全膝关节置换术中髌股关节轨迹不良的处理策略及疗效探讨

目的总结分析全膝关节置换术(total knee arthroplasty,TKA)中髌股关节轨迹不良的个体化处理策略及其治疗效果。方法选取2012年8月至2017年8月广州医科大学附属第二医院骨外科收治的145例(184膝)拟初次行保留髌骨TKA的膝关节病变患者作为研究对象,术中根据髌股关节轨迹不良情况酌情采用假体位置调整、髌骨修整成形、髌骨内外侧支持带张力调整及Goldthwait-Roux术处理,评估术前及术后疼痛视觉模拟评分法(visual analogue scale,VAS)评分、美国膝关节协会评分(knee society score,KSS)、Feller髌骨评分以及胫骨角、股骨角、胫骨后倾角及股骨屈曲角等假体力线相关参数变化情况,记录假体松动、髌骨坏死、髌骨骨折和骨溶解等并发症发生情况。结果术后所有患者均无假体松动、髌骨坏死、髌骨骨折和骨溶解等并发症发生;随访(16.72±4.16)个月,患者VAS评分明显低于术前(t=38.483,P=0.000),KSS评分、Feller髌骨评分均明显高于术前(t=36.110、17.700,P均=0.000),胫骨角、股骨角、胫骨后倾角、股骨屈曲角均明显大于术前(t=99.997、87.499、14.084、4.101,P均=0.000)。结论 TKA术中根据患者髌股关节轨迹不良情况个性化采用假体位置调整、髌骨修整成形、髌骨内外侧支持带张力调整及Goldthwait-Roux术处理,可纠正患者髌股关节轨迹不良,缓解膝前痛,改善膝关节功能,临床应用价值较高。     

胫骨平台截骨参考点在全膝关节置换术胫骨假体定位中的应用效果分析

【摘要】 目的 探讨胫骨平台截骨参考点在全膝关节置换术胫骨假体定位中的应用效果。方法 选取 2019年 4 月至 2021 年 12 月济源市人民医院收治的 50 例拟行全膝关节置换术治疗的膝关节疾病患者作为研究对象,按照随机数表法将其随机分为观察组 (25 例) 和对照组 (25 例), 观察组患者全膝关节置换术中通过胫骨平台截骨参考点确定胫骨假体放置角度, 对照组患者全膝关节置换术中通过胫骨结节中内侧线确定胫骨假体放置角度, 对比观察两组患者疼痛程度、膝关节功能以及局部解剖结构。结果 术后 2 周、1 个月及 3 个月, 观察组患者视觉模拟评分法 (VAS) 评分与对照组无明显差异 (t = 1.584、1.186、1.182, P = 0.120、0.241、0.243), 而美国特种外科医院 (HSS) 评分均明显高于对照组 (t = 3.112、2.127、2.603, P = 0.003、0.039、0.012); 术后3 个月, 观察组患者胫骨结节至滑车中线距离明显短于对照组 ( t = 2.595, P = 0.013), 髌骨倾斜角以及屈膝30°、60°、90°时髌股指数均明显小于对照组 ( t = 3.382、2.774、2.357、2.795, P = 0.001、0.008、0.023?0.007)。结论 通过胫骨平台截骨参考点进行胫骨假体定位更有利于改善全膝关节置换术后膝关节功能, 提高髌骨稳定性, 避免髌骨倾斜, 值得临床推广应用。     

