全膝关节置换治疗中重度膝内翻畸形

[目的]评估应用全膝关节置换术治疗膝关节骨性关节炎伴中重度膝内翻畸形的中期疗效,并探究手术技巧及相关经验。[方法]回顾性分析2008年2月~2013年10月应用全膝关节置换术治疗膝关节骨性关节炎伴中重度膝内翻畸形(内翻>10°)病例50例(50膝),其中原发骨性关节炎36例,类风湿性关节炎14例。平均病程12.5年(3~24年),均采用后稳定型假体,术中应用骨赘清理、缩小胫骨平台截骨、选择性的软组织松解等技术矫正膝内翻畸形,术后采取常规抗凝及对症的康复治疗。术前及术后摄取X线片测量患者股胫角,记录手术时间、术中及术后显性失血量,定期随访行X线复查假体位置,检查膝关节活动度并进行KSS评分。[结果]平均随访时间25个月(15~60个月)。无失访病例。手术时间58~94 min,平均73 min,显性失血量650~1 025 ml,平均770 ml,膝关节平均股胫角由术前的内翻13.1°改善成为术后外翻5.3°,置换后有3例术后出现膝关节僵硬并发症,13例术后出现膝前痛。无血管及神经损伤、髌骨骨折、髌骨低位等并发症发生,下肢力线均恢复正常。随访期间复查X线片,未出现假体松动、下沉等并发症,末次随访膝关节活动度、膝关节KSS评分显著优于术前(P<0.05)。[结论]膝关节骨性关节炎伴重度内翻畸形行全膝关节置换术治疗,术中应用骨赘清理、缩小胫骨平台截骨及选择性软组织松解等手术技巧,内翻畸形可得到纠正,术后下肢力线恢复,随访膝关节活动度及功能较前明显改善,中期临床效果满意。     

严重屈曲畸形膝的人工膝关节置换术

目的 探讨病变晚期的严重屈曲畸形膝关节行人工全膝关节置换术的临床疗效.方法 自2007年6月～2010年5月行人工全膝关节置换术的严重屈曲畸形112例(173膝)为A组(术前膝关节屈曲畸形≥20°),并随机选出同期手术的术前屈曲畸形小于20°者150例(214膝)为B组,随访1年以上,观察各组膝关节活动度、KSS评分、WOMAC评分的变化.结果 术后所有患者的膝关节活动度、KSS评分及WOMAC评分和术前相比差异有统计学意义(P＜0.05),术后A、B两组的活动度较术前分别增加了44.6°、22.6°,其中伸直活动度分别增加了25.3°、5.3°,屈曲活动度分别增加了19.3°、17.3°,KSS临床评分分别增加了69.0、45.8分,功能评分分别增加了33.5、32.5分,WOMAC疼痛评分分别减少了9.8、8.8分,僵硬评分分别减少了3.9、3.2分,功能评分分别减少了32.3、29.1分.结论 严重屈曲畸形的膝关节在关节置换术后能够获得很好的活动度和功能.     

股骨内髁滑移截骨技术在全膝关节置换术治疗RanawatⅡ型膝外翻畸形中的应用及疗效分析

目的 分析应用股骨内髁滑移截骨技术行全膝关节置换术治疗RanawatⅡ型膝外翻畸形的手术疗效。方法 回顾性分析自2012-06—2017-06应用股骨内髁滑移截骨技术行全膝关节置换术治疗的65例RanawatⅡ型膝外翻畸形,其中31例术中行股骨内髁滑移截骨（截骨组）,34例常规方法行外侧软组织松解（常规组）。记录两组术后并发症发生情况,比较两组术后髋膝踝角、膝关节KSS临床评分、膝关节KSS功能评分、膝关节活动度。结果 所有患者均获得随访,随访时间4.0～7.8年,平均6.3年。常规组6例、截骨组4例术后出现下肢深静脉血栓形成,经抗凝、溶栓治疗后均于术后2周左右恢复。截骨组3例因骨质疏松出现部分螺钉少许退钉,其中1例因螺钉退出较多作小切口将螺钉重新置入,另2例无明显症状未做特殊处理。所有患者滑移截骨块与股骨髁均愈合,影像学检查显示截骨块骨折线消失时间为术后3～6个月,平均3.2个月,无骨折不愈合发生。末次随访截骨组膝关节KSS临床评分、膝关节KSS功能评分、膝关节活动度均优于常规组（P<0.05）,两组髋膝踝角差异无统计学意义（P>0.05）。结论 股骨内髁滑移截骨技术在全...     

