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Z Orthop Unfall 2016; 154(01): 50-57
DOI: 10.1055/s-0035-1558074
Originalarbeit
Georg Thieme Verlag KG Stuttgart · New York

Vergleich funktioneller Ergebnisse zwischen medialem parapatellarem und Midvastus-Zugang in der Knieendoprothetik

Functional Comparison of the Outcome after Midvastus and Medial Parapatellar Surgical Approach in Total Knee Arthroplasty
F. Layher
1   Lehrstuhl für Orthopädie, Abteilung Biomechanik, Universitätsklinikum Jena, Waldkrankenhaus „Rudolf Elle“, Eisenberg
,
M. Zipfel
2   Lehrstuhl für Orthopädie, Klinik für Orthopädie, Universitätsklinikum Jena, Waldkrankenhaus „Rudolf Elle“, Eisenberg
3   derzeitige Adresse: Zentrum für Unfallchirurgie und Orthopädie, Helios Klinikum Wuppertal, Wuppertal-Barmen
,
K. Sander
1   Lehrstuhl für Orthopädie, Abteilung Biomechanik, Universitätsklinikum Jena, Waldkrankenhaus „Rudolf Elle“, Eisenberg
,
G. Matziolis
2   Lehrstuhl für Orthopädie, Klinik für Orthopädie, Universitätsklinikum Jena, Waldkrankenhaus „Rudolf Elle“, Eisenberg
,
A. Roth
2   Lehrstuhl für Orthopädie, Klinik für Orthopädie, Universitätsklinikum Jena, Waldkrankenhaus „Rudolf Elle“, Eisenberg
4   derzeitige Adresse: Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Bereich Endoprothetik/, Orthopädie, Universitätsklinik Leipzig
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Publication History

Publication Date:
20 November 2015 (online)

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Zusammenfassung

Für die Implantation von Knietotalendoprothesen kommen verschiedene operative Zugänge zur Anwendung. Klinische Analysen belegen, dass insbesondere dem Midvastus-Zugang (MV) in der frühen Rehabilitationsphase ein Vorteil gegenüber dem medialen parapatellaren Zugang (MPP) zugeschrieben wird. Ziel dieser Arbeit war es, herauszufinden, ob der klinische sich auch in einem funktionellen Vorteil des MV äußert. Die prospektiv-randomisierte Studie wurde einfach verblindet basierend auf eine Poweranalyse angelegt. Zufällig einer Gruppe zugeordnete Patienten (MPP = 10, MV = 11) wurden mittels instrumenteller Ganganalyse (VICON) vor, 5 Wochen (5 W) und 6 Monate (6 M) nach der Operation untersucht. Die Ergebnisse wurden einer gesunden Vergleichsgruppe (VG = 53) gegenübergestellt. Der primäre Zielpunkt war neben klinischen Parametern die Analyse objektiver Gangparameter, der sekundäre die subjektive Selbsteinschätzung in Form klinischer Scores (Knee Society Score, WOMAC). Im postoperativen Untersuchungszeitraum verbesserten sich die Messwerte der Ganganalyseparameter in beiden Gruppen, ohne das Niveau der VG zu erreichen. Vorteile für die MV-Gruppe zeigten sich in den kinetischen Parametern sagittales Kniemoment (5 W) und Kniepower (5 W, 6 M). Ebenfalls in MV fand sich eine bessere subjektive Selbsteinschätzung (WOMAC, 6 M). In den klinischen Parametern unterschieden sich MV- und MPP-Zugang nicht. Zusammenfassend ist festzustellen, dass die MV- gegenüber der MPP-Gruppe in der frühen postoperativen Phase funktionell im Vorteil war und dieses durch das subjektive Allgemeinbefinden bestätigt wurde. Aus biomechanischer Sicht ist der MV-Zugang deshalb zu bevorzugen.

