À≈—° ”§—≠ „π°“√ºà“ µ—¥ minimally invasive surgery
Transcription
À≈—° ”§—≠ „π°“√ºà“ µ—¥ minimally invasive surgery
∫ ∑ ∑’Ë 3 CHAPTER À≈—° ”§—≠„π°“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty Surgical principle of minimally invasive surgery-total knee arthroplasty Õ“√’ µπ“«≈’ ∫∑π” (introduction) §«“¡À≈“°À≈“¬¢ÕßÀ≈—° ”§—≠„π°“√ºà“µ—¥ MIS-TKA (variation of surgical principle of MIS-TKA) À≈—° ”§—≠„π°“√ºà“µ—¥ MIS-TKA (surgical principles of MIS-TKA) ‡§≈◊ËÕπÀπ⓵à“ߺ‘«Àπ—ß„π¢π“¥·º≈∑’Ë®”°—¥ (mobile skin window in limited incision) ¢âÕ‡¢à“Õ¬Ÿà„π∑à“ßÕÀ≈“¬Ê ¡ÿ¡„π¢≥–∑”ºà“µ—¥ (multiple knee flexion angle) ‡≈◊ËÕπ°√–¥Ÿ° –∫Ⓣª¥â“π¢â“ß (patellar subluxation) ‡§√◊ËÕß¡◊Õ∑’˙૬„π°“√ºà“µ—¥ (facilitating instruments) √ÿª (conclusion) °“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty ∫∑π” (introduction) °“√∑”ºà “ µ— ¥ minimally invasive surgery-total knee arthroplasty (MIS-TKA) ‰¡à‰¥â‡πâπ‡©æ“–°“√∑” °“√ºà“µ—¥∑’¡Ë ¢’ π“¥·º≈‡≈Á°≈ß°«à“°“√∑”ºà“µ—¥ standard total knee arthroplasty (STD-TKA) ‡∑à“π—Èπ ·µà¡’®ÿ¥ ¡ÿßà À¡“¬∑’ Ë ”§—≠ §◊Õ ∑”°“√ºà“µ—¥„π∫√‘‡«≥·º≈¢π“¥‡≈Á° ·≈–∑”„À⇰‘¥°“√∫“¥‡®Á∫¢Õ߇π◊ÕÈ ‡¬◊ÕË πâÕ¬∑’ Ë ¥ÿ ‚¥¬À≈—° ”§—≠„π°“√ºà“µ—¥ TKA (surgical principle of TKA) ¬—ߧ߇À¡◊Õπ‡¥‘¡ §◊Õ‡À¡◊Õπ°—∫°“√ºà“µ—¥ STD-TKA ·µà ¡’À≈—°°“√‡æ‘Ë¡‡µ‘¡ ‡æ◊ËÕ∑”„Àâ°“√∑”ºà“µ—¥‡°‘¥§«“¡πÿà¡ π«≈ ·≈–‡°‘¥°“√∫“¥‡®Á∫¢Õ߇π◊ÕÈ ‡¬◊ÕË πâÕ¬∑’ Ë ¥ÿ ‚¥¬‡©æ“– °“√¥÷ß√—ßÈ º‘«Àπ—ß ·≈–‡π◊ÕÈ ‡¬◊ÕË Õ◊πË Ê „π¢≥–ºà“µ—¥ ·≈–∑” „Àâº≈¢Õß°“√ºà“µ—¥ ”‡√Á®Õ¬à“ß ¡Ë”‡ ¡Õ ·¡â«“à ·π«§‘¥ ¢Õß minimally invasive knee arthroplasty ¡’ª®í ®—¬À≈—° 3 ªí®®—¬ §◊Õ surgical technique, anesthesia & postoperative pain control ·≈– postoperative rehabilitation protocol »—≈¬·æ∑¬å¡—°„Àâ§«“¡ ”§—≠°—∫ªí®®—¬ ‡√◊ÕË ß surgical technique À√◊Õ‡∑§π‘§ª≈’°¬àÕ¬‡©æ“–¢Õß °“√ºà“µ—¥¡“°‡ªìπæ‘‡»… ´÷Ëß°àÕπ∑’Ë®–°≈à“«∂÷ß surgical technique ¢Õß°“√ºà“µ—¥ MIS-TKA „π∫∑π’ºÈ πŸâ æ‘ π∏åπ” ‡ πÕ surgical principle „π°“√ºà“µ—¥ MIS-TKA à«π∑’Ë ‡æ‘¡Ë ‡µ‘¡®“° surgical principle „π°“√ºà“µ—¥ STD-TKA ‡æ◊ÕË „À⇰‘¥§«“¡‡¢â“„®„π°“√ºà“µ—¥«‘∏π’ ‡’È ªìπÕ¬à“ߥ’. §«“¡À≈“°À≈“¬¢ÕßÀ≈—° ”§—≠ „π°“√ºà“µ—¥ MIS-TKA (variation of surgical principle of MIS-TKA) µ—Èß·µà„π√–¬–·√°¢Õß°“√𔇠πÕ°“√ºà“µ—¥ MIS- 18 TKA surgical principle ·≈– surgical technique æ—≤π“ ¡“®“°°≈ÿà¡»—≈¬·æ∑¬åºŸâ∫ÿ°‡∫‘°·µà≈–°≈ÿà¡ „π≈—°…≥–∑’Ë µà“ß°≈ÿ¡à µà“ß∑”°“√æ—≤π“ ‚¥¬¡’§«“¡ —¡æ—π∏å°π— °—∫∫√‘…—∑∑’ˇªìπºŸâº≈‘µ¢âÕ‡∑’¬¡·µà≈–¬’ËÀâÕ ¥—ßπ—Èπ √“¬ß“π„π «“√ “√∑“ß°“√·æ∑¬å√–¬–·√° ®÷߇ªìπ°“√«∫√«¡ surgical principle ·≈– surgical technique ¢Õß»—≈¬·æ∑¬å ·µà≈–°≈ÿ¡à ¡“𔇠πÕ ¥—ßπ—πÈ surgical principle ¢Õß°“√ ºà“µ—¥ MIS-TKA ®÷ß¡’§«“¡·µ°µà“ß°—π‰ªµ“¡§«“¡‡ÀÁπ ‡©æ“–°≈ÿ¡à ∫ÿ§§≈ ¥—ßπ’È π“¬·æ∑¬å Gobler ·≈– Justin1 °≈à“«∂÷ß surgical principle ¢Õß°“√ºà“µ—¥ MIS-TKA ª√–°Õ∫¥â«¬ 5 Õß§å ª√–°Õ∫ ¥—ßπ’È 1. Minimal interruption of nervous tissue and vascular supply in the knee region 2. Minimal dissection of muscles, tendons, and ligaments 3. Minimal resection of bone 4. Minimal loss of blood 5. Minimal pain to the patient ‡¡◊ËÕæ‘®“√≥“ surgical principle µ“¡§«“¡‡ÀÁπ¢Õß π“¬·æ∑¬å Gobler ·≈– Justin ºŸ‡â ¢’¬π¡’§«“¡‡ÀÁπ«à“Õß§å ª√–°Õ∫¢âÕ 1 (minimal interruption of nervous tissue and vascular supply in the knee region) ·≈–¢âÕ 2 (minimal dissection of muscles, tendons, and ligaments) ¡’§«“¡ ¡‡Àµÿ ¡º≈ ·µàÕß§åª√–°Õ∫¢âÕ 3 (minimal resection of bone) ‡ªìπÕß§åª√–°Õ∫∑’‰Ë ¡à‡ªìπ®√‘ß „π∑“ߪؑ∫—µ‘ ‡æ√“–À≈—ß®“°°“√µ—¥°√–¥Ÿ°·≈â« °“√„ à ¢âÕ‡∑’¬¡ ·≈–À¡Õπ√ÕߢâÕ‡∑’¬¡¡’¢π“¥·≈–§«“¡Àπ“ ‰¡à‰¥â·µ°µà“ß®“°°“√ºà“µ—¥ STD-TKA à«πÕß§åª√–°Õ∫¢âÕ 4 (minimal loss of blood) ·≈–¢âÕ 5 (minimal 19 pain to the patient) πà“®–‡ªìπº≈æ≈Õ¬‰¥â®“°°“√∑”„Àâ ‡π◊ÕÈ ‡¬◊ÕË ∫“¥‡®Á∫πâÕ¬¡“°°«à“ 𓬷æ∑¬å Bonutti ·≈–§≥–2 °≈à“«∂÷ßÕß§åª√–°Õ∫ ∑’ Ë ”§—≠ 10 ª√–°“√ ¢Õß°“√ºà“µ—¥ MIS-TKA §◊Õ 1. Decreased skin incision length 2. Flexion and extension of leg for exposure 3. Symbiotic use of retractors 4. Quadriceps-sparing approach 5. Inferior and superior patellar capsular releases 6. Lack of patellar eversion 7. No joint dislocation 8. Downsized instrumentation 9. Use of bone platforms with bone taken out in a piecemeal manner when necessary 10. Suspended leg technique3 ‡¡◊ËÕæ‘®“√≥“Õß§åª√–°Õ∫¢Õß𓬷æ∑¬å Bonutti ·≈–§≥– ºŸâπ‘æπ∏å¡’§«“¡‡ÀÁπ«à“Õß§åª√–°Õ∫∑ÿ°¢âÕ¡’ §«“¡ ¡‡Àµÿ ¡º≈ ·µàÕ“®¡’°“√‡√’¬°™◊ÕË Õß§åª√–°Õ∫·µà ≈–¢âÕ∑’Ë·µ°µà“ß°—𠇙àπ Õß§åª√–°Õ∫¢âÕ 3 (symbiotic use of retractors) ¡’§«“¡À¡“¬‡¥’¬«°—∫ çmobile skin windowé ´÷ËßÀ¡“¬∂÷ß°“√‚¬°Àπ⓵à“ߺ‘«Àπ—ߢ≥–∑” ºà“µ—¥ µàÕ¡“§”«à“ mobile skin window ‡ªìπ§”∑’Ëπ‘¬¡ °≈à“«∂÷ß∫àÕ¬°«à“ Õß§åª√–°Õ∫¢âÕ 4 (quadriceps-sparing approach) ¡’§«“¡À¡“¬∂÷ß°“√ºà“µ—¥‡¢â“ Ÿà¢âÕ‡¢à“ (surgical approach for the knee) ∑’ËÀ≈’°‡≈’ˬ߰“√∫“¥‡®Á∫µàÕ°≈â“¡ ‡π◊ÈÕ quadriceps ´÷ËßÕ“®∑”„À⇰‘¥§«“¡‡¢â“„® —∫ π°—∫ surgical approach for the knee ·∫∫‡©æ“– ™◊ËÕ quadriceps-sparing approach À√◊Õ QS approach ∑’Ë π” ‡ πÕ‚¥¬§≥–¢Õß𓬷æ∑¬å Tria4 ‰¥â „π¢≥–∑’ËÕß§å À≈—° ”§—≠„π°“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty ª√–°Õ∫¢âÕ 9 (use of bone platforms with bone taken out in a piecemeal manner when necessary) ·≈– ¢â Õ 10 (suspended leg technique) ‡ªìπ§«“¡∂π—¥ à«πµ—«¢Õß»—≈¬·æ∑¬å°≈ÿà¡π’È ´÷Ëß»—≈¬·æ∑¬å à«π„À≠ൗ¥ °√–¥Ÿ° ·≈–‡Õ“ÕÕ°·∫∫‡ªìπ™‘πÈ „À≠à™π‘È ‡¥’¬« ·≈–‰¡à𬑠¡ °“√ÀâÕ¬¢“µ“¡°≈ÿ¡à ¢Õß𓬷æ∑¬å Bonutti 𓬷æ∑¬å Tria5 ´÷ßË ‡ªìπÀπ÷ßË „π»—≈¬·æ∑¬åº∫Ÿâ °ÿ ‡∫‘° °“√ºà“µ—¥ MIS-TKA ‚¥¬„™â surgical approach ™π‘¥ quadriceps-sparing (QS)4 ´÷ßË ¡’¢Õâ ®”°—¥„π°“√¡Õ߇ÀÁπ ¿“¬„π¢âÕ Ÿß ‰¥â°≈à“«¬È”∂÷ß∫∑∫“∑¢Õ߇§√◊ËÕß¡◊Õ∑’Ë„™â„π °“√∑”ºà“µ—¥ MIS-TKA ´÷ßË ¡’¢π“¥∫“ß ‡√’¬« ·≈–Õÿª°√≥å ∫“ß™‘Èπ “¡“√∂π”‡¢â“‰ªª√–°Õ∫°—π¿“¬„π¢âÕ‰¥â ‚¥¬ 𓬷æ∑¬å Tria „Àâ§«“¡‡ÀÁπ«à“ ‡§√◊ÕË ß¡◊Õ∑’æË ‡‘ »…‡À≈à“π’È ∂◊Õ‡ªìπªí®®—¬À≈—°¢âÕÀπ÷Ëß„π°“√ºà“µ—¥ TKA „π∫√‘‡«≥ °“√¡Õ߇ÀÁπ∑’®Ë ”°—¥ ´÷ßË ‡§√◊ÕË ß¡◊Õµ—¥°√–¥Ÿ° distal femur ·≈– proximal tibia „π°“√ºà“µ—¥ MIS-TKA ™π‘¥ QS µ—¥ °√–¥Ÿ°∑“ߥâ“π medial ·∑π∑’®Ë –µ—¥®“°¥â“π anterior À≈—° ”§—≠„π°“√ºà“µ—¥ MIS-TKA (surgical principle of MIS-TKA) æ—≤π“°“√¢Õß MIS-TKA √ÿ¥Àπâ“¡“µ≈Õ¥®π∂÷ß ªí®®ÿ∫π— ‚¥¬√“¬ß“πº≈°“√ºà“µ—¥„π√–¬–·√°¢Õß MISTKA „Àâº≈¥’6-11 ·µàµàÕ¡“¡’√“¬ß“π∑’Ë· ¥ßº≈¢—¥·¬âß «à “ MIS-TKA „Àâº≈°“√√—°…“‰¡à·µ°µà“ß®“° STDTKA12,13 ´÷ßË ‰¡à “¡“√∂∑√“∫‰¥â«“à °≈ÿ¡à »—≈¬·æ∑¬åº√Ÿâ “¬ ß“πº≈°“√ºà“µ—¥∑’ˉ¡à¥’π’È¡’ surgical principle ”À√—∫ °“√ºà“µ—¥ MIS-TKA ‡ªìπ‡™àπ‰√ ·≈–„π¢≥–‡¥’¬«°—π°≈ÿ¡à »—≈¬·æ∑¬åº∫Ÿâ °ÿ ‡∫‘°°“√ºà“µ—¥«‘∏’ minimally invasive surgery (MIS) °Á‰¡à‰¥â √ÿª„Àâ™—¥‡®π«à“ surgical principle °“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty „π°“√ºà“µ—¥ MIS-TKA §«√‡ªìπÕ¬à“߉√ ¥—ßπ—πÈ ®“°°“√ √«∫√«¡«√√≥°√√¡‡°’¬Ë «°—∫ MIS-TKA ·≈–®“°ª√– ∫°“√≥å°“√‡√’¬π√Ÿ«â ∏‘ °’ “√ºà“µ—¥ MIS-TKA ∑—ßÈ „π√à“ßÕ“®“√¬å „À≠à ·≈–„πºŸâªÉ«¬¡“ª√–¡“≥ 8 ªï ºŸâπ‘æπ∏å𔇠πÕ À≈—° ”§—≠„π°“√ºà“µ—¥ MIS-TKA §«√¡’Õß§åª√–°Õ∫ 4 ¢âÕ ¥—ßπ’È 1. ‡§≈◊ÕË πÀπ⓵à“ߺ‘«Àπ—ß„π¢π“¥·º≈∑’®Ë ”°—¥14 (mobile skin window in limited incision) º‘«Àπ—ß·≈–‡π◊ÕÈ ‡¬◊ÕË „µâº«‘ Àπ—߇ªìπ‡π◊ÕÈ ‡¬◊ÕË ÕàÕπ (soft tissue) ∑’Ë¡’§ÿ≥ ¡∫—µ‘¬◊¥À¬ÿàπ‰¥â ‚¥¬‡©æ“–Õ¬à“߬‘Ëß º‘« Àπ—ß·≈–‡π◊ÈÕ‡¬◊ËÕ„µâº‘«Àπ—ß∫√‘‡«≥√Õ∫Ê ¢âÕ∑’Ë¡’æ‘ —¬°“√ ‡§≈◊ËÕπ‰À« (range of motion) ‰¥â¡“° ‡π◊ËÕß®“°§«“¡ ¬◊¥À¬ÿàπ¢Õ߇π◊ÈÕ‡¬◊ËÕ‡À≈à“π’ș૬ à߇ √‘¡„Àâ¢âÕ‡§≈◊ËÕπ‰À« ‰¥â¥’ „π·º≈ºà“µ—¥∑’Ë¡’¢π“¥‡≈Á° ‡¡◊ËÕ°√’¥·º≈„Àâ≈÷°≈ß®π ‡¢â“ Ÿà¢âÕ‡¢à“·≈â« °“√¡Õ߇¢â“‰ª¿“¬„π¢âÕ‡¢à“®–‡ ¡◊Õπ °“√¡Õߺà“π™àÕßÀπ⓵à“ß ®÷ß∑”„Àâ¡’ºŸâ‡√’¬°·º≈ºà“µ—¥ ¢π“¥‡≈Á°π’È«à“‡ªìπ™àÕßÀπ⓵à“ߺ‘«Àπ—ß (skin window) °“√‡§≈◊ËÕπÀπ⓵à“ߺ‘«Àπ—ß„π¢≥–∑”ºà“µ—¥ §◊ Õ °“√ ‡§≈◊ËÕπ™àÕß∑’ˇªìπ∫√‘‡«≥·º≈ºà“µ—¥ ‚¥¬°“√„™â retractor ¥÷ß√—È߇π◊ÈÕ‡¬◊ËÕ‡À≈à“π’È„À⇧≈◊ËÕπµ—«‰ª„π∑‘»∑“ß„¥∑‘»∑“ß Àπ÷ËߢÕß∫√‘‡«≥ºà“µ—¥ ´÷Ëß»—≈¬·æ∑¬åºŸâ™à«¬µâÕߺàÕπ·√ß ¥÷ß√—ßÈ ‡π◊ÕÈ ‡¬◊ÕË Ωíßò µ√ߢⓡ‡ ¡Õ ‡æ◊ÕË ∑”„À⇰‘¥°“√‚¬°¢Õß ™àÕßÀπ⓵à“ߺ‘«Àπ—ß ∑”„Àâ»≈— ¬·æ∑¬å “¡“√∂¬â“¬®ÿ¥∑” ß“π‰ª‰¥âÀ≈“¬Ê ®ÿ¥„π∫√‘‡«≥ºà“µ—¥∑’Ë¡’¢π“¥·º≈®”°—¥ ‰¥â ·≈– “¡“√∂¡Õ߇ÀÁπ¿“¬„π¢âÕÕ¬à“ß∑—Ë«∂÷ß (√Ÿ ª ∑’Ë 3.1) ¥—ßπ—Èπ Õß§åª√–°Õ∫¢âÕπ’ȵ√ß°—∫§”∑’Ë𓬷æ∑¬å Bonutti ·≈–§≥–‡√’¬°«à“ symbiotic use of retractors2 ”À√—∫ºŸâªÉ«¬∑’Ë¡’¢“‚°àß °“√‡≈◊Õ°µ”·ÀπàߢÕß°“√ 20 °√’¥·º≈ºà“µ—¥§àÕπ¡“∑“ߥâ“π„π (medial) ¢ÕߢâÕ‡¢à“ ‡≈Á°πâÕ¬ §◊Õ Àà“ß®“°·π«°≈“ß (midline) ¢ÕߢâÕ‡¢à“ ª√–¡“≥ 1-2 ´¡. À√◊Õ‡ªìπ·π«∑’µË √ß°—∫¢Õ∫¥â“π medial ¢Õß°√–¥Ÿ° –∫â“ ·≈–‡¡◊ËÕ°√’¥¡’¥ºà“π™—Èπ‡π◊ÈÕ‡¬◊ËÕ∑’Ë ≈÷°≈߉ª‡æ◊ËÕ‡ªî¥‡¢â“ Ÿà¢âÕ‡¢à“ °Á¬—ß§ß°√’¥¡’¥„π·π«‡¥’¬« °—π ∑”„Àâ»—≈¬·æ∑¬å‡§≈◊ËÕπÀπ⓵à“ߺ‘«Àπ—߉ª∑“ߥâ“π medial ßà“¬¢÷Èπ ∑”„Àâ‡≈“–‡π◊ÈÕ‡¬◊ËÕ∑“ߥâ“π medial ¢Õß °√–¥Ÿ°Àπâ“·¢âß (medial proximal tibial release) –¥«° ´÷ßË À≈—ß®“°π—πÈ »—≈¬·æ∑¬åÀ¡ÿπ°√–¥Ÿ°Àπâ“·¢âßÕÕ° ‰ª¥â“ππÕ° (tibial external rotation) ‰¥âßà“¬¢÷Èπ ·≈– ‡°‘¥·√ßµ÷ߢÕ߇π◊ÕÈ ‡¬◊ÕË ¥â“π medial „π¢≥–∑”ºà“µ—¥πâÕ¬ ≈ß °“√°√’¥·º≈ºà“µ—¥„Àâª≈“¬·º≈ à«πµâπ (proximal end) ‚§â߉ªµ“¡¢Õ∫∫π¥â“π„π (superomedial edge) ¢Õß°√–¥Ÿ° –∫â“15 ∑”„Àâ¡Õ߇ÀÁπ·º≈¡’¢π“¥ —πÈ ≈ß (‡¡◊ÕË ‡¢à“Õ¬Ÿà„π∑à“‡À¬’¬¥) ‰¡à¢—¥¢«“ß°“√∑”ß“π‡¡◊ËÕ‚¬° Àπ⓵à“ߺ‘«Àπ—ß ·≈–‡¡◊ËÕ·º≈ºà“µ—¥À“¬¥’·≈â« §«“¡‚§âß ¢Õß·º≈π’ÈÕ¬Ÿà„π·π«„°≈⇧’¬ß√Õ¬¬àπ¢Õߺ‘«Àπ—ß ®÷ ß ∑”„Àâ·º≈‡ªìπ¥Ÿ¢π“¥ —πÈ ≈ß ·≈–Õ“®¡Õ߇ÀÁπ·º≈‡ªìπ‰¡à ™—¥‡®π ·µà®“°ª√– ∫°“√≥å¢ÕߺŸâπ‘æπ∏å„πºŸâªÉ«¬™“« ‰∑¬ æ∫«à“ºŸâªÉ«¬¡—°‰¡à™Õ∫·º≈‡ªìπ∑’Ë¡’≈—°…≥–‚§âß∑’Ë ª≈“¬·º≈ à«π proximal ¥â«¬§«“¡√Ÿ â °÷ «à“‡ªìπ·º≈ºà“µ—¥ ∑’‡Ë °‘¥®“°°“√°√’¥¡’¥∑’∫Ë ¥‘ ‡∫’¬È « ·µà™Õ∫·º≈ºà“µ—¥∑’‡Ë ªìπ ·π«µ√ß ¥—ßπ—πÈ „π‡«≈“µàÕ¡“ºŸπâ æ‘ π∏å®ß÷ ≈ß¡’¥„π∑‘»∑“ß ‡ªìπ·π«µ√ß°—∫ºŸªâ «É ¬∑ÿ°√“¬ 2. ¢âÕ‡¢à“Õ¬Ÿ„à π∑à“ßÕÀ≈“¬Ê ¡ÿ¡„π¢≥–∑”ºà“µ—¥2 (multiple knee flexion angle) „π°“√ºà“µ—¥ STD-TKA ‡¡◊ÕË »—≈¬·æ∑¬å‡ªî¥·º≈ºà“ µ—¥∑’¡Ë ¢’ π“¥·º≈„À≠à ·≈–æ≈‘°°√–¥Ÿ° –∫â“·≈â« °Á¡°— „Àâ À≈—° ”§—≠„π°“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty 21 A B C D √Ÿª∑’Ë 3.1 · ¥ß°“√‡§≈◊ËÕπÀπ⓵à“ߺ‘«Àπ—ß„π¢π“¥·º≈∑’Ë®”°—¥ ‡æ◊ËÕ‡æ‘Ë¡°“√¡Õ߇ÀÁπ¿“¬„π¢âÕ ¥—ßµ—«Õ¬à“ß (‡¢à“¢â“ߢ«“·≈–Õ¬Ÿà „π∑à“‡À¬’¬¥µ√ß) A. °“√¡Õ߇ÀÁπ distal femur ∫√‘‡«≥ anterolateral ‡¡◊ÕË Àπ⓵à“ߺ‘«Àπ—߇§≈◊ÕË π∑“ߥâ“π superior ·≈–¥â“π lateral B. °“√¡Õ߇ÀÁπ distal femur ∫√‘‡«≥ anterior ‡¡◊ÕË Àπ⓵à“ߺ‘«Àπ—߇§≈◊ÕË π∑“ߥâ“π superior C.