膝关节内翻屈曲畸形全膝关节置换的早期疗效

目的 探讨膝关节内翻屈曲挛缩畸形施行全膝关节置换(TKA)后的早期疗效.方法 回顾性分析自2007年7月～2009年5月,对膝关节内翻屈曲畸形49例(57膝)施行TKA的资料.行单膝TKA术41例,行双膝TKA 8例.术前平均膝关节内翻角、屈曲挛缩度数、膝关节HSS评分分别为(13.1±1.5)°、(18.55±0.6)°、(37.9±3.4)分.结果 患者获随访5～30个月,平均18个月.术后平均膝关节股胫角、屈曲挛缩度数分别为(174.2±1.9)°、(0.3±0.15)°.膝关节HSS评分术后为(88.3±5.1)分,与术前比较差异具有统计学意义(P＜0.05).无切口、深部感染及再翻修者.结论 人工全膝关节置换治疗膝关节屈曲挛缩畸形临床疗效较好.术中准确切骨、软组织平衡是矫正膝关节内翻屈曲挛缩畸形的关键.     

Total Knee Arthroplasty in Patients with Ipsilateral Fused Hip: A Technical Note

We report the surgical technique used to perform posterior-stabilized total knee arthroplasty (TKA) in two patients with a well positioned and functional hip arthrodesis. Intraoperatively, the operating table was placed in an increased Trendelenburg position. Episodically, we flexed the foot of the table by 90° to allow maximal knee flexion to facilitate exposure and bone cuts. We opted to resect the patella and tibia first to enable exposure, given the stiffness of the arthritic knee. One patient''s medical condition prohibited complex conversion total hip arthroplasty (THA) prior to the TKA. The other patient''s scarred soft tissues around the hip, due to chronic infection and multiple operations, made THA risky. The final outcome provided satisfactory results at a minimum of 2 years postoperatively. TKA can be successfully performed with adjustments of table position and modification of the sequence of surgical steps in patients with ipsilateral hip fusion.     

膝关节类风湿关节炎伴重度屈曲畸形患者关节置换术后的中长期随访

目的分析膝关节类风湿关节炎(RA)伴重度屈曲畸形行全膝关节置换术(TKA)中长期随访结果,探讨其关键的手术技术和康复措施。方法 1998年1月至2005年12月,18例RA伴重度屈曲畸形患者32膝行TKA,平均年龄38.8岁。RA病程14.2年,畸形时间6.5年;术前畸形67.5°,活动度20.3°,合并内翻畸形3例,外翻11例;术前股四头肌肌力3级7例,4级11例;HSS评分21.1分。术前锻炼股四头肌肌力,术中软组织松解及增加截骨,术后伸直支具及伸膝锻炼。术后1、2、3、6、12个月及以后每年随访,评价关节活动度、生存率、HSS评分等。结果 16例患者获得随访,5～10年随访10例18膝,10年以上6例11膝。最后一次随访,膝关节屈曲畸形3.7°,活动度103.2°,HSS评分为81.4分,与术前相比差异有统计学意义(P<0.05)。2膝翻修,假体生存率93.1%。无感染及侧副韧带损伤。结论通过加强术前术后股四头肌功能训练,术中软组织松解及增加股骨远端截骨,膝关节RA伴重度屈曲畸形患者TKA术后中长期随访效果满意。     

The role of flexion contracture on outcomes in primary total knee arthroplasty

This study examined the role that flexion contracture plays in postoperative outcomes after total knee arthroplasty using a retrospective database review. The relationships between preoperative and postoperative knee extension, walking ability, stair climbing ability, Knee Society scores, pain scores, and knee function scores were studied in 5,622 knees. A preoperative flexion contracture was associated with an increased incidence of a persistent postoperative flexion deformity. A postoperative flexion contracture was associated with poorer postoperative results. Furthermore, a postoperative hyperextension deformity of greater than 10 degrees was associated with an increased risk of suboptimal pain and Knee Society scores. Knee extension deformities play a substantial detrimental role in the functional outcome of primary total knee arthroplasty.     

