基于三维重建技术对国人胫骨近端截面的形态学测量

[目的]通过建立正常膝关节数字模型,测量胫骨近端不同截面线性参数,探讨性别及截骨厚度差异对胫骨假体基底部形态设计的影响.[方法]选取36例正常成人左侧膝关节,男女各半,年龄18～55岁,平均43岁;利用原始CT扫描图像资料重建膝关节,对胫骨近端进行模拟截骨,测量各截面内外侧前后径和横径.比较各测量值在性别间及截骨面间的差异.[结果]获取正常胫骨近端截面内外侧前后径、横径、前后径与横径的比值,内外侧前后径、横经、前后径与横径的比值在不同性别的差异具有统计学意义,内外侧前后径、前后径与横径的比值在不同截骨面高度的差异具有统计学意义.[结论]胫骨平台截面的几何形态不同于西方人,应用进口胫骨假体要考虑国人的特点;性别及胫骨截骨厚度会影响胫骨假体的设计和置换术中假体的选择.     

国人胫骨平台截骨面与国人膝关节假体的涵盖率分析

[目的]测量国人正常胫骨近端截面的线面参数,并与作者自主研发的新型国产膝关节假体胫骨组件(CY-knee)进行涵盖率分析,从而为新型国产人工膝关节假体(CY-knee)的设计提供数据支持.[方法]随机选取健康国人志愿者共120人(210膝),其中男性68例(126膝),女性52例(84膝).年龄19～81岁,平均45.8岁.通过CT三维重建测量一定截骨高度、一定后倾角度胫骨近端截面的横径及前后径,并利用5 mm容差范围法与新型国人膝关节假体胫骨组件(CY-knee)进行涵盖率研究.[结果]测得胫骨截面横径平均为(75.00±4.87)mm,前后径平均为(51.39±4.06)mm;此种新型国产膝关节假体胫骨组件(CY-knee)对国人全膝关节置换术胫骨平台承受面适配涵盖率平均值为89%.[结论]国人胫骨近端的几何形态与解剖特点同西方人有明显的区别;较目前国内常用进口膝关节假体,此种新型国人胫骨假体组件(CY-knee)涵盖率更高,更适合应用于国人的全膝关节置换术中.     

国人胫骨平台截骨面与西方进口胫骨假体解剖学参数的偏差

 目的 测量中国北方汉族人胫骨平台截骨面与进口胫骨假体解剖学参数的偏差。方法 中国北方汉族健康志愿者82名（135膝）,男52名（85膝）,女30名（50膝）;年龄19～82岁,平均47.2岁。行膝关节横断面CT扫描,获得“.dicom”格式图像。将图像存储至与CT机联网的计算机三维重建工作站（Adw 4.3）,利用三维容积重建软件建立膝关节三维图像。对三维图像的胫骨进行旋转、切割,测量不同截骨高度及后倾角度各截骨面的胫骨近端横径、前后径及纵横比;采用5 mm容差范围法对三种西方进口假体（A、B、C）与国人胫骨平台截骨面的匹配程度进行初步评估。结果 男性胫骨近端截骨面横径平均值为（78.03±2.92） mm,女性为（69.85±2.70） mm;男性胫骨近端截骨面前后径平均值为（50.62±2.46） mm,女性为（46.14±2.61） mm;男性胫骨近端截骨面纵横比平均值为0.649±0.032,女性为0.661±0.031。不同性别胫骨近端截骨面横径与前后径的差异均有统计学意义,男性大于女性;纵横比平均值女性大于男性,差异有统计学意义。假体A对所有受试者各截骨面的平均涵盖率为42.55%,假体B平均为44.61%,假体C平均为27.41%。A与B两种假体涵盖率的差异无统计学意义,而两者与假体C涵盖率的差异均有统计学意义。结论 国人正常胫骨平台截骨面的几何形态与西方进口假体的匹配度普遍较低。     

