人工全膝关节置换术在外翻膝的临床应用

[目的]探讨人工全膝关节置换术在外翻膝中的手术技术和临床疗效.[方法]2004年3月～2008年9月,对14例16个外翻膝行膝前正中、髌旁内侧入路,常规截骨、外侧软组织松解,后方稳定型假体或后交叉韧带保留型假体的人工全膝关节置换术进行回顾性研究.患者男3例,女11例,平均年龄60.5岁(45～77岁).经过随访比较手术前后膝关节屈伸活动度、KSS评分、膝关节X线情况来评估手术临床效果.[结果]术后平均随访42个月(24～54个月),膝关节屈伸活动度由术前平均82°(伸直0°～屈曲120°)提高到术后120°(伸直0°～屈曲150°);KSS评分:临床评分由术前平均43分(10～65分)提高到术后平均83.9分(70～100分),功能评分由术前平均52.9分(30～70分)提高到术后平均89.3分(75～100分);胫股角由术前平均16.5°(8°～30°)改善纠术后平均7°(5°～10°),膝外翻畸形得到良好的矫正.随访中无深静脉血栓、膝关节感染、髌骨半脱位或脱位并发症发生.[结论]膝前正中、髌旁内侧入路,常规截骨、外侧软组织松解,后方稳定型假体或后交叉韧带保留型假体的TKA治疗外翻膝临床疗效满意.     

全膝关节置换治疗膝关节骨关节炎

目的研究全膝关节置换治疗骨关节炎的近中期手术效果,探讨手术方法与术后效果。 方法回顾性分析了皖南医学院弋矶山医院2010年7年至2018年3月临床资料。膝关节骨关节炎手术患者共81例,平均疼痛时间(8±3)年,均采用后稳定型假体,膝关节内外翻、屈曲畸形通过术中骨赘清理、内外侧副韧带和后方关节囊等软组织松解等技术矫正。术后关节囊内注入氨甲环酸抗凝及早期进行康复治疗。术前及术后拍摄下肢全长X片及膝关节正侧位X片记录股胫角度和屈曲畸形角度,统计手术时间、术后引流量。术后随访1、3、6、12、24月复查膝关节正侧位X线,记录膝关节活动度和疼痛情况,并进行膝关节协会评分(KSS)。用SPSS 17.0软件,数据采用配对t检验分析。 结果平均随访时间(22±5)个月,手术时间平均(71±6)min,引流量平均(380±5)ml,膝关节股胫角术后平均为(1.3±1.0)°,术后有4例术后出现膝前痛。无血管及神经损伤等并发症,下肢力线基本恢复正常。无术后感染发生。随访复查膝关节正侧位X线片,未发现假体松动、下沉。随访膝关节活动度、疼痛。膝关节KSS评分有显著改善(临床t＝－66,功能t＝－91.7,P<0.05) 。 结论全膝关节置换术治疗膝关节骨关节炎,术中应用骨赘清理、内外侧,后方关节囊等软组织松解等手术技术,可纠正内外翻畸形,恢复下肢力线、改善膝关节活动度和缓解疼痛,临床效果满意。     

膝关节外翻畸形的人工全膝关节置换术

目的探讨膝关节外翻畸形患者行人工全膝关节置换术(TKA)的手术方法和临床效果。方法对1996年1月至2004年8月74例87个膝关节外翻畸形TKA手术进行回顾分析。患者男11例,女63例,平均年龄63岁(26~80岁);股胫角(股骨和胫骨解剖轴线的夹角)平均为21·59°(12°~40°);应用后稳定型假体,采用髌旁内侧入路、常规截骨加单纯外侧软组织松解方法。随访检查膝关节活动度、X线外翻角度及KSS评分以评价手术效果。结果术后评价随访时间33·8个月(5个月~9年),根据膝关节活动度数及KSS评分评估关节功能情况。膝关节平均活动度为112·4°(80°~130°),KSS评分平均为81·7分(71~93分),比术前提高了59分;功能评分平均为86·3分,比术前提高了59·8分。所有膝关节在行TKA后外翻畸形基本得到矫正,随访时外翻度数(股胫角)平均为8·7°(0°~11°),较术前有明显改善。随访时1例患者有膝关节轻度不稳症状,1例术前严重髌脱位患者术后髌骨存在半脱位,其余正常。结论对于膝关节外翻畸形患者,采用髌旁内侧入路、常规截骨加单纯外侧软组织松解以及安装后稳定型假体的方法,可取得比较满意的临床效果。     