The natural history of flexion contracture in total knee arthroplasty. A prospective study

A prospective study was carried out to document the natural history of flexion contractures of the knee after total knee arthroplasty (TKA). Thirty-five knees in 33 patients with TKA were followed for a mean duration of 55 weeks. In no case did the surgical procedure include excessive bony resection in order to correct a flexion contracture. Standard goniometric measurements were used to determine the knee flexion contractures preoperatively and postoperatively while the patient was anesthetized and at each successive follow-up visit. All preoperative and postoperative flexion contractures were less than 30 degrees. The mean fixed flexion deformity of the entire group preoperatively was 12.9 degrees; immediately postoperatively, 14.8 degrees; and at final follow-up, 2.9 degrees. No difference was found in the amount of flexion contracture present at final follow-up evaluation with respect to age or gender. The impression that fixed flexion contractures must be corrected at the time of arthroplasty has led to the intraoperative removal of excess bone from the distal femur and/or proximal tibia. The present findings indicate that knee flexion contractures can significantly improve after TKA. There appears to be little, if any indication for excessive removal of bone in an attempt to achieve intraoperative correction.     

Soft tissue releasing and serial casting for management of flexion contracture after primary total knee arthroplasty in a patient with hemophilia

Introduction and importanceFlexion contracture following total knee arthroplasty (TKA) in patients with hemophilia is not uncommon, and this complication reduces knee range of motion and produces morbidity for the patient. This report states the success of treatment of flexion contracture after primary TKA in a patient with hemophilia; by open soft tissue contracture releasing and serial casting.Case presentationA 20-year-old-man presented with hemophilia type A. He had undergone TKA for treatment of secondary osteoarthritis, following chronic hemophilic arthropathy of his right knee. After surgery, the patient had progressive flexion contracture posture, until he had 45 degrees of knee flexion contracture at his 3 month follow up. The patient received open soft tissue releasing, then serial casting for 6 weeks. After this, the cast was removed and he continued with a home rehabilitation program. At 1 year follow, his knee flexion contraction contracture had improved up to 10 degrees. The patients function had recovered and he was satisfied with this treatment.Clinical discussionThe complications after TKA in patients with hemophilia are very challenging in there management; with flexion contracture after TKA being a common complication in patients with hemophilia.ConclusionIn severe flexion contracture following TKA, soft tissue releasing combined with serial casting is effective, and might be an option that is less invasive than revising all of the TKA components.     

Total hip and knee arthroplasty in juvenile rheumatoid arthritis

Total hip or knee arthroplasty is indicated in patients with juvenile rheumatoid arthritis when there is marked functional impairment and/or severe disabling pain from advanced structural hip or knee joint involvement. Relief of pain and dramatic improvement in function can be achieved in most patients. When both the hip and knee are involved, hip arthroplasty should probably be done first. Regional anesthesia is preferable. Careful preoperative planning is essential because custom prostheses are often required. Small bone size, osteoporosis, and soft-tissue contractures make the surgery technically demanding. Skeletal immaturity is not an absolute contraindication to surgery. Component loosening is the most frequent late complication in hip arthroplasty. It is less common in condylar metal-to-plastic knee arthroplasty in which patellar complications predominate. Cementless arthroplasty has an evolving role in the patient with juvenile rheumatoid arthritis and, to date, is more often used in the hip than in the knee.     

The influence of preoperative deformity on intraoperative soft tissue balance in posterior-stabilized total knee arthroplasty

Using a tensor for total knee arthroplasty (TKA) enabling soft tissue balance measurements with a reduced patellofemoral joint and femoral component in place, we examined the influence of preoperative deformity on intraoperative soft tissue balance during posterior-stabilized TKA at 0°, 10°, 45°, 90°, and 135° of flexion in 60 varus-type osteoarthritic patients. Despite more than 20° of preoperative varus deformity influencing intraoperative ligament balance in varus, joint gap showed no significant difference regardless of the amount of preoperative varus deformity. Accordingly, even in pre-operative severe varus deformed knees, gap balancing can be adjusted during PS TKA.     

