AutoCAD软件对全膝关节表面置换术X线片的预测和评估

目的探讨AutoCAD软件对全膝关节表面术X线片分析的精确性及其对手术的指导意义。方法用数码相机拍摄190例全膝关节表面置换术前和术后的DR X片,用AutoCAD软件处理图片,测量术前胫骨平台前后径和左右径、股骨髁的前后径和左右径、股骨假体角、胫骨假体角和胫骨假体的前后径和左右径、股骨假体的前后径和左右径,分析术前和术后数值之间的相关性。结果经测量得到的股骨假体角和胫骨假体角、股骨假体倾斜角、胫骨假体倾斜角分别为(86.21±1.96)°,(90.02±1.21)°,(88.32±3.12)°、(91.92±4.96)°。股骨假体和胫骨假体的测量值和真实值之间差异无统计学意义(P>0.05)。结论膝关节表面置换术可以通过AutoCAD软件来分析术前和术后X片,有利于术前预测、术中配合、术后评价.     

Prevalence of proximal tibia vara in Indonesian population with knee osteoarthritis

BackgroundProximal tibia vara has drawn interest since the concept of constitutional varus was introduced. Proximal tibia vara is a condition where the knee varus tilt the tibia condyle medially and shift the tibial articular surface medially. This condition affects medial proximal tibial angle measurements and the placement of the tibial implant in knee replacement surgery. Thus, it challenged the neutral knee arthroplasty alignment target because some people may present a proximal tibia vara. This study assesses the prevalence of the proximal tibia vara and the correlation to knee osteoarthritis grade.MethodsThis retrospective study was carried out from January 2021 to June 2021. Eighty-five limbs were included with the following inclusion criteria: knee osteoarthritis patients who received a long view lower extremity radiograph. The exclusions criteria were (1) patients who had undergone arthroplasty and lower extremity surgery before and (2) valgus knee deformity. The outcomes in this study were HKAA, MAD, TAD, MPTA, PTRP, LDFA, and PTS. Intraclass correlation (ICC) using two-way mixed was used to assess the reproducibility of the radiographic parameters. Multiple logistic regression was used to evaluate the correlation between knee osteoarthritis grade and radiographs parameters (MAD and TAD).ResultA total 85 limbs from 52 patients were assessed in this study. Proximal tibia vara was found in 18 knees (21%.). The logistic regression was performed to assess the correlation between the severity of the knee osteoarthritis and radiographic parameters (MAD, TAD, LDFA, and PTS) with an overall p-value < 0.001 and pseudo-R² = 0.29.ConclusionA significant portion of patients with knee osteoarthritis have proximal tibia vara, and it is a pre-existing condition. Since the pre-existing proximal tibia vara affects preoperative measurements, a long-standing lower extremity x-ray is recommended to be obtained as part of knee replacement preparation.     

Computer-assisted alignment system for tibial component placement in total knee replacement: a radiological study

In total knee replacement (TKR), regarding tibial component positioning, almost all implants offer both an intramedullary and an extramedullary alignment guide, leaving it up to the surgeon which guide to use. However, early failure in TKR can be caused by incorrect positioning or orientation with poor limb alignment. Recently computer-based alignment systems have been developed to help the surgeon to overcome these complications. The Authors retrospectively analysed their experience using a computer-based CT-free alignment system. They assessed the radiological alignment of the tibial components in 38 computer-assisted TKR 6 months after surgery. The frontal tibial component angle (FTC) and the sagittal orientation of the tibial component (slope) were evaluated 6 months after the operation. The results were compared to those achieved with traditional alignment systems. The surgical time was statistically longer in the computer-assisted group but in this group all the tibial components were aligned within 4° of all the ideal measurements in both frontal and sagittal planes.     

PROMs in total knee replacement: analysis of negative outcomes

IntroductionNHS England uses the Oxford Knee Score (OKS) as part of patient-reported outcome measures (PROMs) to evaluate ‘health gains’ following total knee replacement. Policy makers use this to guide healthcare funding and resource allocation. Our study aims to undertake a qualitative and quantitative analysis of OKS among patients who experienced a negative outcome after a total knee replacement at our centre.Materials and methodsBetween April 2017-March 2018, 19 of 189 (10%) patients had a worsened OKS at our centre. We retrospectively and prospectively reviewed 14 of these patients. Structured telephone interviews with a repeat OKS were carried out in September 2019 (18–29 months post-operation).ResultsEight patients were female and the total age range was 57–95, mean average 75.6 (SD 9.9 years). Of 48 (higher scores meaning better outcomes), the average preoperative OKS was 24.2 and the average postoperative OKS at 6 months was 19.4 (decrease of 20%). The average postoperative OKS at 18–29 months was 35.6 (an increase of 83.5% from 6 months).DiscussionThe OKS was developed and validated over 20 years ago in Oxford. In our study, four patients asked for clarification of questions 4, 6 and 10 owing to ambiguous language. All 14 patients who had negative OKS outcomes had positive outcomes when retested after 18 months, depicting ‘health gains’ not conveyed in PROMs analysis.ConclusionThe OKS needs to be revalidated on current patient groups for accurate and reliable data. Further prospective studies should be undertaken on larger cohorts to understand the recovery course and whether PROMs should be carried out later.     

