膝关节形态学测量在人工膝关节置换领域的价值及意义

背景：对人工膝关节假体形态尺寸进行观察及测量,并对相关测量统计数据进行人工膝关节形态设计,有利于促进膝关节假体植入后的稳定性和组织相容性。目的：结合文献探讨形态学测量在临床上膝关节置换中的重要性。方法：以＂膝关节;假体;测量;设计;置换＂为中文关键词,以＂artificial knee joint;prosthesis;measure;design;replacement＂为英文关键词。采用计算机检索1998-01/2011-12有关人工膝关节假体设计、测量及膝关节假体植入后相容性的文章。结果与结论：膝关节的形态学测量即膝关节的三维有限元模型、相关参数及角度、生物力学研究与膝关节假体选择及设计有着重要相关性。膝关节的形态测量有二维和三维测量,以三维测量法精确。膝关节线性尺寸之间、身高与线性尺寸之间均有很好的相关性,所测量的数据在临床上均有应用意义。典型的膝关节三维解剖模型,能为膝关节参数的测量提供一种可靠的方法,提高手术的成功。     

胫骨近端的形态学测量与膝关节置换

背景:胫骨近端为膝关节假体构成的下半部分,胫骨近端是膝关节假体放置的底部位.目的:评价胫骨近端的形态测量在临床上膝关节置换中的重要性.方法:以 膝关节;假体;置换为中文关键词,以Knee; Prosthesis; replacement 为英文关键词.采用计算机检索1995-01/2011-10有关磁共振图像测量在临床上膝关节置换中假体旋转对线中应用的文章.结果与结论:胫骨近端的形态测量即胫骨近端的三维有限元模型、相关参数及角度、生物力学研究与膝关节假体选择及设计有着重要相关性.胫骨近端的形态测量有二维和三维测量,以三维测量法精确,测量胫骨平台宽和倾斜角度、胫骨内外侧平台前后径,所测量的数据在临床上均有应用意义.胫骨近端是膝关节假体放置的底位置,而胫骨近端的三维模型与假体模型底部行模拟对接,提高手术的成功.     

髌骨置换在全膝关节置换中的意义及存在问题

背景:在进行全膝关节置换时是否常规行髌骨置换一直存在争议,那么髌骨置换中不同参数如髌骨厚度、骨床形态、固定柱形式及固定方式对于人工全膝膝关节置换后效果影响如何呢?目的:就髌骨置换目前存在的争议和髌骨置换中的技术参数要求做一介绍.方法:以"人工膝关节,髌骨置换"为中文检索词,检索中国期刊全文数据库(1999-01/2009-06);以"artificial knee joint, athroplasty,pattela surfacing"为英文检索词,检索PubMed数据库(1999-01/2009-06).纳入人工膝关节置换髌骨置换与未行髌骨置换者的临床研究;排除动物实验.文章重点从以下几个方面进行了讨论:①髌骨置换的适应证和并发症.②对髌骨置换目前存在的争议.③保留髌骨厚度对人工膝关节置换的影响.④髌骨置换假体设计及固定方式对术后效果的影响.⑤置换技术对人工膝关节的影响.结果与结论:目前对髌骨置换存在3种认识:即全部(常规)置换、均不置换及选择性置换.对髌骨的争论主要是关于髌骨的外形.对于髌骨假体的固定目前多应用骨水泥固定.进行髌骨置换时应遵循以下原则:①尽量恢复髌骨厚度.②保持关节面对称.③保护髌骨血运.④确保髌骨有合理的运动轨迹.全膝置换时是否置换髌骨目前尚无定论,作者认为应考虑到原发病、病变程度、假体类型以及患者的活动量和体质量等诸多因素来综合决定髌骨置换适应证.     

人工膝关节的生物摩擦学特点

目的:探讨膝关节屈曲活动时的动态特征,为人工膝关节生物摩擦学的研究提供相对运动和应力分布等生物力学数据.方法:由第一作者采用电子检索的方式,在中国期刊全文数据库(CNKI:1994/2009)中检索有关人工膝关节运动及摩擦的文献,检索词为"膝关节假体,生物力学,磨损颗粒,仿生滑液".排除较陈旧的文章及重复性研究,共检索到符合标准的文献22篇.结果:建立包括人体主要骨与软组织的全膝关节置换前后的膝关节的动态有限模型,通过有限元分析,获得与屈曲膝关节的三维相对运动参数,胫骨关节和髋股关节的接触位置和应力等动态力学参数.结论:人工膝关节磨损性能受到较多因素的影响,多数学者在研究这些因素时以单因素研究为主,对多因素研究较少而且研究主要集中于对实验结果的描述,很少有对关节运动及磨损机制进行深入研究的报道.对人工膝关节运动及摩擦性能的研究需要把运动学和力学与磨损状态结合起来,共同期待今后进行磨损状况的预测.     

