膝表面置换术在类风湿性膝关节炎和骨性膝关节炎的应用和比较

目的探讨膝关节表面置换术治疗类膝关节风湿性关节炎(RA)和膝关节骨性关节炎(OA)的临床疗效、安全性差异。方法自2010-01—2012-04采用膝关节表面置换术治疗68例(84膝)膝关节疾患,按照疾病类型分为OA组和RA组,对比分析2组手术时间、术中出血量、VAS评分、切口愈合时间、HSS单项评分及总分等。结果术后68例(84膝)获得平均47个月随访,随访期间无人工膝关节假体脱位。OA组手术时间、术中失血量、术后引流量及VAS评分显著低于RA组,差异有统计学意义(P0.05)。OA组术后1个月疼痛和HSS总分显著高于RA组,差异有统计学意义(P0.05),OA组术后1年和3年疼痛、功能、活动范围单项评分和HSS总分均显著高于RA组,差异有统计学意义(P0.05)。结论OA及RA人工全膝置换术后功能均有一定改善,与OA相比,RA患者术后近中期疗效相对较差,但远期疗效差异有待进一步研究。     

类风湿性关节炎全膝关节置换的临床疗效观察

目的:观察人工全膝关节置换术治疗严重类风湿性关节炎的临床疗效.方法:我院2003年3月-2005年12月对11例严重类风湿关节炎患者行人工全膝关节置换术,平均随访13个月,按美国特种外科医院膝关节评分系统(HSS)进行疗效评定.结果:所有患者没有一例行翻修手术,X线显示所有置换假体植入位置满意,没有假体松动、移位现象出现.11个膝关节的术后情况比较满意.HSS评分平均指数从术前的41分提高到术后的90分.结论:人工全膝关节置换术可作为类风湿性关节炎患者保存关节功能,改善疼痛的一种有价值的治疗方法.     

The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method

The purpose of this study was to demonstrate the effectiveness of the Ilizarov method and circular external fixator in order to eradicate the infection and restore bone union, limb anatomy and functionality in cases with infected nonunion of the tibia following intramedullary nailing.During 7 years nine patients suffering from infected nonunion of the tibia after intramedullary nailing were treated in our department. The series comprised seven men and two women with an average age of 39.7 years (range 21-75 years). The patients had previously undergone an average of 4.8 operations (range 3-6 operations). Active purulent bone infection occurred in all nine patients. Bone defect was present in all patients with a mean size of 5 cm (range 2-12 cm). In three cases with bone defect less than 2 cm, monofocal compression osteosynthesis technique was used. In the rest cases where bone defect exceeded 2 cm, bifocal consecutive distraction-compression osteosynthesis technique was applied. Three patients required a local gastrocnemius flap. The mean follow-up period was 26.6 months (range 13-42 months). Results were evaluated using Paley's functional and radiological scoring system.Bone union was achieved in all nine patients without recurrence of infection during the follow-up period. Bone results were graded as excellent in five cases and good in the rest four cases. Functional results were graded as excellent in three cases, good in four and fare in two cases. Mean external fixation time was 187.4 days (range 89-412 days) and mean lengthening index was 32 days/cm (range 27-39 days/cm). Complications observed included eight grade II pin tract infections, axial deformity at the lengthening site in two cases and at the nonunion site in another two cases. Ankle joint stiffness was detected in five cases.The Ilizarov method may be an effective method in infected nonunions of the tibia following intramedullary nailing.     

全膝关节置换术治疗类风湿性关节炎15例

目的。评价人工全膝关节置换术治疗严重类风湿性关节炎的效果．方法：对15例全膝关节置换术进行临床分析和总结，并采用美国Tohn．M．Insall评分标准进行分析。结果：手术优良率为93．3％，病人术后在疼痛、功能及关节活动度等方面都有明显改善，尤其是在缓解疼痛方面效果显。结论：全膝关节置换术是治疗严重类风湿性关节炎的有效方法。     