维吾尔族人正常胫骨平台线性参数测量及特性分析

目的 初步获得维吾尔族人胫骨平台线性参数正常参考值,为国产人工膝关节假体设计以及针对性的进行全膝关节置换术提供参考依据.方法 选取45例87膝,男21例40膝,女24例47膝,维吾尔族人正常膝关节;年龄l8～65岁,平均33.9岁;按照性别进行分组;利用原始CT扫描图像资料重建膝关节,并在工作平台上对胫骨进行旋转、切割,测量胫骨平台相关线性参数.结果 测得所有受试者胫骨平台宽平均为(70.98±2.21)mm,胫骨内侧平台宽(28.66±1.20)mm,胫骨外侧平台宽(31.04±1.22)mm,胫骨内侧平台前后径(44.96±1.66)mm,胫骨外侧平台前后径(38.95±1.51)mm;并分析得出胫骨平台各线性参数在不同性别间差异均有显著统计学意义(P<0.01).结论 维吾尔族人正常胫骨平台形态同汉族国人存在一定的区别;应用西方人设计的胫骨平台假体要考虑到维吾尔族人的特点和性别差异;设计国人膝关节假体以及进行全膝关节置换手术时应该注意到民族及性别的差异.     

中国汉族与维吾尔族胫骨平台几何特点的对比及临床意义研究

[目的]通过对新疆维吾尔族胫骨平台几何参数的测定为提高少数民族全膝关节置换术的成功率及假体匹配性提供数据支持;同时对中国汉族与新疆维吾尔族胫骨平台几何特征的对比,掌握我国民族间的差异和共性,为假体多样性设计及选择提供理论依据.[方法]选取50例/100膝(男50膝,女50膝)汉族人正常膝关节,年龄18～74岁,平均43.2岁.选取100例/200膝(男100膝,女100膝)维吾尔族人正常膝关节,年龄18～65岁,平均31.4岁.按照性别进行分组,利用原始CT扫描图像资料重建膝关节,并在工作平台上对胫骨进行旋转、切割,测量胫骨平台相关线性参数.[结果]同一民族组内比较,男性胫骨平台各项线性指标均明显大于女性(P<0.01);外侧平台比内侧平台宽,但前后径小于内侧平台(P<0.05);维吾尔族受试组胫骨平台的内外侧宽及内外侧前后径分别要比同性别的汉族受试组更接近(P<0.05);在汉族和维吾尔族受试组中,胫骨平台宽与内外侧胫骨平台前后径存在着正相关关系(P<0.05);维吾尔族受试组男性、女性胫骨平台线性参数分别大于同性别的汉族受试组(P<0.05),但小于西方人群.[结论]维吾尔族人正常胫骨平台形态同汉族国人存在一定的区别;应用西方人设计的胫骨平台假体要考虑到维吾尔族人的特点和性别差异;设计国人膝关节假体以及进行全膝关节置换手术时应该注意到民族及性别的差异.     

TKA术后胫骨近端截骨块参数测量及其临床意义

[目的]测量全膝关节置换术(TKA)术后患者的胫骨平台截骨骨块参数,为制作符合国人解剖特点的TKA胫骨假体提供数值依据,并为建立国人全膝关节置换术胫骨近端数据库提供数值参考.[方法]回顾分析2011年7月～2012年8月在本院进行全膝关节置换术患者共60例,其中男性30例,女性30例,测量术后胫骨平台截骨骨块的各项参数指标,通过多元回归分析,分析国人的性别、年龄及身高等因素对截骨骨块的影响.[结果]全膝关节置换术胫骨平台截骨骨块前后径为(51.31±5.70)mm,胫骨平台内外径为(71.53-5.05) mm,胫骨平台面率(前后径/内外径)为(0.73 ±0.07) mm.性别、年龄对胫骨平台截取骨块的前后径、内外径、胫骨平台面率(前后径/左右径)的影响无统计学意义,但身高对胫骨平台截骨块的前后径、内外径及胫骨平台面率的影响均有统计学差异.[结论]国人胫骨平台截面的几何形态近似方圆,随着身高的增加,胫骨平台截骨骨块的前后径、内外径及胫骨平台面率都随之增加,可为符合国人解剖特点的胫骨平台假体的设计提供有效的数据参考.     

