Legion假体在膝外翻畸形初次全膝关节置换手术中应用疗效

目的探讨Legion假体在膝外翻畸形初次全膝关节置换手术中的临床应用疗效。方法回顾性分析沈阳军区总医院骨科2012年1月至2015年12月收治的膝外翻畸形患者32例(37膝)。记录患者术后髌股轨迹、切口愈合情况、膝外翻矫正角度、膝关节Harris评分(HSS)。结果所有患者术后均获得随访。32例患者膝关节髌股轨迹良好,切口愈合情况佳,无感染发生。34膝完全矫正了膝外翻畸形,仅余3膝存在3°~5°膝外翻遗留。患者HSS评分由术前34.5分提升至术后87.0分。结论在膝外翻畸形患者的初次膝关节置换手术中应用Legion假体可以达到满意的手术疗效,术后患者膝关节稳定,大部分患者的膝外翻畸形得到了纠正,患者在术后早期功能锻炼即可达到屈曲90°、伸直0°。     

人工全膝关节置换术治疗严重畸形膝关节临床研究

目的：探讨人工全膝关节置换术（total knee arthroplasty, TKA）治疗严重畸形膝关节的手术方法和临床疗效。方法对人工全膝关节置换术916例（1031膝）,严重畸形膝关节置换术80例,其中56例（70膝）成功随访。严重内翻畸形19例（23膝）、严重外翻畸形21例（27膝）、严重屈曲畸形16例（20膝）。术后平均随访时间60个月（6个月～10年）。对膝关节屈伸活动度、HSS、KSS膝关节评分系统对手术前后进行回顾性研究。结果膝关节屈伸活动度由术前平均80°（伸直0°～屈曲120°）提高到术后115°（伸直0°～屈曲130°）,膝关节评分系统 HSS、KSS术前及随访时比较差异有统计学意义（P＜0．05）,KSS评分：临床评分由术前平均33分（10～68分）提高到术后平均81分（70～100分）,HSS临床评分由术前平均43分（27～68分）提高到术后平均86分（72～100分）。膝内外翻、屈曲挛缩畸形得到较好矫正。结论严重畸形膝关节通过关节置换术同样能恢复正常的关节功能,提高了患者生活质量,获得满意的临床疗效。     

人工全膝关节置换术股骨截骨方法改良及效果

目的对人工全膝关节置换术股骨截骨方法进行改良,通过截骨厚度的测量和临床随访对改良截骨方法的手术效果进行评估。方法改良股骨截骨模板,股骨后髁截骨厚度增加3mm。对81例人工全膝关节置换术中的各向截骨厚度进行测量,分为膝内翻和膝外翻两组,对截骨厚度和假体厚度进行比较分析。术后平均随访27.1个月。结果全组患者屈膝间隙和伸膝间隙平均截骨厚度均小于假体厚度。膝内翻和膝外翻组间除股骨后髁内侧截骨厚度外,各项测量值间差异均存在显著性意义(P<0.01)。膝内翻组内侧屈伸膝间隙截骨厚度和假体厚度差异最大;膝外翻组,外侧屈伸膝间隙截骨厚度和假体厚度差异最大。膝内翻组,外侧屈膝间隙存在过度截骨(0.57mm);膝外翻组,内侧屈膝间隙存在过度截骨(0.92mm)。术后关节活动度良好,仅7%的患者存在轻度屈膝不稳,无中重度不稳。结论对股骨截骨模板的改良是可行的,股骨后髁截骨厚度增加3mm不会出现过度截骨和屈膝不稳的情况。     

