后稳定型全膝关节假体置换术后疗效分析

目的　分析后稳定型全膝关节假体置换术的处理方式、手术经验及疗效。方法　对 14例15膝行关节置换 ,使用Apollo后稳定型假体 ,单膝关节置换 13例 ,双膝同期置换 1例。原发疾病为类风湿性关节炎 3例 4膝 ,骨关节炎 11例 11膝。术后随访时间平均 11个月。结果　 15个膝关节术前伸曲活动度平均 75°,全膝关节置换术后 2个月关节活动度恢复至平均 10 0°。 14例患者均可自如行走、上下楼梯 ,膝关节稳定性好。 1膝术后脂肪液化致表层伤口裂开 ,清创后愈合 ,余膝术后伤口均愈合良好。结论　后稳定型假体植入的全膝关节置换手术方式简单、疗效肯定、术后并发症少。     

人工假体置换在膝关节周围侵袭性骨肿瘤中的应用

目的: 探讨人工假体在膝关节周围原发侵袭性骨肿瘤保肢术中的临床应用效果。方法: 膝关节周围原发侵袭性骨肿瘤患者 42例。其中股骨远端 24例, 胫骨近端 16例, 腓骨上端 2例。病理类型: 骨肉瘤 21例, 骨巨细胞瘤 (Ⅱ~Ⅲ级) 16例, 软骨肉瘤 4例, 滑膜肉瘤 1例。行骨肿瘤的广泛切除或根治性切除后, 采用人工膝关节假体置换重建, 对骨肉瘤患者同时采用新辅助化疗治疗。结果: 42例患者术后随访 12~72个月, 其中 30例患者无局部复发或远处转移, 12例出现复发。膝关节活动范围: 伸 0°, 屈 85 ~120°。按Enneking法评定功能, ≥23分 22例, 15~22分 17例, <15分 3例, 优良率达到 86%。结论: 人工假体是一种治疗膝关节周围恶性骨肿瘤较好的保肢方法, 能降低局部并发症及提高临床疗效。     

膝关节屈曲畸形的全膝关节置换术

目的探讨全膝关节置换术对矫正膝关节屈曲畸形所采用的方法和临床经验。方法 46例膝关节屈曲畸形患者均行常规后稳定型膝关节置换术。结果 40例屈曲畸形患者得以完全矫正,2例残留<5°的屈曲,3例残留5°～10°的屈曲,1例残留10°～15°的屈曲。随访时间0.5～2 a,平均1.8 a。KSS膝关节评分由术前平均29分提高至81分,功能评分由术前平均32分提高至84分。结论全膝关节置换术时,彻底松解膝关节周围软组织、保护软组织平衡,可以适当增加股骨远端和胫骨平台的截骨,是矫正屈曲畸形的有效方法。     

非骨水泥假体在全膝关节置换术中的应用进展

全膝关节置换术(TKA)是治疗膝关节终末期骨关节炎及风湿性关节炎的有效手段,传统的骨水泥假体在TKA中应用一直占据主流地位。针对年轻患者(≤60岁)和有运动需求的患者而设计的非骨水泥假体在早期由于设计和技术上的限制,未能获得较好的预后,因此没有得到广泛推崇。随着设计理念及材料技术的提升,新型非骨水泥假体优势突显,逐渐受到关节科医生的青睐。本文就非骨水泥假体的设计初衷、发展历程、新技术特点、临床预后以及目前研究的不足等角度出发,对非骨水泥假体在TKA中的应用进行全面的综合评述。     

全髋关节置换术中使用广泛性轻磷灰石涂膜人工股骨干的临床研究

目的探讨广泛性轻磷灰石涂膜人工股骨干用于全髋关节置换术进行中期效果的研究。方法从1998年至2004年，共37例患者在全髋关节置换术中使用了广泛性轻磷灰石涂膜人工股骨干，研究项目包括骨内生长、松脱及翻修手术的原因、其他并发症及广泛性轻磷灰石涂膜人工股骨干的存活率。结果平均手术年龄为62．6岁及平均术后随访为5年。在术后4年，1例（2．7％）人工股骨干因深层感染需要拆除，它当时已经是固定良好。在术后1．6年及6．3年，分别有2例（5．4％）出现无菌性松脱沉降需要做翻修术；另外有1例（2．7％）因有其他的临床问题没有翻重修术。3例松脱沉降的患者都在前14例中出现。这3例松脱患者，在x光检查中发现股骨干的尺码相对股骨较细小因而引致松脱。机械式的失败率为8．1％，81％的股骨干被分类为稳定而有骨内生长。如果端点为翻修手术及放射照片松脱，广泛性轻磷灰石涂膜人工股骨干的9年存活率分别为91．2％及93．9％。结论广泛性轻磷灰石涂膜人工股骨干的临床效果可以与广泛性多孔涂膜人工股骨干相媲美。但是，精通手术植入的技巧需要较长时间掌握。     

