膝内翻全膝关节置换术软组织平衡方法探讨

目的分析骨性关节炎膝内翻角度的组成,探讨全膝关节置换术(totalkneearthroplasty,TKA)中软组织平衡方法。方法分析1999年1月～2003年12月因骨性关节炎行TKA的100例145侧膝内翻患者,其中男18例25个膝关节,女82例120个膝关节。平均年龄62.4岁(45～80岁)。膝关节HSS(hospitalofspecialsurgery)评分38.0±3.2分。根据下肢力线情况准确截骨,恢复膝关节静态骨性对线,然后根据内翻角度组成情况决定软组织松解部位及范围。软组织松解分3步进行,即截骨前暴露时松解、截骨时松解和截骨后安装假体前彻底松解。松解要点包括:韧带及关节囊松解、骨赘清除及髌骨外侧支持带松解。结果术前膝内翻总角度为9.2±3.1°,软组织失衡性内翻占53.2%,胫骨结构性内翻占46.8%,二者差异无统计学意义(P>0.05)。胫骨结构性内翻中胫骨骨性内翻占22.8%,胫骨平台关节面磨损及破坏占24.0%。术后结果表明,平均胫骨平台截骨角度为4.3°,占膝内翻矫正度数的27.9%;软组织平衡术矫正的度数为10.7°,占膝内翻矫正度数的72.1%。术后HSS评分为87.0±4.5分,与术前比较差异有统计学意义(P<0.05)。结论骨性关节炎膝内翻角度由两方面组成:即胫骨结构性内翻和膝关节侧副韧带及软组织失衡导致的内翻。其中后者占膝内翻角度的主要部分,通过松解内侧软组织进行矫正,松解的关键部位为内侧侧副韧带胫骨侧止点及后关节囊。松解时应循序渐进,随时测试,且勿松解过度。     

全膝关节置换术中下肢力线对线的研究进展

全膝关节置换术(TKA)可有效治疗终末期退行性骨关节疾病。在TKA中,精确地矫正下肢力线是重要的目标,它影响着关节稳定的维持和关节功能的恢复。该文就TKA中的下肢力线对线研究进展进行综述,分析下肢力线不同对线方法的临床效果及存在的问题,包括影像学对线(冠状位对线、矢状位对线、旋转位对线)和解剖学对线(机械对线、运动力学对线、解剖对线、功能对线),旨在为外科医师在TKA中选择不同的下肢力线对线方案提供参考。     

人工全膝关节置换术治疗单侧膝内翻合并屈曲挛缩畸形的临床分析

目的对人工全膝关节置换术(TKA)治疗单侧膝内翻合并屈曲挛缩畸形进行临床分析。方法对15例膝内翻(内翻角度5～20°)合并屈曲挛缩畸形(屈曲畸形角度>20°)患者行人工全膝关节置换术。分析术中软组织的松解、下肢力线的恢复以及术后双下肢的等长问题。结果术中除1例原屈曲挛缩角度60°者手术矫正后仍残留5°屈曲,其余14例术后均达到膝关节完全伸直。结论对于膝内翻合并屈曲挛缩畸形,股骨、胫骨要求对线准确,保证假体置入后股骨头中心、膝关节中心与踝关节中心位于一条直线,使力线得到矫正;软组织松解的平衡要求每完成一步都要进行测量,预防术后关节不稳;下肢长度要恢复等长,防止术后跛行。     

全膝关节置换中膝内翻的处理

膝内翻病人行全膝关节置换往往需要在胫骨侧松解内侧结构,重建外侧松弛结构的张力,合理选择是否保留后交叉韧带,确定截骨的部位并正确实施。不同原因所致膝内翻的处理方法不同。松解始终保持在骨膜下进行,而且只松解引起畸形的部分,既要充分,又不过度,以防止聚乙烯假体磨损和胫骨假体早期松动．外翻松弛和屈膝不稳。     

