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全膝關(guān)節(jié)置換術(shù)中軟組織平衡技術(shù)進(jìn)展

2016-10-19 15:01:17何玄蔡宏張克
關(guān)鍵詞:力線過(guò)度韌帶

何玄 蔡宏 張克

[摘要] 隨著全膝關(guān)節(jié)置換術(shù)技術(shù)的不斷進(jìn)步,軟組織平衡的問(wèn)題開(kāi)始被關(guān)注,對(duì)關(guān)節(jié)周?chē)M織的結(jié)構(gòu)特點(diǎn)和力學(xué)特性的認(rèn)識(shí)不斷加深,軟組織平衡的評(píng)價(jià)測(cè)量方法和松解技術(shù)也不斷發(fā)展,臨床上軟組織平衡技術(shù)用于治療截骨后仍然無(wú)法完全糾正內(nèi)翻或外翻畸形的膝關(guān)節(jié),軟組織平衡技術(shù)包括滑移截骨技術(shù)、Insall松解技術(shù)、從關(guān)節(jié)鏡手術(shù)中引進(jìn)的Pie Crusting松解技術(shù),相關(guān)的研究及隨訪表明這些方法能夠有效地糾正不平衡的軟組織,但每種技術(shù)都存在缺陷。本文分別對(duì)軟組織平衡的基礎(chǔ)研究和手術(shù)技術(shù)進(jìn)行總結(jié),并介紹軟組織平衡技術(shù)的近期發(fā)展。

[關(guān)鍵詞] 全膝關(guān)節(jié)置換術(shù);軟組織平衡;松解技術(shù);Pie Crusting松解技術(shù)

[中圖分類號(hào)] R687.42 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1673-7210(2016)03(c)-0080-04

[Abstract] With the development of total knee arthroplasty, the issue of soft tissue banlance is getting more and more attention. People have a further congnition of anotomic structure and mechanical properties while the evaluation method and release technque is updated. This technique treat cases with varus and vaglus deformity which cannot be corrected by osteotomy. Releasing technique includes sliding osteotomy and Insall releasing techinque, and Pie Crusting technique which is imported from arthroscopic surgery. These techniques show a reasonable outcome for the cases with severe deformity after relative studies. However, there are some defects of each technique. This article will review basic study and releasing technique of soft tissue banlance, and introduce the updated information.

[Key words] Tolal knee artroplasty; Soft tissue balance; Release technique; Pie Crusting technique

隨著社會(huì)的發(fā)展以及醫(yī)療技術(shù)進(jìn)步,膝關(guān)節(jié)置換術(shù)(TKA)已經(jīng)成為終末期膝關(guān)節(jié)疾病治療的常規(guī)手段[1],大部分患者在經(jīng)過(guò)手術(shù)后疼痛癥狀得到緩解,生活質(zhì)量得到改善,腿部畸形也得到糾正。經(jīng)過(guò)多年的基礎(chǔ)研究及臨床實(shí)踐,TKA手術(shù)技術(shù)不斷完善,在基本解決了截骨準(zhǔn)確性等問(wèn)題以后,臨床醫(yī)生發(fā)現(xiàn)圍繞膝關(guān)節(jié)的內(nèi)外翻畸形,并非都能通過(guò)正確的截骨得以矯正[2-3],原因可能是關(guān)節(jié)周?chē)浗M織結(jié)構(gòu)在疾病發(fā)展過(guò)程中力學(xué)特性發(fā)生了改變,破環(huán)了正常力學(xué)平衡,繼而出現(xiàn)嚴(yán)重的骨性畸形;再有股骨或脛骨的先天異?;蚣韧耐鈧材軐?dǎo)致正常解剖結(jié)構(gòu)的破壞;另外有一些病例是因?yàn)殄e(cuò)誤的截骨導(dǎo)致了關(guān)節(jié)間隙的不平衡。如何通過(guò)手術(shù)技術(shù)重新獲得軟組織平衡成為T(mén)KA手術(shù)成功與否的關(guān)鍵。因此,在TKA的發(fā)展過(guò)程中,出現(xiàn)了多種軟組織平衡的技術(shù)與評(píng)估方法,本文就以上內(nèi)容進(jìn)行綜述。

