止血带对全膝关节置换术中股骨远端旋转定位时髌骨轨迹的影响

目的 探讨止血带对全膝关节置换术中以外科髁上轴线为股骨远端旋转定位线的髌骨轨迹的影响.方法 2002年12月至2008年8月,首选以外科髁上轴线为股骨远端旋转定位标志的初次全膝关节置换349例(526膝),男124例(155膝),女225例(371膝);年龄33～84岁,平均68岁.膝内翻387膝,膝外翻94膝.均使用同一种保留后十字韧带的活动平台假体,由同一位手术医生操作.采用前内侧髌旁入路,以外科髁上轴线为股骨远端旋转定位线,以no thumb test检测髌骨轨迹.对髌骨轨迹不良者,缝合髌骨内上缘支持带并松开止血带.对再次检查髌骨轨迹不良者行外侧支持带松解术.术后3个月患者能够极度屈曲膝关节时摄X线片检查髌骨轨迹.结果 术中no thumb test阳性138膝,其中半脱位12膝(膝外翻),髌骨倾斜126膝(膝外翻74膝).缝合髌骨内上缘支持带并松开止血带后,no thumb test阳性40膝,其中半脱位8膝(膝外翻),髌骨倾斜32膝(膝外翻29膝).髌骨外侧支持带松解率7.6%(40/526),膝外翻松解率39.4%(37/94).结论 在全膝关节置换术中,高压止血带对髌骨轨迹有干扰作用.术中缝合髌骨内上缘支持带并松开止血带,可降低外侧支持带松解率.     

全膝关节置换术中放开止血带并缝合内上缘支持带对髌骨轨迹的影响

目的 探讨在初次全膝关节置换术(TKA)中放开止血带且缝合内上缘支持带对髌骨轨迹的影响.方法 选择2006年3月至2008年2月初次行TKA的83例患者136侧膝关节.使用前内侧髌旁人路,检测髌骨轨迹.对于不良的髌骨轨迹,术中松开止血带且仅用一针缝合髌骨内上缘支持带.再次检查髌骨轨迹.最后,对残留不良髌骨轨迹的患者行外侧支持带松解术,以求获得满意的髌骨轨迹.采用no-thumb试验作为检测髌骨轨迹的标准.结果 在初次行TKA的83例患者136侧膝关节中,在未松开止血带前,髌骨轨迹不良率为64.7%(88/136).放开止血带且缝合髌骨内上缘支持带后,髌骨外侧支持带松解率为26.5%(36/136),差异有统计学意义(X2=38.55,P＜0.01).其中,膝外翻畸形患者的松解率为58.6%(17/29),膝内翻和无明显畸形患者的松解率为17.8%(19/107).结论 高压止血带对行前内侧髌旁人路TKA的患者髌骨轨迹的干扰作用非常明显.术中松开止血带且缝合髌骨内上缘支持带明显降低了外侧支持带的松解率,从而降低了其可能带来的并发症.     

全膝关节置换术中髌骨置换与髌骨成形对膝关节功能的影响

 目的 探讨髌骨置换与髌骨成形对全膝关节置换术后膝关节功能的影响。方法 对2010年8月至11月拟行全膝关节置换术的48例(69膝)膝关节骨关节炎患者进行随机分组,髌骨置换组24例(35膝)、髌骨成形组24例(34膝)。两组患者年龄、体重、身高、体重指数、美国膝关节协会(Knee Society Score,KSS)膝评分及功能评分、髌骨评分的差异均无统计学意义。比较两组术后6周、3个月、6个月、12个月、24个月的KSS膝评分及功能评分、髌骨评分、术后膝前痛发生率及影像学表现。结果 髌骨置换组20例(30膝)与髌骨成形组20例(29膝)获得随访。术后各时点两组KSS膝评分的差异无统计学意义;6个月以后髌骨置换组KSS功能评分高于髌骨成形组,12个月以后髌骨置换组髌骨评分高于髌骨成形组,差异有统计学意义。术后各时点髌骨置换组膝前痛发生率与髌骨成形组的差异有统计学意义。术后24个月髌骨置换组与髌骨成形组术后胫股角(174.25°±0.97°与173.63°±0.48°)、髌韧带比值(1.01±0.09与1.09±0.07)、髌骨倾斜角(4.58°±0.18°与4.41°±0.19°)、髌骨适合角(2.69°±4.15°与2.56°±3.72°)、髌骨移位距离[(1.53±1.34) mm与(1.68±1.23) mm]的差异均无统计学意义。结论 全膝关节置换术中行髌骨置换可以改善膝关节和髌骨功能,降低术后膝前痛的发生率。     

