加速康复外科理念在膝关节置换术围术期应用

目的评价加速康复(ERAS)外科理念在膝关节置换术围术期的应用疗效。方法收集2015年1月至2016年1月收治的因膝关节骨性关节炎行膝关节置换术的82例患者,随机分为ERAS组(n=40)和常规组(n=42),比较两组围手术期疗效。结果患者82例随访1个月。所有患者切口均一期愈合,术后12 d拆线。ERAS组术中出血量、输血量均明显少于常规组,差异有统计学意义(P<0.05)。两组手术时间比较,差异无统计学意义(P>0.05)。ERAS组术后住院(8.0±3.4)d,明显低于常规组的(11.5±3.6)d,两组平均住院日比较,差异有统计学意义(P<0.05)。两组均未发生切口并发症。两组深静脉血栓、泌尿系统感染并发症发生率比较,差异无统计学意义(P>0.05)。比较术后12 d和术后1个月的膝关节KSS评分,ERAS组膝关节KSS评分优于常规组,差异有统计学意义(P<0.05)。结论 ERAS外科理论在膝关节置换围术期的应用能明显缩短术后住院时间和住院费用,可以促进患者膝关节功能的康复,值得推广和应用。     

人工全膝关节置换术围术期的护理体会

人工全膝关节置换术主要用于骨性关节炎、类风湿性关节炎、创伤性关节炎等引起严重的膝关节疼痛、畸形、活动障碍,严重影响工作及生活质量的患者。我科于2008年1月-2011年10月,共行38例人工全膝关节置换术,经过对患者围手期的精心护理,以及术后合理的康复训练,获得较好的膝关节功能。现分析报告如下。     

人工全膝关节置换术后的康复锻练

目的：为减轻人工膝关节置换术后患者的疼痛,以及增加术后人工关节的活动范围,提高患者术后的生活质量,为患者提供并施行康复训练计划。方法对膝关节置换术患者术前进行心理疏导,术后给予护理及康复锻炼指导,出院进行健康宣教,并定期随访。结果优19例,良4例,可2例。手术效果满意。结论人工膝关节置换术后患者通过康复锻炼,能够得到更好的功能恢复,可以减少并发症。     

全膝关节置换术后的康复治疗

全膝关节置换术（total knee arthroplasty,TKA）现已得到广泛应用,术后的康复治疗对全膝关节置换术（TKA）的总体效果有重要影响。笔者对康复治疗在TKA的重要作用加以综述。     

膝关节置换术后康复护理

我科自2003年3月-2005年11月，行膝关节置换术15例，效果非常理想，在护理中积累了一些经验，现总结如下：     

全膝关节置换术后的康复护理

目前行全膝关节置换术者越来越多，手术能否成功，手术后相关护理非常重要，功能锻炼更是本病术成功的关键。     

人工全膝关节置换术中髌骨置换的临床研究

目的探讨人工全膝关节置换术中髌骨置换之后的临床疗效,为临床上是否要进行髌骨置换提供参考依据。方法选择2009年12月—2012年2月于我院急诊科、骨科就诊并拟行人工全膝关节置换术的骨关节炎患者84例,按随机数字随机将所有入选患者分为对照组42例和研究组42例,研究组患者在关节置换术中接受髌骨置换的治疗,对照组则不进行髌骨置换,治疗后所有患者接受为期1年的随访,对两组疗效进行比较。结果两组术后2、3个月的美国膝关节协会评分系统(KSS)临床评分差异均无统计学意义(P>0.05),术后6、12个月KSS临床评分差异有统计学意义(P<0.05);两组术后2、3、6个月的Feller髌骨评分差异均无统计学意义(P>0.05),术后12个月Feller髌骨评分差异有统计学意义(P<0.05)。结论人工全膝关节置换术中行髌骨置换能在一定程度上改善膝关节功能评分和髌骨评分。     

人工髋关节置换术后康复锻炼效果观察

目的：观察康复锻炼对人工髋关节置换术（THR）术后功能恢复的影响。方法：选择THR术后42例,随机分为观察组22例和对照组20例;观察组术后在正规指导下进行系统康复锻炼,对照组不锻炼;连续随访5年,主要从Harris评分,以及术后疼痛、步态、关节活动范围和肌力等方面进行对比分析。结果：两组患者术后1年Harris评分差异非常显著（P〈0.01）,术后5年评分差异显著（P〈0.05）;术后5年,对照组术后疼痛和跛行发生率显著高于观察组（P〈0.05）,患肢屈髋角度≥90°者和臀肌肌力≥4级者显著少于观察组（P〈0.05）。结论：康复锻炼不但有利于髋关节置换术后功能恢复,而且可以有效预防并发症。     