人工假体置换在膝关节周围恶性肿瘤中的临床应用研究

<正>骨瘤是目前常见的骨原发性恶性肿瘤之一,多发于15～25岁男性。其发病部位主要集中在长骨管状端、股骨远端及胫骨近端等膝关节周围[1],具有易复发、易转移、预后差等特点。随着放疗及化疗等技术的发展,骨肿瘤近五年生存率较高。随着人工假体材料、工艺的进步,其已成为骨肿瘤主要的保肢重建方法[2]。本研究通过跟踪观察我院行人工假体置换手术患者30例,以探讨人工假体置换在膝关     

膝关节置换的适应证及假体选择

背景:选择合适的人工膝关节对于膝关节置换患者是非常重要的.目的:结合文献探讨膝关节假体置换的适应证.方法:由第一作者采用电子检索的方式,在万方数据库(http://www.wanfangdata.com.cn/)中检索有关膝关节置换适应证及其相应假体选择的文章,检索时间范围:2000-01/2010-12,关键词为"膝关节置换,适应证,人工假体,生物相容性".经检索共查到相关文献50余篇,排除内容重复、普通综述、Meta分析类文章后,筛选纳入5篇文献进行评价.结果与结论:不同患者应根据病情、关节限制程度、固定方式和半月板功能来选择不同的人工膝关节.不同膝关节假体置换的适应证应由膝关节的骨和软组织条件决定,膝关节韧带的质量和状态、关节畸形以及关节软骨破坏的程度决定假体的选择.     

膝关节置换的适应证及假体选择

背景：选择合适的人工膝关节对于膝关节置换患者是非常重要的。目的：结合文献探讨膝关节假体置换的适应证。方法：由第一作者采用电子检索的方式,在万方数据库（http：//www.wanfangdata.com.cn/）中检索有关膝关节置换适应证及其相应假体选择的文章,检索时间范围：2000-01/2010-12,关键词为＂膝关节置换,适应证,人工假体,生物相容性＂。经检索共查到相关文献50余篇,排除内容重复、普通综述、Meta分析类文章后,筛选纳入5篇文献进行评价。结果与结论：不同患者应根据病情、关节限制程度、固定方式和半月板功能来选择不同的人工膝关节。不同膝关节假体置换的适应证应由膝关节的骨和软组织条件决定,膝关节韧带的质量和状态、关节畸形以及关节软骨破坏的程度决定假体的选择。     

特制型人工膝关节置换治疗膝关节周围恶性骨肿瘤的护理

回顾性总结46例特制型人工膝关节置换治疗膝关节周围恶性骨肿瘤的围手术期护理体会,主要措施包括术前一般护理、心理护理、化疗护理,术后病情观察、一般护理、疼痛护理、康复指导和详细的出院指导,认为特制型人工膝关节置换对膝关节周围恶性骨肿瘤患者进行保肢治疗,具有肿瘤切除彻底、术后关节功能良好等优点,正确有效的围手术期护理能够使患者更好地配合手术和做好康复锻炼,对提高手术疗效和膝关节功能的恢复,减少术后并发症的发生起着重要的作用,进而达到满意的效果。     

人工膝关节置换后的假体周围感染

目的:总结近年有关人工膝关节置换后出现假体周围感染的现状.方法:由作者应用计算机检索维普数据库中与人工膝关节置换后出现假体周围感染有关的文献,检索时限1998-01/2009-10.检索词:膝关节;全膝置换;感染.对资料进行初审,并查看每篇文献后的引文.共入选18篇文献进一步分析.结果:膝关节置换后持续性疼痛和进行性关节僵直应高度怀疑深部感染.血沉、C-反应蛋白及关节穿刺物的培养是诊断感染的重要指标.单纯使用抗生素治疗不能去除深部感染,并且预后较差.使用抗生素骨水泥进行Ⅱ期翻修是去除感染的最有效治疗方案.结论:全膝关节置换后感染是十分严重的并发症,一旦发生感染应及早进行诊断,同时根据病情选择合适的治疗方案.     

