人工全踝关节置换假体类型及其评价系统

背景：人工全踝关节置换在国内外已相继开展,其中远期疗效不甚满意。人工踝关节假体的设计研究与开发、疗效评价系统的优化和规范与其中远期疗效密切相关。 目的：分析近年来人工踝关节假体设计与开发及踝关节置换后疗效评价系统的研究进展。 方法：电子检索CNKI数据库、万方数据库、维普数据库等中文数据库和PubMed数据库中1980/2010关于人工踝关节置换假体类型与评价系统的相关综述和研究报告,在标题和关键词中以“踝关节,置换术,假体,评价系统”或“ankle joint, replacement, prosthesis, evaluation system”为检索词进行检索。选择文章内容与人工踝关节置换相关,同一领域文献则选择近期发表或发表在权威杂志上的文章,分析踝关节置换假体类型与评价系统,适应症与禁忌症的研究进展。 结果与结论：共纳入人工踝关节置换假体研究与评价系统的相关文献33篇。人工关节置换治疗疼痛踝关节是一直探索不辍的课题,人工踝关节置换术的中远期疗效有赖于踝关节假体的设计研究与开发、疗效评价系统的优化和规范,人工踝关节应该有较大的改进和提高,使人工全踝关节置换达到更优的疗效和更高的生存率,同时应有更合理和规范的评价系统来评价疗效。     

髋关节置换前后髋关节功能与维生素D水平的多元线性回归分析

BACKGROUND: The incidence of low serum level of vitamin D in patients undergoing hip arthroplasty and its impact has not been reported in China, indicating that it has not been brought to the forefront.     

单侧全髋关节置换后遗症期的下肢步态参数

背景：全髋关节置换可以为患者缓解疼痛、恢复步行功能,数年后步态是否能达到正常化仍存在争议。 目的：分析单侧髋关节置换后遗症期患者平地步行中下肢的时空参数特征,探讨患者步行能力。 方法：根据运动重建实验室检测病例数据库资料分析的方法,选择全髋关节置换后5-10年的患者14例为实验组,14例相匹配的健康人为对照组。采用Vicon Nexus采集患者平地步行时下肢的步态参数,应用Polygon分析步态周期中下肢时空参数特征。 结果与结论：与对照组相比,实验组术侧和健侧步速减慢,步频减小,步幅、跨步长变短,双支撑相延长,对侧足离地比增大(P < 0.05);术侧跨步时间、单步时间增大(P < 0.05);健侧足离地比增大(P < 0.05)。术侧与健侧比较,各时空参数差异均无显著性意义(P > 0.05)。结果表明全髋关节置换后5-10年的患者步态对称性较好,但仍没有达到正常水平,步行能力差于正常人,需要系统康复训练以恢复其步行能力。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;组织工程全文链接：     

个性化踝关节假体的设计及三维有限元分析

目的针对当前踝关节假体失效率高、临床应用风险大的问题,提出一种个性化解剖型踝关节假体的设计。方法首先建立正常人体足踝系统的三维有限元非线性模型,对模型的有效性进行验证;设计解剖型踝关节假体,对全踝关节假体置换进行几何仿真,建立假体-足踝系统的三维有限元模型;施加步态载荷,计算分析假体的生物力学特性。结果正常踝关节系统足底最大接触应力为214.6 k Pa,足骨最大等效应力为8.96 MPa。对比文献与仿真所得足底反力与足骨应力,验证了正常足踝有限元模型的可靠性。假体植入后,仿真所得距骨钛合金假体、聚乙烯衬垫、胫骨假体等效应力峰值分别为23.88、19.24、73.01 MPa,足踝假体应力相较正常足踝应力有大幅度上升。结论有限元分析的对比结果考察了个性化踝关节假体的可行性,为进一步假体设计优化以及临床应用提供参考。     

