全膝关节置换术后翻修的原因分析

目的 对行全膝关节置换术后行翻修手术患者的翻修原因进行研究分析,并与先前报道的结果进行对比。方法 收集济宁医学院附属医院关节与运动医学科自2014年1月至2021年11月完成的89例全膝关节翻修术患者资料,均为初次全膝关节置换术后行翻修手术,其中男28例,女61例;年龄27～84岁,平均(66.60±8.53)岁。左侧51例,右侧38例。将患者分为早期翻修组(假体使用年限低于2年)和晚期翻修组(假体使用年限不低于2年),对翻修手术的原因进行统计。结果 49例(55.1%)全膝关节翻修原因为假体周围感染,18例(20.2%)为假体松动,10例(11.2%)为关节不稳,5例(5.6%)为疼痛,4例(4.5%)为假体周围骨折,2例(2.2%)脱位,1例(1.1%)聚乙烯磨损。89例假体使用时间为(2.69±3.15)年,早期组51例,假体使用时间为(0.66±0.45)年;晚期组38例,假体使用时间为(5.42±3.15)年。早期组中31例假体周围感染,9例关节不稳,4例疼痛,3例假体周围骨折,2例脱位,聚乙烯磨损和无菌性松动各1例。晚期组中18例假体周围感染,17例假体松动,假体周围骨折、...     

人工全膝关节翻修

随着全膝关节置换病例的增加，及患者年龄的降低，近年来在发达国家全膝关节翻修病例也呈快速增长趋势，仅美国每年就有 2万多例患者需行全膝关节翻修术 [1]。据统计，全膝关节翻修率约占全膝关节置换总数的 5％～ 10％ [2,3]。 全膝关节翻修在技术上比全膝关节置换更具挑战性     

人工膝关节翻修假体的选择

随着全膝关节置换病例的增加及患者低龄化 ,全膝关节置换术后翻修病例也呈快速增长趋势 ,仅美国每年就有 2万多例患者需行全膝关节翻修术[1] ;据统计 ,翻修率为 5 %～ 10 % [2 ,3 ] 。翻修时往往由于骨缺损、关节周围软组织及韧带平衡失调、关节力线不正等原因 ,所以在技术上更具挑战性。研究表明 ,普通假体并不完全适合人工膝关节翻修 ,为了提高全膝关节翻修的效果 ,已经研制开发出翻修假体系统 ,包括各种厚度的楔形金属垫块和不同长度和粗细的股骨和胫骨假体柄组件、特制假体以及同种异体骨制成的全膝假体等。然而 ,通过严格病例随访和分…     

人工膝关节术后感染的诊断和二期翻修术

目的：对人工膝关节(TKA)术后感染接受二次翻修术的膝关节进行评估。方法：1996年1月～2002年1月实行人工膝关节置换术353膝，其中5个膝关节在术后出现感染，行二期翻修术即一期手术取出原假体，彻底清创，置入抗生素骨水泥间隙垫，术后使用6周以上的敏感抗生素，二期手术作假体翻修术。结果：平均随访2年，无1例翻修的膝关节发生感染或无菌性松动。最近一次随访时平均膝关节功能评分从翻修术前的0分增加到术后的58分(20～100分)，平均膝关节疼痛评分从术前的38分(24～50分)增加到术后的93分(87—100分)。结论：应该尽量采用二期翻修术处理TKA术后感染，以彻底的清除感染灶，使病人获得良好的功能。     

感染性人工膝关节翻修术中抗生素的选择

目的:探讨二期翻修术治疗人工膝关节术后感染的抗生素选择原则.方法:1990～2000年本科采用二期翻修术处理11膝人工膝关节术后感染.第1次手术时,彻底清创后膝关节内植入庆大霉素骨水泥间隙垫,之后根据细菌的药物敏感试验结果和医生的经验选择合理的抗生素治疗6周以上(非胃肠道途径).翻修术后平均随访32个月(24～43个月),采用膝关节临床评分系统对这些膝关节进行评估.结果:没有一个翻修的膝关节因为感染或者无菌性松动而接受再次翻修术,所有部件均获得良好固定.最后一次随访时,平均膝关节功能评分从翻修术前的0分增加到术后的63分(20～100分),平均膝关节疼痛评分从术前的42分(24～50分)增加到术后的95分(87～100分).结论:为彻底清除人工膝关节术后感染,临床医生应该尽量明确致病菌,根据药物敏感试验的结果和医生的经验选择有效的抗生素进行系统的治疗,并在膝关节内使用抗生素骨水泥间隙垫.     

