§«“¡‡ªìπ ¡“¢Õß minimally invasive surgery „π knee arthroplasty

§«“¡‡ªìπ ¡“¢Õß minimally invasive surgery „π knee arthroplasty

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1
CHAPTER
§«“¡‡ªìπ¡“¢Õß minimally invasive surgery
„π knee arthroplasty
Background of minimally invasive surgery
in knee arthroplasty
Õ“√’ µπ“«≈’
∫∑π”
(introduction)
Minimally invasive surgery „π “¢“ÕÕ√å‚∏ªî¥‘° å
(minimally invasive surgery in orthopedics)
°“√ºà“µ—¥‡ª≈’ˬπ¢âÕ‡¢à“‡∑’¬¡«‘∏’¡“µ√∞“π
(standard total knee arthroplasty)
°“√ºà“µ—¥«‘∏’ minimally invasive „π knee arthroplasty
(minimally invasive surgery in knee arthroplasty)
°“√ºà“µ—¥«‘∏’ minimally invasive „π knee arthroplasty „πª√–‡∑»‰∑¬
(minimally invasive surgery in knee arthroplasty in Thailand)
√ÿª
(conclusion)
°“√ºà“µ—¥ minimally invasive
surgery-total knee arthroplasty
∫∑π” (introduction)
„πªí®®ÿ∫π— §«“¡√Ÿ∑â “ß°“√·æ∑¬å„π∑ÿ° “¢“‰¥âæ≤
— π“
‰ªÕ¬à“ß¡“° ‚¥¬¡’°“√æ—≤π“∑—È߇√◊ËÕß°“√µ√«®«‘π‘®©—¬
‚√§§«∫§Ÿà‰ª°—∫°“√æ—≤π“‡√◊ËÕß«‘∏’°“√√—°…“‚√§ ´÷Ëß√«¡
∂÷ß«‘∏’°“√√—°…“¥â«¬°“√ºà“µ—¥ ∑—Èßπ’È „π∑»«√√…∑’˺à“π
¡“ ·π«§‘¥„π‡√◊ÕË ß°“√æ—≤π“«‘∏°’ “√√—°…“¥â«¬°“√ºà“µ—¥
¡ÿà߇πâπ‰ª∑“ߥâ“π°“√‡ª≈’ˬπ·ª≈ß°“√ºà“µ—¥®“°«‘∏’
¡“µ√∞“π (standard surgical approach) À√◊Õ‡√’¬°Õ’°
Õ¬à“ßÀπ÷ßË «à“°“√ºà“µ—¥«‘∏¥’ ß—È ‡¥‘¡ (conventional surgical
approach) „À⇪ìπ°“√ºà“µ—¥∑’Ë∑”„À⇰‘¥°“√√ÿ°°“¬πâÕ¬
(minimally invasive surgery, MIS) ‚¥¬°“√ºà“µ—¥√—°…“
«‘∏’ MIS π’ȉ¥â°√–®“¬µ—«‰ª„π∑ÿ°Ê “¢“¢Õß°“√·æ∑¬å
¥â“π»—≈¬°√√¡ ·≈–∑”„Àâ»≈— ¬·æ∑¬å “¢“µà“ßÊ ‡°‘¥§«“¡
µ◊πË µ—«„π°“√‡√’¬π√Ÿ°â “√ºà“µ—¥«‘∏’ MIS „π “¢“¢Õßµπ‡Õß
‡æ‘¡Ë ¢÷πÈ Õ¬à“ßµàÕ‡π◊ÕË ß
‚¥¬∑—Ë«‰ª·≈â« °“√ºà“µ—¥«‘∏’ MIS ¡—°‡ªìπ°“√ºà“µ—¥
¥â«¬°“√„™â°≈âÕß (arthroscopy or laparoscopy) ‡æ◊ÕË ™à«¬
»—≈¬·æ∑¬å„π°“√¡Õ߇ÀÁπºà“π°≈âÕ߉¥âÕ¬à“ß™—¥‡®π„π
∫√‘‡«≥ºà“µ—¥ ∑—Èß∑’Ë·º≈ºà“µ—¥¡’¢π“¥‡≈Á°¡“° πÕ°®“°
π’È ¬—ß¡’Õÿª°√≥å摇»…∑’˙૬„Àâ»—≈¬·æ∑¬å∑”°“√ºà“µ—¥
„π∫√‘‡«≥∑’Ë¡’æ◊Èπ∑’Ë®”°—¥‰¥âßà“¬¢÷Èπ ‚¥¬„™âÕÿª°√≥åºà“µ—¥
