初次全膝关节置换术或翻修术中应用股四头肌V-Y成形术暴露僵硬膝关节的临床疗效

Clinical effect of V-Y quadricepsplasty for exposing the stiff knee joint in primary TKA and revision surgery

背景:股四头肌V-Y成形术作为初次全膝关节置换术(TKA)或翻修术中膝关节难以显露时选择的手术入路之一,国内相关报道鲜见。目的:评价初次TKA或翻修术采用股四头肌V-Y成形术暴露僵硬膝关节的有效性及安全性,探讨其操作要点与临床意义。方法:2013年11月至2018年9月采用股四头肌V-Y成形术暴露僵硬膝关节8例9膝,男1例1膝,女7例8膝,左膝4例,右膝5例。术前诊断包括骨关节炎(OA)2例2膝,类风湿性关节炎2例3膝,前交叉韧带术后骨性融合1例1膝,血友病性关节炎1例1膝及TKA术后僵硬膝关节2例2膝;初次TKA 7膝,膝关节翻修2膝。年龄41~79岁,平均(59.9±12.9)岁。临床评价指标包括美国膝关节协会评分(KSS)及关节活动度(ROM)。结果:全部获得随访,随访时间9~57个月,平均(32.7±20.7)个月。术前膝关节KSS临床评分平均(38.8±13.1)分(17~57分),功能评分平均(41.1±22.5)分(0~70分);末次随访时KSS评分平均(78.0±15.9)分(43~97分),功能评分平均(80.0±19.5)分(55~100分),与术前比较差异均有统计学意义(t=-7.934,P<0.001;t=-4.603,P=0.002)。术前最大伸膝角度平均10.0°±8.3°(0~25°),末次随访时平均4.4°±5.8°(0~15°);术前最大屈膝角度平均17.8°±13.0°(5°~40°);末次随访时平均78.9°±31.0°(30°~110°);术前膝关节最大活动范围平均7.8°±9.4°(0~30°),末次随访时平均74.4°±35.5°(15°~110°),手术前后比较差异均有统计学意义(t=3.592,P=0.007;t=-4.736,P=0.001;t=-5.431,P=0.001)。随访时因术前残余较大的屈伸活动受限,仍有2例膝关节活动范围不足50°。结论:对于僵硬膝关节的患肢,采取股四头肌V-Y成形术暴露膝关节及延长股四头肌肌腱更易于暴露膝关节,以改善患者屈曲挛缩畸形及膝关节活动范围,提高患者的膝关节功能及生活质量。

Background: V-Y Quadricepsplasty is one of the surgical approaches selected when the knee joint is difficult to expose during primary total knee arthroplasty(TKA) or revision, which was rarely reported in China. Objective: To evaluate the clinical efficacy and safety of V-Y quadricepsplasty on the exposure of stiff knee joint during TKA, and to explore the key points of the operation and clinical significance. Methods: From November 2013 to September 2018, 8 patients(9 knees) were treated with quadruple tendon VY angioplasty, including 1 man with 1 knee and 7 women with 8 knees, and 4 left knees and 5 right knees. two patients were diagnosed as osteoarthritis, 2 patients(3 knees) were diagnosed as rheumatoid arthritis, 1 patient was diagnosed as osseous fusion after anterior cruciate ligament surgery, 1 patient was diagnosed as hemophilia arthritis and 2 patients were diagnosed as knee stiffness after TKA. Seven knees underwent primary total knee arthroplasty and 2 knees underwent knee revision. The patients were aged from 41 to 79 years with an average of(59.9±12.9) years old. American Knee Association Score(KSS) and the range of joint activities(ROM) were taken as the evaluation indices. Results: All patients were followed up for 9-57 months with an average of(32.7±20.7) months. The average knee KSS score was 38.8±13.1(range:17-57)and the functional score was 41.1±22.5(range: 0-70) before the opeartion. The average KSS score was 78.0±15.9(range: 43-97)and the average functional score was 80.0±19.5(range: 55-100) at the last follow-up. Statistically significant differences were observed in the KSS score and functional score before and after surgery(t=-7.934, P<0.001;t=-4.603, P=0.002). The average maximum knee extension angle was 10.0°±8.3°(range: 0-25°) before operation and 4.4°±5.8°(0-15°) at the final follow up;the average maximum knee flexion angle was 17.8°±13.0°(5°-40°) before surgery and 78.9°±31.0°(30°-110°) at the final follow up;the average knee motion range was 7.8°±8.4°(0-30°) before surgery and 74.4°±35.5°(15°-110°) at the final follow up;significant differences were observed in above data between the preoperation and the final follow up(t=3.592,P=0.007;t=-4.736,P=0.001;t=-5.431,P=0.001). During the follow-up period, 2 patients had their knee joint activity range less than 50° due to the limited residual flexion and extension activity before surgery. Conclusion: V-Y Quadricepsplasty can expose the knee joint and extend the quadriceps tendon can expose the knee joint more easily, which can improve the flexion contracture deformity and knee range of motion, so that make the knee joint function and quality of life better for the patients.