牛津膝关节评分与膝关节单髁置换术术后满意度的相关性研究

目的:比较手术前后牛津膝关节评分与膝关节单髁置换术后患者满意度的相关性以及确定不同满意度对应的牛津膝关节评分阈值。方法:选取2017年1月至2018年6月行膝关节单髁置换术患者88例,其中男24例,女64例;年龄52～77(65.39±7.33)岁。所有患者在术前和术后6个月完成牛津膝关节评分问卷以及满意度调查问卷。采用Spearman秩相关检验分析比较牛津膝关节评分和满意度之间的相关性,以满意度为金标准,绘制ROC曲线判断手术前后牛津膝关节评分对患者满意度的评判价值,并计算约登指数探索其最佳阈值。结果:术前牛津膝关节评分和满意度之间无明显相关性(r=-0.058,P0.05);术后牛津膝关节评分和满意度之间呈中度正相关(r=0.51,P0.05),即术后牛津膝关节评分越高,患者满意度越高。术前牛津膝关节评分的ROC曲线下面积为0.55[95%CI(0.40,0.70),P0.05],无统计学意义;术后牛津膝关节评分的ROC曲线下面积为0.95[95%CI (0.90,0.99),P0.05],有统计学意义。术后牛津膝关节评分阈值为35.5时,评判满意度的敏感度为0.86,特异度为1.00,约登指数最大,为0.86。以35.5分为阈值比较高分组与低分组患者满意率,差异有统计学意义(P0.001)。结论:术前牛津膝关节评分与膝关节单髁置换术后患者满意度相关性差,其在预测患者满意度方面不具有准确性,术后牛津膝关节评分与患者满意度具有明显相关性,术后牛津膝关节评分在35.5分及以上的患者可认为对手术效果满意。同时,结果证实牛津膝关节评分在对全膝关节置换术和膝关节单髁置换术后患者主观满意度的评价具有相同的阈值。     

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。     

Total knee arthroplasty without patellar resurfacing

One hundred and eleven total knee replacements without patellar resurfacing were followed-up for a minimum of 48.8 months (range 48.8-108.2 months; average 78.2 months). Evaluation was performed using the Knee Society Clinical Rating System (KS-CRS). Preoperatively, the mean knee score was 34.3 points and the mean function score was 42.2 points. Postoperatively, this knee score improved to a mean of 91.1 points and the function score improved to mean of 89.6 points at the most recent follow-up. There were no significant differences among the knees with mild, moderate, or severe degenerative change to the patella with regard to the preoperative (p=0.83) and postoperative (p=0.39) knee pain score. It seems likely that the postoperative knee pain is not related to the severity of degenerative change to the patella in total knee arthroplasties performed without patellar resurfacing, and none of those patients required patellar resurfacing to achieve knee pain relief.     

全膝关节表面置换术治疗晚期骨性关节炎

目的总结全膝关节表面置换术治疗膝骨性关节炎的经验,探讨其治疗效果。方法对215例（226膝）骨性关节炎患者行全膝关节表面置换术,应用KSS膝关节评分系统进行疗效分析。结果178例获得随访,时间15d～11年5个月,平均（29±8．2）个月,膝关节评分平均（87±3．9）分,优良率91．5％;膝关节功能评分平均（76±9．9）分,优良率66．6％。结论全膝关节表面置换术对于严重膝骨性关节炎的疼痛缓解、功能改善方面有良好疗效。     

Balance sheets of knee and functional scores 5 years after total knee arthroplasty for osteoarthritis: a source for patient information

To improve patient information on the results of total knee arthroplasty (TKA) for osteoarthritis, 253 primary TKAs of a prospective study with a mean follow-up of 5.3 years were analyzed. The increase or decrease of the individual variables of the Knee Society knee and function score and the percentage of operated knees in which these variables increased were determined. Improvement in pain rating had the largest increase of all variables, contributing 60% to the knee score increase. Pain improved in 95% of the knees. Alignment improved in about 90% of knees and accounted for 25% of knee score increase. Improvement in level walking contributed more to increase of function score than better stair-climbing abilities. Level walking improved in 80% of knees and stair climbing in 55%. Pain is the most rewarding indication for TKA, followed by deformity and poor walking ability. Key words: total knee arthroplasty, knee score, functional score, patient information.     