人工髋关节置换后的功能康复训练

背景：人工髋关节置换后的功能康复训练可改善假体功能,促进患者恢复体力,增强肌力,增大关节活动度,恢复日常生活协调性。 目的：总结人工髋关节置换后功能康复训练的研究进展。 方法：以“人工髋关节,置换,功能康复;artificial hip joints, Replacement, Sports rehabilitation”为关键词,应用计算机检索1997/2011 PubMed数据库、中国期刊网、万方数据库、Springer Link数据库和Science Direct数据库,有关人工髋关节置换后的功能康复训练的文章。 结果与结论：人工髋关节置换可及时有效地缓解疼痛,重建髋关节功能,改善患者日常生活能力,提高生活质量。人工髋关节置换围手术期进行科学合理的功能康复训练指导,遵循个体化、循序渐进和全面训练的原则,训练程序根据具体情况、合并症及对疾病的耐受性和功能恢复的期望值而制定,活动量由小到大、时间由短到长、频率由少到多的详细训练计划,进行肌力训练才能使患者达到康复快、关节功能恢复效果好、并发症少的目的。提示早期功能康复训练对人工髋关节置换后患者功能恢复具有重要的意义,早期的康复训练可改善患者疼痛程度、行走功能,增强关节活动度功能;后期的功能康复训练能有效地预防肢体被迫制动而引起的肌张力降低和肌萎缩。     

人工髋关节置换治疗严重髋关节疾病

背景：终末期髋关节疾病施行人工全髋关节置换难度大,涉及面多,包括置换入路、置换中截骨、假体的植入、类型的选择等,专家学者各不相同,意见不统一,争议较多。 目的：探讨人工全髋关节置换治疗终末期髋关节疾病的方法及临床效果。 方法：回顾性分析52例(57髋)人工髋关节置换患者,进行长期随访,随访时间14-86个月,平均随访时间为27个月。随访并记录置换前后(末次随访时)的目测类比评分、Harris评分,分析比较置换前后评分并对结果进行统计学分析。 结果与结论：52例患者中目测类比评分由置换前的(7.0±1.2)分降至置换后的(2.0±0.7)分,Harris评分从置换前的(35.9±5.4)分增加到末次随访的(89.7±3.1)分,与置换前相比差异有显著性意义(P < 0.05)。52例患者置换后均可扶拐或助行器下地行走,3个月后能独立行走,生活自理,X射线评估无假体松动,治疗效果满意。说明精心的置换前准备、科学严谨的操作技术可预防髋部假体松动、感染、疼痛等并发症,置换后科学正确的康复锻炼是减少置换后疼痛、功能最大程度恢复的重要措施。     

一期全髋置换与股骨头置换修复老年股骨颈骨折：髋关节功能与并发症的Meta分析

BACKGROUND: There are objections to the efficacy and safety of total hip arthroplasty and artificial femoral head arthroplasty in the treatment of femoral neck fracture.     

基于3D打印个性化手术导航模板辅助下的人工全膝关节置换

背景：膝关节的解剖形态个体差异显著,而传统膝关节置换手术定位力线方法复杂,不能准确预测术中患者的力线位置、假体大小及截骨量。 目的：探讨基于医学图像三维重建、计算机辅助设计技术以及3D打印制造的个性化手术导航模板辅助下全膝关节置换的临床效果。 方法：采用CT或者磁共振扫描设备对患者进行扫描,获取患者医学图像数据;采用二维医学图像处理技术进行骨骼的三维重构;利用计算机辅助设计技术进行导航模板的设计;采用3D打印技术制造个性化手术导航模板,并进行临床全膝关节置换;置换后采用影像学评估术后效果。 结果与结论：Arigin 3D Pro(昕健医疗技术有限公司)能够准确重构出患者下肢骨骼三维模型,自主研发的三维设计软件Arigin Surgical Templating(昕健医疗)能够精确定位包括下肢力线、股骨旋转轴等在内的下肢相关轴线及截骨参考点。该组研究设计和制作的个性化膝关节手术导航模板,术中和股骨髁与胫骨平台骨性解剖结构贴合紧密,无明显移动;全膝关节置换后患者下肢力线偏差小于3°。 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     

