Outcomes of cementless unicompartmental and total knee arthroplasty: A systematic review

Background

Aseptic loosening is a common failure mode in cemented unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). This led to the development of cementless designs but the historical outcomes were poor. Recent developments in cementless designs have improved outcomes, but the current status is unknown. Therefore, a systematic review was performed to assess recent outcomes of cementless knee arthroplasty.

人工全膝关节研究新进展

膝关节是人体最大、解剖最复杂、对运动要求最高的关节之一。全膝关节置换术(total knee arthroplasty,TKA)在全世界每年以高于10%的比例增长。TKA是在全髋关节置换术的基础上发展起来的,经过近30的发展,取得了很大进展。本文对近年来假体类型的演变、假体几何外形与尺寸的研究,以及膝关节生物力学方面取得的突破进行了阐述;对目前TKA中存在争议的问题进行了讨论;并结合目前最新发展的技术,对TKA未来发展的方向进行了展望和预测。     

Long-term outcome of knee arthroplasty in the setting of pigmented villonodular synovitis

Background

Pigmented villonodular synovitis (PVNS) is a rare, benign proliferation of the synovium, commonly affecting the knee. Arthroplasty can successfully manage arthrosis in this population; however, outcome data is limited. The purpose of this study was to investigate the oncologic and functional outcome of patients undergoing total knee arthroplasty (TKA) in the setting of PVNS.

Incidence,temporal trends and potential risk factors for aseptic loosening following primary unicompartmental knee arthroplasty: A meta-analysis of 96,294 knees

BackgroundAseptic loosening (AL) is among the major reasons for revision of failed primary unicompartmental knee arthroplasty (UKA). There is an ongoing temporal increase in the use of UKA with a resultant increase in the revision burden. We aimed to evaluate the incidence of, temporal trends and risk factors for AL.MethodsLongitudinal studies reporting the incidence of AL following primary UKA were sought from MEDLINE, Embase, Web of Science and Cochrane Library up to 6th April 2020. Incidence and relative risks (RR) (with 95% confidence intervals) were calculated.ResultsWe identified 62 studies for inclusion. Overall, 96,294 primary UKA procedures accounting for 1752 AL cases were included. AL incidence ranged from 0.00% to 22.70% over a 7.7 year weighted mean follow-up. The pooled random effects incidence (95% CI) was 1.77% (1.34–2.25) in the same follow-up period. The annual rate of AL was 0.10% (0.02–0.22). AL incidence increased with length of follow-up, but there was a temporal decrease from the 1970s onwards. Tibial loosening was more common than femoral component loosening: incidence (95% CI) of 1.63% (0.96–2.44) and 0.58% (0.20–1.09) respectively over a weighted follow-up of 6.6 years. Fixed bearing implant design and cemented fixation were both associated with increased AL risk, whereas robotic-assisted surgery was associated with decreased risk.ConclusionThe overall incidence of AL following primary UKA is primarily driven by tibial component loosening and there is a temporal decline in rates. The use of mobile bearing, uncemented implants inserted with robotic assisted surgery may reduce the risk of AL.     

An intraoperatively moulded PMMA prostheses like spacer for two-stage revision of infected total knee arthroplasty

We report a series of 16 consecutive total knee arthroplasty (TKA) revision procedures for deep infection, treated with a newly developed intraoperatively moulded PMMA cement-prostheses-like spacer (CPLS). The standard treatment consisted of a two-stage protocol with initial explantation of the infected components combined with radical debridement, followed by implantation of a temporary cement spacer and final reimplantation of a new TKA. A sterilizeable Teflon tapered aluminium mould was developed for production of a custom made CPLS during the intervention. Stable implantation of the CPLS was achieved with a second cementation, allowing for correct alignment and ligament balancing. The spacer remained 3.5 months on average until reimplantation of a TKA occurred. At time of reimplantation, patients had an average KSS score of 84.44 points with an average flexion capacity of 102°. There was no recurrent infection during the study period of minimum 2 years. With this new technique, a low friction articulation with good stability, high comfort and a better range of motion compared to handcrafted spacers was achieved. The use of this spacer is a time sparing, cheap and convenient option in 2-stage TKA revision.     

