人工全膝关节置换后连续被动运动患者的血凝状态

背景：前期对连续被动运动的研究主要集中在改善关节活动度和缓解关节肿胀方面。 目的：探讨连续被动运动对全膝关节置换后患者凝血状态及下肢深静脉血栓发生的影响。 方法：80例全膝关节置换患者随机等分为试验组及对照组,对照组沿用传统的方法,实行常规治疗与护理加个人主动功能锻炼;试验组在对照组基础上,置换后24 h开始使用CPM机进行患膝关节持续被动屈曲训练。比较置换后2周两组凝血综合指数及肢深静脉血栓的发生率。 结果与结论：置换后2周试验组凝血综合指数为2.66±1.04,下肢深静脉血栓形成的发生率为2.5%;对照组凝血综合指数为3.98±1.36,下肢深静脉血栓形成的发生率为17.5%,两组比较,试验组凝血综合指数及下肢深静脉血栓形成的发生率明显低于对照组(P < 0.05)。提示全膝关节置换后早期应用CPM机进行持续被动活动训练能改善凝血综合指数,改善患者的血凝状态,对预防人工全膝关节置换后下肢深静脉血栓形成有较好的效果。     

Accelerated rehabilitation after total knee replacement

This study records the length of hospital stay of 50 total knee arthroplasty patients involved in an accelerated postoperative rehabilitation protocol, and a control group of patients undergoing routine rehabilitation. This protocol involved modifications to normal knee replacement procedure, including infiltration of bupivacaine and adrenaline to the divided tissue layers at the time of surgery, spinal anaesthesia, and mobilisation on the day of surgery. These modifications were combined with an organised multidisciplinary approach anticipating issues that may delay discharge. In addition, patients and hospital staff were encouraged to expect an earlier discharge from the hospital. The mean length of hospital stay after surgery was reduced to 3.6 (S.D. 1.0) days, from a previous departmental average of 10.5 days. The control group inpatient stay was 6.6 (S.D. 2.6) days. Plasma bupivacaine levels were found to be well within safe levels, and pain records indicated that the protocol did not cause increased levels of discomfort. American Knee Society and Oxford knee scores demonstrated good levels of knee function at 6 weeks post surgery. In addition, it was noted that no postoperative blood transfusions were required. This is regarded as a significant further benefit.     

人工全膝关节置换后关节活动度影响因素的研究趋势

背景：人工全膝关节置换后关节活动度是评价患者对治疗是否满意的关键,是患者膝关节功能恢复的主要观察指标。 目的：分析人工全膝关节置换后关节活动度研究领域的发展趋势,探讨人工全膝关节置换后关节活动度的影响因素。 方法：由作者用计算机检索CNKI数据库2002/2011收录的有关人工全膝关节置换后关节活动度的相关文献,检索时间为2002/2011,中文检索词为“膝关节,人工关节,人工假体,关节活动度”,英文检索词为“knee,artificial joint,prosthesis,range of motion”。共检索到244篇文章,按纳入标准和排除标准对文献进行筛选和分析,共纳入211篇文章。从膝关节置换前膝关节活动度、人工假体类型和置换后康复训练等方面来分析其影响因素。 结果与结论：近10年来,CNKI数据库学术期刊收录膝关节置换后关节活动度研究文献数量呈上升趋势,2010年发表文献量最多为38篇,占总文献量的18.0%;从检索的关键词可见膝关节置换在骨关节炎疾病的治疗中应用最多;相关研究文献的基金资助项目较少;《中国组织工程研究与临床康复》杂志因设有硬组织植入物栏目,发表的相关文献量最多为41篇,占全部文献量的19.4%。文献计量学的分析为中国从事人工全膝关节置换的临床医务工作者提供更有价值的参考信息,影响人工全膝关节置换后关节活动度因素有很多,而且存在很多争议,临床医生应该不断提高治疗技术和康复训练方法,尽可能的恢复患者的膝关节活动功能。     

Multifactorial analysis of dissatisfaction after primary total knee replacement

Background

The aims of this study were to identify the prevalence and causes of dissatisfaction in a cohort of private practice patients, and to compare the psychological characteristics of dissatisfied patients to matched, satisfied controls.

