微創型與客製化導引植入全人工膝關節之三維活體功能運動學比較研究

Abstract

全人工膝關節置換術為晚期退行性骨關節炎主要的治療方式之一。傳統標準的全人工膝關節置換術（CS-TKR）已經可達到良好的膝關節使用壽命。近年來，全人工膝關節置換之微創手術（MIS-TKR）的方法已開始蓬勃發展，旨在減少術中軟組織的傷害，以盡量縮短術後恢復期，加速病患在功能上的恢復。另一方面，客製化手術器械的全人工膝關節置換術（PSI-TKR）為最新被提出且已運用在臨床上的手術方式，PSI-TKR 手術透過術前以三維影像模擬並製作專屬手術模具，手術醫師因此可依個人化之模具更精準的植入人工關節植體以增進術後膝關節在功能上的恢復。然而，三種不同的手術方式，對於術後日常活動功能表現之影響，卻從未有過定量的評估與比較。 因此，本研究的目的旨在量測並量化患者在兩種不同的全人工膝關節置換後之運動（MIS-TKR與PSI-TKR），量測的運動項目包含了主動的膝關節屈曲與伸展和坐到站等日常生活常見之動作，進一步的了解不同的手術方法對於術後膝關節功能恢復的影響。其結果顯示，MIS-TKR與PSI-TKR患者於位移之運動學表現皆相同。然而，MIS-TKR患者於三種動作下皆處於外轉角度，使之缺少螺旋歸位機轉，並且在表面運動學上的表現有接觸點集中的現象，而長期的受力不良容易造成外側墊片的損毀，進而降低人工關節之壽命。建議微創手術時應謹慎處理避免造成過多外轉角度所造成的後遺症。

Total knee replacements (TKR) have been the main choice of treatment for alleviating pain and restoring physical function in advanced degenerative osteoarthritis (OA) of the knee. In recent years, interests in minimally invasive surgery TKR (MIS-TKR) have increased substantially in industry and between orthopedic surgeons and patients. Moreover, patient-specific instrumentation (PSI) was designed to replace the previous surgical instrumentations without the needs for the computer navigation system. PSI-TKR was a newly developed surgical technique, aiming to more accurately restore the knee axis of the TKR than previous approaches, and was conducted with the minimally invasive surgical approaches in general. Therefore, the purposes of the project were to measure the 3D kinematics of the TKR in vivo. The kinematic data of the knee for the patients with MIS-TKR and PSI-TKR after surgery six-monthly have been calculated during functional tasks , i.e. active knee extension, flexion and sit-to-stand. According to the results, The performances of MIS-TKR and PSI-TKR patients are regarded to be equal on the translation except on the M/L direction. However, the differences on the M/L direction were too slight to affect the movement clinically. To be mentioned, MIS-TKR didn’t externally rotate to represent the screw home mechanism as a normal knee. It could induce abnormal articular contact pattern to the plastic insert which might shorten the life cycle of the TKR. It is suggested that the anatomical pose of the TKR in the minimally invasive surgery should be dealt with much more care to avoid consistent lateral contact broken.