三维CT重建应用于个体化全膝关节置换术的研究

目的探讨三维CT重建在个体化全膝关节置换术中应用的临床效果,研究两者的有机结合点,为进行标准化个体化全膝关节置换术提供依据。方法对2011年3月~2014年5月入组的72例中重度膝骨性关节炎病例行双下肢全长CT扫描并三维建模,获取关键角度和截骨数据,制定个体化截骨方案,获得最佳下肢力线和截骨参数,将术前所得数据付诸手术操作中,分别于术前和术后第2周获取下肢力线角与标准角度的偏差度数和美国特种外科医院膝关节评分(HSS)数据,计算优良率。结果术后患者的下肢力线接近理想力线,术前下肢力线角与标准角偏差度数为8.1482°±1.5957°,术后下肢力线角与标准角偏差度数为1.0627°±0.6401°,术前术后偏差度数采用配对资料t检验(t=13.6683,P=0.039),具有统计学意义;膝关节HSS评分较高,由术前的(49.6±6.1)分提高到术后2周的(88.2±4.1)分,术后与术前相比,有统计学意义(P=0.041);根据术后HSS评分进行评价,优58例,良10例,中3例,差1例,优良率为94.44%。结论术前三维重建膝关节,测量重要参数并制定术前规划,能够减少手术误差,提高手术精度,有助于正确重建下肢力线、准确定位截骨和植入假体,为实现全膝关节置换术的个体化和标准化提供临床依据。     

全膝关节置换术中髌骨置换对骨性关节炎患者早期疗效及膝前痛的影响

目的：探讨全膝关节置换术中是否进行髌骨置换对骨性关节炎患者的临床疗效及术后疼痛的影响。方法笔者采用随机数字表法将骨科2011年5月～2013年7月收治的93例行人工全膝关节置换术患者分为髌骨置换组43例和未置换组50例,比较两组患者治疗前与治疗后不同时间的相关指标变化差异。结果术前髌骨置换组与非置换组的膝关节KSS（美国膝关节协会）评分、Feller评分差异不显著（ P＞0．05）;术后第3、6、12个月髌骨置换组膝关节KSS评分、Feller评分显著高于非置换组（P＜0．05）;术前髌骨置换组与非置换组的膝关节视觉模拟评分（VAS）差异不显著（P＞0．05）;术后第3、6、12个月髌骨置换组膝关节VAS评分显著低于非置换组（P＜0．05）;两组患者术前、术后的胫股角,髌韧带比值,关节活动度ROM屈、伸值在两组间比较差异均不显著（ P＞0．05）;术后第12个月两组患者的胫股角、髌韧带比值,关节活动度ROM屈、伸值较治疗前均显著好转（ P＜0．05）。结论全膝关节置换术中进行髌骨置换对改善膝关节功能评分、髌骨评分、术后疼痛评分均有显著的效果。     

基于磁共振MERGE序列膝关节软骨厚度的定量研究

目的 运用多回波梯度成像(MERGE)序列研究健康志愿者膝关节软骨分布特点和正常软骨的平均厚度值,比较不同程度骨性关节炎(OA)患者之间软骨厚度差异.方法 健康志愿者20例及OA患者45例均行4个常规膝关节扫描序列后,附加矢状位MERGE序列、矢状位脂肪抑制序列(OSAG-STIR)、三维抑脂扰相梯度回波序列(FS-3D-FSPGR)扫描.参照WORMS将健康志愿者膝关节软骨划分为15个小亚区,定量记录每个亚区软骨厚度,比较各亚区合并后大部位的厚度差异,总结膝关节整体软骨分布特点.用两独立样本t检验比较健康志愿者组与轻、重度膝骨性关节炎(KOA)组软骨厚度之间的差异性.结果 (1)健康志愿者组膝关节软骨平均厚度从厚到薄依次为髌骨区(3.31 mm)、股骨外侧滑车区(3.27 mm)、胫骨外侧平台区(2.59 mm)、股骨外侧髁区(2.26 mm)、胫骨内侧平台区(2.09 mm)、股骨内侧髁区(2.05 mm).(2)健康志愿者组与轻度()A患者组之间软骨厚度比较后P值＞0.05,无统计学意义;健康志愿者组与重度OA患者组之间除胫骨内外侧平台软骨厚度变化不明显外,其余部位P值＜0.01,差异有显著统计学意义.结论 (1)膝关节软骨厚度由厚到薄依次为髌骨区、股骨外侧滑车区、胫骨外侧平台区、股骨外侧髁区、胫骨内侧平台区、股骨内侧髁区.(2)随着软骨退变的发展,软骨厚度及体积逐渐变小,胫骨平台软骨最后缺失.     

