人工全膝关节置换术中髌骨置换的临床研究

目的探讨人工全膝关节置换术中髌骨置换之后的临床疗效,为临床上是否要进行髌骨置换提供参考依据。方法选择2009年12月—2012年2月于我院急诊科、骨科就诊并拟行人工全膝关节置换术的骨关节炎患者84例,按随机数字随机将所有入选患者分为对照组42例和研究组42例,研究组患者在关节置换术中接受髌骨置换的治疗,对照组则不进行髌骨置换,治疗后所有患者接受为期1年的随访,对两组疗效进行比较。结果两组术后2、3个月的美国膝关节协会评分系统(KSS)临床评分差异均无统计学意义(P>0.05),术后6、12个月KSS临床评分差异有统计学意义(P<0.05);两组术后2、3、6个月的Feller髌骨评分差异均无统计学意义(P>0.05),术后12个月Feller髌骨评分差异有统计学意义(P<0.05)。结论人工全膝关节置换术中行髌骨置换能在一定程度上改善膝关节功能评分和髌骨评分。     

全膝关节置换术中髌骨处理方法的研究

目的 比较全膝关节置换术(total knee arthroplasty,TKA)中保留髌骨下进行髌骨成形与髌骨置换的术后临床疗效,探讨膝关节置换中合适的髌骨处理方法.方法 回顾性分析2002年1月-2008年12月收治的共198例行TKA治疗的单纯骨关节炎患者,其中62例行髌骨置换术,136例行保留髌骨下髌骨成形术.术中对髌骨进行去除骨赘后进行成形,使之与原髌骨关节面比较相近.术后定期随访进行美国膝关节协会评分(KSS)、Bristol髌骨评分、患者满意度、膝关节活动度及分析术后膝前疼痛发生率,并复查X线片了解内置物情况.结果 共125例获得随访,其中置换组43例,成形组82例,随访时间36～80个月,平均51个月.两组患者术后较术前各项评分明显提高.术后1年随访时两组患者术后膝关节活动度、KSS总评分、髌骨评分、患者满意度差异无统计学意义,而KSS功能评分两组之间差异有统计学意义,成形组优于置换组.而术后膝前疼痛发生率两者有差异但无统计学意义.术后X线片示髌股匹配程度、术后膝前疼痛发生率及髌骨相关并发症发生率两组间差异无统计学意义.结论 髌骨成形术在TKA中髌骨不置换时能够使髌股关节达到良好匹配,术后膝前疼痛发生率低,中短期疗效与髌骨置换相当.     

全膝关节置换术中髌股关节轨迹不良的处理策略及疗效探讨

目的总结分析全膝关节置换术(total knee arthroplasty,TKA)中髌股关节轨迹不良的个体化处理策略及其治疗效果。方法选取2012年8月至2017年8月广州医科大学附属第二医院骨外科收治的145例(184膝)拟初次行保留髌骨TKA的膝关节病变患者作为研究对象,术中根据髌股关节轨迹不良情况酌情采用假体位置调整、髌骨修整成形、髌骨内外侧支持带张力调整及Goldthwait-Roux术处理,评估术前及术后疼痛视觉模拟评分法(visual analogue scale,VAS)评分、美国膝关节协会评分(knee society score,KSS)、Feller髌骨评分以及胫骨角、股骨角、胫骨后倾角及股骨屈曲角等假体力线相关参数变化情况,记录假体松动、髌骨坏死、髌骨骨折和骨溶解等并发症发生情况。结果术后所有患者均无假体松动、髌骨坏死、髌骨骨折和骨溶解等并发症发生;随访(16.72±4.16)个月,患者VAS评分明显低于术前(t=38.483,P=0.000),KSS评分、Feller髌骨评分均明显高于术前(t=36.110、17.700,P均=0.000),胫骨角、股骨角、胫骨后倾角、股骨屈曲角均明显大于术前(t=99.997、87.499、14.084、4.101,P均=0.000)。结论 TKA术中根据患者髌股关节轨迹不良情况个性化采用假体位置调整、髌骨修整成形、髌骨内外侧支持带张力调整及Goldthwait-Roux术处理,可纠正患者髌股关节轨迹不良,缓解膝前痛,改善膝关节功能,临床应用价值较高。     

