全膝关节置换术后膝关节疼痛的临床处理

目的 探讨全膝关节置换术(TKA)后膝关节疼痛的原因和临床处理方法.方法 2004年1月至2009年6月,收治TKA术后疼痛患者41例,其中男性9例9膝,女性32例35膝;年龄51～84岁,平均63.5岁.关节外疼痛6例中1例为1型复杂区域疼痛综合征(CRPS-1)行保守治疗,其余5例手术治疗.关节内疼痛35例中关节失稳4例、髌骨低位1例、假体悬挂致周围软组织磨损2例、胭肌腱撞击1例采用保守治疗,其余27例手术治疗.定期随访并记录膝关节美国膝关节学会评分(KSS评分)、疼痛视觉模拟评分(VAS评分).结果 41例均获随访,随访时间1～6年.关节外疼痛手术5例,末次随访VAS评分、KSS临床和功能评分分别为2.5±0.2、92.8±2.6和89.0±3.4,膝关节疼痛缓解,功能改善.1例CRPS-1保守治疗,效果尚可.关节内疼痛感染组12例中截肢1例、抗生素骨水泥隔体植入3例、二期翻修8例,随访感染均治愈,术后VAS、KSS临床和功能评分分别为3.8±0.2、88.3±4.6和85.0±4.6,和术前相比差异有统计学意义(P＜0.05).非感染组保守治疗8例,末次随访VAS、KSS临床和功能评分4.5±0.4、85.4±4.2和84.2±2.3;手术治疗15例,末次随访VAS、KSS临床和功能评分3.4±0.1、86.6±5.4和87.1±2.4,与术前相比差异有统计学意义(P＜0.05).结论 TKA术后疼痛需要对手术和患者情况进行系统评估以明确其原因,确诊后制定合理治疗方案一般可获得满意效果,确诊之前严禁手术干预.

Abstract：

Objective To evaluate causes and clinical management of postoperative pain after total knee arthroplasty(TKA). Methods From January 2004 to June 2009, 41 patients(44 knees)with knee pain post TKA were treated. There were 9 male and 32 female patients aging from 51 to 84 years with a mean of 63.5 years. The diagnosis followed to Brown diagnostic system. One case of extraarticular pain was complex regional pain syndrome type 1(CRPS-1)and underwent conservative treatment, the remaining 5cases were treated by surgery. Three cases of joint instability, 1 case of patellar baja, 2 cases of soft tissue impingement caused by overhang of the prosthesis, 1 case of popliteal tendon impact underwent conservative treatment, the other 27 cases underwent surgical intervention. The patients were followed up and the Knee Society Score(KSS)knee score, pain visual analog scale(VAS)score were recorded. Results Forty-one cases were followed up for 1 to 6 years. At the last time of follow-up, the 5 cases received surgical treatment to extra-articular pain showed VAS score as 2. 5 ± 0. 2, KSS clinical and functional score as 92. 8 ± 2. 6 and 89.0 ± 3.4. There was significantly difference compared with preoperative(P ＜ 0. 05). One case of CRPS-1 performed conservative treatment, the therapy was effective. In the infected 12 cases of intra-articular pain, 1 case received amputation, 3 cases received antibiotic bone cement insert, 8 cases received two stage revision. All infections were cured, and VAS score was 3. 8 ± 0. 2, KSS clinical score was 88. 3 ± 4.6,function score was 85.0 ± 4. 6 postoperatively, with significantly difference compared with preoperative(P ＜0. 05). In the 8 cases received conservative treatment in non-infected group, at the last time of follow-up,VAS score was 4. 5 ± 0. 4, KSS clinical and functional score was 85.4 ± 4. 2 and 84. 2 ± 2. 3, with significantly difference compared with preoperative(P ＜ 0. 05). Fifteen cases underwent surgical treatment,at the last time of follow-up, VAS score was 3.4 ± 0. 1, KSS clinical and functional score was 86. 6 ± 5.4and 87. 1 ± 2. 4, with significantly difference compared with preoperative(P ＜ 0. 05). Conclusions Patients with knee pain post TKA need systematic assessment to identify the causes. Appropriate treatment due to the positive diagnosis generally lead to satisfactory results, surgical intervention with indefinite causes is strictly prohibited.     

