肥胖病人全膝关节表面置换术后疗效观察

[目的]本研究回顾性研究肥胖（根据体重指数）是否是全膝关节表面置换术的危险因素。[方法]由同一组医生使用同一种假体对320例520个膝骨性关节炎患者行全膝关节表面置换手术治疗。[结果]术前肥胖组功能评分较超重组、非肥胖组为低（分别P〈0．05），但关节评分无显著性差异。通过平均28．3个月的随访，无论膝评分和功能评分各组术后均明显提高，各组提高的幅度比较在统计学上无显著性差异（分别P〉0．05）。肥胖组围手术期并发症明显增高。[结论]肥胖病人膝关节置换手术可以取得满意疗效，但围手术期并发症增多，包括伤口愈合、感染、内侧副韧带损伤，注意伤口缝合技术和保护内侧副韧带可减少此类并发症。     

Instabilty in total knee replacement: Causes and management

Instability after total knee replacement can be a common cause for revision surgery, causing pain, swelling, and lack of function in patients. Symptoms of instability can be subtle, so it is important to have a high suspicion when patients complain of persistent or functional limitations after TKR. Causes of knee instability include implant loosening or malposition, polyethylene wear, ligament rupture, or failure to balance the soft tissues at the time of the original procedure. Extension instability usually requires release of the tight soft tissues and placement of a thicker insert, in order to tension the lax soft tissue structures. Flexion instability is addressed by revising the femoral implant to a larger size. A hinged-knee replacement may be necessary in situations of ligament incompetence.     

Infection after total knee replacement —Influence of prosthesis design and previous surgery

Summary From 1975 t0 1990, 302 total knee replacements (257 patients) were performed and followed t0 detect any post-operative infection. The influence of the prosthesis design and 0f previous surgery was studied. Sixty-four hinged prostheses (Guepar 0r Shiers-group 1), 141 mobile-hinge prostheses (CSB-group 2) and 97 unconstrained implants (group 3) were used. Sixteen post-operative infections were noted (5.3%): 8 in group 1 (12.5%), 6 in group 2 (4.3%) and 2 in group 3 (2.1%). These differences are significant (p=0.011). Two hundred and eight knees had had n0 previous surgery before TKR: 6 infections were noted (2.9%). In 94 cases there had been one 0r more previous operations before TKR: 10 infections were noted (10.6%). This difference is significant (p=0.012). Among previous operations the authors selected 24 possibly contaminated ones (valgus osteotomy with external fixator) with 2 infections (8.3%) and 70 uncontaminated ones with 8 infections (11.4%). This difference is not significant (p=0.50). The multivariate analysis shows that implant design has more influence than previous surgery on the incidence 0f sepsis.

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Infection après prothèse totale de genou. Influence de la forme de la prothèse et des antécédents chirurgicaux

Résumé Entre 1975 et 1990, 302 arthroplasties totales du genou (257 malades) ont été effectuées et suivies afin de déceler une infection. L'influence du type de prothèse et d'une éventuelle chirurgie précédente font l'objet de cette étude. Soixante quatre prothèses à charnière avec des longues tiges centro-medullaire (Guepar 0u Schiers-groupe 1), 141 prothèses semi-rigides à pivot (GSB-groupe2) et 97 prothèses à glissement (groupe 3) ont été implantées. Seize cas ont connu une infection (5,3 %) : dont 8 du groupe 1(12,5 %), 6 du groupe 2 (4,3 %) et 2 du groupe 3 (2,1 %).Ces différences sont significatives (p=0,011). Deux cent huit cas n'ont jamais été opérés avant la PTG : 6 infections ont été décellées (2,9 %). Dans 94 cas, une 0u plusieurs opérations ont été effectuées avant la PTG et dans ce groupe 10 infections (10,6 %) se sont présentées. Cette différence est significative (p=0,012). Parmis les 94 cas déjà opérés antérieurement nous avons pu séparer 24 malades qui ont bénificié d'une osteotomie de valgisation par fixateur externe (Procédure de Blaimont-Macquet), 2 cas se sont infectés = 8,3 %. Les autres 70 malades ont subi différentes interventions dans 8 infections =11,4 %. Cette différence n'est pas significative (p=0,50). Une analyse multi-variée nous montre que c'est le genre de prothèse qui influence le plus le risque septique.