应用旋转平台人工全膝关节置换术的初步报告

目的探讨旋转平台人工全膝关节置换术的临床效果。方法对49例患者行70膝的Sigma旋转平台人工全膝关节置换术，其中21例为双侧膝关节置换。男7例，女42例；年龄38—78岁，平均63岁。术前诊断膝骨关节炎42例，类风湿关节炎7例。采用正中切口髌旁内侧入路、后稳定型假体，所有膝关节都未进行髌骨置换，但对髌骨进行去神经化和修复术。结果本组随访时间6—22个月，平均12．7个月，共70膝。影像学显示均无松动，无髌骨脱位。对膝关节临床评定采用美国膝关节学会评分（KSS评分），术前膝评分49分（35—70分），膝功能评分40分（30—60分），术后最后一次随访膝评分为96分（83—100分）；功能评分为95分（65—100分），没有旋转平台的旋出，没有翻修或者感染的发生。结论旋转平台人工全膝关节置换术在运动学分析和实验室磨损试验的数据上有潜在的优势，尤其是在年轻的活动能力强的患者，近期随访获得了满意的疗效，远期的疗效还需进一步随访。     

氨甲环酸的不同应用方式对全膝关节置换术中及术后失血量的影响

目的：探讨氨甲环酸的不同应用方式对全膝关节置换术术中及术后失血量的影响。方法选取2013年～2014年行全膝关节置换的100例患者,分为A组50例关节置换前1 g稀释于100 mL生理盐水后静脉注射氨甲环酸;B组50例在止血带释放前关节囊缝合后局部关节腔注射浓度为3％氨甲环酸稀释溶液50 mL。结果两组在术中的失血量对比无差异（P＞0．05）,比较术后的出血量、输血量、输血人数、血红蛋白差异有统计学意义（P＜0．05）,A组优于B组。结论全膝关节置换术前10 min静脉滴注氨甲环酸能明显降低患者术后出血量及输血量,此药物安全有效,可有效用于全膝关节置换手术。     

外后侧弧形切口双肌间隙入路治疗不同分型胫骨后外侧平台塌陷骨折

目的：探讨胫骨后外侧平台塌陷骨折采用外后侧弧形切口双肌间隙入路手术治疗的临床效果。方法笔者回顾性分析2011年7月～2013年7月收治的60例胫骨后外侧平台塌陷骨折患者的临床治疗及随访资料,根据Schatzker骨折分型分为：SchatzkerⅢ＋Ⅳ组28例,SchatzkerⅤ＋Ⅵ组32例,分别对两组患者的术中情况、术后效果指标进行统计分析。结果 SchatzkerⅢ＋Ⅳ组的手术时间、术中出血量均显著低于SchatzkerⅤ＋Ⅵ组（ P＜0．05）,两组患者的切口长度、住院时间、骨折愈合时间指标差异不显著（ P＞0．05）;两组术后3d复位分布比较差异不显著（P＞0．05）,复位优良率SchatzkerⅢ＋Ⅳ组96．43％高于SchatzkerⅤ＋Ⅵ组的90．62％但差异不显著（P＜0．05）。 SchatzkerⅢ＋Ⅳ组与SchatzkerⅤ＋Ⅵ组在术后3、6个月的Rasmussen、膝关节功能HSS评分差异不显著（P＞0．05）,但SchatzkerⅢ＋Ⅳ组术后12个月、末次随访的Rasmussen、HSS膝关节功能评分显著优于SchatzkerⅤ＋Ⅵ组（ P＜0．05）。末次随访SchatzkerⅢ＋Ⅳ组患者的膝关节功能优良率为85．71％,高于SchatzkerⅤ＋Ⅵ组的75％,但差异不显著（ P＞0．05）。结论胫骨后外侧平台塌陷骨折患者采用外后侧弧形切口双肌间隙入路手术治疗能够取得较好的术后复位及功能恢复效果,同时SchatzkerⅢ＋Ⅳ组患者的术后膝关节功能恢复较SchatzkerⅤ＋Ⅵ组好。     

人工全膝关节置换术治疗严重畸形膝关节临床研究

目的：探讨人工全膝关节置换术（total knee arthroplasty, TKA）治疗严重畸形膝关节的手术方法和临床疗效。方法对人工全膝关节置换术916例（1031膝）,严重畸形膝关节置换术80例,其中56例（70膝）成功随访。严重内翻畸形19例（23膝）、严重外翻畸形21例（27膝）、严重屈曲畸形16例（20膝）。术后平均随访时间60个月（6个月～10年）。对膝关节屈伸活动度、HSS、KSS膝关节评分系统对手术前后进行回顾性研究。结果膝关节屈伸活动度由术前平均80°（伸直0°～屈曲120°）提高到术后115°（伸直0°～屈曲130°）,膝关节评分系统 HSS、KSS术前及随访时比较差异有统计学意义（P＜0．05）,KSS评分：临床评分由术前平均33分（10～68分）提高到术后平均81分（70～100分）,HSS临床评分由术前平均43分（27～68分）提高到术后平均86分（72～100分）。膝内外翻、屈曲挛缩畸形得到较好矫正。结论严重畸形膝关节通过关节置换术同样能恢复正常的关节功能,提高了患者生活质量,获得满意的临床疗效。     