关节线控制器的研制及其初步临床效果

目的设计自制的关节线控制器(joint line controller,JLC)并探讨在人工膝关节翻修术中的使用价值。方法行人工膝关节翻修术20例,在10例术中使用JLC(JLC组),10例没有使用JLC(对照组)。收集患者术前和术后以及对侧膝关节的X线片,将翻修后膝关节和对侧膝关节的关节线高度进行比较。结果对照组对侧膝关节的关节线平均高度为23.5mm(21.5～26mm),JLC组为24.25mm(22～28mm);翻修术后,对照组膝关节的关节线高度平均为28.8mm(26～31mm),JLC组为26.8mm(23～31mm),即对照组关节线高度平均抬高5.3mm,JLC组平均抬高2.55mm,两组对比,有显著性差异(P=0.0030)。结论JLC可以有效地帮助临床医生在人工膝关节翻修术中重建正常的关节线高度、选择合适型号的股骨部件。     

膝关节肿瘤型假体置换术后关节不稳远期翻修1例

对于膝关节原发性骨肉瘤,保留肢体的肿瘤型假体置换术已经成为常用的手术方法[1].该手术的优点包括技术简单,术后短时间内即可恢复膝关节的生物力学稳定性,中短期功能康复结果令人满意.然而,其长期并发症的发生率仍然很高[2].但是青年骨肉瘤患者远期生存率较低,文献鲜有此类患者实施膝关节肿瘤型假体置换术后出现远期并发症及行翻修...     

全膝关节成形术术后骨丢失的翻修

全膝关节成形术（ｔｏｔａｌｋｎｅｅａｒｔｈｒｏｐｌａｓｔｙ，ＴＫＡ）术后翻修的目的与ＴＫＡ一样，也是为了尽量恢复关节线到正常水平和纠正关节解剖对线不良，从而获得满意的关节稳定性和功能状态。但膝关节多次手术带来的诸如感染、软组织挛缩、支持韧带损伤与骨丢失等问题会使上述目的难以达到，尤其是ＴＫＡ后明显的骨丢失会引起假体松动、置入物非支持部分骨折和假体周围骨折。严重骨缺损使重建手术面临困难［１］。一、ＴＫＡ后骨丢失的形成机制（一）机械性骨丢失［２，３］：ＴＫＡ手术中，在对线不良、过度内翻等基础上的过…     

初次全膝关节置换术后并发症及翻修手术的原因分析

目的 探讨初次全膝关节置换术后30 d内相关并发症发生情况及翻修手术的相关因素.方法 收集2001年1月至2012年12月在北京协和医院骨科进行初次全膝关节置换术患者的临床资料,假体均为固定平台假体,采用骨水泥固定,排除翻修病例及血友病关节炎患者.共有1 920例患者(2 779例次全膝关节置换手术)纳入研究,男性323例,女性1 607例;年龄25～86岁,平均(66±9)岁.骨关节炎1 720例(89.58％),类风湿关节炎168例(8.75％),强直性脊柱炎12例(0.63％),继发骨关节炎20例(1.04％).随访患者术后30 d内发生的主要系统并发症、局部并发症及发生的翻修手术及相关因素.结果 随访截至2013年12月,共有1 854例患者(2 693个关节)获得随访,失访率为3.44％.术后平均随访67个月,死亡3例.41例(2.21％)患者出现系统并发症,其中最常见的为呼吸系统并发症(0.49％,9/1 854)及心血管并发症(0.38％,7/1 854).术后经超声证实的症状性深静脉血栓形成发生率为3.02％ (56/1 854),其中7例发生肺栓塞.术后发生局部并发症24例(1.29％),包括伤口愈合不良、伤口感染、神经损伤.59个关节接受翻修手术治疗,常见原因包括感染后松动(1.19％,32/2 693)和术后关节僵硬(0.37％,10/2693).结论 初次全膝关节置换术后30 d内最常见系统并发症为呼吸系统及心血管系统并发症.感染后松动是术后翻修最常见的原因.     

