保留和置换髌骨对全膝关节置换术中髌股关节轨迹不良临床效果的影响

目的探讨保留和置换髌骨对全膝关节置换术(TKA)中髌股关节轨迹不良术后的临床效果和影像学评价的影响。方法回顾性分析78例(80膝)TKA中髌股关节轨迹不良患者:保留髌骨组40例(41膝):保留髌骨进行TKA手术。置换髌骨组38例(39膝):置换髌骨,其余TKA手术操作相同。比较两组术后HSS评分、髌骨FELLER评分及影像学评价。结果术后随访时间23~132个月,平均64.2个月。两组数据HSS功能、髌骨FELLER评分手术前后对比有明显提高,而两组间差异无统计学意义(P0.05)。影像学评价:膝关节侧位片两组Caton Index指数没有明显变化=1.47(P0.05)、屈膝45°Knutsson髌骨轴位X线片髌股指数置换髌骨组优于保留髌骨组=2.65(P0.05),CT扫描外侧髌骨移位=3.12和髌骨倾斜角=3.39,置换髌骨组较保留髌骨组改善(P0.05),两组比较差异有统计学意义。结论对于髌股关节轨迹不良患者,恰当选择置换髌骨进行膝关节置换可改善髌股轨迹,进一步减少髌股关节并发症,提高人工膝关节置换的疗效。     

全膝关节置换过程中髌股关节轨迹不良的处理

背景：人工全膝关节置换后膝前痛的主要原因是髌股关节并发症。 目的：探讨全膝关节置换过程中髌股关节轨迹不良的处理方法。 方法：31例32膝在全膝关节置换过程中出现髌股关节轨迹不良,均为女性,年龄53-85岁,平均68.5岁,病程8-25年,平均22.3年,其中骨性关节炎27例28膝,类风湿性关节炎4例4膝。膝外翻角12°-32°,平均20°;Q角为13°-23°,平均16°。采用正确截骨,调整假体位置,髌骨内外侧软组织平衡,或加行Goldthwait-Roux术进行纠正。 结果与结论：随访时间12-120个月。膝关节平均活动度数(98.2±10.3)°。KSS评分从置换前平均35分提高到置换后平均81分;KSS功能评分从置换前平均34分提高到置换后平均83分。置换后切口均Ⅰ期愈合,未发生皮肤坏死、切口感染等并发症。屈膝45° Knutsson髌骨轴位X射线片检查无髌骨倾斜、半脱位或脱位。结果说明在全膝关节置换过程中出现髌股关节轨迹不良时采用稳定性假体,正确截骨及调整假体位置,髌骨内外侧软组织平衡,或加行Goldthwait-Roux术,可取得比较满意的疗效。     

全膝关节置换中是否需要髌骨置换

背景：全膝关节置换中髌骨置换与否一直存在争议。 目的：对临床全膝关节置换中是否进行髌骨置换进行对比观察。 方法：随机选取2009年7月至2012年4月在盐城市第一人民医院膝关节骨性关节炎患者56例,共60膝,按全膝关节置换时是否进行髌骨置换分为髌骨置换组和髌骨未置换组。 结果与结论：全膝关节置换3个月后,髌骨置换组患者在膝关节功能评定量表评分、髌骨评分、活动度和Q角与髌骨未置换组比明显降低(P < 0.05),而膝前痛评分和膝外翻角与髌骨未置换组患者的差异无显著性意义(P > 0.05)。提示全膝关节置换中合理进行髌骨处理可有效改善髌股关节运动轨迹,明显降低髌骨并发症。对于髌股关节匹配及力线良好的患者保留髌骨可提高关节的功能恢复,在全膝关节置换中进行髌骨置换较髌骨不置换总体效果好。     