膝内翻畸形程度对全膝关节置换术的影响

[目的]探讨膝内翻畸形程度对全膝关节置换术（total knee arthroplasty, TKA）疗效的影响。[方法]回顾性分析2020年4月—2022年4月86例在本院行TKA的膝骨关节炎患者的临床资料。根据术前髋-膝-踝角（hip-knee-ankle angle,HKAA）,54例为轻度内翻（≤10°）,32例为中度内翻畸形（10°～20°）。分析下肢力线与临床评分的相关性。[结果]两组均顺利手术,无严重并发症,两组间围手术期指标的差异均无统计学意义（P>0.05）。随时间推移,两组术后VAS评分、WOMAC评分、膝伸-屈ROM及HSS评分均显著改善（P<0.05）。术前及术后3个月轻度组VAS、HSS、WOMAC及膝伸-屈ROM均显著优于中度组（P<0.05）。影像方面,轻度组术前股胫角（femorotibial angle, FTA）[(190.4±5.6)°vs (196.3±6.1)°, P<0.001]、胫骨近端内侧角（medial proximal tibial angle, MPTA）[(73.4±3.8)°vs (67.2±3.1)°,...     

OrthoPilot计算机红外线导航系统在膝内翻畸形全膝关节置换术中的应用

目的 探讨OrthoPilot计算机红外线导航系统在合并膝内翻畸形膝关节骨性关节炎全膝关节置换术中应用的效果.方法 纳入自2018-01-2019-01行单侧全膝关节置换术治疗的40例合并膝内翻畸形的膝关节骨性关节炎,20例采用OrthoPilot计算机红外线导航系统辅助手术(导航组),20例采用常规髓内定位技术(常规...     

全膝关节置换术后下肢深静脉血栓发生的时间分布

[目的]研究全膝关节置换(total knee arthroplasty,TKA)术后,在气压泵和利伐沙班双重预防下,下肢深静脉血栓(deep venous thrombosis,DVT)发生的时间分布。[方法]于术前,术后第1、2、3 d晨分别进行下肢血管B超检查,于术后第3 d下午行下肢深静脉造影检查;术后当晚开始给予利伐沙班口服(15 mg,1次/d);术后第1 d开始应用双侧间歇性充气加压装置进行血栓预防(1 h/d);术后当晚及第1 d开始有专门康复医师指导患者行关节活动训练。[结果]健侧、术侧DVT的总发生率分别为6.25%、13.75%。健侧肢体术前、术后当日,术后第1、2、3 d发生的血栓数为1(发生率1.25%,占总血栓数20%)、3(3.75%,60%)、1(1.25%,20%)、0(0%,0%)、0(0%,0%);术侧肢体术前,术后当日,术后第1、2、3 d发生的血栓数为0(0%,0%)、9(11.25%,81.8%)、1(1.25%,9.09%)、1(1.25%,9.09%)、0(0%,0%)。[结论]TKA术后,在气压泵和利伐沙班的双重预防下,患者术后当日新发DVT占总数的比例最高(健侧60%、术侧81.8%),而术后第1、2、3 d新发例数则迅速下降,占比重较低。因此DVT的预防需要加强且应从术中开始实行。     

合并膝内翻骨性关节炎全膝关节置换的处理

目的探讨膝骨性关节炎合并膝内翻畸形者行膝关节置换时膝内翻的矫正方法。方法172例（190膝）合并内翻畸形骨性关节炎患者进行全膝关节表面置换术。术前测量膝内翻角、关节面夹角、胫骨角、胫骨内翻角及胫骨平台后倾角,其内翻角为8°～21°,参考关节面夹角、胫骨角及胫骨内翻角确定膝内翻的类型,术中根据膝内翻的类型及构成因素进行相应的胫骨截骨及适度的软组织松解。结果出现切口感染2例（2膝）,1例为急性感染,1例为迟发性感染,2例均经清创、假体取出并膝关节融合术后痊愈。术后内翻矫正157膝,仍有膝内翻33膝,内翻角3°～9°（4.8°±0.9°）。165例（182膝）获得随访,时间8～90（40±3.5）个月。末次随访时除2例感染外,余膝关节活动度为：伸直0°168膝,伸直受限＆lt;10°11膝,伸直受限11°～15°3膝;屈曲90°～130°。临床及X线检查未见明显松动迹象。HSS膝关节评分由术前12～57（30±5.5）分提高到76～89（79.2±4.3）分。结论术前明确膝内翻的类型及构成因素,术中采取针对性操作进行适度的软组织松解及正确的截骨,是全膝关节置换膝内翻获得矫正的有效方法。     