羟基磷灰石涂层股骨柄假体全髋关节置换术的中期疗效

目的 评价羟基磷灰石涂层股骨柄假体伞髋关节置换术的中期疗效.方法 2000年2月至2001年2月,采用U2钛合金羟基磷灰石涂层股骨柄假体行非骨水泥全髋关节置换术65例(70髋),男20例,女45例;年龄40～82岁,平均63岁.术前诊断:股骨颈骨折30例,髋关节骨关节炎15例,股骨头缺血性坏死9例,人工股骨头术后松动8例,类风湿髋关节炎2例,髋关节融合术后1例.分别于术后1周、3个月、6个月随访,以后每年随访1次,对髋关节功能(Harris评分)和X线片进行复查.结果 4例死于癌症,余61例(66髋)获7～8年随访,平均7.5年.末次随访时髋关节Harris评分85～100分,平均96分.3髋(4.5%)出现轻度大腿痛,无一髋需行翻修术治疗.术后1年内假体下沉小于1.5 mm者7髋,此后未再出现假体下沉.术后3～6个月在Gruen 2区和6区近段羟基磷灰石涂层部位出现典型的骨锚固征及松质骨和皮质骨密度增高影像.此后所有患者包括年龄大于70岁和Dorr C型髓腔者均无柄端周围的骨质增生或"底座征",也尤股骨近段或远段髓内骨溶解及假体松动.按Engh标准评定全部患者均获骨性固定.结论 羟基磷灰石涂层能增强股骨柄假体的初始固定,促进早期骨长入和生物学固定,阻止聚乙烯磨屑的髓内迁移和远段髓内骨溶解,用于非骨水泥全髋置换术中期疗效满意.     

肿瘤型假体重建膝关节周围原发性肿瘤切除后骨缺损

目的总结膝关节周围原发性骨肿瘤保肢手术中人工关节重建的疗效和并发症。方法回顾性分析我院1995年12月至2005年12月83例应用肿瘤型假体重建膝关节周围骨肿瘤切除后骨缺损的临床资料。其中骨肉瘤58例,多中心骨肉瘤2例,皮质旁骨肉瘤1例,恶性纤维组织细胞瘤4例,骨巨细胞瘤13例,平滑肌肉瘤1例,尤文肉瘤2例,软骨肉瘤2例。根据骨缺损重建部位分组：股骨下端组44例,胫骨上端组34例,全股骨置换组5例。结果所有患者均获得随访,随访时间12～130个月,平均41个月。局部复发6例,2例晚期感染,假体松动2例,无假体断裂;假体3、5年生存率分别为88．2％、82．1％。41例植骨患者形成皮质外骨桥。肢体肌肉骨骼肿瘤外科治疗重建术后功能评分：股骨下端组19．0—29．0分,平均25．0分;胫骨上端组17．0—28．0分,平均24．4分;全股骨置换组16．0—21．0分,平均19．0分。股骨下端组和胫骨上端组功能优于全股骨置换。结论肿瘤型人工关节重建膝关节周围骨肿瘤并发症发生率低,关节功能良好。     

人工全膝关节置换术股骨假体矢状位位置的影响因素

目的 :探讨造成人工全膝关节置换术(total knee arthroplasty,TKA)后矢状面上股骨假体不同位置放置的原因。方法:回顾性的收集2012年2月1日至2014年2月1日之间,因膝关节骨性关节炎入院,且由同一主刀行初次人工全膝关节置换术患者共251例作为研究对象。根据术后全长片矢状面股骨假体屈曲角(femoral prosthesis flexion angle,FPFA)分为3组:FPFA3°为屈曲组共68例,其中男18例,女50例,平均年龄(68.59±6.16)岁;0°~3°为中立组共143例,其中男33例,女110例,平均年龄(69.26±6.74)岁;0°为过伸组共40例,其中男8例,女32例,平均年龄(70.31±6.70)岁。观察并记录各组研究对象的身高、性别、体重指数(body mass index,BMI)、股骨长度、股骨前弓角度及术中股骨远端切除厚度等资料,并做统计学分析。结果:屈曲组、中立组及过伸组的FPFA分别为(4.48±1.52)°、(1.93±0.57)°、(-1.52±0.43)°,差异有统计学意义(P0.05);各观察指标中股骨前弓角、身高、股骨长度各自在3组之间差异均有统计学意义(P0.05);FPFA与股骨前弓角、身高、股骨长度的回归系数分别为0.605、0.164、0.390。结论:股骨前弓角度大、股骨长度短、身高矮均会造成术后股骨假体的过伸位放置,其中股骨前弓角度影响最大。     