髌股关节骨性关节炎严重程度不影响保留髌骨全膝关节置换患者的预后

文题释义： 髌骨适合角：自股骨内外髁最高点分别向股骨髁间沟的最低点画2条直线，这2条线的夹角即为沟角，其角平分线和其顶点与髌骨下级之间的连线形成的夹角为适合角。 髌韧带比值：屈膝30°侧位像上使用Insall-Salvati指数评价髌骨的高度，测量髌腱长度即自髌骨下级至胫骨结节定点上缘，再测量髌骨最长对角线的长度，两者之间比为髌韧带比值。 背景：目前关于全膝关节置换过程中髌骨是否置换尚没有统一标准，对于髌骨置换和不置换的对照研究很多，但是在全膝关节置换不置换髌骨的研究中根据髌股关节炎严重程度分级来比较预后的研究很少。 目的：根据髌股关节炎的严重程度进行分级，比较髌股关节炎的轻重对保留髌骨的全膝关节置换疗效的影响。 方法：回顾性分析2016年1月至2017年1月郑州大学第一附属医院使用强生假体行髌骨保留的全膝关节置换患者192例的临床资料，随访时间大于2年。根据髌股关节炎影像学严重程度Lwano分类系统将患者分为2组，轻度组(0-Ⅰ期)83例，重度组(Ⅱ-Ⅳ期)109例。所有患者对治疗及试验方案均知情同意，且得到医院伦理委员会批准。使用美国膝关节协会评分、功能评分、Feller评分、膝前疼痛评分评估临床预后，使用髌骨倾斜角、适合角、髌骨外移距离、髌韧带比值评估影像学预后。运用t检验，分析患者术前、术后的临床和影像学结果。 结果与结论：①术后1例患者出现持续性膝前疼痛，1例患者伤口渗液，清创后二期愈合，其余均一期愈合；②术前轻度组和重度组患者的功能评分和美国膝关节协会评分差异有显著性意义(P < 0.05)，但术后2组功能评分和美国膝关节协会评分差异均无显著性意义(P > 0.05)；③影像学上，2组术前髌骨倾斜角、适合角、髌骨外移距离差异有显著性意义(P < 0.05)，但术后2组髌骨倾斜角、适合角、髌骨外移距离差异均无显著性意义(P > 0.05)；④提示在对保留髌骨的全膝关节置换患者进行至少2年的随访后发现，髌股关节炎的严重程度对患者的临床和影像学预后没有影响；即使在重度髌股关节炎患者中，保留髌骨的全膝关节置换后也能获得良好的预后。 ORCID: 0000-0002-2784-1542(徐长波) 中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程     

初次全膝关节表面置换后的低位髌骨

背景:全膝关节表面置换后有关髌股关节问题的并发症高达39%,而造成置换后髌股关节并发症的原因很多,其中低位髌骨是引起髌股关节并发症的原因之一,但是常被临床医生忽视。目的:分析初次全膝关节表面置换后导致髌股关节并发症的原因之一髌骨低位的发生机制。方法:回顾性分析2003-07/2009-01河北医科大学第三医院关节骨科行初次全膝关节表面置换患者78例85膝临床资料。按照HSS膝关节评分将病例分成两组,高分组和低分组。将两组置换前后膝关节X射线片对照,应用Insall-salvati法测量髌骨的高度,并利用Hofmann方法测量关节线的位置变化。运用Logistic回归分析方法分析低位髌骨与Insall-salvati指数及关节线变化的相关性。结果与结论:高分组59膝未发生低位髌骨;低分组26膝中23膝发生不同程度的髌骨低位,其中6膝Insall-salvati指数为1.1±0.1,17膝关节线上移(7.0±2.3)mm。Logistic回归分析结果显示低位髌骨发生与Insall-salvati指数和关节线的上移有一定关系。提示初次全膝表面置换后髌骨下移的发生是由于胫骨聚已烯垫的厚度大于截骨的厚度即关节线上移和髌韧带的挛缩引起的。因此在初次全膝关节表面置换中要最大程度恢复原有的膝关节线位置,并加强早期的膝关节功能锻炼,以尽快恢复膝关节的活动度,防止髌韧带的挛缩。     