人工全膝关节置换术后躯体重心转移与患者恢复程度的关系

目的探讨膝关节骨性关节炎(OA)患者行单侧全膝关节置换术(TKA)后躯体重心位置(GCP)在水平方向上转移情况,并判断其转移程度与患肢功能恢复情况是否存在相关性。方法用重心测量仪对176例接受单侧TKA的膝关节OA患者进行GCP测定,根据HSS评分标准对患者术前1周、术后6个月、术后1年的患肢功能情况进行评估;同时记录患者GCP,量化GCP转移程度,并与术侧膝关节HSS评分变化程度进行Pearson分析。结果 176例患者在TKA术后6个月和术后1年时HSS功能评分均较术前有明显改善,且随着术侧关节功能进一步恢复,患者GCP由起初的位置逐渐向术侧方向移动。结论术后GCP转移程度与同一时期患者HSS评分变化程度呈线性相关,患者GCP转移程度与同一时期HSS评分变化相关系数R2分别为0.584和0.498。     

全膝关节置换术后患肢机械轴力线变化趋势研究

目的 探讨全膝关节置换术后不同时间点下肢负重位全长X线片测量下肢机械轴力线的变化趋势.方法 纳入自2018-01-2019-06行单侧全膝关节置换术的26例膝关节骨性关节炎,患者分别于术前、术后l周、术后3个月、术后12个月摄下肢负重位全长X线片并测量下肢机械轴力线,观察其变化趋势.结果 大部分患者术后1周时测量下肢机...     

个性化截骨技术在严重膝内翻骨关节炎初次TKA中的应用价值分析

目的:探讨个性化截骨技术在严重膝内翻骨关节炎初次全膝关节置换术(total knee arthroplasty,TKA)中的应用价值和疗效分析。方法:自2018年6月至2020年1月收治36例(49膝)严重膝内翻骨关节炎患者,男15例(21膝),女21例(28膝);年龄59～82(67.6±6.5)岁;病程9.5～20.5 (15.0±4.5)年;骨关节炎Kellgren-Lawrence分级Ⅲ级11例(15膝),Ⅳ级25例(34膝);胫骨骨缺损分型AORI分型ⅠTa 8例(15膝),ⅡT2a型16例(18膝)。所有病例股-胫角(femor-tibial angle FTA)>15°,采用个性化截骨技术接受初次TKA,使用后稳定假体(posterior stability,PS)33例(45膝),PS假体胫骨侧联合使用金属垫块延长杆13例(15膝),踝限制性假体(legacy constrained condyarknee,LCCK)3例(4膝)。采用医院影像归档和通讯系统(picture archiving and communication systems,PACS)软件测量...     

膝关节置换时股骨髓内定位对假体排列的影响

目的 :探讨膝关节置换时股骨髓内定位杆进针点的位置对下肢力线造成的误差及其相关的影响殷素。方法 :选取行TACK膝关节置换的骨关节病患者 40例。术中股骨截骨髓内定位杆的进针点为股骨滑车中心。术前术后于 14英寸× 17英寸X线片测量膝关节的股胫角 (FTA)、股骨外侧角。并根据数学模型计算TACK置换后可能造成的最大误差。结果 :股骨解剖轴线一般与股骨内侧髁相交 ,距滑车中心平均 7mm ( 0～ 11mm) ,膝外翻者股骨解剖轴线偏离滑车中心更多。术后测量股骨假体外侧角为 80～ 90° ,内外翻误差 2°以内者占 70 % ,理论计算如果进针点位于滑车中心 ,会导致外翻误差增加。结论 :真正的髓内定位杆进针点应位于股骨解剖轴线上 ,进针点外移会导致股骨假体过度外翻。术前应在全长或 14英寸× 17英寸站立正位X线画出股骨解剖轴线 ,根据股骨轴线与股骨髁交点的实际位置进行髓内定位 ,可减小误差     