胫骨近端截骨面与胫骨假体的数字化形态学研究

目的 利用数字化技术获取健康成人正常胫骨近端截而及假体的参数参考值,探讨适合不同人种且具有性别差异的胫骨假体设计.方法 对55名志愿者中的92侧正常膝关节(男42侧,女50侧)进行螺旋CT扫描,将断层扣描数据导入Mimics10.1软件建立膝关节三维数字模型,然后将模型导入Geomagic Studio 8软件系统对胫骨近端模型进行模拟截骨、形态学测量,分析不同性别胫骨近端截面的形态学差异.再将获得的模型与通过激光扫描获得的假体(PFC和Nexgen)三维模型进行模拟装配、参数测量.结果 胫骨近端截骨面的前后径(AP)为(49.87 ±3.90)mm、内外侧横径(ML)为(73.50±5.60)mm,AP与ML呈正相关.男性胫骨平台AP为(53.24±4.10)mm、ML为(75.85±3.50)mm,均比女性[AP为(47.61±3,70)mm,ML为(67.68±2.60)mm]大.内侧前后径(MAP)比外侧前后径(LAP)大,男性平均大(3.90±2.90)mm,女性平均大(3.70±2.70)mm.PFC假体(0.75±0.05)和Nexgen假体(0.69±0.03)的AP/MP比值与本研究正常成人(0.68±0.03)相比,差异均有统计学意义(P<0.05).结论 不同性别及人种的胫骨截面形态存在显著差异,为提高人工膝关节胫骨假体的覆盖率,胫骨假体设计及临床操作均要考虑不同人种和性别的形态学特点.     

TKA中胫骨近端截骨面的研究现状与展望

膝关节骨性关节炎是骨关节炎中发病率最高的关节病变,而人工全膝关节置换术（TKA）是治疗终末期退行性骨性关节炎的有效手段。不论在国外还是国内,TKA的开展都较以往增多。在人工膝关节假体置换后,减少假体松动（尤其是胫骨侧假体的松动）是提高膝关节置换术后生存率的重要问题,而假体松动跟假体与骨截面之间的匹配性有密切关系。目前,国内膝关节置换术中的应用的假体大部分是由欧美国家进口或者是以之为范本制造的,胫骨侧假体与胫骨截骨面的匹配性较差,这一问题已经引起各国业界人士的注意。欧美、韩国、日本等国家分别有人以放射学资料或者尸体标本为研究对象,研究本国人种的胫骨截骨面特点;在国内,台湾、华北、东北、华东、华南等人群的胫骨截骨面特点也分别有人相继研究归纳出来。亚洲人胫骨平台截面的几何形态不同于西方人,而国内各人群之间亦各自有其特点,应用进口胫骨假体要考虑国人的特点,性别及胫骨截骨厚度是影响胫骨侧假体设计与选择的重要因素。放眼未来,根据每个患者胫骨截面特点特异性地制造其应用的假体可能是假体制造的发展趋势。     

旋转平台全膝关节置换术中胫骨假体的旋转安放及相关研究

目的通过对旋转平台全膝关节置换术（total knee arthroplasty,TKA）术中胫骨假体自行确定的旋转中立位与胫骨结节内侧缘、胫骨结节中内1／3等解剖标志点相互位置关系的比较,探讨TKA术中胫骨假体的正确旋转放置位置。方法2006年3月至2008年3月,对30例患者行初次单膝关节置换术,女21例,男9例;年龄54—77岁,平均62岁。术前诊断：骨关节炎23例,类风湿关节炎7例。所有手术均采用旋转平台膝关节假体。胫骨假体的旋转放置以胫骨前后轴为参照。假体试件安装完毕、关节复位后,全范围内屈伸膝关节数次,使旋转平台在股骨假体的导引下自行确定其伸直位时的旋转中立位。借助于试件前方的刻度标志测量胫骨平台旋转试件相对于金属托中心（胫骨结节内侧缘）的旋转角度。结果胫骨旋转平台试件的中点相对于胫骨结节内侧缘的平均旋转角度为外旋2．3°±3．4°,其中男性平均为2．2°±3．6°,女性平均为2．4°±3．4°,男、女性比较差异无统计学意义。膝内、外翻平均外旋角度分别为2．9°±3．0°和1．4°±3．9°,膝内翻外旋角度大于膝外翻。本次研究的结果显著小于国人胫骨前后轴与后十字韧带中点胫骨结节中内1／3连线的夹角。结论国人TKA术中采用固定平台膝关节假体时,以胫骨结节中内1／3为标准行胫骨假体旋转放置时,有导致胫骨假体相对于股骨假体外旋过度的可能,满意的胫骨假体旋转安放位置应位于胫骨结节内侧缘稍外侧。     

