人工全膝关节表面置换术后膝前疼痛影响的相关因素研究进展
Research Progress on Related Factors of Anterior Knee Pain Effect after Resurfacing Total Knee Arthroplasty
DOI: 10.12677/ACM.2022.124448, PDF, HTML, XML, 下载: 134  浏览: 202 
作者: 张 科, 蒋电明*:重庆医科大学附属第三医院骨科,重庆
关键词: 关节成形术置换髌骨膝前疼痛Arthroplasty Replacement Knee Patella Anterior Knee Pain
摘要: 人工全膝关节表面置换术(TKA)是目前治疗重度膝关节疾病安全、有效手段之一。但术中在修整髌骨的术式上目前仍有较大的争议,国内外尚未达成统一共识。膝前疼痛是TKA术后最常见的并发症之一,而术后是否伴有膝前疼痛是TKA术后判定临床疗效的非常重要指标之一。本文主要是对膝关节置换术后膝前疼痛的发生率与髌骨修整的关系研究进展进行综述。
Abstract: Total knee arthroplasty (TKA) is one of the secure and valid methods to treat serious gonarthrosis. Present, controversy still exists regarding the trim of patella during the TKA, No consensus has been reached at home or abroad. The most common complication postoperative in TKA is anterior knee pain, which is one of the most important indicators to determine the clinical efficacy after TKA. This article reviewed the research progress of the association between patella trimming during TKA and postoperative anterior knee pain.
文章引用:张科, 蒋电明. 人工全膝关节表面置换术后膝前疼痛影响的相关因素研究进展[J]. 临床医学进展, 2022, 12(4): 3104-3110. https://doi.org/10.12677/ACM.2022.124448

1. 引言

目前治疗重度膝关节骨关节炎、晚期类风湿关节炎等膝关节疾患临床疗效较满意且比较安全的治疗方式之一是人工全膝关节表面置换术(Resurfacing total knee arthroplasty, TKA),它首先是能有效地缓解膝关节疼痛的症状、其次是改善膝关节的活动状况、最后它还能纠正膝关节的畸形,达到提高患者生活质量的目的。但患者的选择、疾病的种类及严重程度、手术适应症的把握、术前准备是否充分、假体设计是否合理、手术技术本身及术后并发症、术后康复训练等因素会对TKA的临床疗效产生较大的影响。同时,TKA术后可能会有术后膝前疼痛、感染、血栓等并发症,其中膝前疼痛(anterior knee pain, AKP)最为常见 [1],往往对整个临床疗效过程产生影响。虽然目前市面上膝关节假体厂家生产的种类繁多、各有特点,但每一种假体也不尽完美。尽管近年来假体设计越来越符合临床的需求,与前些年相比较患者术后膝前疼痛的发生情况有减少的趋势,据Houten A H V [2] 等的研究数据TKA术后膝前疼痛的发生率仍有约4%~49%。临床上在TKA术中,对于修整髌骨的术式分为髌骨表面置换与不置换两类,通过对其术后临床疗效、髌股关节并发症及再手术率等进行对比研究尚无统一结论。目前临床上主要有三种主流观点:髌骨软骨面保留、髌骨表面置换和选择性髌骨置换 [3]。髌骨软骨面保留又包括髌骨软骨面成形术(髌骨关节面成形术)、髌骨周围电灼去神经化、开孔髌骨减压、髌外侧支持带松解等手术方法 [4] [5]。

2. 关于髌骨表面置换和髌骨选择性置换

Petersen Wolf [6] 等研究认为影响术后膝前疼痛的因素很多,包括假体尺寸大小不合适、假体旋转对位误差、髌骨轨迹不良等结构性因素。也包含一些心理精神因素,比如术前抑郁、焦虑状态等 [7]。本文注重阐述结构相关性因素。

鲍亮 [8] 等研究认为髌骨表面置换与否与TKA术后膝前疼痛的发生明确相关,术中行髌骨表面置换术与否被认为是影响患者术后膝前疼痛的重要因素。

Antinolfi [9] 等研究认为髌骨关节面置换术后可出现新的并发症,如假体松动、髌骨骨折、髌股关节不稳、肌腱断裂和软组织撞击等。然而Matz Jacob [10] 等认为髌骨保留或者髌骨置换均可发生涉及髌股关节的并发症,包括膝关节前方痛、髌骨轨迹不良、髌骨骨折、髌骨坏死和髌骨撞击。同时Adravanti [11] 等对1280例TKA中髌骨表面置换的患者中期随访研究得出TKA期间髌骨表面置换相关并发症的发生率非常低。

