股四头肌保留入路用于全膝关节置换术的临床研究

发布时间：2018-11-25 20:18

【摘要】：研究背景:1974年,世界上骨科学界报道了第一例全膝关节置换,自此之后,全膝关节置换术作为一种先进的,能够有效治疗膝关节骨性关节炎的治疗手段得到了飞速的发展。经过30年的飞速发展,目前髌骨旁内侧入路作为主流的操作入路得到广泛的应用,因为,髌骨旁内侧入路能够展现良好的手术视野和提供足够的操作空间。但是髌骨旁内侧入路能够提供良好的手术暴露视野是因为其破坏了股四头肌及相关韧带同时将髌骨翻开。因此21世纪初期,人工全膝关节的微创术式等被关节外科医生提出。根据大量研究表明,股四头肌保留入路的人工全膝关节置换术能够提供能快的术后康复、更少的手术出血,更大的膝关节活动度以及更少的围手术期疼痛感。然而,仍然有一些研究提出了股四头肌保留入路的微创人工全膝关节置换术会带来大量的并发症。因此,股四头肌保留入路的微创全膝关节置换术的选择与否,得到了越来越多的研究人员的关注。研究目的:本文通过对股四头肌保留入路应用于人工全膝关节置换术的发展进行综述,并通过纳入现有的、所有的随机临床研究来对股四头肌保留入路应用于全膝置换术的临床预后进行荟萃分析与系统回顾来比较股四头肌保留入路和传统髌骨旁入路在术后短期及长期随访的临床疗效差异。以期指导临床关节外科医生选择更加合适的入路来完成人工全膝关节置换术。研究方法:本文通过网络对 PubMed,Embase,Cochrane Library,以及 Web of Science 等数据库对从1990年至2016年8月期间所有相关的研究进行检索。检索的关键词包括:"total knee replacement"、"total knee arthroplasty"、"quadriceps muscle-sparing"。通过阅读全文,对其文献进行详细的了解后,对其研究结果进行分析,所有相关的随机对照研究被纳入至meta分析,利用RevMan5.3软件进行数据分析,连续型变量通过对于加权均数差(WMD)和95%可信区间(CI)进行报告,二分类变量通过危险度(OR)值和95%可信区间(CI)报告,异质性通过I2检验进行。研究结果:本文总共纳入7篇RCT,共520条膝关节,根据合并效应量后结果发现在术后疼痛VAS评分、直腿抬高情况以及术后KSS评分等在两组之间无明显差异,其余评价指标通过合并后均无明显差异。与此同时,股四头肌保留入路容易出现更多的极端现象或失败案例。结论股四头肌保留入路因其手术原理的特征具有以下不足:(1)手术视野暴露过小,手术操作过程相对复杂,难度相对较大,可能使得假体安置的位置不准确;(2)手术难度增大带来的相关并发症,同时也延长了手术的时间、止血带的使用时间,并因此增加了手术时间延长而带来例如感染、下肢肿胀、下肢深静脉血栓等并发症的风险。因此我们认为股四头肌保留入路应当推荐给高年资的具有丰富全膝关节初次置换手术经验的医生去使用。
[Abstract]:Background: the first case of total knee arthroplasty was reported by bone science in the world in 1974. Since then total knee arthroplasty as an advanced and effective treatment of knee osteoarthritis has been rapidly developed. With the rapid development of 30 years, the medial approach of patella has been widely used as the mainstream approach, because the medial approach of patella can show a good visual field and provide enough operation space. But the medial approach to the patella provides a good surgical exposure because it destroys the quadriceps femoris and associated ligaments and opens the patella. Therefore, in the early 21 st century, the minimally invasive operation of artificial total knee joint was proposed by the arthrosurgeon. According to a large number of studies, total knee arthroplasty with quadriceps femoris reserve approach can provide faster postoperative recovery, less operative bleeding, greater knee motion and less perioperative pain. However, some studies have suggested that minimally invasive total knee arthroplasty with quadriceps femoris retention approach can cause a large number of complications. Therefore, the choice of minimally invasive total knee arthroplasty with quadriceps femoris approach has attracted more and more attention. Objective: to review the development of total knee arthroplasty with quadriceps femoris reserved approach, and to include the existing, All randomized clinical studies were conducted to analyze the clinical prognosis of quadriceps femoris reserved approach for total knee arthroplasty and to compare the short and long term postoperative outcomes between the quadriceps femoris reserved approach and the traditional patellar approach. The clinical efficacy was different in follow-up. In order to guide clinical joint surgeons to choose a more appropriate approach to complete total knee arthroplasty. Methods: PubMed,Embase,Cochrane Library, and Web of Science databases were used to search all the relevant studies from 1990 to 2016. Keywords retrieved include: "total knee replacement", "total knee arthroplasty", "quadriceps muscle-sparing". After reading the full text and understanding the literature in detail, the results of the study were analyzed. All the relevant randomized controlled studies were included in the meta analysis, and the data were analyzed using RevMan5.3 software. Continuous variables were reported by weighted mean difference (WMD) and 95% confidence interval (CI). The second class variables were reported by risk (OR) value and 95% confidence interval (CI). The heterogeneity was tested by I2 test. The results showed that there were no significant differences between the two groups in pain VAS score, straight leg elevation and postoperative KSS score. There was no significant difference between the other evaluation indexes after the merger. At the same time, the quadriceps femoris approach is prone to more extreme phenomena or failures. Conclusion the reserved approach of quadriceps femoris has the following shortcomings because of its characteristics: (1) the surgical field of vision is too small, the operation process is relatively complex, and the difficulty is relatively large, which may make the position of prosthesis placement inaccurate; (2) the complications associated with the increased difficulty of the operation, as well as the prolongation of the operation time, the use of the tourniquet, and, consequently, the prolongation of the operative time leading to, for example, infections, swelling of the lower extremities, Risk of complications such as deep venous thrombosis of the lower extremity. Therefore, we suggest that the quadriceps femoris approach should be recommended to senior doctors with extensive experience in total knee arthroplasty.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.4

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