人工全膝关节置换术中髌股关节轨迹不良的处理策略及疗效

目的　总结人工全膝关节置换（total knee arthroplasty,TKA）术中,纠正髌股关节轨迹不良的方法及效果。 方法　2012年6月-2014 年12 月,对52例58膝TKA术中出现髌骨向外侧脱位倾向髌股关节轨迹不良的患者,针对发生原因,通过单纯调整髌骨内、外侧支持带张力,髌骨修整成形或调整胫骨假体位置等方法,或者联合应用上述两种或两种以上方法进行纠正。 结果 术中无拇指试验髌股关节轨迹恢复正常,术后髌骨未出现向外脱位倾向。术后切口均Ⅰ期愈合,2例因外翻明显,术中外侧支持带松解范围较大,术后出现关节积血,经对症处理后好转,无其他并发症发生。所有患者术后均获随访,随访时间 17-47个月,平均32个月。膝关节内、外翻畸形均获得矫正,4例残留 5-10°(平均8°）左右的屈曲畸形。随访末期KSS评分78-89分,平均84分,膝关节KSS功能评分为82-91分,平均86分。术后至随访期末X线片均显示人工关节位置正常,无松动及感染迹象。 结论 TKA术中出现髌股关节轨迹不良时,通过单纯调整髌骨内、外侧支持带张力,髌骨修整成形或调整胫骨假体等方法,或者联合应用上述两种或两种以上方法等进行调整,是处理髌股轨迹不良的有效方法,有利于术后膝关节的功能恢复。     

关节镜下外侧支持带松解后的髌骨轨迹分析(英文)

背景:外侧支持带松解是治疗髌股关节紊乱症首选的治疗方法,然而有些文献报道部分病例的长期随访结果并不满意。目的:分析关节镜下外侧支持带松解后的髌骨轨迹,以探讨外侧支持带松解后部分病例随访优良率下降的原因。方法:临床采集符合纳入标准的57膝(34例)样本,松解前后分别行10°,20°,30°,40°屈膝位髌股关节CT扫描,测量髌股适合角、髌骨外移角和股骨远端内侧扭转角,比较松解前后髌骨轨迹的变化。结果与结论:通过测量髌股适合角,髌骨外移角发现髌骨轨迹17膝松解后无改善,40膝明显改善。40膝的股骨远端内侧扭转角均大于9°,17膝的股骨远端内侧扭转角均小于9°。说明股骨远端内侧扭转角可能是影响外侧支持带松解后髌骨轨迹的一个重要因素。     

全膝关节置换不同入路对伸膝装置影响的比较

背景:传统的人工全膝关节置换采用标准内侧髌旁入路,但其手术创伤大、康复时间长,且易对股四头肌腱在髌骨上极的止点造成干扰。经股内侧肌下方入路作为一种不干扰伸膝装置的入路方式,由于其无法提供充分的术野暴露,易对股肌造成损伤,目前其应用及安全性仍存在争议。目的:比较分析内侧髌旁和经股内侧肌下方入路行人工全膝关节置换的临床疗效。方法:将78例(82膝)择期行人工全膝关节置换的患者随机分为治疗组(39例41膝)和对照组(39例41膝),治疗组采用经股内侧肌下方入路,对照组采用内侧髌旁入路。观察两组患者人工全膝关节置换后膝关节功能、关节活动度及并发症的发生情况。结果与结论:与对照组比较,治疗组的手术时间明显增加,但其置换后伤口引流量明显减少、直腿抬高时间及下地行走时间均明显缩短(P0.05)。两组置换前、置换后12周的HSS评分差异无显著性意义(P0.05),而治疗组置换后1周、6周的HSS评分明显高于对照组(P0.05)。置换后,两组患者膝关节的关节活动度和股四头肌MMT分级均显著改善(P0.05),而治疗组置换后关节活动度和股四头肌MMT分级的改善程度较对照组更为明显(P0.05)。治疗组和对照组并发症的发生率分别为2.6%和15.4%,差异有显著性意义(P0.05)。结果表明经股内侧肌下方入路行人工全膝关节置换对伸膝装置影响小,可促进置换后关节功能及关节活动度的恢复,减少置换后并发症。     

