Blom Ashley W, Hunt Linda P, Matharu Gulraj S, Reed Michael, Whitehouse Michael R
Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol BS10 5NB, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK.
Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol BS10 5NB, UK.
Knee. 2021 Aug;31:144-157. doi: 10.1016/j.knee.2021.04.009. Epub 2021 Jun 25.
Total knee replacement (TKR) is clinically and cost-effective. The surgical approach employed influences the outcome, however there is little generalisable and robust evidence to guide practice. We compared outcomes between the common primary TKR surgical approaches.
875,166 primary TKRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient reported outcome measures (PROMs) data, with up to 15.75 years follow-up were analysed. There were 10 surgical approach groups: medial parapatellar, midvastus, subvastus, lateral parapatellar, 'other' and their minimally invasive versions. Survival methods were used to compare revision rates and 45-day mortality. Groups were compared using Cox proportional hazards regression and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, TKR fixation, year of primary, body mass index, and for mortality, deprivation and Charlson comorbidity subgroups. PROMs were analysed with regression modelling or non-parametric methods.
The conventional midvastus approach was associated with lower revision rates (Hazard Rate Ratio (HRR) 0.80 (95% CI 0.71-0.91) P = 0.001) and the lateral parapatellar with higher revision rates (HRR 1.35 (95% CI 1.12-1.63) P = 0.002) compared to the conventional medial parapatellar approach. Mortality rates were similar between approaches. PROMs showed statistically significant, but not clinically important, differences.
There is little difference in PROMs between the various surgical approaches in TKR with all resulting in good outcomes. However, the conventional midvastus approach (used in 3% of cases) was associated with a 20% reduced risk of revision surgery compared to the most commonly used knee approach (the conventional medial parapatellar: used in 91.9% of cases). This data supports the use of the midvastus approach and thus surgeons should consider utilising this approach more frequently. Minimally invasive approaches did not appear to convey any clinical advantage in this study over conventional approaches for primary TKR.
全膝关节置换术（TKR）在临床和成本效益方面表现良好。然而，所采用的手术方式会影响手术效果，目前几乎没有可广泛适用且有力的证据来指导临床实践。我们比较了常见的初次全膝关节置换术手术方式的效果。
分析了国家关节登记处记录的875166例初次全膝关节置换术病例，这些病例与医院住院患者、死亡率及患者报告结局指标（PROMs）数据相关联，随访时间长达15.75年。共有10个手术方式组：内侧髌旁入路、股直肌中间入路、股直肌下入路、外侧髌旁入路、“其他”入路及其微创版本。采用生存分析方法比较翻修率和45天死亡率。使用Cox比例风险回归和灵活参数生存模型（FPM）对各手术方式组进行比较。混杂因素包括手术时年龄、性别、风险组（骨关节炎以外的适应症）、美国麻醉医师协会分级、全膝关节置换术固定方式、初次手术年份、体重指数，对于死亡率分析，还包括贫困程度和Charlson合并症亚组。采用回归模型或非参数方法分析PROMs。
与传统内侧髌旁入路相比，传统股直肌中间入路的翻修率较低（风险率比（HRR）为0.80（95%置信区间0.71 - 0.91），P = 0.001），而外侧髌旁入路的翻修率较高（HRR为1.35（95%置信区间1.12 - 1.63），P = 0.002）。各手术方式的死亡率相似。PROMs显示出统计学上的显著差异，但在临床上并不重要。
全膝关节置换术的各种手术方式在PROMs方面差异不大，所有手术方式均能取得良好效果。然而，与最常用的膝关节手术入路（传统内侧髌旁入路：91.9%的病例使用）相比，传统股直肌中间入路（3%的病例使用）的翻修手术风险降低了20%。这些数据支持使用股直肌中间入路，因此外科医生应更频繁地考虑采用这种入路。在本研究中，对于初次全膝关节置换术，微创入路似乎没有比传统入路带来任何临床优势。