骨性关节炎胫骨近端解剖形态性别差异及临床意义

[目的]分析骨性关节炎患者胫骨近端截骨面各解剖参数的性别差异,为国产人工膝关节胫骨假体的设计提供依据。[方法]对116例(男58例,女58例)汉族骨性关节炎患者膝关节CT扫描图像进行三维重建。胫骨外侧平台下10 mm、后倾7°行胫骨近端截骨,测量胫骨平台内外径(ML)、胫骨平台中部前后径(AP)、胫骨内侧平台前后径(MAP)、胫骨外侧平台前后径(LAP),计算ML/AP比值,根据AP(<48 mm,48~52 mm,>52 mm)将ML/AP分为三组,比较胫骨近端截骨面各参数的性别差异。[结果]男性胫骨近端截骨面各解剖参数均大于女性,差异有统计学差异(P<0.001)。胫骨近端ML/AP与AP呈负相关,随着AP的增大ML/AP减小,并且在相同的AP值下,男性胫骨ML/AP大于女性,显示一个给定AP尺寸假体,男性胫骨ML有可能会覆盖不全,女性悬空。[结论]胫骨近端截骨面男性和女性存在尺寸和形态的差异。在设计胫骨假体时,ML/AP应该考虑作为参考设计性别差异性胫骨假体。     

Resection specimen analysis of proximal tibial anatomy based on 100 total knee arthroplasty specimens

Although it is known that there is some asymmetry of the tibial plateau, most total knee arthroplasty designs currently have a symmetric tibial component. Using resection specimen analysis of the tibial plateau from 100 total knee arthroplasty specimens, the authors have examined the tibial plateau to further delineate, quantitatively, the medial and lateral tibial configuration. Unmagnified radiographs of each of the specimens were produced. A line was drawn along the mediolateral axis. The midpoint and points 10, 20, and 30% from the medial and lateral peripheries were then calculated. The average anteroposterior medial 10, 20, and 30% dimensions were 3.79, 4.74, and 5.06 cm, respectively. The average anteroposterior lateral 10, 20, and 30% dimensions were 3.48, 4.10, and 4.16 cm, respectively. The ratios of the lateral/medial anteroposterior distances at 10, 20, and 30% from the periphery were 92.10, 86.77, and 82.46%, respectively. A total knee arthroplasty system that recognizes the difference in the medial and lateral tibial plateaus and designs a prosthesis to account for the smaller, lateral tibial plateau may achieve the goal of maximizing tibial coverage as well as eliminate the problems associated with a symmetric design.     

Differences of Knee Anthropometry Between Chinese and White Men and Women

Whether there are differences in knee anthropometry between Asian and white knees remains unclear. Three-dimensional knee models were constructed using computed tomography or magnetic resonance imaging of healthy Chinese and white subjects. The morphologic measurements of the femur included mediolateral, anteroposterior dimensions, and aspect ratio. The tibial measurements included mediolateral, medial/lateral anteroposterior dimension, aspect ratio, and posterior slope of medial/lateral plateau. The results showed that Chinese knees were generally smaller than white knees. In addition, the femoral aspect ratio of Chinese females was significantly smaller than that of white females (1.24 ± 0.04 vs 1.28 ± 0.06). Tibial aspect ratio differences between Chinese and white males (1.82 ± 0.07 vs 1.75 ± 0.11), though significant, were likely a reflection of differences in knee size between races. These racial differences should be considered in the design of total knee arthroplasty prosthesis for Asian population.     

