开放楔形胫骨高位截骨联合关节镜清理术治疗内侧间室膝骨关节炎的疗效分析

[摘要]目的 探讨开放楔形胫骨高位截骨（OWHTO）联合关节镜清理术治疗内侧间室膝骨关节炎的近期疗效及其手术前后的步态变化。方法 选择河北省沧州中西医结合医院2017年6月至2019年12月期间收治的内侧单间室膝骨关节炎患者80例（80膝）为研究对象,均采用OWHTO联合关节镜清理术治疗。对患者进行为期12个月的随访,采用视觉模拟疼痛评分（VAS）、美国特种外科医院膝关节评分（HSS）、美国西安大略与麦克马斯特大学骨关节炎指数评分（WOMAC）进行疗效分析;对比手术前后股骨胫骨角（FTA）、胫骨平台后倾角（PTS）、Insall-Salvati指数（IS）、下肢力线通过平台Fujisawa点等影像学指标;三维步态分析系统采集患者不同时间点膝关节运动数据,并以1∶4个体匹配原则选取20名健康志愿者正常步态与之进行对比。结果 患者均获得随访,2例术后2周时出现切口浅表感染,予对症处理后好转。末次随访时,患者VAS评分与WOMAC评分降低,HSS评分升高,与术前比较均具有统计学意义（P<0.05）;FTA、PTS、IS指数、下肢力线通过平台Fujisawa点较术前均有明显改善（P<0.05）;患者术前站立及摆动时屈伸角、内外翻角、内外旋角均与正常膝关节存在显著差异（P<0.05）,术后12个月与正常膝比较,差异无统计学意义（P>0.05）。结论 关节镜下清理术联合OWHTO治疗内侧间室膝骨关节炎可有效缓解患者膝关节疼痛,促进膝关节活动及功能恢复,疗效显著。随着康复时间的推移,患者患肢膝关节逐步趋于稳定,在术后12个月时患者膝关节屈伸、内外翻、内外旋等步态运动与正常膝比较无明显差异。     

单侧全膝置换前后女性患者步态特征分析

目的研究单侧全膝置换(total knee arthroplasty,TKA)手术前后女性患者双侧下肢步态特征。方法基于三维步态采集和独立样本t检验,对比10例女性患者单侧TKA手术前后双侧下肢的步态参数,并分别与对照组10例健康志愿者比较,分析女性患者双侧步态差异及分别与正常步态的差异。结果术前患者非手术侧支撑期、膝关节内收角度峰值、冠状面活动度和屈曲力矩峰值显著大于手术侧(P0.05),术后无统计学差异;与对照组比较,术前患者步速、步长较小,双支撑期较长,手术侧膝关节伸展和内收角度峰值、冠状面活动度、屈曲和外展力矩峰值较小,内收力矩峰值较大,非手术侧膝关节伸展角度峰值较小,屈曲和内收力矩峰值较大,均存在统计学差异(P0.05),术后双侧膝关节伸展角度和内收力矩峰值与对照组的显著差异持续存在(P0.05)。结论单侧TKA能减轻患者疼痛,改善双侧下肢步态偏差,但与对照步态仍存在差异。患者肌力及本体感受等关节功能尚未恢复,病理步态与不良体态仍然存在,应加强患侧肌力锻炼及步态矫正训练。女性患者术后同时应注意步速控制,以防膝关节受力增加。     

全膝关节置换前后患者下肢肌骨模型步态模拟与分析

目的比较分析全膝关节置换患者术前、术后步态周期站立相下肢肌肉激活规律和膝关节受力。方法基于Open Sim平台建立1名健康受试者和3名单侧全膝关节置换(total knee arthroplasty,TKA)患者术前、术后下肢肌骨模型。使用三维动作捕捉系统和测力台采集受试者步行期间下肢运动学数据和地面反作用力作为输入参数,模拟计算下肢肌肉激活和膝关节受力。结果肌骨模型计算结果与基于三维动作捕捉系统的逆动力学计算结果基本一致。不同于健康受试者,患者股直肌在承重反应期、支撑相中期激活,3名患者术后股四头肌的激活时间与激活程度较术前明显不同。患者TKA术前关节受力峰值为3. 15、2. 95、3. 43倍身体质量(body weight,BW),支撑相中期维持2倍BW以上载荷。TKA术后关节受力峰值分别2. 09、2. 48和3. 73倍BW。结论所建肌骨模型计算结果具有一定的可靠性,该模型今后可为TKA治疗提供生物力学的辅助手段。     