Influence of hip position on knee flexion angle in patients undergoing total knee arthroplasty

The influence of hip position on knee flexion angle before total knee arthroplasty (TKA) and that after TKA were investigated and compared. Sixty-six patients (70 knees) with osteoarthritis who were undergoing TKA were examined using lateral radiographs of maximum knee flexion angle with the hip joint at 0 degrees extension and 90 degrees flexion. The postoperative rate of decrease in knee flexion angle caused by hip extension was significantly larger compared with the value before surgery. The preoperative rate of decrease in knee flexion angle caused by hip extension showed strong inverse correlation with the preoperative and postoperative knee flexion angle ratio. In conclusion, tightness of the extensor mechanism is present in all knees undergoing TKA and especially has a strong influence on the postoperative flexion angle of the knee.     

Associations among pain catastrophizing,muscle strength,and physical performance after total knee and hip arthroplasty

AIM To investigate whether reductions in pain catastrophizing associated with physical performance in the early period after total knee arthroplasty(TKA) or total hip arthroplasty(THA).METHODS The study group of 46 participants underwent TKA or THA. The participants were evaluated within 7d before the operation and at 14d afterwards. Physical performance was measured by the Timed Up and Go(TUG) test, and 10-m gait time was measured at comfortable and maximum speeds. They rated their knee or hip pain using a visual analog scale(VAS) for daily life activities. Psychological characteristics were measured by the Pain Catastrophizing Scale(PCS). Physical characteristics were measured by isometric muscle strength of knee extensors and hip abductors on the operated side. The variables of percent changes between pre-and postoperation were calculated by dividing post-operation score by pre-operation score.RESULTS Postoperative VAS and PCS were better than preoperative for both TKA and THA. Postoperative physical performance and muscle strength were poorer than preoperative for both TKA and THA. The percent change in physical performance showed no correlation with preoperative variables. In TKA patients, the percent change of PCS showed correlation with percent change of TUG(P = 0.016), 10-m gait time at comfortable speeds(P = 0.003), and 10-m gait time at maximum speeds(P = 0.042). The percent change of muscle strength showed partial correlation with physical performances.The percent change of VAS showed no correlation with physical performances. On the other hand, in THA patients, the percent change of hip abductor strength showed correlation with percent change of TUG(P =0.047), 10-m gait time at comfortable speeds(P = 0.001),and 10-m gait time at maximum speeds(P = 0.021). The percent change of knee extensor strength showed partial correlation with physical performances. The percent change of VAS and PCS showed no correlation with physical performances.CONCLUSION Changes in pain catastrophizing significantly associated with changes in physical performance in the early period after TKA. It contributes to future postoperative rehabilitation of arthroplasty.     

Patient perspective survey of total hip vs total knee arthroplasty surgery

A 42-item survey was developed and administered to determine patient perception of and satisfaction with total hip arthroplasty (THA) vs total knee arthroplasty (TKA). A total of 153 patients who had both primary THA and TKA for osteoarthritis with 1-year follow-up were identified. Survey response rate was 72%. Patients were more satisfied with THA meeting expectations for improvement in function and quality of life (P < .05), whereas pain relief expectations were equivalent. Most patients (70.9%) reported that TKA required more physiotherapy. One-year Oxford score and improvement in Oxford score from preoperative to 1 year were superior for THAs (P = .000). Despite equivalent pain relief, THAs trend toward higher satisfaction compared with TKAs. THA is more likely to "feel normal" with greater improvement in Oxford score. Recovery from TKA requires more physiotherapy and a longer time to achieve a satisfactory recovery status. Patients should be counseled accordingly.     