Short-term survival of cementless Oxford unicondylar knee arthroplasty based on the Finnish Arthroplasty Register

BackgroundCementless unicondylar knee arthroplasty (UKA) was introduced to secure long-term fixation and reduce the risk of revision. Experience with cementless UKA fixation is limited.MethodsThe short-term survival (up to five years) of cementless Oxford UKA was assessed using data from the Finish Arthroplasty Register and was compared with that of cemented Oxford 3 UKA and total knee arthroplasty (TKA). Datawere obtained, from the Finnish Arthroplasty Register, on 1076 cementless Oxford UKAs and 2279 cemented Oxford 3 UKAs performed for primary osteoarthritis in 2005-2015. The Kaplan-Meier method, with revision for any reason as the endpoint, was used to assess the survival of these two UKA groups, and the results were compared with that of 65,563 cemented TKAs treated for primary osteoarthritis over the same period. The risk of revision of both Oxford prostheses was compared using Cox regression model, with adjustment for age and sex, with the cemented TKA group as reference.ResultsThe three-year survival was 93.7% for the cementless Oxford, 92.2% for the cemented Oxford 3, and 97.3% for the cemented TKA. The corresponding figures at five years were 92.3%, 88.9%, and 96.6%, respectively. The revision rate for both the cementless Oxford and the cemented Oxford 3 was significantly increased when compared with the cemented TKA (P < 0.001).ConclusionsThe survival of the cementless Oxford method was higher than that of the cemented Oxford 3 in the short term. The overall survival of Oxford UKA was poor in comparison with contemporary TKAs.     

前稳定型垫片在全膝关节置换术中的早期临床研究

目的探讨全膝关节置换术(TKA)中应用前稳定型(AS)垫片的临床效果。方法 2018年1月至2018年12月选取北京大学人民医院收治的107例终末期骨性关节炎行全膝关节置换患者,术中采用邦美公司提供的后交叉韧带保留型(CR)Vanguard膝关节假体,其中使用AS垫片组45例,CR垫片组62例。统计全部患者的手术时间,术后伤口引流量,感染并发症,术前、术后膝关节活动度和膝关节协会评分,比较AS垫片组和CR垫片组之间的差异。结果全部病例均获得随访,随访时间为12~24个月,平均(20.3±2.8)个月。术前AS垫片组、CR垫片组膝关节活动度分别为平均90.2°±17.4°、92.7°±18.6°,术后末次随访时AS垫片组、CR垫片组分别为平均108.5°±22.3°、110.6°±19.3°。膝关节协会评分术前AS垫片组为临床评分(50±15)分、功能评分(52±21)分,CR垫片组为临床评分(49±13)分,功能评分(52±19)分;术后末次随访时AS垫片组临床评分(80±16)分、功能评分(82±20)分;CR垫片组临床评分(82±15)分、功能评分(83±22)分。上述各评价指标、手术时间、术后伤口引流量两组间差异均无统计学意义。所有病例均未出现感染并发症。结论 TKA术中应用AS垫片术后早期膝关节活动度、膝关节协会评分结果良好,与CR垫片相比较效果相当。     

个性化截骨工具辅助下人工全膝关节置换与传统人工全膝关节置换手术精确度及临床疗效比较

目的比较3D打印个性化截骨工具辅助(patient-specific instrumentation,PSI)下人工全膝关节置换术(total knee arthroplasty,TKA)与传统TKA的手术精确度和临床疗效。方法自2017年9月至2018年12月,将40例拟接受初次膝关节置换患者随机分为2组,每组均为20人。一组应用个性化截骨工具辅助TKA手术(PSI组),另一组接受传统TKA(对照组)。比较两组患者的冠状面下肢机械轴线、手术时间、术中出血量、术后引流量以及HSS评分。结果对照组和PSI组的手术时间分别为(103.3±18.7) min和(91.3±15.7) min;术中出血量分别为(372.0±53.0)mL和(332.8±47.0)mL;术后引流量分别为(378.8±97.2)mL和(315.0±89.0)mL。两组手术时间、术中出血量、术后引流量比较差异均有统计学意义(P0.05)。对照组和PSI组术后2周HSS评分分别为(89.3±2.8)分和(88.7±2.9)分,两组比较差异无统计学意义(P0.05)。对照组和PSI组术后全下肢力线差值分别为(1.9±1.1)°和(1.2±1.0)°,冠状面股骨假体角度(frontal femoral component angle,FFC)差值分别为(2.1±1.1)°和(1.1±0.9)°,两组比较差异有统计学意义(P0.05)。冠状面胫骨假体角度(frontal tibia component angle,FTC)差值分别为(1.3±0.8)°和(1.4±0.8)°,两组比较差异无统计学意义(P0.05)。结论PSI辅助TKA较传统TKA手术时间更短、术中出血量更少,并且术后冠状面全下肢力线及股骨力线的改善优于传统TKA手术。     