后稳定型全膝关节置换术治疗成人膝大骨节病混合畸形

背景：成人膝大骨节病（Kashin-Beck disease,KBD）混合畸形采用常规方法治疗很难奏效,常需关节置换手术治疗。应用后稳定型全膝关节置换术（total knee arthroplasty,TKA）治疗成人膝KBD混合畸形的治疗方法及疗效有待探讨。目的：探讨后稳定型TKA治疗成人膝KBD混合畸形的手术方法及临床疗效。方法：应用TKA治疗成人膝KBD混合畸形23例（27膝）,男14例（17膝）,女9例（10膝）;年龄54～79岁,平均63.2岁;病程3.8～27年,平均13.5年。膝内翻畸形5°～20°,平均11.5°;膝外翻畸形10°～35°,平均18.5°;术前屈曲挛缩畸形5°～40°,平均12.4°。应用膝关节HSS评分标准及畸形矫治角度进行效果评价,膝关节HSS评分术前33.4～75.6分,平均43.5分,良3膝（11.1%）,可15膝（55.6%）,差9膝（33.3%）。混合畸形包括内翻内旋、外翻外旋和屈曲挛缩畸形。结果：随访时间为2个月～6年,平均28个月。1例下肢血栓性静脉炎经保守治疗痊愈;1例术后6个月时髌前痛,行股四头肌功能锻炼疼痛消失。随访期间无一例出现假体周围透明带、假体下沉或松动、植骨块移位、骨折、骨吸收、骨不愈合及胫骨平台塌陷。终末随访HSS评分为63.7～89.4分,平均82.6分,优18膝（66.67%）,良7膝（25.93%）,可2膝（7.40%）。各种混合畸形角度得到很大程度矫治。结论：应用后稳定型TKA治疗成人膝KBD混合畸形,可有效矫治内外翻、屈曲、旋转畸形,缓解疼痛,恢复膝关节功能,近期疗效满意。     

全膝关节置换术中不同截骨顺序的比较

目的 比较不同截骨顺序在全膝关节置换术中应用的临床效果.方法 对40例患者40膝行全膝关节置换术,根据不同截骨顺序分成2组:观察组20膝,先行股骨截骨;对照组20膝,先行胫骨截骨.比较两组手术时间、术后引流量、术前术后膝关节功能情况及HSS评分,并进行统计学分析.结果 40例患者均获得随访,时间3～14个月.手术时间和术后引流量:观察组分别为(52.1±14.3)min和(324±46)ml;对照组分别为(75.5±16.7)min和(416±50)ml,差异有统计学意义(P<0.01).术后6周和12周的膝关节活动度:观察组分别为87.5°±13.1°和100.5°±8.2°;对照组分别为86.6°±14.7°和101.3°±6.2°,差异无统计学意义(P>0.05).术后6周和12周的HSS评分:观察组分别为(89.43±9.6)分和(91.72±7.6)分;对照组分别为(89.95±8.9)分和(90.87±8.5)分,差异无统计学意义(P>0.05).结论 全膝关节置换术先行股骨截骨可以为胫骨的操作获得更大的操作空间,手术操作简便,可以缩短手术时间,减少失血量.     

膝关节屈曲挛缩畸形全膝关节置换术的软组织平衡

目的探索膝关节屈曲挛缩畸形施行全膝关节置换术的软组织平衡方法。方法采用针对性的软组织平衡程序对33例膝关节屈曲挛缩大于20°(20°~60°)的患者在全膝关节置换术中进行软组织松解,回顾性分析患者术前畸形程度、术中软组织松解情况、术后畸形矫正和膝关节功能等。结果33例患者中20例(60.6%)仅靠软组织松解即可在手术中基本矫正膝关节的屈曲畸形,术中需行股骨远端2次截骨者不到40%,且均为屈曲挛缩大于30°的患者。屈曲挛缩大于40°的患者,除松解紧张侧侧副韧带外,均需松解内外两侧后方关节囊;屈曲挛缩小于40°时,内外翻畸形越严重,两侧后方关节囊需要同时松解的概率越低。临床疗效显示,术中除2例仍残留5°和8°屈曲挛缩畸形外,其余31例患者术中均能完全伸直。随访31.3个月(6~66个月),膝关节评分(HSS评分)由术前的平均28.8分增加到平均79.2分,膝关节平均屈曲挛缩1.3°(-3°~10°)。膝关节活动范围(ROM)由术前平均57.69°增加至97.69°。结论软组织松解是矫正膝关节屈曲挛缩的主要手段,对不同的膝关节疾病和畸形程度其术中软组织松解方法各不相同。良好合理的软组织平衡仍可使高度屈曲挛缩的膝关节在全膝关节置换术后获得明显的功能恢复和畸形矫正。     