单间室膝关节置换治疗膝关节病变

目的了解单间室膝关节置换治疗骨关节炎及骨坏死的近期疗效,探讨其手术适应证及手术要点。方法自1999年4月～2000年7月对20例患者行单间室膝关节置换术,男10例(12膝),女10例(12膝);其中骨关节炎18例(22膝),骨坏死2例(2膝);术后随访13～34个月,平均25.7个月。随访主要指标为站立位下肢胫股角(femorotibialangle,FTA)、膝关节伸屈活动度及JOA(日本骨科学会)膝关节功能评分。结果术后平均FTA与术前相比差异有非常显著性意义(P<0.001)。随访时24膝平均活动度与术前相比差异有显著性意义,关节屈曲挛缩得到明显改善(P=0.0025);随访时屈曲度与术前相比差异无显著性,而术前与术后的屈曲度相关性分析显示两者间差异有非常显著性意义(r=0.742,P<0.001)。结论单间室膝关节置换术具有手术创伤小、活动度恢复好的优点,近期效果相当满意。严格掌握手术指征是手术成功的关键,同时对手术技术及手术经验也有较高要求,中远期效果有待进一步随访。     

Total knee arthroplasty for the stiff knee

The underlying cause of stiffness must be carefully evaluated when considering total knee arthrolasty for the stiff knee. Any previous skin incision must be recorded as well as the state of the extensor mechanism. The choice of prosthesis constraint should be decided on the state of the soft-tissues often released extensively to gain flexion. A quadriceps release or plasty and a tibial tubercle osteotomy are the current options for exposure, soft-tissue release and bone cuts. Postoperatively, the motion should be started early combined to pain control in order to obtain an average of 65° of flexion at follow-up. The complication rate remains high including recurrent stiffness, delayed wound healing and deep infection.     

Total knee arthroplasty in the valgus knee

Valgus knee deformity is a challenge in total knee arthroplasty (TKA) and it is observed in nearly 10 % of patients undergoing TKA. The valgus deformity is sustained by anatomical variations divided into bone remodelling and soft tissue contraction/elongation. Bone tissue variations consist of lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodelling. Soft tissue variations are represented by tightening of lateral structures: lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendons, the lateral head of the gastrocnemius and iliotibial band. Complete pre-operative planning and clinical examination are mandatory to manage bone deformities and soft tissue contractions/elongations and to decide if a higher constrained prosthesis is necessary. Two different approaches have been described to perform TKA in a valgus knee: the anteromedial approach and the anterolateral one. In valgus knee deformity bone cuts can be performed differently in order to correct low-grade deformities and reduce great deformities. There is still debate in the literature on the sequence of lateral soft tissue release to achieve the best alignment without any instability. The aim of this article is to review the anatomical variations underlying a valgus knee, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. We will also review the main approaches and surgical techniques both for bone cuts and soft tissue management. Finally, we will report on our experience and technique.     

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。     

Preoperative knee stiffness and total knee arthroplasty outcomes

A retrospective case-control study was conducted to evaluate 1-year total knee arthroplasty (TKA) outcomes among preoperative stiff knees, range of motion (ROM) 80° or less, compared with nonstiff preoperative knees, ROM 100° or greater. A total of 134 stiff knee cases were compared with a matched cohort of 134 non-stiff knee controls. Knee Society Score and Oxford Knee Score change scores from baseline to 1 year were similar between the groups. Stiff knees experienced a significantly greater mean improvement in ROM from baseline to 1 year (30.8° ± 18.8°) as compared with nonstiff knees (1.1° ± 12.8°) (P < .0001). Although ultimate ROM of a TKA can be restricted secondary to preoperative stiffness, improvements in outcomes and ROM are not affected. We conclude that progression of stiffness should not in and of itself lead to earlier intervention of TKA in most cases.     

Anterior knee pain following primary total knee arthroplasty

Despite improvements in technique and technology for total knee arthroplasty (TKA), anterior knee pain impacts patient outcomes and satisfaction. Addressing the prosthetic and surgical technique related causes of pain after TKA, specifically as it relates to anterior knee pain, can aid surgeons in addressing these issues with their patients. Design features of the femoral and patellar components which have been reported as pain generators include: Improper femoral as well as patellar component sizing or designs that result in patellofemoral stuffing; a shortened trochlear groove distance from the flange to the intercondylar box; and then surgical technique related issues resulting in: Lateral patellar facet syndrome; overstuffed patella/flange combination; asymmetric patellar resurfacing, improper transverse plane component rotation resulting in patellar subluxation/tilt. Any design consideration that allows impingement of extensor mechanism anatomical elements has the possibility of impacting outcome by becoming a pain generator. As the number of TKA procedures continues to increase, it is increasingly critical to develop improved, evidence based prostheses that maximize function and patient satisfaction while minimizing pain and other complications.     