膝关节骨性关节炎的X线测量与分析

目的:通过对膝关节骨性关节炎患者X线片的测量,分析膝关节骨性关节炎患者股骨、胫骨和髌骨形态学改变,以及三者之间排列关系的改变,进而分析这些改变在膝关节骨性关节炎中的诊治意义和作用。方法:取正常组100例膝和膝关节骨性关节炎组127例膝,拍摄正位、侧位和髌骨轴位CR片,并对其分组逐一测量股骨角等指标,应用统计学方法对测量结果卡方检验,对检验结果进行分析,并结合临床进行讨论。结果:膝关节骨性关节炎组(KOA组)胫骨角等的检验结果与正常组存在差异,有统计学意义。而股骨角的检验结果与正常组间无差异。结论:①在膝关节骨性关节炎患者影像学分析中,出现了胫骨角等指标的变化。股骨角对于膝关节骨性关节炎的影像学分析不敏感。②在膝关节骨性关节炎患者影像学分析和统计学检验中,验证了膝内翻发生率高于膝外翻,股胫关节内侧间隙狭窄多于股胫关节外侧间隙狭窄。③在膝关节骨性关节炎患者X线分析中,发现髌股关节可出现髌骨外翻脱位。     

人工全膝关节置换术中髌骨置换的临床研究

目的探讨人工全膝关节置换术中髌骨置换之后的临床疗效,为临床上是否要进行髌骨置换提供参考依据。方法选择2009年12月—2012年2月于我院急诊科、骨科就诊并拟行人工全膝关节置换术的骨关节炎患者84例,按随机数字随机将所有入选患者分为对照组42例和研究组42例,研究组患者在关节置换术中接受髌骨置换的治疗,对照组则不进行髌骨置换,治疗后所有患者接受为期1年的随访,对两组疗效进行比较。结果两组术后2、3个月的美国膝关节协会评分系统(KSS)临床评分差异均无统计学意义(P>0.05),术后6、12个月KSS临床评分差异有统计学意义(P<0.05);两组术后2、3、6个月的Feller髌骨评分差异均无统计学意义(P>0.05),术后12个月Feller髌骨评分差异有统计学意义(P<0.05)。结论人工全膝关节置换术中行髌骨置换能在一定程度上改善膝关节功能评分和髌骨评分。     

CT结合双下肢负重位力线X线影像制作3D打印个性化模具辅助行膝关节置换术临床研究

目的探讨膝关节CT结合双下肢负重位力线X线影像制作3D打印个性化模具在全膝关节置换术(TKA)精确截骨中的应用价值。方法选取自2014年4月至2016年6月沈阳军区总医院骨科收治的须行TKA患者32例,随机分为3D打印TKA组(20膝)和常规TKA组(19膝)各16例。3D打印TKA组应用膝关节CT结合双下肢负重位力线X线影像制作3D打印个性化模具辅助行TKA;对照组应用常规截骨器械行TKA。记录两组患者完成股骨及胫骨截骨所用的时间、所得胫骨侧截骨片厚度与术前规划之间的偏差以及两组患者的手术时间。结果 3D打印TKA组股骨及胫骨截骨的完成时间为(27.8±4.3)min,常规TKA组为(36.5±6.2)min,两组比较,差异有统计学意义(t=31.752,P<0.05)。3D打印TKA组胫骨侧截骨厚度与术前规划厚度偏差为(1.60±0.67)mm,常规TKA组为(3.40±1.35)mm,两组比较,差异有统计学意义(t=23.247,P<0.05);3D打印TKA组手术时间为(57.0±7.3)min,常规TKA组为(58.0±8.0)min,两组比较,差异无统计学意义(t=0.961,P>0.05)。两组患者均未出现并发症。结论应用膝关节CT结合双下肢负重位力线X线影像制作3D打印个性化模具辅助行TKA能缩短股骨及胫骨截骨所需时间,使胫骨侧截骨更加精确,但对整个TKA所需时间无明显改善。     