Total knee arthroplasty in hemophilic arthropathy

Total knee arthroplasty (TKA) is very effective in relieving pain and improving function in patients with advanced hemophilic arthropathy. Because of intra-articular fibrosis and extra-articular muscle contracture, the gain in motion after TKA has been unsatisfactory. The purpose of this study is to report the results of TKA in patients with hemophilia using posterior cruciate ligament (PCL)-sacrificing prostheses. From April 1987 to May 1998, 9 patients underwent 14 PCL-sacrificing TKAs for advanced hemophilic arthropathy. The average length of follow-up evaluation in surviving patients (13 knees) was 77 months (range, 25-159). A statistically significant difference was found between the preoperative and postoperative values with respect to pain score (5 vs 48), functional score (42 vs 78), flexion deformity (17 degrees vs 5 degrees ), and flexion range (56 degrees vs 81 degrees ). Nine complications occurred in 6 knees. One patient died from HIV-related complications, and none of the patients seroconverted to HIV during the follow-up period.     

Psychological predictors of acute postoperative pain after total knee and hip arthroplasty: A systematic review

Background

Identifying patients at high risk of acute postoperative pain after total knee or hip arthroplasty (TKA/THA) will facilitate individualized pain management and research on the efficacy of treatment options. Numerous studies have reported that psychological patient factors may influence acute postoperative pain, but most reviews have focused on chronic pain and functional outcomes. This systematic review aims to evaluate which psychological metrics are associated with acute postoperative pain after TKA and THA.

Methods

A systematic search was conducted using the databases PubMed, EMBASE, Web of Science, and Cochrane Library until June 2022. Full-text articles reporting associations of preoperative psychological factors with acute pain within 48 h of TKA or THA surgery were identified. Quality was assessed using the Quality in Prognostic Studies tool.

Results

Eighteen studies containing 16 unique study populations were included. TKA was the most common procedure, and anxiety and depression were the most evaluated psychological metrics. Several different anesthetic techniques and analgesic regimens were used. The studies were generally rated as having a low to moderate risk of bias. Catastrophizing was associated with acute pain in six studies (of nine), mainly after TKA. In contrast, three studies (of 13) and two studies (of 13) found anxiety and depression, respectively, to be associated with acute postoperative pain.

Conclusion

Pain catastrophizing seemed to be the most consistent psychological predictor of acute postoperative pain after TKA. The results for other psychological factors and THA were inconsistent. However, the interpretation of results was limited by considerable methodological heterogeneity.     

复杂膝关节畸形的TKA治疗

目的探讨复杂膝关节畸形行人工全膝关节置换术（TKA）的可行性和手术方法。方法回顾性分析自2000-01—2008-12行TKA的20例（26膝）复杂膝关节畸形伴严重功能障碍患者,经过充分术前准备后,针对不同畸形特点采用不同的截骨矫形方式,并进行相应挛缩软组织松解。内翻畸形以调整胫骨截骨矫正为主,外翻以调整股骨截骨矫正为主,屈曲行调整股骨远端及胫骨后倾截骨,术后加以系统的康复训练。结果本组术后获得1~5年随访,平均矫正内翻畸形15°,外翻畸形10°,屈曲畸形35°。末次随访HSS评分平均（86.5±8.6）分,较术前平均（36.2±15.4）分明显提高,差异有统计学意义（t=-12.812,P〈0.05）。结论复杂膝关节畸形患者行TKA需重视术前评估,并依据膝关节骨质畸形、软组织形成等病理特点,选择针对性的手术方式及系统性的康复训练,最终可获得一个畸形矫正、稳定无痛、功能良好的膝关节。     

Heterotopic ossification after hip and knee arthroplasty: risk factors,prevention, and treatment

Symptomatic heterotopic ossification (HO) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is relatively rare. Patients at high risk for developing HO after THA include men with bilateral hypertrophic osteoarthritis, patients with a history of HO in either hip, and patients with posttraumatic arthritis characterized by hypertrophic osteophytosis. Patients at moderate risk are those with ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, Paget's disease, or unilateral hypertrophic osteoarthritis. Patients at high risk for developing HO after TKA include those with limited postoperative knee flexion, increased lumbar bone mineral density, hypertrophic arthrosis, excessive periosteal trauma and/or notching of the anterior femur, and those who require forced manipulation after TKA. Preoperative radiation is effective for preventing HO after THA, as are post-operative prophylactic drug regimens and single-dose radiation treatments. Recurrence of HO after surgical excision should be expected unless prophylaxis is administered. Prophylactic measures against HO after THA and TKA should be administered before the fifth postoperative day, optimally within 24 to 48 hours.     