     

Current concepts review: Symmetry versus asymmetry in the design of total knee femoral components-An unresolved controversy

Despite the excellent success of earlier total knee replacement designs such as the Total Condylar Knee (Johnson & Johnson, Raynham, MA), which had a symmetrical femoral component, the majority of modern designs feature a more anatomic and asymmetric femoral prosthesis. A raised lateral phalange, an angled trochlear groove, or both are thought to improve patellar tracking. Laboratory studies, however, suggest that surgical technique may be the dominant factor in determining patellofemoral kinematics. Component design has not been proven to be significant. A prosthesis with asymmetric femoral components may cost more. The literature reviewed in this article finds no advantage to the use of asymmetric versus symmetrical femoral components in total knee replacement.     

全膝关节表面置换术治疗晚期骨性关节炎

目的总结全膝关节表面置换术治疗膝骨性关节炎的经验,探讨其治疗效果。方法对215例（226膝）骨性关节炎患者行全膝关节表面置换术,应用KSS膝关节评分系统进行疗效分析。结果178例获得随访,时间15d～11年5个月,平均（29±8．2）个月,膝关节评分平均（87±3．9）分,优良率91．5％;膝关节功能评分平均（76±9．9）分,优良率66．6％。结论全膝关节表面置换术对于严重膝骨性关节炎的疼痛缓解、功能改善方面有良好疗效。     

髌骨合理设计在全膝关节置换中的临床效果

目的探讨髌骨合理设计后重塑在全膝关节置换(TKA)中的临床效果。方法根据股骨假体滑动轨迹及所需置换髌骨的形态,对56例TKA患者(72膝)术中进行髌骨合理设计并重塑,观察患者术后的关节活动度及疼痛情况,用KSS膝关节评分系统评定治疗效果。结果 56例均获得随访,时间6~18个月。仅1例患者膝关节活动度70°,活动较差,但疼痛明显减轻;其余患者屈曲活动度在0°~110°。KSS评分:优69膝,良2膝,中1膝,优良率达到98.6%。结论术中根据股骨假体滑动轨迹对髌骨合理设计并重塑,可以使未进行髌骨置换的TKA患者取得满意的治疗效果。     

全膝关节置换术后深静脉血栓的预防

目的 探讨全膝关节置换术后深静脉血栓形成的预防措施.方法 回顾苏州大学附属第三医院2004年至2007年87例TKR手术后深静脉血栓形成情况.结果 87例患者中,15例患者术后发生深静脉血栓,38例术后使用低分子肝素,5例患者发生深静脉血栓形成,35例使用阿司匹林患者中,6例深静脉血栓形成,与使用低分子肝素组比较无统计学意义,仅使用机械预防措施10例患者中发生4例深静脉血栓形成.结论 术前使用低分子肝素可以预防深静脉血栓形成的发生,采用硬膜外麻醉,术后采用药物阿司匹林或低分子肝素可以较好地预防深静脉血栓的形成.     

全膝关节置换术髌骨置换与否的比较

目的回顾性分析、比较全膝关节置换术髌骨置换与否的疗效及优缺点,为临床治疗提供参考。方法自1994年1月～2000年12月间住院治疗的骨关节炎及类风湿性关节炎患者86例(109膝)。对髌骨置换和未置换的两组患者进行随访,膝关节评分采用美国HSS评分系统,髌骨评分采用Feller等的髌骨评分标准。随访时拍摄膝关节正、侧位及髌骨30°、90°轴位X线片。结果使用SPSS统计软件进行统计学分析。结果置换组与未置换组术后疗效及并发症的发生率无明显差异,髌骨功能评分差异有非常显著性意义(P<0.01)。置换组部分功能(上下楼梯及从椅子上坐起)略好于未置换组,未置换组术后膝前痛的发生率高于置换组,但多为轻度,差异有显著性意义(P<0.05)。术后髌骨不稳定和半脱位的发生率无统计学差异。结论髌骨不稳定的发生与术前畸形明显及术前髌骨外侧偏移倾向有关,是造成未置换组膝前痛的因素之一。未置换组髌骨不稳定与髌骨分型有关,建议如果术前拍摄髌骨轴位X线片时发现髌骨属于Ⅲ型者应置换髌骨。     