全膝关节置换治疗僵硬膝关节的早期疗效分析

Objective To evaluate the outcome of primary total knee arthroplasty (TKA) in treatment of stiff knee, and discuss the key points of operative technique and rehabilitation. Methods From February 2005 to April 2009, 23 patients with 34 stiff knees were treated with primary TKA. The study included 3 males (4 knees) and 20 females (30 knees), with the mean age of 56.9 years. Primary disease of the patients included rheumatoid arthritis (26 knees in 15 cases) and osteoarthritis (8 knees in 8 cases). Varus deformity was found in 10 knees (5°-15°), and valgus was found in 5 knees (5°-10°). Evaluations included preoperative and postoperative range of motion (ROM) measurement, hospital for special surgery knee score (HSS), blood loss, operative time and assessment of postoperative complications. Results All patients were followed up. The mean follow-up time was 32.2 (range, 24 to 40) months. At the final follow-up visit, the HSS score increased from 42.9±5.2 preoperatively to 85.7±4.3, the range of motion increased from 42.6°±5.7° preoperatively to 89.2°±10.5°. Sixteen knees in 12 cases underwent manipulation at 3 to 8 weeks postoperatively for unsatisfied ROM, but ROM was still less than 90° in 8 knees at the last follow-up. The average blood loss were (632.4±180.2) ml in first 24 hours (450-850 ml) and the operative time were (98.1±18.6) min (80-150 min). Deep venous thrombosis was found in 3 patients. All the symptoms relieved after anticoagulant therapy. Postoperative varus deformity was seen in one patient, but the function of knee was good. No revision was needed. Conclusion Primary total knee arthroplasty is reliable method in treatment of stiff knees. Sufficient soft tissue release during the operation, postoperative muscle strength exercise and essential manipulation are key points for satisfactory outcomes.     

可活动关节间隔垫技术治疗严重全膝关节置换术后感染

目的 探讨运用可活动关节间隔垫技术治疗有内科基础病及局部窦道形成的严重全膝关节置换术后感染的疗效和安全性.方法 2002年1月至2008年3月,10例全膝关节置换术后延迟感染患者,男3例,女7例;年龄23～73岁,中位年龄67岁.患者均采用二期再置换手术治疗:第一期手术,取出假体、彻底清创,并植入含抗生素的可活动间隔垫,切除窦道,封闭原窦道口.术后予以积极抗感染和功能康复治疗.待感染控制后行第二期手术,取出可活动间隔垫,植入新的关节假体.采用美国特种外科医院(the hospital for special surgery,HSS)膝关节评分以及膝关节活动度评价治疗效果.结果 1例患者治疗期间血糖控制不佳,一期手术后感染未得到控制而行关节融合术,另外9例患者感染均获治愈.随访时间24～90个月,平均50个月.随访期内无一例发生感染复发及并发症,患者无膝周肿痛等不适主诉.术前患膝HSS评分32～63分,平均48分;二期手术前HSS评分62～91分,平均79分;末次随访时HSS评分74～95分,平均89分.术前、二期术前以及二期术后患膝关节功能的优良率分别为0、80%和100%.术前膝关节活动度为13°～70°,一期术后膝关节活动度为8°～93°,末次随访时膝关节活动度为3°～110°.结论 可活动关节间隔垫技术是治疗全膝关节置换术后严重感染的一种安全、有效的方法,可在控制感染的基础上尽可能保留关节功能.

Abstract：

Objective To investigate the efficiency and safety of articulating spacer for severe infected knee arthroplasty in patients with medical comorbidities and local sinus tracts. Methods Ten consecutive patients with medical comorbidities (rheumatoid arthritis, diabetes mellitus, etc) or local sinus tracts,who were complicated with late infected TKA, were included in the study. All the patients underwent twostage revision using articulating spacers. All of the patients were debridement thoroughly and followed by implantation of an antibiotic-loaded cement articulated spacer. Two-stage revisions were not followed untill the infection were controlled. The hospital for special surgery (HSS) knee scoring system and range of motion were used to evaluate the outcomes. Results One patient underwent knee fusion because the infection was not controlled after first-stage surgery. The other 9 patients had no evidence of infection. The mean follow-up was 50 months (range, 24-90 months), no recurrent infection developed for these 9 patients. The mean modified HSS score had improved from 48 points (range, 32-63) before the resection surgery to 79 points (range,62-91) at the end of the spacer period. At the latest follow-up, the modified HSS score averaged 89 points (range, 74-95). The good and excellent rate was 0, 80% and 100%, respectively. The average range of motion had increased from 13°-70° preoperatively to 8°-93° prior to the revision. And at the latest follow-up, the range of motion averaged 3° to 110°. Conclusion The delayed two-stage revision using an articulating spacer is effective in the treatment of chronically infected TKA characterized by simple, good reproducible, high rate of infection control, better joint function after surgeries     