骨性关节炎和炎症性关节炎行全膝关节置换翻修术临床效果的比较及相关分析

目的对应用单一翻修假体系统行膝关节置换翻修术的骨性关节炎与炎症性关节炎的临床材料进行汇总分析、对比。方法1994至2000年间,共69例患者71膝在芬兰坦配雷大学医学院医院应用翻修假体TCⅢ行全膝关节置换翻修术。56膝为女性,16膝为男性,平均年龄69．1岁（36～85岁）,平均随访时间为5.9年（3．0—10．2年）;16膝为炎症性关节炎,55膝为骨性关节炎,初次手术和翻修术的时间间隔平均为6．8年。临床评估参照KSS评分系统,再次翻修、截肢和死亡视为随访终止。结果所有患者术后1年和最终随访时的膝关节总评分、功能评分、活动范围、疼痛评分、行走评分及上楼评分等与术前相比差异有统计学意义（P〈0．001）。尽管23例假体周围有无症状性骨吸收线,但是关节均无明显结构上的松脱。并发症包括4例术后感染,1例髌骨疼痛综合症,1例髌腱断裂。以再次翻修作为终点,假体5年生存率为95％,8年生存率为94％。最终随访时,骨性关节炎患者的各项数据比炎症性关节炎患者稍好,但统计学分析结果示两组之间的差异无统计学意义。结论尽管炎症性关节炎会导致患者韧带松弛,容易感染,骨质破坏,一般情况较差,但是其行全膝关节置换翻修术的疗效与骨关节炎相接近。     

An accurate and reproducible method for locating the joint line during a revision total knee arthroplasty

Studies have shown that the position of the joint line has a direct effect on postoperative results, including range of motion, functional knee scores, and midflexion stability. Four anatomic landmarks were investigated as references for locating the joint line during a revision knee surgery--the medial femoral epicondyle, the fibular head, the tibial tubercle, and the inferior pole of the patella. Measurements from 6 cadaver knees identified the distance of each landmark to the joint line. These distances were used to design instruments to aid in the intraoperative positioning of the joint line. The instruments were validated on 94 primary total knees. The instrument referencing the medial epicondyle had 99% and 93% accuracy for locating the natural position of the joint line within 5 and 3 mm, respectively.     

Joint line and patellar height restoration after revision total knee arthroplasty

Background:

Restoration of proper joint line (JL) position and patellar height in revision total knee arthroplasty (TKA) is essential in the recovery of knee function and kinematics. We determined whether the JL position and patellar height could be restored in patients undergoing septic and aseptic revision TKA.

Materials and Methods:

We retrospectively reviewed 70 patients (74 knees) who had revision TKA between September 2004 and December 2010. Forty seven knees had a two stage revision for infected TKA and 27 knees for aseptic failure. The JL position, patellar height and patellar tendon (PT) length were measured and compared between primary TKA and post revision. The clinical scores including a hospital for special surgery (HSS), Knee Society Score (KSS), Western Ontario and McMaster Universities (WOMAC) and range of motion (ROM) were compared.

Results:

The overall JL increased from 17.51 mm to 18.37 mm post revision, the Insall-Salvati (IS) ratio declined from 0.98 to 0.92, and the PT length declined from 42.92 mm to 39.45 mm. 9 of the 21 patellar baja knees improved to normal patellar height. After revision, the JL in the septic group (17.02 mm) was significantly lower than the aseptic group (20.74 mm). The changes of the JL position and IS ratio in the septic group were significantly larger than the aseptic groups (P < 0.05). JL position had a positive correlation to the IS ratio and PT length post revision. The knee function scores including HSS, KSS, WOMAC scores, and ROM all improved post revision compared to pre revision (P < 0.05), and the septic group had a lower knee function compared to the aseptic group. JL position and IS ratio post revision had no correlation to the HSS, KSS, WOMAC scores, and ROM.

Conclusions:

JL position can be sufficiently restored with appropriate distal femoral augment reconstruction after revision TKA, but the patellar height cannot be well improved, especially in the septic revision with obvious PT contracture. No correlation was found between the JL position and patellar height to the knee function post revision TKA.     

