初次人工全膝关节表面置换术治疗膝关节骨关节病108例的疗效观察

[目的]探讨初次人工全膝关节表面置换术(total knee arthroplasty,TKA)治疗膝关节病的临床疗效。[方法]对108例130个膝关节行TKA,男50例(60膝),女58例(70膝);年龄47～87岁,平均71.5岁,术前诊断骨性关节炎62例(70膝),类风湿性关节炎37例(51膝),创伤性关节炎4例,滑膜软骨瘤病2例,色素沉着绒毛结节性滑膜炎2例,陈旧关节结核1例,采用后方稳定假体80例(92膝),后交叉韧带保留假体28例(38膝)。[结果]108例患者均获随访,时间24～84个月,平均50.3个月。患者术后在疼痛、功能、活动度方面改善明显,采用HSS评分系统进行评分,由术前平均48.4分提高到89.3分。术后130个膝关节平均活动度为102°,126个膝关节术后力线正常,3例残留6°～8°内翻,1例后遗15°外翻畸形,手术优良率90.5%。[结论]TKA对治疗严重膝关节病效果满意,术中正确的选择切口,注意假体软组织平衡,精确截骨,注重术中髌骨轨迹的纠正是手术成功的关键。     

标准型股骨髁、胫骨托与高切迹胫骨聚乙烯垫组合TKA治疗严重膝关节骨性关节炎并膝内、外翻畸形

目的探讨采用标准型股骨髁、胫骨托与高切迹胫骨聚乙烯垫组合全膝关节置换术（TKA）治疗严重膝关节骨性关节炎并膝内、外翻畸形的临床疗效。方法采用标准型股骨髁、胫骨托与高切迹胫骨聚乙烯垫组合TKA治疗20例（25膝）严重膝关节骨性关节炎并膝内、外翻畸形,其中2例保留后交叉韧带,18例不保留后交叉韧带。结果本组20例术后获得平均12（5~60）个月随访。术前膝关节活动范围15°~85°,术后0°~130°。膝内、外翻畸形得到矫正。术前KSS评分（11.50±1.61）分,术后（91.35±1.23）分。结论采用标准型股骨髁、胫骨托与高切迹胫骨聚乙烯垫组合TKA治疗严重膝关节骨性关节炎并膝内、外翻畸形术中通过软组织平衡技术的应用,操作方便,假体稳定性及关节活动度好。早期临床疗效满意,远期疗效有待进一步随访观察。     

屈曲挛缩畸形全膝关节置换的软组织平衡

目的探讨屈曲挛缩畸形的膝关节行全膝关节置换术(TKA)的方法,重点关注术中膝关节周围软组织平衡的手术方法、技巧及术后疗效。方法晚期膝骨关节病合并膝关节屈曲挛缩畸形156例(213膝)行TKA进行治疗。分别记录手术前后膝关节畸形程度、HSS评分、活动范围,并进行比较。结果所有患者均获得平均22.6(12~32)个月随访,屈曲挛缩畸形均得到改善。膝关节HSS评分由术前平均20.7分提高到末次随访时平均73.6分。膝关节活动范围(ROM)由术前平均32.6°(0~55°)提高到末次随访时平均92.7°(80~125°)。结论晚期膝关节病所致的屈曲挛缩畸形的膝关节行TKA,除了在术中要注意准确截骨外,还应着重注意软组织松解与力线调整。     

人工全膝关节置换术在外翻膝的临床应用

[目的]探讨人工全膝关节置换术在外翻膝中的手术技术和临床疗效.[方法]2004年3月～2008年9月,对14例16个外翻膝行膝前正中、髌旁内侧入路,常规截骨、外侧软组织松解,后方稳定型假体或后交叉韧带保留型假体的人工全膝关节置换术进行回顾性研究.患者男3例,女11例,平均年龄60.5岁(45～77岁).经过随访比较手术前后膝关节屈伸活动度、KSS评分、膝关节X线情况来评估手术临床效果.[结果]术后平均随访42个月(24～54个月),膝关节屈伸活动度由术前平均82°(伸直0°～屈曲120°)提高到术后120°(伸直0°～屈曲150°);KSS评分:临床评分由术前平均43分(10～65分)提高到术后平均83.9分(70～100分),功能评分由术前平均52.9分(30～70分)提高到术后平均89.3分(75～100分);胫股角由术前平均16.5°(8°～30°)改善纠术后平均7°(5°～10°),膝外翻畸形得到良好的矫正.随访中无深静脉血栓、膝关节感染、髌骨半脱位或脱位并发症发生.[结论]膝前正中、髌旁内侧入路,常规截骨、外侧软组织松解,后方稳定型假体或后交叉韧带保留型假体的TKA治疗外翻膝临床疗效满意.     

