股肌下结合微斜切入路全膝关节置换术治疗膝外翻

doi:10.3877/cma.j.issn.1674-134X.2020.05.005

目的

评估股肌下结合微斜切入路(SMOC)实施人工全膝关节置换术治疗膝关节外翻畸形的可行性及早期临床效果。

方法

回顾性分析2015年4月至2017年10月在青岛大学附属医院关节外科50例(60膝)行初次人工膝关节置换术治疗并获得完整随访的膝外翻患者，排除年龄> 85岁、既往膝关节手术史及身体质量指数> 30 kg/m²的患者。男13例，女37例，年龄平均(60±8)岁。诊断为类风湿性关节炎42例52膝，骨关节炎5例5膝，创伤性关节炎3例3膝。采用SMOC入路行人工全膝关节置换术患者25例(31膝)，内侧髌旁入路者25例(29膝)。记录并比较两组患者的术前一般资料、血红蛋白、视觉模拟评分法(VAS)、美国特种外科医院(HSS)评分、膝关节被动活动度(ROM)、外翻角度；手术时间、术中出血量、外侧支持带松解率、术后2 d血红蛋白含量、术后引流量、输血率、直腿抬高时间、辅助镇痛药物使用情况、术后下肢力线、髌股适合角；24 h VAS，以及术后1周HSS评分及膝关节ROM，独立样本t检验或卡方检验比较分析两组差异。

结果

术前一般资料两组无差异(P>0.05)，随访期间无感染及假体松动等并发症。术后外翻膝均得到矫正，两组在手术时间、术中出血量、术后引流量、术后2 d血红蛋白含量、输血率、术后下肢力线、髌股适合角方面两组差异无统计学意义(P>0.05)；SMOC组在直腿抬高时间(t＝10.500，P<0.01)、外侧支持带松解率(χ² ＝5.711，P<0.05)、辅助镇痛药使用(χ² ＝9.934，P<0.01)方面优于内侧髌旁入路。术后24 h VAS评分SMOC组低于髌旁组(t＝10.540，P<0.001)、1周HSS评分(t＝8.110，P<0.001)及ROM(t＝2.085，P<0.05)，SMOC组低于髌旁组。

结论

利用SMOC入路全膝置换术可有效治疗膝外翻畸形，与髌旁入路相比，髌外侧支持带松解率更低，可获得更快速的近期康复效果。

关键词: 骨关节炎, 关节成形术, 膝关节, 关节炎, 类风湿

Objective

To evaluate and compare the feasibility and early clinical results of minimally invasive total knee arthroplasty (TKA) by subvastus with minimal oblique cut (SMOC) approach for valgus knee.

Methods

From April 2015 to October 2017, 50 patients (60 knees) who underwent total knee arthroplasty with valgus knee arthroplasty in the Department of Joint Surgery of Qingdao University Affiliated Hospital were retrospectively analyzed. The patients with age over 85 years, previous knee surgery history and body mass index > 30 kg / m² were excluded. There were 13 males and 37 females, with age of (60 ± 8) years on average. Preoperative diagnosis included 30 cases of rheumatoid arthritis (52 knees), 15 cases of osteoarthritis (15knees) and three cases of traumatic arthritis (three knees). TKA via SMOC approach was performed in 31 knees of 25 patients (SMOC group), and TKA via traditional medial parapatellar approach was performed in 29 knees of 25 patients (parapatellar group). Preoperative demographics, hemoglobin(Hb), VAS, HSS score, range of motion (ROM), Lower limb force line, surgical time, lateral retinacular release, blood loss, Hb two days after surgery, drainage, blood transfusion rate, straight leg raising time, analgesic, postoperative lower limb strength and patellofemoral fit angle, visual analogue scale (VAS) at 24 h, Hospital for Special Surgery (HSS) score and range of motion (ROM) at one week, were recorded. The differences between the two groups were analyzed by independent sample t test or chi-square test.

Results

No complications like infection, loose of components were found during the follow-up. No difference existed in preoperative demographics (P>0.05). Valgus deformity was corrected after surgery in both group. Similar results were found between groups in operation time, blood loss, drainage, Hb at postoperative two days, transfusion, postoperative lower limb strength and patellofemoral fit angle (P>0.05). In SMOC group, better straight leg raising (t=10.500, P<0.01), lateral release rate (χ²=5.711, P<0.05) and analgesic were demonstrated(χ²=9.934, P<0.01). VAS score 24 h after operation in SMOC group was lower than that in parapatellar group (t=10.540, P<0.001), HSS score at one week after operation (t=8.110, P<0.001) and ROM one week after operation (t=2.085, P<0.05) in SMOC group were lower than those in parapatellar group (t=10.540, P<0.001).

Conclusion

Valgus knee can be treated successfully by TKA through SMOC approach, with less lateral retinaculum faster short-term recovery effect compared with traditional parapatellar approach.