Clinical and radiographic analysis of accurate restoration of the joint line in revision total knee arthroplasty

A clinical and radiographic analysis was performed on 89 consecutive revision total knee arthroplasties. The postoperative joint line position was evaluated and correlated with the clinical outcome. The joint line position was evaluated radiographically. Average follow-up was 8.2 years (24-197 months). Clinical outcome values were correlated to joint line position. More improvement was seen with recreation of the normal joint line to within +/-4 mm of the normal unaffected knee for Knee Society Score, average total arc of motion, flexion, and extension. There was a significant difference found for all 4 variables when combined outliers were compared with goal range (-4 to 4 mm). In this study, clinical outcome was improved if the joint line was accurately reproduced.     

Restoration of the joint line in total knee arthroplasty

The purpose of the study was to assess the effect of the joint line position in a posterior cruciate ligament–retaining, mobile-bearing total knee arthroplasty (TKA). Seventy-six consecutive TKAs performed by 1 surgeon were prospectively assessed for a minimum of 2.5 years. Posterior cruciate ligament–retaining, mobile-bearing TKA was performed in all cases. The joint line was elevated 1 mm on average (range, −11 to +10). There was no correlation between joint line position and range of motion, knee function scores, knee pain scores, or patellar height. The joint line position in a posterior cruciate–retaining, mobile-bearing (LCS AP Glide; DePuy, Leeds, United Kingdom) TKA did not affect the early clinical results.     

The impact of joint line restoration on functional results after hinged knee prosthesis

Background:

Hinged knee prosthesis is an effective treatment method as a salvage procedure in marked ligamentous insufficiency and severe bone defects. Joint line determination and restoration are difficult due to large bone defects and distorted anatomy. We evaluated the impact of joint line alteration on the outcome in rotating hinge knee arthroplasty (RHKA).

Materials and Methods:

35 patients who had rotating hinged knee prosthesis applied between 2008 and 2013 were evaluated in this retrospective study. The patients were studied radiologically and clinically. Five patients were lost to followup and two patients died, leaving a total of 28 (7 male, 21 female) patients for final evaluation. The average age of the patients was 66.19 ± 8.35 years (range 52–83 years). The patients were evaluated clinically with Knee Society knee and functional score and patellar score. The joint line positions were evaluated radiographically with femoral epicondylar ratio method. The outcomes were also evaluated according to age, body weight and gender. Student''s t-test, independent t-test, and the Wilcoxon signed rank test were used in the statistical analysis.

Results:

The mean Knee Society knee and functional score significantly improved from preoperative 19.52 ± 11.77 and 12.5 ± 15.66 respectively to 72.46 ± 14.01 and 70.36 ± 9.22 respectively postoperatively (P < 0.001). The mean range of motion of the knee improved from 55.95° ± 25.08° preoperatively to 92.14° ± 13.47° postoperatively (P < 0.001). Joint line position was restored in 20 patients (71.4%). Joint line alteration did not affect Knee Society Scores (KSSs) in contrast to patellar scores. Additionally, KSS was better in the patients with body mass index ≤30 at followup (P = 0.022 and P = 0.045).

Conclusion:

RHKA is an effective salvage procedure for serious instability and large bone defects. Restoration of the joint line improves the patellar score although it had no effect on the clinical outcome.     

The causes of total knee arthroplasty failure: Avoiding your next revision

This article is a personal retrospective of the author׳s more than 35 years of experience as an arthroplasty surgeon and specifically addresses how to avoid revision total knee arthroplasty.

• 1.Avoid revision surgery if the patient is satisfied, unless imminent danger of prosthetic failure appears.
• 2.Use proper technique at the primary arthroplasty to avoid the problems of aseptic loosening, instability, malalignment, and infection that force most revisions. Scrupulous attention to detail in patient selection and operative technique at the primary surgery will help avert revision surgery.
• 3.Remember that surgical technique is prosthesis specific. Understanding the design and insertion philosophy of each implant is crucial to success; every implant system is different.
• 4.Strive to understand the underlying reason that an arthroplasty has failed to make a patient satisfied and fix the problem at revision. If the reason for revision is unclear, it is unlikely that surgery will make the patient better.
• 5.Avoid revision surgery if the problem is pain with no identifiable, surgically correctable problem.
• 6.Maintain strict selection criteria for obese patients, who have higher prevalence of problems that can lead to total knee revision. Surgeons who operate on obese patients likely will have more revision cases. Often, however, obese patients have gratifying results in terms of pain relief and improved function.