CR假体与PS假体全膝关节置换治疗膝骨性关节炎合并膝外翻畸形的疗效分析

目的 比较后交叉韧带保留型（CR）假体与后方稳定型（PS）假体行人工全膝关节置换术（TKA）治疗膝骨性关节炎合并膝外翻畸形的临床疗效。方法 回顾性分析南昌大学附属赣州医院关节外科2019年5月至2021年5月收治的60例（60膝）膝骨性关节炎合并膝外翻畸形患者资料,均为单侧置换。30例采用CR假体行TKA治疗（CR组）,30例采用PS假体行TKA治疗（PS组）。比较两组患者的手术时间、术中失血量、术后引流量、术后3 d血红蛋白（Hb）下降量及深静脉血栓发生情况;比较两组患者手术前后膝外翻角;比较两组患者术后1周、1个月、3个月、6个月、1年疼痛视觉模拟评分（VAS）、膝关节活动度（ROM）、美国特种外科医院膝关节评分（HSS）。结果 60例患者均顺利完成TKA手术,所有患者随访13 ～ 28个月,平均（18.51±0.90）个月。CR组术中出血量、术后引流量、术后3 d的Hb下降量较PS组减少（P＜0.05）;两组手术时间相当、术后均无深静脉血栓发生,差异无统计学意义（P＞0.05）;两组手术前后膝外翻角的比较差异无统计学意义（P＞0.05）;CR组术后1周、1个月VAS评分较PS组更低（P＜0.05）,两组术后3个月、6月、1年VAS评分比较差异无统计学意义（P＞0.05）;CR组术后1周、1个月、3个月膝关节ROM和HSS评分优于PS组（P＜0.05）,两组术后6个月、1年膝关节ROM和HSS评分比较差异无统计学意义（P＞0.05）。结论 采用CR或PS假体行TKA手术治疗膝骨性关节炎合并膝外翻畸形均可有效纠正膝关节畸形、减轻膝关节疼痛、改善膝关节活动度及功能,取得满意临床疗效;但相对PS假体,CR假体保留了后交叉韧带,减少了股骨髁部截骨量,从而减少手术出血,更好减轻早期术后疼痛,有助于TKA术后早期功能康复。     

骨水泥型与非骨水泥型全膝关节置换后的步态差异

背景：全膝关节置换已经被证明是一种有效治疗膝骨性关节炎的方法,但是不同类型的全膝关节置换假体固定方式术后所产生的膝关节下肢生物力学差异至今仍不明确。 目的：通过三维步态分析骨水泥固定和非骨水泥固定两种不同的全膝关节置换术后患者的膝关节生物力学差异。 方法：分别选取骨水泥型全膝关节置换以及非骨水泥型全膝关节置换患者各16例,通过测力台以及三维步态分析系统比较2组患者术前以及术后3个月的膝关节生物力学变化并进行对比。 结果与结论：与手术前相比两组患者术后步速及步长均明显增加,支撑相在整个步态周期中的百分比明显减小, 膝关节屈在支撑相及摆动相中最大屈曲角度均明显增加,膝关节外翻角度增加。两种患者术后膝关节内翻角度以及膝关节内收力矩均明显减小。提示,骨水泥型与非骨水泥型全膝关节置换术均能有效改善膝骨性关节炎患者的步行能力以及下肢关节功能,两者间未见明显生物力学差异。     