Abstract

There are various approaches for total knee arthroplasty (TKA). On the basis of an analysis of the clinical results, it has been demonstrated that the midvastus approach (MV) is advantageous in the early postoperative period compared to the medial parapatellar surgical approach (MPP). The aim of this investigation was therefore to investigate whether the clinical advantage of MV is reflected in the functional outcome. This single blinded, prospective, randomised study was based on a power analysis. Selected randomised patients (MPP = 10, MV = 11) were examined using an instrumental gait analysis system (VICON) preoperatively, and 5 weeks (5 W) and 6 months (6 M) after implantation. The results were compared to a healthy control group (CG = 53). Besides clinical parameters, the primary objective of this study was to measure objective gait parameters; the secondary objective was to record self-assessment (Knee Society score, WOMAC). In both treatment groups, the measurements improved during the investigation period, although most parameters did not reach the CG levels. MV gave better values for the kinetic parameters sagittal knee moment (5 W) and knee power (5 W, 6 M), as well as self-assessment (WOMAC, 6 M). Other clinical parameters were similar in the two groups. In summary, in the early postoperative period, MV led to advantages in function and in subjective behaviour in daily life. From the biomechanical point of view, the MV approach is preferable.

Schlüsselwörter

Knietotalendoprothese - operativer Zugang - Ganganalyse

Key words

total knee arthroplasty - surgical approach - gait analysis
 

  • Literatur

  • 1 Räuchle M, Cemerka M, Eibenberger B et al. Arthrose – update 2012. Radiologe 2012; 52: 149-155
    CrossrefPubMedGoogle Scholar
  • 2 Merx H, Dreinhöfer KE, Günther KP. Sozialmedizinische Bedeutung der Arthrose in Deutschland. Z Orthop Unfall 2007; 145: 421-429
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 von Langenbeck B. Zur Resektion des Kniegelenkes. Verh Dtsch Gesellsch Chir 1879; 7: 23-56
    PubMedGoogle Scholar
  • 4 Engh GA, Parks NL. Surgical technique of the midvastus arthrotomy. Clin Orthop Relat Res 1998; 351: 270-274
    CrossrefPubMedGoogle Scholar
  • 5 Engh GA, Holt BT, Parks NL. A midvastus muscle-splitting approach for total knee arthroplasty. J Arthroplasty 1997; 12: 322-331
    CrossrefPubMedGoogle Scholar
  • 6 Dalury DF, Jiranek WA. A comparison of the midvastus and paramedian approaches for total knee arthroplasty. J Arthroplasty 1999; 14: 33-37
    CrossrefPubMedGoogle Scholar
  • 7 Parentis MA, Rumi MN, Deol GS et al. A comparison of the vastus splitting and median parapatellar approaches in total knee arthroplasty. Clin Orthop Relat Res 1999; 367: 107-116
    CrossrefPubMedGoogle Scholar
  • 8 White jr. RE, Allman JK, Trauger JA et al. Clinical comparison of the midvastus and medial parapatellar surgical approaches. Clin Orthop Relat Res 1999; 367: 117-122
    PubMedGoogle Scholar
  • 9 Maestro A, Suarez MA, Rodriguez L et al. The midvastus surgical approach in total knee arthroplasty. Int Orthop 2000; 24: 104-107
    CrossrefPubMedGoogle Scholar
  • 10 Bäthis H, Perlick L, Blum C et al. Midvastus approach in total knee arthroplasty: a randomized, double-blinded study on early rehabilitation. Knee Surg Sports Traumatol Arthrosc 2005; 13: 545-550
    CrossrefPubMedGoogle Scholar
  • 11 Faul F, Erdfelder E, Lang AG et al. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39: 175-191
    CrossrefPubMedGoogle Scholar
  • 12 Cohen J. Statistical power analysis for the behavioral sciences. New Jersey: Lawrence Erlbaum Associates; 1988
    Google Scholar
  • 13 Hof AL. Scaling gait data to body size. Gait Posture 1996; 4: 222-223
    CrossrefPubMedGoogle Scholar