应用Gemini PS后稳定型膝关节假体置换术后早期疗效分析

目的 探讨后稳定型膝关节假体进行膝关节置换早期疗效.方法 应用Gemini PS后稳定型膝关节假体对20例膝关节骨性关节炎患者进行初次关节置换.记录术前及随访时膝关节评分、膝前疼痛评分、功能评分、髌骨评分和膝关节最大屈曲度.结果 20例均获完整随访.术后在疼痛、功能方面均有明显改善,尤其在缓解疼痛及膝关节活动范围方面效果明显,随访12个月时HSS评分、髌骨评分、膝前痛评分、髌骨功能评分、最大屈膝度均较术前明显增加(P<0.01).结论 Gemini PS后稳定型膝关节假体,能够有效缓解膝关节骨性关节炎患者的疼痛和改善膝关节功能,早期疗效满意.     

Minimally Invasive Stryker-Osteonics unicondylar knee prosthesis with metal-backed tibia component: a 5-year follow-up

INTRODUCTION: The aim of this study was to evaluate the medium-term results of minimally invasive unicompartmental knee joint arthroplasty with a metal-backed tibia component. MATERIAL AND METHODS: Ninety-one unicompartmental knee replacements with a metal-backed tibia component, type SCR-Stryker Osteonics, were implanted in a minimally invasive technique in 91 patients between 1997 and 1999. The evaluation of medium-term results was based on The Knee Society Clinical Rating System by Insall and Scott and was done at 6 weeks, 1, 3 and 5 years after surgery. This rating system is based on the clinical and symptoms of the patient (maximum score 100). RESULTS: Preoperatively, the average knee score was 57.6 (44-66), the function score 63.3 (48-71). Throughout the period of investigation all patients had an increased knee and function score. One year after surgery the knee and function scores increased to 94.8 (39-100) and 93.6 (75-100). Five years post-implantation only 64 patients could be re-evaluated but they also had a knee and function score corresponding to the 3-year results [knee score: 98.2 (94-100); function score: 98.9 (85-100)]. Revision surgery using a total knee prosthesis was performed in 3 cases. DISCUSSION: The unicompartmental knee arthroplasty was a good surgical method for managing medial, unicompartmental arthritis of the knee joint. The results presented by the authors and corroborated by many literature data provide evidence that unicompartmental arthroplasty is of great importance in the treatment of unicompartmental knee arthritis. The results achieved by the minimally invasive technique of a unicompartmental knee arthroplasty with a metal-backed tibia component of the type Stryker-Osteonics were equal to the conventional surgical technique in literature. Good indications were patients older than 60 years with normal weight and normal sports activity. Well-functioning collateral and cruciate ligaments were mandatory. Moreover, the minimally invasive technique may lead to a shorter time of rehabilitation because of the reduced soft tissue damage.     

Acute primary total knee arthroplasty for peri-articular knee fractures in patients over 65 years of age

Peri-articular knee fractures in osteoporotic or osteoarthritic bone present a challenge to fixation, mobilisation or non-operative management. We present a series of 15 proximal tibial and 11 distal femoral fractures treated with total knee arthroplasty at over mean follow-up period of 38.8 months. The mean age of the patients was 80 years. The choice of the implant and level of constraint was determined as per the nature of injury and preference of the surgeon dealing with the fracture. Patients were allowed rapid mobilisation with immediate full weight-bearing. Good clinical results were achieved with fracture healing, sound fixation and well-aligned flexible knees. Mean Knee Society knee score was 90.2; Knee Society function score was 35.5; Oxford Knee score was 39.5; and Short Form (SF)-36 physical function score was 37.3 and mental score 50.6. Good correlation was noted between Knee society knee score and SF-36 physical function score (Pearson's 0.76, p = 0.001), suggesting that generic health would dictate the final function achieved, whilst high knee scores suggest the satisfactory results of the operation. Analogous to arthroplasty for hip fractures, this technique should be considered as a treatment option in elderly peri-articular knee fractures with osteoporosis and/or osteoarthritis.     