羟基磷灰石涂层股骨柄假体全髋关节置换术的中期疗效

目的 评价羟基磷灰石涂层股骨柄假体伞髋关节置换术的中期疗效.方法 2000年2月至2001年2月,采用U2钛合金羟基磷灰石涂层股骨柄假体行非骨水泥全髋关节置换术65例(70髋),男20例,女45例;年龄40～82岁,平均63岁.术前诊断:股骨颈骨折30例,髋关节骨关节炎15例,股骨头缺血性坏死9例,人工股骨头术后松动8例,类风湿髋关节炎2例,髋关节融合术后1例.分别于术后1周、3个月、6个月随访,以后每年随访1次,对髋关节功能(Harris评分)和X线片进行复查.结果 4例死于癌症,余61例(66髋)获7～8年随访,平均7.5年.末次随访时髋关节Harris评分85～100分,平均96分.3髋(4.5%)出现轻度大腿痛,无一髋需行翻修术治疗.术后1年内假体下沉小于1.5 mm者7髋,此后未再出现假体下沉.术后3～6个月在Gruen 2区和6区近段羟基磷灰石涂层部位出现典型的骨锚固征及松质骨和皮质骨密度增高影像.此后所有患者包括年龄大于70岁和Dorr C型髓腔者均无柄端周围的骨质增生或"底座征",也尤股骨近段或远段髓内骨溶解及假体松动.按Engh标准评定全部患者均获骨性固定.结论 羟基磷灰石涂层能增强股骨柄假体的初始固定,促进早期骨长入和生物学固定,阻止聚乙烯磨屑的髓内迁移和远段髓内骨溶解,用于非骨水泥全髋置换术中期疗效满意.     

人工全膝关节置换术后单纯金属底座髌骨假体的翻修

目的分析带金属底座髌骨假体失败的原因,并观察单纯髌骨假体翻修的临床疗效。方法对 22例 (30膝 )人工全膝关节置换术后因金属底座髌骨假体失败而行单纯髌骨假体翻修者进行回顾性分析。假体均为同一类型的后十字韧带保留型假体,以金属底座髌骨假体置换髌骨。应用膝关节 KSS评分标准评价翻修术后的临床转归。结果髌骨假体失败时间在人工全膝关节置换术后的 26～ 96个月,平均 62.3个月,主要症状有金属摩擦感 (80％ )和膝关节疼痛 (70％ )。术中发现 23膝 (76.7％ )聚乙烯完全磨损、金属底座外露; 9膝髌骨倾斜或半脱位; 2膝完全脱位。 30膝均成功施行骨水泥全聚乙烯髌骨翻修术,随访时间 24～ 81个月,平均 42.5个月。所有患者主诉症状消失,可独立行走活动,膝关节评分从术前的平均 73分（ 27～ 88分）增加至 87分（ 60～ 100分）;膝关节屈曲度由术前的平均 91°增加至 99.5°。结论 (1)金属底座髌骨假体早期失败率较高; (2)髌骨位线不良和异常滑动轨迹是导致带金属底座髌骨假体失败的诱发因素; (3)单纯髌骨假体翻修可获满意的临床结果,其发生并发症的潜在危险和人工全膝关节翻修术相似,应予以重视。     

Rotating hinged total knee replacement: use with caution

BACKGROUND: A rotating hinged total knee prosthesis may be utilized for the treatment of global instability or severe bone loss around the knee. Older generations of rotating hinged designs were associated with suboptimal outcomes. We evaluated the outcome of salvage knee reconstructions that had been performed with use of modern-generation modular segmental kinematic rotating hinged total knee prostheses. METHODS: The cohort included forty-three patients (twenty-nine women and fourteen men) who underwent forty-four knee arthroplasties for the treatment of a non-neoplastic condition with use of a modern-generation kinematic rotating hinged prosthesis. Revision of a previous total knee arthroplasty in the presence of massive bone loss was the most common indication for surgery. Complete clinical and radiographic data were collected for all patients after a mean duration of follow-up of 4.2 years. RESULTS: Reconstruction with a rotating hinged total knee prosthesis provided substantial improvement in function and reduction in pain. However, a relatively large number of complications and failures (including revision because of periprosthetic infection [three knees], aseptic loosening [four], and periprosthetic fracture [one]) were encountered, with a mean time to failure of 1.7 years. The rate of prosthetic survival was 79.6% at one year and 68.2% at five years with revision or reoperation as the end point. CONCLUSIONS: The present study highlights the commonly held opinion that a modular kinematic rotating hinged total knee prosthesis has a role for salvage reconstruction of the knee. In light of the relatively high rate of complications, we believe that this salvage procedure should be reserved primarily for elderly and sedentary patients.     

Distal femoral fractures treated by hinged total knee replacement in elderly patients

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile. Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low. A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.     