选择性软组织松解技术在重度膝外翻畸形全膝关节置换术中的应用

目的探讨全膝关节置换（TKA）术中对重度膝外翻畸形软组织平衡的处理方法。方法自2003-07—2009-12对29例（32膝）膝外翻畸形（胫股角〉15°）的患者均采用术中局部选择性松解技术实现软组织平衡。分别于术前和术后1、3、6、12、24个月摄膝关节正位X线片、测定膝关节活动度（ROM）和进行HSS评分,评估术后临床疗效。结果 21例（24膝）获得随访,随访时间9~47个月,平均27.2个月。X线片显示假体位置良好,未见明显松动和下沉迹象。术前关节活动度平均（103.5±8.7）°,末次随访时平均（123.3±6.3）°。术前HSS评分平均（62.5±8.6）分,末次随访时平均（86.9±4.6）分。术后均未出现严重并发症。结论局部选择性软组织松解技术在处理重度膝外翻畸形软组织失衡方面疗效确切,该技术损伤小、安全简便,是TKA术中矫正重度外翻畸形较理想的方法。     

全膝关节置换术治疗老年重度膝关节炎伴胫骨平台骨折

目的探讨全膝关节置换术(TKA)治疗老年重度膝关节炎伴胫骨平台骨折的可行性。方法对19例重度膝关节炎伴胫骨平台骨折的老年患者进行TKA治疗,评估患者术后3、6个月时膝关节屈膝范围及HSS评分。结果患者均获得随访,时间6个月~3年。患者术后3个月膝关节屈伸范围95°~100°,HSS评分为82~90分;术后6个月膝关节屈伸范围100°~120°,HSS评分为85~96分,均达到满意的临床效果。结论TKA治疗老年重度膝关节炎伴胫骨平台骨折,患者关节功能恢复好,满意度高,不增加额外的手术风险。     

全膝关节置换术治疗膝关节骨性关节炎的临床观察

目的观察全膝关节置换术（TKA）治疗膝关节骨性关节炎的临床疗效。方法自2012-01—2012-12对50例（59膝）膝关节骨性关节炎行TKA。采用HSS评分标准对手术前后膝关节功能进行评估,并观察有无并发症发生。术后于下肢全长正位X线片上测量机械轴内侧角和股骨假体角（FFC angle）及胫骨假体角（FTC angle）,在侧位X线片上测量股骨假体角（LFC angle）和胫骨假体角（LTC angle）。结果 50例（59膝）均得到平均9（6~12）个月随访。患膝疼痛得到明显缓解或者消失,畸形获得矫正,活动明显改善。末次随访时HSS评分平均（83.66±7.78）分,较术前明显提高。术后X线片均显示假体的位置良好。术后在站立位下肢全长正位X线片上测量机械轴内侧角176°~185°,平均（178±3）°。FFC angle 85°~94°,平均（87±3）°;FTC angle 87°~96°,平均为（90±3）°。LFC angle 78°~89°,平均（85±4）°;LTC angle 77°~95°,平均（87±2）°。结论 TKA可以有效治疗膝关节骨性关节炎,精确测量下肢的力线、恢复膝关节正常的外翻角、注意周围的韧带和软组织的松解平衡是手术的关键。     

全膝关节置换治疗创伤后膝僵硬畸形

目的探讨全膝关节置换术(TKA)对创伤后膝僵硬畸形的治疗效果。方法对13例创伤后膝僵硬畸形患者采用TKA手术治疗,对比分析手术前后关节活动度范围以及膝关节HSS评分变化。结果 13例患者均获随访,时间3个月～3年6个月。HSS评分由术前的27～47(36±3.8)分提高到术后的80～92(86±3)分,关节活动范围由术前的5°～35°(20±3.5°)提高到术后的85°～100°(90°±5°),术前术后比较均有明显改善(P<0.05)。结论创伤后膝僵硬畸形采取TKA治疗可以明显改善关节活动范围,缓解症状,恢复功能,疗效满意。     