Benazzo [12] 等研究认为髌骨表面置换术后膝前疼痛发生率和二次手术率较低,Calvisi [13] 等也这样认为。

Pavlou [14] 等对通过对18个随机对照试验,总数为7075例膝的meta分析得出髌骨表面置换组的二次手术率较低,但膝前疼痛发生率没有显著差异。

Toro-Ibarguen A N [15]、Bmz A [16] 研究也认为TKA术中做髌骨表面置换与否和术后膝前疼痛统计学差异不大,髌骨表面置换与非置换组膝关节协会评分(Knee Society score, KSS)评分统计学差异也不大。

Grassi A [17] 等做了一项关于初次全膝关节置换术中髌骨表面置换与髌骨保留的meta分析中指出对于髌骨保留的TKA会有较高的再次手术风险这一说法并不赞同,认为髌骨表面置换与髌骨保留相比并无明显优势。

Chen Kai [18] 等通过对32个随机对照试验研究,总数为6887例的Meta分析得出髌骨表面置换与非置换组的术后膝前疼痛发生率无明显统计学差异,但髌骨表面置换可以减少患者术后再次手术的发生率且能够提高术后KSS评分。Tang Xiao-Bo [19] 也得出相同的结论,髌骨表面置换可以减少患者术后再次手术的发生和提高术后KSS评分。

权衡利弊,同样地在世界范围内不同国家和地区TKA术中是否行髌骨置换的意见也不尽统一,Fraser [20]、Abdel [21] 等指出在美国大多数外科医生(约82%)行髌骨表面置换,在欧洲国家(其中挪威约4%)有选择性地髌骨表面置换,而大多数的亚洲外科医生都不做髌骨表面置换,因为亚洲人身材矮小,髌骨薄,且会增加初次膝关节置换手术的额外费用,髌骨表面置换仅适用于患有类风湿性关节炎或软骨严重受损的患者。支持者认为髌骨表面置换术后可以减少术后膝前疼痛的出现和二次手术率。然而反对者Panni A S [22]、Schindler [23] 认为,髌骨表面置换可能增加髌骨并发症,一旦发生可造成灾难性后果。由此可见,目前TKA术中处理髌骨的术式究竟是髌骨表面置换还是不置换尚有争议。

Antholz [24] 等和Meneghini [25] 等提出需根据患者特异性,如体重指数、软骨软化程度和髌股关节的一致性等因素,可做髌骨选择性置换。Hsu W W [26] 等研究指出当存在炎症性关节炎、关节面硬化和髌股关节轨迹不良时,建议在TKA术中进行髌骨表置面换,而髌骨轨迹良好、髌骨过小、关节面无明显异常时,则不应髌骨表置面换。关于髌骨表面置换的适应症:当出现重度髌股关节炎、髌骨运动轨迹不佳等情况时需要考虑置换,同时也要根据髌骨软骨磨损程度、髌骨厚度、髌骨是否畸形及髌骨缺损等情况来决定。

3. 关于髌骨保留

1) 髌骨软骨面成形术(髌骨关节面成形术)

髌骨软骨面成形术(髌骨关节面成形术,简称髌骨成形术)就是根据做髌骨关节面置换时使用的假体以及股骨假体滑车结构对髌骨关节面进行塑形,增加股骨假体滑车与重塑髌骨关节面的匹配度,在股骨假体滑车轨迹内让髌骨活动不受限制。Cerciello [27] 等研究认为虽然TKA术中行髌骨表面置换比行髌骨成形术的术后膝前疼痛发生率低,但是髌骨成形术的髌骨并发症却发生率却相对较低。

Sun [28] 等对152例诊断为膝关节骨性关节炎并接受TKA术的患者进行了回顾性研究,比较髌骨软骨面成形术和传统髌骨处理(即仅仅处理髌骨关节面周围的骨赘)这两种方式的临床效果,得出的结论是髌骨成形术比传统髌骨处理的KSS评分及患者满意度均要高,故髌骨成形术更能好的缓解膝前疼痛、增加病人的满意度。Upan A [29] 等研究也得出类似的结论。