胫骨假体内外翻角对固定平台单髁关节置换后近期疗效的影响

背景：既往国内外均有文献报道活动平台单髁关节置换后胫骨假体内外翻角度对术后短期疗效的影响，然而对固定平台单髁关节置换后胫骨假体内外翻角度短期疗效的影响鲜有报道。目的：探讨膝关节内侧骨关节炎患者接受固定平台单髁关节置换后，胫骨假体内外翻角对近期临床疗效的影响。方法：选择2020年8月至2023年1月因膝关节内侧骨关节炎于徐州医科大学附属医院骨关节科行固定平台单髁关节置换的120例患者(122膝)为研究对象，分别由2名医师基于术后X射线片测量单髁关节置换后股骨假体内外翻角、胫骨假体内外翻角、股骨假体屈伸角以及胫骨假体后倾角。排除其余3个角度的影响后，将胫骨假体内外翻角测量结果分为<-2°、-2°-2°、> 2°3组，分别记为第1,2,3组。记录各组患者术前、术后末次随访的膝关节活动度、美国特种外科医院膝关节评分、美国膝关节协会评分及人工关节遗忘指数，并进行对比。结果与结论：(1)共纳入120例患者(122膝)，根据术后胫骨假体内外翻角大小进行分组，第1组37例，第2组60例，第3组23例，3组患者在年龄、性别、术侧等基线资料上差异无显著性意义(P> 0.05)；(2)患者...     

虚拟现实同步减重训练脑梗死患者可改善下肢运动功能

背景:脑卒中患者多有步行功能障碍,虚拟现实同步减重训练开始运用于脑梗死患者的步态训练。目的:评估虚拟现实同步减重训练对亚急性期脑梗死患者下肢运动功能的影响。方法:20例起病3个月内的脑梗死患者随机分配至实验组(虚拟现实同步减重训练)和常规组(常规物理治疗)。在3周步态训练前后各做一次三维步态并进行下肢运动功能评估。对以下参数进行训练前后组内和组间对比:步行速度、步调、步行时间、单腿支撑时间(%)、双腿支撑时间(%)、摆动时间、步长、步幅、下肢各关节活动度、功能性步行分类、下肢Fugl-Meyer评分和Brunel平衡评分。结果与结论:训练前两组患者的性别、年龄、病程、偏瘫侧、步行速度、功能性步行分类、下肢Fugl-Meyer评分和Brunel平衡评分差异无显著性(P0.05)。训练后两组患者的下肢Fugl-Meyer评分和功能性步行分类均有改善(P0.05)。实验组在步行速度、步调、患侧步行时间、健侧步行时间、患侧单腿支撑时间、患侧摆动时间、健侧摆动时间、步幅、患侧步长和健侧步长的改善方面较常规组有优势。     

第四代Oxford单髁置换术对膝关节内侧间室骨关节炎患者的疗效评估及步态分析

目的探讨第四代Oxford单髁置换术对膝关节内侧间室骨关节炎患者的临床疗效及对患者步态恢复的影响。方法将2016年1月至2018年1月收治并符合标准的30例(30膝)膝关节内侧间室骨关节炎患者纳入研究并作为试验组,另外再纳入20例(20膝)膝关节正常的志愿者作为本研究的正常组。试验组患者接受第四代Oxford单髁置换术,正常组研究对象不做任何治疗干预,仅作为观测指标对照。本研究观测指标主要包括疼痛视觉模拟评分(VAS评分)、膝关节学会评分系统(KSS)、美国WOMAC骨关节炎指数评分、美国特种外科医院膝关节评分(HSS评分)和步态分析运动学参数。比较试验组在术前、术后6个月及术后12个月的观测指标的差异,并分别与正常组作比较。结果试验组患者术前、术后6个月及术后12个月3个时间段两两之间的VAS评分、HSS评分、WOMAC评分以及KSS评分比较,差异均具有统计学意义(0.05)。试验组患者术前、术后6个月及术后12个月的步态分析各运动学参数的差异均具有统计学意义(0.05)。其中除最大前位移和最大内位移在术后6个月及术后12个月两个时间段差异无统计学意义之外,其他步态分析各运动学参数在3个时间段两两之间差异均具有统计学意义(0.05);试验组患者在术后12个月与正常组步态分析各运动学参数相比,最大伸直角、最大内位移和最大外位移比较,差异无统计学意义(0.05),但其余各步态分析各运动学参数差异仍然存在统计学意义(0.05)。结论在选择适当的病例和严格掌握手术适应证的前提下,第四代Oxford单髁置换术对膝关节内侧间室骨关节炎患者的近、中期疗效满意,术后患者关节功能更接近生理状态。     

