膝关节置换术后非感染性翻修的经验体会

目的探讨膝关节置换术后非感染性翻修手术的原因、治疗方案以及功能恢复情况。方法检索北京协和医院骨科1991年5月至2014年12月期间所有入院行膝关节翻修的病例。于病案科进行电脑检索,检索词条为出院诊断"疼痛"或"翻修"或"松动"或"膝关节置换术后"。排除重复住院、非膝关节翻修手术以及资料丢失病例,并进一步排除其中诊断膝关节感染,以及关节液或关节组织培养阴性,但关节液呈脓性并按膝关节感染处理的病例后,共18例患者入院行膝关节置换术后非感染性翻修。根据感染性翻修的病因进行分组,总结各组翻修手术处理方式,分析翻修手术距离初次手术的间隔时间、翻修前后关节力线及关节功能采用美国膝关节协会评分(KSS评分)进行评估。鉴于所收集病例数较少,翻修手术与初次TKA的间隔时间以及翻修前后的关节力线主要进行描述分析;翻修前后的关节功能KSS评分为计量资料,先行Kolmogorov-Smirnov检验,若数据服从正态分布,则行配对t检验分析。结果共筛选出18例(20膝)患者入院行非感染性膝关节翻修术。翻修病因包括:假体无菌性松动10膝[50%(10/20)],其中1膝翻修部分置换了胫骨侧假体,其余9膝均行全膝关节翻修术;膝关节僵直5膝[25%(5/20)],均行手术松解(关节镜下粘连松解1膝);初次置换术后出现垫片脱位有2例[3膝,15%(3/20)],均行垫片置换手术;关节腔异物1膝[5%(1/20)],行膝关节后路异物取出术;髌骨外翻半脱位1膝[5%(1/20)],行髌骨外侧支持带松解、内侧紧缩术。翻修术后66.7%(4/6)膝关节力线得到良好恢复,膝关节功能术后KSS评分平均为(79.1±2.8)分,较术前(56.4±9.9)分改善(t=-7.329,P0.05)。结论导致膝关节无菌性翻修的主要原因是初次膝关节置换术后假体无菌性松动(50%)。针对初次全膝关节置换术后出现假体无菌性松动、关节僵直等问题,全膝关节置换翻修术能够有效地恢复关节力线及膝关节功能。     

全膝关节置换术后翻修原因分析

目的探讨单中心十五年间膝关节翻修原因构成及变化, 并分析不同翻修原因对假体生存时间、翻修手术时间和出血量的影响。方法回顾性分析2007年1月至2021年12月于北京大学人民医院骨关节科行初次膝关节翻修术的患者337例(345膝), 男57例、女288例, 年龄(69.3±8.6)岁(范围26～88岁)。统计分析345膝的翻修原因, 并比较早期(术后2年内)与晚期(术后超过2年)、2012年以前与2012年以后的翻修原因构成。比较不同翻修原因的假体生存时间、手术时间、出血量的差异。结果 345膝的翻修原因为假体周围感染133膝(38.6%), 其次是无菌性松动97膝(28.1%)和关节不稳定35膝(10.1%)。早期翻修171膝(49.6%)中假体周围感染96膝(56.1%)最多, 晚期翻修174膝(50.4%)中无菌性松动86膝(49.4%)最多。2012年以前翻修59膝, 2012年以后翻修286膝, 最常见的翻修原因均为假体周围感染, 但2012年后因感染行翻修手术者(33.2%)较2012年前(64.4%)减少, 差异有统计学意义(χ2=18.790, P<0.001);2...     

髋关节置换术后失败原因分析

[目的]分析髋关节置换术后接受翻修手术的病例,探讨髋关节置换术后不同时期失败的原因和特点.[临床资料]回顾性分析1995年6月～2005年6月间髋关节置换术后失败接受翻修手术的病例78例.其中全髋置换术后翻修42例,股骨头置换术后翻修36例.初次髋关节置换术后5年以内翻修的共36例,5年以上翻修的42例.[结果]在早期失败(5年以内)的病例中,失败原因主要是感染(16例),其次是假体无菌性松动,髋臼磨损和机械性失败.在晚期失败(5年以上)的病例中,失败原因主要为无菌性松动,髋臼磨损.[结论]感染是全髋关节置换术后早期松动的主要原因之一.而全髋关节置换术后的主要原因是晚期无菌性松动.     