Computed Tomography Morphometric Study of Gender Differences in Osteoarthritis Proximal Tibias

One hundred and thirty osteoarthritic knees(65 males, 65 females) from a Chinese population were measured by computed tomography for tibial mediolateral (ML), middle anteroposterior (AP), medial anteroposterior (MAP), lateral anteroposterior (LAP) dimensions and ML/AP aspect ratio. The ML/AP aspect ratio were classified into 3 groups based on AP dimensions(< 48 mm, 48–52 mm, > 52 mm) to compare the morphologic differences of proximal tibia between males and females. The mean ML, AP, MAP and LAP dimensions of proximal tibia showed significant differences for sex (P < .01). We found a progressively decreased in the ML/AP aspect ratio with an increasing AP dimension, and males have larger ML/AP aspect ratio than that of females under a given AP dimension (P < .01). This indicates that under a given AP dimension prosthesis, the tibial ML dimension have the potential to be undersized in males and to overhang in females. This study may provide important reference in designing proper gender-specific tibia prosthesis with different ML/AP aspect ratio for Chinese males and females.     

膝关节后交叉韧带保留型假体置换术15年远期疗效研究

目的 针对后交叉韧带(posterior cruciate ligament,PCL)保留型膝关节假体置换术进行15年以上临床随访研究,分析其临床疗效及失败原因.方法 对Medico-Chirurgical du Cedre中心1990年9月至1992年3月行PCL保留型全膝关节假体初次置换术获得随访的153例(178膝)患者的临床资料进行回顾性研究.对其采用术后X线测量结合随访时国际膝关节协会临床评分评估手术疗效,X线测量包括髋膝踝角(HKA)平均值、HKA绝对偏差、α角、β角、髌骨指数(AP/AT)、胫骨后倾角(PTA)等.以翻修率作为假体生存率最终评定标准.结果 153例患者随访时31例(49膝)死亡,4例(4膝)失访,获访118例(125膝).翻修11膝,15年以上假体生存率93.7%.翻修11膝原因分别为:9膝为假体界面无菌性松动(其中7膝伴严重骨溶解,2膝为胫骨假体周围透亮线伴疼痛),1膝反曲畸形,1膝内侧胫骨平台塌陷.术后随访时膝关节协会评分达173分,优良率95.9%.对比翻修患者与未翻修患者临床资料:对侧未手术膝关节内外翻角、术前正位X线片β角、两组手术前后膝关节协会评分差异均有统计学意义(P＜0.05).结论 PCL保留型假体可以较好地恢复膝关节生物力学特性,15年以上生存率优良.仅个别病例失败与PCL失效有关,聚乙烯衬垫后部过度磨损和髌股关节并发症少见.未手术侧膝关节畸形程度和术侧膝关节胫骨侧内翻畸形程度可能是影响假体翻修率的重要因素.     

膝关节单髁置换中期随访报告

目的探讨膝关节单髁置换的技术特点和临床疗效。方法回顾性分析2005年1月至2009年5月,在本组行单髁置换的62例患者（85膝）,单侧39膝,双侧23例（46膝）;其中男8例10膝,女54例75膝。男：女为1：7．5;年龄44～78岁,平均63岁;内侧单髁置换79膝,外单髁置换6膝,所有患者均使用LINK单髁假体（WMdemar Link GmbH＆Co）,将术前及最后一次复查KSS评分分值及关节活动度对比,评定膝关节功能。术后定期拍x线平片评估假体位置及未置换间室退变情况。结果获得随访的患者62例85膝,平均随访时间65．8个月（48～99个月）。膝关节KSS评分：术前（58．22±20．07）分,术后最后一次随访（81．24±17．96）分（P〈0．01）。关节活动度：术前（126．73°±7．53°）,术后最后一次随访（124．65°±8．65°）（P〉0．05）。术后首次与最后一次随访X线平片检查,未置换间室退变进展不明显。5例患者6膝分别在术后11—42个月出现胫骨部分假体松动,3膝做全膝翻修术。另2例（3膝）患者服用镇痛药,可行走及坚持日常活动,目前在随访中。结论单髁置换可以获得良好的关节功能,在一定程度上减缓了膝关节退变进展速度,但胫骨假体松动有较高的发病率,需要高度重视。     

Anatomical references to assess the posterior tibial slope in total knee arthroplasty: a comparison of 5 anatomical axes