全膝关节初次单侧表面置换与双侧同时置换术后并发症的比较分析

Objective To compare postoperative complications in patients firstly undergoing primary unilateral total knee arthroplasty (UTAK) and simultaneous bilateral total knee arthroplasty (SBTKA) .Methods From November 2006 to November 2009, 339 patients underwent primary UTAK and SBTKA in our hospital and followed up. The UTKA group had 178 patients (50 men and 128 women) who were aged from 26 to 81 years (mean, 64. 2 years) and a mean American Knee Society Score (KSS) of 34. 0 ± 13. 3points before surgery. The SBTKA group had 161 patients (32 men and 129 women) who were aged from 34 to 80 years (mean, 65. 3 years) and a mean KSS of 33. 4 ± 11. 1 points before surgery. The postoperative complications were compared between the 2 groups and clinical outcomes were evaluated according to KSS system. Results The patients were followed for 18. 4 months on average (range, 3 months to 3 years) . The incidence of postoperative complications was 6. 2% (11/178) in the UTKA group and 4. 3% (7/161) in the SBTKA group, with no significant difference (x2 =0. 564, P = 0. 453) . The KSS score at the final follow-up was all increased in both groups. It was 92. 5 ± 10. 6 in the UTKA group and 91. 9 ± 11. 1 in the SBTKA group, with no significant difference (t =0.511, P = 0.610). Conclusions SBTKA is not an independent risk factor for postoperative complications. Careful operative preparation and assessment, good surgical skills, comprehensive postoperative monitoring and supporting management, and proper rehabilitation can significantly reduce complications following SBTKA. But for a patient who has been complicated with multiple internal diseases, SBTKA decision should not be made before a careful tolerance assessment of the patient.     

全髋及全膝置换术后感染的治疗概论

To discuss the management of infections around total knee and hip arthroplasties.Methods and Results:We present the results of our management of 521 patients with infection around total hip arthroplasty and 262 with infected total knee arthroplasty between 1970 and 2001.131 of the hips and 94 of the knees were managed conservatively.Nine total knees and 11 total hips with infection were managed by soft tissue debridement and irrigation without removing the arthroplasty.Two of the knees and 3 of the hips were well cured of their infection while 5 from each group had a fair result.Seventeen patients had their knee arthroplasties exchanged in one stage.Nine were confirmed infected,4 were well cured.Fifty were revised in two stages of whom 37 were well cleared.Fort three had hip revision in one stage for infection,of whom 31 were well healed and 198 were revised in two stages with 128 well cured.Seventy-seven of the total knees were managed by arthrodesis.One hundred and froty-two patients were managed with an excision arthrophasty of the hip.Seventy one were cured at first attempt and another 18 after two attempts.Eight patients required limb ablation.Five of these above the knee and three through the hip .four patients died in this series(3 hip and 1 knee arthroplasty),Three had serious vascular complications(2 hip and 1 knee arthroplasty).Conclusion:Low grade musculo skeletal infection presents little or no threat to health,let alone life in the majority of cases,A single operation has some obvious advantages,The costs are halved and the period of hospitalisation or recumbency is halved for knees and reduced to one third for hips.The less ovious advantages of one stage exchanges of knees are the greatly reduced incidence of wound morbidity and in both hips and knees there is a lower incidence of thrombo-embolic disease-a potentially fatal complication.Naturally post-operative rehabilitation will be expedited.The most important advantage of a two stage programme is better chance of curing infection.It may take longer to rehabilitate after a two stage programme but at the end of the day there is little difference in the final level of pain and function between one and two stage exchanges of hips and knees.Among the advantages of a two stage propramme is the fact that one has not burnt one‘s bridges because if the operation fails to bring the infection under control one can either repeat the debridement or switch to arthrodesis in the case of a failed knee arthroplasty or leave the hip as an excision arthroplasty.     

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.     

