Total knee arthroplasty with retention of both cruciate ligaments. A nine to eleven-year follow-up study.

BACKGROUND: Although many early designs of total knee arthroplasty allowed the retention of both cruciate ligaments, in most current designs of knee replacement systems, either both cruciate ligaments are removed or the posterior cruciate ligament alone is retained. This report is a review of a series of total knee arthroplasties in which both cruciate ligaments were retained. METHODS: The results of 163 total knee arthroplasties (130 patients) in which both cruciate ligaments were retained were assessed prospectively. One hundred and seven knees (eighty-nine patients) were followed for an average of ten years. There were thirty-four men and ninety-six women, and the average age at the time of the index arthroplasty was sixty-seven years (range, forty-two to eighty-four years). The diagnosis was osteoarthritis in 122 (75 percent) of the knees and rheumatoid arthritis in forty-one (25 percent). Twenty-six knees had a valgus deformity, 109 had a varus deformity, and twenty-eight had a normal alignment of 5 to 10 degrees of valgus. The anterior cruciate ligament was relatively normal in ninety-six knees and was partly degenerated in sixty-seven knees. With use of the rating system of the Knee Society, all 163 knees were prospectively evaluated at yearly intervals; fifty-six of these knees (in forty-one patients) were followed in this manner until the patient died or was lost to follow-up. RESULTS: One hundred and four (97 percent) of the 107 knees available for study at an average of ten years had an excellent or good result. At the time of the latest follow-up, pain was adequately relieved in ninety-seven knees (91 percent) and the average range of flexion was 107+/-12.6 degrees (range, 65 to 135 degrees). Ninety-five knees (89 percent) had normal anteroposterior stability (less than five millimeters of movement in this plane), and twelve knees (11 percent) had five to ten millimeters of movement as demonstrated by the drawer sign. Ninety-six knees (90 percent) had normal mediolateral stability, and eleven (10 percent) had 5 to 10 degrees of laxity. Ninety-four knees (88 percent) had valgus alignment of 5 to 10 degrees. The average knee score was 91+/-8.4 points (range, 54 to 100 points), and the average functional score was 82+/-21 (range, 10 to 100 points). The survival rate at ten years, with revision as the end point, was 95+/-2.0 percent. Seven (4 percent) of the 163 knees in this series were revised. There were no revisions for patellar problems or aseptic loosening of the tibial component. CONCLUSIONS: The good anteroposterior stability in this series after an average follow-up period of ten years indicates that both the anterior and the posterior cruciate ligaments, even when partly degenerated, remain functional when they are preserved in a total knee arthroplasty.     

A contemporary bicruciate total knee arthroplasty

Bicruciate retaining total knee arthroplasty dates back to the 1970s. The polycentric knee and the duocondylar spared the cruciate ligaments but led to early failures and loss of fixation. Designing surgeons excised the cruciates in order to facilitate the surgical procedure and improve the clinical results. Ultimately, the posterior cruciate sparing and substituting designs dominated the market. Most total knees are now anterior cruciate ligament deficient and 15–20% of patients are not satisfied with their surgical result. Bicruciate sparing total knee arthroplasties are now returning to the market and may afford improved results and satisfaction.     

Total knee arthroplasty in the valgus knee

Valgus knee deformity is a challenge in total knee arthroplasty (TKA) and it is observed in nearly 10 % of patients undergoing TKA. The valgus deformity is sustained by anatomical variations divided into bone remodelling and soft tissue contraction/elongation. Bone tissue variations consist of lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodelling. Soft tissue variations are represented by tightening of lateral structures: lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendons, the lateral head of the gastrocnemius and iliotibial band. Complete pre-operative planning and clinical examination are mandatory to manage bone deformities and soft tissue contractions/elongations and to decide if a higher constrained prosthesis is necessary. Two different approaches have been described to perform TKA in a valgus knee: the anteromedial approach and the anterolateral one. In valgus knee deformity bone cuts can be performed differently in order to correct low-grade deformities and reduce great deformities. There is still debate in the literature on the sequence of lateral soft tissue release to achieve the best alignment without any instability. The aim of this article is to review the anatomical variations underlying a valgus knee, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. We will also review the main approaches and surgical techniques both for bone cuts and soft tissue management. Finally, we will report on our experience and technique.     

