人工全膝关节置换术中的两种截骨技术的系统综述

目的：人工全膝关节置换术（Total Knee Arthroplasty,TKA）中用于屈伸间隙和内外侧间隙平衡的截骨技术主要有间隙平衡法（Gap Balancing; GB）和测量截骨法（Measured Resection; MR）两种,而两种技术的优劣一直存在争议,本研究对两种技术进行了比较。方法:本研究通过系统回顾两种截骨技术的随机对照研究和队列研究,比较其各自的优劣。结果：纳入5篇RCT和10篇队列研究,结果表明GB组相对于MR组能够获得更好的内外侧间隙的平衡,但是,其关节线较MR组明显升高。而在关节活动度、下肢力线、截骨量、功能评分和并发症等方面,两者无明显差异。结论：GB组相对于MR组能够获得更好的内外侧间隙的平衡,但是关节线明显提高。两者在临床结果方面无明显差异,在临床实践中,应根据患者实际情况和医生熟悉的手术技术进行选择。     

全膝关节置换术中间隙平衡技术的应用进展

正全膝关节置换术是治疗晚期膝关节骨性关节炎的有效方法,其主要包括测量截骨技术和间隙平衡技术~[1]。全膝关节置换术的目标是重塑下肢正常力线并获得内外侧及屈伸间隙平衡。精确的内外侧软组织平衡和准确截骨是全膝关节置换技术的关键,不精确的截骨和软组织松解会导致髌股关节不稳、膝前疼痛等并发症~[2]。测量截骨技术又称为等量截骨技术,维持了术后关节线稳定,具有学习曲线短、操作简单、操作时间短等     

间隙平衡技术在全膝关节置换术中应用的中期随访研究

[目的]分析间隙平衡技术在全膝关节置换(total knee arthroplasty,TKA)术中应用的临床效果及注意事项.[方法]回顾分析2004年3月～ 2006年3月应用间隙平衡(gap balancing,GB)技术的TKA患者45例(49膝),男16例,女29例,手术时年龄52 ～ 79岁,平均62.4岁.另取同期采用测量截骨(measured resection,MR)技术的TKA患者70例(76膝)设为对照组.比较分析两组患者的手术情况、影像学、膝关节功能恢复情况.[结果] 115例患者均获随访,时间6～8年,平均6.8年.GB组单膝手术时间、胫骨截骨量、股骨截骨量均明显低于MR组,术中股骨假体相对外上髁解剖轴内旋角度GB组大于MR组(P＜0.05).TKA术后两组患者髌骨外倾角度存在显著性差异(P＜0.05),GB组明显大于MR组.术后膝关节KSS、VAS评分及并发症发生率两组比较均无显著性差异(P＞0.05).[结论] TKA术中应用GB技术手术时间短,截骨量少,股骨假体相对外上髁解剖轴内旋和髌骨倾斜角度较大,中期随访临床效果和MR技术无明显差异,GB技术应避免内侧软组织过度松解,预防术后屈曲失稳及髌股关节并发症.     

全膝关节置换术中测量截骨与间隙平衡截骨的疗效比较

目的探讨在全膝关节置换术(TKA)中测量截骨与间隙平衡截骨的临床效果。方法笔者自2008-01-2013-06行人工全膝关节置换术诊治126例(130膝)骨性关节炎,测量组76例,平衡组50例,比较2组的手术情况、影像学、膝关节功能恢复情况。结果 126例均获随访2~5年,平均3.4年。测量组与平衡组单膝手术时间比较差异无统计学意义(P0.05),但术中2钉孔连线与股骨通髁线夹角2°,测量组外旋角度(1.04±0.62)°,平衡组内旋角度(1.24±0.57)°,术后患膝伸直应力位X线片示内外侧股胫关节角2组间差异无统计学意义(P0.05)。但屈膝90°应力下X线片示内外侧股胫关节角2组间差异有统计学意义(P0.05)。术后下肢力线与小腿解剖轴线夹角2组间比较差异有统计学意义(P0.05)。术后膝关节KSS评分及并发症发生率2组比较差异均无统计学意义(P0.05)。结论间隙平衡截骨技术在保证下肢力线及屈伸间隙平衡方面优于测量截骨技术,但易导致股骨假体内旋,术中要注意调整两钉孔连线与股骨通髁线夹角。     