Outcomes of fixation for periprosthetic tibia fractures around and below total knee arthroplasty

IntroductionThe incidence of periprosthetic fractures after total knee arthroplasty (TKA) is rising due to an increasing number of TKAs performed annually and the growing elderly population. Like periprosthetic fractures of the distal femur, periprosthetic tibia fractures are primarily treated with operative fixation; however, there is limited scientific literature that has reported outcomes of periprosthetic tibia fractures treated with modern plating techniques. To our knowledge, this is the largest series of non-intraoperative periprosthetic tibia fractures treated with open reduction internal fixation (ORIF) ever reported.MethodsRetrospective chart review of 4557 operatively treated tibia fractures with ORIF over a 16-year period at two Level 1 Trauma Centers.Results38 patients with an average follow-up of 15.3 months (range 3–24) were identified. 11 (28.9%) fractures were in the proximal tibia (four with extension into the plateau (Felix 1A) and seven adjacent to the tibial stem (Felix 2A)), six (15.8%) in the midshaft/diaphysis (Felix 3A), and 21 (55.3%) in the distal 1/3rd (metaphysis, Felix 3A). 76.3% (29/38) of fractures united by 6 months following the index procedure, leaving 9 nonunions. The overall re-operation rate was 31.6% (12/38). There were no significant differences in rates of union (p = 1.00), reoperation (p = 0.66), superficial infection (p = 0.66), or deep infection (p = 0.31) in patients treated with single versus dual plating.ConclusionPeriprosthetic tibia fractures are difficult to treat and have a high risk of nonunion and reoperation even with modern plating techniques. Most patients can be treated to union with operative fixation and do not require revision arthroplasty, if the components are stable initially. We recommend dual plating for fractures in the proximal third, and either single plating or nailing for fractures in the middle and distal thirds depending on bone quality, implant positioning, and fracture morphology.     

Patient perceptions regarding minimally invasive total knee replacement

Interest in minimally invasive total knee replacement has increased in recent years. This has occurred despite a lack of long-term data regarding complications and outcomes. The aim of this study was to explore patients’ opinions relating to this relatively new technique. A questionnaire-based study was performed using patients attending clinics of consultant orthopaedic surgeons with an interest in knee arthroplasty. Low complication rates and implant survival were the items of highest importance to patients followed by a shorter recovery period. The duration of hospital stay and length of scar were of less importance to patients. Forty percent of patients would wish to go ahead with the procedure despite the lack of long-term outcome data. Only a small proportion of patients appear to be willing to undergo the procedure despite a lack of long-term data. Before taking up newer treatment methods patients must be convinced of the potential benefits and should be made aware that no long-term outcomes are available, at present.     

Balancing training and outcomes in total knee replacement: A ten-year review

Introduction

10-year study examining differences in total knee arthroplasty (TKA) functional outcomes and survivorship in patients operated on by consultant and trainee orthopaedic surgeons.

膝表面置换术在类风湿性膝关节炎和骨性膝关节炎的应用和比较

目的探讨膝关节表面置换术治疗类膝关节风湿性关节炎(RA)和膝关节骨性关节炎(OA)的临床疗效、安全性差异。方法自2010-01—2012-04采用膝关节表面置换术治疗68例(84膝)膝关节疾患,按照疾病类型分为OA组和RA组,对比分析2组手术时间、术中出血量、VAS评分、切口愈合时间、HSS单项评分及总分等。结果术后68例(84膝)获得平均47个月随访,随访期间无人工膝关节假体脱位。OA组手术时间、术中失血量、术后引流量及VAS评分显著低于RA组,差异有统计学意义(P0.05)。OA组术后1个月疼痛和HSS总分显著高于RA组,差异有统计学意义(P0.05),OA组术后1年和3年疼痛、功能、活动范围单项评分和HSS总分均显著高于RA组,差异有统计学意义(P0.05)。结论OA及RA人工全膝置换术后功能均有一定改善,与OA相比,RA患者术后近中期疗效相对较差,但远期疗效差异有待进一步研究。     