微骨折术治疗膝骨关节炎与髌内侧滑膜皱襞的相关性

目的研究不同解剖类型髌内侧滑膜皱襞对微骨折术治疗膝骨性关节炎患者手术前后的影响。方法收集2011-04-2014-01在安徽医科大学合肥第三临床医院关节镜手术治疗的30例膝骨性关节炎患者。将有无合并髌内侧滑膜皱襞分成两组,进行手术前后膝关节功能Lysholm评分,统计学采用两样本t检验。不同解剖类型髌内侧滑膜皱襞分成两组,进行手术前后膝关节功能Lysholm评分,统计学采用两样本t检验。结果不合并内侧滑膜皱襞评分高于合并组,手术前后膝关节功能Lysholm评分均有差异（P〈0.05）。A,B型髌内侧皱襞手术前后Lysholm评分高于C,D型髌内侧皱襞手术前后Lysholm评分（P﹤0.05）;C,D型髌内侧皱襞更影响疗效。30例膝骨性关节炎患者手术前后膝关节功能Lysholm评分有差异（P〈0.05）,术后评分较术前大幅提高。结论微骨折术治疗膝关节骨性关节炎效果满意。不同解剖类型髌内侧滑膜皱襞影响膝骨性关节炎手术前后的评分。特别是解剖类型为C,D型。术中准确处理髌内侧滑膜皱襞对微骨折术治疗膝骨性关节炎至关重要。     

Hip and knee replacement after longstanding hip arthrodesis

This study determined whether patients with severe knee disease below a hip arthrodesis can be treated successfully with total knee replacement alone or whether such patients require total hip arthroplasty followed by knee replacement. Eighteen patients who had hip arthrodesis for a mean of 33 years underwent total hip replacement alone, total knee replacement alone, or a combination of both. The Harris hip score improved from a mean of 55.3 to a mean of 86.9 points at 45 months after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 33 to a mean of 78 points in patients who had total knee replacement after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 35 to a mean of 44 points in patients having total knee replacement alone below a hip arthrodesis. The followup after total knee replacement averaged 53 months. These data suggest that a knee replacement alone in a patient with a fused hip is unlikely to provide a satisfactory result. Patients with severe knee disease below hip arthrodesis require total hip arthroplasty followed by knee replacement. This applies even when severe osteoarthritis of the knee is the primary complaint.     

单半径后稳定型假体全膝置换术后的中期随访报告

目的探讨单半径后稳定型假体全膝关节置换术后中期疗效。 方法回顾性研究上海市东方医院骨科自2012年6月至2015年1月,应用单半径后稳定型假体行全膝关节置换术(TKA)的20例(20膝)为观察组,纳入标准：初次单侧TKA,符合膝关节骨关节炎诊断标准;排除标准为双侧全膝关节置换术TKA或合并其他手术、药物成瘾、严重肝肾功能不全、类风湿关节炎、痛风性关节炎等其它炎症疾病、膝关节感染或可疑感染。其中女15例,男5例;平均年龄(68.3±0.5)岁。对照组20例为采用多半径后稳定型假体全膝置换。采用记录术前、末次随访美国膝关节协会评分(KSS评分)、膝关节功能评分,观察组与对照组的年龄、身体质量指数(BMI)、手术时间、KSS评分、功能评分比较采用t检验;观察组的术前与术后KSS评分、KSS功能评分及对照组的术前与术后KSS评分、KSS功能评分比较采用t检验,性别比例采用卡方检验。 结果所有病例均无感染,松动及静脉血栓症,平均随访(4.1±0. 6)年。术后随访X线片观察膝关节假体位置、力线等均显示良好。两组术后膝关节KSS评分(t＝1.428,P <0.05)、膝功能评分比较(t ＝2.75,P<0.01)差异均有统计学意义。 结论单半径后稳定型假体中期有令人满意的临床疗效。     

Do we need to replace the patella in knee arthroplasty for rheumatoid disease?