全膝关节置换术两种入路效果比较

 目的  比较经股内侧肌入路与内侧髌旁入路行全膝关节置换术的临床疗效。 方法 25例行同期双侧全膝关节置换术,每例患者随机一侧采用经股内侧肌入路,另一侧采用内侧髌旁入路,观察两组手术时间、术后引流量、术后6周关节活动度、直腿抬高恢复时间,术后第1、2、3、6天对每例患者双侧膝关节进行视觉模拟疼痛评分（visual analog scale,VAS）。 结果 经股内侧肌入路组在直腿抬高恢复时间［（2.2±0.8） d vs （4.4±1.4）d］、VAS评分方面明显优于内侧髌旁入路组( P <0．05 ),两组在术后引流量、手术时间、术后6周膝关节活动度方面差异无统计学意义( P >0．05)。 结论 经股内侧肌入路行全膝关节置换术与髌旁入路相比,可以减轻术后的疼痛,减少直腿抬高恢复时间,较早恢复膝关节功能,值得临床推广和应用。     

超前多模式联合镇痛在人工膝关节置换术后关节功能恢复的效果观察

将180例人工膝关节置换术患者随机分为观察组（超前多模式联合镇痛组,90例）和对照组（90例）,两组术后同时进行康复训练,观察两组术后不同时间点的疼痛程度、膝关节评分（ HSS）、平均住院费用及患者康复满意度。观察组术后不同时间点静息痛及运动疼痛视觉模拟评分明显低于对照组（P＜0．05）,HSS明显高于对照组（P＜0．05）,平均住院费用低于对照组,康复效果满意度明显高于对照组。超前多模式联合镇痛方法效果满意,能有效促进膝关节术后功能恢复。     

髌股关节置换治疗单纯髌股关节骨关节炎的近期疗效分析

目的：探讨髌股关节置换术治疗单纯髌股关节骨关节炎的近期临床疗效。方法9例单纯髌股关节骨关节炎行髌股关节置换术的患者均于术前1d给予口服塞来昔布;术后第1d开始主、被动屈伸膝关节。术前对患者进行疼痛视觉模拟评分（VAS）和美国特种外科医院膝关节评分（HSS）,出院后第1、6、12个月随访复查膝关节正侧位片,进行VAS和HSS评分并询问患者主观满意度,将记录结果行统计学分析。结果所有患者伤口均Ⅰ期愈合并随访,随访时间25~37个月,平均28.4个月;末次随访VAS 0~1分,平均（0.32±0.12）分, HSS 93~98分,平均（96.34±3.64）分;随访期间无1例患者出现髌骨轨迹不良、髌骨脱位及假体松动等并发症;患者对本次手术满意率100%。结论髌股关节置换能有效减轻乃至消除单纯髌股关节骨关节炎所致疼痛,改善因髌股关节骨关节炎所致的关节功能障碍,是保守治疗失败后治疗单纯髌股关节骨关节炎的良好选择。     

全膝关节置换术后应用局部间断冰敷治疗效果分析

目的探讨全膝关节置换术后应用局部间断冰敷治疗的临床效果。方法选取2012年11月至2016年11月行全膝关节置换术的患者51例(51膝),其中,术后应用局部间断冰敷治疗(冰敷组)29例,常规治疗(常规组)22例。观察并比较两组患者术后第1、2、3天的膝关节术前术后髌骨中点周径差、视觉模拟疼痛评分(VAS)及总引流量。结果术后第2、3天冰敷组膝关节术前术后髌骨中点周径差明显小于常规组(P<0.05),术后第1、2、3天冰敷组VAS明显低于常规组(P<0.05),术后冰敷组总引流量明显少于常规组(P<0.05)。结论全膝关节置换术后应用局部间断冰敷治疗可明显促进患肢局部消肿,缓解术区疼痛,减少术后出血。     

No difference in ROM and knee function between mobile and floating platforms in TKA

Purpose

The purpose of this study was to determine whether the floating platforms (FP) were superior to rotating platforms (RP) in computer-navigated total knee arthroplasty (TKA) comparing the range of motion (ROM) as well as clinical and subjective function of the knee.