Coronal alignment predicts the use of semi-constrained implants in contemporary total knee arthroplasty

Background

Semi-constrained, or varus–valgus constrained, implants are occasionally necessary to achieve stability in primary total knee arthroplasty (TKA). However, outcomes with these implants are largely unknown. Therefore, the primary goals of this study were to determine 1) can we identify preoperatively which patients might require a semi-constrained implant and 2) are there any clinical and or radiographic differences for those that require a semi-constrained implant?

Deviation of femoral intramedullary alignment rod influences coronal and sagittal alignment during total knee arthroplasty

Background

An intramedullary (IM) rod is used to resect the distal femur vertically to the femoral mechanical axis in the coronal plane in many cases of total knee arthroplasties (TKA). The valgus angle between the mechanical axis and the anatomical axis of the distal femur is estimated preoperatively. It is known the deviation of the IM rod in the femoral canal could influence the femoral component alignment. However, there is no published data regarding how many degrees of deviation to make with the IM rod. The purpose of this study is to measure each deviation of the IM rod using three-dimensional (3D) computer simulations.

膝关节置换术中胫骨截骨厚度对胫骨截面的生物力学影响

目的获得不同截骨厚度及不同活动状态下胫骨截面的生物力学情况,为临床膝关节置换术截骨厚度及指导患者术后活动提供理论基础。方法重建下肢骨性三维立体模型,依据全膝关节置换术截骨原则将胫骨近端分别截骨0、5、7、9 mm,对截骨后胫骨模型进行材料属性赋值,并分析站立、慢步、快跑、上楼4种活动状态下胫骨截面的应力、应变情况。结果在相同活动状态下,随着截骨厚度的增加,胫骨截骨面的最大应力和位移呈增长趋势。在同一截骨厚度下,随着活动强度的增强,胫骨截面的最大应力和位移总体上呈增长趋势。结论临床全膝关节置换术时胫骨截骨厚度越大、术后活动强度越强,胫骨截面的应力及应变越大。术中应避免过多截骨、术后应避免高强度活动,可减少胫骨平台的应力及应变,有利于假体的长期寿命。     

Short-term and mid-term results of lateral condyle sliding osteotomy in the treatment of valgus total knee arthroplasty: A successful therapy option in Grade 2 valgus total knee arthroplasty

Background

Different methods exist for deformity correction and ligament balancing in total knee arthroplasty (TKA) of valgus knees, the sliding osteotomy being one of them. The objective of the current study was to analyze the clinical and radiological short-term and mid-term results of this technique in a larger series.

膝关节置换术后皮肤麻痹的解剖基础及相关临床研究

目的 　探讨膝关节置换术后隐神经髌下支损伤所致的皮肤麻痹的解剖基础,改良手术切口,减少膝前皮肤麻木并发症。 方法　解剖观察12例成人尸体下肢标本,观测隐神经髌下支形态、神经束的走行及毗邻关系。设计改良膝外侧皮肤切口行膝关节置换手术入路进行临床验证,比较术后效果。 结果　解剖研究发现隐神经髌下支自缝匠肌穿出后,标本在髌骨中心平面神经距髌骨内侧缘约3.2 cm,75%标本有3束分支分布于髌骨下极及胫骨粗隆区域,以髌骨下极与粗隆连线中点为中心作圆,神经纤维主要分布左侧在第2象限,右侧在第1象限。临床研究采用改良膝关节外侧切口行膝关节置换术15例,方法可行,术后膝前皮肤麻木的发生率及范围较对照组减少,有统计学意义。 结论　根据膝关节隐神经髌下支解剖分布特点,改良膝前皮肤切口行膝关节置换术可减少术后膝前麻木。     

Experience of total knee arthroplasty using a novel navigation system within the surgical field

Background

With the aim of improving component alignment and outcome in total knee arthroplasty (TKA), several computer-assisted devices (CAD) have been developed.

