前交叉韧带重建术后关节粘连患者在体胫股关节运动学分析

目的 定量分析前交叉韧带重建(anterior cruciate ligament reconstruction, ACLR)术后关节粘连患者在体胫股关节 6 自由度的运动学特征。 方法 纳入 15 例 ACLR 术后关节粘连患者和 15 例健康受试者,运用便携式膝关节三维运动分析系统采集受试者负重屈膝和非负重屈膝时胫股相对于股骨的运动轨迹,获取胫股关节 6 自由度的运动学数据。 结果 与健康人相比,负重屈膝 30°、45°、60°和 75°时,膝关节粘连患者患侧胫骨内旋角度明显减少(P<0. 001);负重屈膝 30° 和 45° 时,膝关节粘连患者患侧胫骨相对于股骨的外翻角度较健康人明显减小(P<0. 05)。 非负重屈膝 75°时,膝关节粘连患者患侧胫骨内移距离较健康人明显减少(P<0. 05)。 结论 关节粘连限制了胫骨相对于股骨的旋转和内外移,对于胫骨相对于股骨的前后移动影响不大。 因此,临床上应该利用各种治疗手段松解股骨内外侧沟的粘连和外侧副韧带挛缩,解决旋转和内外移动受限的问题,以最大程度恢复膝关节功能。     

外侧副韧带松弛的内翻膝患者在TKA术中的胫骨截骨量分析

目的　探讨合并外侧副韧带松弛的内翻膝患者的截骨量是否受影响。 方法　选取本院2016年至2018年行膝关节置换的内翻膝患者92例,其中25例合并外侧副韧带松弛的患者为观察组;其余患者为对照组。两组均采用等量截骨法进行截骨。术中测量股骨远端外髁、股骨后外髁、胫骨外侧平台截骨量,随访测量胫股解剖角（anatomic tibiofemoral angle,ATFA）、髌骨倾斜角（patellar tilt angle,PTA）、股骨后髁偏距（posterior condylar offset,PCO）。采用美国膝关节协会评分（AKS）、美国特种外科医院（HSS）评分以及关节活动度评价关节功能。 结果　两组股骨远端外髁截骨量差异无统计学意义（P>0.05）,观察组术中胫骨外侧平台截骨量低于对照组（P<0.05）。两组患者术后6周、6个月及12个月ATFA、PTA、PCO、AKS评分、HSS评分及膝关节活动度无统计学差异（P>0.05）。 结论　合并外侧副韧带松弛的内翻膝患者的胫骨外侧平台截骨量较小。     

人体膝关节股胫关节运动特性分析

目的　分析人体正常膝关节和人工膝关节高屈曲活动下股胫关节的运动,为膝关节运动特性研究、假体设计提供参考。 方法　选取健康志愿者,利用CT和MRI扫描数据建立正常全膝关节三维有限元模型以及TKA术后有限元模型,采取三束股四头肌肌力非同步变力加载,模拟人体下蹲运动,以分析股胫关节的相对运动特性,并检索相关研究结果以便对比分析。 结果　获得正常膝关节以及TKA术后人体下蹲过程中股骨相对胫骨的三维相对运动数据,结果表明,TKA术前、后股胫关节相对运动的总体趋势相近,同时在前后位移、远近位移、内外位移、内收外展和内外旋等最大值方面存在差异;同时通过对比分析TKA前后股胫关节相对运动以及相关文献数据,发现结果存在不同程度差异。 结论　究其原因,正常膝关节相对运动差异主要在于股胫关节各个运动方向上和不同屈曲度时约束程度的改变;人工膝关节相对运动差异主要来源于膝关节型面和结构的改变;同时与坐标系的定义、在体和离体的差异、负荷加载的差异相关。本研究针对人体正常膝关节和TKA术后膝关节股胫关节运动进行有限元仿真分析,对膝关节运动特性研究具有一定的参考价值。     

高屈曲状态下膝关节静力稳定结构的生物力学研究进展

膝关节高屈曲状态在亚洲国家和中东地区的日常生活及特殊职业中极为常见。膝关节静力稳定结构包括前、后交叉韧带,内、外侧副韧带及关节囊,其主要功能是维持关节稳定性,其生物力学和运动学特点对全膝置换术中软组织松解、膝关节韧带重建及损伤后的康复具有重要意义。本文对近年来膝关节生物力学的研究方法及静力稳定结构在膝关节由伸直到高屈曲运动过程中的生物力学特点进行了阐述;对今后全膝置换术中软组织平衡、膝关节韧带修复与重建及伤后与术后康复方面的研究方向进行了展望和预测。     