保留假体清创治疗人工膝关节置换术后感染的作用

[目的]探讨保留假体清创在治疗人工膝关节置换术后感染中的可行性、适应证、成功和失败的相关因素以及注意事项.[方法]回顾分析本院自1990～2004年收治的人工膝关节置换术后感染病例,发现9例病人在治疗开始时曾尝试采用清创灌注冲洗的方法保留假体,对这9例病人进行总结,并对可能影响清创是否成功的因素进行统计学分析.[结果]本组9例病人中4例保留了假体,平均随访18个月（10～25个月）,感染均无复发.由于病例数较少,本研究针对可能影响清创成功的因素未能得出有意义的统计学结果,但从结果看：急性感染清创容易成功,而慢性感染则很难获得成功;表皮葡萄球菌成功率较高,金黄色葡萄球菌均失败;表面膝置换成功率较高,而铰链膝置换则难以获得成功;出现症状后应该抓紧时间进行清创,延误的时间越长,成功的可能性越低.[结论]保留假体清创在人工膝关节置换术后感染的治疗中有一定的应用价值,对于术后急性感染病人和术后晚期急性血源性感染病人应尝试进行保留假体清创治疗,但必须严格掌握手术时机及适应证才能获得成功.     

Systematic review of periprosthetic tibia fracture after total knee arthroplasties

AIM: To investigate the known incidences, treatment options, and related outcomes of periprosthetic tibia fractures after total knee arthroplasty (TKA).METHODS: A literature search was done to identify studies that fit the inclusion criteria. The database search yielded 185 results, which were further reduced by the exclusion criteria to 13 papers, totaling 157 patients that met these criteria. Incidence rates of the different types of periprosthetic tibia fractures were determined and their treatments were subsequently analyzed based on the fracture’s subclass, with patient outcomes being overall favorable.RESULTS: Of the 144 documented patients, 54 (37.5%) had a subclass C fracture, which are frequently seen in revision arthroplasties or when using cement intraoperatively. The fractures of subclasses A and B occur postoperatively. There were 90 subclass A and B fractures with incidences of 18.75% and 43.75% respectively. When broken down by type, 62 (55.36%) were type 1, 24 (21.4%) were type 2, 24 (21.4%) were type 3, and 2 (1.8%) were type 4. Furthermore, from the studies that included origin of injury, the types were further classified as having non-traumatic or traumatic origins. Type 1 had 78% (40/51) non-traumatic origin and 22% (11/51) traumatic origin. Fifteen fractures were type 2, but 5 were falls and 1 through a motor vehicle accident, giving a trauma causation of 40% (6/15). Of the 24 type 3 fractures, 12 were falls and 2 vehicular accidents, leading to a trauma causation of 58% (14/24).CONCLUSION: Type 1 fractures were the most common. Subclass A was treated with locking plates, B required a revision TKA, and C was treated intraoperatively or nonoperatively.     

保留后交叉韧带全膝关节置换术治疗骨性关节炎

目的 :探讨保留后交叉韧带全膝关节置换术治疗重症老年性骨性膝关节炎的临床疗效。方法 :回顾性分析 1999年 6月～ 2 0 0 4年 1月间本院对 16例患有严重老年性骨性膝关节炎采用保留后交叉韧带的非限制性全膝关节置换术治疗的临床结果 ,并采用HSS评分标准对其临床结果进行分析。结果 :16例患者均获得随访 ,随访时间为6～ 42个月 ,疗效优 10例 ,良 6例。结论 :保留后交叉韧带全膝关节置换术为重症老年性骨性膝关节炎提供了一种行之有效的治疗方法     

Medial knee osteophytes have little influence on the medial collateral laxity during total knee replacement

Introduction  To get balanced ligaments is generally accepted as a relevant prognostic factor after total knee replacement (TKR). The exact influence of the medial osteophytes on the medial collateral laxity has never been investigated. We hypothesized that the resection of the medial femoral and tibial osteophytes would increase the medial laxity during TKR. Materials and methods  We studied 20 cases of varus gonarthrosis operated on for TKR under navigation control. Medial laxity before and after osteophyte resection were measured with the navigation system. The thickness of the resected osteophytes from the femur and the tibia was measured by comparing the pre-operative and post-operative coronal plain X-rays. Medial laxity before and after osteophyte resection were compared with a Spearman test at a 0.05 level of significance. Correlation between the difference in medial laxity and the thickness of the resected osteophytes was studied with the calculation of the Spearman correlation test at a 0.05 level of significance. Results  The mean paired difference between pre-resection and post-resection laxity was 0.5° ± 1.0°; this difference was statistically significant but of little clinical relevance. There was no difference between pre- and post-resection medial laxity by 10 patients, a 1° difference in 9 patients, and a 2° difference in one patient. There was no correlation between the thickness of the resected osteophytes (femur, tibia and total) and the difference between pre- and post-resection medial laxity. Conclusion  We demonstrated that the medial osteophytes had no clinically significant influence on the medial laxity during TKR. There is no need for routine medial osteophytes resection only for the purpose of ligamentous balancing during TKR.     