伴有关节外畸形的全膝关节置换术

<正>全膝关节置换(total knee arthroplasty,TKA)是目前临床常用的严重膝关节损伤及病变治疗手段。TKA的长期生存率有赖于术中精确的软组织平衡和术后下肢机械轴线的良好恢复[1]。对于简单病例,应用标准的手术技术和手术器械就能解决问题。但对严重的膝关节畸形病人,需要在手术中运用一些特殊的手术技巧或手术工具及选用不同的假体,方能顺利解决手术中的难点。大部分存在关节内畸形的TKA通过适当的截骨和软组织松解,均可获得准确的软组     

ACCK髁限制性假体治疗重度膝关节畸形的初期临床疗效

[目的]探讨对重度膝关节畸形采用ACCK髁限制性假体行初次人工全膝关节置换术的初期临床疗效。[方法]回顾分析2014年1月~2014年9月采用ACCK髁限制性假体行初次人工膝关节置换术的18例重度膝关节畸形病例。男4例,女14例;平均年龄69.5岁(50~74岁)。左膝8例,右膝10例。病因:原发性骨关节炎8例,类风湿性关节炎7例,创伤性关节炎2例,夏科关节病1例。内翻畸形11例,外翻畸形7例。胫骨侧骨缺损,AORIⅠ型5例,Ⅱ型13例。记录手术时间,观察切口愈合及并发症发生情况,使用Gross方程评估围手术期失血量。记录术后X线髋膝踝角、冠状股骨角、冠状胫骨角和胫骨后倾角。随访期测量膝关节屈伸活动度,检测KSS评分。[结果]手术时间平均85 min(70~100 min)。围手术期平均失血量681.8 ml(440~1 360 ml)。术后髋膝踝角度平均为(179.8±1.5)°,冠状股骨角度平均为(89.7±1.4)°,冠状胫骨角平均为(90.1±1.5)°,胫骨后倾角平均为(6.6±1.5)°。18例获平均12.3个月随访(6~15个月),切口均Ⅰ期愈合。在随访期内均无感染、髌骨骨折、骨溶解、假体松动、下肢力线改变等并发症。末次随访时膝关节屈伸活动度和膝关节KSS评分均显著优于术前,差异有统计学意义(P0.001)。[结论]在初次膝关节置换术中采用ACCK髁限制性假体治疗重度膝关节畸形的初期临床疗效较好。     

人工全膝关节置换术中联合股骨外髁滑移截骨术矫正股骨外弓畸形的疗效分析

目的探讨人工全膝关节置换术(total knee arthroplasty,TKA)中采用股骨外髁滑移截骨术(lateral condyle sliding osteotomy,LCSO)矫正股骨外弓畸形的疗效。方法回顾分析2018年7月—2020年7月TKA中采用LCSO治疗的17例伴股骨外弓畸形的骨关节炎患者临床资料。男3例,女14例;年龄58~68岁,平均63.2岁。股骨外弓畸形病因:股骨发育畸形12例,股骨骨折畸形愈合5例。膝关节骨关节炎KellgrenLawrence分级:Ⅲ级4例,Ⅳ级13例。术前生理外翻角为9.5°~12.5°,平均10.94°。病程3~25年,平均15.1年。术前及末次随访时测量股骨远端机械外侧角(mechanical lateral distal femur angle,mLDFA)、髋-膝-踝角(hip-knee-ankle angle,HKA)、机械轴偏向(mechanical axis deviation,MAD),评估关节外畸形在关节内矫正及下肢机械力线恢复情况;采用膝关节学会评分系统(KSS)膝评分和功能评分、疼痛视觉模拟评分(VAS)、膝关节活动度(range of motion,ROM)评估疗效;行膝内、外翻应力试验,X线片复查截骨片愈合情况,评估关节稳定性及LCSO的安全性。结果术后患者切口均Ⅰ期愈合,无切口感染、下肢深静脉血栓形成等术后早期并发症发生。17例患者均获随访,随访时间12~36个月,平均23.9个月。截骨片均达骨性愈合,愈合时间2~5个月,平均3.1个月。术后膝内、外翻应力试验均为阴性,未发生外侧副韧带松弛、断裂,膝关节不稳,假体松动、翻修、感染等情况。末次随访时mLDFA、HKA、MAD及膝关节ROM、VAS评分、KSS膝评分和功能评分均较术前显著改善,差异有统计学意义(P<0.05)。结论在伴有股骨外弓畸形TKA中应用LCSO疗效确切且安全,关节外畸形在关节内矫正,一次手术可同时恢复下肢机械力线和关节平衡。     

Arthroscopy of the painful dysfunctional total knee replacement

Arthroscopy of the painful failed total knee arthroplasty has rarely been reported. The indications and results in terms of diagnosis and treatment of pathologic conditions in 13 knees after total knee arthroplasty are reviewed. Arthroscopy established the diagnosis for pain in 12 of 13 knees. Several problems were commonly encountered, including arthrofibrosis and fracture of the polyethylene button. Arthroscopic surgery for arthrofibrosis was successful in improving range of motion and knee-rating score.     