Telethermographic findings after uncomplicated and septic total knee replacement

Thermal imaging with infrared thermography is a noninvasive approach to monitoring surgical site healing and detecting septic complications. The aim of this study was to set reference values for telethermographic patterns of wound healing after total knee replacement (TKR) not complicated by infection and to compare them against thermograms from patients with knee prosthesis infection. Forty consecutive patients operated for TKR underwent telethermography of the operated and the contralateral knee before and up to 12 months after uncomplicated surgery. The imaging data sets were then compared against those obtained starting 8 months after TKR in 15 other patients with diagnosed periprosthetic infection. Presurgical assessment thermograms showed no difference between the affected and the healthy knees. At assessment 3 days postoperative, the temperature of the operated knee had increased markedly, with a peak differential temperature (operated minus non-operated knee joint temperature) of 3.4±0.7°C; measurement at 90 days after surgery showed a return to baseline knee joint temperature in the patients with uncomplicated surgery. In the patients with septic complications, the mean differential temperature was 1.6±0.6°C (range, 1.1-2.5°C). Thermal imaging showed a measurable, reproducible telethermographic pattern of surgical site healing in patients with uncomplicated TKR and an elevated mean differential temperature >1.0°C in those with persistent prosthesis infection.     

Revision of failed unicompartmental knee replacement to total knee replacement

Recent reports suggest good outcome results following unicompartmental knee replacement (UKR). However, a number of authors have commented on the problem of osseous defects requiring technically difficult revision surgery. We reviewed clinical outcomes following revision total knee replacement (TKR) for failed UKR and analysed the reasons for failure and the technical aspects of the revision surgery. Between 2001 and 2010 our institute performed 132 UKR's out of which 33 required revision to TKR during a period 6 years. Demographics, details and indications for primary and revision surgery, the revised prosthesis including augments, technical difficulties and complications were noted. Patient outcome assessment was based on the Oxford knee score (OKS). Survival analysis for the UKR prosthesis was calculated using Kaplan-Meier Survival curves. Reasons for revision included aseptic loosening, persistent pain, dislocated meniscus, mal-alignment and other compartment osteoarthritis. Median time to revision was 19 months (range 2-159). Using revision as the end-point the survival proportion at 5-years was 69%. 18 revisions required additional intra-operative constructs including stemmed implants, wedge augmentation or bone graft. The mean 1 year post-operative OKS was 29 compared to 39 for primary TKR during the same period (p<0.001). Aseptic loosening was the commonest mode of failure. UKR survivorship at a non-specialist institute is considerably lower than at originating centres. Two thirds of the revisions were technically difficult and required additional constructs. The clinical outcome after revision surgery was inferior to that of primary TKR. The role of UKR needs to be more clearly defined.     

全膝关节置换术的康复治疗及护理

目的 探讨人工全膝关节置换术后的康复训练方法。方法 回顾分析2001年8月至2005年8月16例（17膝）人工全膝关节置换术后病人康复训练的过程及效果。结果 人工全膝关节置换术后经过系统康复训练，所有膝关节功能评分达到（70-86分）平均80分。结论 人工全膝关节置换手术效果与术后全面系统的康复训练密切相关。     

血友病患者全膝置换围手术期的凝血因子替代治疗

背景：世界血友病协会的治疗指南明确表示,关节置换应当在保证患者凝血因子活性的情况下进行。 目的：观察血友病关节炎患者行人工膝关节置换围手术期凝血因子替代治疗的安全性和有效性。 方法：1997/2006在血液内科的配合下,围手术期行凝血因子Ⅷ和Ⅸ活性水平监测,根据指南制定常规流程,进行因子Ⅷ(冻干人凝血因子Ⅷ)或因子Ⅸ(凝血酶原复合物)的替代治疗,对4例血友病关节炎患者共6个膝关节行人工膝关节置换治疗。 结果与结论：围手术期应用凝血因子进行常规替代治疗,血友病患者围手术期出血量与类风湿关节炎和骨关节炎患者差异无显著性意义(P=0.885)。置换后早期3个膝关节出现关节内血肿或肌肉出血,其中1例患者因凝血因子抑制性抗体形成,导致1侧膝关节置换后伤口裂开,行扩创清理后,伤口愈合良好。4例患者6个膝关节置换后没有晚期感染、假体松动、移位和断裂等并发症发生。所有4例患者置换前膝关节KSS评分平均28.2分,功能评分平均35分。置换后KSS评分85.2分,功能评分87分,与普通类风湿关节炎和骨关节炎膝关节置换后评分相似,但平均住院天数延长约3倍,住院费用为普通膝关节置换的2.5~3倍。结果显示凝血因子的替代治疗和凝血因子水平监测是保证血友病关节炎行人工膝关节置换最后成功的关键。     