数字化3D打印截骨导向器在全膝关节置换术中的应用研究

目的探究3D打印截骨导向器在全膝关节置换术中的临床应用价值和精准性。方法2015年6月至2017年6月共纳入10例骨关节炎患者,其中男4例,女6例;年龄61~81岁,平均年龄76岁。所有患者均行双下肢多排双源螺旋CT平扫,利用计算机软件Mimics 17.0对患者下肢CT导出的DICOM格式数据进行骨骼数据建模,测量力线和畸形角度,重建骨骼模型;使用UG(Unigraphics)NX 8.5进行数字化截骨导向器设计和术前模拟截骨操作;术中使用SLA 3D打印机制造导向器进行截骨定位,安装假体,术后复查膝关节正侧位X线片,记录术前、术后4周的美国特种外科医院(hospital for special surgery,HSS)膝关节评分情况、膝关节活动度(range of motion,ROM)、下肢力线角度(股骨与胫骨机械轴的夹角)。结果所有患者手术过程顺利,膝关节假体位置良好,关节间隙平行等宽,膝关节畸形得以矫正,术后4周HSS评分为(86.2±2.53)分,关节活动度ROM为(101.7±2.54)°,下肢力线角度(股骨与胫骨机械轴的夹角)为(1.93±0.31)°。患者均恢复满意膝关节活动度和正常的下肢生物学力线。结论数字化3D打印截骨导向器应用于全膝关节置换术可简化手术步骤,提高截骨精准性,获得良好的下肢力线,为全膝关节置换术(total knee arthroplasty,TKA)提供了一种简便、有效的方法。     

全膝关节置换术应用间隙平衡截骨的疗效评价

目的探讨间隙平衡截骨法结合测量截骨法在全膝关节置换(TKA)术中应用价值和疗效评价。 方法笔者自2012年1月至2015年6月在濮阳市中医院接受人工全膝关节置换术78例(82膝)骨关节炎的患者,纳入标准：初次全膝关节置换术;膝屈曲挛缩畸形角度≤ 15°;膝内翻畸形角度≤ 20°;Kellgren-Lawrence分期Ⅲ、Ⅳ级。排除标准：膝炎性关节疾病施行人工全膝关节置换术的患者;患者伴发严重的内科疾病;资料不完整、未使用同一厂家生产的后稳定型固定平台假体的患者。其中平衡组38例(40膝),测量组40例(42膝)。比较分析2组患者的手术情况、影像学、膝关节功能恢复情况及患者满意度。采用成组设计资料t检验进行统计学分析。 结果78例患者均获随访,随访时间平均(7.6±2.4)个月。2组患者的年龄、性别、体重指数、术前下肢机械力线及KSS评分等指标的差异无统计学意义(P>0.05)。测量组与平衡组单膝手术时间比较差异无统计学意义(P>0.05),术中2组胫骨外侧及股骨远端外侧截骨量差异无统计学意义(P>0.05),2组股骨外后髁截骨量比较有显著性差异(t＝4.36, P<0.05)。平衡组选择9 mm垫片者(29例)显著多于测量组(13例)(Z＝－5.28,P<0.05)。术中两钉孔连线B线与AP垂直线A线的夹角<2°,测量组外旋角度(1.1±0.5)°,平衡组内旋角度(1.2±0.5)°,术后患膝伸直应力位X线片示内外侧股胫关节角2组间差异无统计学意义(P>0.05)。但屈膝90°应力下X线片示内外侧股胫关节角2组间差异有统计学意义(内t＝6.76,外t＝7.18, P<0.05)。术后下肢力线与小腿解剖轴线夹角两组间比较差异无统计学意义(P>0.05)。术后3个月膝关节KSS评分2组间差异有统计学意义(t＝4.86, P<0.05),术后患者满意度调查表示平衡组优良率87.5%(35/40例),测量组优良率71.4%(30/42例)。 结论间隙平衡截骨法结合测量截骨法能取得良好的下肢力线和屈伸间隙平衡,还能避免屈曲失稳的并发症。术中易导致股骨假体内旋,要注意调整两钉孔连线B线与AP垂直线A线的夹角。     

