不同切口人工膝关节置换术后的早期并发症比较

COMPARATIVE STUDY ON EARLY COMPLICATION AFTER TOTAL KNEE ARTHROPLASTY SURGERY BY DIFFERENT INCISIONS

目的比较小切口与常规切口人工膝关节置换术(total knee arthroplasty,TKA)术后早期并发症,评估小切口技术在TKA中的应用价值。方法2004年5月-2005年7月,对38例(46膝)患者行小切口TKA(小切口组),同期对43例(54膝)患者行常规切口TKA(常规切口组)。小切口组:男12例12膝,女26例34膝;年龄52～76岁。骨性关节炎24例28膝,类风湿性关节炎14例18膝。膝内翻30例34膝,膝外翻8例12膝。根据美国膝关节协会评分标准(AmericanKneeSocitetyScore,AKSS)评分为(37.5±12.6)分。病程(7.5±2.3)年。常规切口组:男15例19膝,女28例35膝;年龄55～82岁。骨性关节炎32例37膝,类风湿性关节炎11例17膝。膝内翻34例41膝,膝外翻9例13膝。AKSS评分为(31.1±10.2)分。病程(10.1±4.2)年。两组一般资料差异无统计学意义(P>0.05)。结果小切口组切口长度、手术时间及术后引流量分别为(12.6±1.2)cm、(95±15)min、(650.1±10.0)mL;常规切口组分别为(18.7±2.3)cm、(63±11)min、(300.0±20.0)mL;两组比较差异均有统计学意义(P<0.05)。小切口组术后出现早期及晚期关节感染各2例2膝,均经对症处理后愈合;术后第3天出现1例下肢深静脉栓塞,经溶栓治疗后愈合;术后第7天和第9天分别出现1例皮缘部分坏死,采用局部换药后愈合;术后12个月1例因摔跤导致股骨髁上骨折,但假体稳定,行钢板内固定术后骨折临床愈合。常规切口组中术后第10天1例1膝出现关节感染,对症治疗后愈合;无术后骨折、皮缘坏死、下肢深静脉血栓等并发症发生。术后患者均获随访,小切口组随访时间为(3.7±0.4)年,常规切口组为(3.9±0.6)年。末次随访时小切口组AKSS评分为(78.2±6.7)分,常规切口组为(81.2±7.3)分;两组与术前比较差异均有统计学意义(P<0.05),两组间差异无统计学意义(P>0.05)。结论与常规切口相比,采用小切口技术行TKA术后早期并发症较多,严格的手术适应证选择、熟练的人工膝关节置换技术、更合理的手术器械、细致入微的围手术期管理是取得手术成功的关键。

Objective To evaluate the usefulness of minimal incision technique in total knee arthroplasty （TKA） by comparing theffearly complications after minimal incision TKA and those after traditional incision. Methods From May 2004 to July 2005,38 patients （46 knees） underwent TKA using the minimal incision technique （minimal incision group）,and 43 patients （54 knees） underwent TKA using the traditional incision technique at the same period （traditional incision group）. The minimal incision group included 12 male patients （12 knees） and 26 female patients （34 knees）,and their ages ranged from 52 to 76 years. Twenty-four patients （28 knees） had osteoarthritis and 14 patients （18 knees） had rheumatic arthritis. The varus deformity of the knee was found in 30 patients （34 knees） and valgus deformity was found in 8 patients （12 knees）. The American Knee Society Score （AKSS） score was 37.5 ± 12.6,and the disease course was （7.5 ± 2.3） years. The traditional incision group included 15 male patients （19 knees） and 28 female patients （35 knees）,and their ages ranged from 55 to 82 years. Thirty-two patients （37 knees） had osteoarthritis and 11 patients （17 knees） had rheumatic arthritis. Varus deformity of the knee was found in 34 patients （41 knees） and valgus deformity was found in 9 patients （13 knees）. The AKSS score was 31.1 ± 10.2,and the disease course was （10.1 ± 4.2） years. There were no statistically signi cant di erences in the general data between two groups （P 〉 0.05）. Results The incision length,the operation time and the drainage ow were （12.6 ± 1.2） cm,（95 ± 15） minutes and （650.1 ± 10.0） mL in the minimal incision group and （18.7 ± 2.3） cm,（63 ± 11） minutes and （300.0 ± 20.0） mL in the traditional incision group; showing statistically signi cant di erences between two groups （P 〈 0.05）. In the minimal incision group,4 patients （4 knees） developed infections at the operated knees,including 2 early infection and 2 late infection,which were all cured by corresponding treatment. Deep vein thrombosis occurred in 1 patient on the third day after operation and was managed successfully by thrombolytic therapy. Cutaneous necrosis was found in 2 patients on the seventh and ninth postoperative day separately,which healed uneventfully after intensive local treatment. On the twelfth postoperative month,1 patient had femoral fractured at the site of supracondylar region after a careless fall,but the prosthesis was stable. The fracture was xed by a plate and healed uneventfully. In the traditional incision group,only 1 patient （1 knee） developed early infection at the operated knee on the tenth postoperative day,which was managed by corresponding treatment. And there were no periprosthetic fracture,cutaneous necrosis or deep vein thrombosis. The patients were followed up for （3.7 ± 0.4） years in the minimal incision group and （3.9 ± 0.6） years in the traditional incision group. At the latest follow-up,the AKSS scores were 78.2 ± 6.7 in the minimal incision group and 81.2 ± 7.3 in the traditional incision group,showing statistically signi cant di erences （P 〈 0.05） when compared with those before operation and no statistically signi cant di erence between two groups （P 〉 0.05）. Conclusion Minimally invasive TKA has relatively higher complication rate than traditional incision. Strict patient inclusion criteria,competent surgery skill,proper instrument and intensive perioperative management areffessential to success.