初次全膝关节置换股内侧肌中间入路与内侧髌旁入路置入假体的优势对比(英文)

Comparison of midvastus and standard medial parapatellar approaches in total knee arthroplasty

背景:国外研究已表明在膝关节置换过程中,股内侧肌中间入路不仅能较好地保留股四头肌内侧结构的完整性,较早恢复伸膝装置功能,而且能减少膝关节内侧血供的破坏,较好保留膝关节本体感觉。目的:进一步验证采用股内侧肌中间入路对全膝关节假体置入后早期功能训练的影响,并与内侧髌旁入路比较。设计:前瞻性随机双盲对比观察试验。单位:解放军第二军医大学长征医院。对象:选择2004-03/2006-03解放军第二军医大学长征医院收治的双侧膝关节同期置换患者34例,其中男7例,女27例;年龄56～78岁,平均70.5岁。其中骨性关节炎24例,类风湿关节炎10例。双侧膝内翻24例、双侧膝外翻9例,一侧内翻一侧外翻1例。患者均知情同意参加本实验,并签署手术知情同意书。主要材料:交叉替代型假体(PFC-Sigama,英国DUPUY公司),在胫骨衬垫中央加入一个聚乙烯突起,相应的股骨假体使用前后向切骨及斜面切骨,与保留型假体相同。方法:34例患者两侧膝关节的手术入路进行随机分配,一侧采用股内侧肌中间入路,另一侧采用内侧髌旁入路。比较两组间的外科参数和临床参数。主要观察指标:①外科参数包括暴露的难易程度、手术时间、术中失血量和外侧支持带松解的比例。②临床参数包括术后静息和运动时疼痛、直腿抬高时间、主动屈曲到90°的时间、术后膝关节活动度和并发症。结果:34例患者均进入结果分析。两组手术时间无明显差异,采用股内侧肌中间入路一侧的膝关节术中失血较少[(286±29.8)mL,(368±35.8)mL,P<0.05],外翻膝需要做外侧支持带松解的比例较小(20%,50%,P<0.05),术后1周内疼痛较轻(P<0.05),能较早地进行主动直腿抬高运动[(1.8±0.3)d,(4.5±0.8)d,P<0.01],较早地屈曲到90°[(3.2±0.8)d,(7.1±1.2)d,P<0.01],术后45d活动度改善较快[(107°±20°),(98°±12°),P<0.05]。结论:股内侧肌中间入路对伸膝装置和髌周血管丛的破坏较少,全膝关节假体置入后早期疼痛较轻,活动度恢复更好。

BACKGROUND： Some overseas searchers have shown that, the midvastus approach in total knee arthroplasty （TKA） can reserve the complete medial structure of quadriceps femoris, improve the functional recovery of knee extension apparatus, but also preserve the blood supply of medial knee joint and maintain proprioceptive sense of knee joint. OBJECTIVE： To evaluate the early functional outcome of midvastus approach and standard medial parapatellar approach in TKA. DESIGN： A prospective, randomized, double-blind, comparative study. SETTING： Changzheng Hospital Affiliated to the Second Military Medical University of Chinese PLA. PARTICIPANTS： From March 2004 to March 2006, 34 patients undergoing bilateral TKA simultaneously were admitted to the Changzheng Hospital Affiliated to the Second Military Medical University of Chinese PLA, including 7 males and 27 females. They aged 56-78 years with a mean of 70.5 years, and consisted of 24 cases with osteoarthritis, and 10 cases with rheumatoid arthritis; 24 cases With bilateral genu varum, 9 cases with bilateral genu valgum, and 1 case with lateral genu varum and contralateral genu valgum. Informed consents were obtained from all the included patients. Materials： Press Fit Condylar （PFC） Sigma knee prosthesis （DUPUY Company）, the central tibial pad was added with a polyethylene prominence, while the corresponding femoral prosthesis was treated with anterioposterior osteotomy, identical with the remained prosthesis. METHODS： The surgical approach of 34 patients was randomized into a midvastus approach in one knee and a standard medial parapatellar approach in the other knee. The comparison included the surgical parameters and clinical parameters. MAIN OUTCOME MEASURES： （1） The surgical parameters consisted of the difficulty of exposure, surgical time, blood loss and incidence of lateral retinacular release.（2） The clinical parameters included pain assessment in rest and under movement, the time of performing an active straight leg raise, the time of reaching 90° knee flexion, range of motion and complications. RESULTS： All of 34 patients were involved in the result analysis. There was no significant difference in the surgical time between the two groups. The assessment revealed significantly less blood loss [（286±29.8） mL, （368±35.8） mL, P 〈 0.05], fewer lateral release in valgus knee （20%, 50%, P 〈 0.05）, less pain in the first week （P 〈 0.05）, earlier return of active straight-leg raise [（1.8±0.3） days, （4.5±0.8） days, P 〈 0.01], earlier reach of 90° knee flexion [（3.2±0.8） days, （7.1±1.2） days, P 〈 0.01] and greater range of motion at 45 day [（107±20）° , （98±12）° , P 〈 0.05] in the midvastus approach group. CONCLUSION： The midvastus approach, which is based on diminished disruption of extensor mechanism and peripatellar plexus of vessels, relieves pain and improves range of motion in the early rehabilitation period following TKA.