Total knee arthroplasty coincident with high tibial osteotomy

Established lower limb alignment and knee stability are the two main prognosis factors influencing good functional result and prosthesis life. During Total Knee Arthroplasty (TKA), correction of tibial extra-articular deformity cannot be achieved without ligament balancing. Excessive valgus deformity after a failed high tibial osteotomy (HTO) necessitates a much larger resection of bone from the medial tibial plateau resulting in a trapezoidal extension gap. In overcorrected valgus knee patients after failed HTO, meticulous preoperative planning is required to predict complementary procedures needed to achieve flexion-extension balance with optimal postoperative lower limb alignment. This article details the preoperative planning involved and the intraoperative technique used in such cases. We describe a planning methodology consisting of measuring medial and lateral distance between future femoral and tibial orthogonal resection lines, drawn on valgus and varus stress radiographs (arrows). If the medial distance (medial arrows) on the valgus stress radiographs is longer than the lateral arrows on the varus stress radiographs, a lateral release will be necessary to achieve a rectangular extension gap during TKA procedure. However, the lateral release needed to compensate medial bone resection is limited. This limit must not exceed 10 millimeters (about 8 to 10° of valgus malunion). Over this limit, total knee arthroplasty plus corrective tibial osteotomy is one of the solutions. We prefer to insert prosthesis inside the “ligament box”; without any ligamentous release. The limb alignment is achieved with corrective tibial osteotomy. We propose and describe how to carry out TKA based on a rectangular extension gap, associated, in the same procedure, with a HTO to restore a neutral alignment of the leg.     

Coordination of the anterior and posterior cruciate ligaments in constraining the varus–valgus and internal–external rotatory instability of the knee

 Tension along both cruciate ligaments was measured simultaneously under various loading conditions, and the interaction of these ligaments as constraints on knee instability was analyzed. Six fresh cadaveric knees were used. The attachments for both cruciate ligaments were detached from the femur and reattached to their original positions using metal plates equipped with 12 strain gauges. Each knee was moved under various loading conditions, and changes in tension along the cruciate ligaments were recorded simultaneously using the output of the strain gauges. Under varus torque, tension along the anterior cruciate ligament increased near full extension whereas that along the posterior cruciate ligament increased near 90° of flexion. Similar results were obtained under valgus torque. Under internal rotatory torque, a pattern similar to that under varus torque was also observed. Under external rotatory torque, no remarkable changes in tension were observed along either cruciate ligament. Thus, we conclude that both the anterior cruciate ligament and the posterior cruciate ligament cooperate to control varus–valgus and internal rotatory instabilities of the knee, and that the constraining function is transferred from the anterior cruciate ligament to the posterior cruciate ligament as the knee joint is flexed. Received: July 30, 2001 / Accepted: January 7, 2002     

全膝关节置换治疗膝关节骨关节炎

目的研究全膝关节置换治疗骨关节炎的近中期手术效果,探讨手术方法与术后效果。 方法回顾性分析了皖南医学院弋矶山医院2010年7年至2018年3月临床资料。膝关节骨关节炎手术患者共81例,平均疼痛时间(8±3)年,均采用后稳定型假体,膝关节内外翻、屈曲畸形通过术中骨赘清理、内外侧副韧带和后方关节囊等软组织松解等技术矫正。术后关节囊内注入氨甲环酸抗凝及早期进行康复治疗。术前及术后拍摄下肢全长X片及膝关节正侧位X片记录股胫角度和屈曲畸形角度,统计手术时间、术后引流量。术后随访1、3、6、12、24月复查膝关节正侧位X线,记录膝关节活动度和疼痛情况,并进行膝关节协会评分(KSS)。用SPSS 17.0软件,数据采用配对t检验分析。 结果平均随访时间(22±5)个月,手术时间平均(71±6)min,引流量平均(380±5)ml,膝关节股胫角术后平均为(1.3±1.0)°,术后有4例术后出现膝前痛。无血管及神经损伤等并发症,下肢力线基本恢复正常。无术后感染发生。随访复查膝关节正侧位X线片,未发现假体松动、下沉。随访膝关节活动度、疼痛。膝关节KSS评分有显著改善(临床t＝－66,功能t＝－91.7,P<0.05) 。 结论全膝关节置换术治疗膝关节骨关节炎,术中应用骨赘清理、内外侧,后方关节囊等软组织松解等手术技术,可纠正内外翻畸形,恢复下肢力线、改善膝关节活动度和缓解疼痛,临床效果满意。     