Õ¬à“ßÕ◊πË ‡™àπ §’¡ °√√‰°√ Õÿª°√≥凬Á∫∑’ÕË Õ°·∫∫摇»…
„Àâ Õ¥ºà“π√Ÿ·º≈‡≈Á°Ê ‰¥â‡æ◊ËÕ„Àâ Õ¥§≈âÕß°—∫°“√ºà“µ—¥
∑’„Ë ™â°≈âÕß
2
·æ∑¬å “¢“ÕÕ√å‚∏ªî¥‘° å ‡√‘Ë¡µ—Èß·µà°“√ºà“µ—¥∑’Ë„™â°≈âÕß
àÕ߇¢â“‰ª„π¢âÕ‡¢à“ (knee arthroscopy)1 ´÷ßË √–¬–·√°
‡πâπ„π‡√◊ÕË ß°“√«‘π®‘ ©—¬‚√§ ®πµàÕ¡“«‘∏°’ “√ºà“µ—¥¥â«¬°“√
„™â°≈âÕß¡’§«“¡°â“«ÀπⓉªÕ¬à“ß¡“° ∑”„Àâ»—≈¬·æ∑¬å
“¡“√∂∑”ºà“µ—¥„π¢âÕ‰¥âÀ≈“°À≈“¬À—µ∂°“√¥—ß∑’ˇÀÁπ
„πªí®®ÿ∫π— π’È
”À√—∫§«“¡°â“«Àπâ“¢Õß°“√ºà“µ—¥ MIS „π°“√
‡ª≈’¬Ë π¢âÕ‡∑’¬¡ (arthroplasty) ‚¥¬‡©æ“–¢âÕ‡¢à“ ·≈–¢âÕ
–‚æ° ‰¡à “¡“√∂æ—≤𓉪„™â°≈âÕ߇À¡◊Õπ°—∫°“√ºà“µ—¥
∑“ßÕÕ√å‚∏ªî¥°‘ å¥ß— °≈à“«¡“·≈â« ‡π◊ÕË ß®“°¡’§«“¡®”‡ªìπ
µâÕß„ à¢âÕ‡∑’¬¡ (prosthesis) ´÷Ëß¡’¢π“¥„À≠à‡¢â“‰ª„π
√à“ß°“¬ ¥—ßπ—Èπ °“√æ—≤π“°“√ºà“µ—¥‡ª≈’ˬπ¢âÕ‡∑’¬¡«‘∏’
MIS (´÷Ëß¡—°‡πâπ°“√ºà“µ—¥«‘∏’π’È ”À√—∫¢âÕ‡¢à“ ·≈–¢âÕ
–‚æ°) ®÷߇ªìπ°“√∑”ºà“µ—¥∑’Ë∑”„Àâ·º≈ºà“µ—¥¡’¢π“¥
‡≈Á° (mini-incision) ·≈–µ—¥‡π◊ÕÈ ‡¬◊ÕË µà“ßÊ ‡™àπ °≈â“¡‡π◊ÕÈ
„ÀâπÕâ ¬∑’ Ë ¥ÿ À√◊Õ‰¡àµ¥— ‡≈¬ ‡æ’¬ß‡æ◊ÕË „À⇰‘¥∑’∑Ë ”ß“π‡æ’¬ß
æÕ„Àâ»≈— ¬·æ∑¬å„ à¢Õâ ‡∑’¬¡‡¢â“‰ª‰¥â
Õπ÷Ëß À≈—°°“√„π°“√„ à¢âÕ‡∑’¬¡ ‡™àπ µ”·ÀπàߢÕß
¢âÕ‡∑’¬¡‰¡à«“à ®–‡ªìπ¢âÕ‡¢à“ À√◊Õ¢âÕ –‚æ° °Á¬ß— §ß‡À¡◊Õπ
°—∫°“√ºà“µ—¥«‘∏’¡“µ√∞“π ‡æ’¬ß·µà°“√ºà“µ—¥‡ª≈’ˬπ¢âÕ
‡∑’¬¡«‘∏’ MIS À«—ߺ≈„À⇰‘¥°“√∫“¥‡®Á∫¢Õ߇π◊ÕÈ ‡¬◊ÕË ·≈–
°≈â“¡‡π◊ÈÕπâÕ¬≈ß ºŸâªÉ«¬‡ ’¬‡≈◊Õ¥®“°°“√ºà“µ—¥πâÕ¬≈ß
∑”„Àâ “¡“√∂‡§≈◊ËÕπ‰À« À√◊Õ‡¥‘πÀ≈—ß®“°°“√∑”ºà“µ—¥
‰¥â‡√Á«¢÷πÈ °“√øóπô µ—«À≈—ß®“°°“√ºà“µ—¥‡√Á«¢÷πÈ ·≈–ºŸªâ «É ¬
“¡“√∂°≈—∫‰ªª√–°Õ∫¿“√°‘®‡À¡◊Õπ§πª°µ‘‰¥â‡√Á«¢÷πÈ
Minimally invasive surgery „π “¢“ÕÕ√å‚∏ªî¥°‘ å °“√ºà“µ—¥‡ª≈’ˬπ¢âÕ‡¢à“‡∑’¬¡«‘∏’¡“µ√∞“π
(minimally invasive surgery in Orthopedics)
æ—≤π“°“√¢Õß°“√∑”ºà“µ—¥«‘∏’ MIS ”À√—∫»—≈¬-
(standard total knee arthroplasty)
°“√√—°…“‚√§¢âÕ‡¢à“‡ ◊ËÕ¡„π√–¬–∑⓬¥â«¬°“√∑”
3
ºà“µ—¥‡ª≈’ˬπ¢âÕ‡¢à“‡∑’¬¡∫“ß à«πÀ√◊Õ∑—ÈߢâÕ (knee arthroplasty) ‡ªìπ«‘∏’°“√√—°…“∑’Ë»—≈¬·æ∑¬å‰¥â≈Õßπ”¡“
„™â‡ªìπ‡«≈“π“π¡“°·≈â« ·µà„π√–¬–·√°°“√ÕÕ°·∫∫
¢âÕ‡∑’¬¡ ·≈–«‘∏’°“√ºà“µ—¥¬—߇ ¡◊Õπ°“√≈Õߺ‘¥≈Õß∂Ÿ°
∑”„Àâº≈°“√ºà“µ—¥ knee arthroplasty „π¬ÿ§·√°Ê ‰¡à¥’