CR假体全膝关节置换术治疗膝骨关节炎的近期疗效

目的探讨保留后交叉韧带假体(CR假体)全膝关节置换术(TKA)治疗膝骨关节炎的近期临床疗效。方法 56例(64膝)膝关节骨关节炎患者采用CR假体进行TKA。比较患者术前、术后1周、术后3个月及术后2年膝关节活动度及膝关节HSS评分。结果 56例TKA患者均恢复满意,且均获得2年以上随访。无一例出现感染、松动及异响。患者术后膝关节疼痛、功能和活动度方面均有明显改善。HSS评分由术前的34~48(41.00±4.34)分提高到术后2年的68~97(86.50±7.57)分,差异有统计学意义(P0.01);其中优46膝,良16膝,可2膝,优良率96.9%。关节活动度由术前的34°~90°(61.93°±18.22°)提高到术后2年的117°~130°(122.17°±3.92°),差异有统计学意义(P0.01)。结论 CR假体TKA对治疗膝骨关节炎近期疗效良好。     

全膝关节置换术治疗重型血友病性膝关节炎的临床研究

目的分析全膝关节置换术(TKA)治疗重型血友病性膝关节炎的临床疗效。方法对8例(10膝)重型血友病性膝关节炎行TKA,比较手术前后膝关节HSS功能评分。结果 8例均获得随访12-60个月,平均24个月。术后患膝HSS功能评分:优1膝,良5膝,可4膝。手术前后HSS评分经t检验后P<0.05,差异有统计学意义,术后膝关节功能有明显改善。结论全膝关节置换术能够改善重型血友病性膝关节炎患者膝关节功能。     

Displaced tibial shaft fractures: A prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients

Of 53 patients with unilateral, displaced and closed or grade 1 open tibial shaft fractures, 27 patients (group I) were randomized to treatment with an intramedullary nail and 26 patients (group II) to treatment with a plaster cast. 12 fractures in the latter group were considered stable enough for treatment with only a cast (group IIa), while 14 fractures in group II showed redisplacement during reduction under anesthesia or at 1 week follow-up. Therefore, these fractures were stabilized with cerclage or screws (group IIb), which was a prerequisite for continuing cast treatment. The mean time-to-union was 19 weeks for group I, and 25 weeks for group II. 6 patients in group I and 16 in group II had delayed union. The Nottingham Health Profile index scores on physical mobility, social isolation, work ability, and sexual life were significantly better in group I than in group II at 3 months after injury. Delayed union, malunion, and restricted range of motion at the ankle joint were common complications when these fractures were treated with a cast. We recommend intramedullary nailing for these fractures.     

膝关节单间室置换术的研究进展

膝关节单间室置换术（单髁置换术,unicompartmental knee arthroplasty,UKA）已沿用30多年,被认为是治疗膝关节单间室骨性关节炎及骨坏死的一种有效术式。此术式有很多成功病例的报道,也有引发灾难性后果需要再次手术的情况。由于UKA多采用微创手术方式,因而在术后恢复及患者病死率等方面优于全膝关节置换;并且有学者经过10年的随访,发现关节存活率令人满意。随着手术技术日趋成熟、关节假体制造工艺越来越精细、     

Total condylar knee arthroplasty: Prosthetic component positioning and radiolucent lines

Prosthetic positioning and overall postoperative alignment were studied in 138 consecutive total knee replacements, using the Insall/Burstein® total condylar knee system. Overall alignment was within 7 ± 5 degrees of valgus in 63 per cent of the knees, while tibial component positioning was within 4 degrees of tilt in any direction in 53 per cent of the knees. A radiolucency index incorporating width and extent of radiolucent zones at the tibia was shown to progress from 3 months to 2 years postoperatively. The radiolucency index 2 years postoperatively was higher with postoperative varus alignment in the rheumatoid arthritis group; a tibial component tilt of more than 4 degrees in any direction increased the radiolucency index in both treatment groups.     

Image-guided surgical simulation—a proven improvement

Background and purpose Primary spontaneous osteonecrosis of the knee is a painful lesion in the elderly without any known cause. The onset of pain is usually acute. The prognosis is poor with high frequency of osteoarthritis, joint surface collapse, and subsequent knee surgery. In the present study, we determined whether bisphosphonates can prevent the joint surface collapse by delaying the post-necrotic remodeling.

Patients and methods Between 2006 and 2009, 17 consecutive patients (mean age 68 years) with clinical and radiographic signs of knee osteonecrosis were identified and given alendronate, 70 mg perorally, once a week for a minimum of 6 months. The patients were followed clinically, radiographically, and by MRI.