Total knee arthroplasty with posterior cruciate ligament retention

Total knee arthroplasty with posterior cruciate ligament retention requires strict attention to the restoration of femoraland tibial anatomy, restoration of the joint line, and soft-tissue balancing. Component sizing and orientation are dependent on an understanding of normal knee anatomy and play a critical role in the success of the reconstruction. The results of knee arthroplasty with this technique have been excellent, and with continued refinements in prosthesis design and polyethylene manufacturing and sterilization, total knee arthroplasty with posterior cruciate ligament retention should continue to play a significant role in the management of patients with debilitating arthritis of the knee.     

前交叉韧带损伤对膝关节侧副韧带影响的运动还原在体稳定性研究

目的 对前交叉韧带(ACL)损伤膝关节侧副韧带长度变化进行运动还原在体稳定性研究.方法 2008年1月至6月收治8例单侧膝关节ACL断裂而对侧膝关节止常的患者,男6例,女2例;平均年龄25.3岁;在生理负重膝关节屈曲0°、15°、30°、60°和90°时采集相互垂直的二维(2D)图像,与三维CT(3D)图像在虚拟X线投射系统进行2D/3D图像配准,还原膝关节不同角度时股骨和胫骨的相对三维位置关系,并通过韧带止点还原的方法对内侧副韧带(MCL)、外侧副韧带(LCL)进行韧带长度分析,对比两侧膝关节侧副韧带的长度差异.结果 ACL损伤后在0°、15°和30°患膝MCL长度分别为(40.16±1.63)、(39.11±1.77)、(37.86±1.84)mm,健膝分别为(38.17±1.40)、(37.63±1.37)、(36.60±1.86)mm,健、患膝比较差异均有统计学意义(P<0.05);ACL损伤后在0°、15°和30°患膝LCL长度分别为(50.23±1.18)、(50.30±1.68)、(49.26±1.67)mm,健膝分别为(52.56±1.64)、(52.30±1.48)、(51.83±1.77)mm,健、患膝比较差异均有统计学意义(P<0.05).ACL损伤后60°和90°健、患膝MCL、LCL长度差异均无统计学意义(P>0.05).结论 通过2D/3D图像配准技术可以实现膝火节的运动还原并获得ACL损伤后生理屈曲过程中MCL和LCL的长度变化规律.在0°、15°和30°,ACL损伤后患膝MCL长度较健膝增加,而LCL长度较健膝缩短.     

Total knee arthroplasty in elderly patients with severe Kashin-Beck disease of the knee

Purpose

The treatment of elderly KBD knee remains a significant clinical challenge, and clinical data are lacking. This study aimed to prospectively determine the functional outcomes of total knee arthroplasty (TKA) in adult patients with severe Kashin-Beck disease (KBD) of the knee.

Method

Fifteen cases that included 18 occurrences of KBD of the knee were treated by primary knee arthroplasty and followed up for at least two years. Clinical assessments for each patient were performed at time zero (pre-operatively), one, three, six and 12 months and yearly thereafter. The efficacy measures included the visual analogue scale (VAS) pain score, Hospital for Special Surgery (HSS) score, and Functional Score for Adult Tibetans with Kashin-Beck Disease (FSAT-KBD) as well as radiographic findings.

Results

All patients were followed for a mean length of 32.47±10.05 months. All force lines in the lower limbs had been improved significantly. No radiographic evidence of loosening or changes in component positioning was observed at the last follow up. The VAS decreased significantly during the first six months after surgery and was maintained until the last follow up (p < 0.01). Similar trends were found in both HSS and FSAT-KBD, which increased significantly post-operatively (p < 0.01).

Conclusion

Knee arthroplasty can reduce pain and improve function in patients with severe KBD of the knee. Additional studies will be necessary to confirm our findings.     