‡∑à“∑’˧«√ ®”‡ªìπµâÕß¡’°“√ª√—∫ª√ÿß°“√ÕÕ°·∫∫¢âÕ
‡∑’¬¡‡æ‘Ë¡‡µ‘¡ ®÷ß∑”„Àâ°“√ºà“µ—¥ knee arthroplasty „π
√–¬–·√°‰¡à‡ªìπ∑’·Ë æ√àÀ≈“¬
®π°√–∑—Ëß„πªï §.».1976 𓬷æ∑¬å Insall ·≈–
§≥–2 ‰¥â𔇠πÕº≈ß“π°“√ºà“µ—¥ knee arthroplasty
∑’ËÕÕ°·∫∫„ÀâÀπ⓺‘«¢âÕ‡∑’¬¡¡’§«“¡°«â“߇µÁ¡Àπ⓺‘«
‡À¡◊Õπ¢âÕ‡¢à“∏√√¡™“µ‘ ‚¥¬‡√’¬°¢âÕ‡¢à“‡∑’¬¡™π‘¥π’È«à“
total condylar prosthesis ´÷Ëß√“¬ß“ππ’È¡’º≈°“√ºà“µ—¥
¥’ ·≈–„π√“¬ß“πµàÕ¡“· ¥ß„Àâ‡ÀÁπ«à“ ¢âÕ‡∑’¬¡™π‘¥π’È¡’
§«“¡∑π∑“π„π°“√„™âß“π¬“«π“π°«à“¢âÕ‡¢à“‡∑’¬¡™π‘¥
µà“ßÊ „πÕ¥’µ3 ∑”„À⇰‘¥°“√¬Õ¡√—∫Õ¬à“ß·æ√àÀ≈“¬«à“
°“√ºà“µ—¥ knee arthroplasty ‚¥¬‡≈◊Õ°„™â¢âÕ‡∑’¬¡™π‘¥
total condylar prosthesis ‡ªìπ«‘∏’°“√√—°…“¢âÕ‡¢à“‡ ◊ËÕ¡
√–¬–∑⓬∑’‰Ë ¥âº≈¥’
°“√ºà“µ—¥ knee arthroplasty ‚¥¬„™â¢âÕ‡∑’¬¡™π‘¥
total condylar prosthesis π’πÈ ¬‘ ¡‡√’¬°«à“ total knee arthroplasty (TKA) ‚¥¬«‘∏°’ “√ºà“µ—¥‡¢â“ Ÿ¢à Õâ ‡¢à“µ“¡·∫∫
¢Õß𓬷æ∑¬å Insall ´÷Ë߇ªî¥‡¢â“„π¢âÕ‡¢à“®“°¥â“πÀπâ“
¡’¢π“¥·º≈¬“«ª√–¡“≥ 20-25 ´¡. ·≈â«∑”°“√æ≈‘°
°√–¥Ÿ° –∫â“ (patella) ·≈–ßÕ¢âÕ‡¢à“ª√–¡“≥ 100-130
Õß»“„π¢≥–∑”ºà“µ—¥ ¡’¢Õâ ¥’§Õ◊ ‡ÀÁπ‚§√ß √â“ßµà“ßÊ ∑“ß
°“¬«‘¿“§¿“¬„π¢âÕ‡¢à“™—¥‡®π
®“°°“√∑’πË “¬·æ∑¬å Insall √“¬ß“π°“√ºà“µ—¥ TKA
¥â«¬°“√„™â«∏‘ º’ “à µ—¥‡¢â“ Ÿ¢à Õâ ‡¢à“‡™àππ’«È “à ‰¥âº≈ ”‡√Á®¥’ ®÷ß
∂◊Õ‰¥â«à“«‘∏’ºà“µ—¥‡¢â“ Ÿà¢âÕ‡¢à“µ“¡·∫∫¢Õß𓬷æ∑¬å
§«“¡‡ªìπ¡“¢Õß minimally invasive surgery
„π knee arthroplasty
Insall ‡ªìπ«‘∏º’ “à µ—¥‡¢â“ Ÿ¢à Õâ ‡¢à“¡“µ√∞“π (standard surgical approach) ·≈–∑”„Àâ„π‡«≈“µàÕ¡“¡’°“√‡√’¬°°“√
ºà“µ—¥ TKA ¥â«¬°“√ºà“µ—¥‡¢â“ Ÿ¢à Õâ ‡¢à“∑’¡Ë ·’ º≈¢π“¥„À≠à
·≈–µâÕßæ≈‘°°√–¥Ÿ° –∫Ⓡ™àππ’«È “à °“√ºà“µ—¥‡ª≈’¬Ë π¢âÕ‡¢à“
‡∑’¬¡«‘∏’¡“µ√∞“π (standard total knee arthroplasty,
STD-TKA) À√◊Õ°“√ºà“µ—¥‡ª≈’ˬπ¢âÕ‡¢à“‡∑’¬¡«‘∏’¥—È߇¥‘¡
(conventional total knee arthroplasty)
Õπ÷ßË »—≈¬·æ∑¬åÕ“®‡≈◊Õ°„™â standard surgical approach ”À√—∫°“√ºà“µ—¥‡¢â“ Ÿà¢âÕ‡¢à“∑“ߥâ“πÀπâ“™π‘¥
¬àÕ¬Ê ∑’·Ë µ°µà“ß°—𠇙àπ medial parapatellar approach,
subvastus approach, midvastus approach À√◊Õ lateral approach ´÷ßË ¡’§«“¡À≈“°À≈“¬„π√“¬≈–‡Õ’¬¥°“√