Results 10 of the 17 patients did not develop osteoarthritis (group A), 4 patients developed mild osteoarthritis but no knee joint surface collapse (group B), and 3 patients had a joint surface collapse (group C). 2 of the 3 patients in group C—as compared to none in the other groups—stopped medication prematurely, due to side effects.

Interpretation Compared to a previous, untreated series of osteonecrosis patients at our hospital, the clinical results in the present series appeared better. 59% of the patients had a complete radiographic recovery, as compared to 25% in the original study. 12% were failures regarding need to undergo surgery when bisphosphonates were given, as compared to 32% in the previous untreated series. An anticatabolic drug delaying the remodeling might be an effective treatment in osteonecrosis of the knee but further (preferably randomized) studies are necessary.     

Load Bearing Characteristics of the Patello-Femoral Joint

This study of normal patello-femoral biomechanics defines some functional specifications which may be useful in future total knee prosthesis design. Serial lateral X-rays of 15 fresh knees and their patellar mechanisms at several flexion angles provided definition of the direction of the resolved patello-femoral forces. Assuming that the patella acts as a frictionless pulley, the magnitude of the patello-femoral forces during several activities was calculated using data from Morrison (1970) and Smidt (1973). It ranged between 421 and 3420 newtons for the various activities and for isometric exercise. A methylene blue contact print technique was used to measure the bearing areas. These data indicate that between 13 and 38 per cent of the patellar surface bears joint loadings. Patello-femoral contact stresses were calculated to range from 1.28 to 12.6 N/mm². A 696 new-ton man climbing stairs would, for example, generate a patello-femoral force of 1754 newtons and would experience patello-femoral contact stresses between 3.73 and 6.87 N/mm². Stress values were equal to or in excess of anticipated tibial-femoral stresses. The high patello-femoral load values, the small bearing surfaces, and the consequent significant stress magnitudes indicate the need for caution in development of a patello-femoral joint prosthetic replacement.     

人工全膝关节表面置换术20例体会

2005年3月～2009年3月,我科对20例22个膝关节行人工全膝关节表面置换术(TKA),疗效满意. 1　材料与方法 1.1　病例资料　本组20例 (22膝),男8例,女12例,年龄 50～68岁.单膝置换18例,双膝置换2例.其中骨关节炎14例16膝（见图1A、B,2A）,类风湿性关节炎6例6膝.屈曲畸形者6膝,<20°者4膝,20°～40°者2膝.假体类型:后稳定型假体16例18膝;后交叉韧带(PCL)保留型假体4例4膝.     

膝骨关节炎病因、X线片及临床表现分析

目的探讨国人膝骨关节炎病因,临床表现和Ｘ线片的相关性,为临床诊治提供依据。方法对骨科门诊膝骨关节炎患者进行病因,临床表现调查,摄单腿站立位膝关节正侧位、髌骨轴位片,分析Ｘ线征象并作骨关节炎分级、分型。结果膝骨关节炎原发性占８７％,继发性占１３％,膝骨关节炎分型：初期型３８％,股型２８．５％,内侧－髌股型２３．２％。随关节炎分类程度的加重,稞症状向严重发展（Ｐ〈０．０１）。胫股角越大,Ｘ线分级趋向病     

关节镜在膝关节疾患中的应用体会

目的 总结关节镜诊断和治疗膝关节疾患的临床经验。方法 应用关节镜诊治膝关节疾患87例（93膝）。结果 93膝通过关节镜检查和镜视下手术进一步明确了诊断，综合评分由术有3．8分改善了9．3分，总有效率达94．6％。结论 关节镜对膝关节内疾患的诊断直观，明确，镜视下手术创伤小，并发症少，疗效好。     

全膝关节表面置换治疗严重膝关节畸形

目的探讨人工全膝关节表面置换术(TKA)治疗严重膝关节畸形临床疗效。方法应用全膝关节表面置换治疗严重膝关节畸形36例(48膝)。使用HSS评分标准评估分析术前、术后膝关节功能及术后疼痛、膝关节活动度的改善情况。43膝采用后稳定型人工全膝关节假体,5膝采用CCK型人工全膝关节假体。结果术后早期均无感染等并发症发生。术后X线片示假体位置良好,下肢力线良好。患者均获得随访,时间6～18个月。HSS评分术前为(41±5.3)分,术后6个月为(87.7±6.5)分。手术优良率为83.3%。患者疼痛、功能方面及活动度均有明显改善。结论全膝关节置换术对严重膝关节畸形的治疗效果满意。但应严格掌握手术适应证。