两种不同股骨假体旋转设计对全膝关节置换术后髌骨轨迹的影响

目的探讨传统股骨假体外旋技术和内置外旋的股骨假体设计对全膝关节置换（TKA）术后髌骨轨迹和整体疗效的影响.方法 本前瞻随机对照研究纳入2004年9月至2008年3月间共360例接受TKA的患者,术前随机将患者分为A组（股骨假体外旋放置组,使用PFC Sigma固定平台假体）和B组（内置外旋股骨假体组,使用Genesis Ⅱ固定平台假体）,每组各180例.所有手术均由同一组高年资关节外科医师实施,均未置换髌骨,仅行髌骨表面修整,根据术中髌骨轨迹决定是否需要行外侧支持带松解,术后接受相同的围手术期镇痛和康复训练流程.术后常规随访,使用HSS评分和WOMAC评分评估整体疗效,术后1年及末次随访时拍摄髌骨轴位片评估髌骨位置.结果 纳入研究的360例患者,均完成术后3个月及1年的随访.坚持随访的163例患者（A组74例,B组89例）平均随访时间为5.25年（3.5～7年）,其中2例因术后假体感染而翻修,无假体失败病例.术中外侧支持带松解发生率A组为8.1%（13/160）,B组为6.9%（11/160）,两组间没有统计学差异.术后1年髌骨轴位片两组均未出现髌骨脱位病例.两组间术后膝前疼痛的发生率、术后HSS评分与WOMAC评分无统计学差异.结论 传统股骨假体外旋技术和内置外旋的股骨假体设计均可获得良好的平衡伸直-屈曲间隙,改善髌骨轨迹.鉴于患者股骨外旋变异较大,传统股骨假体外旋技术应综合参照后髁轴和经上髁轴,内置外旋的股骨假体设计也应根据患者个体差异进行调整.     

止血带释放时机对全膝关节置换术失血的影响

目的 探讨止血带释放时机对全膝关节置换术(TKA)失血的影响.方法 2006年6月至2008年6月,80例TKA患者随机分为两组,每组40例.A组:释放止血带彻底止血后关闭切口,B组:关闭切口弹力绷带包扎后释放止血带.比较两组患者的失血量、输血例数、手术时间、止血带使用时间及膝关节屈曲度.结果 A组术中失血量[(161.5±50.1)mL]多于B组((70.0±19.4)mL],术后失血量[(357.8±104.7)mL]少于B组[(467.9±116.0)mLl,总失血量[(516.8±107.9)mL]少于B组[(579.5±140.2)mL],差异均有统计学意义(P＜0.05);但两组输血例数差异无统计学意义(P＞0.05).A组手术时间为(77.7±14.6)min,B组为(73.6±17.5)min,两组比较差异无统计学意义(P＞0.05).A组止血带使用时间为(69.4±14.4)min,B组为(73.6±17.5)min,两组比较差异无统计学意义(P＞0.05).术后1周膝关节屈曲A组为93°、B组为84°,术后2周A组为113°、B组为103°,两组比较差异均有统计学意义(P＜0.05);但8周后A组膝关节屈曲为117°、B组为113°,差异无统计学意义(P＞0.05).结论 释放止血带彻底止血后关闭切口可减少手术总失血量.     