µ—¥°≈â“¡‡π◊ÕÈ quadriceps ∑’·Ë µ°µà“ß°—π
πÕ°®“°π’È·≈â« π“¬·æ∑¬å Insall ¬—ß𔇠πÕÀ≈—°
”§—≠„π°“√ºà“µ—¥ TKA (surgical principle of TKA)
Õ—πª√–°Õ∫¥â«¬À≈—°°“√µ—¥°√–¥Ÿ° ·≈–À≈—°°“√ª√—∫·√ß
µ÷ߢÕß joint capsule ·≈– ligament ¿“¬„π¢âÕ‡¢à“‡æ◊ËÕ
ª√—∫„Àâ·π«·°π√—∫πÈ”Àπ—°¢ÕߢâÕ‡¢à“Õ¬Ÿàµ√ß°≈“ߢâÕ
·≈–∑”„Àâ¢âÕ‡§≈◊ËÕπ‰À«‰¥âÕ¬à“ß¡—Ëπ§ß ®÷ß∑”„Àâº≈°“√
ºà“µ—¥ TKA ‚¥¬„™â¢âÕ‡∑’¬¡™π‘¥ total condylar prosthesis ·≈–„™âÀ≈—°°“√ºà“µ—¥µ“¡·∫∫¢Õß𓬷æ∑¬å
Insall ‰¥âº≈¥’‡ªìπ∑’πË “à æÕ„®‡ªìπ√–¬–‡«≈“¬“«π“π∂÷ß°«à“
20 ªï4-9
¥— ß π—È π surgical principle ·≈–‡∑§π‘§°“√ºà“µ—¥
(surgical technique) ”À√—∫ TKA ∑’πË ”‡ πÕ‚¥¬π“¬·æ∑¬å Insall ·≈–§≥– ®÷߇ªìπ·∫∫Õ¬à“ß°“√ªØ‘∫—µ‘ ·≈–
°“√π”¡“ ÕπµàÕÊ °—π¡“®π∂÷ßªí®®ÿ∫—π ‚¥¬µ≈Õ¥‡«≈“
‡°◊Õ∫ 40 ªï¡“π’È¡’°“√æ—≤π“ surgical technique ‡æ‘Ë¡
‡µ‘¡®“°∑’πË “¬·æ∑¬å Insall 𔇠πÕÕ’°‡æ’¬ß‡≈Á°πâÕ¬‡∑à“
π—πÈ (√Ÿª∑’Ë 1.1)
°“√ºà“µ—¥ minimally invasive
surgery-total knee arthroplasty
√Ÿª∑’Ë 1.1 √Ÿª∂à“¬‡¡◊ËÕªï §.».1998 ¢Õß𓬷æ∑¬å John N
Insall ·≈–ºŸâπ‘æπ∏å ≥ ‡¡◊Õß New York ª√–‡∑»
À√—∞Õ‡¡√‘°“
°“√ºà“µ—¥«‘∏’ minimally invasive
„π knee arthroplasty
(minimally invasive surgery
in knee arthroplasty)
°“√ºà“µ—¥«‘∏’ MIS „π knee arthroplasty ‡√‘Ë¡µâπ¡“
®“°°“√æ—≤π“«‘∏º’ “à µ—¥‡ª≈’¬Ë π¢âÕ‡¢à“‡∑’¬¡´’°‡¥’¬« (unicompartmental knee arthroplasty À√◊ Õ unicondylar knee arthroplasty, UKA) ‚¥¬„πª≈“¬∑»«√√…
∑’Ë 2000 𓬷æ∑¬å Repicci ·≈–§≥–10 ‡√‘Ë¡∑”°“√ºà“
µ—¥ UKA ¥â«¬«‘∏’ MIS ´÷Ëß¡’¢π“¥·º≈ºà“µ—¥‡æ’¬ß 34 π‘«È Õ—π∂◊Õ‰¥â«“à ‡ªìπ·º≈ºà“µ—¥∑’¡Ë ¢’ 𓥇≈Á°°«à“·º≈ºà“
µ—¥¥â«¬«‘∏’¡“µ√∞“π¡“° ·≈–‡√’¬°°“√ºà“µ—¥π’È«à“ MISUKA ∑”„Àâ°“√ºà“µ—¥«‘∏π’ ‡’È ªìπ∑’πË “à π„®„πÀ¡Ÿ»à ≈— ¬·æ∑¬å
ÕÕ√å‚∏ªî¥°‘ å
„πªï §.».1999 𓬷æ∑¬å Repicci ·≈–§≥–10
‰¥â√“¬ß“π°“√ºà“µ—¥ MIS-UKA ∑’Ë ‰ ¥â º ≈¥’ ∑”„Àâ À— «
4
¢âÕ MIS-UKA °≈“¬‡ªìπÀ—«¢âÕ ”§—≠À—«¢âÕÀπ÷Ëß„π°“√
ª√–™ÿ¡«‘™“°“√ª√–®”ªï¢Õß«‘∑¬“≈—¬·æ∑¬åÕÕ√å‚∏ªî¥‘° å
¢Õߪ√–‡∑» À√—∞Õ‡¡√‘°“ (American Academy of Orthopaedic Surgeons) πÕ°®“°π’È𓬷æ∑¬å Repicci
¬—ß√“¬ß“πº≈∑’Ë¥’¢Õß MIS-UKA ‡æ‘Ë¡‡µ‘¡Õ’°„πªï §.».