全膝关节置换术后翻修的原因分析

目的 对行全膝关节置换术后行翻修手术患者的翻修原因进行研究分析,并与先前报道的结果进行对比。方法 收集济宁医学院附属医院关节与运动医学科自2014年1月至2021年11月完成的89例全膝关节翻修术患者资料,均为初次全膝关节置换术后行翻修手术,其中男28例,女61例;年龄27～84岁,平均(66.60±8.53)岁。左侧51例,右侧38例。将患者分为早期翻修组(假体使用年限低于2年)和晚期翻修组(假体使用年限不低于2年),对翻修手术的原因进行统计。结果 49例(55.1%)全膝关节翻修原因为假体周围感染,18例(20.2%)为假体松动,10例(11.2%)为关节不稳,5例(5.6%)为疼痛,4例(4.5%)为假体周围骨折,2例(2.2%)脱位,1例(1.1%)聚乙烯磨损。89例假体使用时间为(2.69±3.15)年,早期组51例,假体使用时间为(0.66±0.45)年;晚期组38例,假体使用时间为(5.42±3.15)年。早期组中31例假体周围感染,9例关节不稳,4例疼痛,3例假体周围骨折,2例脱位,聚乙烯磨损和无菌性松动各1例。晚期组中18例假体周围感染,17例假体松动,假体周围骨折、...     

髋关节翻修术失败原因分析

目的 对髋关节翻修术失败原因以及与失败相关的手术技术、假体材料和患者相关易感因素对于不同失败原因的影响进行分析.方法 回顾性分析1995年11月至2008年6月30例髋关节翻修术失败(26例为初次翻修术失败,4例为再次翻修术失败)患者的临床资料.其中男性18例,女性12例;均为单侧病例.患者初次置换平均年龄49岁(25～68岁),初次翻修平均年龄53岁(27～72岁),平均间隔时间43.8个月(0～156个月).对比分析髋关节翻修术与初次置换的失败原因,同时对初次翻修年龄以及翻修失败时间进行分组,比较各组间相关危险因素的统计学意义.结果 以再次翻修或假体取出作为终止点,30例翻修术失败原因包括:无菌性松动22例(73.3%)、感染性松动4例(13.3%)、假体周围骨折3例(其中1例合并假体柄断裂)(10.0%)以及假体不稳定1例(3.3%).患者行最后一次翻修或假体取出平均年龄58岁(38～77岁),距离上一次翻修平均间隔78.8个月(1～216个月).初次翻修时高龄组(60岁以上,n=12)翻修失败时间显著低于低龄组(60岁以下,n=18)(P<0.01).结论 未能获得翻修假体的有效固定与感染复发是全髋关节翻修术失败的主要原因,关节重建理念的局限与手术技术的缺陷是导致翻修失败的重要因素.     

327例初次人工髋关节置换术失败原因探讨

目的 探讨初次人工髋关节置换术后失败的原因及相关危险因素.方法 回顾性分析1988年11月至2008年7月收治的327例人工髋关节初次翻修手术患者的病史、临床和影像学资料以及手术记录.结果 以髋关节翻修术作为终止点,共分析327例行初次髋关节翻修术的患者资料,具体失败原因包括假体无菌性松动(226/327,69.1%)、感染(52/327,15.9%)、假体周围骨折(22/327,6.7%)、假体不稳定(17/327,5.2%)、假体柄断裂(5/327,1.5%)、髋臼内衬脱落(5/327,1.5%).结论 假体无菌性松动和感染是初次髋关节置换失败的主要机制,手术适应证和假体选择不当以及外科理念及技术局限是造成失败的关键因素.     

膝关节定制型肿瘤假体的翻修

目的通过对膝关节定制型肿瘤假体的翻修进行回顾性分析,总结手术技术和翻修原因,明确翻修术后并发症的发生,以及假体生存和功能情况。方法回顾性分析2002年6月-2007年6月收治的33例膝关节定制型肿瘤假体置换术后再次翻修患者的临床资料。其中男17例,女16例;年龄16～67岁,平均33.1岁。骨肉瘤17例,骨巨细胞瘤11例,骨恶性纤维组织细胞瘤2例,软骨肉瘤、滑膜肉瘤、脂肪肉瘤各1例。肿瘤部位:股骨远端22例,胫骨近端11例。翻修术与置换术间隔时间为6～180个月,平均45.3个月。翻修原因:肿瘤局部复发2例,假体周围感染8例,假体无菌性松动7例,创伤后假体周围骨折伴松动1例,假体柄折断6例,假体铰链机构失败9例。6例假体周围感染者,将原假体取出后行二期假体翻修;其余患者均行一期翻修。翻修假体均采用骨水泥固定假体,其中2例残留髓腔长度短于翻修假体柄,用异体骨段移植复合假体植入。结果17例两次手术均于同一医院进行的患者,首次置换手术时间为(149.8±40.5)min,翻修术为(189.9±43.8)min;置换术出血量为(605.2±308.0)mL,翻修术为(834.1±429.9)mL;以上指标比较差异均有统计学意义(P0.05)。患者术后均获随访,随访时间12～76个月,平均45.1个月。2例行异体骨移植者分别于术后1年半和2年达骨性愈合。3例于翻修术后12～24个月死于肺转移;3例发生肺转移,随访期间带瘤生存。术后30例存活患者9例出现并发症,发生率为30%;其中浅表感染2例,深部感染5例,机械性并发症2例。7例发生假体失败,失败率为23.3%。Kaplan-Meier生存曲线分析翻修假体5年生存率为68.6%。翻修术前患者肢体功能根据1993年美国骨肿瘤学会评分系统(MSTS93)评分为57.1%±10.6%,术后6个月为73.6%±14.4%,差异有统计学意义(P0.01)。结论膝关节定制型肿瘤假体的翻修主要原因是机械性问题和感染,翻修手术虽较复杂,具有一定并发症,但可保留大部分患者的肢体并恢复其功能。     