自体富白细胞-血小板纤维蛋白凝胶与腘绳肌腱修复创伤性髌骨脱位

背景：临床上创伤性髌骨脱位合并内侧髌股韧带股骨止点或体部撕裂多采用内侧髌股韧带重建手术，为促进内侧髌股韧带重建术后的腱骨愈合，研究者采用了包括生长因子、干细胞、富血小板血浆在内的多种生物治疗技术。目的：探讨自体富白细胞-血小板纤维蛋白凝胶联合腘绳肌腱重建内侧髌股韧带修复创伤性髌骨脱位的临床疗效。方法：选择2019年2月至2021年2月秦皇岛市第一医院诊治的创伤性髌骨脱位患者37例，采用随机数字表法分为试验组(n=18)与对照组(n=19)，试验组接受自体富白细胞-血小板纤维蛋白凝胶联合自体腘绳肌腱重建内侧髌股韧带手术，对照组接受单纯自体绳肌腱重建内侧髌股韧带手术。两组患者术后随访12个月，通过目测类比评分、Lysholm评分、Kujala髌股关节评分及膝关节活动度评估患者膝关节疼痛及功能状态，通过MRI及CT片测量髌股关节髌骨倾斜角、髌骨适合角及髌骨外移率，评估髌股关节的稳定性及改善情况。结果与结论：(1)两组术后6,12个月的目测类比评分均低于术前(P <0.05)，术后6,12个月的Lysholm评分、Kujala髌股关节评分均高于术前(P <0.05)；试验组术后6个...     

保留髌骨型全膝关节置换修复退变性骨关节炎:髌软骨退变等级对疗效的影响

背景:全膝关节置换中是否置换髌骨以及髌骨软骨对疗效的影响还存在争议。目的:评价膝关节退变性骨关节炎行保留髌骨型全膝关节置换后膝前痛发生率、临床功能及髌骨软骨退变等级对临床疗效的影响。方法:回顾分析2008年6月至2010年2月采用保留髌骨型全膝关节置换治疗162例(162膝)膝关节退变性骨关节炎患者的临床资料。髌骨软骨退变等级采用Outerbridge分级标准、置换后膝前痛采用目测类比评分评分、临床功能采用美国膝关节学会评分和髌骨评分。结果与结论:所有患者切口达Ⅰ期愈合。髌骨软骨退变等级:Ⅰ级18例;Ⅱ级36例;Ⅲ级62例;Ⅳ级35例。末次随访时,6例(4.0%)患者有膝前疼痛,其中轻度疼痛4例,中度2例,无重度疼痛。患者平均美国膝关节学会、髌骨评分均明显提高。髌骨软骨退变等级不影响置换后膝前痛发生率(χ2=0.42,P=0.94)、美国膝关节学会评分(膝评分:F=1.83,P=0.14;功能评分:F=0.56,P=0.64)和髌骨评分(F=0.78,P=0.51)。说明膝关节退变性骨性关节炎行保留髌骨型全膝关节置换可取得满意的临床疗效,髌骨软骨退变等级不影响临床疗效。     

Is patellar resurfacing superior than nonresurfacing in total knee arthroplasty? A meta-analysis of randomized trials

Conflicting results from abundant studies have made it unclear whether the patella should be resurfaced during total knee replacement. A meta-analysis was undertaken to pool the results of randomized controlled studies (RCTs) and to compare the outcomes and postoperative complications after total knee arthroplasty with patellar resurfacing or nonresurfacing. Sixteen RCTs including 3034 knees between 1966 and December 2009 were analyzed. Reoperation for patellofemoral problems was significantly more likely in the nonresurfacing group (P = 0.03). There was no difference between the two groups in terms of anterior knee pain rate, knee pain score, knee society score and knee function score. The results indicate that patellar resurfacing would reduce the risk of reoperation after total knee replacement, but it seems that the benefits are limited on other aspects, and the analysis of high-quality studies shows no advantage of resurfacing over nonresurfacoing group, even in the aspect of reoperation risk. More carefully and scientifically designed RCTs are beneficial and necessary to further prove the results.     

Patellar reshaping versus resurfacing in total knee arthroplasty - Results of a randomized prospective trial at a minimum of 7 years' follow-up

ObjectiveTo compare the results of primary total knee arthroplasty with patellar reshaping or resurfacing.MethodsOne hundred thirty-three patients were randomized into patellar reshaping group and patellar resurfacing group. Patellar reshaping includes resecting the partial lateral facet of the patella and the osteophytes surrounding the patella, trimming the patella to match the trochlea of the femoral component. The minimum follow-up time was 7 years. The outcome was measured by anterior knee pain rate, Knee Society clinical score, and radiographs.ResultsEight patients in the reshaping group (12.5%) and 10 patients in the resurfacing group (14.7%) complained of anterior knee pain (P = 0.712). Meanwhile, there were no significant differences between the two groups in terms of total Knee Society score, Knee Society pain score, Knee Society function score, as well as anterior knee pain rate.ConclusionsWith the numbers available, there was no significant difference between the groups treated with patellar reshaping or patellar resurfacing with regard to the KSS, anterior knee pain rate and radiographs. We prefer reshaping the patella to resurfacing the patella because the former preserves sufficient patellar bone stock and can easily be converted to patellar replacement if patients complain of recurrent anterior knee pain.     