人工全膝关节置换术治疗类风湿性关节炎的疗效分析

目的探讨人工全膝关节置换术治疗类风湿性关节炎的临床效果。方法对35例类风湿性关节炎患者(64膝)进行全膝关节置换。根据软组织平衡情况采用后稳定型膝关节非限制性假体(58膝)或者限制性假体(6膝)。根据HSS评分系统对患者手术前后的膝关节功能进行评分。结果 35例均获随访,时间6个月~7年。关节功能明显改善,尤其是在畸形矫正方面效果显著。HSS评分:优27例,良4例,可4例,优良率达88.5%。无感染发生及深静脉血栓形成。结论类风湿性关节炎病理改变复杂,手术难度大,需要很好的软组织平衡技术,韧带损伤严重者需要采用限制性假体才能取得满意的疗效。     

人工全膝关节置换术治疗终末期膝关节病变合并膝外翻畸形的手术技巧及临床疗效评价

目的探讨对终末期膝关节病变合并膝外翻畸形患者行经髌旁内侧入路人工全膝关节置换(total kneearthroplasty,TKA)时膝外翻畸形矫正方法及临床疗效。方法 1998年11月-2010年10月,收治64例72膝合并膝外翻畸形的终末期膝关节病变患者。男18例,女46例;年龄23～82岁,平均62.5岁。骨关节炎44例49膝,类风湿性关节炎17例20膝,血友病性关节炎2例2膝,创伤性关节炎1例1膝。双膝8例,单膝56例。膝关节屈伸活动度为(82.2±28.7)°,X线片测量股胫角为(18.0±5.8)°。膝关节学会评分系统(KSS)临床评分为(31.2±10.1)分,功能评分(37.3±9.0)分。根据Krackow膝外翻分型标准:Ⅰ型65膝,Ⅱ型7膝。手术经髌旁内侧入路,采用常规方法行股骨及胫骨截骨,Ranawat技术进行软组织松解。6例7膝采用保留后交叉韧带型假体,54例60膝采用后稳定型假体,4例5膝采用髁限制型假体。结果术后患者切口均Ⅰ期愈合。1例血友病性关节炎合并严重膝外翻畸形(股胫角41°)、屈曲挛缩20°的患者术后出现腓总神经麻痹,经保守治疗1年后神经功能恢复。1例术后2年发生深部感染,行二期翻修术后治愈。患者术后均获随访,随访时间1～13年,平均4.9年。末次随访时X线片示股胫角为(7.0±2.5)°,与术前比较差异有统计学意义(t=15.502,P=0.000)。KSS临床评分为(83.0±6.6)分,功能评分(85.1±10.5)分,膝关节屈伸活动度为(106.1±17.0)°,与术前比较差异均有统计学意义(P0.05)。5例遗留12～15°膝外翻畸形,但患膝关节功能良好。结论通过恰当的术中截骨和软组织平衡,采用经髌旁内侧入路TKA治疗合并膝外翻畸形的终末期膝关节病变可有效改善膝外翻畸形和恢复关节功能,临床疗效满意。     

Dislocation following total knee arthroplasty: A report of six cases

Background:

Dislocation following total knee arthroplasty (TKA) is the worst form of instability. The incidence is from 0.15 to 0.5%. We report six cases of TKA dislocation and analyze the patterns of dislocation and the factors related to each of them.

Materials and Methods:

Six patients with dislocation of knee following TKA are reported. The causes for the dislocations were an imbalance of the flexion gap (n=4), an inadequate selection of implants (n=1), malrotation of components (n=1) leading to incompetence of the extensor mechanism, or rupture of the medial collateral ligament (MCC). The patients presented complained of pain, giving way episodes, joint effusion and difficulty in climbing stairs. Five patients suffered posterior dislocation while one anterior dislocation. An urgent closed reduction of dislocation was performed under general anaesthesia in all patients. All patients were operated for residual instability by revision arthroplasty after a period of conservative treatment.

Results:

One patient had deep infection and knee was arthrodesed. Two patients have a minimal residual lag for active extension, including a patient with a previous patellectomy. Result was considered excellent or good in four cases and fair in one, without residual instability. Five out of six patients in our series had a cruciate retaining (CR) TKA designs: four were revised to a posterior stabilized (PS) TKA and one to a rotating hinge design because of the presence of a ruptured MCL.

Conclusion:

Further episodes of dislocation or instability will be prevented by identifying and treating major causes of instability. The increase in the level of constraint and correction of previous technical mistakes is mandatory.     