Less valgus alignment in total knee arthroplasty for the varus knee

Constitutional varus of the leg is well recognizable anatomically. Moreland[1] studied long standing radiographs of normal males with a range of varus from 2.6-3° in the proximal tibia. Victor et al. [2] reported constitution varus of 3 degree in 32% men, 17% women. The authors routine technique during total knee arthroplasty (TKA) is to cut the distal femur at 5° valgus and the tibia at neutral for the valgus leg and cut the distal femur at 5° valgus and the tibia 2° varus for varus aligned limbs. 127 consecutive long standing knee radiographs were not retrospectively studied pre and post operatively with 2 year minimum follow up. Average age was 68 years (range 51-90). Average weight was 215 lbs (range 110 – 333). Average tourniquet time was 32 minutes for all patients prior to closure.For the varus group (72 knees), average pre-op tibial femoral alignment was 3.3° varus (range 0-13°). Post-op tibial femoral alignment was 1.2° valgus (range 1° varus - 5° valgus) with the mechanical axis falling into the medial compartment in all patients. Average pre-op knee score was 88 and post-op was 180 at minimum of 2 years.For the valgus group (55 knees), average pre-op tibial femoral alignment was 7.5° (range 2°-24°) valgus. Average post-op tibial femoral alignment was 3.8° (range 1°-10°) valgus. Average pre-op knee score was 107 and post-op was 182 at minimum of 2 years. The authors agree with aiming for valgus alignment for the classic valgus leg (mechanical axis centered on hip, knee, ankle) and less valgus alignment for the varus knee (mechanical axis into the medial compartment). Following the patients anatomy eliminates the need for major soft tissue releases while still avoiding “malalignment”. No special soft tissue releases were required in any patient with pre-op varus or valgus alignment. The clinical outcome is not effected by leaving pre-op varus aligned extremities in less valgus with their TKA’s.     

全膝关节置换术中股骨内髁滑移截骨治疗伴有关节外畸形的膝内翻

目的：探讨股骨内髁滑移截骨术（medial condyle sliding osteotomy, MCSO）在全膝关节置换术中纠正患者内翻膝关节外畸形的临床疗效。方法通过回顾性研究2013年1月至2015年12月在第三军医大学附属西南医院关节外科中心于全膝关节置换术中采用MCSO在关节内纠正股骨侧的关节外内翻畸形的12例患者,统计该组患者手术前后的股骨远端外侧力线角（mechanical lateral distal femoral angle, mLDFA）、髋-膝-踝（hip?knee?ankle, HKA）角、疼痛视觉模拟量表（visual analogue scale, VAS）评分及美国膝关节协会（American Knee Society, AKS）综合评分系统中的膝评分和功能评分等,评价MCSO纠正关节外的内翻畸形的效果。结果本组患者随访6~40个月,无感染、骨折、假体松动、截骨不愈合等并发症发生。本组患者手术前后的mLDFA分别为117.4°±4.7°、91.6°±1.4°;手术前后的HKA角分别为167.2°±9.8°、179.6°±1.6°;手术前后的VAS评分分别为（6.4±1.1）分、（1.8±1.5）分;手术前后的AKS膝评分分别为（60.2±17.6）分、（92.6±9.4）分;手术前后的AKS功能评分分别为（69.4±21.3）分、（87.6±14.9）分。手术前后以上指标的差异均有统计学意义（均P＜0.05）。结论在合并关节外畸形的内翻膝的关节置换手术中,采用MCSO技术可以正确纠正内翻力线,更容易实现伸屈间隙平衡,达到满意的手术疗效。能有效避免对膝关节后内侧和内侧组织结构的过度松解,从而避免单纯依赖软组织松解而导致的屈曲位内侧间隙松弛及髌股关节对位不良等问题。     

Mid-to long-term results of total hip arthroplasty after contralateral lower extremity amputation

Objective

There is limited literature concerning the outcomes and role of THA as a surgical option for amputee patients. The aim of this study is to determine the mid-to long-term survival and complication rates of cementless total hip arthroplasty (THA) in patients with contralateral below knee amputations.

TKA治疗膝关节骨性关节炎238例临床分析

目的分析采用全膝关节置换术(TKA)治疗膝关节骨性关节炎(OA)的临床疗效。方法笔者自2014-01—2014-12采用TKA治疗238例OA,采用膝关节功能HSS评分评价手术前后膝关节功能。结果术后失访28例,210例获得随访平均10(3~15)个月,均无不良反应及严重并发症。患者术前HSS评分为(48.8±7.6)分,术后HSS评分为(93.7±3.6)分,手术前后HSS评分差异有统计学意义(Z=-12.569,P0.001);术后膝关节伸屈活动度100°~140°(122.8±10.3)°,明显优于术前屈伸活动度15°~135°(81.7±20.1)°,差异有统计学意义(Z=-13.694,P0.001)。结论 TKA治疗OA是一种安全、高效的手段,能够极大程度地改善、消除患者所承受的痛苦,促进下肢运动功能的恢复,使患者的生活质量得到很大提高,是比较理想的治疗手段。     

Better results with patelloplasty compared to traditional total knee arthroplasty

Purpose

The aim of this study was to compare the results of primary total knee arthroplasty with or without patelloplasty.