Methods

This retrospective non-randomized single-centre cohort study includes 255 patients with a primary implanted computer-navigated e.motion? (Aesculap B. Braun) TKA system, implanted because of clinical and radiological verified gonarthrosis. In 129 patients, the FP platform was implanted, and in 126 patients, the RP platform. As statistical procedures for differences between inlay type RP/FP in ROM and Knee Society Score (KSS) after 3- and 24-month follow-up, an analysis of covariance (with risk factors gender, age, BMI, preoperative ROM and preoperative KSS) was performed.

Results

Although preoperative ROM and knee society function score (KSS partII) were significantly higher in the FP group before surgery, there was no significant difference between RP and FP in ROM and KSS at 3- and 24-month follow-up.

Conclusion

The FP platform design did not have an advantage in ROM as well as in clinical and subjective knee function compared with the RP platform in computer-navigated TKA neither in early follow-up examinations at 3 months postoperatively nor at long-time follow-up at 24 months postoperatively.

Level of evidence

Therapeutic study, Level III.     

Do tibiofemoral contact point and posterior condylar offset influence outcome and range of motion in a mobile-bearing total knee arthroplasty?

Purpose

The posterior condylar offset (PCO) and the tibiofemoral contact point (CP) have been reported as important factors that can influence range of motion and clinical outcome after total knee arthroplasty. A mobile-bearing knee implant with an anterior posterior gliding insert would in theory be more sensitive for changes in PCO and CP. For this reason, we analysed the PCO and CP and the relation with outcome and range of motion in 132 patients from a prospectively documented cohort in this type of implant.

Methods

The prosthesis used was a posterior cruciate retaining AP gliding mobile-bearing total knee replacement (SAL II Sulzer Medica, Switzerland). In 132 knees, the pre- and postoperative PCO and postoperative CP were evaluated. Measurements were made on X-rays of the knee taken in approximately 90° of flexion and with less than 3-mm rotation of the femur condyles. The outcome parameters, range of motion (ROM) and the knee society score (KSS), for each knee were determined preoperatively and at 5-year follow-up.

Results

The mean KSS improved from 91 to 161 at 5-year follow-up (p < 0.001) and the mean ROM from 102 to 108 (p < 0.05). The mean PCO difference (postoperative PCO–preoperative PCO) was—0.05 mm (SD 2.15). The CP was on average 53.9 % (SD 5.5 %). ROM was different between the 3 PCO groups (p = 0.05): patients with 3 or more mm decrease in PCO had the best postoperative ROM (p = 0.047). There was no statistical difference between the postoperative ROM between patients with a stable PCO and those with an increased PCO. There was no correlation between the difference in PCO and the difference in ROM; R _Pearson = ?0.056. There was no difference in postoperative ROM or postoperative total KSS between CP <60 % and CP >60 %: p = 0.22, p = 0.99, for ROM and KSS, respectively. Scatter plots showed uniform clouds of values: increase or decrease in PCO and CP had no significant influence on ROM or KSS.

Conclusion

The hypotheses that a stable PCO and a more natural CP increase postoperative ROM and improve clinical outcome could not be confirmed. On the contrary, a decreased PCO seemed to improve knee flexion. Furthermore, a relationship between PCO and CP could not be found.

Level of evidence

Prospective cohort study, Level II.     

The anterior–posterior laxity after total knee arthroplasty inserted with a ligament tensor

Goal of this study is to determine the anterior–posterior laxity in 30° of knee flexion for a posterior cruciate retaining total knee arthroplasty with a relative dished insert and implanted with a ligament tensor. Furthermore, the correlation between these AP laxities and the postoperative range of motion (ROM) and postoperative Knee Society Score (KSS) is analysed. Fifty-one balanSys™ total knee arthroplasties were performed in 49 patients between 1998 and 2000. These arthroplasties are analysed with respect to AP laxity (Rolimeter), ROM and KSS with a mean follow-up of 4.6 years. The mean anterior laxity is 2.8 mm with no posterior laxities at all. The average postoperative ROM is 110° with an average KSS of 142. No correlations between AP-laxity and postoperative ROM or between AP-laxity and postoperative KSS are found. A posterior cruciate retaining TKA with a relative dished insert and implanted with a tensor is very stable in the anterior–posterior direction in 30° of knee flexion. This limited laxity does not seem to disadvantage the mean postoperative ROM and KSS, when compared to other TKA studies.     