Femoral neck fracture following ipsilateral total knee replacement: an analysis of associations and risk factors

There have been case reports of ipsilateral femoral neck fracture after total knee replacement. This occurrence has been attributed to risk factors such as rheumatoid arthritis, osteoporosis, steroid use and poor mobility. The aim of this study was to see if total knee replacement is a risk factor for neck of femur fracture and to study the associated risk factors. Twenty two patients who had sustained subsequent ipsilateral femoral neck fracture were identified from 1,362 patients who had previously undergone a posterior cruciate ligament-substituting total knee replacement. Clinical chart review and radiological assessment were performed. The average age of the patients was 77(±7) years and the fracture occurred 35(±27) months following the total knee replacement. Positive associations were identified between ipsilateral neck of femur fracture and total knee replacement (P < 0.01), age (P < 0.01), female sex (P < 0.025) and rheumatoid arthritis (P < 0.05). We did not find an association between ipsilateral neck of femur fracture following total knee replacement and preoperative knee deformity (P > 0.5). We also observed an increased risk of supracondylar fracture of the ipsilateral femur in patients who had sustained a neck of femur fracture following total knee replacement (P < 0.001).     

Management of knee rheumatoid arthritis and tibia nonunion with one-stage total knee arthroplasty and intramedullary nailing: A report of two cases

Total knee arthroplasty (TKA) is a surgical procedure which is widely used in the treatment of gonarthrosis secondary to rheumatoid arthritis (RA). The incidence of stress fractures in tibia in the patients with RA is higher compared to normal patients. In this study, we report two cases of TKA and intramedullary nailing in RA patients with severe knee arthritis and tibial nonunion. Both patients had a satisfactory clinical outcome with radiological healing of the tibial fracture.     

全膝关节置换患者围术期睡眠质量及影响因素分析

目的研究ERAS管理模式下全膝关节置换(TKA)患者围手术期睡眠质量及其危险因素,为今后临床干预研究提供重要理论依据。 方法采用一般情况调查表、匹兹堡睡眠质量问卷(PSQI)、Epworth嗜睡量表(ESS)、视觉模拟评分(VAS)、流行病学研究中心抑郁量表(CESD)及Zung焦虑自评量表(ZSAS)对满足入排标准的118例初次单侧TKA患者术前2周、手术当天和术后1、2、4、8、12周的睡眠质量进行评价,logistic回归分析其睡眠障碍的影响因素。纳入标准：年龄>18岁;初次单侧全膝关节置换患者。排除标准：膝关节置换术后翻修或同期双侧TKA患者;术前2周规律服用安眠药者或有精神病史者。 结果TKA患者术前睡眠障碍(PSD)的发生率为53.4%,手术当天达87.3%,随后开始下降,术后2周又接近高峰,术后4周后快速下降。术后2周内各时间点PSQI、ESS得分比术前2周增加,术后4周后PSQI、ESS得分显著减少(t＝7.136、5.269,均为P<0.001),且PSQI与ESS得分之间存在正相关(r＝0.380,P<0.001)。术后各时间点VAS得分比术前2周均减少,且PSQI与VAS得分之间存在正相关(r＝0.198,P＝0.032)。Logistic回归分析提示疼痛、焦虑、抑郁是术后2周PSD的独立危险因素[比值比(OR)＝1.384,P＝0.007;OR＝1.260,P＝0.038;OR＝1.203,P＝0.049]。 结论超过一半以上的TKA患者术前即已存在PSD,术后发生率更高,且可持续2周以上,疼痛、焦虑、抑郁情绪是PSD的三个独立危险因素。     