全膝关节置换后关节线变化对髌股关节生物力学的影响

BACKGROUND: In addition to infection, the reasons for total knee arthroplasty revision are polyethylene liner wear and prosthesis loosening. The impact of joint line height on patellofemoral biomechanics was inconclusive. OBJECTIVE: To study the impact of joint line changes after total knee arthroplasty on patellofemoral joint biomechanics. METHODS: Three-dimensional finite element models were established after total knee arthroplasty. The impact of different joint line height on quadriceps tensile force, patella tendon tension, and patellofemoral joint forces was calculated at range of flexion of 0°, 30°, 60° and 90°.  RESULTS AND CONCLUSION: (1) At knee flexion of 0°, the height of the joint line in -3 mm-4.5 mm did not have great impacts on quadriceps tensile force, patella tendon tension and patellofemoral joint forces. (2) At knee flexion of 30°-90°, the height of the joint line below 3 mm did not have great impacts on quadriceps tensile force, patella tendon tension and patellofemoral joint forces. The height of the joint line more than 3 mm had obvious impacts on quadriceps tensile force, patella tendon tension and patellofemoral joint forces. (3) It was recommended that the height of joint line in total knee arthroplasty was preferably controlled within 3 mm.      

股四头肌V-Y成形技术在僵直或强直膝TKA术中的应用

目的 探讨僵直或强直膝全膝关节置换术(TKA)中采用股四头肌V-Y成形技术改善膝关节活动度的可行性及有效性.方法 回顾性分析自2014年4月至2018年4月宁德师范学院附属宁德市医院采用TKA治疗11例(13膝)僵直或强直膝患者资料,术中采用股四头肌V-Y成形技术,比较分析手术前后膝关节HSS评分和关节活动度变化.结果...     

单侧全膝关节置换术后两下肢受力不对称性的影响因素

全膝关节置换术(total knee arthroplasty,TKA)是晚期膝骨关节炎最常见的手术治疗手段。已有研究发现,单侧TKA术后两下肢受力不对称,对侧膝关节承担更大载荷,从而使骨关节炎加重面临再次置换的风险。综述单侧TKA术后可能引起两下肢受力不对称的影响因素,主要介绍下肢力线、疼痛、肌肉、本体感受、心理原因等;同时探讨这些影响因素对人体总的影响效果、人体对不对称载荷的补偿机制以及临床干预手段。通过对单侧TKA术后两下肢受力影响因素的分析,可以制定针对性的临床干预手段,用以减小患者对侧膝关节发展为骨关节炎甚至置换的风险。     

胫骨假体旋转对线技术影响髌股关节生物力学的作用机制

BACKGROUND: At present, the placement of tibial anatomic landmarks has no gold standard during total knee arthroplasty. In order to achieve the most ideal rotation function of the tibial prosthesis, we should do the preparation before surgery, understand tibial rotational alignment to rationally select and apply the prosthesis.     

同期双侧全膝关节置换与选择性单侧全膝关节置换后的早期功能恢复

背景：同期双侧全膝关节置换与选择性单侧全膝关节置换后的早期功能恢复一直存在着争议。 目的：评价双膝骨关节炎患者同期双侧全膝关节置换与选择性单侧全膝关节置换后功能恢复情况的差异。 方法：根据置换方案将初次行全膝关节置换的双膝骨关节炎患者86例(116膝)分为两组,双膝组(n=29,58膝)行同期双侧全膝关节置换,单膝组(n =57,57膝)行单侧全膝关节置换。分别对两组患者置换前后的关节活动度、屈曲挛缩度、肌力、疼痛评分、双下肢不等长及HSS评分进行比较分析,并记录并发症的发生率。 结果与结论：置换后1年随访,两组患者置换后关节活动度和肌力差异无显著性意义(P=0.171,0.418);置换后屈曲挛缩度、疼痛评分及双下肢不等长双膝组均显著低于单膝组(P=0.006,0.0013,0.026);同时双膝组置换后HSS评分优于单膝组(P=0.003)。提示同期双侧全膝关节置换患者在屈曲挛缩度、疼痛症状评分、双下肢不等长及HSS评分方面优于单侧全膝关节置换,而两种方案在置换后关节活动度和下肢肌力方面无明显差异。     

全膝关节置换治疗成人膝外翻畸形：胫股角及膝关节活动度变化

背景：膝外翻畸形施行人工全膝关节置换难度很大,涉及面多,争议亦颇多。 目的：观察全膝关节置换治疗成人膝外翻畸形的手术方法和临床效果。 方法：对12例15膝采用髌骨内侧入路,正确截骨,选择性的软组织松解,恢复膝关节正常的力线和软组织平衡,采用后稳定型假体进行全膝关节置换,获得膝关节的稳定,置换后采取针对性的康复训练,置换前后测量胫股角,并置换后定期随访检查膝关节活动度并进行HSS评分。 结果与结论：所有患者获得随访均>6个月。置换前胫股角平均21.47°降低至置换后的5.47°(P < 0.01),膝关节活动度由置换前的81.33°提高到121.07°(P < 0.01);HSS评分由置换前的25.47分提高到89.87分(P < 0.01)。置换后1例出现关节积液较多,2例出现膝关节内测不稳。无髌骨脱位或半脱位,下肢力线均恢复正常。提示成人膝外翻畸形经全膝关节置换后外翻畸形均得到纠正,功能较前明显改善。     