氨酚曲马多在人工膝关节围置换期镇痛的安全性

背景：中老年全膝关节置换患者身体功能较差,如在手术过程中缺乏理想的麻醉方法,可能导致患者预后较差,因此,有必要探索适用于人工膝关节置换的镇痛药物。 目的：探讨氨酚曲马多在人工膝关节围置换期镇痛中的临床应用效果及其药物安全性。 方法：从南京医科大学附属淮安第一医院骨科2013年12月至2015年1月收治的单侧人工全膝关节置换的患者中按随机数字表法选择200例进行研究,根据围置换期不同镇痛方法将患者分为对照组和实验组,每组100例,对照组采用静脉自控镇痛,实验组口服氨酚曲马多镇痛,分析氨酚曲马多在人工膝关节围置换期镇痛中的临床应用效果及其药物安全性。 结果与结论：两组患者置换即刻、置换后第4,5天目测类比评分差异无显著性意义;实验组患者置换后第1-3天目测类比评分显著低于对照组。实验组患者置换后7 d和12个月时的HSS评分与置换后24,72 h的SS评分均显著高于对照组。实验组患者置换后24和48 h追加氨酚曲马多剂量以及2次总药量显著低于对照组。实验组患者并发症发生率显著低于对照组。提示在人工膝关节围置换期镇痛中采用氨酚曲马多效果理想,能够缓解患者疼痛,利于膝关节功能恢复,药物不良反应少,具有一定的临床应用价值。 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     

椎间盘置换中体位对假体置入后活动度的影响

背景：颈椎间盘置换由于其能保留目标节段的运动功能同时延缓临近节段的退变,目前的应用十分广泛。但是在颈椎间盘置换中,患者的体位放置及其对置换后假体活动度的影响尚不明确。 目的：探讨颈椎间盘置换中体位摆放和置换后植入假体活动度的相关性。 方法：对四川大学华西医院2008-01/2010-07接受单节段PRESTIGE LP颈椎间盘置换共49例患者的影像学资料进行回顾性研究。收集患者置换中C臂透视及置换前后的颈椎矢状中立位及功能位(过伸、过屈位)X射线片,测量目标椎间盘的Cobb角,对其置换前中的差异、置换前后的改善等数据进行线性相关检验及线性回归分析。 结果与结论：与置换前相比,目标椎间盘在置换中的前凸角度变化差异无显著性意义(P > 0.05),置换后中立位、过屈位及过伸位的角度均有不同程度改善(P < 0.01),置换后整体活动范围部分变化差异无显著性意义,其中前屈动度增加(P < 0.01),后伸动度变化差异无显著性意义(P > 0.05)。目标椎间盘置换后假体的角度及活动范围与置换前中角度差异存在线性相关(P < 0.01)。证实颈椎间盘置换中颈椎位置的合理放置对植入椎间盘置换后的活动范围,尤其是前屈活动范围的改善具有重要影响。     

Gait analysis of patients following total knee replacement: a systematic review

Gait analysis has been used to objectively measure patients' function following total knee replacement (TKR). Whilst the findings of this research may have important implications for the understanding of the outcomes of TKR, the methodology of existing research appears to be diverse and many of the results inconsistent. The objective of this systematic review was to synthesise reported findings and to summarise the methods used by researchers in this field. Eleven articles published in the medical literature that used gait analysis to compare patients following TKR with controls were identified for inclusion in this review. Each article was assessed for methodologic quality and data was compared across studies through the calculation of effect sizes. Consistently large effect sizes showed that patients following TKR walk with less total knee motion during gait and with less knee flexion during swing than controls. Kinetic discrepancies between patients and controls were also identified. The substantial methodologic differences between studies may contribute to the inconsistencies in reported findings for many gait outcomes. Future research is needed to determine the clinical relevance of these findings.     

男性青年踝关节外侧副韧带损伤后行走步态分析

目的 获取青年男性踝关节外侧韧带损伤者行走时踝关节的运动学和动力学参数,探讨损伤者行走步态的生物力学特性。方法 采用Qualisys MCU500三维运动影像捕捉系统与Kistler三维测力台,对踝关节外侧副韧带损伤者与健康者各15名的行走步态进行三维同步测试。结果 踝关节外侧副韧带损伤者竖直方向的地面反力变化平缓;在支撑时相中前期,损伤者前后方向的力要比健康者大;在步态周期的60%之前,损伤者左右方向的力明显大于健康者。损伤者关节跖屈力矩变化与健康者相似,患侧外翻力矩、外旋力矩最大,损伤者健侧输出功率最大。结论 损伤者踝关节的稳定性下降,行走时步态异常,为减少患侧负荷,健侧出现代偿效应,足着地瞬间加速过度到垂直支撑时相。本研究为预防踝关节以及损伤后的临床治疗以及康复训练等提供一定的理论参考。     