拉网式松解技术在人工膝关节置换术治疗重度外翻膝中临床应用

目的探讨拉网式松解技术在人工膝关节置换术治疗外翻膝中的安全性及疗效。方法回顾性分析2014年10月至2015年5月北京积水潭医院矫形骨科采用人工膝关节置换术治疗的膝关节外翻畸形患者20例(23膝)的临床资料。所有患者均进行膝关节置换手术治疗,在术后1、3、6个月及1年进行随访,拍摄膝关节负重位X线影像、下肢全长X线影像,观察有无腓总神经损伤的症状,并进行美国膝关节协会(KSS)评分。结果本组20例患者,18例使用后稳定型假体,2例使用限制性假体。全部患者膝关节置换术中行外侧软组织的拉网式松解,松解深度≤5 mm。平均手术时间(79±12)min,平均出血量(150±30)ml,术中及术后无输异体血,术后伤口平均引流量(190±70)ml。术后第1天患者可以扶拐杖下地活动。术后和随访过程中均未发现腓总神经损伤的并发症。KSS评分从术前的(39±10)分提高至术后的(91±6)分,术前、术后KSS评分比较,差异有统计学意义(P<0.05)。结论拉网式松解技术是人工膝关节置换术治疗膝关节外翻畸形的有效方法,松解深度≤5 mm安全、有效,可以得到满意的软组织平衡。     

软组织平衡对全膝关节置换时膝外翻畸形的矫正作用观察

目前认为,膝关节周围软组织不平衡是影响全膝关节置换术后远期效果的主要因素之一,可使金属假体与聚乙烯内衬之间应力集中,加速内衬磨损,也可由于膝关节不稳定而导致假体松动。因此,保证全膝关节置换术中软组织平衡极为重要。膝外翻畸形患者行人工全膝关节置换术难度较大,争议颇多,我科2006-2010年行膝关节置换矫正外翻畸形23例,术中应用软组织平衡技术,取得了较好疗效,现报告如下。     

膝关节置换术中膝内翻角度与胫骨近端内外侧截骨厚度差值的相关性探讨

目的在膝关节置换术中,胫骨截骨多采取髓外定位。由于术者经验及手术切口较小及铺单较厚等原因,胫骨定位杆的放置容易受到影响,导致胫骨近端截骨不准确,最终造成膝畸形纠正不足。本研究通过在术前计算测量病人下肢力线得出膝内翻角度,在膝关节置换术中靠胫骨近端内侧平台与外侧平台截骨厚度差值,来矫正膝内翻恢复下肢力线,为术中胫骨截骨提供数字化的依据。方法:通过收集本院自2015年至今的膝关节置换患者62例,根据膝内翻角度分为<10°、10-14°、15-20°、>20°四组,术前常规摄下肢全长X线正位片,从股骨头中心至股骨髁中心连线,胫骨近端中心与距骨中心连线,两线夹角为膝内翻角度。根据膝内翻角度,计算胫骨近端内外侧截骨的厚度差,为手术中胫骨截骨提供依据,并与术后拍片测量检验截骨效果结果通过术前术后数据收集、统计及分析,总结4组内翻角度的截骨差值,根据差值作为术前的胫骨截骨指导,与术中测量有少许偏差,但对于手术力线有明显的指导作用。结论在基层医院,由于没有导航系统帮助,只能根据膝内翻角度,计算胫骨近端内外侧截骨的厚度差。在手术当中以这个高度差为基准截骨,可以确保胫骨近端截骨的准确性,从而保证了胫骨假体的垂直力线安装,无内外翻畸形恢复了下肢力线保证了手术效果。     