双锥面螺旋臼固定治疗髋关节中心性脱位的中长期临床效果分析

目的 探讨使用双锥面螺旋臼假体固定髋关节中心性脱位病例的长期临床效果.方法 1998年5月至2006年9月北京大学人民医院关节病诊疗研究中心对31例髋关节中心性脱位患者的39侧髋关节行人工全髋关节置换术或翻修术,其中男性12例,女性19例.手术时平均年龄为57.6岁(30～82岁).引起髋关节中心性脱位的病因包括:类风湿关节炎3例6髋;股骨头坏死继发髋关节炎7例12髋,人工股骨头置换术后髋臼磨损11例11髋、髋臼假体松动10例10髋.术中髋臼部分均使用双锥面螺旋臼进行生物学固定.术前Harris评分平均为31.0分(14～61分).结果 所有病例均在术后6个月、1年时随访,2例3髋患者分别因肺癌、急性心肌梗死死亡.24例31髋获得随访,平均随访时间7.4年(5.0～11.5年).末次随访时Harris评分平均为84.7分(70～95分).1例股骨头坏死行双髋同时置换患者术后右髋出现感染,行关节取出骨水泥旷置术,但因内科疾病不稳定未再行翻修术.1例类风湿关节炎患者双髋关节分期手术,术后7年随访时左侧髋臼假体有内侧轻度移位,边缘有透亮线,但患者日常功能好,无疼痛.其余所有病例双锥面螺旋臼假体全部存留,患者日常生活功能良好,对手术效果满意.结论 髋关节中心性脱位使用双锥面螺旋臼的固定效果确切,平均超过7.4年的中长期随访结果显示效果良好.

Abstract：

Objective To discuss long-term clinical results of using Zweymüller cup to treat protrusio acetabuli. Methods From May 1998 to September 2006, 31 patients with 39 hips diagnosed protrusio acetabuli were treated with Zweymtüller cup in total hip arthroplasties or revisions. There were 12 men and 19 women with average age of 57.6 years (from 30 to 82 years). The reasons causing protrusio acetabuli were as followed: rheumatoid arthritis 3 cases 6 hips, osteoarthritis followed femoral head necrosis 7 cases 12 hips, acetabular wear after hemi-arthroplasty 11 cases 11 hips and acetabular component Results All cases were followed up 6 months and one year after operations. Two patients with 3 hips were died for lung cancer and acute myocardial infarction respectively. Twenty-four cases with 31 hips got recent follow-up with average 7. 4 years (from 5.0 to 11.5 years). The average Harris score improved from 31.0 (from 14 to 61) preoperatively to 84. 7(from 70 to 95) postoperatively. There was one infection in right hip after bilateral hip arthroplasty treating by removel prosthesis and cement spacer insert. But until now this patient still did not get revision for her internal medicine. One rheumatoid arthritis patient with two-stage bilateral hip arthroplasty was found slight internal migration and loosening line of left acetabular component,but the patient had no pain with good hip function. All other cases had good hip functions and were very fixations and perfect medium and long-term clinical results for over 7.4 years.     

Treatment of tibiofibular fractures of Gustilo type Ⅲ by vacuum, sealing drainage and external fixation

Objective To report clinical efficacy of vacuum sealing drainage(VSD)and external fixation in the treatment of tibiofibular fractures of Gustilo type Ⅲ. Methods From October 2006 to November 2009,19 cases of Gustilo type Ⅲ tibiofibular fracture were treated in our department.They were 14men and 5 women,with an average age of 30.1 years(from 17 to 62 years).There were 9 cases of type ⅢA,8 cases of Type ⅢB 2 cases of typeⅢC.After emergency debridement,all the fractures were fixed with an extemal fixator following indirect reduction.The wounds were sealed with VSD.When the wounds were clean and granulation appeared,they were repaired by direct suture(5 cases),split-thickness skin graft(9 cases)and flap transposition(5 cases). Results The 19 cases were followed up for 12 to 24 months,with an average of 16.3 months.A11 the wounds were closed'after VSD for 5 to 17 days.Wound infection occurred in 2 cases and was finally repaired by flap transposition following repeated debridement and VSD.The fractures healed after 4 to 10 months(average,5.6 months). Conclusion External fixation combined with VSD is a simple and effective treatment for tibiofibular fractures of Gustilo type Ⅲ.because it can provide not only rapid fixation but also early wound sealing to facilitate fracture healing and reduce incidence of complications.     