Dynamic foot function changes following total knee replacement surgery

BackgroundIndividuals with knee osteoarthritis (OA) have flatter/more pronated feet than those without OA, but it is unclear whether altered foot posture and function are a cause or consequence of knee OA. The purpose of this study was to examine whether changes in foot posture and function occur after realignment of the knee following total knee replacement (TKR).Materials and methodsNineteen patients with predominantly medial compartment knee OA were tested prior to and 12 months after TKR. The Foot Posture Index (FPI) and Arch Index (AI) were measured as well as motion of the tibia, rearfoot and forefoot using a 3D motion analysis system incorporating a multisegment foot model.ResultsThere were no significant changes in FPI or AI following TKR, however gait analysis revealed significant increases in tibial external rotation (? 18.7 ± 7.0° vs ? 22.5 ± 8.7°, p = 0.002), tibial transverse plane range of motion (? 9.1 ± 4.6° vs ? 11.4 ± 6.1°, p = 0.0028) and rearfoot range of motion in the frontal plane (8.6 ± 2.6° vs 10.4 ± 2.7°, p = 0.002), and a decrease in rearfoot transverse plane range of motion (8.7 ± 5.3° vs 5.9 ± 4.1°, p = 0.038) following the procedure.ConclusionsTKR produces no change in static foot posture, but results in significant changes in rearfoot kinematics during gait. These findings suggest that rearfoot motion compensates for changes in the alignment of the knee, highlighting the ability of the foot to accommodate for proximal skeletal malalignment.     

髋关节置换后双下肢不等长对功能影响的Meta分析

背景：髋关节置换后肢体不等长对功能的影响仍存在不同观点,近年已有一些学者进行了置换后肢体不等长对功能影响的随机对照研究,对这些随机对照研究进行系统评价能更客观地反映情况,为临床工作所借鉴。 目的：系统评价全髋关节置换后肢体不等长对功能的影响。 方法：计算机检索Cochrane图书馆、Cochrane协作网专业试验数据库、MEDLINE(1950/2010-09),EMBASE (1979/2010-09)、中国生物医学文献数据库(1978/2010-09),手工检索中文文献(截至2010-09),收集所有髋关节置换后双下肢不等长对功能影响的所有随机对照试验或临床对照试验,对其逐个进行方法学质量评价并采用RevMan 5软件进行系统评价。 结果与结论：共纳入6篇临床对照试验,包括1 304例患者。其中4篇数据完善,可满足就置换后肢体等长组与非等长组关节功能差异进行Meta分析。结果提示,置换后肢体不等长可影响关节的功能,平衡双下长度,对于减轻跛行步态,提高关节功能有一定临床意义。随时间推移,肢体不等长者的功能障碍有所改善,但与等长者仍存差异。置换后肢体不等长与并发症的发生,诸如脱位、神经损伤、磨损、松动等,由于纳入研究及病例数太少,尚需更多设计严格的研究以增加证据的强度。     

Pyrexia following total knee replacement

This study aims to determine the incidence and factors associated with pyrexia following total knee replacement (TKR). We performed a retrospective analysis of the temperature charts and histories of patients who underwent 170 TKRs. There was a statistically significant increase in mean temperature from pre-operation to post-operation, and this increase remained significant through to 5 days post surgery (p<0.0001). Sixty-two (36.5%) patients were pyrexial (>or=38 degrees C) at some point. Fourteen patients developed a clinical infection, but only four of these were pyrexial. There was no association between pyrexia and infection, allogenic blood transfusion, haemoglobin loss, use of urinary catheter, rheumatoid arthritis, anaesthetic type, and previous pyrexia following TKR. Pyrexia as a diagnostic test for the development of infection had a sensitivity of 0.286 (95% CI=0.084-0.581), specificity of 0.628 (95% CI=0.548-0.704) and positive predictive value of 0.065 (95% CI=0.018-0.157). Pyrexia in the first 5 days following TKR is usually a normal physiological response and should not cause undue concern about the presence of infection.     