Osteotomy of the tibial tubercle in complex primary total knee replacement

Objective  Stiffness and severe deformity pose a major challenge in total knee arthroplasty. Numerous techniques have been described to gain exposure and improve knee flexion. Tibial tubercle osteotomy provides excellent and safe exposure of the joint, although mechanical and wound complications have been reported. Materials and methods  We present a series of 32 consecutive complex primary total replacements where an osteotomy of the tibial tubercle was utilised. Results  The patients had a mean follow-up of 2 years and 11 months. Following the procedure, with the exception of one case complicated with deep infection, all of the patients had improved clinically. The mean postoperative range of motion had increased to 102° (give P value < 0.005) and there were no cases of delayed union or non-union. A mechanical complication related to technique occurred in one patient; there were no other cases with a postoperative extension lag. Conclusion  In this challenging population group, we have found a tibial tubercle tuberosity osteotomy to greatly facilitate exposure without compromising the clinical and radiographic outcome.     

人工全膝关节置换术治疗终末期膝关节病变合并膝外翻畸形的手术技巧及临床疗效评价

目的探讨对终末期膝关节病变合并膝外翻畸形患者行经髌旁内侧入路人工全膝关节置换(total kneearthroplasty,TKA)时膝外翻畸形矫正方法及临床疗效。方法 1998年11月-2010年10月,收治64例72膝合并膝外翻畸形的终末期膝关节病变患者。男18例,女46例;年龄23～82岁,平均62.5岁。骨关节炎44例49膝,类风湿性关节炎17例20膝,血友病性关节炎2例2膝,创伤性关节炎1例1膝。双膝8例,单膝56例。膝关节屈伸活动度为(82.2±28.7)°,X线片测量股胫角为(18.0±5.8)°。膝关节学会评分系统(KSS)临床评分为(31.2±10.1)分,功能评分(37.3±9.0)分。根据Krackow膝外翻分型标准:Ⅰ型65膝,Ⅱ型7膝。手术经髌旁内侧入路,采用常规方法行股骨及胫骨截骨,Ranawat技术进行软组织松解。6例7膝采用保留后交叉韧带型假体,54例60膝采用后稳定型假体,4例5膝采用髁限制型假体。结果术后患者切口均Ⅰ期愈合。1例血友病性关节炎合并严重膝外翻畸形(股胫角41°)、屈曲挛缩20°的患者术后出现腓总神经麻痹,经保守治疗1年后神经功能恢复。1例术后2年发生深部感染,行二期翻修术后治愈。患者术后均获随访,随访时间1～13年,平均4.9年。末次随访时X线片示股胫角为(7.0±2.5)°,与术前比较差异有统计学意义(t=15.502,P=0.000)。KSS临床评分为(83.0±6.6)分,功能评分(85.1±10.5)分,膝关节屈伸活动度为(106.1±17.0)°,与术前比较差异均有统计学意义(P0.05)。5例遗留12～15°膝外翻畸形,但患膝关节功能良好。结论通过恰当的术中截骨和软组织平衡,采用经髌旁内侧入路TKA治疗合并膝外翻畸形的终末期膝关节病变可有效改善膝外翻畸形和恢复关节功能,临床疗效满意。     

Total knee arthroplasty for the stiff knee

The underlying cause of stiffness must be carefully evaluated when considering total knee arthrolasty for the stiff knee. Any previous skin incision must be recorded as well as the state of the extensor mechanism. The choice of prosthesis constraint should be decided on the state of the soft-tissues often released extensively to gain flexion. A quadriceps release or plasty and a tibial tubercle osteotomy are the current options for exposure, soft-tissue release and bone cuts. Postoperatively, the motion should be started early combined to pain control in order to obtain an average of 65° of flexion at follow-up. The complication rate remains high including recurrent stiffness, delayed wound healing and deep infection.     

Balancing training and outcomes in total knee replacement: A ten-year review

Introduction

10-year study examining differences in total knee arthroplasty (TKA) functional outcomes and survivorship in patients operated on by consultant and trainee orthopaedic surgeons.