快速康复理念在腹腔镜结直肠癌围手术期中的应用价值

目的 研究快速康复理念在腹腔镜结直肠癌围手术期中的应用价值.方法 选取结直肠癌患者100例作为临床研究对象,按照入院顺序进行编号,按照数字奇偶性分组,分为研究组及参照组各50例.研究组患者在围手术期给予快速康复理念,参照组患者在围手术期给予传统的康复理念.比较两足患者的术后肠蠕动(肛门排气)恢复时间,术后开始饮食时间,患者的总住院天数及患者有无并发症情况.结果 研究组患者术后肠蠕动(肛门排气)恢复时间,术后开始饮食时间,患者的总住院天数等各项指标比较优于参照组(P<0.05);两组患者术后并发症比较:恶心呕吐、肺部感染、吻合口瘘、肠梗阻等并发症发生率研究组显著低于参照组(P<0.05);下肢深静脉血栓、泌尿系统感染及吻合口出血等并发症两组发生率没有统计学意义(P>0.05).结论 腹腔镜下行结直肠癌手术,在围手术期给与患者实施快速康复理念,有利于患者疾病的早日康复,减少患者的总入院日期,对患者术后并发症的发生率具有预防控制效果,值得临床应用.     

临床护理路径在人工膝关节表面置换术中的临床应用效果

目的：探讨临床护理路径在人工膝关节表面置换术中的临床应用效果。方法选取人工膝关节表面置换术治疗的77例患者,按护理方式不同分为对照组34例和观察组33例,对照组患者采用常规护理方式护理,观察组给予临床护理路径进行护理,对比观察两组患者的护理效果。结果对照组33例患者出院前的膝关节功能评分,优19例,良8例,中6例,优良率为81．82％,住院时间（15．5±4．7）天,对护理的满意度为78．79％;观察组34例患者出院前的膝关节功能评分,优26例,良6例,中2例,优良率为94．12％,住院时间（11．2±2．3）天,对护理的满意度为91．18％。两组比较,观察组明显优于对照组,P＜0．05,差异具有统计学意义。结论临床护理路径在人工膝关节表面置换术中的临床应用效果好,能有效促进患者膝关节功能恢复,缩短住院时间,提高患者满意度。     

CPM机锻炼在人工全膝关节置换术后早期康复训练中的效果评价

目的探讨CPM机持续被动锻炼在人工膝关节置换术后早期康复训练中的应用及效果评价。方法对92例人工膝关节置换进行早期CPM康复训练指导并进行随访。结果本组所有病例在术后7～14 d在步行器的帮助下步行,膝关节自主屈曲活动均达到90°以上,伸直0°,出院2～3个月后生活完全自理。结论对膝关节置换术后患者应用CPM机进行功能康复训练指导,可以有效防止关节粘连,使膝关节早日恢复良好状态。     

The femoral sulcus in total knee arthroplasty

The position of the femoral sulcus relative to the midline of the distal femoral resection in total knee arthroplasty (TKA) was studied to determine if centralized placement of the femoral component on the distal femur was justified in terms of aligning the prosthetic sulcus with the native femoral sulcus. The location of the femoral sulcus was studied in 112 consecutive patients undergoing TKA. The mean sulcus position was 0.7 mm lateral to the midline of the distal femoral resection (SD 1.4, 95% CI, 0.5–1.0 mm). However, the variation in sulcus positions ranged from 4 mm medial to 4 mm lateral to the midline. The mean sulcus position in valgus knees was 1.0 mm lateral to the midline (SD 1.8), and that in varus knees was 0.7 mm lateral to the midline (SD 1.2) (P = 0.501). It appears prudent to centre the femoral component on the native sulcus rather than the midline of the distal femoral resection, so as to ensure accurate alignment of the prosthetic sulcus with the native sulcus and to encourage normal patella tracking.     

Arthrodesis of the knee after failed infected total knee arthroplasty

Infection after total knee arthroplasty (TKA) can be a challenging and difficult problem to treat. In selected patients, knee arthrodesis is a well-recognized salvage procedure after infected TKA. The authors retrospectively reviewed their experience with this treatment option, presenting 20 patients (8 women, 12 men), performed between 1990 and 2002. The average age was 67 years (range: 47–81 years) and the mean number of previous surgical procedures was 6 (range: 4–11 procedures). There were multiple indications for knee arthrodesis, including extensive bone or soft tissue loss, poor bone stock, and recurring infections. One-stage fusion was done in 7 knees while, on the other 13, arthrodesis was performed as two-stage fusions. The average clinical follow-up was 4.5 years (range: 2–11 years). 18 of the 20 patients were interviewed and graded using the Visual Analogue Scale (VAS) for pain, the Short Form-36 Health Survey (SF-36), and the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire that has knee-related quality of life items. According to the VAS, the mean intensity was 3.4 points. 6 (33%) of the patients had no difficulty with the knee and 9 (50%) of them had mild or moderate difficulty. The SF-36 scores were similar to those for normative data for patients after TKA, with only the social functioning, role emotional, and physical functioning scores being lower and the role physical and social functioning scores being higher. Three of 20 fusions failed, whereas two knees became non-infected non-unions. In one, the knee infection persisted and required above-knee amputation. The two-stage arthrodesis gave the most predictable rate of fusion. Persistent infection and extensive bone stock losses led to failure even under the best circumstances. In our opinion, arthrodesis of the knee is a satisfactory salvage procedure following a failed TKA, and can provide reliable expectation for a stable, painless extremity for high-functioning patients who are able to walk.     