°“√¡Õ߇ÀÁπ proximal tibia ∫√‘‡«≥ anterolateral ‡¡◊ÕË Àπ⓵à“ߺ‘«Àπ—߇§≈◊ÕË π∑“ߥâ“π inferior ·≈–¥â“π lateral D.°“√¡Õ߇ÀÁπ∑—ßÈ distal femur ·≈– proximal tibia ∫√‘‡«≥ anteromedial ‡¡◊ÕË Àπ⓵à“ߺ‘«Àπ—߇§≈◊ÕË π∑“ߥâ“π medial ¢âÕ‡¢à“Õ¬Ÿà„π¡ÿ¡ßÕª√–¡“≥ 100-120 Õß»“ À≈—ß®“° π—Èπ¢—ÈπµÕπµà“ßÊ „π°“√µ—¥°√–¥Ÿ°µâπ¢“ (femur) ·≈– °√–¥Ÿ°Àπâ“·¢âß (tibia) √ÿ¥ÀπⓉª‚¥¬∑’Ë¢âÕ‡¢à“Õ¬Ÿà„π¡ÿ¡ ßÕ‡¢à“∑’˧ß∑’ˇ™àππ’ȇªìπ à«π„À≠à ‡π◊ËÕß®“°»—≈¬·æ∑¬å “¡“√∂¡Õ߇ÀÁπ‚§√ß √â“ßµà“ßÊ µ“¡°“¬«‘¿“§¿“¬„π¢âÕ ‡¢à“‰¥â™¥— ‡®πµ≈Õ¥∑ÿ°¢—πÈ µÕπ ¬°‡«âπ¢—πÈ µÕπµ√«® Õ∫ flexion-extension gap À√◊Õ¢—ÈπµÕπ∑¥ Õ∫°“√‡§≈◊ËÕπ ‰À«¢ÕߢâÕ‡¢à“‡∑’¬¡∑—ßÈ µ—«∑¥≈Õß·≈–µ—«®√‘ß ·µà„π°“√ºà“µ—¥ MIS-TKA »—≈¬·æ∑¬å¡¢’ Õâ ®”°—¥„π °“√¡Õ߇ÀÁπ (visualization) ¥—ßπ—Èπ °“√‡§≈◊ËÕπÀπ⓵à“ß º‘«Àπ—ßæ√âÕ¡°—∫°“√ª√—∫‡ª≈’ˬπ„Àâ¢âÕ‡¢à“Õ¬Ÿà„π¡ÿ¡ßÕ∑’Ë ·µ°µà“ß°—π„π¢≥–ºà“µ—¥ ™à«¬∑”„Àâ»—≈¬·æ∑¬å¡Õ߇ÀÁπ ‚§√ß √â“ßµà“ßÊ µ“¡°“¬«‘¿“§¿“¬„π¢âÕ‡¢à“‰¥â ∑—ßÈ Ê ∑’Ë ·º≈¡’¢π“¥‡≈Á° ·≈–≈¥‚Õ°“ ∑”„Àâ‡π◊ÕÈ ‡¬◊ÕË ∫“¥‡®Á∫®“° °“√∑’ˉ¡à‰¥â¥÷ß√—Èߺ‘«Àπ—ß·≈–‡π◊ÈÕ‡¬◊ËÕ„µâº‘«Àπ—ßÕ¬à“ß¡“° (√Ÿª∑’Ë 3.2) ´÷ËßÕß§åª√–°Õ∫¢âÕπ’ȵ√ß°—∫§”∑’Ë𓬷æ∑¬å °“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty A 22 B √Ÿª∑’Ë 3.2 · ¥ß°“√¡Õ߇ÀÁπ¿“¬„π¢âÕ‡¢à“¥â«¬¡ÿ¡ßÕ¢âÕ‡¢à“∑’·Ë µ°µà“ß°—π‚¥¬¡’¢π“¥·º≈®”°—¥ (‡¢à“¢â“ߢ«“) A. ‡¢à“Õ¬Ÿ„à π∑à“‡À¬’¬¥µ√ß ∑”„Àâ»≈— ¬·æ∑¬å¡Õ߇ÀÁπ∫√‘‡«≥ anterior ¢Õß distal femur‰¥â¥’ B. ‡¢à“Õ¬Ÿ„à π∑à“ßÕª√–¡“≥ 45-60 Õß»“ ∑”„Àâ»≈— ¬·æ∑¬å¡Õ߇ÀÁπ∫√‘‡«≥ anteromedial ¢Õß proximal tibia ¡“°¢÷πÈ Bonutti ·≈–§≥– ‡√’¬°«à“ flexion and extension of leg for exposure µ—«Õ¬à“ß ‡™àπ „π∑à“‡¢à“ßÕª√–¡“≥ 45-60 Õß»“ (´÷ß Ë ‡√’¬°«à“ mid-flexion position) °“√µ—¥°√–¥Ÿ°∑—Èß distal femur ·≈– proximal tibia ‡ªìπ‰ª‚¥¬ßà“¬ ·≈–¡’·√ߥ÷ß√—Èß®“° ‡π◊ÈÕ‡¬◊ËÕÕ◊ËπÊ πâÕ¬ (·µà»—≈¬·æ∑¬å®”‡ªìπµâÕß√–¡—¥√–«—ß °“√„™â‡≈◊ËÕ¬µ—¥°√–¥Ÿ°‰¡à„Àâ≈÷°‡°‘π posterior cortex) πÕ°®“°π’È °“√ßÕ¢âÕ‡¢à“¡ÿ¡ mid-flexion ∑”„Àâ°“√„ à polyethylene insert ßà“¬¢÷πÈ ¡“° „π∑à“‡¢à“‡À¬’¬¥µ√ß À√◊Õ¢âÕ‡¢à“ßÕ¡ÿ¡πâÕ¬Ê ∑” „Àâ»—≈¬·æ∑¬å “¡“√∂‡ÀÁπ anterior femoral cortex ‰¥â Õ¬à“ß™—¥‡®π ·≈– “¡“√∂µ√«® Õ∫‡æ◊ËÕªÑÕß°—π¿“«– anterior femoral notching ®“°°“√µ—¥ anterior femoral bone cut ‚¥¬°“√„™â boom °«“¥ºà“π∫√‘‡«≥ anterior femoral cortex ´÷Ëß¡Õ߇ÀÁπ‰¥â‚¥¬µ√ß (direct