两组,前外侧入路微创组和标准后外侧入路组,各100例患者,对两组手术时间、围手术期出血量、引流量、切口长度、术后住院时间、并发症、疼痛评分、Harris评分进行比较.[结果]平均随访20个月(12 ～30个月).两组患者均无骨折、感染、脱位、血管神经损伤、血栓形成等并发症.两组相比平均手术时间、末次随访VAS评分、平均Harris评分及术后影像学评价,差异无统计学意义(P＞0.05);平均切口长度、围手术期出血量、引流量、输血量、平均住院时间,两组差异有统计学意义(P＜0.05).[结论]前外侧入路微创全髋关节置换具有创伤小、出血少、疼痛小、恢复快的特点,是一种安全、有效、可靠的方法.     

Navigation-assisted less invasive total knee arthroplasty compared with conventional total knee arthroplasty: a randomized prospective trial

The purpose of this study was to evaluate the hypothesis that a less invasive (LIS) surgical technique using a navigation system would promote rapid recovery and improve alignment compared with conventional technique in total knee arthroplasty (TKA). This study compared 49 navigation-assisted LIS TKAs with 53 conventionally performed TKAs using a medial parapatellar arthrotomy with patellar eversion. Navigation-assisted LIS TKA used a shorter skin incision, a midvastus approach without patella eversion, and a navigation system. Navigation-assisted LIS TKA had better pain scores, shorter times to achieve 90 degrees flexion and straight leg raise, and a smaller extension lag during the very early postoperative period. However, there were no differences between the groups 2 weeks postoperatively. There were no differences in mean prosthetic alignment between the 2 groups, but the navigation-assisted LIS group had fewer "outliers" than the conventionally performed TKA group.     

Navigation in minimally invasive unicompartmental knee arthroplasty has no advantage in comparison to a conventional minimally invasive implantation

Introduction  

Minimally invasive implantation of unicompartmental knee prostheses can shorten rehabilitation time and lead to better functional results than conventional implantation. Exact positioning of the implant should be achieved, as this is a factor for the long-term survival of the prosthesis, although malpositioning can result due to the poor intraoperative view when using the minimally invasive approach. Navigation of the unicompartmental prosthesis could lead to a better implant positioning without losing the advantages of a minimally invasive approach.     

股内侧肌下入路全膝关节置换术初步观察研究

[目的]探讨股内侧肌下入路小切口微创全膝关节置换术的优点、风险及手术要点。[方法]自2005年4月-2006年12月本院共行全膝关节置换术204例（344膝），其中传统切口（convention incision，CI）置换组146例（246膝），经股内侧肌下入路微创（minimally invasive，MIS）置换组58例（98膝），均采用Zimmer公司NEXGEN-LPS人工全膝关节，记录麻醉时间、手术时间、住院时间；比较患者术后第一次下地时间，不同时间阶段行走距离、膝关节主动活动度、手术前后HSS评分以及手术并发症情况。[结果]204例均获随访，时间4—7个月（平均5个月），微创组和对照组麻醉时间、切口长度、手术时间、住院时间、下地时间比较差异均有统计学意义（u检验，P〈0．05），微创组麻醉时间、手术时间均大于对照组，切口长度、住院时间、下地时间均小于对照组。术后24h、1周、1月行走距离两组之间存在显著性差异（u检验，P〈0．05），术后3个月行走距离两组之间无显著性差异（u检验，P〉0．05）。术后24h、1周、2周非负重主动活动度两组之间存在显著性差异（u检验，P〈0．05），术后1个月行走距离两组之间无显著性差异（u检验，P〉0．05）。HSS评分术后24h、1周、2周膝关节HSS评分两组之间存在显著性差异（u检验，P〈0．05），术后1月HSS评分两组之间无显著性差异（u检验，P〉0．05）。[结论]股内侧肌下入路小切口微创全膝关节置换术股四头肌损伤小，术后膝关节主动活动时间较早，膝关节功能恢复较快，术后远期步行距离、膝关节非负重主动活动度及HSS评分两者无明显差别。     

Comparison of drain clamp after bilateral total knee arthroplasty

Suction drains provide an easy and feasible method for controlling hemorrhage after total knee arthroplasty. However, there has been no compromise regarding the optimum clamping time for these drains. We conducted a randomized clinical trial in 50 patients to compare 12-hour drain clamping and continuous drainage after total knee arthroplasty in terms of wound complications, blood loss, and articular arc of motion. To eliminate any other factor except duration of clamping, we chose to compare only knees belonging to a single patient and to restrict the study to those knees undergoing surgery due to osteoarthritis. From a total of 100 knees (50 patients) studied, the 12-hour-clamping method resulted in a significantly smaller amount of postoperative blood loss (p < 0.001). The passive ranges of motion and wound complications were not significantly different between the two groups.     

Component alignment after minimally invasive total knee arthroplasty: results of the first 100 cases performed

It has been suggested that minimally invasive total knee arthroplasties increase the risk of component malalignment. Results during the period of initial learning curve on component malalignment are relatively unknown but should be addressed. This study reports the component alignment data of the first 100 minimally invasive total knee arthroplasties performed by a single surgeon from the very start of a community-based practice immediately after fellowship training. The results indicate that the initial learning curve produces results comparable to reported results of standard total knee arthroplasties.     

Influence of bilateral sequential total knee arthroplasty on functional recovery

Background:

Main concerns of patients undergoing bilateral surgery is the quantum of pain and the progress of functional recovery. We studied functional recovery in terms of pain, range of motion (ROM), SF12, WOMAC scores and a unique TUG (timed up and go) test for patients undergoing unilateral total knee arthroplasty (U/L-TKA) and sequential bilateral total knee arthroplasty (B/L-TKA).

Materials and Methods:

Three groups of 77 consecutive patients (91 knees) were retrospectively compared. They were B/L TKA group (28 knees: 14 patients), Unilateral TKA group with contralateral knee nonoperated i.e., U/L-TKA group (42 knees) and Unilateral TKA with contralateral TKA already done i.e., U/L + C/L TKA group (21 knees). Patients were assessed preoperatively and on postoperative days 3, 5, 14, 42, 90 and 1 year.

Results:

The WOMAC score was statistically better preoperatively in the U/L + C/L TKA group, and SF12 MCS score was statistically better preoperatively in the B/L-TKA group. The TUG test time in the B/L-TKA group was statistically longer on days 3 and 5 as compared to other groups and became comparable by day 14. The TUG score became better than the preoperative value by day 42 in the B/L-TKA group, which took 90 days in other groups.

Conclusion:

The early functional recovery of bilateral TKA patient lags behind that of unilateral TKA patient for the first 5 days, becomes equal by the 14^th day and remains equal till 1 year after surgery. Bilateral TKA patients regain their preoperative functional status by 6 weeks against 3 months for unilateral TKA. The operative status of the contralateral knee makes no difference to early functional recovery after unilateral TKA. With bilateral TKA, there is no difference in pain and ROM parameters.