止血带对全膝关节置换术后深静脉血栓形成的影响

目的 探讨止血带对全膝关节置换术后深静脉血栓形成的影响.方法 采用随机对照研究,将连续入院的拟行初次全膝关节置换的80例患者随机分为两组:一组使用止血带(止血带组,40例),一组不使用止血带(非止血带组,40例).全部采用后十字韧带替代型骨水泥固定人工膝关节(Smith-Nephew),手术由同一组医生完成.比较两组患者围手术期失血量、深静脉血栓和肺动脉栓塞发生率、术中栓子面积百分率%Ae(即总栓子面积占右心房面积的百分率).术前及术后第1～10天行彩色多普勒超声检查,观察双下肢深静脉血栓的发生;术中使用经食道超声心动图监测右心房,评估止血带释放后的%Ae.结果 止血带组患者术中失血最小于非止血带组患者,但两组患者围手术期总失血量比较差异无统计学意义.止血带组患者和非止血带组患者深静脉血栓发生率比较无统计学差异,两组均未发生肺动脉栓塞.止血带组患者%Ae在释放止血带后的1 min达到高峰;非止血带组患者%Ae仅在扩髓和植入假体时出现高峰,然后缓慢下降;止血带组患者%Ae在释放止血带后大于非止血带组患者.结论 止血带的使用对全膝关节置换术围手术期总失血量并无明显影响,不增加深静脉血栓和肺栓塞的发生风险.     

全膝关节置换术中髌骨置换与否对膝前痛发生的影响

[目的]回顾性分析、比较全膝关节置换术中髌骨置换与否对膝前痛发生的影响,为临床治疗提供参考。[方法]对1994年10月~2004年10月行人工全膝关节置换术病人125例(148膝)按髌骨置换(84膝)和未置换(64膝)分为2组,并对其随访资料进行分析,膝关节评分采用HSS评分系统,髌骨评分采用Feller评分标准。结果使用SPSS统计软件进行统计学分析。[结果]置换组HSS评分由术前的(39.6±39.8)分进步为末次随访时的(90.9±8.2)分,髌骨评分由(14.4±6.4)分进步到(25.2±4.8)分,膝前痛分数也由(4.6±3.9)分进步为(10.6±4.1)分;未置换组HSS评分由术前的(38.8±9.8)分进步为(90.2±8.9)分,髌骨评分由(14.2±6.2)分进步到(25.1±4.8)分,膝前痛分数也由(4.8±3.8)分进步为(10.3±4.1)分。2组患者末次随访时膝前痛均较术前明显减轻,差异有显著性意义;置换组与未置换组比较,膝前痛减轻的差别无显著性意义。[结论]无论髌骨置换与否,患者的合理选择和正确的手术操作是避免术后膝前痛的关键所在。     

全膝关节置换术髌骨置换与否的比较

目的回顾性分析、比较全膝关节置换术髌骨置换与否的疗效及优缺点,为临床治疗提供参考。方法自1994年1月～2000年12月间住院治疗的骨关节炎及类风湿性关节炎患者86例(109膝)。对髌骨置换和未置换的两组患者进行随访,膝关节评分采用美国HSS评分系统,髌骨评分采用Feller等的髌骨评分标准。随访时拍摄膝关节正、侧位及髌骨30°、90°轴位X线片。结果使用SPSS统计软件进行统计学分析。结果置换组与未置换组术后疗效及并发症的发生率无明显差异,髌骨功能评分差异有非常显著性意义(P<0.01)。置换组部分功能(上下楼梯及从椅子上坐起)略好于未置换组,未置换组术后膝前痛的发生率高于置换组,但多为轻度,差异有显著性意义(P<0.05)。术后髌骨不稳定和半脱位的发生率无统计学差异。结论髌骨不稳定的发生与术前畸形明显及术前髌骨外侧偏移倾向有关,是造成未置换组膝前痛的因素之一。未置换组髌骨不稳定与髌骨分型有关,建议如果术前拍摄髌骨轴位X线片时发现髌骨属于Ⅲ型者应置换髌骨。     