  • 14 Insall JN, Dorr LD, Scott RD et al. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; 248: 13-14
    PubMedGoogle Scholar
  • 15 McConnell S, Kolopack P, Davis AM. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties. Arthritis Rheum 2001; 45: 453-461
    CrossrefPubMedGoogle Scholar
  • 16 Insall J, Salvati E. Patella position in the normal knee joint. Radiology 1971; 101: 101-104
    CrossrefPubMedGoogle Scholar
  • 17 Thiranagama R. Nerve supply of the human vastus medialis muscle. J Anat 1990; 170: 193-198
    PubMedGoogle Scholar
  • 18 Günal I, Araç S, Sahinoğlu K et al. The innervation of vastus medialis obliquus. J Bone Joint Surg Br 1992; 74: 624
    PubMedGoogle Scholar
  • 19 Kelly MJ, Rumi MN, Kothari M et al. Comparison of the vastus-splitting and median parapatellar approaches for primary total knee arthroplasty: a prospective, randomized study. J Bone Joint Surg Am 2006; 88: 715-720
    CrossrefPubMedGoogle Scholar
  • 20 Dalury DF, Snow RG, Adams MJ. Electromyographic evaluation of the midvastus approach. J Arthroplasty 2008; 23: 136-140
    CrossrefPubMedGoogle Scholar
  • 21 Keating EM, Faris PM, Meding JB et al. Comparison of the midvastus muscle-splitting approach with the median parapatellar approach in total knee arthroplasty. J Arthroplasty 1999; 14: 29-32
    CrossrefPubMedGoogle Scholar
  • 22 Bonutti PM, Zywiel MG, Seyler TM et al. Minimally invasive total knee arthroplasty using the contralateral knee as a control group: a case-control study. Int Orthop 2010; 34: 491-495
    CrossrefPubMedGoogle Scholar
  • 23 Hofmann AA, Bachus KN, Wyatt RW. Effect of the tibial cut on subsidence following total knee arthroplasty. Clin Orthop Relat Res 1991; 269: 63-69
    PubMedGoogle Scholar
  • 24 Ebert JR, Munsie C, Joss B. Guidelines for the early restoration of active knee flexion after total knee arthroplasty: implications for rehabilitation and early intervention. Arch Phys Med Rehabil 2014; 95: 1135-1140
    CrossrefPubMedGoogle Scholar
  • 25 Paley D. Principles of Deformity Correction. Berlin: Springer; 2002
    CrossrefGoogle Scholar
  • 26 Matsuda S, Miura H, Nagamine R et al. Posterior tibial slope in the normal and varus knee. Am J Knee Surg 1999; 12: 165-168
    PubMedGoogle Scholar
  • 27 Chiu KY, Zhang SD, Zhang GH. Posterior slope of tibial plateau in Chinese. J Arthroplasty 2000; 15: 224-227
    CrossrefPubMedGoogle Scholar
  • 28 Kuwano T, Urabe K, Miura H et al. Importance of the lateral anatomic tibial slope as a guide to the tibial cut in total knee arthroplasty in Japanese patients. J Orthop Sci 2005; 10: 42-47
    CrossrefPubMedGoogle Scholar
  • 29 Meneghini RM, Ritter MA, Pierson JL et al. The effect of the Insall-Salvati ratio on outcome after total knee arthroplasty. J Arthroplasty 2006; 21 (Suppl. 02) S116-S120
    CrossrefPubMedGoogle Scholar
  • 30 Kesmezacar H, Erginer R, Ogut T et al. Evaluation of patellar height and measurement methods after valgus high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2005; 13: 539-544
    CrossrefPubMedGoogle Scholar
  • 31 Marks KE, Bentley G. Patella alta and chondromalacia. J Bone Joint Surg Br 1978; 60: 71-73
    PubMedGoogle Scholar
  • 32 Solak AS, Kentel B, Ateş Y. Does bilateral total knee arthroplasty affect gait in women? Comparison of gait analyses before and after total knee arthroplasty compared with normal knees. J Arthroplasty 2005; 20: 745-750
    CrossrefPubMedGoogle Scholar
  • 33 Satterly T, Neeley R, Johnson-Wo AK et al. Role of total knee arthroplasty approaches in gait recovery through 6 months. J Knee Surg 2013; 26: 257-262
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Benedetti MG, Bonato P, Catani F et al. Myoelectric activation pattern during gait in total knee replacement: relationship with kinematics, kinetics, and clinical outcome. IEEE Trans Rehabil Eng 1999; 7: 140-149