visualization) πÕ°®“°π’È °“√‡À¬’¬¥¢âÕ‡¢à“¬—ß¡’ª√–‚¬™πå∑”„Àâ °“√µ—¥º‘«°√–¥Ÿ° –∫â“ßà“¬¢÷πÈ ¡“° „π∑à“‡¢à“ßÕª√–¡“≥ 90 Õß»“ √à«¡°—∫„Àâ»≈ — ¬·æ∑¬åºŸâ™à«¬À‘È«µâπ¢“„À⠟ߢ÷Èπ ∑”„Àâ°“√ «¡ femoral component ßà“¬¢÷πÈ ‚¥¬‡π◊ÕÈ ‡¬◊ÕË ‰¡à¥ß÷ √—ßÈ ¡“°‡∑à“°—∫°“√ «¡‡¡◊ÕË ¡’¡¡ÿ ßÕ‡¢à“∑’¡Ë “° „π∑à“‡¢à“ßÕª√–¡“≥ 100-110 Õß»“ √à«¡°—∫„Àâ »—≈¬·æ∑¬åºŸâ™à«¬¥—π distal femur „À≪∑“ß distal À√◊Õ ª≈“¬‡µ’¬ß ∑”„Àâ°“√‡µ√’¬¡ ·≈– «¡ tibial component ßà“¬¢÷Èπ ‚¥¬¡Õ߇ÀÁπ¢Õ∫¢Õß tibial cortex ‰¥â‚¥¬√Õ∫ °√–¥Ÿ° 3. ‡≈◊ËÕπ°√–¥Ÿ° –∫Ⓣª¥â“π¢â“ß (patellar subluxation) µ—Èß·µà„π√–¬–·√°¢Õß°“√𔇠πÕ«‘∏’ºà“µ—¥ MISTKA »—≈¬·æ∑¬åºŸâ∫ÿ°‡∫‘°∑ÿ°°≈ÿࡇÀÁπæâÕß°—π«à“ µâÕß ‡≈◊ÕË π°√–¥Ÿ° –∫Ⓣª¥â“π¢â“ß (lateral) (√Ÿª∑’Ë 3.3) ·∑π À≈—° ”§—≠„π°“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty 23 A B C D √Ÿª∑’Ë 3.3 · ¥ß°“√‡≈◊ËÕπ°√–¥Ÿ° –∫Ⓣª¥â“π¢â“ß·∑π°“√æ≈‘° ´÷Ëß®”‡ªìπµâÕ߇≈◊ËÕπ®π°√–¥Ÿ° –∫â“æâπ‰ª®“°¢Õ∫¢Õß lateral femoral condyle (‡¢à“¢â“ߴ⓬) A. ¿“æ®”≈Õß· ¥ß°“√‡≈◊ÕË π°√–¥Ÿ° –∫Ⓣª¥â“π¢â“ß ‡æ◊ÕË °“√∑”ß“π∫√‘‡«≥°√–¥Ÿ° distal femur B. ‡¡◊ÕË ‡¢à“Õ¬Ÿ„à π∑à“‡À¬’¬¥ °“√‡≈◊ÕË π°√–¥Ÿ° –∫â“∑”‰¥âß“à ¬®πÕ“®∑”„À⇰◊Õ∫æ≈‘°°√–¥Ÿ° –∫Ⓣ¥â C.·≈– D. °“√‡≈◊ËÕπ°√–¥Ÿ° –∫â“®πæâπ®“°¢Õ∫¢Õß lateral femoral condyle ¡’§«“¡®”‡ªìπ¡“°¢≥–µ—¥°√–¥Ÿ° distal femur ·≈–¢≥– «¡ femoral component °“√æ≈‘°°√–¥Ÿ° –∫â“1-7 ‚¥¬®“°°“√»÷°…“¢Õß𓬷æ∑¬å Bonutti2 æ∫«à“ „π°“√ºà“µ—¥ STD-TKA ´÷ßË ¡’°“√ æ≈‘°°√–¥Ÿ° –∫â“¢≥–ºà“µ—¥π—Èπ ‡°‘¥·√ßµ÷ß∑’˰≈â“¡‡π◊ÈÕ quadriceps ¡“° ·µà‡¡◊ÕË ‡ª≈’¬Ë π‡ªìπ°“√‡≈◊ÕË π°√–¥Ÿ° –∫Ⓣª¥â“π lateral ∑”„Àâ·√ßµ÷ßπ’≈È ¥≈߇ªìπ‡∑à“µ—« ´÷ßË °“√ æ≈‘°°√–¥Ÿ° –∫Ⓡ°◊Õ∫µ≈Õ¥‡«≈“¢Õß°“√ºà“µ—¥ TKA ∑” °“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty 24 A B √Ÿª∑’Ë 3.4 · ¥ß‡§√◊ÕË ß¡◊Õ ”À√—∫°“√ºà“µ—¥ TKA ™π‘¥µà“ßÊ A. ‡§√◊ÕË ß¡◊Õ¡“µ√∞“π B. ‡§√◊ÕË ß¡◊Õ mini-instrument ´÷ßË ¥—¥·ª≈߇§√◊ÕË ß¡◊Õ‡¥‘¡„Àâ‡≈Á°≈ß „À⇰‘¥¿“«– quadriceps dysfunction À√◊ÕÕàÕπ·√ßÀ≈—ß ®“°°“√ºà“µ—¥‡ªìπ‡«≈“π“π ¡’ß“π«‘®¬— ´÷ßË · ¥ß«à“ ∑’√Ë –¬– 3 ‡¥◊ÕπÀ≈—ß°“√ºà“µ—¥ STD-TKA æ∫«à“√âÕ¬≈– 60 ¢Õß ºŸªâ «É ¬¬—ßµâÕß„™â¡Õ◊ ™à«¬æ¬ÿߢ≥–≈ÿ°®“°‡°â“Õ’16 È πÕ°®“° π’È ¡’ß“π«‘®¬— ∑’ Ë π—∫ πÿπ«à“°“√‡≈◊ÕË π°√–¥Ÿ° –∫â“¥’°«à“°“√ æ≈‘°°√–¥Ÿ° –∫â“ ‚¥¬æ∫«à“°“√‡≈◊ËÕπ°√–¥Ÿ° –∫â“¢≥– ºà“µ—¥¡’¢Õâ ¥’ §◊Õ ∑”„Àâ‡≈◊Õ¥¡“‡≈’¬È ß°√–¥Ÿ° –∫â“¡“°°«à“ °“√æ≈‘°°√–¥Ÿ° –∫â“Õ¬à“ß¡’π¬— ”§—≠∑“ß ∂‘µ17,18 ‘ ·≈– ™à«¬∑”„Àâæ‘ —¬°“√‡§≈◊ËÕπ‰À« (range of motion) ¢Õß ¢âÕ‡¢à“À≈—ß°“√ºà“µ—¥¥’¢π÷È 19 Õ¬à“߉√°Áµ“¡ „π√–¬–‰¡àπ“π¡“π’È ¡’ß“π«‘®—¬™π‘¥ randomized controlled trial20 ∑’·Ë ¥ßº≈À—°≈â“ß«à“ °“√ ‡≈◊ÕË π°√–¥Ÿ° –∫Ⓣª¥â“π lateral ‰¡à‰¥â∑”„Àâº≈°“√√—°…“ ¥’°«à“°“√æ≈‘°°√–¥Ÿ° –∫â“„π¢≥–∑”ºà“µ—¥ ∑—Èß„π‡√◊ËÕß °“√ßÕ‡¢à“ °“√øóôπµ—«¢Õß°≈â“¡‡π◊ÈÕ quadriceps ·≈–º≈ °“√√—°…“®π∂÷ß√–¬– 6 ‡¥◊ÕπÀ≈—ß®“°°“√ºà“µ—¥ πÕ° ®“°π’Ȭ—ß¡’ß“π«‘®—¬∑’Ë· ¥ß«à“°“√æ≈‘°°√–¥Ÿ° –∫â“¢≥– ºà“µ—¥ TKA ‰¡à‰¥â∑”„À⇰‘¥¿“«–°√–¥Ÿ° –∫Ⓡ§≈◊ÕË πµ—«µË” ≈ß (patellar baja) „π¿“¬À≈—ß®“°°“√ºà“µ—¥21 Õ—π‡ªìπ ªí®®—¬∑’Ë àߺ≈°√–∑∫µàÕ°“√¢÷Èπ≈ß∫—π‰¥ ·≈– function score ®“°°“√ºà“µ—¥ TKA πâÕ¬≈ß22 À“°æ‘®“√≥“®“°¢âÕ‡∑Á®®√‘ß·≈â«®–‡ÀÁπ«à“ ‡¡◊ËÕ·º≈ ºà“µ—¥¢ÕߢâÕ‡¢à“¡’¢π“¥§«“¡¬“«∑’®Ë ”°—¥ »—≈¬·æ∑¬å “¡“√∂‡≈◊ËÕπ°√–¥Ÿ° –∫Ⓣª¥â“π¢â“߉¥â∑—Èß∑à“‡À¬’¬¥ ·≈– À≈—° ”§—≠„π°“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty 25 A B C D √Ÿª∑’Ë 3.5 · ¥ß‡§√◊ÕË ß¡◊Õ ”À√—∫°“√ºà“µ—¥ TKA ∑’‰Ë ¥â√∫— °“√ÕÕ°·∫∫摇»… ”À√—∫™à«¬°“√ºà“µ—¥∑’¡Ë °’ “√‡ªî¥·º≈¢π“¥‡≈Á° A. Distal femoral cutting guide ∑’¡Ë ·’ π«µ—¥°√–¥Ÿ°®“°¥â“π medial B. Proximal tibial cutting guide ∑’¡Ë ·’ π«µ—¥°√–¥Ÿ°®“°¥â“π medial C.Femoral sizing guide ·≈– rotation ∑’¡Ë √’ ªŸ √à“߇√’¬« ·≈–∫“ß D.Femoral 4-in-1 cutting guide ∑’¡Ë ¥’ “â ¡®—∫¬◊πË ÕÕ°∑”„Àâ∑”ß“π‰¥â –¥«°¢÷πÈ ßÕ‡¢à“ „π¢≥–‡¥’¬«°—π »—≈¬·æ∑¬åÕ“® “¡“√∂æ≈‘°°√–¥Ÿ° –∫Ⓣ¥â„π∑à“‡À¬’¬¥‡¢à“ ·µà‰¡à “¡“√∂æ≈‘°°√–¥Ÿ° –∫â“„π∑à“ßÕ‡¢à“‰¥â¥—߇™àπ·º≈ºà“µ—¥∑’Ë¡’¢π“¥„À≠à ¥—ß π—Èπ „π§«“¡‡ÀÁπ¢ÕߺŸâπ‘æπ∏å °“√‡≈◊ËÕπ°√–¥Ÿ° –∫Ⓣª ¥â“π lateral ¬—ߧ߇ªìπÀ≈—° ”§—≠¢Õß°“√ºà“µ—¥ MISTKA ∑—Èßπ’Ȱ“√¢÷Èπ·√ߥ—π tourniquet ‡¡◊ËÕ‡¢à“Õ¬Ÿà„π∑à“ deep flexion √à«¡°—∫°“√µ—¥ patellar fat pad ·≈–°“√∑” lateral proximal tibial release ™à«¬∑”„Àâ‡≈◊ËÕπ°√–¥Ÿ° –∫Ⓣª¥â“π¢â“߉¥â¡“°¢÷πÈ 23 4. ‡§√◊ËÕß¡◊Õ∑’˙૬„π°“√ºà“µ—¥ (facilitating instruments) ‡π◊ËÕß®“°‡§√◊ËÕß¡◊Õ„π°“√ºà“µ—¥ TKA ∑’Ë„™âÕ¬Ÿà∑—Ë«‰ª ‰¥â √— ∫ °“√ÕÕ°·∫∫ ”À√— ∫ °“√ºà “ µ— ¥ ∑’Ë ¡’ ° “√‡ªî ¥ ·º≈ ¢π“¥„À≠à ·≈–»—≈¬·æ∑¬å¡Õ߇ÀÁπ¿“¬„π¢âÕ‰¥â∑—Ë« ¥—ß π—πÈ ¢π“¥¢Õ߇§√◊ÕË ß¡◊Õ®÷ß¡—°¡’¢π“¥„À≠൓¡°—π‰ª ‡¡◊ÕË °“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty 26 A B C √Ÿª∑’Ë 3.6 · ¥ßµ—«Õ¬à“ß°“√„™â‡§√◊ÕË ß¡◊Õ∑’‰Ë ¥â√∫— °“√ÕÕ°·∫∫ ”À√—∫™à«¬°“√ºà“µ—¥∑’¡Ë °’ “√‡ªî¥·º≈¢π“¥‡≈Á°„πºŸªâ «É ¬®√‘ß (‡¢à“¢â“ß ´â“¬) A. „ à distal femoral 4-in-1 cutting guide ‚¥¬∑·¬ß‡¢â“∑’≈–¥â“π B. „ à femoral sizing guide „π∑à“‡¢à“ßÕ C.