Thromboembolic disease in patients with rheumatoid arthritis undergoing joint arthroplasty: Update on prophylaxes

The risk of venous thromboembolism (VTE) in rheumatoid arthritis (RA) and the higher incidence of RA patients undergoing major orthopedic surgery is well recognized. The objective of the present study is to describe the incidence of VTE and discuss the correct prophylaxis in RA patients undergoing knee or hip replacement. A systematic review of studies on thromboprophylaxis in RA patients undergoing major orthopedic surgery was performed. Detailed information was extracted to calculate the rate of VTE in RA orthopedic patients and analyze the thromboprophylaxis performed and bleeding complications. Eight articles were eligible for full review. No difference in the overall rate of VTE was observed between RA patients and controls. No significant differences were found in RA patients in terms of bleeding complications. The data on the optimal prophylaxis to be used in RA patients were insufficient to recommend any of the several options available. In the absence of dedicated guidelines for the care of RA patients undergoing orthopedic surgery, management must be individualized to obtain favorable patient outcome, weighing up all the factors that might put the patient at risk for higher bleeding and thrombotic events.     

Results of cementless total knee arthroplasty in an older rheumatoid arthritis population

Fifty-five total knee arthroplasties (TKAs) in thirty-nine adult (mean age, 62 years) patients with rheumatoid arthritis were studied prospectively for a period of 1-7 years. All of the procedures were performed using cementless fixation of the tibial and femoral components. The Knee Society clinical rating system mean knee scores increased 56 points after operation (mean, 88 points), and the mean functional scores increased 28 points (mean, 64 points). Two revisions (4%) have been required, one for secondary late infection and one for failure of a cementless metal-backed patellar component. Good bone stock was retained in both, allowing for uneventful cementless revision. Forty-two arthroplasties (76%) were completely pain-free, twelve (22%) had mild, occasional discomfort with weight-bearing, and one (2%) had moderate pain at last examination. In this older rheumatoid population, cementless TKA offers good or excellent early clinical results and excellent preservation of bone stock should revision become necessary.     

Supracondylar nailing of periprosthetic fractures above total knee arthroplasties

Supracondylar nailing was performed in 10 patients who sustained periprosthetic fractures above total knee arthroplasties. The fractures occurred in women with an average age of 67.4 years (range, 42–92 years). All fractures healed in a satisfactory alignment in an average duration of 13.2 weeks (range, 12–18 weeks). None of the fractures needed bone grafting. There were no cases of wound infections, nonunion or delayed union. All patients achieved satisfactory range of movement of the knee joint and preoperative functional status. Main complications included loosening of a distal screw in one patient and fracture above the short nail following a second injury in another patient. Use of a longer nail where possible and a condylar bolt for distal locking can easily avoid these complications. We conclude that supracondylar nailing, despite some limitations, is a satisfactory method of treatment for a majority of displaced periprosthetic fractures above well-fixed total knee arthroplasties.     

人工全膝关节置换术治疗膝关节类风湿性关节炎中短期疗效随访

目的：为了观察人工全膝关节置换术（ TKA）治疗膝关节类风湿性关节炎（ RA）的中短期治疗效果。方法随访2007至2011年间行TKA治疗的38例（58膝）膝关节RA患者。采用HSS评分、KSS评分、WOMAC评分、VAS视觉疼痛评分对术前及术后患者的膝关节功能进行评价、同时对术后随访影像学资料进行评价;采用SF-36量表对患者健康状况进行评价。结果所有患者均未出现感染且获得平均3.3年（2～6年）随访,膝关节功能均明显改善,患者膝关节HSS评分由术前45.92±13.49分提高到术后88.19±5.98分,两者采用配对t 检验比较差异有统计学意义（ P ＝0.00）,其中优21膝,良34膝,优良率94.83％。膝关节屈曲畸形明显改善,膝关节活动度（ROM）由术前71.81°±32.58°提高到术后100.98°±13.99°,两者比较差异有统计学意义（ P＝0.00）。膝关节假体X线片采用膝关节学会的X线评价与计分系统评价未见假体松动。 SF-36评分中PCS由术前的26.27±3.91分提高到术后48.09±6.65分,两者比较差异有统计学意义（ P＝0.00）;MCS由术前的41.59±5.61分提高到51.83±5.44分,两者比较差异有统计学意义（ P＝0.00）。结论 TKA是治疗膝关节RA的有效方法,可提高患者生活质量。     