全膝关节初次单侧表面置换与双侧同时置换术后并发症的比较分析

目的 比较全膝关节初次单侧表面置换与双侧同时置换术后并发症的发生情况.方法对2006年11月至2009年11月收治且获得随访的339例初次行全膝关节表面置换患者的资料进行回顾性分析,根据是否行双膝关节表面置换分为两组:单膝置换组(行单侧膝关节表面置换)178例,男50例,女128例;平均年龄64.2岁(26～81岁);术前美国膝关节协会(KSS)评分平均为(34.0±13.3)分.双膝置换组(行双侧膝关节表面置换)161例,男32例,女129例;平均年龄65.3岁(34～80岁);术前KSS评分平均为(33.4±11.1)分.比较两组患者术后并发症的发生情况,并采用KSS评分评定临床疗效.结果 339例患者术后获3个月至3年(平均18.4个月)随访.单膝置换组术后并发症发生率为6.2%(11/178),双膝置换组术后并发症发生率为4.3%(7/161),两组比较差异无统计学意义(x2=0.564,P=0.453).末次随访时单膝置换组KSS评分平均为(92.5±10.6)分,双膝置换组平均为(91.9±11.1)分,两组比较差异无统计学意义(t=0.511,P=0.610).结论双膝关节置换与单膝关节置换术后并发症发生率无明显差异.术前充分准备、较好的手术技术、完善的术后监测和支持治疗及合理的康复训练,可以降低一期舣膝关节置换术后并发症的发生率;但对于术前合并多种内科疾病的患者,应认真评估手术耐受性后再进行抉择.

Abstract：

Objective To compare postoperative complications in patients firstly undergoing primary unilateral total knee arthroplasty (UTAK) and simultaneous bilateral total knee arthroplasty (SBTKA) .Methods From November 2006 to November 2009, 339 patients underwent primary UTAK and SBTKA in our hospital and followed up. The UTKA group had 178 patients (50 men and 128 women) who were aged from 26 to 81 years (mean, 64. 2 years) and a mean American Knee Society Score (KSS) of 34. 0 ± 13. 3points before surgery. The SBTKA group had 161 patients (32 men and 129 women) who were aged from 34 to 80 years (mean, 65. 3 years) and a mean KSS of 33. 4 ± 11. 1 points before surgery. The postoperative complications were compared between the 2 groups and clinical outcomes were evaluated according to KSS system. Results The patients were followed for 18. 4 months on average (range, 3 months to 3 years) . The incidence of postoperative complications was 6. 2% (11/178) in the UTKA group and 4. 3% (7/161) in the SBTKA group, with no significant difference (x2 =0. 564, P = 0. 453) . The KSS score at the final follow-up was all increased in both groups. It was 92. 5 ± 10. 6 in the UTKA group and 91. 9 ± 11. 1 in the SBTKA group, with no significant difference (t =0.511, P = 0.610). Conclusions SBTKA is not an independent risk factor for postoperative complications. Careful operative preparation and assessment, good surgical skills, comprehensive postoperative monitoring and supporting management, and proper rehabilitation can significantly reduce complications following SBTKA. But for a patient who has been complicated with multiple internal diseases, SBTKA decision should not be made before a careful tolerance assessment of the patient.     

膝关节单室置换的近期疗效

Objective To explore the indication and observe short-term clinical outcome of the medial Oxford Ⅲ mobile bearing unicompartmental knee replacement (UKR) through a minimal invasive approach for the patients with osteoarthritis of the knee. Methods A retrospective study of the clinical outcomes from May 2006 to May 2008 was done on 30 knees in 21 patients after receiving the UKR with the mobile bearing Oxford Ⅲ prosthesis. There were 9 males (12 knees), 12 females (18 knees), with the mean age of (61.4±7.3) years (ranged 46-76 years). All patients were evaluated pre and postoperatively using X-ray image, the Knee Society Score (KSS) and the WOMAC osteoarthritis index and examined the ROM and the varus deformity of the knee with osteoarthritis. Results The average follow-up time was 17 months. The mean operation time was (83.0±12.9) min and the mean hospital stay was (9.3±2.0) days. No complications of infection, thrombosis, mobile beating dislocation were found. The loss of flexion of the operated knee was not significant. The average femorotibial angle decreased from 182.0°±4.3° preoperatively to 177.0°±3.5° postoperatively in the anterioposterior view of X-ray. The KSS clinical score and function score were improved from average 44.0±3.7 and 54.0±5.1 to 93.0±3.2 and 92.0±2.4 respectively. The WOMAC Score was average 48.0±4.2 preoperatively, 14.0±2.5 at the last evaluation. Statistically significant differences were found pre and postoperatively from the aforementioned evaluation criterions. Conclusion The short-term clinical outcomes of medial Oxford Ⅲ mobile bearing UKR through a minimally invasive approach are ideal, and it is a good therapy choice for the patients with medial osteoarthritis of the knee. But it is also important to choose the suitable patients with indications.     