Methods

We retrospectively reviewed 89 patients who had received total knee arthroplasty. In patelloplasty, the patellar cartilage was resected using a tangential saw cut, and in the traditional treatment, only the surrounding osteophytes were removed. The outcome was measured using radiographs, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, Knee Society Score, Knee Society Function Score and Knee Society Pain Score.

Results

Patelloplasty patients had a better outcome according to the Oxford Knee Score (P = 0.012), Knee Injury and Osteoarthritis Outcome Score (P = 0.003) and all of the Knee Injury and Osteoarthritis Outcome Score subscales (P < 0.05). The patella was significantly thinner (P = 0.001) post-operatively in the patelloplasty patients, but there was no statistically significant correlation between Oxford Knee Score or Knee Injury and Osteoarthritis Outcome Score and post-operative patellar thickness in the patelloplasty group.

Conclusions

In this follow-up, patelloplasty was better than traditional treatment in relieving pain and improving function and quality of life.     

Evaluation of the hindfoot alignment before and after total knee arthroplasty

BackgroundOpen wedge high tibial osteotomy (OWHTO) and total knee arthroplasty (TKA) alter the ankle joint line obliquity (AJLO) to be more horizontal relative to the ground and aligns the valgus subtalar joint (SJ) neutrally. A previous study of the hindfoot alignment angle (HAA) showed that lower limb alignment after OWHTO becomes under-corrected because of abnormal compensation by the SJ. However, because TKA can exclude effects of femorotibial joint instability, analysis of a post-TKA cohort enables a more accurate evaluation of SJ compensation than analysis of a post-OWHTO cohort. In the present study, we performed radiographic evaluations before and after TKA to analyze SJ compensation.MethodsLower limb and hindfoot alignment were measured on plain radiographs in 46 patients (48 knees) who underwent TKA in our department. The patients were divided into Group A (postoperative AJLO within ±1°) and Group B (postoperative AJLO greater than ±1°), and various parameters were compared between the groups. The preoperative HAA that resulted in an abnormal postoperative AJLO was investigated.ResultsGroup A had a significantly smaller preoperative HAA (p = 0.03) and postoperative HAA (p < 0.01) than Group B. Differences in the preoperative HAA between the two groups showed a cut-off value of 9.06°.ConclusionPatients with an HAA of more than 9.06° are likely to have abnormal hindfoot compensation.     

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.     

全膝关节置换术后严重异位骨化与关节僵硬

[目的]探讨全膝关节置换术后严重异位骨化与关节僵硬的关系。[方法]对420例接受全膝关节置换术的患者随访,其中9例出现了Ⅲ级异位骨化,分别测量并记录该9例患者术后2周、12个月的疼痛评分和膝关节活动度,拍摄X线片,测量异位骨的大小。随机抽取9例无异位骨化的关节置换术后患者作为对照组,并测量疼痛评分及活动度。分别将异位骨化组和对照组的结果进行对比。[结果]关节置换术后Ⅲ级异位骨化的发病率为2.1%,X线片显示异位骨>5 cm,侵及股四头肌,引起关节疼痛。异位骨化组术后2周疼痛评分平均25.6分,关节最大伸直角度平均1.1°,最大屈曲角度119.1°,与对照组比较差异均无统计学意义(P>0.05)。异位骨化组术后12个月疼痛评分平均15.56分,低于术后2周(P<0.01),与对照组术后12个月(25分)比较有显著差异(P<0.01)。关节活动度:伸直6.1°,屈曲91.7°与术后2周和对照组术后12个月比较均有显著差异(P<0.01)。[结论]全膝关节置换术后Ⅲ级异位骨化可以导致关节疼痛和活动度受限,是术后关节僵硬的原因之一,严重影响置换术后临床效果。