We have examined the anterior knee function in two patient groups who had undergone primary knee arthroplasty without patellar resurfacing to identify differences for osteoarthrosis compared with rheumatoid disease. We identified two consecutive series of patients who had undergone knee replacement surgery for either osteoarthritis or rheumatoid disease between 1992 and 1994 under the care of a single surgeon using the same implant and surgical technique. There were 90 patients in each group. All were examined and asked to complete a questionnaire so as to determine Hospital for Special Surgery (HSS) score, Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score, Bartlett patellar score and a Visual Analogue score (VAS) for any persistent anterior knee pain at rest. We failed to identify any significant differences in terms of anterior knee function between these two groups of patients. The re-operation rate was similar for both groups. It would appear that primary knee replacement for rheumatoid disease is met with a similarly good outcome for anterior knee function despite absence of patellar resurfacing. We would question the contention that patellar resurfacing is necessary for patients undergoing knee replacement for rheumatoid disease.     

Scoring systems in total knee arthroplasty

For assessment of total knee arthroplasty outcome, various scoring systems have been introduced. The current study assessed the interobserver correlation of four commonly used total knee arthroplasty outcome scores. One hundred eighteen total knee arthroplasties were investigated by two independent observers, using the Hungerford score, the Hospital for Special Surgery score, the Knee Society score, and the Bristol score. Each score consisted of three subscores: pain, knee, and function. For the highest interobserver correlation was computed for the Bristol score (interobserver correlation coefficient, 0.88). For knee range of motion, flexion contracture, and extension lag there was high interobserver correlation (interobserver correlation coefficient > 0.8 each). For walking distance and walking aids, there also was a high interobserver correlation (interobserver correlation coefficient > 0.7 each). For clinical assessment of total knee arthroplasty, pain should be measured on a four-step system, the knee should be assessed by measurement of range of motion, extension lag, and flexion contracture, and function should be measured on a separate score assessing walking distance and walking aids.     

5- to 18-year follow-up study of cemented total knee arthroplasty for patients 55 years old or younger

Seventy-two cemented total knee arthroplasties were performed on 52 patients who were 55 years old or younger. Results on 68 knees in 50 patients with an average follow-up period of 9.92 years are reported. The average age of the patients was 50.7 years (range, 30–55) at the time of surgery. The diagnosis was osteoarthritis in 37 knees, rheumatoid arthritis in 29 knees, and ankylosing spondylitis in 2 knees. The average preoperative Knee Society knee score was 23, and the average follow-up knee score was 97. All knees were rated as good or excellent for knee score. The average latest function score was 75 (preoperative, 36). Both knees in one patient required revision for loose components. This review demonstrates that cemented total knee arthroplasty in younger patients with osteoarthritis and rheumatoid arthritis can attain results comparable to the excellent results obtained in the older age groups.     

The severity and prediction of anterior knee pain post tibial nail insertion

OBJECTIVES: To compare the prevalence of anterior knee pain and functional impairment post-tibial nailing to the contralateral knee and a background population. DESIGN: Patients were assessed by postal questionnaire, case note, and radiographic review. An age demographically matched control group answered the same questions. SETTING: The Orthopaedic Department at our institution. PATIENTS/PARTICIPANTS: Patients who had a tibial nail inserted between September 1999 and November 2004 in our hospital (85 patients). Twelve were excluded, and 52 replies from 73 cases (71%) were received. The mean age was 39.4 years (range 22-69), and 38 of the patients were men. INTERVENTION: Patients treated with AO tibial nail. MAIN OUTCOME MEASUREMENTS: Both knees were assessed using an analogue pain score (0-10) and a functional anterior knee pain score (0-50). RESULTS: Of the patients, 83% had anterior knee pain following tibial nailing. The mean analogue pain score was 4.3, and the functional score was 33.3. The prevalence of anterior knee pain in the uninjured knee was 40%; in the control group it was 42%. Mean visual analogue scores were 1.3 and 1.2, respectively (both P<0.001 compared to the nailed side). Functional knee pain scores were 43.3 and 46.8 (both P<0.001 compared to the nailed side). Pain scores between both the knee on the injured and the contralateral sides correlated significantly (P<0.01). Last, the pain scores of the patients' knees of the uninjured side in the operative group and the scores from the control group appeared similar but not with statistical significance (P<0.57 analogue pain score and P<0.77 functional knee pain score). CONCLUSIONS: There is a significant preinjury prevalence of anterior knee pain. Postnailing knee pain severity correlates with that in the uninjured limb. Relative risk of anterior knee pain postnailing is twice that of a comparative population.     