膝关节内翻屈曲畸形全膝关节置换的软组织平衡

目的探索对膝关节内翻屈曲畸形患者施行的全膝关节置换（total knee arthroplasty,TKA）软组织平衡技术。方法2001年1月～2005年12月,对实施的86例104膝骨性关节炎（osteoarthritis,OA）行TKA的膝内翻屈曲畸形患者进行回顾性研究,对术中的软组织平衡问题进行讨论。其中男19例23膝,女67例81膝;年龄57岁～78岁,平均66岁。行单侧TKA术68例,双侧18例。均为初次行TKA的OA患者。术前内翻角为6～34°,平均12.3°;其中软组织性内翻占总内翻角的56.7%,骨性内翻占43.3%。术前膝关节屈曲挛缩畸形10°以下21膝,10～19°45膝,20～29°22膝,30°以上16膝,平均18.9°。结果患者术前膝关节平均屈曲挛缩18.9°,术中除4例残留5°屈曲挛缩外,其余患者术中膝关节均能达到完全伸直。术后随访6～72个月,平均37个月,6例残留5～10°屈曲挛缩,余膝关节可达到完全伸直。术前内翻角6～34°,平均12.3°;术后测量股胫角170.3～175.6°,平均174.7°,其中2例残留内翻角〉3°。术中、术后发生并发症6例,其中内侧副韧带股骨起点损伤2例;髌骨弹响2例;脑栓塞及腔隙性脑梗塞各1例,经内科治疗后未遗留神经症状。均无皮肤坏死、切口感染及深部感染发生。结论软组织平衡是矫正膝关节内翻屈曲挛缩畸形的主要手段,良好合理的软组织平衡可使高度畸形的膝关节在TKA术后获得明显的功能恢复和畸形矫正。     

Predictors of Chronic Pain in Elderly Patients Undergoing Total Knee and Hip Arthroplasty: A Prospective Observational Study

BackgroundChronic postsurgical pain (CPSP) after total knee arthroplasty and total hip arthroplasty (TKA and THA) is an important clinical problem in which many factors play a role. The risk factors for CPSP in elderly individuals are currently unknown. Therefore, our aim was to predict the risk factors for CPSP after TKA and THA and to provide help regarding early screening and interventions for elderly individuals at risk.MethodsIn this prospective observational study, we collected and analyzed 177 TKA patients and 80 THA patients. Based on pain results at the 3-month follow-up, they were divided into the no chronic postsurgical pain and CPSP groups, respectively. The preoperative baseline conditions, including pain intensity (Numerical Rating Scale) and sleep quality (Pittsburgh Sleep Quality Index), as well as intraoperative and postoperative factors, were compared. Factors with P < .05 were included in binary regression analyses to establish prediction models for CPSP after TKA and THA.ResultsThe prevalence of CPSP was 20.9% after TKA and 7.5% after THA. The preoperative sleep disorders were an independent risk factor of CPSP after TKA, but no risk factors of CPSP after THA were identified.ConclusionThis study indicated that the prevalence of CPSP after TKA was significantly higher than after THA, and that preoperative sleep disorders were an independent risk factor for CPSP after TKA, which may aid clinicians in screening people at risk for CPSP for primary prevention.     