抗生素骨水泥间置器治疗髓内固定术后骨髓炎合并骨不连

目的探讨抗生素骨水泥间置器治疗髓内固定术后骨髓炎合并骨不连的临床疗效。方法 2002年6月-2006年5月,收治12例行切开复位交锁髓内钉内固定术后骨髓炎合并骨不连患者。男8例,女4例;年龄26～53岁,平均40.2岁。骨折部位:胫骨7例,股骨5例。髓内固定术后2周内感染7例,3个月内感染5例。患者于感染发生后1～24个月入院,平均5个月。细菌培养10例呈阳性,2例呈阴性。白细胞计数、红细胞沉降率、高敏C反应蛋白均高于正常值。一期手术取出内固定物,髓内插入抗生素骨水泥间置器临时固定;3～6个月待感染控制后,二期手术取出间置器,行自体髂骨植骨锁定钢板内固定术。结果患者两期手术切口均Ⅰ期愈合,无早期相关并发症发生。二期术后患者均获随访,随访时间24～48个月,平均34个月。二期术后3个月红细胞沉降率、白细胞计数以及高敏C反应蛋白均正常。X线片复查,骨折均在二期术后10～14周达临床愈合,平均12周。除1例患者膝关节屈曲约90°外,其余患者下肢功能均恢复正常。随访期间均无感染复发。结论采用抗生素骨水泥间置器临时固定可以有效控制感染,待感染控制后二期手术取出间置器行植骨内固定,是治疗髓内固定术后骨髓炎合并骨不连的有效方法之一。     

类风湿性关节炎与骨性关节炎行全膝关节置换术时失血量的探讨

目的比较类风湿性关节炎（RA）与骨性关节炎（OA）行人工全膝关节置换术（TKA）时的失血量,为制定适宜的输血方案提供参考依据。方法实施TKA的RA（30例）与OA（62例）共92个膝关节为研究对象,筛选时制定了严格的剔除方案,比较两组行TKA时总失血量。结果RA组TKA的平均失血量为（334.33±221.87）ml,OA组TKA的平均失血量为（495.97±242.83）ml。两组失血量的比较差异有显著性（P〈0.05）。结论不同膝关节疾病行TKA时失血量有差异,因而在制定输血方案时应因病制宜。     

Femoral neck fracture following intramedullary nailing with misplacement of an end cup: report of two cases

Femoral neck fracture is an unusual complication of intramedullary fixation of a broken femur. We report on two cases of femoral neck fractures attributed to misplacement of an end cup and subsequent invasive maneuvers in an effort to remove it. Iatrogenic fractures of the femoral neck during or after intramedullary nailing are reported in the medical literature. Authors associate it with many possible technical mistakes performed during the procedure, yet no complications after missed end cup placement were noted. We suggest that the fractures described below were a consequence of injury to the vascular supply and bone stock of the initially intact femoral neck.     

人工膝关节表面置换治疗类风湿性关节炎屈膝畸形

目的探讨人工全膝关节置换术治疗类风湿性关节炎屈膝畸形的临床效果。方法选用后稳定型钴合金假体对21例类风湿性关节炎屈膝畸形患者进行人工全膝关节置换术,其中单侧膝关节置换5例,双侧膝关节置换16例,手术前后对患者的膝关节功能进行评分。结果随访1~5年,术前患者平均膝评分(22.84±6.06)分,平均功能评分(12.86±16.09)分;术后2周平均膝评分(70.16±2.71)分,平均功能评分(58.10±8.14)分;术后12周随访平均膝评分(86.14±3.12)分,平均功能评分(89.05±3.01)分。结论人工全膝关节置换术能显著纠正类风湿性关节炎屈膝畸形患者膝关节的畸形,解除疼痛,改善患膝的功能。     

Results of total hip arthroplasty with bone graft and support ring for protrusio acetabuli in rheumatoid arthritis