Five year results of selective patellar resurfacing in cruciate sparing total knee replacements

We performed a prospective study on 129 knees with a selective approach to patellar resurfacing. One hundred and five knees were followed up at an average of 57 months. Of these, 48 knees met the eligibility criteria, thus leaving 57 knees with unresurfaced patellas. Mean follow up was 57 months. Parameters studied included HSS scores, pain, function, range of motion and patellofemoral symptoms including the ability to rise from a chair and to negotiate stairs. Approximately 90% good to excellent results were observed in both groups. The incidence of anterior knee pain and patellofemoral related problems was lower than the average reported in literature. None of the knees was revised for patellofemoral problems. Our findings suggest that the results of patellofemoral resurfacing with modern TKR designs are dependent on a careful patient selection and meticulous surgical technique. With a selective approach to resurfacing, one can achieve a high percentage of good results in both groups. Post-operative anterior knee pain is probably not related to the fact as to whether the patella is resurfaced or not.     

Patellar resurfacing in total knee arthroplasty for osteoarthritis: a systematic review

A systematic review was performed to determine the advantages and disadvantages of patellar resurfacing during total knee replacement for osteoarthritis. Three randomised controlled studies were analysed. These studies recruited 302 knees and 235 knees (78%) were reviewed at least 5 years postoperatively (range 5–10 years). Patients undergoing patellar resurfacing received a cemented all polyethylene patella component. A patelloplasty was performed in some of the unresurfaced knees.

For the dichotomous data, odds ratios and 95% confidence intervals were calculated. Each outcome measure tested was assessed for heterogeneity using the Cochran Q test. If significant heterogeneity was present (p<0.10), data from the studies were not combined. If there was no significant heterogeneity, a combined odds ratio was calculated using a fixed effects model and a Z test was performed to test the overall effect.

Reoperation for patellofemoral problems was significantly more likely in the unresurfaced group (p=0.003). The overall rate for reoperation for a patellofemoral problem was 0.7% in the resurfaced group and 11% in the unresurfaced group. Study data on anterior knee pain could not be analysed together as there was significant heterogeneity. There was no difference between the two groups in terms of revision. This study found no mid- to long-term benefit to leaving the patella unresurfaced.     

Should the patella be resurfaced during total knee replacement?

Patellar resurfacing during total knee replacement (TKR) has been a controversial subject for many years. In 1990 a randomised prospective study was started to compare policies of resurfacing, not resurfacing and selectively resurfacing the patella. One hundred and twenty-five cases (suitable for a cruciate sparing TKR) were randomised. At the 5-year review, the group in which the patella had not been resurfaced had needed significantly more secondary surgery than the other groups. Global knee scoring systems showed little difference between the groups but a scoring system which focused on the patella revealed differences and demonstrated worse results when the patella was not resurfaced. A minor degree, of maltracking was tolerated in resurfaced knees but tended to cause pain and articular cartilage wear in unresurfaced patellae. Four knees with good patellar articular cartilage at surgery did poorly when not resurfaced, suggesting that a selective policy is not totally reliable. Routine patellar resurfacing gave the most reliable results.     

