股四頭肌保留入路用于全膝關(guān)節(jié)置換術(shù)的臨床研究
發(fā)布時間：2018-11-25 20:18
【摘要】：研究背景:1974年,世界上骨科學(xué)界報道了第一例全膝關(guān)節(jié)置換,自此之后,全膝關(guān)節(jié)置換術(shù)作為一種先進的,能夠有效治療膝關(guān)節(jié)骨性關(guān)節(jié)炎的治療手段得到了飛速的發(fā)展。經(jīng)過30年的飛速發(fā)展,目前髕骨旁內(nèi)側(cè)入路作為主流的操作入路得到廣泛的應(yīng)用,因為,髕骨旁內(nèi)側(cè)入路能夠展現(xiàn)良好的手術(shù)視野和提供足夠的操作空間。但是髕骨旁內(nèi)側(cè)入路能夠提供良好的手術(shù)暴露視野是因為其破壞了股四頭肌及相關(guān)韌帶同時將髕骨翻開。因此21世紀(jì)初期,人工全膝關(guān)節(jié)的微創(chuàng)術(shù)式等被關(guān)節(jié)外科醫(yī)生提出。根據(jù)大量研究表明,股四頭肌保留入路的人工全膝關(guān)節(jié)置換術(shù)能夠提供能快的術(shù)后康復(fù)、更少的手術(shù)出血,更大的膝關(guān)節(jié)活動度以及更少的圍手術(shù)期疼痛感。然而,仍然有一些研究提出了股四頭肌保留入路的微創(chuàng)人工全膝關(guān)節(jié)置換術(shù)會帶來大量的并發(fā)癥。因此,股四頭肌保留入路的微創(chuàng)全膝關(guān)節(jié)置換術(shù)的選擇與否,得到了越來越多的研究人員的關(guān)注。研究目的:本文通過對股四頭肌保留入路應(yīng)用于人工全膝關(guān)節(jié)置換術(shù)的發(fā)展進行綜述,并通過納入現(xiàn)有的、所有的隨機臨床研究來對股四頭肌保留入路應(yīng)用于全膝置換術(shù)的臨床預(yù)后進行薈萃分析與系統(tǒng)回顧來比較股四頭肌保留入路和傳統(tǒng)髕骨旁入路在術(shù)后短期及長期隨訪的臨床療效差異。以期指導(dǎo)臨床關(guān)節(jié)外科醫(yī)生選擇更加合適的入路來完成人工全膝關(guān)節(jié)置換術(shù)。研究方法:本文通過網(wǎng)絡(luò)對 PubMed,Embase,Cochrane Library,以及 Web of Science 等數(shù)據(jù)庫對從1990年至2016年8月期間所有相關(guān)的研究進行檢索。檢索的關(guān)鍵詞包括:"total knee replacement"、"total knee arthroplasty"、"quadriceps muscle-sparing"。通過閱讀全文,對其文獻(xiàn)進行詳細(xì)的了解后,對其研究結(jié)果進行分析,所有相關(guān)的隨機對照研究被納入至meta分析,利用RevMan5.3軟件進行數(shù)據(jù)分析,連續(xù)型變量通過對于加權(quán)均數(shù)差(WMD)和95%可信區(qū)間(CI)進行報告,二分類變量通過危險度(OR)值和95%可信區(qū)間(CI)報告,異質(zhì)性通過I2檢驗進行。研究結(jié)果:本文總共納入7篇RCT,共520條膝關(guān)節(jié),根據(jù)合并效應(yīng)量后結(jié)果發(fā)現(xiàn)在術(shù)后疼痛VAS評分、直腿抬高情況以及術(shù)后KSS評分等在兩組之間無明顯差異,其余評價指標(biāo)通過合并后均無明顯差異。與此同時,股四頭肌保留入路容易出現(xiàn)更多的極端現(xiàn)象或失敗案例。結(jié)論股四頭肌保留入路因其手術(shù)原理的特征具有以下不足:(1)手術(shù)視野暴露過小,手術(shù)操作過程相對復(fù)雜,難度相對較大,可能使得假體安置的位置不準(zhǔn)確;(2)手術(shù)難度增大帶來的相關(guān)并發(fā)癥,同時也延長了手術(shù)的時間、止血帶的使用時間,并因此增加了手術(shù)時間延長而帶來例如感染、下肢腫脹、下肢深靜脈血栓等并發(fā)癥的風(fēng)險。因此我們認(rèn)為股四頭肌保留入路應(yīng)當(dāng)推薦給高年資的具有豐富全膝關(guān)節(jié)初次置換手術(shù)經(jīng)驗的醫(yī)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.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R687.4
[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.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R687.4
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