髋关节置换术后早期失败原因的回顾性分析

目的探讨髋关节置换术后早期失败的原因和特点。方法对1995年1月至2009年1月本组收治的342例初次髋关节置换（THA）失败患者进行回顾性分析,将这些失败的患者分为早期失败组（初次髋关节置换术后〈5年内失败组）和晚期失败组（初次髋关节置换术后〉5年失败组）,再对早期失败组患者的翻修原因进行分析。结果以髋关节翻修作为终止点,42．1％（144／342）的患者在初次THA术后5年内进行翻修,在早期失败的两个主要原因中,31．2％是因为无菌性松动,24．3％是因为髋关节脱位。结论THA术后早期的失败原因是无菌性松动和髋关节脱位。外科医师要提高手术技术,以避免THA术后的早期失败。     

膝关节肿瘤型假体翻修的原因及疗效分析

目的探讨膝关节肿瘤型假体翻修的原因及疗效。方法回顾性分析2004年6月至2018年6月于天津市天津医院及解放军第九六〇医院接受膝关节肿瘤型假体翻修手术的33例患者资料, 男25例、女8例, 年龄(45±13.1)岁(范围19～64岁)。肿瘤病理学诊断为骨巨细胞瘤17例, 骨肉瘤9例, 恶性纤维组织细胞瘤3例, 软骨肉瘤、周围神经鞘瘤、韧带样纤维瘤和骨转移瘤各1例。翻修原因为无菌性松动23例, 假体周围骨折、假体断裂、假体脱位各2例, 感染3例, 肿瘤复发1例。观察患者肿瘤学结果, 分析假体翻修原因, 采用肌肉骨骼肿瘤协会(Musculoskeletal Tumor Society, MSTS)评分和多伦多保肢评分(Toronto extremity salvage score, TESS)评估功能, 记录并发症情况。结果 33例随访时间48.0(24.0, 107.0)个月。翻修最常见的原因是无菌性松动(88%, 29/33), 其次是感染(9%, 3/33)和局部复发(3%, 1/33)。生存期>1年的32例患者术后1年MSTS评分为(24.28±4.74)分(范围9～30分)...     

膝关节肿瘤型假体非感染性失败骨水泥固定翻修术的疗效

目的探讨非感染因素导致的膝关节肿瘤型假体失败病例进行骨水泥固定翻修的临床效果。方法回顾性分析2002年2月至2020年8月北京大学人民医院骨与软组织肿瘤治疗中心128例膝关节肿瘤型假体失败接受骨水泥固定翻修手术患者的临床资料, 男71例、女57例, 年龄(33.5±15.4)岁(范围8～77岁)。128例患者中骨肉瘤73例、骨巨细胞瘤38例、未分化肉瘤8例、软骨肉瘤4例、Ewing肉瘤2例、纤维肉瘤2例、滑膜肉瘤1例。假体翻修部位:股骨远端假体105例、胫骨近端假体23例。翻修原因:无菌性松动64例、假体部件损坏47例、肿瘤复发17例。经初次骨水泥固定翻修术后失败19例, 其中16例接受了二次骨水泥固定翻修术。主要观察指标为假体生存情况、手术时间、术中出血量、流行病学数据、手术相关并发症及美国肌肉骨骼肿瘤协会(Musculoskeletal Tumor Society, MSTS)93膝关节功能评分等。结果 128例初次骨水泥固定翻修患者的随访时间为(127±33)个月(范围6～326个月)。初次翻修手术后发生并发症25例(19.5%), 其中导致假体寿命终结19例(14.8%), 包...     