We evaluated 19 hips of 15 rheumatoid arthritis patients with protrusio acetabuli that had been surgically treated with total hip arthroplasty (THA) using a support ring; four hips were replaced with a TACT cup supporter, one hip with a Kerboull plate, six hips with a Ganz ring, and eight hips with a Müller ring. The average age was 60.2 years (range 48–75 years), and the average follow-up was 38 months (range 6–74 months). Two patients (three hips) died before the final follow-up, and two patients (two hips) underwent revision owing to loosening of the Ganz ring. Hip functions were rated according to the evaluation chart of hip joint functions of the Japanese Orthopaedic Association (JOA score). The mean total JOA score was 25.2 ± 8.6 preoperatively and 55.6 ± 8.7 postoperatively. Radiographically, 17 hips (minus the two revised hips) showed satisfactory incorporation of bone graft and no loosening of the support ring. The mean depth of protrusio acetabuli for these 17 hips was 3.5 ± 4.1mm before operation, 2.8 ± 5.1mm just after operation, and 2.3 ± 3.9mm at the final follow-up (no significant difference at the critical rate of 5%). Our study indicated the usefulness of THAs using a bone graft and a support ring in RA patients with protrusio acetabuli.     

Retrograde femoral nailing of periprosthetic fractures around total knee replacements

IntroductionThe incidence of primary total knee replacement (TKR) is increasing with a resultant rise in those patients sustaining distal femoral periprosthetic fractures around TKRs. The management of these fractures pose a significant challenge. The compatibility of retrograde femoral intramedullary (IM) nails with femoral TKR components needs to be considered preoperatively when this complex pathology is addressed. The aim of this study was to update the literature and assess the compatibility of the most commonly used primary TKR prostheses and retrograde femoral IM nails using a Sawbone anatomical model.Methods and materialsEight of the most commonly used primary TKR prostheses and four of the most commonly used retrograde femoral IM nails were identified. The femoral components of the TKRs were implanted onto left sided femoral Sawbones using the manufacturer's guides and cutting blocks and positioned appropriately. The retrograde IM nails were inserted using the conventional entry point and a nail was deemed compatible if this was possible through the femoral prosthesis. Details of whether a posterior entry point was required to allow insertion, whether the femoral nail was scratched by the femoral TKR prosthesis on insertion and whether excess force was required to insert the retrograde femoral IM nail were recorded.ResultsThe Biomet AGC Cruciate Retaining (CR) and Posterior Stabilised (PS) TKR were the only prostheses that were compatible with all the nails used. The other TKR prostheses were not compatible because of the force required to gain entry, scratching of the retrograde femoral IM nail or because a posterior entry point was required to gain entry through the intercondylar notch.ConclusionThe majority of standard sized retrograde femoral nails are technically feasible for insertion through most femoral TKR components but this study has found that they are not compatible due to excessive force required for insertion, damage to the nail during insertion or the risk of anterior cortex perforation. Further studies are required to update the compatibility table and cadaveric studies would confirm the findings and allow further mechanical testing.     

15-year follow-up study of total knee arthroplasty in patients with rheumatoid arthritis

In 25 patients with rheumatoid arthritis, 36 cases of cemented Kinematic total knee arthroplasty were reviewed clinically and radiographically at 13 to 19 years after surgery. The mean age at the time of surgery was 51.6 +/- 8.9 years. According to the follow-up results evaluated with the Hospital for Special Surgery knee scoring system, 28 knees (77.7%) were classified as good or excellent. The mean flexion angle at follow-up evaluation was 99 degrees +/- 24 degrees (10 degrees -140 degrees ). At the tibial or femoral bone-cement interfaces, a radiolucent line was seen in 10 of 36 knees (27.8%) at follow-up evaluation. The survival rate of prostheses with revision as the endpoint was estimated to be 93.7% at 15 years. Kinematic total knee arthroplasty in rheumatoid arthritis patients provided a good long-term outcome.     

Bone mineral density after total joint arthroplasty of lower extremities in rheumatoid arthritis patients

We studied the effects on the axial bone mass of total joint arthroplasty (TJA) for lower extremities in 48 female rheumatoid arthritis (RA) patients by using dual-energy X-ray absorptiometry (DXA). Twenty-nine postmenopausal RA patients treated only with nonsteroidal anti-inflammatory drugs (NSAIDs) served as controls. They were studied for an average duration of 63 months. The reduction in the bone mineral density (BMD) of the lumbar spine (L2–4) was significant in both groups (p < 0.01∼0.05), but it was not statistically different between the two groups. The BMD of the femoral neck decreased significantly in both groups (p < 0.01–0.05) after 2 years, but it was not statistically different between the two groups. Our data suggest that TJA slowed the rapid axial bone loss usually associated with advanced RA. Received: 7 February 2000