Legion假体在膝外翻畸形初次全膝关节置换手术中应用疗效

目的探讨Legion假体在膝外翻畸形初次全膝关节置换手术中的临床应用疗效。方法回顾性分析沈阳军区总医院骨科2012年1月至2015年12月收治的膝外翻畸形患者32例(37膝)。记录患者术后髌股轨迹、切口愈合情况、膝外翻矫正角度、膝关节Harris评分(HSS)。结果所有患者术后均获得随访。32例患者膝关节髌股轨迹良好,切口愈合情况佳,无感染发生。34膝完全矫正了膝外翻畸形,仅余3膝存在3°~5°膝外翻遗留。患者HSS评分由术前34.5分提升至术后87.0分。结论在膝外翻畸形患者的初次膝关节置换手术中应用Legion假体可以达到满意的手术疗效,术后患者膝关节稳定,大部分患者的膝外翻畸形得到了纠正,患者在术后早期功能锻炼即可达到屈曲90°、伸直0°。     

Patients’ perspective on controversial issues in total knee arthroplasty

We investigated the level of patient knowledge and preferences over the currently controversial issues in TKA. One hundred patients who had decided to undergo TKA for advanced osteoarthritis were asked to complete a questionnaire inquiring their knowledge and preferences over three controversial issues: (1) computer assisted surgery (CAS), (2) minimal invasive surgery (MIS), and (3) ceramic femoral component. The patient preferences over the three issues were questioned again after they had been informed of advantages and disadvantages of each option using an explanatory document. Most (more than 75%) of the patients did not have sufficient knowledge and their knowledge was based on non-professional sources (more than 85%). Before the information was given, most (more than 80%) of the patients preferred a new option. After the information was provided, more patients preferred a standard option in the issues of CAS (60%) and MIS (88%). This study prompts health care providers to become more active in providing accurate information and to consider patients perspective in making decisions which will influence the benefits and risk of the patients.     

Midvastus approach in total knee arthroplasty: a randomized, double-blinded study on early rehabilitation

The medial parapatellar approach has become the standard technique in total knee arthroplasty (TKA). However, recent studies have reported superior results regarding functional recovery when using the midvastus approach. It was the aim of this study to evaluate the early functional outcome of both surgical techniques. In a prospective, double-blinded, randomized study, 50 patients for TKA were consecutively operated on either by the medial parapatellar or the midvastus approach. Exclusion criteria were defined as previous open knee surgery and leg deformity of more than 10° varus or valgus. TKA was performed in all patients by one surgeon using the same type of implants in both groups. Pain scores (VAS) were documented and follow-up data including quadriceps strength and proprioception were obtained 3 weeks and 6 weeks postoperatively. Both groups were comparable in preoperative demographic data. Postoperatively, patients in the midvastus group demonstrated significantly lower pain in rest (VAS: mean 2.25 vs. 3.03) and under movement (VAS: mean 2.92 vs. 3.13). Further, they showed superior isometric quadriceps strength at 3 weeks (41.4 vs. 27.6 Nm) and 6 weeks (47.6 vs. 35.5 Nm). Moreover, this group showed a superior postoperative proprioception, while the range of motion was similar in both groups. The midvastus approach offers advantages over the standard parapatellar arthrotomy, in the early rehabilitation period. No adverse effects were observed associated with this approach. Therefore, the midvastus approach should be considered as a valuable alternative in TKA.     