应用抗生素骨水泥间隔体二期翻修治疗人工全膝关节置换术后迟发感染

目的探讨应用抗生素骨水泥间隔体二期翻修治疗人工全膝关节置换术后迟发感染的临床疗效。方法 2007年1月-2009年12月,收治23例(23膝)人工全膝关节置换术后迟发感染患者。男15例,女8例;年龄43～75岁,平均65.2岁。置换术后至出现感染时间为13～52个月,平均17.3个月;发生感染至入院翻修时间为15 d～7个月,平均2.1个月。一期清创、取出假体,植入含庆大霉素抗生素骨水泥间隔体;8～10周感染控制后二期植入假体。分别采用美国特种外科医院(HSS)评分及膝关节学会评分系统(KSS)评价翻修前后患膝功能,并统计总体感染控制率。结果术后患者切口均Ⅰ期愈合。2例二期翻修术后发生再感染,余21例感染控制,总体感染控制率91.3%。患者均获随访,随访时间2～5年,平均3.6年。HSS评分由术前(60.6±9.8)分提高至末次随访时(82.3±7.4)分,KSS评分由术前(110.7±9.6)分提高至末次随访时(134.0±10.5)分,手术前后比较差异均有统计学意义(P<0.01)。X线片复查示假体位置良好,无松动、断裂、假体周围透亮影等异常表现。结论应用抗生素骨水泥间隔体二期翻修能有效控制人工全膝关节置换术后迟发感染,并能较好恢复患膝功能。     

术前活动度对人工全膝关节置换术后功能影响的观察

目的回顾性分析患者手术前的活动度对人工全膝关节置换(TKA)术后功能的影响。方法随访2000年1月—2003年12月在我科行TKA的患者65例(97膝),年龄64．8±9．9岁(35～85岁)。其中骨性关节炎55例(81膝),类风湿关节炎10例(16膝)。单膝置换33例,双膝同时置换32例。所有患者按术前膝关节活动度数(ROM)分成两组,≤90°(5°～90°)49膝,>90°(95°～140°)48膝。对两组患者进行疗效(最大屈膝度、活动度、KSS评分及功能评分)对比。所有患者均采用Scorpio后稳定型骨水泥固定的假体,均为初期置换,全部手术由同一组医师完成。术后3 d在同一康复师指导下行患肢CPM及主动功能锻炼至出院。结果平均随访时间29个月(10～44个月)。所有膝关节的活动度从术前的平均84．2°(5°～140°)提高到术后的平均101．6°(40°～140°) (P=0．000);而最大屈膝度数术前的平均103．5°(25°～140°)与术后的平均101．6°(40°～140°)无显著差异(P=0．439);KSS膝关节评分从术前平均19．5分(-24～62分)提高到术后平均78．8分(50～95分)(P=0．000)。所有患者的总满意度为93．8％(61／65)。两个分组比较,ROM≤90°的膝关节ROM及最大屈膝度术后均较术前有提高,而ROM>90°的膝关节平均最大屈膝度术后反而下降。没有翻修及深部感染。结论(1)在影响TKA术后膝关节功能的多种因素中,手术技术是关键因素。(2)在其他因素相同的情况下,术前膝关节的活动度对TKA术后的功能也有很大的影响,术前活动度大的膝关节比那些术前活动度小的膝关节术后能获得更好的功能。     