200211
µàÕ¡“𓬷æ∑¬å Tria Jr. (·µà„π∫∑§«“¡ Àπ—ß ◊Õ
·≈–µ”√“π‘¬¡‡√’¬°«à“ Tria) ·≈– Coon12 ´÷Ë߇ªìπ°≈ÿà¡
»—≈¬·æ∑¬å∑’Ë∑”ºà“µ—¥ MIS-UKA µ“¡«‘∏’¢Õß Repicci
Õ¬Ÿ·à ≈â« ‡√‘¡Ë ‡°‘¥§«“¡ π„®„π§«“¡‡ªìπ‰ª‰¥â∑®’Ë –∑”°“√
ºà“µ—¥ TKA ‚¥¬„™â«∏‘ ’ MIS ‡™àπ‡¥’¬«°—∫°“√ºà“µ—¥ MISUKA ‚¥¬‡√‘Ë¡∑”°“√∑¥≈Õßºà“µ—¥„π™à«ßª≈“¬ªï §.».
2001 ·≈–‡√’¬°°“√ºà“µ—¥™π‘¥π’È«à“ MIS-TKA º≈°“√
√—°…“„π√–¬–‡∫◊ÈÕßµâπ¢Õß°“√ºà“µ—¥ MIS-TKA ÕÕ°¡“
¥’‡™àπ‡¥’¬«°—π°—∫º≈¢Õß MIS-UKA ‚¥¬√“¬ß“π¢Õß
𓬷æ∑¬å Tria ·≈– Coon12 „π°“√ºà“µ—¥ MIS-TKA
™π‘¥ quadriceps-sparing approach æ∫«à“‰¥âº≈‡ªìπ
∑’Ë æ Õ„® ºŸâ ªÉ « ¬ à « π„À≠à “¡“√∂‡√‘Ë ¡ ¬◊ π ·≈–≈ßπÈ” Àπ—°‰¥â√«¥‡√Á« √«¡∂÷ß°≈—∫∫â“π‰¥â‡√Á«¢÷Èπ ∑—Èßπ’È MISTKA ¡’Õµ— √“°“√‡ ’¬‡≈◊Õ¥‡©≈’¬Ë πâÕ¬°«à“°“√ºà“µ—¥ STDTKA
„π™à«ß‡«≈“‡¥’¬«°—ππ’È𓬷æ∑¬å Bonutti13 °Á π”
‡ πÕ«‘∏’ºà“µ—¥ MIS-TKA ‡™àπ°—π ·µà™π‘¥¢Õß surgical
approach ·µ°µà“ß°—π ´÷Ëß𓬷æ∑¬å Bonutti ‡√’¬°«à“
vastus medialis obliquus snip (VMO snip) ·≈–∑”
°“√ºà“µ—¥¥â«¬°“√ÀâÕ¬¢“ ´÷Ëß°Á‰¥âº≈¢Õß°“√ºà“µ—¥ÕÕ°
¡“¥’‡™àπ‡¥’¬«°—∫º≈¢Õß𓬷æ∑¬å Tria ·≈– Coon ∑”
„Àâ ° “√ºà “ µ— ¥ MIS-TKA ‡ªì π ‘Ë ß ∑’Ë πà “ π„®·æ√à À ≈“¬
‰ª∑—Ë«‚≈° µ—Èß·µàªï §.».2002 ‡ªìπµâπ¡“ (√Ÿª∑’Ë 1.21.4)
§«“¡‡ªìπ¡“¢Õß minimally invasive surgery
„π knee arthroplasty
5
A
B
√Ÿª∑’Ë 1.2 · ¥ß°“√‡ªî¥¢âÕ‡¢à“„π°“√ºà“µ—¥ TKA
A. STD-TKA ´÷ßË µ—¥ quadriceps tendon ¬“« 4-8 ´¡. ·≈–æ≈‘°°√–¥Ÿ° –∫â“¢≥–ºà“µ—¥
B. MIS-TKA ´÷Ëß¡’¢π“¥·º≈ºà“µ—¥‡≈Á°°«à“ µ—¥ quadriceps tendon πâÕ¬ ´÷ËßµâÕ߇≈◊ËÕπ°√–¥Ÿ° –∫Ⓣª¥â“π lateral ‡æ◊ËÕ
°“√¡Õ߇ÀÁπ¿“¬„π¢âÕ
°“√ºà“µ—¥«‘∏’ minimally invasive
„π knee arthroplasty „πª√–‡∑»‰∑¬
(minimally invasive surgery
in knee arthroplasty in Thailand)
ºŸâ π‘ æ π∏å ¡’ ‚ Õ°“ »÷ ° …“°— ∫ 𓬷æ∑¬å Tria ≥
ª√–‡∑» À√—∞Õ‡¡√‘°“ „π√–À«à“ß∑’Ë𓬷æ∑¬å Tria ·≈–
𓬷æ∑¬å Coon °”≈—ßæ—≤π“·≈–ª√—∫ª√ÿ߇§√◊ËÕß¡◊Õ
”À√—∫°“√ºà“µ—¥ MIS-TKA ∑”„Àâ¡‚’ Õ°“ ‡ÀÁπÕÿª √√§
µà“ßÊ „π¢≥–ºà“µ—¥«‘∏’π’È √«¡∂÷ß«‘∏’·°â‰¢ªí≠À“∑’ˇ°‘¥¢÷Èπ
‡¡◊ËÕ®∫°“√»÷°…“·≈–°≈—∫¡“ª√–‡∑»‰∑¬ ºŸâπ‘æπ∏剥âΩñ°
°“√ºà“µ—¥ MIS-TKA ‡æ‘Ë¡‡µ‘¡„π√à“ßÕ“®“√¬å„À≠à ·≈–
æ∫«à“ °“√ºà“µ—¥ MIS-TKA Õ“®‡À¡“– ¡°—∫ºŸªâ «É ¬™“«
‡Õ‡™’¬ ‡π◊ËÕß®“°√Ÿª√à“߇≈Á°°«à“ºŸâªÉ«¬™“«µ–«—πµ° ·≈–
ºŸâªÉ«¬‡Õ‡™’¬ à«π„À≠à‡ªìπ‡æ»À≠‘ß ´÷Ëß¡’¢π“¥°√–¥Ÿ°
∑’ˉ¡à„À≠à ·≈–¡’§«“¡¬◊¥À¬ÿàπ¢Õ߇π◊ÈÕ‡¬◊ËÕ√Õ∫¢âÕ‡¢à“¥’
®÷ß∑”„À€°Àπ⓵à“ߺ‘«Àπ—ß (mobile skin window)
¢≥–∑”ºà“µ—¥‰¥âß“à ¬
ºŸâπ‘æπ∏å‡√‘Ë¡∑”°“√ºà“µ—¥ MIS-TKA ‡ªìπ§√—Èß·√°