2) 髌骨周围电灼去神经化

通过阻断膝关节周围疼痛的传导通路来达到减轻疼痛,因为髌周组织的外周神经与疼痛密切相关,可以对环髌骨一周的组织电灼去神经化,是另外一种操作简单的术式。

Satit T [30] 等和Yuan [31] 等研究认为TKA术中应用髌骨周围电灼去神经化的方法是值得推荐的,因为其近期的临床效果较好且安全。Xie [32] 等研究却表明髌骨周围去化可以有效的减轻短期内膝前疼痛,但长期效果欠佳。

而Arirachakaran [33] 等研究认为髌骨周围电灼去神经化可能对改善术后膝关节功能有利,但与髌骨表面置换相比,对减轻膝前疼痛的帮助却不大。

Goicoechea N [34] 研究认为在髌骨表面置换的TKA中髌骨周围电灼去神经化与无去神经化的髌骨表面置换术相比,并不能改善初次TKA患者的AKP和临床预后,故TKA行髌骨置换术时不建议髌骨周围电灼去神经化。刘宁宁 [35] 等和陈阳 [36] 等研究表明,在髌骨保留型的TKA中髌骨周围电灼去神经化对减少膝前疼痛的效果微弱,对病人的预后改善并不明显。

3) 髌外侧支持带松解

Blackman A J [37] 提出观点认为髌骨轨迹不佳可增加髌股关节面接触应力,从而引起膝前疼痛,可通过髌外侧支持带松解让髌骨有良好的运动轨迹,最终达到缓解疼痛的目的。朱永良 [38] 等关于132例单侧膝关节骨关节炎患者的一项前瞻性随机对照研究:非髌骨表面置换的TKA术中是否应该松解髌外侧支持带,结论是非髌骨表面置换的TKA术中行髌外侧支持带松解可降低术后膝前痛发生,且不增加术后相关并发症。

4) 钻孔髌骨减压

Arnoldi [39] 等认为膝关节骨关节炎的患者存在髌股关节内高压现象,赵平 [40] 等研究得出非髌骨表面置换TKA术中行钻孔髌骨减压可显著降低了膝关节前疼痛的发生率,且不增加术后髌骨相关并发症,可以考虑在非髌骨表面置换的TKA术中进行髌骨减压。程鹏 [41] 等研究认为髌骨减压联合髌骨成形术,可提高术后短期疗效且减少术后膝前疼痛的出现。

5) “鸡尾酒”式镇痛

TKA术中关节内“鸡尾酒”式镇痛混合药物注射可以减少术后膝前疼痛的出现,同时减少术后麻醉镇痛剂使用量,且不良反应少 [42]。

6) 加速康复外科理念

加速康复外科(Enhanced Recovery After Surgery, ERAS)理念下对TKA患者实施多模式镇痛,包含术前疼痛评估及相关知识宣教、术前口服非甾体类抗炎药、术中联合神经阻滞麻醉、术后使用镇痛泵,可有效减轻术后膝前疼痛,达到快速康复的目的 [43]。

4. 综上所述,各种治疗方式优势、劣势总结如下

髌骨表面置换术后膝前疼痛发生率和二次手术率较低是其优势,但是可能会出现新的并发症,另外会增加额外的住院费用,增加患者的负担。

髌骨软骨面成形术和髌骨周围电灼去神经化、钻孔髌骨减压具有同样的优点,它们操作简单、安全、时间较短、不会增加手术费用、能够减少近期或中期膝前疼痛的发生,当不做髌骨表面置换的时候,可视情况单独或者联合应用,但是髌骨软骨面成形术发生膝前疼痛发生率和二次手术率可能比髌骨表面置换高,另外髌骨周围电灼去神经化远期疗效需进一步研究,还有钻孔髌骨减压有可能会增加髌骨骨折的风险。

髌外侧支持带松解也具有便捷性、投入成本不高,但是如果不把握好度,可能会影响膝关节的稳定性。

关节内“鸡尾酒式镇痛”混合药物注射,能够减少术中麻药的用量和延长镇痛时间,但是需注意合理地配伍以免带来不良反应。

总之,每一种治疗方式有优缺点,临床上需根据实际情况作合理的选择,才能使患者取得不错的疗效,提高患者满意度。

最后,随着人工智能的发展,未来可借助机器人辅助和配套工具进行标准化的手术治疗,可以获取更高的精确度,减轻病人痛苦,获得更好的临床效果,目前是一大热点,有着不错的前景。

NOTES

*通讯作者。

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