深盘型假体对全膝关节置换初期疗效的影响

目的探讨深盘型假体对全膝关节置换初期疗效的影响。方法 2006年6月~2012年1月,本组应用深盘型垫片假体行TKA的76例（97膝）患者进行随访,随访时间2~6年,平均4.2年,其中女65例,男11例;年龄55~78岁,平均65.8岁;选择男女共76名志愿者,年龄在18~42岁之间,平均30.5岁,随机左右膝。对比TKA组术前、术后KSS评分、功能评分、膝关节ROM、股骨后髁偏心距;对比TKA组与志愿者组膝关节从伸直位到最大屈曲位时股骨相对于胫骨前后移动的距离。结果 TKA组手术前后膝关节KSS评分、功能评分及膝关节ROM比较,差异均有统计学意义（P〈0.05）,手术前后股骨后髁偏心距差异无统计学意义（P〉0.05）。TKA组膝关节从伸直位到最大屈曲位时股骨相对于胫骨向后移动距离之差（6.24±2.45）mm。志愿者组膝关节伸直至最大屈曲位时股骨相对于胫骨向后移动距离之差（10.87±1.49）mm,两者差异有统计学意义（P〈0.05）。1例术后出现伤口浅表感染,经处理后痊愈。1例术后出现膝关节假体周围感染,经二期翻修痊愈出院。术后随访X线片观察膝关节假体位置、力线、固定性能等均显示良好,无松动、透亮线等异常表现。结论使用深盘型膝关节假体行TKA术,初期临床疗效满意;TKA组术后膝关节伸直至最大屈曲位时股骨相对于胫骨后移距离较志愿者组短。     

人工全膝关节置换术后深部感染的治疗

目的探讨人工全膝关节置换(total knee arthroplasty,TKA)术后深部感染的处理方法及疗效。方法2004年1月-2010年1月,收治TKA术后深部感染患者32例(32膝)。男13例,女19例;年龄52～79岁,平均64.6岁。TKA手术距发生感染时间为3周～10年。膝关节功能采用膝关节学会评分系统(KSS)为(104.6±9.1)分,疼痛视觉模拟评分(VAS)为(7.8±1.4)分。急性感染3例行关节切开清创后持续冲洗;急性血源性播散感染3例于关节镜下清创;慢性感染26例,其中行关节切开清创后持续冲洗9例,抗生素骨水泥隔体植入4例,二期翻修12例,抗生素保守治疗1例。结果急性感染者治疗均失败,急性血源性播散感染者1例治疗失败,慢性感染者7例清创及1例保守治疗失败;均经对症治疗后治愈。32例患者均获随访,随访时间2～8年,平均4.6年。末次随访时KSS评分为(158.4±8.3)分,VAS评分为(4.1±0.8)分,与术前比较差异有统计学意义(P<0.05)。随访期间再感染3例,均为二期翻修患者。结论TKA术后耐甲氧西林金黄色葡萄球菌急性感染切开清创成功率低;急性血源性播散感染可试行关节镜下清创;慢性感染二期翻修膝关节功能恢复良好,但远期存在再感染风险。     

联合使用胫骨延长柄和金属垫片假体治疗膝关节置换胫骨缺损

目的 :探讨联合使用胫骨延长柄和金属垫片假体治疗胫骨缺损在膝关节置换中的应用。方法 :回顾性分析2011年1月至2013年5月使用胫骨延长柄膝关节假体行人工全膝关节置换的10例(11膝)临床效果。全部为女性,平均年龄67岁(60~77岁)。所有患者行膝关节CT检查,明确其内侧缺损程度,缺损程度均为T2A。均诊断为膝关节骨关节炎。手术前后使用KSS评分进行疗效评价。结果:10例患者平均手术时间100 min,术中使用止血带,术后均不放置引流,不输血。分别从行走能力、上下楼能力、疼痛、稳定性及活动度方面进行评分。与术前相比,术后12个月评分优于术前。未见感染病例。结论:联合使用胫骨延长柄和金属垫片假体作为治疗严重膝关节疾病的方法,术后功能恢复满意,能显著提高胫骨假体的稳定性。     

多尺寸人工全膝关节系统的临床应用分析及随访结果

目的 探讨应用多尺寸膝关节假体系统的临床应用优势及早期随访结果.方法 回顾性分析自2010年12月至2012年12月78例应用Vanguard膝关节系统进行人工全膝表面关节置换患者.术中记录应用股骨假体型号,术后定期门诊随访,拍摄X线片,应用KSS评分和WOMAC评分评估手术效果.结果 78例患者平均随访15.8个月.术前KSS评分（34.68±8.07）分,WOMAC评分（62.40±3.74）分,术后末次随访KSS评分（84.99±3.64）分,WOMAC评分（25.86±3.31）分.术前患者膝关节平均屈曲度（95.83°±13.83°）,术后末次随访时患者膝关节平均屈曲度（122.63°±9.93°）.患者术后膝关节功能明显改善,评分具有统计学差异（P〈0.01）.常用股骨假体型号在55～70 mm之间,并且70%以上集中在60～65 mm.结论 Vanguard膝关节假体能满足不同个体的需求,适应性强,有利于伸屈间隙的平衡,假体覆盖好,早期随访临床效果满意.     