„πª√–‡∑»‰∑¬ ‡¡◊ËÕ‡¥◊Õπµÿ≈“§¡ ªï §.».200214 ´÷Ëß„π
‡«≈“µàÕ¡“ºŸâπ‘æπ∏剥â𔇠πÕº≈‡∫◊ÈÕßµâπ¢Õß°“√ºà“µ—¥
MIS-TKA ¥â « ¬°“√®— ∫ §Ÿà ° ≈ÿà ¡ ºŸâ ªÉ « ¬∑’Ë ‰ ¥â √— ∫ °“√ºà “ µ— ¥
MIS-TKA °—∫°≈ÿࡺŸâªÉ«¬∑’ˉ¥â√—∫°“√ºà“µ—¥ STD-TKA
‚¥¬‰¥âµ’æ‘¡æå≈ß„π«“√ “√®¥À¡“¬‡Àµÿ∑“ß·æ∑¬å¢Õß
·æ∑¬ ¡“§¡·Ààߪ√–‡∑»‰∑¬ (®æ ∑)15 «à“°“√ºà“µ—¥
MIS-TKA „πª√–‡∑»‰∑¬‰¥âº≈¥’‡™àπ‡¥’¬«°—∫∑’Ë¡’°“√
√“¬ß“π„πµà“ߪ√–‡∑» ∂÷ß·¡â«à“„πª√– ∫°“√≥å√–¬–
·√°¢Õß°“√ºà “ µ— ¥ MIS-TKA „™â ‡ «≈“ºà “ µ— ¥ π“π¢÷È π
‡©≈’ˬª√–¡“≥ 23 π“∑’ ·µàºŸâªÉ«¬ à«π„À≠à “¡“√∂¢÷Èπ
¡“¬◊π À√◊Õ‡¥‘π≈ßπÈ”Àπ—°‰¥â‡√Á« ∑—ÈßÊ ∑’Ë°√–∫«π°“√¥Ÿ
·≈∑“ß°“√欓∫“≈‡ªìπ‰ª‚¥¬√Ÿª·∫∫¥—È߇¥‘¡ ·≈–«‘∏’
°“√„À⬓·°âª«¥°Á‰¡à·µ°µà“ß®“°ºŸâªÉ«¬∑’Ë√—∫°“√ºà“µ—¥
STD-TKA „π‡«≈“µàÕ¡“§«“¡ π„®„π‡√◊ËÕß°“√ºà“µ—¥
MIS-TKA ·æ√àÀ≈“¬¡“°¢÷Èπ„πÀ¡Ÿà»—≈¬·æ∑¬åÕÕ√å‚∏-
°“√ºà“µ—¥ minimally invasive
surgery-total knee arthroplasty
A
6
B
C
√Ÿª∑’Ë 1.3 √Ÿª∂à“¬¢Õß»—≈¬·æ∑¬åº∫Ÿâ °ÿ ‡∫‘°°“√ºà“µ—¥ MIS-TKA
A. 𓬷æ∑¬å Alfred J Tria
B. 𓬷æ∑¬å Thomas M Coon
C.𓬷æ∑¬å Peter M Bonutti
A
B
√Ÿª∑’Ë 1.4 · ¥ß°“√ºà“µ—¥ MIS-TKA ™π‘¥ quadriceps-sparing approach „π√–¬–·√° (‰¥â√—∫§«“¡Õπÿ‡§√“–À宓°π“¬·æ∑¬å
Alfred J Tria)
A. ‡§√◊ÕË ß¡◊Õ ”À√—∫µ—¥ distal femur µ—¥°√–¥Ÿ°¡“®“°¥â“π medial
B. °“√µ—¥°√–¥Ÿ° proximal tibia ‡æ‘Ë¡‡µ‘¡‚¥¬°“√‡≈Áߥ⫬µ“ (eye ball) µàÕ‡π◊ËÕß®“°°“√µ—¥¥â«¬ cutting guide ´÷Ëß¡—°
µ—¥°√–¥Ÿ°‰¥â‰¡à∂ß÷ ¢Õ∫∑“ߥâ“π lateral
ªî¥°‘ å ∑—ßÈ „πª√–‡∑»‰∑¬·≈–„π¿Ÿ¡¿‘ “§‡Õ‡™’¬ ¥—ߪ√“°Ø
Õ¬Ÿ„à πÀ—«¢âÕ°“√ª√–™ÿ¡«‘™“°“√„πÀ≈“¬Ê ª√–‡∑»‡À≈à“π’È
”À√—∫°“√ºà“µ—¥ UKA ‡ªìπ°“√ºà“µ—¥∑’ˇº¬·æ√à„π
ª√–‡∑»‰∑¬πâÕ¬¡“° ‡π◊ÕË ß®“°®”π«πºŸªâ «É ¬∑’‡Ë À¡“–°—∫
°“√ºà“µ—¥ UKA16 ¡’πÕâ ¬°«à“®”π«πºŸªâ «É ¬∑’‡Ë À¡“–°—∫°“√
ºà“µ—¥ TKA Õ¬à“ß¡“° ·≈–®“°¢âÕ¡Ÿ≈¥—È߇¥‘¡∑’˺≈°“√ºà“
7
µ—¥ UKA ‰¡à¥’‡∑à“∑’˧«√ ®π°√–∑—Ëß„π√–¬–µàÕ¡“ °“√
æ—≤π“ªí®®—¬‡√◊ËÕߢâÕ‡∑’¬¡¥’¢÷Èπ ·≈–§«“¡‡¢â“„®„π«‘∏’
°“√ºà“µ—¥¡“°¢÷Èπ ∑”„Àâº≈°“√ºà“µ—¥ UKA ¥’¢÷Èπ¡“„π
√–¥—∫æÕ„® ·≈–‡¡◊ËÕº ¡º “π°—∫°“√ºà“µ—¥ MIS-UKA
®÷߇°‘¥°√–· °“√¬Õ¡√—∫°“√ºà“µ—¥™π‘¥π’¢È π÷È ¡“„À¡à17,18
¥—ßπ—Èπ °“√æ—≤π“°“√ºà“µ—¥ MIS-UKA „πª√–‡∑»‰∑¬
®÷߇√‘Ë¡µâπ„π‡«≈“‡¥’¬«°—π°—∫°“√ºà“µ—¥ MIS-TKA ·µà
‰¡à‡ªìπ∑’Ë·æ√àÀ≈“¬¡“° ‡π◊ËÕß®“°‡ªìπ™π‘¥°“√ºà“µ—¥
·≈–«‘∏∑’ ”°“√ºà“µ—¥∑’»Ë ≈— ¬·æ∑¬å‰¡à§πÿâ ‡§¬π—°
„πªï §.».2002 ºŸâπ‘æπ∏剥â𔇠πÕ∫∑§«“¡«‘™“
°“√‡√◊ËÕ߇∑§π‘§°“√ºà“µ—¥ MIS-UKA19 ‡æ◊ËÕ„Àâ»—≈¬·æ∑¬å‡¢â“„®∂÷ß√“¬≈–‡Õ’¬¥„π°“√ºà“µ—¥ MIS-UKA ´÷Ëß