全膝关节置换中髌骨置换效果的系统评价

背景：在进行全膝关节置换时是否行髌骨置换一直存在争议。 目的：系统评价人工全膝关节置换过程中行髌骨置换的疗效,为进一步的临床研究及医疗实践提供参考。 方法：根据严格制定的纳入和排除标准,按照事先制定的检索策略,计算机检索Cochrane图书馆临床对照试验资料库,EMBASE,MEDLINE,中国生物医学文献数据库,中国期刊全文数据库和维普中文期刊数据库。 使用Cochrane协作网提供的软件Revman 5.0.25进行Meta分析。 结果与结论：14个随机对照试验共纳入1 788例膝,其中886例膝关节置换同时行髌骨置换,902例未行髌骨置换。Meta分析结果显示,髌骨置换组置换后5~7.5年内发生膝前痛的风险低,加权后RR=0.19,95%CI (0.11,0.31),但5年前和7.5年后二者差异无显著性意义;髌骨置换组与非髌骨置换组置换后5年内发生再手术的风险差异均无显著性意义,但5年以上髌骨置换组发生再手术的风险低,加权后RR=0.49,95%CI (0.33,0.75);膝关节KSS评分不论是亚组分析还是总体分析,差异均无显著性意义。总体Meta分析结果,KSS评分加权均数差值(WMD)为0.26,95%CI(-1.39, 1.90);患者满意度不论是亚组Meta分析还是总体Meta分析,差异均无显著性意义。总体Meta分析结果,患者满意度加权后RR=1.01,95%CI(0.97,1.05)。结果显示全膝关节置换中髌骨置换比髌骨不置换总体疗效要好。     

Long-term results of primary total knee arthroplasty with and without patellar resurfacing

Among patients that underwent total knee arthroplasty from June, 1990 to January, 1999, 61 cases (44 patients) that could be followed for more than 10 years were included in this study. The patients were divided into a patellar retention group and a patellar resurfacing group, and were compared with regard to their clinical and radiological outcomes. In patients undergoing primary TKA, a selective patellar resurfacing protocol was used. The indications for patellar retention were a small patella, nearly normal articular cartilage, minimal preoperative patellofemoral pain, poor patellar bone quality, and young patient age. When patellar retention was performed, osteophytes of the patella were removed and marginal electrocauterization was carried out. There were 25 cases (20 patients) in the patellar retention group and 36 cases (29 patients) in the patellar resurfacing group. The mean follow-up period was 140.7 months in the patellar retention group and 149.0 months in the patellar resurfacing group. The selective patellar resurfacing with total knee arthroplasty had a favorable outcome;there were a significant difference noted between the 2 groups in the functional scores, which showed better outcomes in the patellar resurfacing group than in the patellar retention group.     

LCS mobile bearing total knee arthroplasty without patellar resurfacing. Does the unresurfaced patella affect outcome? Survivorship at a minimum 10-year follow-up

BackgroundPatellar resurfacing during total knee arthroplasty (TKA) remains controversial. The aim of this study was to evaluate the long-term outcomes of a mobile-bearing TKA without patellar resurfacing.MethodsWe assessed the outcomes in 503 patients (600 knees) who had cemented LCS (low contact stress) mobile bearing TKA without patellar resurfacing at a minimum follow-up of 10 years. Clinical outcome scores and radiological assessment were used.ResultsFour knees were revised, two had bearing dislocation and nine patients (1.5%) had secondary resurfacing for anterior knee pain. There were no radiolucent lines or osteolytic defects on radiographic evaluation.The overall survivorship was 97.8% with re-operation for any reason as the endpoint.ConclusionNon-resurfacing of the patella does not adversely affect the outcome of the LCS mobile bearing TKA at minimum 10 years follow-up.     

Significance of a “hot patella” in total knee replacement without primary patellar resurfacing

A “hot patella” is a bone scan finding of increased tracer uptake in the patella, greater than the ipsilateral distal femur or the proximal tibia. Increased patellar uptake on the bone scans is a relatively frequent finding; this is often not commented upon. The aim of our study was to define the incidence of a “hot patella” on bone scans following total knee replacements with ongoing symptoms unrelated to sepsis. We wanted to investigate the correlation between the adverse retropatellar symptomatology following total knee replacement with bone scan findings.We undertook a retrospective study of 55 symptomatic total knee replacement patients, who had bone scans. The incidence of a “hot patella” in patients without primary patellar resurfacing was 51% (28/55). Ninety-five percent patients with anterior knee pain and 21% patients with diffuse knee pain had a “hot patella”. Statistical analysis showed a positive association between “hot patella” and anterior knee pain (p value of < 0.001). The patients with “hot patella” who underwent secondary patellar resurfacing had symptomatic relief of symptoms.Our study has shown that the finding of a “hot patella” on a bone scan in patients with anterior knee pain following total knee replacement suggests a problem related to the patellofemoral joint. This study would appear to indicate that a “hot patella” in a patient with clinically defined anterior knee pain is likely to benefit from secondary patellar resurfacing.