     

Morphology of the transepicondylar axis and its application in primary and revision total knee arthroplasty

A morphologic anatomic study was done of the lower extremity to investigate various relationships of the transepicondylar axis (TEA). Thirteen cadaver specimens were dissected and mounted to a metal frame with a pin passing through the TEA. The center of the knee was determined as the depth of the anterior intercondylar groove. The ratio of the upper leg to lower leg measured from femoral head center and ankle center to TEA was 1.02. The mean distance of the TEA to the joint line was 3.08 cm medial and 2.53 cm lateral. The mean femoral angle comparing the TEA to mechanical axis was 0.61° varus. The mean tibial angle comparing the TEA to the mechanical axis was 0.4° varus in extension and 0.43° in flexion, with no significant difference in the lower extremity angle with flexion (P < .01). The TEA is an important landmark that, from this study, is virtually perpendicular to the mechanical axis of the lower extremity and parallels the knee flexion axis. Femoral component rotation and joint line positioning in total knee arthroplasty can be determined using the TEA.     

Fungal prosthetic joint infection after total knee arthroplasty

Fungal prosthetic joint infection after total knee arthroplasty (TKA) is a rare complication. Lacunae exist in the management of this complication. 62 year old lady presented with pain and swelling in left knee and was diagnosed as Candida tropicalis fungal infection after TKA. She underwent debridement, resection arthroplasty and antifungal plus antibiotic loaded cement spacer insertion, antifungal therapy with fluconazole followed by delayed revision TKA and further fluconazole therapy. Total duration of fluconazole therapy was 30 weeks. At 2 year followup, she has pain less range of motion of 10^°-90^° and there is no evidence of recurrence of infection.     

全膝关节表面置换治疗严重膝关节畸形

目的探讨人工全膝关节表面置换术(TKA)治疗严重膝关节畸形临床疗效。方法应用全膝关节表面置换治疗严重膝关节畸形36例(48膝)。使用HSS评分标准评估分析术前、术后膝关节功能及术后疼痛、膝关节活动度的改善情况。43膝采用后稳定型人工全膝关节假体,5膝采用CCK型人工全膝关节假体。结果术后早期均无感染等并发症发生。术后X线片示假体位置良好,下肢力线良好。患者均获得随访,时间6～18个月。HSS评分术前为(41±5.3)分,术后6个月为(87.7±6.5)分。手术优良率为83.3%。患者疼痛、功能方面及活动度均有明显改善。结论全膝关节置换术对严重膝关节畸形的治疗效果满意。但应严格掌握手术适应证。     

人工膝关节置换术后关节线改变的临床研究

目的观察选择保留后交叉韧带的膝关节表面置换术与不保留周围韧带的旋转膝关节置换术后关节线的改变,分析其发生原因及预防方法。方法分别选择保留后交叉韧带的膝关节表面置换术患者25例,不保留周围韧带的旋转膝关节置换患者25例,手术前、后均拍摄膝关节非负重侧位片。术前的侧位片上,平行于胫骨平台负重关节面作一条直线,测量它到胫骨结节的垂直距离（JL）;在术后的侧位片上,平行于胫骨假体负重关节面作一条直线,测量它到胫骨结节的垂直距离（JL’）。JL’和JL之间的差值（JL’-JL）为手术前后关节线的变化值,对其进行统计学处理并分析原因。结果保留后交叉韧带的膝关节表面置换后,JL’-JL为2．0mm（-1．3—7．2mm）,其中5例大于2mm;旋转膝关节置换后,JL’-JL为3．1mm（-1．5—12．3mm）,其中11例大于2mm,两者差异有统计学意义（P〈0．01）。表面置换时关节线升高的原因包括胫骨近端截骨过少、韧带的过度松解、增加股骨远端截骨、股骨假体前后径偏小等;旋转膝关节置换时,关节线的改变主要由骨缺损和缺乏韧带的限制作用所致。结论保留后交叉韧带膝关节表面置换时,虽然有某些原因可以造成关节线的改变,但是由于畸形和骨缺损相对较轻,同时周围韧带的相对完整使其关节线发生改变的几率小、程度轻。由于骨缺损相对较重,同时手术中不保留周围韧带,旋转膝关节置换时更易发生关节线位置异常,应该通过股骨内上髁等骨性标志帮助恢复正常的关节线水平。