糖尿病患者膝关节置换术中髌骨周围去神经化的效果

doi:10.3877/cma.j.issn.1674-134X.2020.02.003

目的

了解髌骨周围去神经化对行膝关节置换术的糖尿病患者的效果及影响。

方法

前瞻性分析2012年1月至2015年12月于新疆维吾尔自治区中医医院行膝关节置换术(TKA)的患者；纳入标准：重度膝关节骨关节炎，单侧TKA，2型糖尿病，围手术期使用胰岛素控制血糖，血糖控制满意且术前糖化血红蛋白(HbA1c)为4%～6%，同意参与该研究。排除标准：髌骨表面置换，既往下肢骨折畸形愈合，既往免疫系统疾病、血液系统疾病、精神性疾病病史，无法配合功能锻炼。按照纳入、排除标准，共纳入88例研究对象，根据是否行髌骨周围去神经化，按照随机数字表法随机将患者纳入去神经化组38人，非去神经化组50人。用t检验比较2组患者术后3个月、6个月的美国膝关节协会(AKS)评分，Feller髌股关节评分，疼痛视觉模拟评分(VAS)。并记录手术切口愈合情况。

结果

术后3个月和术后6个月，去神经化组的AKS膝关节分级(t＝16.474、7.452)、AKS膝关节功能(t＝7.906、1.484)、Feller评分(t＝13.999、13.583)、VAS评分(t＝－10.903、－3.609)均比非去神经化组好，差异具有统计学意义(P<0.05)；对患者术后3个月、6个月的相同指标分别做前后自身对比，AKS膝关节分级(t＝25.506，P<0.05)、AKS膝关节功能(t＝19.173，P<0.05)、Feller评分(t＝11.873，P<0.05)、VAS评分(t＝－10.344，P<0.05)随着时间延长均有改善，差异具有统计学意义。去神经化组有3例(7.9%)患者发生术后手术切口红肿，分别发生在术后第3、3、5天；非去神经化组有4例(8.0%)患者发生手术切口红肿，分别发生在术后第2、3、3、3天，1例(2.0%)患者出现轻微脂肪液化。所有患者均未出现延迟愈合、手术切口裂开、感染。

结论

糖尿病患者TKA术中行髌骨周围去神经化可以改善短期膝关节功能、减轻膝前疼痛，且不会引起手术切口并发症增多。

关键词: 关节成形术, 置换, 膝, 髌骨, 去神经支配, 功能恢复, 疼痛, 手术后

Objective

To explore the effect and influence of patella denervation on diabetic patients undergoing total knee arthroplasty(TKA).

Methods

A prospective analysis of the patients undergoing TKA was carried out in Xinjiang Traditional Chinese Medicine Hospital from January 2012 to December 2015. Inclusion criteria: severe knee osteoarthritis, unilateral TKA, T2DM, use insulin to control blood sugar perioperative, blood sugar level is satisfactory and preoperative glycated hemoglobin (HbA1c) is 4% to 6%, agreed to participate in the study. Exclusion criteria: patellar surface replacement, previous lower limb fracture deformity healing, previous history of immune system diseases, blood system diseases, mental diseases, unable to cooperate with functional exercise.According to the inclusion and exclusion criteria, a total of 88 subjects were included in the study. Patients were randomly included in the denervation group of 38 people and non-denervation group of 50 people according to whether or not to perform denervation around the patella. The t test was used to compare the American Knee Society (AKS) scoring system, Feller patellofemoral joint score, and visual analog score (VAS) at three and six months postoperatively. The healing of surgical incisionwas recorded.