Factors affecting wound ooze in total knee replacement

INTRODUCTION

Wound ooze is common following total knee arthroplasty (TKA) and persistent wound infection is a risk factor for infection, and increased length and cost of hospitalisation.

PATIENTS AND METHODS

We undertook a prospective study to assess the effect of tourniquet time, peri-articular local anaesthesia and surgical approach on wound oozing after TKA.

RESULTS

The medial parapatellar approach was used in 59 patients (77%) and subvastus in 18 patients (23%). Peri-articular local anaesthesia (0.25% Bupivacaine with 1:1,000,000 adrenalin) was used in 34 patients (44%). The mean tourniquet time was 83 min (range, 38–125 min). We found a significant association between cessation of oozing and peri-articular local anaesthesia (P = 0.003), length of the tourniquet time (P = 0.03) and the subvastus approach (P = 0.01).

CONCLUSIONS

Peri-articular local anaesthesia, the subvastus approach and shorter tourniquet time were all associated with less wound oozing after total knee arthroplasty.     

Patello-femoral joint in total knee replacement

Total knee arthroplasty (TKA) surgery is a widely used treatment and has a high success rate. Despite its success, the patello-femoral articulation has been overlooked as a contributor to the successful outcome of TKA. Patello-femoral complications remain the leading cause of failed knee replacement, accounting for up to 10% of complications. To understand the concept of patellar mal-tracking, we explore the normal anatomy and biomechanics of the patello-femoral articulation, and review the surgical factors and complications related to patellar tracking, with an aim to discussing the concepts on how to avoid such complications. Surgeons should be aware of the frequent occurrence of abnormal patellar tracking, and should pay particular attention to the patello-femoral component of knee replacement surgery.     

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.     

Hydroxyapatite in knee arthroplasty

Summary HA interface remains controversial in knee replacement especially as regards the tibial component. When speaking about non cemented knees the poor results afforded by the porous coatings especially microbeads or fibermesh made many surgeons fall in doubt about non using acrylic cement. HA coatings provide us with a very new biologic system and has to be considered as definitely different :1- Biological evidence of reliable implant bonding: Histological analysis performed by many authors including Thomas Bauer from Cleveland demonstrated that there is a very intimate contact between bony formations and metallic substract thanks to HA. This provides very good interlock and long lasting fixation. If the coating resorbs after several years, this resorbtion is a part of the regular bony turn over and HA is replaced by bone. This is finally the ultimate goal of replacement when reliable and sound fixation is achieved directly by the host bone.2- Hip HA experience is very successful at 10 year of FU: We started our hip experience 12 years ago in May '87. To date our personal experience with HA hips reaches 2 000 cases. Results were reported at the Barcelona '97 meeting held by the European Federation of National Associations of Orthopaedic and Traumatology (EFORT). This paper summed up the results of a non selected series. Then global survival rate was 0.985 at 10 year and these results look encouraging and at least as good as the best cemented series.3- HA total knee arthroplasty. A 9-year experience: Our personal experience in TKR using the Omnifit knee started 9 years ago in 1990. The first implant was the 3000 distal-coated Omnifit knee and we now currently use the 7000 fully coated knee. Based upon a series of 51 cases over 5 year of FU (5 to 7 year) of which 100% were reviewed for this study, the knee score according to the International Knee Society score was 96.2 out of 100 (ranging 77 up to 100). The mean function score was 93.2 (ranging from 85 up to 100). To date the failure rate is 0% and we had no clinical failure and no evidence of loosening. Finally the most important finding as regards the HA biological interface was demonstrated by the ability for bone to fill in previous lucent line due to fibrous tissue layer.Finally HA seems to be considered as a reliable third track as our 7 year experience is very encouraging. Radiological stability of patterns over 5 to 9 year, the seal afforded by HA preventing from migrating osteolysis, and mainly the ability for HA to fill in gaps over the years and transform fibrous tissue into bone may be considered as critical assets.     

Patient perceptions regarding minimally invasive total knee replacement

Interest in minimally invasive total knee replacement has increased in recent years. This has occurred despite a lack of long-term data regarding complications and outcomes. The aim of this study was to explore patients’ opinions relating to this relatively new technique. A questionnaire-based study was performed using patients attending clinics of consultant orthopaedic surgeons with an interest in knee arthroplasty. Low complication rates and implant survival were the items of highest importance to patients followed by a shorter recovery period. The duration of hospital stay and length of scar were of less importance to patients. Forty percent of patients would wish to go ahead with the procedure despite the lack of long-term outcome data. Only a small proportion of patients appear to be willing to undergo the procedure despite a lack of long-term data. Before taking up newer treatment methods patients must be convinced of the potential benefits and should be made aware that no long-term outcomes are available, at present.