初次全膝关节置换中应用股四头肌V-Y成形术暴露强直或僵硬膝关节

Exposure of an ankylosed or stiff knee with V-Y quadricepsplasty in primary total knee arthroplasty

目的分析初次全膝关节置换(total knee arthroplasty,TKA)中应用股四头肌V-Y成形术暴露强直或僵硬膝关节的中长期疗效。方法回顾性分析2010年5月至2019年2月于四川大学华西医院因膝关节强直或僵直采用股四头肌V-Y成形术显露的TKA患者12例,男7例、女5例,年龄(53.9±14.9)岁(范围24~72岁),左侧6例、右侧6例。术前诊断:骨关节炎7例、类风湿关节炎2例、创伤性关节炎1例、血友病性关节炎2例。记录患者手术前后膝关节疼痛视觉模拟评分(visual analogue scale,VAS)、关节活动度、股四头肌肌力、美国膝关节协会评分(Knee Society score,KSS)及术后并发症。结果所有患者均顺利完成手术并获得随访,随访时间为(102.2±31.1)个月(范围51~141个月)。手术时间为(87.0±15.7)min(范围73~123 min),术中出血量为(823.6±237.7)ml(范围555~1471 ml),住院时间为(13.3±6.3)d(范围6~28 d)。所有患者术后VAS评分均降低,手术前后比较差异有统计学意义(F=132.000,P<0.001)。术后3个月和末次随访的VAS评分分别为(2.2±0.7)分和(1.2±0.4)分,小于术前的(5.2±0.7)分,差异有统计学意义(P<0.05)。所有患者术后KSS膝评分均升高,手术前后比较差异有统计学意义(F=40.960,P<0.001)。术后3个月和末次随访的KSS膝评分分别为(56.0±14.1)分和(74.3±16.1)分,大于术前的(26.1±7.8)分,差异有统计学意义(P<0.05)。所有患者术后KSS功能评分均升高,手术前后比较差异有统计学意义(F=24.332,P<0.001)。术后3个月和末次随访的KSS功能评分分别为(52.9±19.4)分和(79.2±19.6)分,大于术前的(27.1±15.6)分,差异有统计学意义(P<0.05)。所有患者术后膝关节活动度均升高,手术前后比较差异有统计学意义(F=24.145,P<0.001)。术后3个月和末次随访的膝关节活动度分别为57.5°±22.2°和70.0°±25.9°,大于术前的12.5°±14.1°,差异有统计学意义(P<0.05)。术前股四头肌肌力3级2例,4级10例;末次随访时4级1例,5级11例,肌力较术前改善,差异有统计学意义(Z=11.000,P<0.001)。末次随访时无一例出现伤口渗液、延迟愈合、浅表或深部软组织感染、假体周围感染及松动、下肢深静脉血栓形成及肺栓塞等并发症。结论对接受TKA的膝僵直或强直患者,采用股四头肌V-Y成形术可增加显露,从而可改善膝关节活动度和股四头肌肌力。

Objective To analyze the medium-and long-term outcomes of V-Y quadricepsplasty in primary total knee arthroplasty(TKA)to expose an ankylosed or stiff knee joint.Methods From May 2010 to February 2019,a total of 12 patients with TKA revealed by V-Y quadricepsplasty in West China Hospital of Sichuan University due to knee ankylosis or stiffness were retrospectively analyzed,including 7 males and 5 females,aged(53.9±14.9)years(range,24 to 72 years),6 patients on the left side and 6 patients on the right side.Preoperative diagnosis:7 cases of osteoarthritis,2 cases of rheumatoid arthritis,1 case of traumatic arthritis,and 2 cases of haemophilic arthritis.Visual analogue scale(VAS),range of motion,quadriceps muscle strength,Knee Society score(KSS)and postoperative complications were recorded before and after operation.Results All patients successfully completed the operation and were followed up for 102.2±31.1 months(range,51-141 months).The operation time was 87.0±15.7 min(range,73 to 123 min),the intraoperative blood loss was 823.6±237.7 ml(range,555 to 1471 ml),and the hospital stay was 13.3±6.3 d(range,6 to 28 d).Postoperative VAS scores were decreased in all patients,and the difference before and after operation was statistically significant(F=132.000,P<0.001).The VAS scores at 3 months and the last follow-up were 2.2±0.7 points and 1.2±0.4 points,respectively,lower than those before operation(5.2±0.7 points),and the difference was statistically significant(P<0.05).KSS knee scores were higher in all patients after operation,and the difference was statistically significant before and after operation(F=40.960,P<0.001).KSS knee scores at 3 months and the last follow-up were 56.0±14.1 points and 74.3±16.1 points,respectively,higher than those before operation(26.1±7.8 points),and the difference was statistically significant(P<0.05).Postoperative KSS functional scores were increased in all patients,and the difference before and after operation was statistically significant(F=24.332,P<0.001).The KSS functional scores at 3 months and the last follow-up were 52.9±19.4 points and 79.2±19.6 points,respectively,higher than those before operation(27.1±15.6 points),and the difference was statistically significant(P<0.05).Postoperative knee joint motion was increased in all patients,and the difference was statistically significant before and after operation(F=24.145,P<0.001).The range of motion of the knee joint at 3 months and the last follow-up was 57.5°±22.2°and 70.0°±25.9°,respectively,which was higher than the preoperative 12.5°±14.1°,and the difference was statistically significant(P<0.05).Preoperative quadriceps muscle strength was grade 3 in 2 cases and grade 4 in 10 cases;at the last follow-up,grade 4 in 1 case and grade 5 in 11 cases,and the muscle strength was improved compared with that before operation,the difference was statistically significant(Z=11.000,P<0.001).At the last follow-up,there were no complications such as wound seepage,delayed healing,superficial or deep soft tissue infection,periprosthesis infection and loosening,deep vein thrombosis and pulmonary embolism.Conclusion In patients with ankylosed or stiff knee receiving TKA,the use of V-Y quadricepsplasty can increase the exposure,thereby improving the range of knee motion and quadriceps muscle strength.