单髁关节置换术与全膝关节置换术治疗膝关节内侧间室骨性关节炎术后运动功能恢复的对照研究

目的 对比单髁关节置换术与全膝关节置换术治疗膝关节内侧间室骨性关节炎患者术后运动功能恢复状态。方法 收集2022年1月至2022年12月在云南省滇南中心医院关节外科治疗的55例膝关节内侧间室骨性关节炎患者的临床资料,根据治疗方式的不同分为全膝关节置换组（TKA组,25例）和单髁关节置换组（UKA组,30例）。对比两组患者术后1、2、3、6个月的爬楼梯测试、起立行走测试、6分钟步行测试的功能恢复情况及膝关节WOMAC评分。结果 所有患者均随访6～9个月,平均（7.15±0.81）个月。UKA组患者比TKA组患者较早地获得更好的WOMAC评分（P<0.05）。UKA组术后1、2、3个月时在爬楼梯、起立行走及6分钟步行测试方面均优于TKA组（P<0.05）,但在术后6个月时两组之间除在爬楼梯测试比较差异有统计学意义（P<0.05）以外,起立行走及6分钟步行测试比较差异无统计学意义（P>0.05）。结论 从治疗膝关节内侧间室骨性关节炎术后早期恢复情况来看,单髁关节置换术较全膝关节置换术能够更快、更好地获得功能恢复。     

膝骨关节炎患者本体感觉特征

目的 探讨行单髁膝关节置换术(unicondylar knee arthroplasty,UKA) 和全膝关节置换术(total knee arthroplasty,TKA)膝骨关节炎( knee osteoarthritis,KOA)患者术前膝关节本体感觉特征。方法 选取单间室KOA患者29名,15例接受 UKA 治疗（UKA组）,14例接受 TKA 治疗（TKA组）。术前1~3 d进行测试,对比UKA、TKA组KOA患者膝关节学会评分（knee society score, KSS）以及手术组与健康对照组的位置觉和运动觉特征。结果 UKA、TKA组之间KSS评分有显著差异,位置觉和运动觉无显著差异;UKA、TKA组患者术侧腿和未术侧腿之间位置觉和运动觉均无显著差异,对照组左、右腿位置觉和运动觉无显著差异;与对照组相比,UKA、TKA组在60°位置觉时术侧腿和未术侧腿均有显著差异,患者术侧腿和未术侧腿的运动觉也均有显著差异。结论 与健康对照组相比,KOA患者术前的膝关节本体感觉明显减退,但UKA、TKA组患者术前本体感觉特征相近。     

Relationship between leg extensor muscle strength and knee joint loading during gait before and after total knee arthroplasty

ObjectiveThe aim of the present study was to evaluate an isometric maximal voluntary contraction (MVC) force of the leg extensor muscles and its relationship with knee joint loading during gait prior and after total knee arthroplasty (TKA).MethodsCustom-made dynamometer was used to assess an isometric MVC force of the leg extensor muscles and 3-D motion analysis system was used to evaluate the knee joint loading during gait in 13 female patients (aged 49–68 years) with knee osteoarthritis. Patients were evaluated one day before, and three and six months following TKA in the operated and non-operated leg.ResultsSix months after TKA, MVC force of the leg extensor muscles for the operated leg did not differ significantly as compared to the preoperative level, whereas it remained significantly lower for the non-operated leg and controls. The knee flexion moment and the knee joint power during mid stance of gait was improved six months after TKA, remaining significantly lowered compared with controls. Negative moderate correlation between leg extensor muscles strength and knee joint loading for the operated leg during mid stance was noted three months after TKA.ConclusionsThe correlation analysis indicates that due to weak leg extensor muscles, an excessive load is applied to knee joint during mid stance of gait in patients, whereas in healthy subjects stronger knee-surrounding muscles provide stronger knee joint loading during gait.Level of Evidence: III (correlational study)     

Clinical and objective gait outcomes remained stable seven years after total knee arthroplasty: A prospective longitudinal study of 28 patients

