À≈—° ”§—≠ „π°“√ºà“ µ—¥ minimally invasive surgery

À≈—° ”§—≠ „π°“√ºà“ µ—¥ minimally invasive surgery

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∑
∑’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¡—°„À⧫“¡ ”§—≠°—∫ªí®®—¬
‡√◊ÕË ß surgical technique À√◊Õ‡∑§π‘§ª≈’°¬àÕ¬‡©æ“–¢Õß
°“√ºà“µ—¥¡“°‡ªìπ摇»… ´÷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-
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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
𓬷æ∑¬å Gobler ·≈– Justin1 °≈à“«∂÷ß surgical
principle ¢Õß°“√ºà“µ—¥ MIS-TKA ª√–°Õ∫¥â«¬ 5 Õߧå
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
𓬷æ∑¬å Gobler ·≈– Justin ºŸ‡â ¢’¬π¡’§«“¡‡ÀÁπ«à“Õߧå
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≈ ·µàÕߧåª√–°Õ∫¢âÕ 3 (minimal resection of bone) ‡ªìπÕߧåª√–°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«πÕߧåª√–°Õ∫¢âÕ 4 (minimal loss of blood) ·≈–¢âÕ 5 (minimal
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pain to the patient) πà“®–‡ªìπº≈æ≈Õ¬‰¥â®“°°“√∑”„Àâ
‡π◊ÕÈ ‡¬◊ÕË ∫“¥‡®Á∫πâÕ¬¡“°°«à“
𓬷æ∑¬å Bonutti ·≈–§≥–2 °≈à“«∂÷ßÕߧåª√–°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‘®“√≥“Õߧåª√–°Õ∫¢Õß𓬷æ∑¬å Bonutti
·≈–§≥– ºŸâπ‘æπ∏å¡’§«“¡‡ÀÁπ«à“Õߧåª√–°Õ∫∑ÿ°¢âÕ¡’
§«“¡ ¡‡Àµÿ ¡º≈ ·µàÕ“®¡’°“√‡√’¬°™◊ÕË Õߧåª√–°Õ∫·µà
≈–¢âÕ∑’Ë·µ°µà“ß°—𠇙àπ Õߧåª√–°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“
Õߧåª√–°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¢≥–∑’ËÕߧå
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) ‡ªì𧫓¡∂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 „À⧫“¡‡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 §«√¡’Õߧåª√–°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 Õߧåª√–°Õ∫¢âÕπ’ȵ√ß°—∫§”∑’Ë𓬷æ∑¬å
Bonutti ·≈–§≥–‡√’¬°«à“ symbiotic use of retractors2
”À√—∫ºŸâªÉ«¬∑’Ë¡’¢“‚°àß °“√‡≈◊Õ°µ”·ÀπàߢÕß°“√
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°√’¥·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¬—ߧ߰√’¥¡’¥„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¬
ŧ
°“√°√’¥·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
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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) ´÷ËßÕߧåª√–°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∑’Ë°≈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 „𧫓¡‡ÀÁπ¢ÕߺŸâπ‘æπ∏å °“√‡≈◊ËÕπ°√–¥Ÿ° –∫Ⓣª
¥â“π lateral ¬—ߧ߇ªìπÀ≈—° ”§—≠¢Õß°“√ºà“µ—¥ MISTKA ∑—Èßπ’È°“√¢÷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°·∫∫¡“‡ªìπ摇»… ‡™àπ ¡’
¥â“¡®—∫¬“« √Ÿª√à“ß∫“ß ‰¡à„À≠à‡°‘𧫓¡®”‡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
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¡“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 Õߧåª√–°Õ∫ §◊Õ mobile
skin window, multiple knee flexion angle, patellar
subluxation ·≈– facilitating instruments ∑—È ß π’È surgical principle ∑—Èß 4 Õߧåª√–°Õ∫‡ªìπ ‘Ëß∑’Ë»—≈¬·æ∑¬å
µâÕߧ”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)
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°“√ºà“µ—¥ minimally invasive
surgery-total knee arthroplasty
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