Dynamic reconstruction of the cruciate ligaments of the knee

Summary This paper reports the long term results of dynamic gracilis or semitendinosus transfer in chronic cruciate ligament instability of the knee. During the period 1968–1983, 76 dynamic reconstructions were performed. Sixty-one patients (63 knees) were evaluated. There were 42 males and 19 females. The mean age at operation was 29.5 years and the average time before operation was 3.7 years. The anterior cruciate ligament was reconstructed in 54 cases, the posterior in 7 and the anterior and posterior in 2. Altogether 32 ligaments (12 cruciates) had been repaired and 28 menisci removed at previous operations. A scoring system (up to 50 points, with 16 parameters) was used. An excellent result was achieved in 21 cases, good in 15, fair in 18 and poor in 19 cases at an average follow-up of 7.4 years. The average score was 33.2 points. Subjectively only 4 patients described the end result as poor. The anterior cruciate alone was reconstructed in 25 patients with an average score of 35.4 points. In 12 cases the operative delay was less than one year and in these the average score was 41.2. In 6 cases three ligaments were reconstructed and the average score was 24.0. There were advanced degenerative changes in 6 knees (average score 24.3).

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Résumé Cet article rapporte les résultats éloignés du transfert du droit interne ou du demi-tendineux dans les instabilités chroniques du genou par lésion des ligaments croisés. De 1968 à 1983, 76 reconstructions dynamiques ont été réalisées. 61 patients, 42 hommes et 19 femmes, représentant 63 genoux, ont été examinés. L'âge moyen lors de l'opération était de 29,5 ans et le délai moyen entre l'accident et l'opération était de 3,7 ans. La reconstruction a porté 54 fois sur le ligament croisé antérieur, 7 fois sur le postérieur et 2 fois sur les deux. 32 ligaments (dont 12 croisés) avaient été réparés et 28 ménisques excisés préalablement à l'intervention. On a utilisé une évaluation chiffrée, allant jusqu'à 50 points et comportant 16 paramètres. Les résultats ont été jugés excellents dans 21 cas, bons dans 15, passables dans 18 et mauvais dans 9, avec un recul moyen de 7,4 ans. Le score moyen était de 33,2 points. Le résultat n'était subjectivement considéré comme mauvais que par 4 malades. Le ligament croisé antérieur a été le seul reconstruit chez 25 opérés avec un score moyen de 35,4. Dans 12 cas le délai entre l'accident et l'intervention était inférieur à un an, et dans ces cas le score moyen était de 41,2. Chez 6 malades trois ligaments ont été reconstruits et le score moyen était de 24. Il existait de notables lésions dégénératives au niveau de 6 genoux, avec un score moven de 23,3.

     

膝关节屈曲畸形的全膝关节置换术

目的探讨全膝关节置换术对矫正膝关节屈曲畸形的患者所采用的方法和临床经验。方法本组52例中，男9例，女43例，年龄43～79岁，平均66岁。原发病变：骨性关节炎40例，类风湿性关节炎12例。术前膝关节屈曲畸形程度：10°～20°有39例，20°-40°有9例，40°～60°有3例，600～900有1例；同时合并膝外翻畸形6例，膝内翻畸形26例。49例行常规后稳定型膝关节置换术，3例行铰链式全膝关节置换术。结果术后测量，46例屈曲畸形患者得以完全矫正，4例残留〈5°的屈曲，1例残留5°～10°的屈曲，1例残留10°～15°的屈曲。随访时间6个月～12年，平均7．8年。KSS膝关节评分由术前平均31分提高至79分，功能评分由术前平均29分提高至82分。结论全膝关节置换术时，彻底松解膝关节周围软组织、适当增加股骨远端和胫骨平台的切骨，是矫正屈曲畸形的有效方法，其中松解后关节囊、重建后隐窝是关键。     