Insall Award paper. Why are total knee arthroplasties failing today?

The incidence of failure after knee replacement is low, yet it has been reported that more than 22,000 knee replacements are revised yearly. The purpose of the current study was to determine current mechanisms of failure of total knee arthroplasties. A retrospective review was done on all patients who had revision total knee arthroplasty during a 3-year period (September 1997-October 2000) at one institution. The preoperative evaluation in conjunction with radiographs, laboratory data, and intraoperative findings were used to determine causes of failure. Two hundred twelve surgeries were done on 203 patients (nine patients had bilateral surgeries). The reasons for failure listed in order of prevalence among the patients in this study include polyethylene wear, aseptic loosening, instability, infection, arthrofibrosis, malalignment or malposition, deficient extensor mechanism, avascular necrosis in the patella, periprosthetic fracture, and isolated patellar resurfacing. The cases reviewed included patients who had revision surgery within 9 days to 28 years (average, 3.7 years) after the previous surgery. More than half of the revisions in this group of patients were done less than 2 years after the index operation. Fifty percent of early revision total knee arthroplasties in this series were related to instability, malalignment or malposition, and failure of fixation.     

Bone Defects in Revision Total Knee Arthroplasty and Management

This article reviews the recent updates in revision of total knee arthroplasty (RTKA). We reviewed the recent articles on RTKA in databases including PubMed, Google Scholar, and SCOPUS. Total knee arthroplasty (TKA) involves the replacement of all three compartments of the knee in surgery of the knee joint to restore capacity and function. TKA is one of the most common and reliable surgical treatment options for the treatment of knee diseases. However, some patients require revision of TKA (RTKA) after primary TKA for various reasons, including mechanical wear, implant loosening or breakage, malalignment, infection, instability, periprosthetic fracture, and persistent stiffness. Unfortunately, the overall outcome of RTKA is not as satisfactory as for primary TKA due to the uncertainty regarding the actual success rate and the risk factors for failure. Cementation, modular metal augmentation, bone grafting, autologous bone grafting, allogenic bone grafting, impactation bone grafting, structural bone allografting, metaphyseal fixation, using porous titanium coated press fit metaphyseal sleeves and porous tantalum structural cones, and megaprostheses or customized prostheses are the currently available management options for RTKA. However, most of the management systems possess specific complications. Novel approaches should be developed to improve functional capacity, implant survival rates, and quality of life in a cost‐efficient manner.     

Revision total knee arthroplasty with modular components inserted with metaphyseal cement and stems without cement

The clinical and radiographic outcomes of 50 consecutive revision total knee arthroplasties in 47 patients, placed with metaphyseal cemented femoral and tibial components with press-fit cementless stems, were reviewed at 36-month average follow-up. Revision was performed for aseptic loosening (11/50), infection (17/50), periprosthetic fracture (8/50), component failure (6/50), instability (6/50), and malalignment (2/50). The press-fit cementless stems were 80 to 160 mm in length and tightly contacted the endosteum of the metadiaphyseal areas. Four (9%) knees were re-revised for infection, zero for aseptic loosening. The average modified Hospital for Special Surgery knee score improved from 49 to 87. One patient (2%) reported thigh pain, and 1 reported leg pain. Metaphyseal cemented revision total knee components with press-fit cementless femoral and tibial stems were not associated with significant thigh and leg pain.     

The value of preoperative knee aspiration and arthroscopic biopsy in revision total knee arthroplasty

AIM: The accurate preoperative diagnosis of occult sepsis in endoprosthetic loosening of total knee arthroplasty is the key to successful management of revision total knee arthroplasties. The aim of this study was to evaluate the results of preoperative aspiration in comparison with preoperative arthroscopic biopsy of the synovial tissue. METHOD: From 2000 to 2004 eighty-six revision total knee arthroplasties in 86 patients were performed. 60 patients had only a knee aspiration, 15 an arthroscopic biopsy and an aspiration, 11 only arthroscopic biopsy. The results of both methods were compared with the intraoperative cultures during revision surgery. RESULTS: 69 aseptic and 17 septic knee exchange arthroplasties were performed. The preoperative aspiration of the prosthetic knee joint had a sensitivity of 68.8 %, specificity of 96.6 %, positive predictive value of 84.5 % and a negative predictive value of 92.2 %. The preoperative arthroscopic biopsy had a sensitivity of 100 %, specificity of 94.7 %, positive predictive value of 87.4 % and a negative predictive value of 100 %. CONCLUSION: Preoperative aspiration of the knee is a very helpful study for the diagnosis or exclusion of infection in a prosthetic knee joint and should be a standard procedure in the diagnosis of prosthetic loosening. If after aspiration a suspicion of infection remains, then the biopsy is an accurate procedure to diagnose or exclude periprosthetic sepsis.     