一期人工关节置换治疗晚期活动性膝关节结核

目的探讨一期病灶清除人工关节置换术治疗晚期活动性膝关节结核的可行性及疗效。方法回顾性分析2009年3月至2019年3月在我院骨科中心行一期人工膝关节置换术治疗晚期活动性膝关节结核的15例病人的临床资料,其中男5例(6膝),女10例(10膝),平均年龄为53.9岁(26~77岁),入院时均有膝关节疼痛,膝关节不同程度出现畸形、活动受限,4例出现膝关节强直。术中均采用骨水泥型膝关节假体。收集15例病人入院后首次、术前、术后1周、术后1个月、术后6个月、末次随访时的C反应蛋白(C-reactive protein,CRP)、红细胞沉降率(erythrocyte sedimentation rate,ESR),术前和末次随访时的美国特种外科医院(Hospital for Special Surgery,HSS)膝关节评分和膝关节活动度(range of motion,ROM),以及假体稳定性、结核复发情况。结果所有病人获得12~88个月随访,术后规律抗结核治疗12~18个月。12例术后病理检查见典型的结核性肉芽肿,3例抗酸染色阳性。随访期间1例复发,进行病灶清除术后治愈。ESR和CRP均在术后6个月内基本恢复正常,不同时间的数值整体比较,差异均有统计学意义(P均<0.05)。末次随访时,所有病人未见结核复发,X线检查未见假体松动,膝关节HSS评分由术前的(43.4±9.4)分增加至(82.7±7.5)分,ROM由49.3°±31.3°增加至86.0°±32.5°,手术前后的数值比较,差异均有统计学意义(t=-13.231,P<0.001;t=-5.500,P<0.001)。结论在手术前后规律抗结核治疗、术中彻底病灶清除的前提下,一期人工关节置换治疗晚期活动性膝关节结核可以控制感染,解除疼痛,重建膝关节功能,复发率较低,远期疗效仍需进一步观察研究。     

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。     

Arthroscopy of symptomatic total knee replacements

Between December 1983 and August 1992, 21 knees in 19 patients with symptomatic total knee replacements were arthroscopically diagnosed. The average time between total knee replacement and arthroscopy was 20 months (ranging from 4 to 84 months). All patients were primary total knee replacements. Metal bars, 5 and 8 mm in diameter and 40 cm in length, were made for arthroscopic treatment of fibroarthrosis. Thirteen knees of 11 patients with a diagnosis of arthrofibrosis had an average improvement of 42° arc of motion 1 year after arthroscopic surgery. Three knees with an average of 15° increase of motion were determined to be failures. Another two patients had arthroscopic resection of fibrous bands with complete relief of patella pain. Among six patients who had revision of total knee replacements after arthroscopic diagnosis, four had wear in the metal backed patella components, and two had wear in the tibial insert and loosening of cementless patella component. An early diagnosis of implant failure under arthroscopic control was made, which easily allowed revision of the metal-backed patellar button before the development of metallosis and massive osteolysis caused by the marked wear of polyethylene. With the use of our specially made metal bars for treating arthrofibrosis, we could release the adhesion more easily and avoid damage of valuable arthroscopic instruments.     

全膝关节置换术中胫骨近端倾斜型骨缺损的重建

目的 通过对全膝关节置换术中腔骨近端倾斜型骨缺损的重建，介绍应用自体胫骨进行胫骨平台重建的方法和体会。方法 1992年11月～2000年9月．对22例(29膝)有胫骨近端倾斜型骨缺损的膝关节行全膝关节置换及自体胫骨移植术，男5例(5膝)，女17例(24膝)；年龄43～78岁，平均61．2岁。手术前诊断：骨关节炎13例(14膝)，其中膝内翻12例(13膝)，膝外翻1例(1膝)；类风湿关节炎7例(12膝)；滑膜软骨瘤病1例(1膝)；大骨节病1例(2膝)。术中将胫骨平台倾斜型骨缺损修整成台阶状水平型骨缺损。将截下的胫骨平台骨块修整后使其厚度和形状与缺损处匹配，并将带有皮质骨的部分尽量放置在台阶状缺损的外缘，以承受平台的压力。术中植骨厚度为8～15mm，平均10mm在置入假体以及在骨水泥固化之前，应在植骨块侧方加压。所有膝关节假体均采用抗生素骨水泥固定。结果 术后随访1～9年，平均4．2年，除1例因迟发性感染和植骨吸收再次出现膝内翻畸形和假体松动而行Ⅰ B-Ⅱ楔形假体翻修外．其它病例未发现自体移植骨的不愈合、移位、骨折、骨吸收和胫骨假体松动，HSS膝关节评分由术前10～26分提高到术后76～94分。结论 在胫骨近端倾斜型骨缺损的全膝关节置换术中，采用自体胫骨移植可恢复胫骨平台的完整性．防止平台塌陷．并为假体提供良好的初始稳定性，提高手术的成功率。