髌骨软骨破坏程度对保留髌骨的全膝关节置换术疗效的影响

目的 探讨髌骨软骨破坏程度对保留髌骨的全膝关节置换术疗效的影响.方法 2002年1月至2006年5月行全膝关节置换术163例244膝,根据术中观察到的髌骨软骨破坏程度将患者分为轻度、中度、重度软骨破坏三组.所有手术均不置换髌骨.术后随访88例133膝,轻度组42膝,中度组43膝,重度组48膝.采用美国膝关节学会评分(Knee Society Score,KSS)系统(包括膝评分和膝功能评分)和膝前痛评分系统对三组疗效进行评估.结果 随访48～102个月,平均72个月.KSS膝评分和膝功能评分从术前(35.1±5.4)分和(19.2±9.8)分分别提高到(91.7±5.6)分和(83.7±17.5)分.三组KSS膝评分从术前(34.7±6.2)分、(36.5±5.2)分、(35.3±6.2)分分别提高至(92.6±4.5)分、(90.5±6.7)分、(91.9±5.9)分;膝功能评分从术前(14.2±8.6)分、(16.5±7.4)分、(17.0±7.5)分分别提高至(86.6±12.6)分、(82.0±17.2)分、(82.8±21.1)分.三组术后膝评分和膝功能评分的差异均无统计学意义.术后膝前痛的发生率为11.3%(15/133),轻度、中度、重度软骨破坏组分别为11.9%(5/42)、11.6%(5/43)、10.4%(5/48),差异无统计学意义.结论 全膝关节置换术后疗效及膝前痛的发生率与术前髌骨软骨破坏程度无关,髌骨软骨破坏程度不是全膝关节置换术中置换髌骨的可靠依据.

Abstract：

Objective To determine whether there was any correlation between the degree of degenerative changes in the patellar cartilage and the clinical outcome after TKA without patellar resurfacing.Methods A clinical study was performed on 133 knees of 88 patients that underwent TKA without patellar resurfacing from January 2002 to May 2006. According to the degenerative condition of the patellar cartilage,patients was classified as mild group, moderate group, and severe group. Pre- and post-operative evaluations were performed using the knee and function scores of the Knee Society Clinical Rating System (KSS) and Anterior Knee Pain Rating. Results The duration of follow-up was 72 months (range 48-102). The overall knee score of KSS in all patients were improved from 35.1±5.4 preoperatively to 91.7±5.6 postoperatively,and function score of KSS from 19.2±9.8 preoperatively to 83.7±17.5 postoperatively. The mean knee scores of KSS were improved from 34.7±6.2, 36.5±5.2 and 35.3±6.2 preoperatively to 92.6±4.5, 90.5±6.7 and 91.9±5.9 in mild, moderate, and severe group postoperatively, respectively. The mean function scores of KSS were improved from 14.2±8.6, 16.5±7.4 and 17.0±7.5 postoperatively to 86.6±12.6, 82.0±17.2 and 82.8±21.1 in mild, moderate, and severe group postoperatively, respectively. There was no difference among all groups with regard to the postoperative knee scores and function scores of KSS. The prevalence of anterior knee pain was 11.3% in all, and 11.9% in mild group, 11.6% in moderate group and 10.4% in severe group. There was no difference among all groups with regard to the anterior knee pain. Conclusion The clinical outcome and anterior knee pain after TKA without patellar resurfacing was not correlated with the severity of degenerative changes in the patellar cartilage. The degree of degenerative condition of the patellar cartilage is not indication for patellar resurfacing.     