The stiff total knee replacement: Evaluation and treatment

Stiffness after TKR is a frustrating complication that has many possible causes. Though the definition of stiffness has changed over the years, most would agree that knee flexion of less than 75° and a 15° lack of extension constitutes stiffness. This presentation will focus on the potential causes of a stiff TKR, intraoperative tips to avoid this outcome, the postoperative evaluation and management, and the results of revision for a stiff TKR. The management of this potentially unsatisfying situation begins preoperatively with guidance of the patient’s expectations; it is well known that preoperative stiffness is strongly correlated with postoperative lack of motion. At the time of surgery, osteophytes must be removed and the components properly sized and aligned in all planes. Flexion/extension gaps must be equalized and soft-tissue balancing must be attained. One must avoid overstuffing the tibiofemoral and/or patellofemoral compartments with an inadequate bone resection. Despite these surgical measures and adequate pain control and rehabilitation, certain patients will continue to frustrate our best efforts. These patients likely have a biological predisposition for formation of scar tissue. Other potential causes for the stiff TKR include complex regional pain syndrome or joint infection. Close follow-up of a patient’s progress is crucial for the success in return of ROM. Should motion plateau early in the recovery phase, the patient should be evaluated for manipulation under anesthesia. At our institution, most manipulations are performed within 3 months postop under an epidural anesthetic; on occasion, patients will stay overnight for continuous epidural pain relief and immediate aggressive PT. The results of re-operations for a stiff TKR are variable due to the multiple etiologies. A patient with arthrofibrosis with a clear cause of stiffness, such as component malposition, malrotation, or overstuffing of the joint, has a greater chance of regaining motion than arthrofibrosis without a clear cause. Although surgical treatment with open arthrolysis, isolated component, or complete revision can be used to improve TKR motion, results have been variable and additional procedures are often necessary.     

固定平台与旋转平台假体置换治疗膝外翻畸形疗效的比较研究

目的：探讨全膝关节置换术治疗膝外翻畸形固定平台（fixed bearing,FB）假体和旋转平台（rotating bearing, RB）假体的疗效。方法2007年1月至2013年12月采用人工全膝关节置换术治疗轻、中度膝外翻畸形患者203例,其中181例为初次置换,按纳入及排除标准共168例（168膝）纳入研究。男57例,女111例;年龄40~79岁,平均（59.3±7.2）岁。退变性骨关节炎153例,类风湿性关节炎15例。根据假体选择不同将患者分为固定平台组（83例）和旋转平台组（85例）。所有患者记录术前及末次随访时膝关节活动度、X线股胫角、美国特种外科医院（Hospital for Special Surgery,HSS）膝关节评分及健康调查简表（the MOS item short from health survey, SF?36）评分。结果168例患者均获得随访,随访时间24~84个月,平均37.4个月。固定平台组及旋转平台组患者的膝关节活动度分别从术前72.8°±13.1°和71.2°±12.8°提高至末次随访时106.5°±9.8°和115.4°±7.9°;X线股胫角由术前16.8°±5.3°和15.2°±4.7°降至末次随访时5.6°±2.3°和5.2°±2.1°;HSS膝关节评分分别由术前（47.5±7.1）分和（49.6±8.9）分提高至末次随访时（89.1±4.6）分和（90.2±5.3）分;SF?36评分由术前（52.3±15.4）分和（50.1±17.9）分提高至末次随访时（81.6±12.3）分和（82.2±14.5）分。两组患者末次随访时除膝关节活动度,其余指标的差异均无统计学意义。2例患者术后发生症状性下肢深静脉血栓。1例患者术后早期出现关节僵硬,加强功能锻炼后症状改善。随访期间无感染、假体松动或下沉、膝关节迟发不稳等并发症。结论对于轻、中度膝关节外翻畸形,两种类型的假体在相同的软组织平衡技术下均可改善患者膝关节活动度、矫正外翻畸形,近期疗效满意。     

深盘型假体对全膝关节置换初期疗效的影响

目的探讨深盘型假体对全膝关节置换初期疗效的影响。方法 2006年6月~2012年1月,本组应用深盘型垫片假体行TKA的76例（97膝）患者进行随访,随访时间2~6年,平均4.2年,其中女65例,男11例;年龄55~78岁,平均65.8岁;选择男女共76名志愿者,年龄在18~42岁之间,平均30.5岁,随机左右膝。对比TKA组术前、术后KSS评分、功能评分、膝关节ROM、股骨后髁偏心距;对比TKA组与志愿者组膝关节从伸直位到最大屈曲位时股骨相对于胫骨前后移动的距离。结果 TKA组手术前后膝关节KSS评分、功能评分及膝关节ROM比较,差异均有统计学意义（P〈0.05）,手术前后股骨后髁偏心距差异无统计学意义（P〉0.05）。TKA组膝关节从伸直位到最大屈曲位时股骨相对于胫骨向后移动距离之差（6.24±2.45）mm。志愿者组膝关节伸直至最大屈曲位时股骨相对于胫骨向后移动距离之差（10.87±1.49）mm,两者差异有统计学意义（P〈0.05）。1例术后出现伤口浅表感染,经处理后痊愈。1例术后出现膝关节假体周围感染,经二期翻修痊愈出院。术后随访X线片观察膝关节假体位置、力线、固定性能等均显示良好,无松动、透亮线等异常表现。结论使用深盘型膝关节假体行TKA术,初期临床疗效满意;TKA组术后膝关节伸直至最大屈曲位时股骨相对于胫骨后移距离较志愿者组短。     