Knee biomechanics and contralateral knee osteoarthritis progression after total knee arthroplasty

BackgroundDespite the success rate of Total Knee Arthroplasty (TKA), many patients undergo contralateral TKA. It is possible that altered gait mechanics after unilateral TKA play a role in the progression of contralateral OA progression.Research questionThe purpose of this study was to identify biomechanical predictors of radiographic OA progression in the contralateral (non-surgical) knee after unilateral (primary/initial) TKA. In addition, this study quantified for patients who had contralateral OA progression.MethodsBiomechanical outcomes were collected 6–24 months after unilateral primary TKA and were used to predict changes in contralateral OA severity at follow-up. Participants were divided into “Progressor” and “Non-Progressor” groups based on changes in Kellgren-Lawrence (KL) OA grade and Joint Space Width (JSW) between baseline and follow-up testing sessions. Biomechanical factors during walking were peak knee adduction moment, knee flexion/extension excursions, knee angle at initial foot contact, and peak knee flexion/extension. Multiple independent t-tests were used to examine the magnitude of differences in biomechanical variables between the groups. Logistic regression was used to examine the association between the biomechanical predictors and change in KL scores and JSW.ResultsThe mean time between surgery and follow-up x-rays was 8.8 (2.4) years. Of 40 participants, 62.5–78% had contralateral radiographic knee OA progression by follow-up. There were no significant differences in the biomechanical variables between groups. For the regression analysis, none of the biomechanical variables were found to be predictors for contralateral OA progression.SignificanceAlthough abnormal biomechanics are known risk factors for primary knee OA, it is possible that the mechanisms that result in OA progression of the contralateral limb are different than primary knee OA progression. Future work should evaluate other objective measures of OA progression and determine if cumulative measures of joint loading are related to OA worsening.     

Bone marrow edema in the knee in osteoarthrosis and association with total knee arthroplasty within a three-year follow-up

OBJECTIVE: The purpose of this study was to determine if a correlation exists between magnetic resonance imaging (MRI) findings of bone marrow edema (BME) in osteoarthrosis (OA) of the knee joint and need for total knee arthroplasty (TKA) within a follow-up period of 3 years. MATERIALS AND METHODS: The entire database of knee MR studies over a 3-year period was used to select individuals with knee OA. A chart review was conducted to identify and include only those who had a 3-year follow-up appointment from the time of the initial MR study. There were 25 patients in the OA-only group (four men and 21 women; age range, 28-75; average age, 49.3 years). The OA and BME group had 48 patients (23 men and 25 women; average age, 55.5 years). The MRs were reviewed and interpreted by a musculoskeletal radiologist and were classified into one of four patterns of BME: none, focal, global, or cystic pattern. Meniscal tear and degree of cartilage loss were also assessed. RESULTS: Subjects who had BME of any pattern type were 8.95 times as likely to progress rapidly to a TKA when compared to subjects with no BME (p = 0.016). Subjects with a global pattern of BME were 5.45 times as likely to have a TKA compared to subjects with focal, cyst, or no BME (p < 0.05). Subjects with a global edema pattern were 13.04 times as likely to have a TKA than subjects with no marrow edema in the knee (p < 0.01). There was no correlation of TKA with meniscal tear or cartilage loss. The group of subjects who had a TKA were 12.6 years older than those who did not have a TKA (p < 0.001). However, the BME results were still significant after accounting for the age difference. CONCLUSION: Our classification of patterns into global, focal, cystic, and absence of BME is an attempt to further define edema in osteoarthrosis and how it relates to clinical progression. Patients with BME and OA have an increased risk of TKA as opposed to OA and no marrow edema. The BME pattern with the worst prognosis for the knee is the global pattern.     

Three-phase bone scan pattern in asymptomatic uncemented total knee arthroplasty

In this study we investigated the bone scan pattern in a homogeneous group of asymptomatic patients implanted with the same type of total knee arthroplasty (TKA) and with a minimum follow-up of 2 years. Twenty-nine patients (21 females, 8 males, mean age 62 years), with a total of 30 uncemented Hofmann TKAs, were entered in the study. The time interval from surgery to scintigraphic evaluation ranged from 2 to 4 years. Bone scan was performed using the three-phase technique and images were interpreted by visual analysis using a three-point scale for the dynamic and blood pool phases and a five-point scale for the bone phase. Areas of increased periprosthetic technetium-99m methylene diphosphonate (MDP) uptake were observed until 4 years after surgery. However, comparing the TKAs implanted 2, 3 and 4 years previously, a decreasing pattern in tracer uptake intensity was noted this being more evident in the femoral and lateral tibial components. In some cases, a persistently elevated tracer uptake, not exceeding a moderate grade, was found in the medial tibial component. In conclusion, increased periprosthetic^99mTc-MDP uptake is a common finding in asymptomatic uncemented Hofmann TKAs for a prolonged period after surgery, but the uptake intensity is generally mild or moderate and shows a characteristic decreasing pattern over time. Furthermore, in contrast with other types of asymptomatic knee implants previously investigated, no case of high or very high bone uptake was recorded with this type of implant. We may speculate that scintigraphic parameters of normality, and pathology, should be determined for each type of TKA. It is likely that, with the uncemented Hofmann TKA, a high or very high tracer uptake or a progressive increase in the uptake intensity is suggestive of the presence of complications.