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。     

Pre-operative clinical and radiological assessment of the patellofemoral joint in unicompartmental knee replacement and its influence on outcome

Anterior knee pain and/or radiological evidence of degeneration of the patellofemoral joint are considered to be contraindications to unicompartmental knee replacement. The aim of this study was to determine whether this is the case. Between January 2000 and September 2003, in 100 knees (91 patients) in which Oxford unicompartmental knee replacements were undertaken for anteromedial osteoarthritis, pre-operative anterior knee pain and the radiological status of the patellofemoral joint were defined using the Altman and Ahlback systems. Outcome was evaluated at two years with the Oxford knee score and the American Knee Society score. Pre-operatively 54 knees (54%) had anterior knee pain. The clinical outcome was independent of the presence or absence of pre-operative anterior knee pain. Degenerative changes of the patellofemoral joint were seen in 54 patients (54%) on the skyline radiographs, including ten knees (10%) with joint space obliteration. Patients with medial patellofemoral degeneration had a similar outcome to those without. For some outcome measures patients with lateral patellofemoral degeneration had a worse score than those without, but these patients still had a good outcome, with a mean Oxford knee score of 37.6 (SD 9.5). These results show that neither anterior knee pain nor radiologically-demonstrated medial patellofemoral joint degeneration should be considered a contraindication to Oxford unicompartmental knee replacement. With lateral patellofemoral degeneration the situation is less well defined and caution should be observed.     

Ethnic differences in preoperative function of patients undergoing total knee arthroplasty

The prevalence of osteoarthritis is high in all ethnic and demographic groups. The timing of surgery is important because poor preoperative functional status is related to poor postoperative function. The aim of our study was to compare the preoperative knee function in patients of Asian origin with that of Caucasians living in the same community. We carried out a prospective study of 63 consecutive Asian patients and 63 age- and gender-matched Caucasian patients undergoing total knee arthroplasty. Preoperative Knee Society Clinical Rating System scores were recorded as a separate knee score and knee function score. The mean preoperative knee score in Asian patients was 37.6 compared with 41.5 in Caucasians (p<0.12); this difference was not statistically significant. The mean preoperative knee function score in Asian patients was 32.5 compared with 45.0 in Caucasians (p<0.00015); this difference was highly statistically significant. We conclude that patients of Asian origin undergoing total knee arthroplasty have lower preoperative knee function than Caucasians do. Cultural beliefs and social support partially explain this discrepancy, but health care providers must attempt to educate patients and close family members about the importance of timing the surgery to obtain the optimum benefits of pain relief and function.     

Specificity of the Oxford knee status questionnaire. The effect of disease of the hip or lumbar spine on patients' perception of knee disability

There is a need for the accurate measurement of the outcome after knee surgery. The Oxford Knee Score is being increasingly used since it is reported to be short, simple, inexpensive and validated. We sent the questionnaire to 346 patients awaiting surgery to the hip or lumbar spine. Only 11% of 141 patients with proximal pathology who denied knee problems gave a maximum score. Their mean score was substantially lower than expected at 28.7 (maximum 48), and was significantly lower than the score of 36.5 obtained from patients after total knee replacement. We therefore suggest that the frequent coexistence of hip or spinal pathology will significantly alter both the absolute score and any improvement to be expected after knee surgery. Although sensitive to disability originating from the knee the Oxford Knee Score is not sufficiently specific since it is heavily influenced by more proximal pathology.