胫骨高位截骨术:闭合与开放楔形截骨对比

目的比较胫骨高位截骨术中闭合楔形截骨法(闭合楔)与开放楔形截骨法(开放楔)的临床结果及影像学特点。方法选取2013年7月至2014年6月北京积水潭医院矫形骨科收治的因膝内翻畸形施行的29例(44膝)胫骨高位截骨术患者。其中16例(24膝)采用闭合楔形截骨术,13例(20膝)采用开放楔形截骨术,均采用Tomofix系列钢板进行固定,随访时间分别为平均18.3个月(18~24个月)和16.6个月(18~25个月)。于末次评价两组患者Lysholm评分的变化、关节活动度变化及并发症发生情况。影像学方面,对比两组患者力线矫正的准确性、矫正角度及,术前、术后髌骨高度的变化及胫骨平台后倾角的变化。结果闭合楔组患者Lysholm评分从术前的(96.8±6.3)分增加至术后的(98.2±3.3)分(P=0.828);开放楔组患者从术前的(95.4±8.3)分增加至术后的(98.1±3.4)分(P=0.656)。闭合楔组关节活动度术前为(137.7°±14.2°),术后为(133.5°±15.0°)(P=0.146);开放楔组术前为(138.5°±15.6°),术后为(134.3°±17.3°)(P=0.207)。闭合楔组有1例(1膝,4.2%)出现腓神经损伤症状,半年后恢复;另有1例(1膝,4.2%)出现截骨延迟愈合,术后6个月复查时截骨愈合。闭合楔组与开放楔组畸形矫正满意率分别为87.5%和90%(P=1.000)。闭合楔组矫正胫骨内翻的角度为(10.3°±4.3°);开放楔组为(9.4°±5.3°)(P=0.289)。在髌骨高度方面,术后闭合楔组Caton Deschamps指数(CDI)从(1.09±0.17)增大至(1.11±0.18)(P=0.761);开放楔组从(1.16±0.25)减小至(0.99±0.23)(P=0.034)。闭合楔组胫骨后倾角从(13.4°±5.1°)减小至(9.4°±5.3°)(P=0.010);开放楔组从(12.0°±4.1°)增大至14.9°±5.1°(P=0.050)。结论闭合楔与开放楔两种截骨技术都能获得满意的临床结果。开放楔可能减小髌骨高度,故对于术前即存在髌骨低位的患者,应避免采用开放楔,或者采用开放楔时冠状面截骨斜向前下方,将胫骨结节保留在近端截骨块,以避免进一步加重髌骨低位,影响关节活动。由于闭合楔可能减小胫骨平台后倾而开放楔可能增加后倾,故应按照实际需要个体化地选择截骨方式。     

儿童胫骨上段骨折后并发膝外翻畸形的微创治疗

目的探讨儿童胫骨上段骨折后并发膝外翻畸形的形成原因及微创治疗方法。方法对我院2008年10月～2010年10月间收治的胫骨上端骨折并发膝外翻畸形患儿进行了回顾性分析。本组患儿共12例,男性8例,女性4例,均采用"8"字钢板于胫骨上段内侧骺板行骨骺阻滞术。结果 8例随访2年。1例(11岁)单侧肢体外伤后膝外翻畸形患儿矫正术后1年不满意,后行胫骨近端截骨矫形手术;1例(6岁)单膝外翻,因钢板安置不理想,矫正不满意,1.5年后重新调整钢板;其余6例术后2年测踝间距均减少至2cm以下,已拆除"8"字钢板,膝外翻完全纠正,效果满意。4例随访1年,均按预期矫正观察中。结论应用"8"字钢板进行暂时性骨骺阻滞纠正儿童胫骨上段骨折并发膝外翻畸形是一种微创、安全、效果确切的治疗方法。为保证矫形术后效果满意,应在术后行患肢石膏固定2～3周。此类手术操作简单易行,值得推广。     

截骨内固定术结合拇收肌切断术治疗拇外翻的临床探讨

目的 通过观察、分析及对比随访5年的60例拇外翻患者临床表现、术前及术后患足X片,以期找到一种有效的治疗方法.方法 对重度拇趾外翻患者,根据其年龄、全身情况、临床表现及术前患足负重位正斜位X片检查结果,行相应的截骨术、内固定术,并结合拇收肌切断术进行治疗.结果 本组术后3、6个月及术后1、3、5年复查,患足正斜位X片显示拇外翻角得到有效纠正,拇外翻角均控制在20°以内.随访5年仅2例发现拇外翻角纠正丢失,其余病例纠正的拇外翻角均无明显丢失,未见骨折畸形愈合或不愈合.结论 截骨内固定术结合拇收肌切断术是治疗重度拇外翻行之有效的方法.     