Key words: Osteoarthritis, Arthroplasty, Knee, Arthritis, rheumatoid

图1 SMOC(股肌下结合微斜切)手术示意图。图A为SMOC入路中可进行0～2 cm的微斜切增加显露；图B为SMOC入路假体植入后，可见完好的伸膝装置覆盖于假体上，髌股轨迹良好；图C为SMOC入路内层软组织闭合后，可见伸膝装置的完整性和内侧软组织的连续性

表1 TKA的SMOC入路组与对照组术前一般资料比较

分组	例数	年龄[岁，(±s)]	男性占比(%)	BMI[kg/m²，(±s)]	Hb含量[g/L，(±s)]	VAS评分(±s)	HSS评分(±s)	外翻角度[°，(±s)]	术前ROM[°，(±s)]
SMOC组	25	59.3±8.3	24.0	24.3±5.0	124.4±14.1	5.5±1.7	41.5±9.3	11.3±5.6	105.5±12.3
髌旁组	25	60.6±8.4	28.0	25.4±5.0	122.3±13.6	5.4±1.4	39.9±7.7	10.0±4.8	108.41±13.3
统计值		t＝0.884	χ²＝0.104	t＝0.707	t＝0.505	t＝0.185	t＝0.831	t＝0.640	t＝0.565
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表1 TKA的SMOC入路组与对照组术前一般资料比较

分组	例数	年龄[岁，(±s)]	男性占比(%)	BMI[kg/m²，(±s)]	Hb含量[g/L，(±s)]	VAS评分(±s)	HSS评分(±s)	外翻角度[°，(±s)]	术前ROM[°，(±s)]
SMOC组	25	59.3±8.3	24.0	24.3±5.0	124.4±14.1	5.5±1.7	41.5±9.3	11.3±5.6	105.5±12.3
髌旁组	25	60.6±8.4	28.0	25.4±5.0	122.3±13.6	5.4±1.4	39.9±7.7	10.0±4.8	108.41±13.3
统计值		t＝0.884	χ²＝0.104	t＝0.707	t＝0.505	t＝0.185	t＝0.831	t＝0.640	t＝0.565
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表2 两组TKA手术一般资料比较

分组	例数	手术时间[min，(±s)]	术中出血量[ml，(±s)]	术后引流量[ml，(±s)]	辅助镇痛药物使用(%)	术后2 d Hb[g/L，(±s)]	外侧支持带松解率(%)	直腿抬高时间[d，(±s)]
SMOC组	25	82.3±15.2	152.7±51.2	88.3±35.5	18.8	102.6±11.3	64.0	1.0±0.6
髌旁组	25	80.4±14.5	155.4±52.2	90.4±38.6	62.5	98.9±10.0	93.1	3.1±0.8
统计值		t＝0.452	t＝0.185	t＝0.200	χ²＝9.934	t＝1.226	χ²＝5.711	t＝10.500
P值		>0.05	>0.05	>0.05	<0.01	>0.05	<0.05	<0.001

表2 两组TKA手术一般资料比较

分组	例数	手术时间[min，(±s)]	术中出血量[ml，(±s)]	术后引流量[ml，(±s)]	辅助镇痛药物使用(%)	术后2 d Hb[g/L，(±s)]	外侧支持带松解率(%)	直腿抬高时间[d，(±s)]
SMOC组	25	82.3±15.2	152.7±51.2	88.3±35.5	18.8	102.6±11.3	64.0	1.0±0.6
髌旁组	25	80.4±14.5	155.4±52.2	90.4±38.6	62.5	98.9±10.0	93.1	3.1±0.8
统计值		t＝0.452	t＝0.185	t＝0.200	χ²＝9.934	t＝1.226	χ²＝5.711	t＝10.500
P值		>0.05	>0.05	>0.05	<0.01	>0.05	<0.05	<0.001

图2 患者TKA(全膝关节置换)术前后下肢X线片。图A术前左膝X线侧位片可见骨质增生；图B术前左膝X线正位片，可见膝关节外侧间室狭窄；图C术后左膝X线侧位片，可见骨质增生去除；图D术后X线正位可见术后假体位置良好；图E术前全下肢X线可见膝外翻畸形；图F术后全下肢X线可见外翻畸形矫正

表3 两组影像学指标比较[°，(±s)]

分组	例数	下肢力线	屈膝30°适合角
SMOC组	25	2.2±4.2	16.5±0.7
髌旁组	25	2.0±5.1	16.3±0.8
t值		0.151	0.941
P值		>0.05	>0.05

表3 两组影像学指标比较[°，(±s)]

分组	例数	下肢力线	屈膝30°适合角
SMOC组	25	2.2±4.2	16.5±0.7
髌旁组	25	2.0±5.1	16.3±0.8
t值		0.151	0.941
P值		>0.05	>0.05

表4 两组TKA术后疗效评价(±s)

分组	例数	术后24 h VAS	术后1周ROM(°)	术后1周HSS评分
SMOC组	25	3.1±0.8	92.8±20.1	53.3±5.9
髌旁组	25	5.8±1.0	81.5±18.2	40.9±4.9
t值		10.540	2.085	8.110
P值		<0.001	<0.05	<0.001

表4 两组TKA术后疗效评价(±s)

分组	例数	术后24 h VAS	术后1周ROM(°)	术后1周HSS评分
SMOC组	25	3.1±0.8	92.8±20.1	53.3±5.9
髌旁组	25	5.8±1.0	81.5±18.2	40.9±4.9
t值		10.540	2.085	8.110
P值		<0.001	<0.05	<0.001

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Total knee arthroplasty by subvastus with minimal oblique incision approach in treatment of valgus knee

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Total knee arthroplasty by subvastus with minimal oblique incision approach in treatment of valgus knee