全膝关节置换术中滑移髌骨影响术后低位髌骨发生率

目的分析全膝关节置换术中翻转髌骨或者滑移髌骨对术后低位髌骨发生率的影响。 方法纳入广州中医药大学附属新会中医院2017年4月至2019年9月实施的50例全膝关节置换术患者,纳入标准为Kellgren-Lawrence分级为Ⅲ-Ⅳ级的膝关节骨关节炎患者,术前排除低位髌骨。按随机数字表法将其分为两组,观察组采用术中滑移髌骨(n＝25),对照组采用术中翻转髌骨(n＝25);并进行12个月的随访,分别比较2组的美国特种外科医院(HSS)膝关节评分、术前术后Insall-Salvati(IS)指数、改良Insall-Salvati(MIS)指数、Blackbume-Peel(BP)指数、Caton-Deschamps(CD)指数及术后低位髌骨发病率。应用卡方检验和t检验比较评分和指数的差异。 结果术前两组HSS膝关节评分差异无统计学意义(t＝0.61,P >0.05),术后第6、12个月,观察组的HSS功能评分优于对照组(t＝2.64、2.80,均为P <0.05)。术前两组IS指数、MIS指数、CD指数及BP指数差异无统计学意义(t＝0.684、0.87、1.40、0.57,均为P >0.05);术后观察组IS指数、MIS指数高于对照组(t＝3.004、3.29,均为P <0.05)。术后两组的CD指数、BP指数差异无统计学意义(t ＝－0.06、－0.29,均为P >0.05)。观察组术后低位髌骨发生率低于对照组(χ²＝4.15,P <0.05)。 结论TKA术中滑移髌骨比翻转髌骨术后发生低位髌骨的风险更低,但尚需前瞻性对照研究进一步验证。     

Factors affecting patellar tracking after total knee arthroplasty

This study examined factors that influence patellar tracking after total knee arthroplasty. A total of 62 knees were evaluated radiographically for postoperative patellar tracking. Six factors were examined regarding their influence on postoperative patellar tracking. This study showed the effects of patellar component position, patellar resection angle, and lateral retinacular release on postoperative patellar tracking. There was no significant effect of the remaining 3 factors: the thickness of the patellar resection, preoperative patellar tilt, and rotational alignment of the femoral component. A medialized patellar component and obliquity of resection of the patella are effective for obtaining proper patellar tracking, whereas the evaluation of the influence of the external rotation of the femoral component requires more clinical studies.     

The effect of surgical approaches and tourniquet application on patellofemoral tracking in total knee arthroplasty

The purpose of this study was to assess the influences of surgical approaches and tourniquet application on the lateral retinacular tension (LRT). Single-setting bilateral total knee arthroplasty was performed in 10 patients, and the medial parapatellar and midvastus approaches were randomly performed on each knee using tourniquet application. The LRT was measured using the buckle transducer before and after each approach. Next, the tourniquet was deflated and the measurement was repeated. After the parapatellar approach, LRT was significantly decreased. Conversely, no significant change was seen after the midvastus approach with the tourniquet inflated. However, in the midvastus approach, LRT was significantly decreased after tourniquet deflation. We concluded that both the parapatellar and midvastus approaches influence patellar tracking and LRT.     

The effect of patellar thickness on intraoperative knee flexion and patellar tracking in total knee arthroplasty

We designed a simple IRB-approved study to evaluate the intraoperative effect of patellar thickness on knee flexion and patellar tracking during total knee arthroplasty. Routine PCL-retaining total knee arthroplasty was performed in 31 consecutive knees. With clinical balance and congruent patella tracking established, custom trial patellar components that were thicker than the standard trial by 2-mm increments (2-8 mm) were sequentially placed and trialed. Passive flexion was recorded to the nearest 5 degrees with an intraoperative goniometer and gross mechanics of patellofemoral tracking were visually assessed. On average, passive knee flexion decreased 3 degrees for every 2-mm increment of patellar thickness. Furthermore, for the knee system used in this study, increased patellar thickness had no gross effect on patellar subluxation or tilt.     

Effect of rotational alignment on patellar tracking in total knee arthroplasty

Forty-four consecutive patients (65 knees) who underwent identical condylar type total knee arthroplasty were evaluated retrospectively. In 22 of the patients (32 knees), the femoral component was set parallel to the posterior condylar axis (neutrally aligned group). In the remaining 22 patients (33 knees), it was set in an external rotation position of 3 degrees to 5 degrees relative to the axis (externally aligned group). Of the total knee arthroplasties in the neutrally aligned group, 34% required lateral release, compared with only 6% in the externally aligned group; patellar tracking in the externally aligned group was significantly better than that in the neutrally aligned group. Postoperative measurements performed using computed tomography scans showed that the mean angle between the prosthetic posterior condylar axis and the transepicondylar axis was 7.9 degrees in the neutrally aligned group and 3.2 degrees in the externally aligned group. The external rotation setting of the femoral component diminished the need for lateral retinacular release and may decrease the rate of patellofemoral complications that occur after total knee arthroplasty.     