µ√«® Õ∫°àÕπ°“√µ—¥ anterior femoral cortex „π∑à“‡À¬’¬¥¢âÕ‡¢à“‰¥â ‡æ◊ÕË ªÑÕß°—π‰¡à‡°‘¥ anterior femoral notching »—≈¬·æ∑¬å‡ª≈’ˬπ¡“∑”ºà“µ—¥„π¢π“¥·º≈∑’Ë®”°—¥ °“√ „™â‡§√◊ËÕß¡◊Õ∑’ˉ¥â√—∫°“√ÕÕ°·∫∫¡“‡ªìπæ‘‡»… ‡™àπ ¡’ ¥â“¡®—∫¬“« √Ÿª√à“ß∫“ß ‰¡à„À≠à‡°‘π§«“¡®”‡ªìπ ®÷ ß ¡’ ª√–‚¬™πå™«à ¬„Àâ°“√ºà“µ—¥ ”‡√Á®ßà“¬¢÷πÈ ¡“° „πªí®®ÿ∫—π∫√‘…—∑ºŸâº≈‘µ¢âÕ‡¢à“‡∑’¬¡∑ÿ°∫√‘…—∑®—¥À“ ‡§√◊ÕË ß¡◊Õ‡æ◊ÕË ™à«¬„Àâ°“√ºà“µ—¥ MIS-TKA ∑” ”‡√Á®‰¥âß“à ¬ ¢÷πÈ ‚¥¬¡’∑ß—È ‡§√◊ÕË ß¡◊Õ∑’ÕË Õ°·∫∫¡“‡©æ“– ·≈–‡§√◊ÕË ß¡◊Õ∑’Ë ¥—¥·ª≈ß¡“®“°‡§√◊ÕË ß¡◊Õ¡“µ√∞“π ¡—°‡√’¬°™ÿ¥‡§√◊ÕË ß¡◊Õ ‡À≈à“π’«È “à mini-instruments5,24 ´÷ßË ‡§√◊ÕË ß¡◊Õ·µà≈–™‘πÈ ¡’ ≈—°…≥–§≈⓬‡§√◊ÕË ß¡◊Õ¡“µ√∞“π ·µà¡¢’ 𓥇≈Á°·≈–∫“ß °«à“‡§√◊ËÕß¡◊Õ ”À√—∫°“√ºà“µ—¥ STD-TKA (√Ÿª∑’Ë 3.43.6) ∑—ßÈ π’È °“√ÕÕ°·∫∫‡§√◊ÕË ß¡◊Õ∑’™Ë «à ¬°“√ºà“µ—¥ MIS- 27 TKA ·ª√‰ªµ“¡§«“¡‡ÀÁπ ·≈–§«“¡∂π—¥¢Õß»—≈¬·æ∑¬å ºŸ∫â °ÿ ‡∫‘° ¥—ßπ—πÈ °“√∑’»Ë ≈— ¬·æ∑¬å∑‰’Ë ¡à„™àºÕŸâ Õ°·∫∫‡§√◊ÕË ß ¡◊Õ‰ª„™â‡§√◊ËÕß¡◊Õ∑’ˉ¡à§ÿâπ‡§¬ √à«¡°—∫°“√ºà“µ—¥„π¢π“¥ ·º≈∑’Ë®”°—¥ Õ“®‡°‘¥°“√§≈“¥‡§≈◊ËÕπ¢Õß°“√µ—¥°√–¥Ÿ° ‰¥â ¥—ß¡’√“¬ß“π„Àâ‡ÀÁπ„π«“√ “√∑“ß°“√·æ∑¬å25-27 µ—«Õ¬à“ß∑’Ë™—¥‡®π§◊Õ ‡§√◊ËÕß¡◊Õµ—¥°√–¥Ÿ°®“°¥â“π¢â“ß (side cutting instrument) ”À√—∫°“√µ—¥°√–¥Ÿ° proximal tibia ·≈– distal femur ‡ªìπ‡§√◊ËÕß¡◊Õ∑’Ë»—≈¬·æ∑¬å ºŸâ∫ÿ°‡∫‘°«‘∏’ºà“µ—¥ MIS ‡ªìπºŸâÕÕ°·∫∫ ·≈–„™â·≈⫉¥âº≈ æÕ„®4 ·µà‡¡◊ÕË »—≈¬·æ∑¬åÕπ◊Ë Ê ∑’¡Ë §’ «“¡‡§¬™‘π°—∫°“√µ—¥ °√–¥Ÿ°®“°¥â“πÀπâ“ ¡“„™â‡§√◊ÕË ß¡◊Õµ—¥°√–¥Ÿ°™π‘¥π’È °≈—∫ ‰¥âº≈‰¡à¥‡’ ∑à“∑’§Ë «√26 ¥—ßπ—πÈ »—≈¬·æ∑¬å§«√æ‘®“√≥“‡§√◊ÕË ß¡◊Õ ”À√—∫°“√ ºà“µ—¥ MIS-TKA „À⥒ «à“¡’§«“¡·µ°µà“ß®“°‡§√◊ËÕß¡◊Õ ¡“µ√∞“π∑’Ë„™âÕ¬Ÿà∑—Ë«‰ªÕ¬à“߉√ ·≈–»—≈¬·æ∑¬å§«√®– æ‘®“√≥“«“߇§√◊ËÕß¡◊Õ∑’Ë¡’¢π“¥‡≈Á°≈ß∫π°√–¥Ÿ°„πµ”·Àπàß∑’ˇÀ¡“– ¡ µ—«Õ¬à“߇™àπ °“√«“ß proximal tibial À≈—° ”§—≠„π°“√ºà“µ—¥ minimally invasive surgery-total knee arthroplasty cutting guide ¢π“¥‡≈Á°∑’˧àÕπ‰ª∑“ߥâ“π„π (medial side) °«à“µ”·Àπàߪ°µ‘ ∑”„Àâ¡¡ÿ °“√µ—¥°√–¥Ÿ°„π frontal plane §≈“¥‡§≈◊ÕË π‰¥â √ÿª (conclusion) ·¡â«à“ surgical principle „π°“√ºà“µ—¥ MIS-TKA ¢Õß°≈ÿà¡»—≈¬·æ∑¬åºŸâ∫ÿ°‡∫‘°°“√ºà“µ—¥π’È¡’§«“¡À≈“° À≈“¬¡“° ·µà§«“¡‡ÀÁπ¢ÕߺŸâπ‘æπ∏å surgical principle „π°“√ºà“µ—¥ MIS-TKA ¡’ 4 Õß§åª√–°Õ∫ §◊Õ mobile skin window, multiple knee flexion angle, patellar subluxation ·≈– facilitating instruments ∑—È ß π’È surgical principle ∑—Èß 4 Õß§åª√–°Õ∫‡ªìπ ‘Ëß∑’Ë»—≈¬·æ∑¬å µâÕß§”π÷߇æ‘Ë¡‡µ‘¡®“° surgical principle „π°“√ºà“µ—¥ STD-TKA ´÷Ëߙ૬∑”„Àâ»—≈¬·æ∑¬å∑”°“√ºà“µ—¥¥â«¬ surgical technique ∑’ˇÀ¡“– ¡‰¥âÕ¬à“ßπÿà¡π«≈ ∑—Èß∑’Ë¡’ ¢âÕ®”°—¥¢Õß¢π“¥·º≈ºà“µ—¥ ‡Õ° “√Õâ“ßÕ‘ß (references) 1. 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