滑移截骨在关节外畸形全膝关节置换中的应用

目的:针对伴有复杂股骨关节外畸形导致的严重膝骨性关节炎、内翻膝患者在进行全膝关节置换手术时施行滑移截骨技术达到内外侧软组织平衡,观察其临床疗效。方法:自2014年6月至2018年1月共收治22例伴有复杂股骨关节外畸形的重度膝骨性关节炎患者,施行全膝关节置换手术。男5例,女17例;年龄48~76(61.3±13.8)岁。均为内翻畸形,由股骨关节外畸形所导致。术前测量髋膝踝角(hip-knee-ankle,HKA)角(158.8±9.7)°,膝关节学会评分系统(Knee Society score,KSS)临床评分(32.6±6.1)分,功能评分(35.8±9.6)分,美国特种外科医院(Hospital for Special Surgical,HSS)评分(39.7±4.6)分。术前膝关节活动度(80.6±10.7)°。在关节置换时均采用机械对线法,先平衡屈曲间隙,冠状面的不平衡均采用内侧股骨髁行冠状面垂直上下滑移截骨,伸直间隙内外侧的差距决定截骨块滑移的距离,直至间隙平衡。以数枚螺钉固定截骨块后按常规安装假体。结果:所有患者伤口Ⅰ期愈合,无伤口并发症发生。22例均获随访,时间18~36(28.2±10.1)个月。拍X线片见截骨块骨折线消失时间2~5(3.5±1.5)个月,无骨不愈合发生;末次随访测量HKA角(178.8±0.7)°,较术前提高;HSS评分(91.3±6.0)分,KSS临床评分(93.7±3.5)分,KSS功能评分(81.2±6.5)分,膝关节活动度(121.7±11.6)°,均较术前改善。结论:针对伴有复杂股骨关节外畸形的严重膝骨性关节炎患者施行滑移截骨,内翻畸形严重者向下滑移股骨内髁,手术相对简单、损伤小,易于达到屈伸间隙内外侧软组织平衡,短期临床疗效满意。     

2000年全国膝关节重建外科进展学习班暨国际研讨会纪要

由中华医学会北京分会和北京积水潭医院联合举办的“２０００年全国膝关节重建外科进展学习班暨国际研讨会”于２０００年４月１５～１９日在北京国际饭店和北京积水潭医院举行。会议较全面系统地介绍了近年来国内外在人工膝关节置换术、翻修术、膝关节镜技术、膝关节周围截骨术、膝关节关节内截骨术等领域的新认识、新观念、新方法。一、如何正确安置假体一般来说全膝置换术是膝关节的表面置换过程,该过程通过准确的股骨侧和胫骨侧截骨（髌骨置换者包括髌骨截骨）与精确的关节内外软组织平衡重建来恢复下肢的正常力线与膝关节的稳定性及活…     

术前负重位双下肢全长数字化X线测量在全膝关节置换术中的应用

目的探讨术前负重位双下肢全长数字化X线片(Digital radiography,DR)测量截骨参数在全膝关节置换术中的应用情况及对手术效果的影响。方法回顾性分析自2019-10—2020-10完成的104例单侧全膝关节置换术,其中58例根据术前负重位双下肢全长DR片测量结果截骨(DR组),46例以股骨外翻角5°和外旋角3°为标准截骨(常规组)。结果 104例均获得至少3个月随访。术后切口一期愈合,未发生感染。所有患者术后X线片显示假体在位,下肢力线恢复满意。DR组与常规组术后1个月股骨力线差异无统计学意义(P0.05);DR组下肢力线和关节间隙夹角均低于常规组,差异有统计学意义(P0.05)。DR组术后3个月膝关节活动度、膝关节HSS评分、WHOQOL-Bref评分优于常规组,差异有统计学意义(P0.05)。结论全膝关节置换术前摄负重位双下肢全长DR片可准确评估患肢生物力学特征并测量截骨参数,为术中下肢力线对位和截骨提供准确参考,促进患者膝关节活动度和功能恢复。     

屈膝90°外侧胫股关节间隙确定内翻膝人工全膝关节置换术胫骨截骨量的临床研究

目的探讨屈膝90°外侧胫股关节间隙确定内翻膝人工全膝关节置换术(total knee arthroplasty,TKA)中胫骨截骨量的临床效果。方法选取2013年3月-6月收治且符合选择标准的内翻型膝关节骨关节炎患者60例(60膝),随机分为两组(n=30)。对照组TKA术中采用传统确定胫骨截骨量方法,试验组术中根据屈膝90°外侧胫股关节间隙确定截骨量。两组患者性别构成、年龄、关节侧别、身高体重指数及术前膝关节学会评分系统(KSS)评分、膝关节活动度、胫股解剖角(anatomic tibiofemoral angle,ATFA)、髌骨倾斜角、股骨后髁偏距(posterior condylar offset,PCO)、关节线高度比较,差异均无统计学意义(P0.05),具有可比性。术中测量股骨远端外髁、股骨后外髁、胫骨外侧平台截骨厚度,随访摄X线片测量ATFA、髌骨倾斜角、PCO、关节线高度,采用膝关节学会评分系统(KSS)评分以及关节活动度评价关节功能恢复情况。结果术中试验组胫骨外侧平台及股骨远端外髁截骨量显著低于对照组,股骨后外髁截骨量高于对照组(P0.05)。试验组选择10 mm垫片者(19例)显著多于对照组(8例)(Z=—4.040,P=0.003)。患者均获随访,随访时间13~16个月,平均14.5个月。术后6周两组ATFA、髌骨倾斜角及关节线高度比较,差异均无统计学意义(P0.05);试验组PCO明显小于对照组(P0.05)。两组术后12个月KSS评分及膝关节活动度均明显优于术前(P0.05),且试验组以上两指标明显优于对照组(P0.05)。结论内翻型膝关节骨关节炎TKA术中,采用屈膝90°外侧胫股关节间隙确定胫骨截骨量方法能减少胫骨平台和股骨远端截骨,有效恢复关节线和PCO,术后早期膝关节功能恢复良好。     