Results

At three months and six months after surgery, the AKS knee grade (t =16.474, 7.452), AKS knee function (t =7.906, 1.484), Feller score (t=13.999, 13.583), VAS score (t=-10.903, -3.609)were better than the non-denervation group, the difference is statistically significant (all P<0.05). The same indicators of patients at three months and six months after operation were compared with themselves, AKS knee joint grade (t=25.506, P<0.05), AKS knee joint function (t=19.173, P<0.05), Feller score ( t =11.873, P<0.05), VAS score (t=-10.344, P<0.05) improved with time, the differences were statistically significant.Three patients (7.9%) in the denervation group had postoperative surgical incision redness, which occurred on the third, third, and fifth day after surgery respectively. Four patients (8.0%) in the non-denervation group had surgical incision redness and occurred on the second, third, third, and third day after operation, respectively, and one patient (2.0%) had slight fat liquefaction. None of the patients experienced delayed healing, cracking, or infection of the surgical incision.

Conclusion

Diabetic patients undergoing denervation around the patella during TKA surgery can improve short-term knee function, reduce anterior knee pain, and will not cause increased surgical incision complications.

Key words: Arthroplasty, replacement, knee, Patella, Denervation, Recovery of function, Pain, postoperative

表1 2组患者的性别、年龄、术前WOMAC和HbA1c

分组	例数	性别(男/女)	年龄[岁，(±s)]	术前WOMAC评分(±s)	术前HbA1c[%，(±s)]
去神经化组	38	17/21	70.2±7.0	76.1±9.0	5.2±0.3
非去神经化组	50	18/32	71.5±6.0	74.3±7.0	5.1±0.3
统计值		χ²＝0.688	t＝－1.245	t＝1.257	t＝1.504
P值		>0.05	>0.05	>0.05	>0.05

表1 2组患者的性别、年龄、术前WOMAC和HbA1c

分组	例数	性别(男/女)	年龄[岁，(±s)]	术前WOMAC评分(±s)	术前HbA1c[%，(±s)]
去神经化组	38	17/21	70.2±7.0	76.1±9.0	5.2±0.3
非去神经化组	50	18/32	71.5±6.0	74.3±7.0	5.1±0.3
统计值		χ²＝0.688	t＝－1.245	t＝1.257	t＝1.504
P值		>0.05	>0.05	>0.05	>0.05

表2 术后3个月AKS评分、Feller评分、VAS评分的比较(±s)

分组	例数	AKS膝关节分级	AKS膝关节功能	Feller评分	VAS评分
去神经化组	38	67.6±4.6	62.7±4.3	24.7±2.5	3.1±0.9
非去神经化组	50	51.5±4.5	56.0±3.7	18.2±1.9	5.3±1.1
t值		16.474	7.906	13.999	－10.903
P值		<0.05	<0.05	<0.05	<0.05

表2 术后3个月AKS评分、Feller评分、VAS评分的比较(±s)

分组	例数	AKS膝关节分级	AKS膝关节功能	Feller评分	VAS评分
去神经化组	38	67.6±4.6	62.7±4.3	24.7±2.5	3.1±0.9
非去神经化组	50	51.5±4.5	56.0±3.7	18.2±1.9	5.3±1.1
t值		16.474	7.906	13.999	－10.903
P值		<0.05	<0.05	<0.05	<0.05

表3 术后6个月AKS评分、Feller评分、VAS评分的比较(±s)

分组	例数	AKS膝关节分级	AKS膝关节功能	Feller评分	VAS评分
去神经化组	38	85.0±4.6	71.0±2.8	27.7±2.0	2.1±1.0
非去神经化组	50	76.0±6.7	70.1±3.0	22.5±1.6	2.9±1.1
t值		7.452	1.484	13.583	－3.609
P值		<0.05	<0.05	<0.05	<0.05

表3 术后6个月AKS评分、Feller评分、VAS评分的比较(±s)

分组	例数	AKS膝关节分级	AKS膝关节功能	Feller评分	VAS评分
去神经化组	38	85.0±4.6	71.0±2.8	27.7±2.0	2.1±1.0
非去神经化组	50	76.0±6.7	70.1±3.0	22.5±1.6	2.9±1.1
t值		7.452	1.484	13.583	－3.609
P值		<0.05	<0.05	<0.05	<0.05

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Denervation around patella in the total knee arthroplasty of diabetic patients

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Denervation around patella in the total knee arthroplasty of diabetic patients