Rate of blood loss over 48 hours following total knee replacement

The purpose of this study was to determine the rate of blood loss after total knee arthroplasty and assess the efficacy of drains using autologous blood transfusion. A prospective study was undertaken of 100 consecutive patients undergoing routine total knee arthroplasty. The diagnosis was osteoarthritis in 85% of patients and rheumatoid arthritis in 12% of cases. The rate of blood loss was recorded hourly for the first 12 h, 4 hourly for the subsequent 12 h and 6 hourly for the following 24 h. Autologous blood was reinfused within 12 h of surgery according to the protocol. Eighty-four percent of the total blood drained, was collected in the first 12 h and 94% in the first 24 h. 69% of the total blood which was drained was reinfused. The mean preoperative haemoglobin was 13.18 gm/dl and 10.23 gm/dl on the 5th day. A mean volume of 70-80 ml of homologous blood was reinfused in addition to the autologous transfusion in 11 of the 100 cases. There were no cases of deep or superficial sepsis, nor any identifiable complications related to the autologous blood transfusion. This study suggests it is safe to remove the postoperative joint drain after the 12-h period.     

早期康复对人工全膝关节置换术后功能恢复影响

膝关节是全身最大、结构最复杂的关节，运动功能要求很高。人工膝关节置换术后，要求达到负重、伸屈、外展及旋转功能、稳定性好。2003年至2005年我院进行了45例人工全膝关节置换术，重视对术后患者采取系统的早期功能康复练习，取得满意疗效，现报告如下。     

高龄全膝关节置换中全麻和硬膜外麻醉对凝血功能的影响

背景：在行全膝关节置换的高龄患者围手术期,维持正常的凝血功能至关重要。但多种因素会对患者的围手术期凝血功能产生影响,其中麻醉是一重要的因素。不同的麻醉方式会对患者的凝血功能产生不同的影响,临床需要积极的选择适当的麻醉方式以维持稳定的凝血功能。 目的：观察全麻和硬膜外麻醉在高龄全膝关节置换中的应用及对患者凝血功能的影响。 方法：回顾性分析山东省立集团东营医院2012年9月至2013年9月收治的135例行全膝关节置换高龄患者的临床资料,按照麻醉方式分为两组,对照组67例给予全身麻醉,观察组68例给予硬膜外麻醉。观察两组患者麻醉前、麻醉后6 h、置换后第1天清晨的凝血指标和D-二聚体水平变化,随访12个月检测两组深静脉血栓发生情况,并进行比较。 结果与结论：经统计和比较,两组患者在不同时间点的凝血功能各项指标差异均无显著性意义(P均 > 0.05);但两组患者的D-二聚体水平在麻醉后6 h以及置换后第1天清晨差异有显著性意义,观察组显著低于对照组(P均< 0.05);观察组和对照组的置换后深静脉血栓发生率分别为3%和21%,差异有显著性意义(P < 0.05)。表明在高龄全膝关节置换中对患者实施硬膜外麻醉可以获得更好的应用效果,维持稳定的凝血功能状态。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

Thromboembolic disease after total knee replacement: Experience of 5100 cases

The aim of the study was to quantify the incidence and timing of venous thromboembolic events (VTE) after total knee replacement (TKR). Data from 5100 consecutive TKRs performed over 10 years were prospectively collected. Cases were reviewed to identify thromboprophylaxis given, the diagnosis of VTE, treatment and adverse outcomes. There were 3 deaths (0.059%) from pulmonary embolism (PE). Of 123 VTEs identified, 55 had PE, 17 had above knee deep vein thrombosis (DVT), 28 had calf DVT and 14 had been incorrectly coded as VTE. There was considerable inappropriate treatment of calf DVT with resultant morbidity. There was an increase in diagnosis of PE between days 1 and 5 post surgery in the later part of the study, corresponding with increasing use of CT Pulmonary Angiography. Increasing diagnosis of PE may be due to detection of embolic debris from surgery due to greater vigilance rather than post-operative thromboembolism. Death from PE is rare following TKR.     