Il bilanciamento degli spazi e il ripristino della rima articolare nelle protesi totali di ginocchio

The vast majority of articles in the literature supports the concept that a balanced knee is beneficial to the success of total knee arthroplasty. Inadequate restoration of the knee joint line may lead to a poor clinical outcome. The basis of flexion-extension gap balancing is an attempt to obtain equal sized, rectangular gaps in both flexion and extension. In addition, the gap should be rectangular in both flexion and extension. Currently two popular knee replacement techniques are practiced: “measured resection” and “gap balancing”. Both incorporate ligament balancing during the operation, but with differing emphasis. In this article we describe our technique to restore the joint line and to obtain a balanced knee after total knee replacement with the sequences of ligament release in the varus and valgus knee.     

Gap Balancing vs. Measured Resection Technique in Total Knee Arthroplasty

A goal of total knee arthroplasty is to obtain symmetric and balanced flexion and extension gaps. Controversy exists regarding the best surgical technique to utilize to obtain gap balance. Some favor the use of a measured resection technique in which bone landmarks, such as the transepicondylar, the anterior-posterior, or the posterior condylar axes are used to determine proper femoral component rotation and subsequent gap balance. Others favor a gap balancing technique in which the femoral component is positioned parallel to the resected proximal tibia with each collateral ligament equally tensioned to obtain a rectangular flexion gap. Two scientific studies have been performed comparing the two surgical techniques. The first utilized computer navigation and demonstrated a balanced and rectangular flexion gap was obtained much more frequently with use of a gap balanced technique. The second utilized in vivo video fluoroscopy and demonstrated a much high incidence of femoral condylar lift-off (instability) when a measured resection technique was used. In summary, the authors believe gap balancing techniques provide superior gap balance and function following total knee arthroplasty.     

Gap Balancing Sacrifices Joint-Line Maintenance to Improve Gap Symmetry: 5-Year Follow-Up of a Randomized Controlled Trial

Background

Gap balancing (GB) has been noted to sacrifice joint-line maintenance to improve gap symmetry. This study aims to determine whether this change affects function or quality of life in the midterm.

Navigierte Implantation weichteilbalancierter Knieendoprothesen

Objective

Implantation of a total knee arthroplasty with a correct mechanical axis, a rectangular joint gap and a reconstructed joint line by use of an imageless computer navigation device

Indications

Symptomatic gonarthrosis if non operative treatment or joint preserving operations remains ineffective

Contraindications

Infections; soft tissue damage in the approach area; massive instability of the collateral ligaments

Surgical Technique

Medial parapatellar approach to the knee joint; diminution of the patella; fixation of the reference arrays in tibia and femur; registration of leg axis, ligament balance and surface of the knee joint by use of the navigation system; tibial resection perpendicular to the mechanical axis; ligament balancing to achieve a rectangular extension gap; femoral implant planning to maintain the original joint line and reconstruct an equal joint gap in extension and flexion; femora resection perpendicular to the mechanical axis; reconstruction of the rectangular flexion gap by rotation of the femoral resection; two stage cementing technique for fixation of the original implants; check of the final mechanical axis and symmetry of the joint gap over the whole range of motion; wound closure.

Postoperative Management

Physiotherapy; continuous passive motion treatment; mobilization with 20?kg weight bearing with 2 crutches for 2?weeks, thereafter with 2 crutches and incremental full weight bearing for 4?weeks.

Results

The analysis of 582 consecutive navigated total knee arthroplasties showed one case of extension gap instability ?>?3?mm (0.2%) and 8?patients with flexion gap instability? >?3?mm (1.4%). A too tight flexion gap was registered in 23?patients (4.4%), a too wide flexion gap in 13 cases (2.5%). The joint line was reconstructed with an average inaccuracy of 0?mm, in 17?patients the joint line was elevated ?>?3?mm (2.9%).     