1 軟組織平衡研究的進(jìn)展

1.1 關(guān)節(jié)間隙的測(cè)量

關(guān)節(jié)間隙的準(zhǔn)確測(cè)量是進(jìn)行力學(xué)研究和制訂松解標(biāo)準(zhǔn)的基礎(chǔ),最基礎(chǔ)的方法是通過(guò)側(cè)方應(yīng)力試驗(yàn)進(jìn)行評(píng)估,這種方法可以大致感受兩側(cè)關(guān)節(jié)間隙是否平衡,缺點(diǎn)是無(wú)法具體測(cè)量關(guān)節(jié)間隙并得到相應(yīng)數(shù)據(jù)。撐開(kāi)器的使用彌補(bǔ)了應(yīng)力試驗(yàn)的不足,可以在術(shù)中測(cè)量關(guān)節(jié)間隙寬度以及軟組織張力。Mullaji等[4]和Fishkin等[5]在研究中使用撐開(kāi)器獲得數(shù)據(jù),對(duì)比了正常膝關(guān)節(jié)和骨關(guān)節(jié)炎關(guān)節(jié)軟組織的力學(xué)特性,用數(shù)據(jù)證實(shí)了骨關(guān)節(jié)炎會(huì)導(dǎo)致韌帶組織攣縮的理論。導(dǎo)航技術(shù)通過(guò)紅外線發(fā)射器和感受器在松解過(guò)程中可以即時(shí)反應(yīng)力的線變化,這種技術(shù)將下肢力線和關(guān)節(jié)間隙等概念從抽象的數(shù)字和幾何線條轉(zhuǎn)變?yōu)閷?shí)在的圖像,提高了軟組織平衡的精確度和可控性[6],應(yīng)用導(dǎo)航技術(shù)指導(dǎo)截骨及軟組織平衡將是TKA手術(shù)的發(fā)展趨勢(shì)。

1.2 關(guān)節(jié)周?chē)浗M織對(duì)關(guān)節(jié)間隙的影響

明確軟組織對(duì)關(guān)節(jié)間隙變化的影響是制訂平衡標(biāo)準(zhǔn)的前提,膝關(guān)節(jié)的平衡是周?chē)M織共同作用的結(jié)果,每種組織對(duì)關(guān)節(jié)平衡的影響并不相同,為排除不同組織間相互影響對(duì)研究結(jié)果造成的干擾,研究者在試驗(yàn)中對(duì)僅單一組織進(jìn)行松解,之后測(cè)量關(guān)節(jié)間隙變化,以明確被松解組織在關(guān)節(jié)平衡中的作用。研究發(fā)現(xiàn)對(duì)外側(cè)間隙影響較大的組織是外側(cè)副韌帶及髂脛束[7-8];膝關(guān)節(jié)內(nèi)側(cè)組織更加復(fù)雜,Luring等[9]對(duì)組織松解不同長(zhǎng)度后對(duì)關(guān)節(jié)間隙的影響進(jìn)行了研究,結(jié)果表明松解后交叉韌帶、半膜肌肌腱、內(nèi)側(cè)副韌帶淺層對(duì)軟組織平衡影響最顯著。

1.3 軟組織平衡的標(biāo)準(zhǔn)

制訂正確合理的醫(yī)療標(biāo)準(zhǔn)指導(dǎo)臨床治療是研究軟組織平衡技術(shù)的目的,影像學(xué)檢查及測(cè)量器械的讀數(shù)為醫(yī)生們?cè)谛g(shù)前及術(shù)中判斷是否需要進(jìn)行松解并且選擇合適的松解方式提供了重要信息,Sim等[10]進(jìn)行了分組研究,指出膝關(guān)節(jié)X線反映的力線及關(guān)節(jié)間隙的狀態(tài)可以為術(shù)中松解層次的選擇提供參考,不足的是,作為一項(xiàng)回顧性研究,僅對(duì)比了松解后影像學(xué)參數(shù)的變化,并未進(jìn)行不同層次松解后的分組比較,也沒(méi)有提出軟組織松解的標(biāo)準(zhǔn)。Hakki等[11]分別測(cè)量了膝關(guān)節(jié)屈曲和伸直狀態(tài)下逐步松解后關(guān)節(jié)間隙的寬度,提出了內(nèi)外側(cè)關(guān)節(jié)間隙寬度之差≥5 mm是進(jìn)行組織平衡的標(biāo)準(zhǔn)觀點(diǎn),這項(xiàng)研究量化了本來(lái)比較模糊臨床標(biāo)準(zhǔn),使軟組織平衡技術(shù)有更好的控制性和安全性。當(dāng)然,這些研究所提供的標(biāo)準(zhǔn)還需要更多的研究來(lái)完善和證實(shí),以期能夠總結(jié)出指南性的標(biāo)準(zhǔn)。

2 軟組織平衡技術(shù)在臨床上的應(yīng)用

2.1 滑移截骨

滑移截骨是通過(guò)截骨改變組織止點(diǎn)的位置,相對(duì)延長(zhǎng)組織的長(zhǎng)度,糾正不平衡關(guān)節(jié)間隙的技術(shù)。由于組織附著點(diǎn)可以剝離的范圍有限,可以將軟組織附著的骨塊截下并固定于遠(yuǎn)端,縮短組織在股骨及脛骨附著點(diǎn)之間的距離。一般使用鋒線或加壓螺釘固定骨塊。Mihalko等[12]的研究指出截骨對(duì)軟組織平衡的影響較傳統(tǒng)松解技術(shù)更明顯,被截下的骨塊重新固定后不會(huì)影響松解的效果。