Altered biomechanics in bilateral total knee replacement patients during stair negotiation

BackgroundMany total knee replacement (TKR) patients need to have a contralateral knee replacement. Biomechanical differences between first and second replaced limbs of bilateral TKR have not been examined during stair negotiation. Additionally, it is unknown whether hip and ankle biomechanics of bilateral patients are altered. We examined hip, knee, and ankle biomechanics of first and second replaced limbs bilateral patients, as well as replaced and non-replaced limbs of unilateral patients, during stair ascent and descent.MethodsEleven bilateral TKR patients (70.09 ± 5.41 years, 1.71 ± 0.08 m, 91.78 ± 13.00 kg) and 15 unilateral TKR patients (64.93 ± 5.11 years, 1.75 ± 0.09 m, 89.18 ± 17.55 kg) were recruited. Patients performed three to five trials of stair ascent and descent. The second step, during ascent, was the step of interest when analyzing each limb. A 2 × 2 (limb × group) analysis of variance was performed to determine differences between limbs and groups.ResultsDuring ascent, bilateral patients exhibited decreased peak loading-response knee extension (KEM) and push-off plantarflexion moments. Unilateral replaced limb KEM was lower than non-replaced limbs. During descent, bilateral patients descended the staircase significantly slower, had lower peak loading-response vertical ground reaction force and KEM, and push-off KEM. Bilateral patients had higher peak loading-response hip extension and push-off plantarflexion moments, and increased knee adduction ROM, compared with unilateral TKA patients.ConclusionsBilateral patients exhibited similar hip, knee, and ankle joint moments between first and second replaced limbs. Substantial differences in hip, knee, and ankle biomechanics during stair negotiation in bilateral patients compared with unilateral patients may indicate a more complex adaptation strategy present in these patients.     

Factors affecting blood loss in total knee arthroplasty patients

The aim of the study was to identify the factors affecting major blood loss in patients undergoing total knee arthroplasty (TKA), in order to reduce blood loss and requirements for blood transfusion. This prospective randomized study included 80/184 patients treated by TKA at University Hospital of Traumatology, Zagreb, Croatia, from January 2005 till December 2007. The following parameters were analyzed: patient age, sex, body mass index (BMI), arterial blood pressure, preoperative hemoglobin level and hemoglobin level preceding blood transfusion, length of surgery, blood loss and volume of blood transfused. According to patient age, there were no differences in the length of surgery, blood loss volume, hemoglobin level before blood transfusion and use of blood transfusion. Older patients had lower hemoglobin level before blood transfusion and received greater volumes of blood transfusion, but the difference was not statistically significant. Male patients had a significantly higher preoperative hemoglobin level as compared to female patients (P = 0.012). The mean volume of blood loss and of transfused blood was larger in male than female patients, however, the difference did not reach statistical significance. According to BMI, there were no differences in the length of surgery, blood loss, volume of transfused blood and hemoglobin level before transfusion. Patients with a lower preoperative hemoglobin level did not lose more blood during and after surgery, but the requirement for blood transfusion was significantly higher (P = 0.014). Hypertensive patients had a statistically greater perioperative blood loss (P = 0.038), but did not receive more transfused blood (P = 0.494). Preoperative hemoglobin level was higher in patients with elevated arterial blood pressure than in those with normal blood pressure, but the difference was not statistically significant (P = 0.595). Hemoglobin level before blood transfusion was also higher in hypertensive patients than in those with normal blood pressure, but it was not statistically significant (P = 0.288). In patients with longer duration of surgery, blood loss and volume of blood transfused blood were statistically significantly greater (P = 0.003 and P = 0.015, respectively). Study results yielded a significant positive correlation between the length of surgery and the volume of blood loss (r = 0.282; P = 0.011) as well as between the length of surgery and the volume of blood transfused (r = 0.362; P = 0.001). A significant negative correlation was established between the preoperative hemoglobin level and application of blood transfusion (r = -0.250; P = 0.025). Patients with hypertension had a significantly larger blood loss volume as compared to patients with normal arterial pressure (P = 0.038) and received more blood transfusions than patients with normal blood pressure, but the difference was not statistically significant (P = 0.494). Age, sex and BMI had no statistically significant effect on blood loss volume and application of blood transfusion. Male patients had a significantly higher preoperative hemoglobin level (P=0.012), larger mean blood loss volume (P = 0.057) and received more blood transfusions than female patients, however, the difference did not reach statistical significance (P = 0.562). Based on study results, it is concluded that requirements for blood transfusion will be greater in patients with hypertension and lower preoperative hemoglobin level as well as in all cases with longer duration of surgery. To reduce the use of allogeneic blood transfusion, it is necessary to correct arterial blood pressure before surgery in hypertensive patients and also to magnify preoperative hemoglobin level if it is lower.     