改良Chevron截骨术联合(足母)收肌切断术治疗轻中度(足母)外翻

目的 评估改良Chevron截骨术联合(足母)收肌切断术治疗轻中度外翻患者的手术效果.方法 对符合观察条件的36例(50足)患者进行了临床手术资料的回顾性观察,对其手术前后资料进行整理,并通过美国足踝外科协会(足母)趾-跖趾-趾间关节评分(AOFAS)和视觉模拟评分(VAS)对手术效果进行量化比较.结果 随访及评分结果显示,所有患者术后(足母)外翻症状有了很大改观,术后未出现感染、跖骨头坏死、愈合不良等并发症.HVA由术前(31.1°±4.3°)降至术后(14.8°±2.9°),差异有统计学意义(P ＜0.05);IMA由术前(14.5°±3.4°)降至术后(7.4°±2.5°),差异有统计学意义(P＜0.05);AO-FAS评分由术前(48.7 ±7.0)分升至术后(85.1±5.7)分,差异有统计学意义(P＜0.05).功能评级优26足,良19足,中5足,优良率90％.结论 选择改良后的手术术式进行(足母)外翻畸形的矫正治疗,效果显著,值得临床推广.     

转子间外展截骨治疗股骨头坏死塌陷的长期观察

目的探索转子间截骨与股骨头坏死塌陷的关系。方法转子间外展截骨治疗股骨头坏死塌陷30例35髋,观察术前、术后X线片和CT片影像变化。测量马蹄角、角赘角和角赘比。健侧10髋马蹄角正常对照。结果转子间外展截骨术使马蹄角与头赘媾和关节。股骨头坏死塌陷组,马蹄角均值(19.88±2.27)°;角赘角均值(30.80±2.09)°;角赘比1.3:1。正常组,马蹄角均值(20.00±1.77)°。两组马蹄角比较,统计学无差异。结论股骨头坏死塌陷椭圆变形,马蹄角不变;行转子间外展30°截骨术,启动头赘马蹄关节。     

The results of corrective osteotomy for valgus arthritic knees

Purpose

To evaluate the results of corrective varus osteotomy in the treatment of arthritic knees with valgus deformity.

Methods

The data were retrieved from a literature review. Each relevant study was screened for demographic details, surgical techniques, follow-up periods, clinical outcomes, and complications.

Results

A total of 27 publications describing the results of varus osteotomies for valgus arthritic knees were reviewed. All were small case series studies, variable in their patient population, surgical techniques, rehabilitation protocols, follow-up periods, clinical assessments and were categorized as level IV of scientific evidence.

Conclusion

The role of varus osteotomy remains poorly defined. The literature generally supports this procedure in active and cooperative patients to reduce pain and delay the need for knee replacement. New techniques hold promising results regarding shortening of rehabilitation time and low reoperation and complication rates.

Level of evidence

IV.     

Improvements in surgical technique of valgus high tibial osteotomy

We present four technical modifications of high tibial osteotomy which improve its safety and reproducibility. (a) Open wedge correction: opening wedge osteotomy from the medial side avoids lateral muscle detachment, dissection of the peroneal nerve, proximal fibula osteotomy, and leg shortening; only one osteotomy needs to be performed and the correction can be adapted intraoperatively. (b) Biplanar osteotomy: in addition to the transverse osteotomy of the posterior tibia a second ascending osteotomy in the coronary plane underneath the tibial tuberosity is performed. This provides improved rotational stability of the osteotomy and creates an anterior buttress against sagittal tilting of the osteotomy planes. (c) Incomplete osteotomy with plastic deformation of the tibia: 10 mm of lateral bone stock is left intact. The osteotomy is opened gradually over several minutes by sequential impaction of flat chisels or by use of a special spreading tool. Manifest fractures of the lateral cortex with resulting instability are avoided. Rapid bone healing is promoted. (d) Rigid fixation: stable osteosynthesis allows for early mobilization and avoids losses-of-correction. We use a medial plate-fixator which can be applied percutanously. In 112 patients operated on using this modified technique no pseudarthosis or loss-of-correction was observed.     