滑移截骨也存在缺點(diǎn),此技術(shù)容易造成過(guò)度松解,進(jìn)而導(dǎo)致關(guān)節(jié)不穩(wěn)定;重新固定后的骨塊有時(shí)不能愈合,Klammer等[13]隨訪中發(fā)現(xiàn)46%的病例出現(xiàn)了愈合不良(纖維愈合或者不愈合);為避免損傷膝關(guān)節(jié)周?chē)=M織結(jié)構(gòu),截骨時(shí)需要延長(zhǎng)切口以得到更大操作空間;截骨時(shí)還可能導(dǎo)致腓總神經(jīng)損傷并出現(xiàn)相應(yīng)的癥狀和體征[12]。因此,這項(xiàng)技術(shù)僅用于嚴(yán)重內(nèi)外翻畸形的病例。

2.2 Insall松解技術(shù)

Insall松解技術(shù)是通過(guò)剝離韌帶或肌腱附著點(diǎn),延長(zhǎng)軟組織長(zhǎng)度,糾正不平衡關(guān)節(jié)間隙的技術(shù)。經(jīng)過(guò)對(duì)尸體的研究,發(fā)現(xiàn)剝離韌帶附著點(diǎn)可以有效地糾正不平衡的力線[14-22]。術(shù)者將關(guān)節(jié)間隙緊張一側(cè)的韌帶剝離,大約每松解1 mm的組織,就可以大約糾正1°的力線[4]。手術(shù)中具體松解的順序目前尚未達(dá)成共識(shí),不過(guò)目的和原則是一致的。這種松解技術(shù)短期內(nèi)對(duì)力線糾正的研究結(jié)果和中長(zhǎng)期隨訪結(jié)果都肯定了其有效性,即使是較嚴(yán)重內(nèi)外翻畸形,經(jīng)過(guò)正確處理后也可糾正[15-16]。Insall松解是TKA手術(shù)中重要的技術(shù)。

盡管傳統(tǒng)松解技術(shù)在TKA術(shù)中得到廣泛應(yīng)用,但還是會(huì)導(dǎo)致過(guò)度松解,不同個(gè)體軟組織力學(xué)特性有差異,控制松解范圍有一定困難,術(shù)中要謹(jǐn)慎松解,以免出現(xiàn)松解過(guò)度導(dǎo)致關(guān)節(jié)不穩(wěn)定[23]。過(guò)度松解實(shí)質(zhì)是一種損傷,韌帶損傷后關(guān)節(jié)間隙寬度在受力后會(huì)發(fā)生改變,嚴(yán)重的過(guò)度松解需要重建韌帶結(jié)構(gòu)[24]。不過(guò)也并不是每一位醫(yī)生都在擔(dān)心過(guò)度松解造成的關(guān)節(jié)不穩(wěn)定,Heesterbeek等[25]認(rèn)為過(guò)度松解造成的關(guān)節(jié)間隙寬度變化不如韌帶損傷明顯,不會(huì)導(dǎo)致術(shù)后關(guān)節(jié)不穩(wěn)定,這也可能是因?yàn)檠芯繉?duì)象是患者,術(shù)者不能夠故意進(jìn)行過(guò)度松解,因此松解程度受限所致。

2.3 Pie Crusting技術(shù)

Pie Crusting技術(shù)是指在組織上戳數(shù)個(gè)小切口,延長(zhǎng)組織長(zhǎng)度,糾正不平衡軟組織的技術(shù),中文譯名為剪紙拉花松解。這種松解技術(shù)來(lái)源于關(guān)節(jié)鏡手術(shù),由于鏡下操作空間小,經(jīng)典松解方法會(huì)造成一些并發(fā)癥[26],Agneskirchner等[27]嘗試了這種損傷較小的松解技術(shù),F(xiàn)akioglu等[28]應(yīng)用Pie Crusting技術(shù)松解內(nèi)側(cè)副韌帶淺層,隨訪結(jié)果肯定了該技術(shù)的效果,但是經(jīng)皮的松解技術(shù)容易損傷關(guān)節(jié)周?chē)窠?jīng)血管,而且內(nèi)側(cè)副韌帶淺層相對(duì)深層對(duì)關(guān)節(jié)間隙寬度改變更明顯,容易導(dǎo)致過(guò)度松解。Atoun等[29]由內(nèi)向外應(yīng)用Pie Crusting技術(shù)松解內(nèi)側(cè)副韌帶深層,減少股骨髁及韌帶損傷,降低過(guò)度松解的發(fā)生率。關(guān)節(jié)鏡手術(shù)僅對(duì)早期骨關(guān)節(jié)炎患者有一定療效,對(duì)于晚期骨關(guān)節(jié)炎或類風(fēng)濕關(guān)節(jié)炎的患者而言,微創(chuàng)手術(shù)效果并不理想,TKA仍然作為首選治療方案。