BackgroundThere is a paucity of data on mid to long-term gait outcomes after total knee arthroplasty. The aims of this longitudinal study were: to assess the evolution of both clinical and gait outcomes before and up to seven years after primary total knee arthroplasty (TKA) in a cohort of patients with knee osteoarthritis.MethodsThis study included 28 patients evaluated before and up to seven years after primary TKA with both gait analysis and patient reported outcomes; of these, 20 patients were evaluated one year after surgery as well. Kinematic outcomes during gait (gait velocity, dimensionless gait veolicity, maximal knee flexion and knee range of motion), pain relief, Western Ontario and MacMaster Osteoarthritis Index (WOMAC), quality of life and patient satisfaction were assessed and compared at each visit with the paired Wilcoxon signed rank test (p < 0.05).ResultsThe significant improvement achieved at one year after TKA was stable up to seven years after surgery, with all clinical and kinematic outcomes unchanged, except for gait velocity, with a significant decrease over time (1.3 (1.1–1.4) m/s one year after TKA versus 1.0 (0.9–1.1) m/s, p < 0.05 up to seven years after).ConclusionPatients with knee osteoarthritis significantly improve their clinical and kinematic outcomes at one year postoperatively and maintain the gain up to seven years after primary TKA, except for gait velocity which decreases over time, most likely along with ageing.     

Gait analysis: Comparative evaluation of conventional total knee replacement and modular distal femoral megaprosthesis

BackgroundGait alterations have been studied with computer-assisted gait analysis after megaprosthetic replacement for tumors around the knee. It has never been proven that megaprostheses affects gait more than total knee arthroplasty (TKA); this study aims to compare via gait analysis patients who underwent megaprosthesis with patients with TKA.MethodsWe analyzed 26 patients with a megaprosthetic replacement of the distal femur and 21 patients with a standard TKA. For each subject computerized gait analysis was performed. Range of motion (ROM) of the knee was recorded, Quality of Life and functional evaluation in the oncologic group were assessed with the Musculoskeletal Tumor Society (MSTS) questionnaire, while Short Form-36 (SF-36) scores were calculated for both groups.ResultsAll patients walked slower than healthy people (P < 0.05). Gait analysis showed a lower cadence than in the healthy population but no significant difference between the two groups. A longer swing and a shorter stance phase were detected in the megaprosthetic sample. The osteoarthritis group showed greater flexion during the phase of loading response, even if this was lower than the contralateral limb or healthy population. There was a statically significant difference between the healthy limb and the operated one in both groups regarding ROM, but no significant difference was registered between the two implants. MSTS score and most of SF-36 parameters showed no significant differences compared with literature data.ConclusionsGait analysis shows little discrepancy between the two groups; gait pattern abnormalities do not affect patients with a megaprosthetic replacement more significantly than patients undergoing TKA.     

Relationships between early postoperative gait biomechanical factors and patient-reported outcome measures 6 months after total knee arthroplasty

BackgroundThis study was focused on the gait parameters of the knee extensor and hip abductor muscle groups, which are believed to contribute to knee joint function improvement in early postoperative TKA. The associations between patient-reported outcome measures (PROMs) 6 months after total knee arthroplasty (TKA) and the early postoperative internal knee extension moment, knee extension negative joint power, and internal hip abduction moment while walking were investigated.MethodsTwenty-one patients who underwent primary TKA for knee osteoarthritis were included. Three weeks after TKA, gait at a comfortable speed was measured by three-dimensional motion analysis. The lower limb joint angle, internal joint moment, and joint power parameters on the operated side while standing were calculated. The PROMs 6 months after TKA were assessed using the Japanese Knee Osteoarthritis Measure (JKOM). The relationship between each gait biomechanical parameter and the JKOM was determined.ResultsThe maximum internal knee extension moment and maximum knee extension negative joint power during the early stance showed moderate negative correlations with the JKOM scores. The maximum internal hip abduction moment was not correlated with the JKOM scores. The maximum internal hip extension moment during the early stance and internal hip flexion moment during the late stance showed moderate negative correlations with the total JKOM scores.ConclusionThe early postoperative internal knee extension moment, maximum knee extension negative joint power, and internal hip extension and flexion moment are associated with patient PROMs 6 months after TKA.     

Physical examination and in vivo kinematics in two posterior cruciate ligament retaining total knee arthroplasty designs

The aim of this study was to investigate anteroposterior instability in the CKS and the PFC total knee arthroplasty (TKA) designs. Physical examinations, including VAS, IKS and WOMAC were performed in combination with a detailed fluoroscopic measurement technique for three-dimensional kinematic assessment of TKA design function. Anteroposterior instability rated with the IKS was not significantly different (p = 0.34), but patients with a CKS design showed more limitations according to the WOMAC joint stiffness total score, and for items regarding higher flexion activities in the WOMAC score for knee disability. Kinematic analyses showed that the CKS design tended to have more anterior sliding of the femur on the tibia during mid- and deep flexion activities. The sliding distance was larger at the medial than at the lateral side. This phenomenon has also been described for posterior cruciate ligament deficient knees. Furthermore, the CKS design showed a significantly lower range of tibial rotation (p < 0.05) from maximum extension to maximum flexion during deep knee bend activities. Kinematic differences can be ascribed to posterior cruciate ligament deficiency/laxity or differences in TKA designs.     