Analysis of the kinematics of total knee prostheses with a medial pivot design

Analysis of the kinematics of the FINE Total Knee System (Nakashima Medical, Okayama, Japan) revealed that the medial condyle is fixed and the lateral condyle shows lateral posterior movement and tibial internal rotation. Analysis of the kinematics of the ADVANCE Total Knee System (Wright Medical Technology, Arlington, Tenn) revealed that the medial condyle is fixed and the lateral condyle shows anterior movement in the early stage, changing thereafter to posterior movement. With regard to rotation, initial external rotation subsequently changes to internal rotation. Analysis of the kinematics of the ADVANTIM Total Knee System (Wright Medical Technology) revealed that the bicondyle shows posterior movement, subsequently changing to anterior and posterior movements. Thus, unlike the FINE or ADVANCE Total Knee Systems, the ADVANTIM Total Knee System shows internal rotation.     

The natural history of anterior knee pain in 2 posterior-stabilized, modular total knee arthroplasty designs

Anterior knee pain (AKP) has been a persistent complaint after total knee arthroplasty; however, the natural course of this complaint has not been fully investigated. This is a 10-year follow-up report of a prospective, randomized study between the Insall-Burstein II (Zimmer, Warsaw, IN) and the Press Fit Condylar Modular (Johnson & Johnson, Raynham, MA) knees. Up to one third of total knee arthroplasties will experience mild to moderate AKP at 1-year follow-up, which will persist in approximately 30% of these previously symptomatic knees at 10-year follow-up. New-onset AKP will develop in approximately 10% of previously asymptomatic knees.     

碘伏冲洗对全膝置换术后切口及功能恢复的影响

目的探讨不同的手术冲洗液对全膝置换术后患者切口及功能恢复的影响。方法 150例全膝置换患者随机分为生理盐水组(50例)、庆大霉素液组(50例)及碘伏组(50例),术中分别使用相对应的手术冲洗液,通过观察切口的愈合情况和术后2周及术后1年膝关节功能的HSS评分,比较3种冲洗液的效果。结果庆大霉素液组的切口愈合优良率(90%)明显优于生理盐水组(84%)及碘伏组(76%),庆大霉素液及碘伏冲洗切口在预防感染方面并不优于生理盐水组(P>0.05)。术后2周碘伏组膝关节功能恢复明显差于生理盐水组(P<0.05)及庆大霉素液组(P<0.05)。随访1年时3种冲洗液在患者膝关节功能的恢复方面无差异(P>0.05)。结论术中使用碘伏原液冲洗切口影响患者手术切口的愈合和近期膝关节功能的恢复。     

Innex膝关节假体置换术后活动度与假体设计及手术技术的关系

目的 探讨Innex膝关节假体置换术后膝关节活动度与假体设计及手术技术的关系.方法 2003年9月至2005年12月使用CS型Innex假体行全膝关节置换88例(98膝),均患膝关节骨关节炎,体重指数20～30 kg/m2,内外翻畸形、屈曲畸形＜15°,为初次全膝关节置换并使用相同的手术技术.随访63例(70膝),随访时间4～6年,平均5.3年.分析活动度与股骨后髁偏心距和胫骨平台后倾角的相关性.根据术后、术前股骨后髁偏心距的差值大小将患者分为:1组,＜-2 mm;2组,-2～0 mm;3组,0～2 mm,4组,＞2 mm.分析各组术前体重指数、屈曲畸形、活动度、特种外科医院膝关节评分及术后活动度的差异.结果 随访患者术前膝关节活动度平均96.2°±11.9°,末次随访时平均109.8°±13.0°;术前股骨后髁偏心距平均(24.0±3.5)mm,术后平均(24.5±3.3)mm;术后胫骨平台后倾角平均5.5°±1.8°.膝关节活动度的差值与股骨后髁偏心距的差值相关,术后膝关节活动度与术后胫骨平台后倾角不相关.四组患者术前体重指数、屈曲畸形、活动度、特种外科医院膝关节评分差异无统计学意义,而术后活动度的差异有统计学意义.结论 Innex膝关节假体置换术后膝关节活动度良好.术中行股骨后方截骨时需注意恢复股骨后髁偏心距,以增加术后活动度.术后膝关节活动度与胫骨平台后倾角无关.