Pie Crusting技術(shù)在關(guān)節(jié)鏡手術(shù)中逐漸成熟后,這種技術(shù)也開(kāi)始在TKA術(shù)中應(yīng)用,一方面,TKA手術(shù)組織暴露更加充分,操作的空間更大,可以應(yīng)用的技術(shù)更多樣;另一方面,Pie Crusting松解比傳統(tǒng)組織松解技術(shù)更加細(xì)致,控制性更強(qiáng)。Pie Crusting技術(shù)最早用于松解髂脛束[30-32],內(nèi)側(cè)組織結(jié)構(gòu)復(fù)雜,對(duì)關(guān)節(jié)穩(wěn)定影響更大,松解風(fēng)險(xiǎn)更高,Bellemans[33]選擇松解對(duì)關(guān)節(jié)間隙影響較小的內(nèi)側(cè)副韌帶深層,而非淺層或者半膜肌腱,并提出使用針頭作為松解工具。經(jīng)過(guò)研究,Pie Crusting技術(shù)松解內(nèi)側(cè)組織的效果得到了認(rèn)可[34-35],Verdonk等[36]對(duì)比了傳統(tǒng)方法及Pie Crusting技術(shù)松解內(nèi)側(cè)副韌帶的效果,兩組患者術(shù)后各項(xiàng)指標(biāo)沒(méi)有差異。為了研究Pie Crusting技術(shù)的安全性,Meneghini等[37]在力學(xué)實(shí)驗(yàn)中發(fā)現(xiàn),相比傳統(tǒng)松解表現(xiàn)的一次性組織張力大幅度下降,Pie Crusting技術(shù)表現(xiàn)為多梯次張力下降,組織張力下降后會(huì)出現(xiàn)反彈,這種結(jié)果肯定了Pie Crusting技術(shù)的安全性。

3 總結(jié)

關(guān)節(jié)置換手術(shù)是一種精確度到毫米級(jí)的手術(shù),術(shù)中準(zhǔn)確的截骨以及合理進(jìn)行軟組織平衡是手術(shù)成敗的關(guān)鍵。經(jīng)過(guò)研究和實(shí)踐,軟組織平衡技術(shù)逐漸發(fā)展成熟。就松解技術(shù)而言,通過(guò)剝離組織附著點(diǎn)的Insall松解技術(shù)在臨床中應(yīng)用最廣泛,相關(guān)的隨訪及并發(fā)癥報(bào)道也最全面,但是這種技術(shù)可能不能完全糾正嚴(yán)重的畸形,對(duì)畸形程度較輕的關(guān)節(jié)也有過(guò)度松解的風(fēng)險(xiǎn)?;平毓羌夹g(shù)糾正畸形力線的效果最明顯,但這種技術(shù)帶來(lái)的并發(fā)癥比較多,手術(shù)中并不常規(guī)使用。Pie Crusting松解技術(shù)與前兩者有所不同,這種技術(shù)不是通過(guò)改變組織的附著范圍或位置來(lái)延長(zhǎng)韌帶或肌腱組織的長(zhǎng)度,而是通過(guò)損傷韌帶或肌腱組織本身來(lái)延長(zhǎng)組織的長(zhǎng)度,關(guān)節(jié)間隙與組織自身的張力同時(shí)受到了影響,相比前兩種松解技術(shù)在評(píng)估效果和安全性時(shí)多了一個(gè)變化因素,因此很多醫(yī)生對(duì)這種技術(shù)持比較謹(jǐn)慎的態(tài)度,尤其是在松解膝關(guān)節(jié)內(nèi)側(cè)組織時(shí),還是更多應(yīng)用傳統(tǒng)松解方法,Pie Crusting松解只是在關(guān)節(jié)間隙經(jīng)過(guò)傳統(tǒng)松解后仍存在不平衡的情況下進(jìn)行輔助松解。Pie Crusting松解在國(guó)內(nèi)是一種較新的軟組織平衡技術(shù),近年來(lái)才逐漸在臨床中應(yīng)用,這項(xiàng)技術(shù)的中遠(yuǎn)期臨床效果、具體術(shù)中的操作技巧以及相關(guān)并發(fā)癥還需要后續(xù)的臨床實(shí)踐來(lái)探索。

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(收稿日期:2015-12-05 本文編輯:蘇 暢)

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