复发性髌骨脱位术后膝关节CT表现与临床功能的相关性分析

目的 观察复发性髌骨脱位三联术后中长期随访过程中,膝关节的CT表现及其与膝关节功能评分之间的关系。方法 选取26例(27膝)确诊为复发性髌骨脱位并行髌骨脱位三联术(内侧髌股韧带重组术、外侧髌骨支持带松解术与胫骨结节移位术)的患者为研究对象,比较术后短期(1～2年)及中长期(5年以上) CT测量值的变化,并与膝关节功能评分进行相关性分析。结果 髌骨脱位三联术后短期与术前相比,Insall-Salvati指数(ISI)及胫骨结节-股骨滑车沟(TT-TG)距离均明显减小,差异有统计学意义(P<0.05)。术后短期与术后3天相比,股骨及髌骨隧道宽度扩大,滑车沟适合角(CA)、髌骨倾斜角(PTA)及髌骨外侧移位值(LPD)均增大,外侧髌股角(LPA)减小;术后中长期与术后3天相比,除以上改变外,ISI明显减小;术后中长期与术后短期相比,PTA增大,LPA减小,以上差异均有统计学意义(P<0.05)。术后中长期平均Kujala评分与Lysholm评分较短期均提高,其中Kujula评分差异有统计学意义(P=0.001)。术后中长期随访中,股骨滑车发育不良Dejour分型越高级,Kujal...     

低应力下股骨滑车角与髌骨偏移指数的MRI研究

目的：应用MRI测量并分析膝关节低应力下股骨滑车角、髌骨偏移指数的特点。方法：收集行膝关节MRI检查的正常志愿者27例（共54个膝关节）及髌骨不稳患者15例（共18个膝关节）的资料。测量并记录股骨滑车角、髌骨偏移指数等数据。结果：正常志愿者股骨滑车角、髌骨偏移指数的平均值分别为（145.69±2.63）°、（55.69±5.90）%,且左、右膝间差异均无统计学意义（均P>0.05）,不同性别间差异均有统计学意义（均P<0.05）。髌骨不稳患者股骨滑车角、髌骨偏移指数的平均值分别为（159.44±5.52）°、（89.56±2.53）%,与正常志愿者差异均有统计学意义（均P<0.05）。15例髌骨不稳患者中11例（73.3%）为女性,4例（26.7%）为男性。结论：女性股骨滑车角、髌骨偏移指数较男性大。髌骨不稳患者的股骨滑车角、髌骨偏移指数较正常志愿者大,且女性患病率较男性高。     

Axial alignment of the lower limband its association with disorders of the knee

Lower limb alignment, including its load-bearing axis (LBA), is best appraised by standardized radiography. Rotational orientation, including patellar alignment, is best measured by computed tomography (CT) or magnetic resonance imaging (MRI). Normal limb alignment may be defined as the means ± 1 SD of healthy adult parameters. Ideally, the knee is centered on the LBA (hip-knee-ankle [HKA] angle, zero deviation from linearity), and the quadriceps-patella-tendon (Q angle) is aligned at 11° laterally. A common deformity is varus (bow-legged) with the knee center lateral to LBA. This can cause knee instability and subluxation when the anterior cruciate ligament is lax. Subluxation is accentuated in the varus oblique knee in which the joint surfaces have an exaggerated inward tilt. Arthritic knee patterns relate to alignment through cause or effect or both. In osteoarthritis (OA), varus knee degradation is focused medially. Surveys of OA patients reveal that femoral deformity is more frequently responsible for the varus than tibial deformity. Valgus deformity (knock-knee) is uncommon in OA and linked to inflammatory arthritis, renal rickets, and various dysplasias. Thus, surgical realignment of deformed knees should be based on correction at its source—the femur, the tibia, or both. The frequent patellar malalignment in OA is probably attributable to torsional abnormalities which may call for CT or MRI assessments. Arthritis progression is optimally defined by standardized radiography in which assessments are made of the maximally involved compartment (joint space loss, osteophytes, erosion, and subluxation—which correlate with HKA). New developments include blood and urine analysis for breakdown products of cartilage and bone.     

