Minimally invasive total knee arthroplasty Research
Key words minimally invasive
Minimally invasive (minimally invasive surgery, MIS) total knee replacement began in the 20th century, late 90's, Repicci and Romanowski in unicompartmental knee
replacement (unicondyhr knee arthroplasty, UKA) used the MIS approach, with less bleeding, postoperative pain and light activity from the bed early, after a short recovery time, etc., thus arousing the people some of minimally invasive knee
replacement surgery and of great interest to 〔1,2〕. Their work for the minimally
invasive total knee replacement surgery basis. This paper summarized the literature in recent years, minimally invasive TKA following review.
The definition of a minimally invasive TKA
Currently on the minimally invasive total knee replacement surgery's report was more, but there is no clear definition of the uniform. Minimally invasive TKA should meet the following conditions: (1) skin incision length <14 cm 〔3〕, but it must be
-term effects can not be blind pursuit of a
small incision. (2) try to avoid damage and disrupt the extensor device 〔4〕
(quadriceps sparing, QS). (3) try to avoid flipping the patella. (4) The operation to
avoid knee dislocation, that is in-situ for the femur and tibia osteotomy 〔5〕.
Two minimally invasive TKA indications and contraindications 〔6〕
Size and severity of deformity in patients with surgical operation and postoperative results have a significant impact, so the choice of patients with the following principles should be followed. Minimally invasive TKA far mainly applied to body weight less than 100 kg, knee activity of at least 105 ?, discreet digital X ray film before and after
the knee-degree varus deformity of less than 10 ?, valgus deformity of less than 15 ?, flexion contracture deformity of less than 10 ? in patients with osteoarthritis of the knee. Elderly patients ( "80 years old), can not tolerate a long period of operation; knee
joint in patients with soft tissue contracture, surgery revealed the difficulties, are not
3 minimally invasive TKA surgical technique highlights 〔5〕
3.1 reduced the length of the incision
Standard TKA incision length of 20 ~ 25 cm, while the minimally invasive TKA for 6 ~ 14 cm, this surgical operation the surgeon must have a learning curve, with the surgical experience increases, the length will be shortened gradually.
3.2 through knee flexion and extension revealed surgical field
In a limited incision, the need to pay attention knee flexion and extension in order to achieve satisfactory exposure of the knee. The back of the knee joint flexion exposed structures such as: After the joint capsule, posterior cruciate ligament; stretching in
front of the knee joints exposed structures such as anterior cruciate ligament, meniscus anterior horn and so on. Rather than by extending the incision exposed the entire joint.
3.3 Use of a retractor
This technology is the basic method of minimally invasive surgery that is, "moving window" technology. Retractor incision in the exposed side of the other side when you release. For example, the minimally invasive TKA surgeon loosened retractor exposing the inside of the lateral joint space, allowing a better exposure to surgical area, not that bad cause soft tissue injury, and vice versa.
Dalury and Jiranek 〔7〕 applications into the road or under the medial quadriceps patellar next to the entry road trip 24 cases of bilateral total knee replacement. The results show that micro-surgery approach under quadriceps pain, early functional
recovery more effective than the contralateral medial patellar into the path beside the effect is good.
3.5 patellar the upper and lower releasable joint capsule
be better and make it to the lateral patellar retractor for exposure to the joints, exposed operative field is essential.
3.6 do not flip the patella
Mahoney 〔8〕 such as turning on the patella after TKA quadriceps function was
evaluated, the patient sat in 16-inch-high chair without arm support for a gradual
elevation of knee joint, unilateral line of the traditional total knee arthroplasty in patients with After 3 months only 40% of patients without arm support can independently stand up, after 6 months, accounting fo
TKA do not flip the patella, 90% of the patients 3 weeks and a half can stand up, probably because of quadriceps after rapid recovery.
3.7 No joint dislocation
emur, thus avoiding the
tibiofemoral joint dislocation.
3.8 reduce the size of ancillary equipment
Large size of traditional instruments, must be widely exposed to soft tissue and flip
f its special equipment, about
half of the traditional instruments.
3.9 out osteotomy graded film
tibial plateau osteotomy gradually from the inside out. Surgeons cut out to be used to
gradually remove the bone, rather than the traditional large incision total knee arthroplasty bone block removed.
3.10 leg hanging Technology
Legs hanging beside the operating table, relying on gravity rather than an open joint
space layer by layer using a retractor to open joints.