Superior Survivorship for Posterior Stabilized Versus Constrained Condylar Articulations After Revision Total Knee Arthroplasty: A Retrospective,Comparative Analysis at Short-Term Follow-Up

BackgroundThe decision to use a posterior stabilized (PS) or constrained condylar knee (CCK) articulation in revision total knee arthroplasty (RTKA) has traditionally been based on surgeon preference and knee stability. The purpose of this study is to compare various outcomes and survivorship in RTKA with PS or CCK articulations.MethodsA retrospective comparative study of RTKA with CCK or PS articulations (PS = 106/CCK = 147) was performed with minimum 2-year follow-up. Exclusion criteria were patients with rotating hinged implants or non-CCK/PS constructs. Multivariate logistic regression models were constructed to determine whether implant articulation influenced (1) complications, (2) aseptic loosening, and (3) re-revision. Kaplan-Meier estimates of cumulative implant survival were constructed with revision as the failure variable.ResultsPS articulation was an independent predictor of increased postoperative knee flexion (6.4°, P = .010) and the knee society functional score (10.0, P = .002). Survivorship was significantly reduced for CCK revision articulations when all-cause re-revision was the primary endpoint (P = .0003, log-rank test of equality). The primary reason for re-revision in the CCK cohort was a recurrent/persistent infection of the operative knee (N = 16, 37.2%), followed by aseptic loosening (N = 13, 30.2%). PS articulations conferred a lower likelihood of re-revision (odds ratio [OR] 0.3, P = .001), but articulation design was not associated with complications (OR 0.5, P = .123) or aseptic loosening (OR 2.6, P = .143).ConclusionThe PS articulation when used for appropriate indication conferred superior survivorship for the primary endpoint of all-cause re-revision and overall knee function when compared to the CCK articulation after RTKA. Implant articulation was not a predictor of aseptic loosening or complications.     

Wechseloperationen von Kniegelenksendoprothesen

Thirty-one revisions for aseptic or septic loosening of knee arthroplasty have been performed between 1983 and 1995. In 18 cases we had loosening of uni- or bicondylar prosthesis and in 13 cases a tricompartimental revision arthroplasty. With an average of 53 months (1,5 to 13 years) after the last operation 21 patients could be examined. Main reasons for failure of uni- and bicondylar prosthesis were as well a proceeding of the arthritis in other compartments, instability, incorrect alignment and other reasons depending on the surgical technique. We found similar reasons in aseptic loosening of total knee arthroplasties including wrong choice of non-constrained condylar prosthesis. Seven cases of late infection affected semiconstrained prosthesis. Two of the reimplantations in a 2-stage procedure failed. Using the Insall-Score in the follow-up the patients reached 71,9 points in the knee score and 58.9 points in the functional score. Patients with former aseptic loosening reached better results than these with septic loosening. 38% were absolutely painfree, 14% complained about permanent pain. Unlimited walking was found 5 times, none of the examined persons was unable to walk. Main problems in revision surgery concern reconstruction of a good alignment and the management of bone loss.     

Analysis of unicompartmental knee arthroplasty in a community-based implant registry

Using a unique community implant and explant registry, long-term survival of unicompartmental knee arthroplasty was examined and compared with total knee arthroplasty (TKA) survival. All patients with unicompartmental knee arthroplasties done since September 1, 1991 were followed up prospectively to January 31, 2002 to assess survival and reason for revision. Five hundred sixteen unicompartmental knee arthroplasties of nine different designs were done by 23 surgeons. During this period, 39 of the 516 unicompartmental knee arthroplasties were revised. The major revision reasons for unicompartmental knee arthroplasties were progression of arthritis in the uninvolved compartments (51.3%), aseptic loosening (25.6%), and PE wear (20.5%). Kaplan-Meier survival analysis with revision as the end point revealed survival of 92.6% (range, 90.0%-95.2%) at 5 years for these unicompartmental knee arthroplasties and 88.6% (range, 85.0%-92.2%) at 10 years, compared with 94.8% (range, 93.5%-96.0%) at 10 years for primary TKAs. This community registry experience may more accurately reflect the results obtained in community practice, with different surgeons, varying indications, and numerous designs. The current study showed that revision of unicompartmental knee arthroplasties is done most commonly for progression of arthritis in the contralateral compartment, and at a higher rate than revision of primary cemented TKA.