Total knee arthroplasty without patellar resurfacing in active and overweight patients

Overweight patients are often considered poor candidates for total knee arthroplasty (TKA). A retrospective study of this was done on 47 osteoarthritic knees treated by TKA without patella resurfacing between March 1991 and June 1993. The Hospital for Special Surgery (HSS) rating system was used for clinical evaluation, and radiographs to study the degree of osteoarthritis and radiolucency. Correlations between overweight, range of motion (ROM) and stage of patellar damage and other measured variables (HSS score, patellar pain and radiolucency) were studied. Overweight was not correlated with HSS score, radiolucency or patellar pain. ROM was significantly correlated with patellar pain and HSS score, with better results in patients with ROM between 90° and 110°. Therefore, we believe that TKA in osteoarthritic knees can lead to successful results, even in active or overweight patients. Received: 19 November 1996 Accepted: 7 April 1997     

人工全膝关节置换术治疗胫骨平台骨折内固定术后创伤性关节炎回顾性研究

目的探讨胫骨平台骨折内固定术后创伤性骨关节炎的人工全膝关节置换术及其临床疗效。方法北京积水潭医院矫形骨科自2003年1月至2015年1月,收治12例(12膝)胫骨平台骨折术后创伤性关节炎患者。所有患者骨折后均曾行切开复位内固定术治疗。应用KSS评分和功能评分术前和术后随访评估。术前膝关节屈伸活动度(80.0°±34.9°)。膝关节学会KSS评分(62.7±11.1)分,功能评分(61.7±10.7)分。12例患者均行全膝关节置换术。9例患者选择后稳定型假体,2例患者选择限制性LCCK假体,1例患者选择旋转铰链膝关节假体。结果本组共12例患者,1例患者出现伤口并发症和浅表感染,1例患者术中内侧副韧带部分撕脱。术后随访1~13年(平均4.3年),无晚期并发症出现。末次随访时,KSS评分(80.5±10.4)分,功能评分(82.5±16.6)分,膝关节屈伸活动度(101.7°±16.0°),均较术前显著改善(P<0.05)。结论胫骨平台骨折内固定术后创伤性骨关节炎的人工全膝关节置换术可以显著改善患者的关节功能,但易出现感染及伤口并发症,具有较高的技术要求。     

Early results of high-flex total knee arthroplasty: comparison study at 1 year after surgery

We compared clinical [including maximal flexion and range of motion (ROM)] and radiographical outcomes of high-flex versus conventional implants for total knee arthroplasty (TKA) after 1 year. We also analyzed the factors affecting postoperative ROM in high-flex implants. The high-flex group (n = 90) had an average maximal flexion of 129.8° (standard deviation (SD), 5.2°) significantly higher than the 124.3° (SD, 9.2°) of the conventional group (n = 90), especially for patients with less than 90° of knee flexion (P < 0.05). There was no significant difference in hospital for special surgery (HSS) score between the two groups. No knee developed osteolysis, aseptic loosening, or other complications. We found that, for high-flex implants, preoperative ROM had a significant effect on postoperative ROM.     

帕瑞昔布钠对全膝全髋关节置换术后镇痛的疗效分析

目的 评价帕瑞昔布钠对全膝关节置换术(total knee arthroplasty,TKA)和全髋关节置换术(total hip arthroplasty,THA)术后的镇痛效果. 方法 本研究为前瞻性、随机、双盲研究,由同一组医师完成101例TKA患者和105例THA患者,根据镇痛方式分为三组:(1)术中静脉注射帕瑞昔布钠组;(2)术中关节局部注射帕瑞昔布钠组;(3)对照组.比较术后三组的视觉模拟疼痛评分(VAS)、关节活动度(ROM)、术后直腿抬高能力和恶心、呕吐等并发症的发生率. 结果 术中静脉注射帕瑞昔布钠组和术中关节局部注射帕瑞昔布钠组在术后各时段的VAS评分和术后24 h ROM及直腿抬高能力的差异无统计学意义(P＞0.05),但均明显优于对照组(P＜0.05).使用帕瑞昔布钠后恶心、呕吐等并发症的发生率没有显著增加. 结论 术中静脉注射和术中关节局部注射帕瑞昔布钠对TKA和THA术后的镇痛效果确切,有利于患者关节功能的迅速康复,且操作简便、实用,是TKA和THA镇痛的有效方法之一.