人工膝关节置换:技术发展与临床应用及评价

目的:通过临床验证对人工膝关节置换术技术的发展、运用进行综述与评价.方法:以"人工膝关节;置换;假体;移植重建"为中文关键词,以"total knee arthroplasty,prosthesis"为英文关键词,采用计算机检索1993-01/2009-10相关文章.纳入与人工膝关节置换术技术在膝损伤修复中的应用等相关文献;排除重复研究或Meta分析类文章.以28篇文献为主重点对人工膝关节置换术技术中材料的选择与运用、术后注意事项、易出现的术后问题等进行了讨论和综合分析.结果:人工关节置换术目前常采用的术式有人工全髋、半髋关节置换术,人工全膝关节置换术,膝关节单髁置换术,人工踝关节置换术,全肩、肘工关节置换术和人工手、足关节置换术等.人工关节假体是置入人体内的材料,其形态的设计、表面处理、材料选用、制造工艺以及包装的要求都十分严格.不同膝关节假体的适应证应由膝关节的骨和软组织条件决定、膝关节韧带的质量和状态、关节畸形以及关节软骨破坏的程度决定假体的选择.结论:选择高质量的假体、不断开发和推广使用其配套器械是全膝关节置换术普及和发展的关键.     

全膝关节置换治疗重度膝关节畸形术后的个体化康复方案

目的:探讨严重畸形膝关节置换围手术期康复方法。方法:①对象:选择2005-09/2007-02呼伦贝尔市医院骨科收治的严重风湿病下肢关节畸形施行膝关节置换术患者20例24膝。②干预:对膝内翻患者主要以训练关节活动度和增强肌力为主;对膝外翻患者,主要以增强肌力为主,必要时用支具保护;骨质疏松者康复锻炼以被动活动缓慢过渡到主动活动、由小量短时间逐渐加大运动量并延长康复周期的方法;残余屈曲挛缩畸形主要以手法按压为主。③评估:于手术前、术后2周、1个月及3个月,对患者膝关节平均HSS(纽约特种外科医院)评分及平均活动度进行对比观察,并对术后疼痛、患肢功能及主观满意度进行评估。结果:除1例1膝失访,19例患者顺利度过围手术期康复治疗。①患者膝关节活动度术前平均的35.2°,术后2周提高到92.5°。②HSS评分术前39.1分,术后2周提高到94.1分;平均股四头肌肌力较术前提高1.3级。③患者术后疼痛症状明显缓解,出院时所有患者不扶拐行走距离均超过100m。1个月、3个月随访结果满意,无并发症发生。结论:严重膝关节畸形关节置换的围手术期康复应根据术前关节畸形状态、骨质条件、术中软组织松解范围及截骨情况术后针对性的进行康复锻炼。康复应采取个体化、循序渐进及随时调整的原则进行。     

Biomechanical effects of patellar positioning on intraoperative knee joint gap measurement in total knee arthroplasty

Background

Balancing both the lateral/medial and extension/flexion joint gaps is a prerequisite for soft tissue balance in total knee arthroplasty. The purpose of this study was to quantify the effects of patellar positioning and quadriceps load during total knee arthroplasty on knee joint gap measurements.

Methods

Eight fresh-frozen cadaveric knees ranging in age from 65 to 85 years old were used. Using a medial parapatellar approach, posterior cruciate ligament sacrificing total knee arthroplasty was performed. The specimens were mounted on a custom knee testing system that allowed the femur to be locked in position for knee extension or flexion. Patellar positions of eversion, reduction, and following repair of the arthrotomy were examined. The influence of quadriceps muscle load was investigated by varying the quadriceps load from 0 to 125 N. The lateral and medial joint gaps, represented by the distance from the implanted femoral component surface to the cut tibia surface, were measured with 100 N tibial distraction force using a 3D digitizer in both extension (0°) and flexion (90°).

Findings

Both the medial and lateral joint gaps with patella eversion were significantly smaller than those with patellar reduction and arthrotomy repair (extension: all quadriceps loads, P < 0.0002; flexion: quadriceps loads less than 75 N, P < 0.0002). In patella eversion, quadriceps loading decreased the lateral joint gap more than the medial joint gap in both extension and flexion; however, the effect was greater in knee flexion with significant differences seen at all quadriceps loads, whereas in extension significant differences were only seen for quadriceps loading of 75 N and greater. Patella eversion also caused a lateral-posterior shift and external rotation of the tibia compared to the other conditions (P < 0.005). With patella reduction and repair of the arthrotomy lower quadriceps loading decreased the extension gap significantly more than the flexion gap (P < 0.01). Following repair of the arthrotomy higher quadriceps loading significantly decreased the flexion gap more than the extension gap (P < 0.04).