人工全膝关节研究新进展

膝关节是人体最大、解剖最复杂、对运动要求最高的关节之一。全膝关节置换术(total knee arthroplasty,TKA)在全世界每年以高于10%的比例增长。TKA是在全髋关节置换术的基础上发展起来的,经过近30的发展,取得了很大进展。本文对近年来假体类型的演变、假体几何外形与尺寸的研究,以及膝关节生物力学方面取得的突破进行了阐述;对目前TKA中存在争议的问题进行了讨论;并结合目前最新发展的技术,对TKA未来发展的方向进行了展望和预测。     

The influence of polyethylene bearing thickness on the tibiofemoral kinematics of a bicruciate retaining total knee arthroplasty

Background

The recently reintroduced bicruciate retaining Total Knee Arthroplasty (BCR TKA) is an effort to reproduce kinematics closer to the native knee. However, there is no data on appropriate balancing with this implant. Balancing is crucial and challenging as medial and lateral polyethylene (PE) inlays are modular, which allows for placement of different thicknesses in the medial and lateral compartments. This study aimed at providing a detailed kinematic view on balancing BCR TKA.

Magnetic resonance imaging of in vivo patellofemoral kinematics after total knee arthroplasty

Simulated partial weight bearing during magnetic resonance imaging of the knee was used to measure patellar tilt, medial–lateral patellar shift, and patellofemoral contact area in three groups of subjects; patients with posterior cruciate retaining (PCR) TKA, patients with bicruciate substituting (BCS) TKA, and healthy controls. Contact stress was also calculated based on the contact area and body weight-based estimates of contact force. Contact stress was significantly (p < 0.05) higher in PCR knees (2.5 ± 3.0 MPa) than in BCS knees (0.2 ± 0.1 MPa) when knees were fully extended, but this difference was not significant (3.7 ± 3.5 MPa for PCR knees vs. 1.4 ± 1.9 MPa for BCS knees; p > 0.05) in early flexion. The results also indicate that patellar tilt (normal = 2.4° ± 4.8°, BCS = 5.5° ± 5.5°, PCR = − 3.0° ± 6.9° change in lateral tilt when moving from full extension to early flexion) and contact area (full extension: normal = 267 ± 111 mm², BCS = 344 ± 201 mm², PCR = 83 ± 80 mm²; early flexion: normal = 723 ± 306 mm², BCS = 417 ± 290 mm², PCR = 246 ± 108 mm²) in BCS TKA mimic those in the normal knees more closely than PCR knees do. These results suggest that the patellar component in BCS TKA may be expected to experience less wear than the patellar component in PCR TKA over time.     

膝关节置换术中胫骨截骨厚度对胫骨截面的生物力学影响

目的获得不同截骨厚度及不同活动状态下胫骨截面的生物力学情况,为临床膝关节置换术截骨厚度及指导患者术后活动提供理论基础。方法重建下肢骨性三维立体模型,依据全膝关节置换术截骨原则将胫骨近端分别截骨0、5、7、9 mm,对截骨后胫骨模型进行材料属性赋值,并分析站立、慢步、快跑、上楼4种活动状态下胫骨截面的应力、应变情况。结果在相同活动状态下,随着截骨厚度的增加,胫骨截骨面的最大应力和位移呈增长趋势。在同一截骨厚度下,随着活动强度的增强,胫骨截面的最大应力和位移总体上呈增长趋势。结论临床全膝关节置换术时胫骨截骨厚度越大、术后活动强度越强,胫骨截面的应力及应变越大。术中应避免过多截骨、术后应避免高强度活动,可减少胫骨平台的应力及应变,有利于假体的长期寿命。     

Patellar resurfacing has minimal impact on in vitro tibiofemoral kinematics during deep knee flexion in total knee arthroplasty