Predictors of functional outcome after revision total knee arthroplasty following aseptic failure

BackgroundThere are a limited number of studies related to quality of life and functional outcome after revision total knee arthroplasty (TKA). The present study aimed to identify predictors of functional outcome after revision TKA for aseptic failure.MethodsOne hundred seventy-five patients with mean age of 66.6 years (range, 35–88) who underwent revision TKA for aseptic failure at our institute from 2003 to 2007 were identified. Short-form 36 (SF-36), Western Ontario and McMaster Osteoarthritis Index (WOMAC) and Knee Society Scores (KSS) collected preoperatively and at 2 years follow up were evaluated. Univariate and multivariate analyses were performed to determine predictors of functional outcome in studied patients.ResultsBoth physical and mental dimensions of SF-36, pain, functional, and stiffness subscales of WOMAC and both functional and clinical scores of KSS improved significantly after revision TKA (p < 0.001). In the multivariate analysis, male gender, a lower Charlson comorbidity index, and higher preoperative functional KSS were predictors of higher functional KSS at 2 years after revision. Lower preoperative pain and higher clinical KSS were predictors of better outcome as measured by pain scale of WOMAC. Body mass index (BMI) and preoperative clinical KSS were significant predictors of function and stiffness as measured by WOMAC.ConclusionsBMI is a modifiable predictor of functional outcome after revision TKA. Moreover, patients with higher preoperative functional scores appear to have better postoperative function.Level of evidenceLevel II.     

髌周去神经化预防全膝关节置换术后膝前疼痛

目的　依据髌周解剖学特点，探讨全膝关节置换术（total knee arthroplasty，TKA）中应用髌周电灼去神经化的临床效果。 方法　纳入82名诊断为骨性关节炎的患者（91膝），予行双侧或单侧不置换髌骨的TKA，按随机对照原则将病人分为两组，共有41名实验组患者（45膝）在TKA中接受了髌周去神经化处理，41名对照组患者（46膝）未做该处理。手术主刀为同一骨科医师，均使用相同的膝关节假体系统。主要评价项目包括膝关节KSS评分、Western Ontario and McMaster Universities（WOMAC）、Feller髌骨评分及VAS评分。 结果　82名患者术后均获随访，平均随访时间为12个月，两组病人的膝关节KSS评分、WOMAC、Feller髌骨评分及VAS评分均无显著统计学差异（P>0.05）。 结论　在TKA中行髌周电灼去神经化，不能显著改善病人的预后。     

Can single limb support objectively assess the functional severity of knee osteoarthritis?

There is a lack in objective measurements that can assess the symptoms of knee osteoarthritis (KOA). In a previous study it was shown that pain and function are in higher correlation with the single-limb support gait parameter than with radiographic KOA stage. Single limb support represents a phase in the gait cycle when the body weight is entirely supported by one limb, while the contra-lateral limb swings forward. The purpose of this study was to further examine the relationship between single-limb support and the level of pain and function in patients with KOA. 125 adults with bilateral KOA underwent a physical and radiographic evaluation, and completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the SF-36 health survey. Patients walked barefoot at a self-selected speed on a computerized mat. Statistical analysis was used to divide the patients into quintiles based on single-limb support phase value and determine the differences in WOMAC and SF-36 scores between quintiles. Significant differences were found in WOMAC and SF-36 sub-category scores between the single-limb support quintiles. The means of the WOMAC-pain and WOMAC-function sub-categories decreased gradually over single-limb support quintiles (P < 0.001), and the means of the SF-36 sub-categories increased gradually over the quintiles (P < 0.001). Results show that single-limb support quintiles can help determine the level of pain, function and quality of life in patients with KOA. These results suggest that single-limb support quintiles may be added as an additional scale for generally assessing the symptomatic stage of KOA.