Interpretation

The patellar positioning and quadriceps muscle loading in total knee arthroplasty have a strong influence on intraoperative joint gap measurements.     

旋转平台型与固定平台型假体行全膝关节置换术治疗膝关节病疗效观察

目的比较应用旋转平台和固定平台假体行全膝关节置换术（total knee arthroplasty,TKA）治疗膝关节病的临床疗效。方法50例行TKA治疗的膝关节病患者,根据术中使用假体不同分为旋转平台组（22例）和固定平台组（28例）,比较2组术前及末次随访时美国膝关节协会评分（American Knee Society Score,KSS）、膝关节活动度（range of movement,ROM）、并发症及影像学资料。结果术后随访6～24个月,至末次随访时,2组KSS评分、ROM均较术前明显提高（P〈0．05）,2组KSS评分、ROM、并发症及影像学表现比较差异无统计学意义（P〉0．05）。结论应用旋转平台型和固定平台型假体行TKA治疗膝关节病临床疗效确切,早期效果相近。     

Biomechanical effects of joint line elevation in total knee arthroplasty

Background

Inadequate restoration of the knee joint line after total knee arthroplasty may lead to a poor clinical outcome. The purpose of this study was to quantitatively assess the effects of joint line elevation following total knee arthroplasty with increased joint volume on patellofemoral contact kinematics.

Methods

Six cadaveric specimens were tested. Patellofemoral contact area, contact pressure, and kinematics were measured following total knee arthroplasty with an anatomic joint line and after 4 and 8 mm of joint line elevation, at knee flexion angles of 0°, 30°, 60°, 90° and 120°. Repeated measures analysis of variance with a Tukey post hoc test with a significance level of 0.05 was used for statistical analyses.

Findings

There was a decrease in contact area with joint line elevation at flexion angles of 60°, 90° and 120° (P = 0.009–0.04). There was a significant increase in contact pressure only at 30° of knee flexion with 8 mm of joint line elevation (P = 0.004). Three of the six specimens showed inferior edge loading of the patella component following 8 mm of joint line elevation at 120° of knee flexion. The sagittal plane patellofemoral angle increased significantly with joint line elevation except for 0° knee flexion (P = 0.0002–0.02).

Interpretation

Knee joint line elevation with increased knee volume significantly affects patellofemoral contact area and kinematics and produced inferior edge loading/impingement between the patella and tibial components, this may result in loss of knee range of motion, postoperative pain, and premature component wear.     

正常成年人膝关节的MR测量及其成像

目的通过对正常成年人膝关节MRI的半月板及韧带的测量,为膝关节损伤性疾病的诊断提供参考值.方法 53例正常对照组成人膝关节MRI检查资料,选择矢状位及冠状位PDWI成像序列,分别测量正常成年人半月板、前、后交叉韧带、内、外侧副韧带、胫骨平台的有关数据,并与解剖文献的大体测量结果进行比较.其中13例同时做了矢状位及冠状位的T2WI及PDWI压脂序列扫描,分析、比较压脂序列对显示半月板及韧带的优势.结果半月板的MR测量值较大体解剖测量值大,外侧半月板后角较半月板的其余部分厚.内侧半月板体部横径与胫骨平台宽径及体重呈线性相关.前交叉韧带与Blumensaat线的夹角小于15°,后交叉韧带的角度约为(120.89±5.63)°.结论膝关节的MR测量值较大体解剖测量值更能反映活体的真实情况,为临床膝关节损伤性疾病的诊断提供正常参考值,外侧半月板后角较前角及内侧半月板厚;内侧半月板体部横径与胫骨平台宽径及体重间可建立多元线性回归方程,体重对内侧半月板体部横径的作用稍大于胫骨平台的作用;MR特别是T2WI及PDWI压脂序列对显示膝关节结构具有较高的价值.     

Dynamic joint stiffness and co-contraction in subjects after total knee arthroplasty

Background

Although total knee arthroplasty reduces pain and improves function, patients continue to walk with asymmetrical movement patterns, that may affect muscle activation and joint loading patterns. The purpose of this study was to evaluate the specific biomechanical abnormalities that persist after total knee arthroplasty and examine the neuromuscular mechanisms that may contribute to these asymmetries.

Methods

Dynamic joint stiffness at the hip, knee and ankle, as well as co-contraction at the knee and ankle, were compared between the operated and non-operated limbs of 32 subjects who underwent total knee arthroplasty and 21 subjects without lower extremity impairment.