BackgroundWhile patellar resurfacing can affect patellofemoral kinematics, the effect on tibiofemoral kinematics is unknown. We hypothesized that patellar resurfacing would affect tibiofemoral kinematics during deep knee flexion due to biomechanical alteration of the extensor mechanism.MethodsWe performed cruciate-retaining TKA in fresh-frozen human cadaveric knees (N = 5) and recorded fluoroscopic kinematics during deep knee flexion before and after the patellar resurfacing. To simulate deep knee flexion, cadaver knees were tested on a dynamic, quadriceps-driven, closed-kinetic chain simulator based on the Oxford knee rig design under loads equivalent to stair climbing. To measure knee kinematics, a 2-dimensional to 3-dimensional fluoroscopic registration technique was used. Component rotation, varus-valgus angle, and anteroposterior translation of medial and lateral contact points of the femoral component relative to the tibial component were calculated over the range of flexion.ResultsThere were no significant differences in femoral component external rotation (before patellar resurfacing: 6.6 ± 2.3°, after patellar resurfacing: 7.2 ± 1.8°, p = 0.36), and less than 1° difference in femorotibial varus-valgus angle between patellar resurfacing and non-resurfacing (p = 0.01). For both conditions, the medial and lateral femorotibial contact points moved posteriorly from 0° to 30° of flexion, but not beyond 30° of flexion. At 10° of flexion, after patellar resurfacing, the medial contact point was more anteriorly located than before patellar resurfacing.ConclusionDespite the potential for alteration of the knee extensor biomechanics, patellar resurfacing had minimal effect on tibiofemoral kinematics. Patellar resurfacing, if performed adequately, is unlikely to affect postoperative knee function.     

Clinical and objective gait outcomes remained stable seven years after total knee arthroplasty: A prospective longitudinal study of 28 patients

BackgroundThere is a paucity of data on mid to long-term gait outcomes after total knee arthroplasty. The aims of this longitudinal study were: to assess the evolution of both clinical and gait outcomes before and up to seven years after primary total knee arthroplasty (TKA) in a cohort of patients with knee osteoarthritis.MethodsThis study included 28 patients evaluated before and up to seven years after primary TKA with both gait analysis and patient reported outcomes; of these, 20 patients were evaluated one year after surgery as well. Kinematic outcomes during gait (gait velocity, dimensionless gait veolicity, maximal knee flexion and knee range of motion), pain relief, Western Ontario and MacMaster Osteoarthritis Index (WOMAC), quality of life and patient satisfaction were assessed and compared at each visit with the paired Wilcoxon signed rank test (p < 0.05).ResultsThe significant improvement achieved at one year after TKA was stable up to seven years after surgery, with all clinical and kinematic outcomes unchanged, except for gait velocity, with a significant decrease over time (1.3 (1.1–1.4) m/s one year after TKA versus 1.0 (0.9–1.1) m/s, p < 0.05 up to seven years after).ConclusionPatients with knee osteoarthritis significantly improve their clinical and kinematic outcomes at one year postoperatively and maintain the gain up to seven years after primary TKA, except for gait velocity which decreases over time, most likely along with ageing.     

股内侧肌髌骨止点形态分布对选择TKA股内侧肌下入路的临床意义

目的 观察膝关节股内侧肌髌骨止点形态与体表投影的关系,为全膝关节置换手术(TKA)股内侧肌下入路术前评估提供新思路.方法 在20例下肢尸体标本上对股内侧肌髌骨止点形态的体表投影与解剖形态进行观测,同时对80侧健康成人下肢股内侧肌髌骨止点体表投影进行观测,比较3种情形下的股内侧肌止点在髌骨分布测量结果的差异.结果 55.0%(11例)的尸体标本股内侧肌止点长度与髌骨长度之比在40%～60%之间.股内侧肌髌骨止点长度与髌骨长度之比在尸体标本体表投影组、解剖测量组及健康成人下肢体表投影组分别为(47.8±15.1)%,(48.7±15.4)%及(46.7±14.8)%,3组测量值无统计学差异(P>0.05).结论 股内侧肌髌骨止点与髌骨长度之比的体表投影观察值与解削后测量值差异不明显,术前股内侧肌髌骨止点体表投影评估对TKA手术入路的选择有参考价值.     

Experience of total knee arthroplasty using a novel navigation system within the surgical field

Background

With the aim of improving component alignment and outcome in total knee arthroplasty (TKA), several computer-assisted devices (CAD) have been developed.

髌下脂肪垫血供特点及在TKA术中的意义

目的　观测髌下脂肪垫血供特点,为TKA术中如何保护其提供应用解剖学基础。 方法 　20侧防腐及2侧新鲜成人膝关节标本,用巨微解剖法观测髌下脂肪垫血管网的组成、走行及分布。 结果 髌下脂肪垫血管网外侧由膝下外侧动脉、膝上外侧动脉降支构成,内侧由膝下内侧动脉升支、膝降动脉髌上支的降支、膝降动脉关节支的髌下支构成,各支互相吻合形成网状结构,为"密集血管区",位于在髌骨内、外侧旁开5 mm范围以内,髌尖下约14 mm,髌韧带后面10 mm区域。此血管网向髌骨下极、髌韧带后部、髌下脂肪垫及其表面的滑膜提供血供。 结论　髌下脂肪垫具有滋养其周围结构的功能,在TKA术中应予保留,若需切除至少应保留"密集血管区"部分。