Infrapatellar fat pad size, but not patellar alignment, is associated with patellar tendinopathy

Patellar tendinopathy (PT) is one of the most common overuse injuries of the knee. Recent reports indicate that increased body mass is frequently associated with tendinopathy, not only biomechanically but biochemically. Abnormalities of other structures within the knee extensor mechanism [patellofemoral joint (PFJ) alignment and patellar tendon length] that can directly influence the strain distribution of the patellar tendon are inconsistently implicated in PT. The aim of this study was to compare the infrapatellar fat pad volume, patellar tendon length and PFJ alignment in people with chronic PT and a group of age-, gender-, height-, and activity-matched controls with normal tendons. Axial magnetic resonance (MR) images, from 26 participants with PT and 28 control participants were obtained. Fat pad size, patellar tendon length and PFJ alignment were measured digitally from the MR images, using measurement software, and the results compared between the PT group and control group. People with PT had a significantly larger fat pad than healthy controls when controlled for height (P=0.04). Patellar tendon length was not significantly different between groups (P=0.16), nor were there between-group differences for the measures of PFJ alignment (P=0.07-0.76). Thus, the infrapatellar fat pad may play an important role in PT.     

Ultra-high-field MRI of knee joint at 7.0T: preliminary experience

RATIONALE AND OBJECTIVES: To measure signal-to-noise ratio (SNR), contrast, and relaxation times (T1 and T2) in human knee joint at 7.0T whole-body scanner. MATERIALS AND METHODS: MRI experiments were performed on a 7.0T Siemens whole-body scanner using an 18-cm diameter transmit/receive knee coil. Normalized SNR and relaxation times (T1 and T2) were computed on all volunteers (healthy, n=5) for femoral, tibial, and patellar cartilage. RESULTS: Average T1 values of femoral, tibial, and patellar cartilages were found as 1.55, 1.76, and 1.62 seconds, respectively. Average T2 values of femoral, tibial, and patellar cartilages were found as 51.3, 43.9, and 39.7 milliseconds, respectively. No statistically significant differences were observed between T1 and T2 values of different cartilage tissues (P>.08 for all comparisons). Compared with previously reported relaxation times of cartilage tissue at 3.0T, an approximately 35% increase was observed in T1 values, whereas no significant change was observed in T2. Regional analysis was also performed to investigate the change in relaxation parameters for weight-bearing vs. non-weight-bearing areas. A statistically significant difference was observed in T2 of tibial cartilage (P=.009). The rest of the comparisons yielded insignificant differences (P>.32). CONCLUSION: Our preliminary results demonstrate the feasibility of acquiring high resolution three-dimensional images of knee joint (with and without fat suppression) at 7.0T whole-body scanner.     

The effect of patellar thickness changes on patellar tilt in total knee arthroplasty

We hypothesized that changes in patellar thickness following patellar resurfacing affect patellar tilt in total knee arthroplasty (TKA) patients. The study enrolled 272 TKAs and categorized them into four groups according to change in patellar thickness: (A) thinner by 1 mm or more, (B) equal or thinner by less than 1 mm, (C) thicker by 1 mm or less, and (D) thicker by more than 1 mm. Patellar tilt angle was measured postoperatively using Merchant radiography. There were no significant differences in postoperative patellar tilt among groups A, B, and C (n.s). However, the postoperative patellar tilting angle of group D was significantly higher than that of all other groups (P < 0.05). Postoperative patellar tilt increased when the postoperative patella was >1 mm thicker than the preoperative patella.     

Risk factors for patellar tendinopathy in volleyball and basketball players: A survey‐based prospective cohort study

Patellar tendinopathy (PT) is a common overuse injury of the patellar tendon in jumping athletes. In a recent large cross‐sectional study from 2008 several factors were identified that may be associated with the etiology of PT. However, because of the study design no conclusions could be drawn about causal relations. The primary aim of the current study is to investigate whether the factors identified in the previous 2008 study can also be prospectively recognized as predictors of symptomatic PT in 2011. Nine hundred twenty‐six Dutch elite and non‐elite basketball and volleyball players from the previous study were invited again to complete an online survey about knee complaints and risk factors for PT in 2011. The logistic regression included 385 athletes of which 51 (13%) developed PT since 2008. Male gender [odds ratio (OR) 2.0, 95% confidence interval (CI) 1.1–3.5] was found to be a risk factor for developing PT. No sports‐related variables could be identified to increase the risk of developing PT, but some evidence was found for performing heavy physically demanding work, like being a nurse or a physical education teacher (OR 2.3, 95% CI 0.9–6.3). These findings indicate that, when considering preventive measures, it is important to take into account the total tendon load.     