∂◊Õ«à“‡ªìπ°“√ºà“µ—¥∑’Ë»—≈¬·æ∑¬åµâÕ߇æàߧ«“¡ π„®„π
‡√◊ËÕ߇∑§π‘§°“√ºà“µ—¥¡“° (technical demanding) ∑—Èß
π’ȧ≥–¢ÕߺŸâπ‘æπ∏å20 ‰¥â· ¥ß„Àâ‡ÀÁπ«à“¡’§«“¡§≈“¥
‡§≈◊ÕË π¢Õßµ”·ÀπàߢâÕ‡∑’¬¡ UKA ®“°°“√∑’»Ë ≈— ¬·æ∑¬å
‰¡à§πÿâ ‡§¬„π°“√∑”°“√ºà“µ—¥ UKA √à«¡°—∫°“√∑”ºà“µ—¥
«‘∏’ MIS ¥—ßπ—Èπ ®“°ªí®®—¬§«“¡¬ÿà߬“°‡√◊ËÕß°“√‡≈◊Õ°
ºŸªâ «É ¬∑’‡Ë À¡“– ¡ ‡∑§π‘§°“√ºà“µ—¥∑’‡Ë ©æ“– √à«¡°—∫°“√
∑”ºà“µ—¥«‘∏’ MIS ∑”„Àâ°“√ºà“µ—¥ MIS-UKA „πª√–‡∑»
§«“¡‡ªìπ¡“¢Õß minimally invasive surgery
„π knee arthroplasty
‰∑¬‰¥â√—∫§«“¡π‘¬¡πâÕ¬°«à“ MIS-TKA Õ¬à“ß¡“° ´÷Ëß
¡’≈°— …≥–‡À¡◊Õπ°—∫À≈“¬Ê ª√–‡∑»∑—«Ë ‚≈°
√ÿª (conclusion)
®“°º≈ ”‡√Á®∑’Ë¥’¡“°¢Õß°“√ºà“µ—¥ TKA „π°“√
√—°…“‚√§¢âÕ‡¢à“‡ ◊ËÕ¡√–¬–∑⓬ „π∑»«√√…∑’˺à“π¡“¡’
°“√æ—≤π“«‘∏’°“√ºà“µ—¥®“° STD-TKA ´÷Ë ß ‡ªì π «‘ ∏’ ∑’Ë ¡’
∫“¥·º≈ºà“µ—¥¢π“¥„À≠à ‰ª Ÿà MIS-TKA ´÷Ë߇ªìπ«‘∏’∑’Ë
¡’·º≈ºà“µ—¥∑’Ë¡’¢π“¥‡≈Á° Õ—π‡ªìπæ—≤π“°“√ºà“µ—¥∑’˵àÕ
‡π◊ËÕß¡“®“°°“√ºà“µ—¥ MIS-UKA ‚¥¬°“√ºà“µ—¥ MISTKA ¡ÿßà ∑”„À⇰‘¥°“√∫“¥‡®Á∫µàÕ‡π◊ÕÈ ‡¬◊ÕË √Õ∫¢âÕ‡¢à“πâÕ¬
≈ß ∑”„Àâº≈°“√ºà“µ—¥√–¬–·√° ‚¥¬‡©æ“–°“√øóôπµ—«
¢ÕߺŸâªÉ«¬¥’¬‘Ëߢ÷Èπ ¥—ß· ¥ß„π√“¬ß“πº≈°“√√—°…“‚¥¬
§≥–·æ∑¬åºŸâ∫ÿ°‡∫‘°«‘∏’ºà“µ—¥π’È„πµà“ߪ√–‡∑» ·≈–„π
ª√–‡∑»‰∑¬ àߺ≈„Àâ°“√ºà“µ—¥«‘∏’π’ȉ¥â√—∫§«“¡ π„®
Õ¬à“ß√«¥‡√Á« ·≈–·æ√àÀ≈“¬‰ª∑—Ë«‚≈° „π¢≥–∑’˧«“¡
π‘¬¡¢Õß°“√ºà“µ—¥ MIS-UKA πâÕ¬°«à“ MIS-TKA ¡“°
‡π◊ËÕß®“°¡’ªí®®—¬ª≈’°¬àÕ¬¢Õß UKA ∑’Ë»—≈¬·æ∑¬åµâÕß
§”π÷ß∂÷ß¡“°°«à“ TKA
‡Õ° “√Õâ“ßÕ‘ß (references)
1. Burnan MS, Finkelstein H, Mayer L. Arthroscopy of the
knee joint. J Bone Joint Surg Am. 1934;16:255.
2. Insall J, Ranawat C, Scott WN, Walker P. Total condylar
knee replacement. Preliminary report. Clin Orthop Relat
Res. 1976;120:149-54.
3. Insall J, Tria AJ Jr, Scott WN. The total condylar knee
prosthesis. The first five years. Clin Orthop Relat Res.
1979;145:68-77.
4. Scott RD, Volatile TB. Twelve yearsû experience with
posterior cruciate retaining total knee arthroplasty. Clin
Orthop Relat Res. 1986;205:100-7.
5. Stern S, Insall J. Posterior stabilized prosthesis: results
after follow-up of nine to twelve years. J Bone Joint Surg
Am. 1992;74:980-6.
6. Ranawat C, Flynn W, Saddler S, Hansraj K, Maynard M.
Long-term results of the total condylar knee arthroplasty:
a 15-year survivorship study. Clin Orthop Relat Res.
1993;286:96-102.