全膝关节置换术对髌骨内外倾运动的影响

目的探讨全膝关节置换术(totalkneearthroplasty,TKA)对髌骨内外倾运动的影响,及其在TKA术后膝前痛形成过程中所起的作用。方法采用6具成人尸体左侧下肢标本建立伸膝装置(股内侧、股中间、股外侧肌群按1.25∶1.5∶1的比例施以负荷)按比例负荷膝关节自由运动模型,应用激光束定位与X线摄片技术,分别测量正常膝关节与采用PFCΣ假体行人工膝关节置换术后膝关节屈曲过程中的髌骨内外倾角度。结果胫股关节屈曲30°、60°、90°、120°、150°时,以股骨滑车为参照标准,膝关节置换前后髌骨的倾斜角度分别是:0°±0°、0°±0°、0°±0°、0.24°±0.35°、-3.21°±1.80°;0°±0°、0°±0°、0°±0°、0°±0°、-1.12°±1.20°。三维空间参照系内,膝关节置换术前,膝关节屈曲0°、30°、60°、90°、120°、150°时髌骨平均外倾:0°±0°、-3.10°±2.25°、2.50°±1.07°、5.46°±2.60°、6.32°±2.16°、-2.10°±1.90°;膝关节置换术后,膝关节屈曲0°、30°、60°、90°、120°、150°时髌骨平均外倾:0°±0°、3.24°±0.35°、2.30°±1.39°、1.65°±1.17°、1.29°±1.03°、-0.86°±1.42°。结论TKA术后虽然髌骨与股骨滑车的对合关系保持正常,但在三维立体空间内髌骨的内外倾模式与幅度较未置换前发生了变化。膝关节初始屈曲时,TKA术前髌骨内倾,术后髌骨外倾,其变化的幅度与股骨假体外旋的幅度一致。膝关节屈曲60°￣120°范围内,TKA术后髌骨外倾较术前减小,而表现为相对内倾,内倾幅度与TKA术后股骨假体相对内翻的幅度一致。     

止血带的不同使用方法在膝关节置换术中的研究

目的探讨全膝关节置换术中止血带不同的使用方法的作用。方法2009年9月至2011年6月,对45例骨关节炎患者行单侧膝关节置换手术,根据止血带不同的使用方法分为两组,A组24例,在安装假体前至安装假体后骨水泥硬松开止血带;B组21例,在手术开始至安装假体完毕,骨水泥硬化后松开止血带,术野止血后关闭伤口。观察两组病例的手术时间、术中和术后出血量、术后患肢肿胀情况和术后HSS评分。结果手术时间（t=3．0,P〈0．05）、术中（t=9．2,P〈0．05）和术后（t=13．5,P〈0．05）出血量均有统计学差异,但是总出血量（t=0．6,P〉0．05）间的差异无统计学意义,术后患肢肿胀情况（t=2．3,P〈0．05）两组间差异具有统计学意义。结论减少使用止血带时间可能利于患者早期恢复。     

The effect of femoral component rotation on patellar tracking in total knee arthroplasty

Rotational adjustment of the femoral component in total knee arthroplasty influences patellar tracking. Sixty patients underwent TKA; the femoral component was placed parallel to the epicondylar axis in 30 patients and the femoral component was placed in 3 degrees external rotation to the posterior condylar axis in 30 patients. The epicondylar axis was identified using an image-guided navigation system. Mean patellar shift was 2.65 degrees for the computer assisted group and 3.50 degrees for the control group. Mean patellar tilt was 4.88 degrees for the computer assisted group and 6.68 degrees for the control group. Aligning the femoral component parallel to the epicondylar axis leads to significantly better patellar tracking.