Charcot关节病全膝关节置换手术疗效及文献分析

目的探讨膝关节Charcot关节病行全膝关节置换术（TKA）手术疗效及注意事项。方法对本中心5例Charcot关节病患者8个膝关节行TKA的手术疗效进行回顾分析。5例患者,男2例,女3例,手术平均年龄60岁（54～68岁）。2例行单侧TKA,3例行双侧分次TKA。采用KSS评分标准对手术疗效进行评价。另外,计算机检索Pubmed、Medline、Embase、万方数据库、中国生物医学文献数据库、中文科技期刊数据库近十年（2000—2011）公开发表的文献,同时配合手工检索已发表的骨科论文,并查阅相关文章所附的参考文献。对所纳入的文献研究进行分析讨论。结果随访时间平均12个月（2～20个月）,8个膝关节TKA术后均无感染及松动发生。KSS评分由术前平均39．00分（13～55分）增加到术后平均93．25分（91～96分）,患者对功能及关节的稳定性满意。共有9篇文献描述了Charcot关节病TKA的疗效、假体选择、外科技术、并发症及术后处理。结论本中心膝关节Charcot关节病行TKA的近期随访结果满意,结合文献研究,选择适当的假体、良好的手术操作和术后康复,Charcot关节病患者可以通过TKA获得良好的中期结果。     

抗生素骨水泥间隔体在全膝关节置换术后感染二期翻修中的应用

 目的 总结关节型抗生素骨水泥间隔体技术治疗全膝关节置换术后迟发深部感染的技术要点与初步经验。方法 2006年1月至2009年2月接受二期翻修治疗的全膝关节置换术后迟发深部感染患者21例(21膝),男8例,女13例;年龄56～83岁,平均64.4岁。一期手术中彻底清创,取出假体,植入含高浓度万古霉素的关节型骨水泥间隔体;术后静脉滴注敏感抗生素2～8周,感染控制后二期植入翻修假体。结果 全部患者获得随访,随访时间17~54个月,平均32.2个月。无一例出现感染复发。终末随访时,KSS膝关节评分、功能评分、疼痛评分及膝关节活动范围均较术前明显改善,伸膝迟滞程度无明显加重。两次手术间隔平均11.5周。间隔体取出前后骨缺损程度未见明显改变。治疗期间未见明显肝、肾功能异常及伤口愈合不良、深静脉血栓形成、肺栓塞、心脑血管意外等并发症。结论 应用关节型抗生素骨水泥间隔体技术可在一定程度上保持间隔期内的膝关节功能、避免骨量丢失,相关并发症少。彻底清创、间隔期内使用敏感抗生素、准确判断翻修假体植入时机是治疗成功的关键。     

初次膝关节表面置换术近中期的疗效分析

目的评估初次膝关节表面置换术的早中期疗效,分析主要并发症发生的原因和预防方法。方法回顾分析自2000年1月~2007年12月,本组接受初次膝关节表面置换术的140例176膝,获得随访的患者129例160膝,平均随访时间为(35±8)个月(16~98个月)。术前和随访时对患膝进行KSS和HSS评分,关节活动度检查,所得数据采用SPSS 17.0统计学软件进行统计学分析。结果术后膝关节感染4例(2.5%),其中2例为术后5~6年出现感染,与患者不恰当的局部注射治疗有关。膝关节关节僵硬(活动度小于75°)11例((6.8%),深静脉血栓形成1例(0.8%),假体无菌性松动1例(0.6%)。随访时膝关节表面置换术后HSS及KSS评分均较术前显著提高,优良多达90%以上。膝关节活动度从术前的(87.7±27.7)°提高至术后的(108.8±21.9)°(t=2.272,P0.01)。结论初次膝关节表面置换术对于消除膝关节疼痛,改善关节的活动功能效果明显,术后早中期的并发症发生率低。