°“√ºà“µ—¥ minimally invasive
surgery-total knee arthroplasty
7. Ritter MA, Herbst SA, Keating EM, Faris PM, Meding JB.
Long-term survivorship analysis of a posterior cruciate
retaining total condylar total knee arthroplasty. Clin
Orthop Relat Res. 1994;309:136-45.
8. Colizza W, Insall J, Scuderi G. The posterior stabilized
total knee prosthesis: assessment of polyethylene damage and osteolysis after a ten year minimum follow-up.
J Bone Joint Surg Am. 1995;77:1716-20.
9. Malkani A, Rand J, Bryan R, Wallrich S. Total knee arthroplasty with the kinematic condylar prosthesis: a ten
year follow-up study. J Bone Joint Surg Am. 1995;77:
423-31.
10. Repicci JA, Eberle RW. Minimally invasive surgical
technique for unicondylar knee arthroplasty. J South
Orthop Assoc. 1999;8:20-7.
11. Romanowski MR, Repicci JA. Minimally invasive unicondylar arthroplasty: eight-year follow-up. J Knee Surg.
2002;15:17-22.
12. Tria AJ Jr, Coon TM. Minimal incision total knee arthroplasty: early experience. Clin Orthop Relat Res. 2003;
416:185-90.
13. Bonutti PM, Neal DJ, Kester MA. Minimal incision total
knee arthroplasty using the suspended leg technique.
8
Orthopedics. 2003;26:899-903.
14. Tanavalee A. Minimally invasive surgery for knee arthroplasty. Chula Med J. 2002;46:925-37.
15. Tanavalee A, Thiengwittayaporn S, Ngarmukos S. Rapid
ambulation and range of motion after minimally invasive
total knee arthroplasty. J Med Assoc Thai. 2004;87
Suppl 2:S195-201.
16. Stern SH, Becker MW, Insall JN. Unicondylar knee arthroplasty: an evaluation of selection criteria. Clin Orthop
Relat Res. 1993;286:143-8.
17. Tanavalee A, Yuktanandana P. Unicondylar knee arthroplasty: an overview. Thai J Orthop Surg. 2003;28:3447.
18. Tanavalee A, Choi YJ, Tria AJ Jr. Unicondylar knee arthroplasty: past and present. Orthopaedics. 2005;28:
1423-33.
19. Tanavalee A, Ngarmukos C. Minimally invasive unicondylar knee arthroplasty: the surgical technique. Thai J
Orthop Surg. 2002;27:105-11.
20. Thiengwittayaporn S, Tanavalee A. Accuracy of implant
position in unicondylar knee arthroplasty with minimally
invasive technique: first case experience in average surgeons. Thai J Orthop Surg. 2004;29:57-63.