Elevated corticospinal excitability in patellar tendinopathy compared with other anterior knee pain or no pain

Anterior knee pain (AKP) is a frequent clinical presentation in jumping athletes and may be aggravated by sustained sitting, stair use, and loading of the quadriceps. Corticospinal activation of the quadriceps in athletes with AKP has not yet been investigated, but is important in guiding efficacious treatment. This cross‐sectional study assessed corticospinal excitability (CSE) of the quadriceps in jumping athletes using transcranial magnetic stimulation (TMS). Groups consisted of Control (no knee pain); patellar tendinopathy (PT) [localized inferior pole pain on single‐leg decline squat (SLDS)]; and other AKP (nonlocalized pain around the patella). SLDS (numerical score of pain 0–10), Victorian Institute of Sport Assessment Patellar tendon (VISA‐P), maximal voluntary isometric contraction (MVIC), active motor threshold (AMT), CSE, and M_max were tested. Twenty nine athletes participated; control n = 8, PT n = 11, AKP n = 10. There were no group differences in age (P = 0.23), body mass index (P = 0.16), MVIC (P = 0.38) or weekly activity (P = 0.22). PT had elevated CSE compared with controls and other AKP (P < 0.001), but no differences were detected between AKP and controls (P = 0.47). CSE appears to be greater in PT than controls and other AKP. An improved understanding of the corticospinal responses in different sources of knee pain may direct better treatment approaches.     

膝反射灵敏度与膝关节角度关系的探讨

目的探讨仰卧位膝反射灵敏度与膝关节角度的关系,为临床检查膝反射提供准确的检查体位及理论依据。方法对普通内科住院患者符合入选条件的149例298个膝关节在80～180°范围内不同角度的反射强度进行积分和统计分析。结果膝关节角度在125—130°时,膝反射积分值处在最高水平。结论膝反射灵敏度与膝关节角度相关,仰卧位膝关节角度在125～130°范围时,反射灵敏度最高。     

Patellar tendon length during knee flexion of meniscal-bearing and rotating total knee arthroplasty implants

Purpose

The length of the patellar tendon after total knee arthroplasty (TKA) has most commonly been compared with preoperative measurements. However, there are no reports that discuss changes in the length of the patellar tendon during knee flexion after TKA. The purpose of this study was to evaluate changes in the length of the patellar tendon during knee flexion and to clarify the impact of changes in patellar tendon strain on the length of the patellar tendon and post-operative range of motion (ROM) after TKA.

Methods

Thirty-six patients undergoing sequential bilateral TKA for osteoarthritis were evaluated. Patients received a meniscal-bearing (MB) implant on one side and a rotating platform (RP) implant on the other and were followed for a median of 115 months (range 60–211 months). The lengths of the patellar tendon at maximum extension, 30°, 60°, 90° and maximum flexion were measured, and the post-operative ROM of both knees were assessed. The effects of implant design and the knee flexion angle on the length of the patellar tendon were analysed using a linear mixed-effects model. The relationship between patellar tendon strain and post-operative knee ROM was assessed using Pearson’s correlation coefficients.

Results

Post-operative clinical scores were similar for MB and RP implants. Neither the implant design nor the knee flexion angle significantly affected the length of the patellar tendon. The ROMs in the two designs at final follow-up were equivocal (114° in MB, 113° in RP). There was no correlation between patellar tendon strain and ROM in knees with either implant type.

Conclusions

Patellar tendon lengths after mobile-bearing TKA with implants that permitted different anteroposterior constraints were relatively constant at varying degrees of knee flexion. Differences in patellar tendon strain may not impact ROM. These results provide conclusive evidence that the quality of the patellar tendon may play a less important role in ROM after TKA.

Level of evidence

Therapeutic study, Level II.