Bouncy knee in a semi-automatic knee lock prosthesis

The Bouncy Knee concept has previously proved of value when fitted to stabilised knee units of active amputees. The stance phase flex-extend action afforded by a Bouncy Knee increased the symmetry of gait and also gave better tolerance to slopes and uneven ground. A bouncy function has now been incorporated into a knee of the semi-automatic knee lock design in a pilot laboratory trial involving six patients. These less active patients did not show consistent changes in symmetry of gait, but demonstrated an improved ability to walk on slopes and increased their walking range. Subjective response was positive, as noted in the previous trials.     

Total knee replacement with the Kodama-Yamamoto knee prosthesis

Since 1970, 170 knees have been operated upon using the Kodama-Yamamoto knee prosthesis. Of these 127 had the revised Mark-II prosthesis and of this group 91 cases have been followed for more than a year. Interim results suggest that the total knee score has improved. on the average, from 38 points preoperatively to 74 points after one year. A single early complication involved loosening of the prosthesis in a case of knee infection. Except for this case, no loosening and no radiolucent lines have been observed. Methacrylate bone cement is known to be harmful to bone and soft tissues, and our basic and clinical studies reveal that results improve when the total knee replacement is done without using cement.     

Assessment of knee alignment after bicompartmental knee arthroplasty

A key factor in successful knee arthroplasty is restoration of correct knee alignment. Although traditional total knee arthroplasty effectively restores alignment, it is unclear whether similar results can be consistently obtained with more conservative procedures. The purpose of this study was to assess alignment after implantation of the Journey Deuce Bi-Compartmental Knee System (Smith & Nephew, Inc, Memphis, Tenn). Mechanical axis was assessed in 137 cases. Preoperatively, 77 (56%) of 137 patients had a mechanical axis passing far medial to the center of the knee, consistent with varus deformity. Postoperatively, 130 (95%) of 137 patients had a mechanical axis passing through the center of the knee. These results suggest that the Journey Deuce Bi-Compartmental Knee System supports correction of varus deformity, previously thought to require total knee arthroplasty or osteotomy.     

全膝关节置换术后膝关节线改变与膝前痛的相关性

目的 探讨全膝关节置换术后膝关节线改变与膝前痛的相关性.方法 回顾性分析2008年1月至2010年12月因膝关节骨关节炎行初次全膝关节置换的76例患者的病例资料,男11例,女65例;年龄47～83岁,平均(68.88±7.61)岁.术中应用PFC后稳定型固定平台膝关节假体.术后每12个月定期门诊随访一次.根据Figgie膝关节线测量方法对术前及随访时的关节线进行测量,并计算术前、术后关节线的变化.关节线升高为正值,关节线降低为负值.采用Feller评分法评估术前及随访时的髌骨功能.评估术后24个月的关节线改变水平与Feller髌骨评分的相关性.结果 关节线改变-6.8～10.44 mm,平均(2.69±3.31) mm.随膝关节线升高,Feller髌骨评分呈下降趋势;关节线改变值与Feller髌骨评分呈负相关(r=-0.763,P=0.000).随关节线降低,Feller髌骨评分呈下降趋势;关节线改变值与髌骨评分呈正相关(r=0.914,P=0.000).术后12、24个月关节线改变4 mm以内的患者(55例)Feller髌骨评分均高于关节线改变大于4 mm的患者(21例),差异有统计学意义(t=12.648,P=0.000;t=11.775,P=0.000).结论 对后稳定型固定平台膝关节假体,关节线改变与膝前痛具有相关性,保持关节线变化在±4 mm以内有利于恢复膝关节功能.     