股肌下结合微斜切入路全膝关节置换术治疗膝外翻

目的评估股肌下结合微斜切入路(SMOC)实施人工全膝关节置换术治疗膝关节外翻畸形的可行性及早期临床效果。 方法回顾性分析2015年4月至2017年10月在青岛大学附属医院关节外科50例(60膝)行初次人工膝关节置换术治疗并获得完整随访的膝外翻患者,排除年龄> 85岁、既往膝关节手术史及身体质量指数> 30 kg/m²的患者。男13例,女37例,年龄平均(60±8)岁。诊断为类风湿性关节炎42例52膝,骨关节炎5例5膝,创伤性关节炎3例3膝。采用SMOC入路行人工全膝关节置换术患者25例(31膝),内侧髌旁入路者25例(29膝)。记录并比较两组患者的术前一般资料、血红蛋白、视觉模拟评分法(VAS)、美国特种外科医院(HSS)评分、膝关节被动活动度(ROM)、外翻角度;手术时间、术中出血量、外侧支持带松解率、术后2 d血红蛋白含量、术后引流量、输血率、直腿抬高时间、辅助镇痛药物使用情况、术后下肢力线、髌股适合角;24 h VAS,以及术后1周HSS评分及膝关节ROM,独立样本t检验或卡方检验比较分析两组差异。 结果术前一般资料两组无差异(P>0.05),随访期间无感染及假体松动等并发症。术后外翻膝均得到矫正,两组在手术时间、术中出血量、术后引流量、术后2 d血红蛋白含量、输血率、术后下肢力线、髌股适合角方面两组差异无统计学意义(P>0.05);SMOC组在直腿抬高时间(t＝10.500,P<0.01)、外侧支持带松解率(χ² ＝5.711,P<0.05)、辅助镇痛药使用(χ² ＝9.934,P<0.01)方面优于内侧髌旁入路。术后24 h VAS评分SMOC组低于髌旁组(t＝10.540,P<0.001)、1周HSS评分(t＝8.110,P<0.001)及ROM(t＝2.085,P<0.05),SMOC组低于髌旁组。 结论利用SMOC入路全膝置换术可有效治疗膝外翻畸形,与髌旁入路相比,髌外侧支持带松解率更低,可获得更快速的近期康复效果。     

Locking mechanism failure between tibial baseplate and polyethylene insert in cruciate retaining total knee arthroplasty

We describe a case of total knee arthroplasty performed with one type of cruciate retaining knee prosthesis (Vanguard CR, Zimmer Biomet), wherein failure of locking mechanism occurred between the tibial baseplate and the polyethylene insert 10 months after initial surgery. While there are very few case reports in literature describing such locking mechanism failure, all of these have been in constrained and posterior stabilized knees. This case, to the best of our knowledge is the first such case seen with a cruciate retaining knee design. A 73-year old lady, having undergone left total knee arthroplasty with the above-mentioned prosthesis, presented 10 months after the index surgery with a 3-week history of worsening knee pain and medially protruding hardware. She mentioned an episode of minor twisting of her knee after which she developed pain and swelling over the medial aspect, and was found to have the locking bar backed out on X-rays. She underwent revision surgery, wherein the locking bar was found to have buttonholed through the medial capsule. She underwent polyethylene liner exchange, with a new locking bar. There was no evidence of infection. Her symptoms fully settled following revision surgery.     

Synovial fluid nutrient delivery in the diathrial joint: an analysis of rabbit knee ligaments

The role of synovial fluid in providing nutrition to rabbit knee ligaments and menisci was evaluated by intraarticular injection of a labeled collagen precursor, tritiated proline. Incorporation of this substrate as tritiated hydroxyproline was measured in collateral and cruciate ligaments and menisci. The injectate volume (0.35 ml) did not appreciably change the overall joint pressure as measured by a wick catheter; therefore, no alteration of synovial membrane diffusion characteristics resulted. The concentration of the injected proline (0.52 mg%) was well below that normally present in serum (2.65 mg%). Therefore, incorporation of this substrate was not driven by a concentration gradient and represented normal uptake of synovial fluid and physiological incorporation of label as measured by the presence of tritiated hydroxyproline. Autoradiography was performed on all ligaments and menisci, and demonstrated concentration of the isotope and its metabolite (tritiated proline and tritiated hydroxyproline, respectively) in and around fibroblasts. This study indicates that rabbit knee ligaments and menisci can derive nutrition from a synovial fluid source.     

