微创技术在人工全膝关节置换术中的应用

The minimal invasive technique used in total knee replacement

目的 探讨微创人工全膝关节置换术的优点及手术风险。方法 2005年2月至2006年4月，对54例患者（70膝）行小切口人工全膝关节置换术，女48例（63膝），男6例（7膝）。年龄43-75岁，平均62．4岁。切口长度9—13cm，平均10．5cm。所有患者均诊断为膝关节骨关节炎，术前关节活动度为伸0°～25°（平均-10．5°），屈80°-135°（平均100°）。手术采用膝正中切口，髌旁内侧入路。不翻转髌骨，利用皮肤的可移动性和膝关节屈伸活动的特点，采用特殊手术器械，完成股骨和胫骨的截骨。通过改变手术操作顺序以尽快创造出操作空间，尽可能减少对髌上囊和后关节囊等软组织的切除和剥离。结果所有患者均未出现皮肤坏死或伤口感染等并发症，手术时间平均为70min（55-150min）。手术切口长度平均为10．5cm（9～13cm）。前35膝术后平均引流530ml（200-800m1），后35膝引流为380ml（200-460ml），平均输血500ml（0-1000m1）。术后第2天即开始进行主动股四头肌功能锻炼，患者术后平均下床时间为5．6d（4-8d），术后9-14d出院，出院时关节活动度平均为100°（90°～120°）。术后末次随访，关节活动度为伸5°-5°（平均0°），屈95°～125°（平均115°）。术前膝关节学会评分为46～69分[平均（51±7）分]，术后为82-98分[平均（91±5）分]。结论 微创人工全膝关节置换术最主要的优势在于股四头肌损伤小，膝关节主动活动的时间较早，术后膝关节功能恢复相对较快，且不增加手术风险。

Objective To evaluate the advantage and risk of minimal invasive surgery（MIS） in total knee replacement. Methods From February 2005 to April 2006, 54 patients （70 knees） were perfomed with small-incision total knee replacement（TKA）. There were 48 females（63 knees） and 6 males（7 knees） with the mean age of 62.4 years （43-75 years）. The lengths of incisions changed from 9 to 13 cm, average 10.5 cm. All patients suffered osteoarthritis of knee. The pre-operative ranges of motion were from 0° to -25° with extension（mean -10.5°） and from 80° to 135° with flexion（mean 100°）. Mid-central of knee incision and medial parapatella approach were used. The surgical scope of quadriceps corresponded with the incision of skin. Patella was not everted. Using the character of skin mobility and genual flexion and extension to expose the corresponding surgical view. The special instruments for small-incision TKA were used to complete femoral and tibial osteotomy. Through changing the surgical order to get enough space to perform the opera- tion as fast as possible. Results All patients had not any complications of TKA, including skin necrosis and wound infection. In this study, the mean operating time was 70 min （55-150 min）, and the mean incision length was 10.5 cm （9-13 cm）. The mean drainage was 530 ml （200-800 ml） in the first 35 knees and 380 ml （230-460 ml） in the last 35 knees. The mean blood transfusion was 500 ml （0-1000 ml）. The patients perform exercises of quadriceps with initiative since only 2 d after operation, while the patients began to act on floor with crutches after mean 5.6 d （4-8 d）. The period in hospital was 9-14 d, and the mean activity of flexion was 100°（90°-120°）. While the post-operative until last follow up, ranges of motion was from 5° to - 5° with extension （mean 0°） and from 95° to 125° with flexion （mean 115°）. Knee Society score was 46-69 points, average （51±7） points before operation, then postoperation increased 82-98 points, average （91±5） points. Conclusion The advantages of the minimal invasive technique used by small-incision TKA include minimal invasion of the quadriceps, earlier to practice exercises with initiative, faster to gain good function of knee, and without increasing the risk of TKA.