全膝关节置换后快速康复外科治疗45例*

背景：近年来国内一些医院开始了快速康复外科的研究与应用。 目的：观察快速康复外科对全膝关节置换临床疗效的影响。 方法：45例行全膝关节置换的膝关节骨性关节炎患者,按照快速康复外科理念对其进行置换前、置换中和置换后管理,以HSS评分、关节活动度和目测类比疼痛评分对膝关节功能及疼痛程度进行评价。 结果与结论：患者置换后平均HSS评分和关节活动度均显著高于置换前水平,同时置换后平均目测类比疼痛评分显著低于置换前水平,显示膝关节置换后功能恢复良好、疼痛减轻。未发生感染、下肢深静脉血栓及肺栓塞等并发症。结果表明,快速康复外科应用于全膝关节置换,HSS评分、关节活动度及疼痛评分较置换前明显改善,减少了手术应激及术后并发症,加速了患者康复,增强了治疗效果。关键词：快速康复外科;全膝关节置换;膝关节;功能恢复;疼痛;并发症 缩略语注释：TKA：total knee arthroplasty,全膝关节置换;FST：fast track surgery,快速康复外科 doi:10.3969/j.issn.1673-8225.2012.17.007     

Post-operative drainage after cemented, hybrid and uncemented total knee replacement

We recorded the total and 8-hourly post-operative drainage of 100 consecutive total knee replacements (33 cemented, 35 hybrid and 32 uncemented). The cemented, hybrid and uncemented prostheses had mean total drainage of 745, 1035 and 1220 ml, respectively. The difference in drainage between cemented and both hybrid and uncemented was statistically significant (P<0.05 and P<0.001). A significantly higher percentage of drainage occurred in the first 8-h period in the hybrid and uncemented groups. Total drainage in the cemented group was lower, but occurred more slowly, with a significantly higher percentage of drainage in the 17–48-h post-operative period when compared with the uncemented group (P<0.05). Within the cemented group, posterior-stabilised implants drained significantly more than those with an AP-lipped tibial insert (P<0.05). This information has implications for planning of blood product usage and timing of drain tube removal.     

膝骨关节炎患者全膝关节置换后影响关节功能恢复的因素

BACKGROUND: Functional recovery after joint arthroplasty is an important indicator to evaluate the effect and prognosis of total knee arthroplasty, and is affected by patients and many kinds of outside factors.     

冰敷干预可抑制人工全膝关节置换后血红蛋白降低及疼痛

背景：减少人工全膝关节置换后出血量与血红蛋白降低量成为骨关节科临床研究的重要课题。当前冰敷疗法已被广泛应用于临床上由于各种理化原因导致的局部组织肿胀的消肿、止痛等的常规治疗中。 目的：调查人工全膝关节置换后血红蛋白降低的危险因素,探讨冰敷干预应用的效果。 方法：骨性关节炎患者240例根据随机抽签原则分为治疗组与对照组各120例,对两组的基本信息、疾病状况、诊治情况与预后情况都进行了调查。对照组积极给予人工全膝关节置换;在此基础上治疗组在置换后2 h开始冰敷治疗,连续7 d。 结果与结论：置换后7 d,240例患者置换后发生血红蛋白降低者为34例,发生率为14.2%。多元回归Logistic分析结果显示,患者年龄、未冰敷处理、体质量指数是导致人工全膝关节置换后血红蛋白降低的危险因素(P < 0.05)。与对照组相比,治疗组置换后的血红蛋白值明显升高(P < 0.05),血红蛋白降低值、总失血量、输血率、输血量、置换后第3,7天的疼痛评分均显著降低(P < 0.05)。治疗组的膝关节功能优良率为96.7%,对照组为95.8%,两组差异无显著性意义(P > 0.05)。结果证实,人工全膝关节置换在临床上的应用能促进骨性关节炎患者的膝关节恢复,但是存在血红蛋白大幅度下降与出血的危险,积极地置换后冰敷干预降低危险,并且缓解置换后疼痛。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程