小切口单髁置换术治疗膝关节内侧间室骨关节炎94膝的中短期疗效研究

[目的]探讨小切口单髁置换术治疗膝关节内侧间室骨性关节炎的中短期疗效与手术技术。[方法]回顾性分析本院2003年1月～2010年6月收治的87例(94膝)经小切口单髁置换术治疗的膝关节内侧间室骨性关节炎患者的资料。对患者膝关节疼痛VAS评分、关节活动度、膝关节HSS评分、关节力线等进行评估分析,分析单髁关节置换临床效果、遇到的问题及应对方法。[结果]术后平均随访3.4年(6个月～7年),返修2例,无感染、深静脉血栓、假体脱位等,HSS评分由术前61.05分增至92.67分,优良率达92%。VAS评分由术前6.46分降至2.80分。术后疼痛缓解率94%。膝屈曲度平均达127.53°。术后力线平均内翻2°。[结论]小切口单髁置换术治疗膝关节内侧间室骨性关节炎中短期疗效满意,具有创伤小、恢复快、症状改善明显、术后功能良好等特点。     

Total knee arthroplasty in the valgus knee.

The valgus knee presents a unique set of problems that must be addressed during total knee arthroplasty. Both bone and soft-tissue deformities complicate restoration of proper alignment, positioning of components, and attainment of joint stability. The variables that may need to be addressed include lateral femoral condyle or tibial plateau deficiencies secondary to developmental abnormalities, and/or wear; primary or acquired contracture of the lateral capsular and ligamentous structures; and, occasionally, laxity of the medial collateral ligament. Understanding the specific pathologic anatomy associated with the valgus knee is a prerequisite to selecting the proper surgical method to optimize component position and restore soft-tissue balance.     

Rotating-hinge total knee for revision total knee arthroplasty

Rotating-hinge knee implants are used for revision total knee arthroplasty in patients with severe ligament instability and bone loss. This study evaluated the outcomes of a series of rotating-hinge knees. Thirty-one NexGen Rotating Hinge Knees (Zimmer, Warsaw, Indiana) were implanted in 29 patients (2 bilateral), with an average age of 72.8 years. Indications for surgery were aseptic loosening (n=23), septic loosenings (n=4), tibiofemoral instability (n=3), and wear (n=1). The Hospital for Special Surgery Knee Score and the Knee Society Roentgenographic Evaluation System were used. Statistical and cumulative survival rate analyses were performed. Average follow-up was 60.3 months (range, 32-100 months). The Hospital for Special Surgery Knee Score results indicated statistically significant improvement; the total score increased from 65.5 preoperatively to 88.4 postoperatively. Average range of motion increased from 90.9° preoperatively to 114.4° postoperatively. Radiographs showed no periprosthetic bone fractures or implant ruptures. Radiolucent lines were found in 20 of 26 patients and were progressive in 2 (both revised). Complications occurred in 10 patients. The rigidity of the hinge may be associated with a risk of aseptic loosening due to the increased stress transfer to the bone from the prosthesis through the locked hinge. Rotating-hinge knee implants provided acceptable mid-term outcomes for revision knee surgery with ligamentous instability. They are not at higher risk for early loosening unless short tibial stems are used. The high percentage of failures is more related to the complex surgery and to the status of the patients than to the hinged mechanism.     

二期全膝关节置换治疗膝关节真菌感染1例

膝关节真菌感染发病率低,临床少见.其起病慢,病程长,晚期可出现关节骨质严重破坏,膝关节功能丧失.关节真菌感染临床症状不典型,影像也无特征性表现,尤其在早期,容易出现误诊误治,导致延误治疗.本文报告福建中医药大学附属泉州市正骨医院2019 年9 月收治的1 例膝关节真菌感染的治疗经过,结合文献复习,探讨本病在诊断以及治疗...     

单髁膝关节置换治疗膝关节单间室病变

[目的]了解单髁膝关节置换治疗单问室膝关节病变的早期疗效,探讨单髁膝关节置换手术的手术适应证和手术技术难点.[方法]采用轻度矫正不足(slightly undercorrect)原则和内侧有限松解技术对15例各类单间室膝关节病变患者行单髁膝关节置换术,对术前和随访时HSS评分,股胫角,最大关节活动度进行统计分析,并测量胫骨假体后倾角度.[结果]HSS评分,股胫角,最大关节活动度均较术前有显著改善,胫骨平台后倾角度平均4.2°.[结论]单髁膝关节置换治疗膝关节病变的早期疗效可靠,严格把握手术适应证是单髁膝关节置换疗效的保证,内侧有限松解技术能有效改善屈曲挛缩.     

Arthrodesis of the knee after failed knee replacement

Arthrodesis of the knee is sometimes needed for failed total knee replacement, but fusion can be difficult to obtain. We describe a method of arthrodesis that uses the simple, inexpensive, Portsmouth external fixator. Bony union was obtained in all six patients treated with this technique. These results are compared with those obtained by other methods of arthrodesis.     

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。