Findings

Subjects after total knee arthroplasty demonstrated higher dynamic joint stiffness in the operated knee compared to the non-operated knee (0.056 (0.023) Nm/kg/m/deg vs. 0.043 (0.016) Nm/kg/m/deg, P = 0.003) and the knees from a control group without lower extremity pathology (controls: 0.042 (0.015) Nm/kg/m/deg, P = 0.017). No differences were found between limbs or groups for dynamic joint stiffness at the hip or ankle. There was no relationship between dynamic joint stiffness at the knee and ankle and the amount of co-contraction between antagonistic muscles at those joints.

Interpretation

Patients after total knee arthroplasty walk with less knee joint excursion and greater knee stiffness, although no differences were found between groups for stiffness at the hip or ankle. Mechanisms other than co-contraction are likely the underlying cause of the altered knee mechanics. These findings are clinically relevant because the goal should be to create interventions to reduce these abnormalities and increase function.     

全髋置换对膝关节运动状态的影响(英文)

背景:处在不同运动状态的人体下肢关节系统,其力学特性和关节变形量具有较大的差别.全髋置换是目前解决髋关节严重疾病的最终方法.明确置换前后人体下肢系统,特别是膝关节对置换的响应对于患者的康复训练具有积极意义.目的:通过对健康者和行全髋置换后19个月的患者,在相同的测试环境和测试方法下进行数据采集,对比分析髋关节置换对膝关节在运动中关节变形量的影响.方法:采用NDI公司的动态捕捉系统对行全髋术后19个月的患者进行测量,同时与患者身体状况相似的健康志愿者采用相同的测量仪器和测量方法进行实验.测量内容包括步长,步频,关节转角和关节位移曲线,并根据测量数据计算各关节的速度和加速度.结果与结论:由于髋关节置换对患者的自然关节状态进行了破坏,虽然置换后的步态没有太大的差别,但是通过实验数据可以发现,膝关节的变化量比正常状态下要大,说明人体自身进行了调节,通过增大膝关节的负荷,增加变形量来弥补由于髋关节手术所带来的损伤.     

活动与固定衬垫全膝关节置换后膝关节的活动

背景：目前,在全膝关节置换时无论是使用活动衬垫还是固定衬垫,全膝关节置换后中长期的功能转归和再手术率都相同,但是近期患膝关节功能改善情况各专家意见并不一致。目的：分析活动衬垫型与固定衬垫型假体全膝关节置换后膝关节相关活动的角度变化,以探讨置换后关节活动的改善情况。方法：选择2005年1月至2012年12月确诊为膝关节骨关节炎且患膝既往无手术史的患者90例,应用固定衬垫型假体或活动衬垫型假体进行全膝关节置换治疗。测量患者置换前膝关节活动度,置换后股骨角、胫骨角、膝外翻角、胫骨平台后倾角、髌骨高度。结果与结论：置换后随访4-36个月,末次随访时活动衬垫组的最大屈曲度大于固定衬垫组,差异有显著性意义（P〈0.05）。末次随访时两组的股骨角、胫骨角、膝外翻角、胫骨平台后倾角比较,差异无显著性意义（P〉0.05）。置换前后髌骨高度比较,差异无显著性意义（P〉0.05）。说明活动衬垫型和固定衬垫型假体全膝关节置换后近期患膝关节功能明显改善,且活动衬垫型效果更令人满意。     

Variance analysis in clinical pathways for total hip and knee joint arthroplasty

Clinical pathways are being increasingly used for daily patient care. The pathways consist of a sequence of critical treatment events matched to the patient's recovery. Variance analysis identifies deviations from the pathway and can be used for quality improvement and clinical audit. The aim of this study is to analyse the variances from clinical pathways in two common elective orthopaedic operations. A prospective variance analysis was performed from the clinical pathways of all patients undergoing total hip and total knee arthroplasty over a 12 month period. Variances were categorised according to their source and then further divided into serious and non-serious variances. A total of 65 patients underwent total knee replacement during the study. Eleven serious variances were recorded in eight of these patients (12.3%) with a surprisingly high number of cardiac events. A total of 52 patients underwent total hip replacement with nine serious variances recorded in seven of these patients (13.5%). Clinical pathways can be used as a means of incorporating evidence-based medicine into clinical practice. Variance analysis of the pathways can be utilised as a process of quality control and to improve patient outcomes. Serious variances within this study were higher than anticipated.