    CrossrefPubMedGoogle Scholar
  • 35 Otsuki T, Nawata K, Okuno M. Quantitative evaluation of gait pattern in patients with osteoarthrosis of the knee before and after total knee arthroplasty. Gait analysis using a pressure measuring system. J Orthop Sci 1999; 4: 99-105
    CrossrefPubMedGoogle Scholar
  • 36 Berth A, Urbach D, Becker R et al. Ganganalyse bei Varusgonarthrosepatienten vor und nach unilateraler Knieendoprothesenimplantation. Zentralbl Chir 2002; 127: 868-872
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Smith AJ, Lloyd DG, Wood DJ. Pre-surgery knee joint loading patterns during walking predict the presence and severity of anterior knee pain after total knee arthroplasty. J Orthop Res 2004; 22: 260-266
    CrossrefPubMedGoogle Scholar
  • 38 Saari T, Tranberg R, Zügner R et al. Changed gait pattern in patients with total knee arthroplasty but minimal influence of tibial insert design: gait analysis during level walking in 39 TKR patients and 18 healthy controls. Acta Orthop 2005; 76: 253-260
    CrossrefPubMedGoogle Scholar
  • 39 Chiu MC, Wang MJ. The effect of gait speed and gender on perceived exertion, muscle activity, joint motion of lower extremity, ground reaction force and heart rate during normal walking. Gait Posture 2007; 25: 385-392
    CrossrefPubMedGoogle Scholar
  • 40 Mandeville D, Osternig LR, Chou LS. The effect of total knee replacement on dynamic support of the body during walking and stair ascent. Clin Biomech (Bristol, Avon) 2007; 22: 787-794
    CrossrefPubMedGoogle Scholar
  • 41 Mandeville D, Osternig LR, Chou LS. The effect of total knee replacement surgery on gait stability. Gait Posture 2008; 27: 103-109
    CrossrefPubMedGoogle Scholar
  • 42 McClelland JA, Webster KE, Feller JA et al. Knee kinematics during walking at different speeds in people who have undergone total knee replacement. Knee 2011; 18: 151-155
    CrossrefPubMedGoogle Scholar
  • 43 Bejek Z, Paróczai R, Illyés A et al. The influence of walking speed on gait parameters in healthy people and in patients with osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2006; 14: 612-622
    CrossrefPubMedGoogle Scholar
  • 44 Yoshida Y, Mizner RL, Ramsey DK et al. Examining outcomes from total knee arthroplasty and the relationship between quadriceps strength and knee function over time. Clin Biomech (Bristol, Avon) 2008; 23: 320-328
    Google Scholar
  • 45 Tibesku CO, Daniilidis K, Skwara A et al. Gait analysis and electromyography in fixed- and mobile-bearing total knee replacement: a prospective, comparative study. Knee Surg Sports Traumatol Arthrosc 2011; 19: 2052-2059
    CrossrefPubMedGoogle Scholar
  • 46 Yoshida Y, Zeni J, Snyder-Mackler L. Do patients achieve normal gait patterns 3 years after total knee arthroplasty?. J Orthop Sports Phys Ther 2012; 42: 1039-1049
    CrossrefPubMedGoogle Scholar
  • 47 McClelland JA, Webster KE, Feller JA. Gait analysis of patients following total knee replacement: a systematic review. Knee 2007; 14: 253-263
    CrossrefPubMedGoogle Scholar
  • 48 Benedetti M, Catani F, Bilotta T et al. Muscle activation pattern and gait biomechanics after total knee replacement. Clin Biomech (Bristol, Avon) 2003; 18: 871-876
    CrossrefPubMedGoogle Scholar
  • 49 Fisher NM, White SC, Yack HJ et al. Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation. Disabil Rehabil 1997; 19: 47-55
    CrossrefPubMedGoogle Scholar
  • 50 Smith AJ, Lloyd DG, Wood DJ. A kinematic and kinetic analysis of walking after total knee arthroplasty with and without patellar resurfacing. Clin Biomech (Bristol, Avon) 2006; 21: 379-386
    CrossrefPubMedGoogle Scholar