There has been no consensus on an ideal anatomical reference to determine the posterior slope of tibia plateau. Posterior slope of the medial tibia plateau was measured with reference to a proposed mechanical axis (MA) and 5 clinically relevant anatomical references in 90 osteoarthritic knees of 66 female patients undergoing total knee arthroplasty. The MA was defined as the line connecting the midpoints of the medial tibia plateau and the tibial plafond, and 5 anatomical references included the anterior cortical line of tibia, anatomical axis of proximal and central tibia, posterior cortical line of proximal tibia, and fibular shaft axis. The average posterior slope was 10.6 degrees with reference to the MA, and the amount of posterior slope varied widely among the patients and depending on the anatomical reference used to measure. This study indicates that the anatomical reference used to measure the posterior slope should be identified in studies where posterior slope is used to evaluate the sagittal alignment of total knee arthroplasty.     

Anterior cruciate ligament deficiency alters the in vivo motion of the tibiofemoral cartilage contact points in both the anteroposterior and mediolateral directions

BACKGROUND: Quantifying the effects of anterior cruciate ligament deficiency on joint biomechanics is critical in order to better understand the mechanisms of joint degeneration in anterior cruciate ligament-deficient knees and to improve the surgical treatment of anterior cruciate ligament injuries. We investigated the changes in position of the in vivo tibiofemoral articular cartilage contact points in anterior cruciate ligament-deficient and intact contralateral knees with use of a newly developed dual orthogonal fluoroscopic and magnetic resonance imaging technique. METHODS: Nine patients with an anterior cruciate ligament rupture in one knee and a normal contralateral knee were recruited. Magnetic resonance images were acquired for both the intact and anterior cruciate ligament-deficient knees to construct computer knee models of the surfaces of the bone and cartilage. Each patient performed a single-leg weight-bearing lunge as images were recorded with use of a dual fluoroscopic system at full extension and at 15 degrees , 30 degrees , 60 degrees , and 90 degrees of flexion. The in vivo knee position at each flexion angle was then reproduced with use of the knee models and fluoroscopic images. The contact points were defined as the centroids of the areas of intersection of the tibial and femoral articular cartilage surfaces. RESULTS: The contact points moved not only in the anteroposterior direction but also in the mediolateral direction in both the anterior cruciate ligament-deficient and intact knees. In the anteroposterior direction, the contact points in the medial compartment of the tibia were more posterior in the anterior cruciate ligament-deficient knees than in the intact knees at full extension and 15 degrees of flexion (p < 0.05). No significant differences were observed with regard to the anteroposterior motion of the contact points in the lateral compartment of the tibia. In the mediolateral direction, there was a significant lateral shift of the contact points in the medial compartment of the tibia toward the medial tibial spine between full extension and 60 degrees of flexion (p < 0.05). The contact points in the lateral compartment of the tibia shifted laterally, away from the lateral tibial spine, at 15 degrees and 30 degrees of flexion (p < 0.05). CONCLUSIONS: In the presence of anterior cruciate ligament injury, the contact points shift both posteriorly and laterally on the surface of the tibial plateau. In the medial compartment, the contact points shift toward the medial tibial spine, a region where degeneration is observed in patients with chronic anterior cruciate ligament injuries.     

Anatomic variations should be considered in total knee arthroplasty

The effect of anatomic variations on the operative techniques used in total knee arthroplasty (TKA) was assessed. In 133 Japanese patients with medial osteoarthritis (OA), six parameters were measured on anteroposterior radiographs of the lower extremities taken with the patients in the supine position. The results showed that the characteristics of the knees were bowing of the femoral shaft and proximal tibia vara, with lateral offset of the tibial shaft with respect to the center of the tibial plateau. The angle between a perpendicular to the mechanical axis and the tangent to the distal femoral condyles can be used in determining the external rotation of the femoral component. This angle was more than 3° in 20% of the patients. The femoral component should therefore be externally rotated more than 3° relative to the posterior condylar line in such patients. Because the center of the tibial plateau is located medial to the central line of the tibial shaft in knees with medial OA, the central point of the tibial articular surface should not be used for alignment of the tibial component. The medial offset stem of the tibial component may impinge against the medial wall. Anatomic variations should be evaluated before TKA is attempted. Received for publication on Jan. 6, 1999; accepted on Dec. 2, 1999