Gait analysis: Comparative evaluation of conventional total knee replacement and modular distal femoral megaprosthesis

BackgroundGait alterations have been studied with computer-assisted gait analysis after megaprosthetic replacement for tumors around the knee. It has never been proven that megaprostheses affects gait more than total knee arthroplasty (TKA); this study aims to compare via gait analysis patients who underwent megaprosthesis with patients with TKA.MethodsWe analyzed 26 patients with a megaprosthetic replacement of the distal femur and 21 patients with a standard TKA. For each subject computerized gait analysis was performed. Range of motion (ROM) of the knee was recorded, Quality of Life and functional evaluation in the oncologic group were assessed with the Musculoskeletal Tumor Society (MSTS) questionnaire, while Short Form-36 (SF-36) scores were calculated for both groups.ResultsAll patients walked slower than healthy people (P < 0.05). Gait analysis showed a lower cadence than in the healthy population but no significant difference between the two groups. A longer swing and a shorter stance phase were detected in the megaprosthetic sample. The osteoarthritis group showed greater flexion during the phase of loading response, even if this was lower than the contralateral limb or healthy population. There was a statically significant difference between the healthy limb and the operated one in both groups regarding ROM, but no significant difference was registered between the two implants. MSTS score and most of SF-36 parameters showed no significant differences compared with literature data.ConclusionsGait analysis shows little discrepancy between the two groups; gait pattern abnormalities do not affect patients with a megaprosthetic replacement more significantly than patients undergoing TKA.     

三组件式全踝关节置换假体的设计及应用现状

背景:早期的全踝关节置换假体,由于对踝关节生物力学的认识不足,较高的置入失败率和并发症发生率使得外科医生放弃了这种治疗方案。随着踝关节假体设计理念的不断更新,全踝关节置换越来越受到外科医生的青睐。目前,三组件式全踝关节置换假体被认为更符合正常踝关节生物力学的要求,并且被逐步推广应用于临床。目的:了解踝关节生物力学,总结3种三组件式全踝关节置换假体的设计特点,为进一步的假体设计总结经验。方法:由第一作者应用计算机检索CNKI、Pub Med等数据库建库至2020年2月有关全踝关节置换假体的文献,中文检索词为"全踝关节置换假体设计,STAR假体,HINTEGRA假体,BOX假体",英文检索词为"Total ankle replacement prosthesis design,STAR prosthesis,HINTEGRA prosthesis,BOX prosthesis"。结果与结论:(1)STAR假体、HINTEGRA假体、BOX假体在临床应用中表现出了可接受的生存率及临床结果,但仍然需要大量病例和长时间的随访进行验证;(2)3种全踝关节置换假体的设计都着重于恢复生理踝关节的解剖结构,再现踝关节的运动轴,兼容韧带的几何形状、减少踝关节周围组织的应力和机械对准;(3)要实现最大化的韧带兼容,假体组件的关节面设计必须是2个生理解剖形状或2个非生理解剖形状的关节面;(4)国人踝关节的形态和高加索人踝关节的形态有差异,期待设计研发符合国人踝关节要求的假体。     

Computer-assisted design of the sagittal shapes of a ligament-compatible total ankle replacement

The poor results of total ankle replacement have been attributed to the inability of designers to restore adequately the critical mutual function of the ligaments and the articular surfaces. The purpose of this study was to design sagittal shapes of the articular surfaces for a new ankle prosthesis to be compatible with the geometry of the reticular surfaces for a new ankle prosthesis to be compatible with the geometry of the retained ligamentous structures. Several ligament-compatible pairs of articular surfaces were tested using a computerised version of a four-bar linkage model. The kinematics of the ankle when replaced by non-conforming two-component and by fully conforming three-component designs with either flat, concave or convex tibial surfaces were assessed by the model. A ligament-compatible convex-tibia fully-congruent three-component prosthesis showed the best features. The three-component prosthesis allows complete congruence over the entire range of flexion. A convex shape for the tibial are was preferred because of the better degree of entrapment of the meniscal bearing. A 5 cm convex-tibia arc radius gave 2 mm entrapment together with 9.8 mm of tibial bone cut. Ligament elongation imposed by full congruence of the articular surfaces was less than 0.03% of the original length. The original patterns of joint kinematics and ligament tensioning are closely restored in the joint replaced by the proposed prosthesis.