Changing Surgeons Improves Outcome of Subsequent Primary Total Joint Arthroplasty in Previously Dissatisfied Patients

We assessed whether patients who were dissatisfied with their previous primary hip (THA) or knee (TKA) arthroplasty, done by another surgeon, would have continued dissatisfaction or would have significant improvements in outcome scores following their subsequent primary THA or TKA. The majority of reasons provided for switching surgeons and/or institutions related to dissatisfaction with some aspect of their surgical experience specifically involving the surgeon–patient interaction itself. All 12 THA and TKA patients noted that their subsequent arthroplasty had decreased their pain, improved their function and that they were satisfied with their result. All patients had a statistically significant improvement in their Harris Hip Score or Knee Society Score, WOMAC and SF-36 questionnaires. This study demonstrates that previous dissatisfaction with a THA or THA does not predispose to a suboptimal outcome following subsequent primary hip or knee arthroplasty.     

TKA术中中度屈曲畸形骨与韧带的处理

目的探讨膝关节置换术中中度屈曲畸形骨与韧带的正确处理程序。方法对104例屈曲畸形在20～60°的初次置换患者进行回顾性研究,了解术中软组织松解步骤及每步松解后畸形残留情况。结果在随访36个月后屈曲畸形由术前平均32.4°恢复到术后3.4°。59例膝在内外软组织松解后屈曲畸形矫正;虽然所有患者均进行了不同程度的后关节囊松解,但只有39例是必需的;有6例需要额外的股骨远端截骨。结论充分的后关节囊及内外副韧带松解可以矫正绝大部分屈曲畸形,增加股骨远端截骨并非必须,后交叉韧带松解的原因是因为屈曲间隙紧张和增加股骨假体后方滚动。     

晚期类风湿关节炎患者的假体选择疗效对比

目的探讨晚期膝关节类风湿关节炎(RA)伴重度内翻屈曲畸形和严重骨质疏松患者行全膝关节置换术(TKA)假体选择及临床效果。 方法对2010年1月至2015年12月采用全膝关节置换治疗的晚期RA伴重度内翻屈曲畸形患者21例(27膝)进行回顾性分析。13例17膝采用后稳定型假体,8例10膝采用限制型假体。纳入标准：类风湿性关节炎合并膝关节重度内翻畸形;类风湿性关节炎合并膝关节患者骨密度T-Score<－2.8;无严重心肺疾病。排除标准：合并关节原发性或继发性活动期感染;合并关节外畸形通过单纯截骨无法矫正的患者。采用SPSS 16. 0统计软件分析,术前、术后屈曲挛缩度数、关节活动度及胫骨角均值比较采用配对样本t检验。 结果本组21例27膝均获得随访,病例随访时间2.0～5.3年,平均(3.8±1.1)年。后稳定组膝关节屈曲挛缩由术前(55. 5±12. 5)°(65.0°～85.0°)减少到末次随访时(5. 5±3. 5)°(0°～10.0°)(t ＝28.868,P < 0.01),关节活动度由(32. 5±6. 5)°(0°～40.0°)提高到末次随访时(105. 5±10. 5)°(85.0°～130.0°)(t ＝94.83,P < 0.01);股胫角由术前(31.0±3.5)°(23.0°～45.0°)修正为末次随访时(8.5±2.5)°(0°～12.0°)(t ＝116.913,P <0.01)。限制型假体组膝关节屈曲挛缩由术前(56.5±15.5)°(65.5°～80.0°)减少到末次随访时(6.0±5.0)°(5.0°～15.0°)(t＝25.486,P < 0.01),关节活动度由(32. 0±8.0)° ( 0°～40.0°)提高到末次随访时(100.0±5.5)°(85.0°～120.0°)(t ＝141.335,P < 0.01);股胫角由术前(31.5±5.5)°(22.0°～45.0°)修正为末次随访时(8.0±4.5)°(0°～12.0°)(t＝122.11,P < 0.01),均较术前明显改善,手术前后差异有统计学意义。两组之间术前及末次随访比较各指标得知,限制型假体组显著低于后稳定组关节活动度(t ＝5.716,P <0.01),差异具有统计学意义。 结论对晚期RA伴膝关节重度内翻屈曲畸形和严重骨质疏松患者在假体选择方面,后稳定型假体活动度更好,但在纠正内翻屈曲畸形和股胫角疗效比较方面,未见显著差异,所有患者近期疗效满意。