4 minimally invasive TKA comparison of different surgical approaches
4.1 Minimally invasive TKA quadriceps approach under the
In 1991, Hofmann was first proposed under the quadriceps surgical approach. 2006,
Sporer 〔9〕 reported the application of quadriceps minimally invasive surgical approach under the TKA. Patient was supine, surgery side hip booster, stressing knee flexion 90 ?, OK limb exsanguination, tourniquet inflated, so that devices can prevent
extensor tendon tension. To the upper edge of patella to the medial tibial tuberosity 1 cm to make a flange to the inside of curved incision, the length of the knee extension position for 8 ~ 10 cm, flexion of 12 ~ 14 cm. Incision along the incision of the skin and
deep fascia, the fascia from the superficial to the medial shares blunt separation, until the vastus medialis muscle attachment points. First confirmed that the lower edge of vastus medialis muscle, along the edge of the shares of stock inside the medial
intramuscular abdominal retractor muscle, in the remote unit inside the muscle fiber direction of the joint capsule Traveling cut 1 ~ 2 cm, and then the patella in lateral support to bring stocks within the muscle attachment point and the patellar margin
expanded to the medial tibial tubercle only point 1 cm. Surgery should be retained adjacent to the patella and soft tissue sleeve is about 1 cm, to facilitate postoperative suture joint capsule.
The advantages of this approach to preserve the integrity of extensor device will enable patients to quickly restore quadriceps strength, reduce the complications of the patellofemoral joint and accelerate postoperative functional recovery of the quadriceps and protect patellar blood supply, reduce postoperative pain, increased postoperative patient satisfaction. The disadvantage is an important nerves and blood vessels surrounding many of the incision to extend certain limitations. Revealed limitations, especially for obesity and previous knee surgery done in patients revealed more problems.
4.2 Intermediate approach minimally invasive TKA quadriceps
In 1998, Engh and Parks, introduced into the middle of the quadriceps Road, 2004, Laskin 〔10〕 To report the minimally invasive approach among the quadriceps TKA.
Patient was supine, knee flexion 90 ?, limb exsanguination, tourniquet inflated to the upper edge of patella to the joint space under 2 cm by 2 cm within the margin of the patella 1 / 3 to make a knee straight in front of the middle of the skin incision, skin incision length of the pole from the patella up and down the length of the decision, generally 9 ~ 13 cm. Cut deep fascia, and the next appropriate separation along the inner edge of 1 cm incision patellar articular capsule, up to the patella on the medial margin of 3 cm will be shares of muscle along the muscle fibers in Traveling split 2 cm, down to the tibial tubercle in side. And knee flexion 45 ?, excision of infrapatellar fat pad, the patella to the lateral pull gently, without the need to flip the patella.
The advantages of this approach for the protection of the patella major arteries and quadriceps tendon joints, reduce pain, protect the blood supply of the patella. According to Cooper, who described a 4.5 cm vastus medialis muscle from the patella of the seat belt may be sharp edges of split, if necessary, could be further sharp segregation. If the size is not suitable or preoperative range of motion is limited not make knee under the quadriceps quadriceps surgical approach may be chosen among surgical approach, but the choice ultimately depends on the surgery approach those habits. The disadvantages of this approach relative to the medial patellar into the path beside the operative field revealing the difficulties. Obesity, knees, less than 90 ?, quadriceps strong, patient should not use this approach. Reposted elsewhere in the paper for free download http://
4.3 beside the medial patellar minimally invasive surgical approach TKA
In 1971, Install, who improved by the introduction of the classical Langenbeck surgical approach, Scuderi 〔2004〕 11 reported the application of medial patellar
next to the minimally invasive surgical approach TKA. Patient was supine, limb exsanguination, tourniquet inflated to patella 2 ~ 4 cm for the point of origin to the medial tibial tubercle to the middle of the knee straight in front of the skin incision. Cut deep fascia, and the next appropriate separation of exposed extensor device began in
the patellar articular capsule cut above the 2 ~ 4 cm, quadriceps tendon medial 1 / 3, along the inner edge of the patella to the medial tibial tubercle, minimally invasive TKA can be applied next to the medial patella surgical approach for the knee straight
in front of the middle of the skin incision length of about 10 ~ 14 cm, the joint capsule incision along the upper edge of the patella to the quadriceps tendon near the incision 2
~ 4 cm, patella does not flip, but only to the lateral retractor.
The advantages of this approach into the way a simple incision distant from the major blood vessels, better exposure of the three joints between the rooms, if you need to extend the incision into the way you can use the conventional anatomy. The disadvantages of this approach to a certain extent, damage the extensor device, postoperative pain obviously, recovered slowly.
5 results of operations
For the minimally invasive TKA there are many disputes, advocates stress that these surgical methods are the advantages of reducing soft tissue injury can reduce postoperative bleeding, relieve pain and accelerate postoperative recovery, shorter hospital stay and the incision scar; that the minimally invasive TKA is other disciplines logical extension of minimally invasive therapies. Opponents believe that conventional TKA good long-term efficacy and fewer complications. The minimally invasive TKA surgery due to exposure to bad body position may lead to false negative, neurovascular injury, poor implant fixation, increased risk of postoperative infection and other issues.