The Use of Navigation to Obtain Rectangular Flexion and Extension Gaps During Primary Total Knee Arthroplasty and Midterm Clinical Results

The authors evaluated 112 knees treated by total knee arthroplasty (TKA) using a navigation-assisted modified gap balancing technique. Initial mediolateral gap differences in extension and in 90° of flexion were measured after proximal tibia bone cutting. Final flexion and extension gaps were measured by checking distances under equal tension before prosthesis insertion. Amount of femoral bone cutting and external rotations of femoral components were found to depend on initial gaps. Patients with a final rectangular gap had greater knee flexion angles preoperatively and at 1 year after TKA. However, no differences were observed between the clinical and radiologic outcomes of knees with rectangular and nonrectangular gaps at 1 or 4 years after TKA. The study shows that the navigation-assisted modified gap balancing technique provides an effective means of achieving rectangular flexion and extension gaps during TKA.     

Soft tissue balancing in total condylar knee arthroplasty

Soft tissue balancing and correct bone cuts are an entity in correcting malalignment in total knee arthroplasty, and cannot be considered isolated. Distinct bony deformations/deviations need enlarged soft tissue management. The extent of resection of the bone stock has to be planned exactly before the operation. Exact soft tissue balancing is necessary to stabilize the corrected knee. Soft tissue balancing has to be done primarily on the side of the contracture by lengthening of the shortened and contracted structures. After balancing the ligaments should have the same tension in extension and flexion together with the same height of the extension and flexion gap. Because of the classic resection of the tibial head, the femoral resection must follow the Insall-Line, that means 3 degrees to 5 degrees outer rotation in relation to the condyles. Only in this way a symmetric flexion gap can be achieved in combination with ligamentous stability in extension and flexion.     

A geometric ratio to predict the flexion gap in total knee arthroplasty

Measured resection is a common technique for obtaining symmetric flexion and extension gaps in posterior-stabilized (PS) total knee arthroplasty (TKA). A known limitation of measured resection, however, is its reliance on osseous landmarks to guide bone resection and component alignment while ignoring the geometry of the surrounding soft tissues such as the medial collateral ligament (MCL), a possible reason for knee instability. To address this clinical concern, we introduce a new geometric proportion, the MCL ratio, which incorporates features of condylar geometry and MCL anterior fibers. The goal of this study was to determine whether the MCL ratio can predict the flexion gaps and to determine whether a range of MCL ratio corresponds to balanced gaps. Six computational knee models each implanted with PS TKA were utilized. Medial and lateral gaps were measured in response to varus and valgus loads at extension and flexion. The MCL ratio was related to the measured gaps for each knee. We found that the MCL ratio was associated with the flexion gaps and had a stronger association with the medial gap (β = −7.2 ± 3.05, P < .001) than with the lateral gap (β = 3.9 ± 7.26, P = .04). In addition, an MCL ratio ranging between 1.1 and 1.25 corresponded to balanced flexion gaps in the six knee models. Future studies will focus on defining MCL ratio targets after accounting for variations in ligament properties in TKA patients. Our results suggest that the MCL ratio could help guide femoral bone resections in measured resection TKA, but further clinical validation is required.     

Effects of posterior cruciate ligament resection on the tibiofemoral joint gap

The effect of posterior cruciate ligament resection on the tibiofemoral joint gap was analyzed in 30 patients with varus osteoarthritis of thee knee who underwent total knee replacement. The medial soft tissue was released and the bone cut was made without preserving the bone segment of the tibia to which the posterior cruciate ligament was attached. Then the medial and lateral joint gaps in full extension and 90 degrees flexion were measured before and after the posterior cruciate ligament was resected using a tensioning device. After the resection, the flexion gap significantly increased in the medial and the lateral sides (4.8 +/- 0.4 and 4.5 +/- 0.4 mm, respectively, mean +/- standard error) compared with those seen in the extension gap (0.9 +/- 0.2 and 0.8 +/- 0.2 mm). There was no significant difference between the changes in the medial and lateral gaps. The mean value of the flexion gap was 2 mm smaller than the extension gap before the resection and 1.7 mm larger after the sacrifice. Overall, posterior cruciate ligament resection resulted in an increase in the flexion gap and made space for approximately 3-mm thicker polyethylene. The flexion gap can be controlled selectively with posterior cruciate ligament release.