Optimization of sagittal and coronal planes with robotic-assisted unicompartmental knee arthroplasty

Background

One of the anatomic goals of total knee arthroplasty (TKA) is optimizing in the coronal and sagittal plane. Accurate alignments of both planes have been correlated to functional outcome and range of motion. There is a paucity of evidence on the accuracy of unicompartmental knee arthroplasty (UKA) in balancing biplanar knee alignment – specifically sagittal plane alignment. Because robotic assisted UKA has an advantage of more accurately manipulating sagittal plane for optimal alignment and kinematics based on pre-operative and intraoperative CT planning we assessed the accuracy.

Outcomes of total knee arthroplasty in degenerative osteoarthritic knee with genu recurvatum

Background

This study aimed to assess the incidence of genu recurvatum without neuromuscular disorders in knees that underwent navigation-assisted total knee arthroplasty (TKA), to evaluate short-term radiologic and clinical results of navigation-assisted TKA in genu recurvatum, and to evaluate differences in results according to the degree of pre-operative hyperextension and type of implant and insert.

Tibial metaphyseal sleeves in primary total knee arthroplasty following high tibial osteotomy and tibial plateau fracture; preliminary mid-term survival and outcome

BackgroundPrevious high tibial osteotomy (HTO), and tibial plateau fractures (TPF) may cause problems in subsequent total knee arthroplasty (TKA) due to altered metaphyseal bone structure. Higher rates of loosening of the tibial component have been described.In post-HTO and TPF cases, a more durable fixation could be achieved by tibial sleeves. This study investigates the preliminary short-to-midterm clinical and radiographic results in a cohort of these cases.MethodsA cohort of 28 patients was selected, 11 following HTO, and 17 following TPF. Standard clinical and radiologic follow-up was performed at 6 weeks, and one and two years. Revision with removal of primary prosthesis for any reason was the primary outcome. Patient reported pre- and postoperative pain, satisfaction and general health scores were collected at one and two years. Postoperative radiographs were analyzed for radiolucent lines.ResultsThere were no cases of aseptic loosening. Survival for all reasons was 96.4% (CI 77.2%–99.5%). One progressive radiolucent line was seen. Numerical rating scale (NRS) for pain with and without weightbearing at 2-year follow-up improved from 8 to 3 and from 5 to 2 points respectively. Overall general health scores improved with a median of 70 at ≥ 2 years, compared to 63 pre-operatively.ConclusionWith no revision for aseptic loosening the use of tibial sleeves in primary TKA seems a safe and reliable method for fixation of the tibial component in metaphyseal bone with altered bone structure at short and mid-term follow-up.Level of evidence: Level IV, cohort study.     

术中应用不同假体对全膝关节置换术后引流的影响

目的 探讨术中使用后方稳定型（posterior cruciate stabilization, PS）与后交叉韧带保留型（posterior cruciate retention, CR）假体对全膝关节置换术（total knee arthroplasty, TKA）术后引流的影响。方法 回顾性分析2018年6月至2018年10月终末期骨性关节炎行全膝关节置换的患者102例,其中62例采用后交叉韧带保留型（CR）假体（CR组）,40例采用后稳定型（PS）假体（PS组）。所有患者术中均使用止血带、关节腔注射氨甲环酸（tranexamic acid, TXA）,术后患肢屈曲1 h、引流管夹毕1 h、患肢冰敷24 h。收集术后2、4、24、48 h引流量和引流液中血红蛋白（hemoglobin, HB）含量,以及术后2、24、48 h静脉血中的血红蛋白（HB）含量。统计术后输血情况、早期感染并发症例数。结果 102例患者随访3个月,术后总引流量CR组（292.9±128.3）mL比PS组引流量为（355.2±136.8）mL少,两组比较差异有统计学意义（P＜0.05）。术后1 d的CR组的引流量比PS组少,两组比较差异有统计学意义（P＜0.05）。术后24 h的CR组引流液中血红蛋白含量比PS组明显下降,两组比较差异有统计学意义（P＜0.05）。术后24、48 h的PS组静脉血中血红蛋白含量比CR组明显下降,两组比较差异有统计学意义（P＜0.05）。CR组2例输了2 U红细胞,PS组2例输了1 U红细胞、9例输了2 U红细胞。102例患者术后早期均未出现感染并发症。结论 与PS假体相比,采用CR假体可减少患者的失血量、术后引流量少、降低全膝关节置换术后贫血的发生、减少围术期输血率。     

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.     

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。