Osseointegrated total knee replacement connected to a lower limb prosthesis: 4 cases

Background and purpose — Osseointegrated implants are an alternative for prosthetic attachment in individuals with amputation who are unable to wear a socket. However, the load transmitted through the osseointegrated fixation to the residual tibia and knee joint can be unbearable for those with transtibial amputation and knee arthritis. We report on the feasibility of combining total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment.Patients and methods — We retrospectively reviewed all 4 cases (aged 38–77 years) of transtibial amputations managed with osseointegration and TKR in 2012–2014. The below-the-knee prosthesis was connected to the tibial base plate of a TKR, enabling the tibial residuum and knee joint to act as weight-sharing structures. A 2-stage procedure involved connecting a standard hinged TKR to custom-made implants and creation of a skin-implant interface. Clinical outcomes were assessed at baseline and after 1–3 years of follow-up using standard measures of health-related quality of life, ambulation, and activity level including the questionnaire for transfemoral amputees (Q-TFA) and the 6-minute walk test.Results — There were no major complications, and there was 1 case of superficial infection. All patients showed improved clinical outcomes, with a Q-TFA improvement range of 29–52 and a 6-minute walk test improvement range of 37–84 meters.Interpretation — It is possible to combine TKR with osseointegrated implants.Socket-related discomfort leads to a significant reduction in the quality of life of individuals with lower limb amputation (Dillingham et al. 2001, Gholizadeh et al. 2014). Socket-skin interface problems lead to poor fit, diminished proprioception in the amputated limb, lack of rotational control, and reduction of ipsilateral proximal joint movement (Legro et al. 1999, Lyon et al. 2000, Meulenbelt et al. 2006).A direct connection of the prosthetic limb to the bone using osseointegrated implants can address these socket-related problems (Van de Meent et al. 2013, Tsikandylakis et al. 2014). Brånemark introduced this surgical procedure in 1995. He adapted osseointegration principles established in dental surgery to the rehabilitation of individuals with transfemoral amputation using a percutaneous bone anchoring implant screwed into the femur (Brånemark et al. 2001). Hip replacement spongiosa surface coating technology has been used to make a chrome cobalt intramedullary press-fit implant (Endo-Exo Prosthesis) allowing larger surface area for osseointegration and faster rehabilitation (Staubach and Grundei 2001). Al Muderis et al. (2015) adapted highly porous plasma-sprayed titanium implants to provide optimum initial press-fit and solid bone ingrowth.Studies of transfemoral implants have found improved quality of life, prosthetic use, body image, hip range of motion, sitting comfort, and walking ability (Van de Meent et al. 2013, Hagberg et al. 2014). For example, substantial improvements in health-related quality of life using the Global component of the questionnaire for transfemoral amputees (Q-TFA)—of 38 points (Hagberg et al. 2014) and 24 points (Van de Meent et al. 2013)—have been reported in 2 case series of 51 and 22 patients, respectively.Similar benefits could be expected for transtibial amputees using osseointegrated implants, as the knee joint could possibly enhance their gait. A study of 39 cases involving upper and lower limb prostheses (Tillander et al. 2010) found infections in 7 patients at an average follow-up period of 54 (3–132) months, with no infections reported for 1 tibial implant. At our own center, preliminary evidence of the safety and effectiveness of the tibial impants in 22 transtibial amputees with a minimum of 6 months of follow-up gave results consistent with the published results for transfemoral amputations (Khemka et al. 2015).Few authors have reported on the safety of this procedure (Brånemark et al. 2014, Tsikandylakis et al. 2014). One of the largest studies included 51 patients and reported superficial infections in approximately half of these patients at 2-year follow-up. In that study, the implant was removed in 1 patient due to deep infection and in 3 patients due to aseptic loosening (Brånemark et al. 2014).Osseointegrated implants are not currently recommended for transtibial amputees with ultra-short residuum. In addition to the practical technical challenges, biomechanical studies have suggested that small bone-implant contact is more likely to increase the risk of loosening (Lohr et al. 2000, Henriksen et al. 2003, Carvalho et al. 2012). Osseointegration is also not currently recommended for those suffering from ipsilateral knee osteoarthritis because it is hypothesized that an osseointegrated tibial implant will aggravate arthritic symptoms due to mechanical forces (Frossard et al. 2008).We describe the surgical procedure and early results of combining a total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment for the first time.     

Results of a single total knee prosthesis compared with multiple joint replacement in the lower limb

We present the clinical results of total knee replacement (TKR) in 133 patients who had two or more major joints of the lower limbs replaced, and compare them to the outcome in 406 patients with an isolated TKR. 383 patients had osteoarthritis (OA) and 136 had rheumatoid arthritis (RA) and these were assessed separately. A meniscal bearing prosthesis was used. The functional score was high and there was no statistically significant difference in the incidence of complications between the two groups.