There are data to support minimally invasive TKA can reduce bleeding and accelerate postoperative recovery. Tria 〔12〕 other studies reported 58 cases of
minimally invasive total knee replacement, early results showed that the minimally invasive TKA, compared with the traditional TKA surgery blood loss less, minimally invasive TKA average blood loss 200 ml, the traditional TKA blood loss 350 ~ 400 ml ; less postoperative pain, minimally invasive TKA pain score was 5.2 points, the traditional TKA score of 7.5 points; early access to good movement, length of stay is short, minimally invasive TKA hospital stay was 2.5 d, the traditional TKA length of stay is 4 d .
Another study compared 32 cases of minimally invasive quadriceps under the traditional approach and 26 cases of medial patellar side into the road, results showed that the minimally invasive TKA 〔9〕 can reduce the amount of anesthetic to reduce
the amount of bleeding, early functional recovery. MIS group and the conventional group were morphine sulfate dosage of 55,118 mg (P = 0.01), postoperative drainage MIS group and the conventional group were 573,713 ml (P = 0.04), after 6 weeks, the average knee flexion angle MIS group and the conventional group were 115 ?, 100 ? (P = 0.02). Boerger 〔13〕 reports also proved that minimally invasive approach with the shares of muscle under the medial patellar approach compared to loss of blood next to a small amount of early postoperative functional recovery.
Laskin RS 〔14〕 etc. have been a retrospective cohort study analyzed 58 patients
with an initial period of time TKA patients, of which 32 were treated with minimally invasive quadriceps into the middle of the road inside of 26 cases using traditional side into the patella Road, comparison of 2 postoperative knee score and functional effects.
The results show that minimally invasive TKA postoperative knee function score higher than traditional TKA, pain scores and pain medication than traditional TKA.
However, there are a number of studies reported no significant benefits of minimally
invasive TKA. Tenholder 〔15〕, etc. carried out a study to analyze a period of time 118 cases of the initial TKA patients, 69 were treated with medial patellar incision in the side into the path of less than 14 cm, 49 were treated with medial patellar incision in
the side into the path is greater than or equal to 14 cm, results showed that both length
of stay, activity capacity, tourniquet time and postoperative use of imaging criteria, complications, and there is no difference. Only a small incision in patients with a smaller choice of prosthesis, femoral condyle narrow, need less blood transfusion, postoperative flexion function better. This shows that small-incision group, only
suitable for low body mass index, posture than the thin, pre-knee surgery a better
Dalury other 〔16〕 of 30 cases of minimally invasive TKA and 30 patients a comparative study of conventional TKA, imaging studies found that 4 cases of minimally invasive TKA in patients with tibial prosthesis on the line of bad, while the conventional TKA was no body on the line of a bad vacation, Dalury that the Despite the minimally invasive TKA with the pain and light, the advantages of early postoperative events, but the minimally invasive approach affect the surgeon vision,
increasing the risk of surgery, thereby affecting the long-term effects of surgery.
6 computer-aided technology in the application of minimally invasive TKA
At present the development of minimally invasive TKA followed two directions, one
small incision minimally invasive technique, and the other is a computer-aided
technology, 〔17〕. In July 2002, in the computer-assisted navigation technology by 9
KA, the results are satisfactory
〔18〕. Computer navigation technology to guarantee the implanted prosthesis and the rotation of the line accuracy is very important. Kim and Wixson 〔19〕 other pairs of
69 cases of computer-guided technology, TKA, and 78 cases of a comparative study of
conventional TKA and found that conventional TKA 58% of the prosthesis within 2 ? in the neutral position, while the computer-guided technology for minimally invasive
TKA 78% prosthesis to achieve these criteria (P = 0.008). Seon and Song 〔20〕 other
pairs of 47 cases of computer navigation technology in TKA, and 50 cases of conventional TKA to 1 year follow-up study showed that computer navigation TKA
and conventional TKA flexion angle were 131.9 ?, 125.4 ? (P = 0.001), HSS scores were
92.5 points, 89.4 minutes (P = 0.036), pain score 6.8 points, 8.6 points (P = 0.001). At present, computer-guided technology is at the stage of development, yet I do not know the long-term survival of prosthetic implants and joint function recovery.
Gradually increased in recent years, minimally invasive TKA, this article on the definition of minimally invasive TKA, indications and contraindications, surgical techniques, surgical approaches, treatment, computer-aided technology an objective
postoperative pain, shorter hospital stay, improved functional recovery. However, current conventional TKA techniques, 90% ~ 95% off fitness for 15 years or longer, while the efficacy of minimally invasive TKA patients, and no long-term follow-up.
Thus, a variety of minimally invasive TKA long-term effects need further study.
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