Abstract：

Objective To analysis the influence of component design and related surgical technique on knee range of motion (ROM) after total knee replacement using Innex knee system. Methods Between September 2003 and December 2005, 88 patients with 98 knees had consecutively undergone posterior cruciate-sacrificing TKA with Innex systems. The posterior condylar offset, post-operative tibial slope and knee ROM were measured in 63 patients (70 knees). The relationship of the change in posterior condylar offset and postoperative tibial slope with knee ROM was assessed using a scatterplot graph and Pearson's regression analysis. According to change of posterior condylar offset, which was measured by postoperative minus preoperative posterior condylar offset, patients were divided into 4 groups. The preoperative body mass index,flexion contracture, knee ROM, HSS score and the postoperative knee ROM of four groups were evaluated.Results The mean knee ROM had improved from 96.2°±11.9° preoperative to 109.8°±13.0° at final followup. The mean pre- and post-operative posterior condylar offset was (24.0±3.5) mm and (24.5±3.3) mm, respectively. The mean postoperative tibial slope was 5.5°±1.8°. There was statistical correlation between the difference in the posterior condylar offset and the change in knee ROM after TKA and no correlation between the postoperative tibial slope and knee ROM postoperatively. The preoperative body mass index, flexion contracture, knee ROM, HSS score did not show difference among four groups. There was a statistically difference in postoperative knee ROM among groups. Conclusion Restoration of posterior condylar offset is important to the maximum range of postoperative knee ROM when Orthopedic surgeons perform TKA with Innex systems.There was no correlation between the postoperative tibial slope and postoperative ROM.     

(iii) Modern unicompartmental knee replacement

Unicompartmental knee replacement (UKR) or arthroplasty (UKA) has undergone a resurgence of interest and usage in recent years. This is partly due to the development of minimally invasive surgery (MIS) techniques for UKR. Many experienced arthroplasty surgeons correctly consider that UKR is more technically demanding than total knee replacement (TKR). However, in appropriately selected patients and with carefully performed surgery, the known benefits of UKR can be safely offered. Many previously learned lessons have had to be rediscovered to enable this technically demanding procedure. MIS has been demanded by patients and offered by surgeons but the limited surgical access makes the technical intricacy of UKR surgery even more demanding. Computer aided surgery (CAS) has emerged as a probable solution to this problem. This article examines the current place of UKR in arthroplasty surgery with particular reference to the new techniques of MIS and CAS. UKR has an important place in the selection of surgical options for the treatment of unicompartmental knee arthritis because of the rapid recovery, lower complication rate and high success rate compared to other available procedures.     

Knee injury and obesity in patients undergoing total knee replacement: A retrospective study in 115 patients

The prevalence of obesity and previous knee injury was assessed in a retrospective study of 115 patients under-going total knee replacement due to osteoarthritis. Obesity was considered a contributing factor in the development of osteoarthritis in 37% of the patients, and 33% of the patients had had an injury to the knee in question. Unilateral osteoarthritis was significantly more frequent than bilateral osteoarthritis among patients with a history of previous knee injury. The association of previous injury to the knee and unilateral osteoarthritis was stronger in men than women. Aggressive treatment of patients with knee injuries seems warranted. Received for publication on Oct. 13, 1997; accetped on Aug. 18, 1998     

Range of motion of standard and high-flexion cruciate retaining total knee prostheses

Recently, use of high-flexion design was introduced in cruciate-retaining (CR) total knee prostheses. The purpose of this study was to prospectively compare the ranges of motion (ROMs) of 89 knees with standard and 87 knees with high-flexion CR total knee prostheses. Differences in age, gender, diagnosis, preoperative ROM of the knee, and Knee Society Score between the 2 groups were not statistically significant. At 12-month follow-up, average ROM was 112.0 degrees +/- 12.6 degrees for standard, and 115.3 degrees +/- 13.4 degrees for high-flexion CR prosthesis (P = .101). To our knowledge, this is the first report on the ROM with the high-flexion CR total knee prosthesis. Using the technique of anterior referencing for femoral component sizing and using a fixed 7 degrees slope for the tibial component, we found no significant differences between groups with regard to ROM, clinical, or radiographic parameters.