Evaluation of patellar height and measurement methods after valgus high tibial osteotomy

Several controversies exist regarding the surgical difficulties and the results of total knee arthroplasty performed after failed valgus high tibial osteotomy (HTO), and the main subject is the change in patellar height that results as patella baja or infera. The purpose of this retrospective study was to evaluate patellar height after valgus HTO and the measurement methods that were actually used. Eighty-five knees that were subjected to valgus HTO were evaluated both preoperatively and postoperatively according to the Insall-Salvati Index (ISI), Blackburne-Peel Index (BPI), and Caton Index (CI) to assess any alteration of patellar tendon height that was present. All cases underwent closing wedge osteotomy with three staples or plate internal fixation and were allowed early range of motion. Significant decrease in mean patellar height ratios was detected according to all three indexes at 85 months of mean follow-up. The percentages of the decrease were 8.26% in ISI, 9.08% in BPI, and 6.34% in CI. Two knees showed patella infera according to ISI, one according to BPI and three according to CI. There were no significant correlations between the indexes and clinical status of the patients. Elevation of patella relative to the femur in closing wedge valgus HTO procedure due to the shortening of the segment between tibial tuberosity and joint line is normally expected. A significant decrease in patellar height according to ISI suggests that there should be patellar tendon shortening as patellar height cannot be changed. BPI and CI for determining patellar height in valgus HTO do not accurately measure the alteration of patella because they may affect the tibial inclination and antero-posterior translation of the proximal fragment. Another measuring system based on femoral reference points should be proposed to determine the exact change of patellar height in the valgus HTO procedure.     

Avoiding intraoperative complications in open-wedge high tibial valgus osteotomy: technical advancement

Open-wedge high tibial osteotomy for varus osteoarthritis of the knee is a successful treatment option, but is associated with potential intraoperative complications, jeopardizing outcome. We describe four technical hints avoiding complications as tibia plateau fracture, lateral hinge dislocation, over- and undercorrection, and unwanted increase of the posterior tibial slope and axial malrotation. The technique, which is primarily based on placing five Kirschner-wires (one for the osteotomy direction, two for the external fixator, and two for rotational and slope control) is simple, reproducible, inexpensive, and readily available.     

A case series of lateral opening wedge high tibial osteotomy for valgus malalignment

Introduction

Lateral opening wedge high tibial osteotomy is a rarely employed surgical technique used for the treatment of lateral knee pain and degeneration in the setting of genu valgum. There exists little evidence of the suitability of this procedure for patients requiring osteotomies with a small correction.

Materials and methods

A case series of 23 patients (24 knees) undergoing lateral opening wedge high tibial osteotomy with a minimum follow-up of 2 years was performed between 2002 and 2008. A surgical technique avoiding the need for fibular osteotomy is described. Adverse events, patient-reported outcomes and radiographic measures of alignment were assessed at baseline, at 6 months postoperatively, and at time of final follow-up. A subgroup of 12 patients also underwent 3D gait analysis at the same time points.

Results

The mean follow-up was 52 months (±20.4). Statistically and clinically significant improvements were identified in the lower extremity functional scale [mean change (95 %CI) = 10 (2.4, 17.6)], and in the knee injury and osteoarthritis outcome score [mean change (95 %CI) = 10.9 (0.5, 21.4)]. Mechanical axis changed from 2.4 ± 2.4° valgus to 0 ± 2.6° varus (p<0.001), anatomical axis from 6.9 ± 2.8° to 4.7 ± 2.5° valgus (p < 0.001), with weight-bearing line offset changing from 60.2 ± 11.4 % to 49.5 ± 12.4 % (p < 0.001). Change in lateral tibial slope, from 6.5 ± 2.2° to 7.5 ± 2.3°, was very small and not statistically significant (n.s.). The peak knee adduction moment during gait significantly increased [mean change (95 %CI) = 0.72 %BW*Ht (0.42, 1.02), suggesting a medial shift in dynamic knee joint load. Two patients underwent total knee arthroplasty during the study period.

Conclusions

Lateral opening wedge high tibial osteotomy is a viable surgical option for patients with lateral knee pain and valgus malalignment requiring small degrees of correction.

Level of evidence

IV.