全膝关节置换不同入路对伸膝装置影响的比较

Effect of total knee arthroplasty via different approaches on extensor mechanism

背景:传统的人工全膝关节置换采用标准内侧髌旁入路,但其手术创伤大、康复时间长,且易对股四头肌腱在髌骨上极的止点造成干扰。经股内侧肌下方入路作为一种不干扰伸膝装置的入路方式,由于其无法提供充分的术野暴露,易对股肌造成损伤,目前其应用及安全性仍存在争议。目的:比较分析内侧髌旁和经股内侧肌下方入路行人工全膝关节置换的临床疗效。方法:将78例(82膝)择期行人工全膝关节置换的患者随机分为治疗组(39例41膝)和对照组(39例41膝),治疗组采用经股内侧肌下方入路,对照组采用内侧髌旁入路。观察两组患者人工全膝关节置换后膝关节功能、关节活动度及并发症的发生情况。结果与结论:与对照组比较,治疗组的手术时间明显增加,但其置换后伤口引流量明显减少、直腿抬高时间及下地行走时间均明显缩短(P<0.05)。两组置换前、置换后12周的HSS评分差异无显著性意义(P>0.05),而治疗组置换后1周、6周的HSS评分明显高于对照组(P<0.05)。置换后,两组患者膝关节的关节活动度和股四头肌MMT分级均显著改善(P<0.05),而治疗组置换后关节活动度和股四头肌MMT分级的改善程度较对照组更为明显(P<0.05)。治疗组和对照组并发症的发生率分别为2.6%和15.4%,差异有显著性意义(P<0.05)。结果表明经股内侧肌下方入路行人工全膝关节置换对伸膝装置影响小,可促进置换后关节功能及关节活动度的恢复,减少置换后并发症。

BACKGROUND： Traditional total knee arthroplasty adopts media! parapatellar approach, which induces severe trauma, requires long-term rehabilitation, and interferes the end point of quadriceps femoral tendon on superior patallar pole. Total knee arthroplasty by subvastus approach has no impact on the knee-extension equipment, but it cannot provide sufficient exposure of surgical field and can induce damage to femoral muscle, so its application and safety need further exploration. OBJECTIVE： To explore clinical effect of total knee arthroplasty by subvastus approach and medial parapatellar approach. METHODS： A total of 78 patients with 82 knees who were candidates for total knee arthroplasty were randomly divided into two groups. Treatment group （39 cases; 41 knees） was given subvastus approach and control group （39 cases; 41 knees） was given median parapatellar approach. The knee function, range-of-motion of knee joint and complications after total knee arthroplasty were observed and compared. RESULTS AND CONCLUSION： Compared with control group, the operation time in treatment group was significantly increased, while the postoperative wound drainage, straight leg raising time and walking time were obviously reduced （P 〈 0.05）. The scores of HSS before surgery and 12 weeks after surgery were not significantly different between the two groups （P 〉 0.05）, while at 1 and 6 weeks after surgery the scores in treatment group were significantly higher than those in control group （P 〈 0.05）. The range-of-motion of knee joint and MMT rank for quadriceps muscle were significantly improved in two groups after treatment （P 〈 0.05）, and those indicators in treatment group were more significant than the control group （P 〈 0.05）. The incidences of complications in treatment group and control group were 2.6% and 15.4%, respectively, with statistically significant difference （P 〈 0.05）. The total knee arthroplasty by subvastus approach has less impact on the extensor mechanism, improves the recovery of knee function and range-of-motion of knee joint, and reduces the incidence of complications.