前交叉韧带MRI异常患者单髁膝关节置换随访分析

目的 探讨术前膝关节核磁共振(MRI)前交叉韧带(ACL)异常结果对单髁膝关节置换术(U KA)疗效影响.方法 本研究采用t检验、秩和检验、方差分析等统计方法,回顾性分析广州医科大学附属第一医院关节外科2014年5月至2019年5月收治的单髁膝关节置换术治疗膝前内侧骨关节炎患者.纳入标准:确诊膝关节前内侧骨关节炎、膝关...     

全膝关节置换术治疗血友病膝关节炎

目的：评价全膝关节置换术治疗血友病膝关节病变的疗效、手术特点、假体选择及凝血因子替代治疗的有效性和安全性。方法：2008年1月至2010年6月,采用全膝关节置换术治疗男性血友病性膝关节炎患者10例（12膝）,年龄17～49岁,平均33.6岁,其中8例为甲型血友病,2例为乙型血友病。根据Arnold和Hilgartner影像学分级：7膝为Ⅳ级,5膝为V级。Ⅷ因子替代治疗方案为手术当天补充至80%以上,术后3d内60%以上,术后3d～2周40%以上。Ⅸ因子替代治疗方案为手术当天补充凝血酶原复合物制剂（PCC）使FⅨ活性水平〉40%,术后3d内FⅨ活性水平〉30%,术后3d～2周FⅨ因子活性水平〉20%。观察比较手术前后膝关节HSS评分及各单项评分（包括疼痛、功能、活动度、肌力、屈曲畸形及稳定性）。结果：10例（12膝）均获随访,时间6～24个月,平均11个月。术前HSS（44.9±12.5）分（29～62分）改善为术后（84.4±10.2）分（72～96分）;各单项评分包括疼痛、功能、活动度、肌力、屈曲畸形及稳定性均较术前明显提高。同时发现在疼痛方面由术前平均（8.5±4.1）分改善为术后（24.5±4.4）分,TKA缓解疼痛作用明显。结论：在严格围手术期凝血因子的替代治疗下,TKA已成为血友病性膝关节炎一种安全有效的治疗手段,可以有效减轻膝关节疼痛,改善膝关节功能。     

Total knee arthroplasty for treatment of osteoarthritis associated with extra-articular deformity

Objective

Our purpose was to review senior author results of TKA in patients with extra-articular angular deformities (correction of mechanical axis was performed without an additional procedure for osteotomy).

Computer assisted total knee arthroplasty: 2.5 years follow-up of 200 cases

IntroductionComputer assisted surgery in total knee arthroplasty (TKA) should improve accuracy of both femoral and tibial components placement. This study evaluated the functional outcomes of computer navigated total knee arthroplasty through the Knee Society Score (KSS) and Tegner Lysholm Knee Scoring Scale (TLKSS).Materials and methodsBetween September 2007 and February 2013, 180 patients (200 knees; 109 females and 71 males; mean age: 64 years) undergoing computer-assisted TKA were recruited. Plain radiographs and CT scans were performed post-operatively to evaluate alignment. The clinical outcomes were measured using the KSS and TLKSS pre-operatively and after 6, 12 and 36 months.ResultsThe mean follow-up duration was 2.5 years. The mean tourniquet time was 72 ± 13.4 min, and patients received an average of 0.6 ± 0.82 units of blood after surgery. The average preoperative KSS functional score of 44.6 ± 13.7 improved to 80.4 ± 16.4 after 2 years. The average preoperative TLKSS improved to 71.4 ± 13.5 after 2 years. The mechanical axis was within ±3° in all patients. No axial malalignments were observed on TC Scan. Three patients (1.6% of cases) required revision.ConclusionComputer assisted TKA allows reproducible alignment and kinematics, reducing outliers, provides ligament balancing and ensures good short term outcomes in terms of KSS functional score and TLKSS.     

关节镜下双股半腱肌腱单端固定法重建膝交叉韧带

目的观察膝关节镜下双股半腱肌腱单端固定法重建膝前、后交叉韧带的方法及疗效,探讨其优缺点。方法应用双股半腱肌腱,单端固定,重建前交叉韧带损伤38例,后交叉韧带24例。结果所有患者术后随访6～36个月,平均18个月。按Lysholm膝关节评分标准,由术前43分提高到术后93分。结论双股半腱肌腱,单侧固定法重建前、后交叉韧带具有创伤小,操作简便,是重建前、后交叉韧带的理想方法之一。