膝关节骨关节炎患者胫骨扭转角度的异常及临床意义

目的探讨合并内翻或外翻畸形的骨关节炎患者胫骨扭转异常的方向和程度，并研究胫骨扭转异常对人工膝关节置换手术的影响。方法以10个正常膝关节作为对照，对32位膝关节骨关节炎患者，共62侧下肢膝、踝关节进行旋转中立位CT扫描，分别测量胫骨近端前髁轴、胫骨横轴及胫骨后髁轴与双踝轴之间的角度。测量股骨内外上髁轴在胫骨结节层面的投射线中点与胫骨结节内1／3连线与股骨内外上髁轴线外侧夹角（TT角），股骨内外上髁轴在胫骨结节层面的投射线中点与胫骨结节内1／3连线与双踝轴垂线交角（TT-AA角）。结果正常人胫骨外向扭转角度平均约为25°，合并内翻畸形的膝关节骨关节炎患者胫骨外向扭转角明显降低，平均约为17°（P〈0．05），合并外翻畸形的膝关节胫骨外向扭转角度明显增大，平均约为32°（P〈0．05）；胫骨扭转角的近端参考轴线：胫骨前髁轴、横轴或后髁轴之间的差异没有统计学意义（P〉0．05）；无论内翻和外翻畸形，TT角较正常膝关节明显减小（P〈0．05），TT-AA角与正常膝关节相比没有显著性差异（P〉0．05）。结论膝关节骨关节炎患者存在胫骨扭转异常，合并内翻畸形的膝关节胫骨外向扭转角度减少，而外翻畸形胫骨外向扭转角度增加；合并内翻和外翻畸形的膝关节胫骨结节内1／3相对于股骨远端均发生明显外旋，以胫骨结节内1／3作为胫骨假体旋转定位标记，将导致人工膝关节假体旋转对线不良。     

骨关节炎患者股骨后髁角与股骨髁外翻角、胫骨平台内翻角、股胫角的相关关系

[目的]发展一种膝关节术中直接测量股骨后髁角的新方法,并分析股骨后髁角与股骨髁外翻角、胫骨平台内翻角、股胫角的相关性,探讨各角度在膝关节置换术中的意义.[方法]研制股骨后髁角测定仪.对29例(30膝)在本院行人工膝关节置换术的骨关节炎患者,术前测量患膝负重前后位X线片上股骨髁外翻角、胫骨平台内翻角、股胫角,术中用股骨后髁角测定仪测量后髁角;分析股骨后髁角与股骨髁外翻角、胫骨平台内翻角、股胫角的相关关系.[结果]该组股骨后髁角为5.2°±2.6°,股骨髁外翻角为8.6°±2.9°,胫骨平台内翻角为4.1°±4.0°,股胫角为4.1°±7.3°,股骨后髁角和股骨髁外翻角、胫骨平台内翻角之间存在正相关关系,和股胫角尤相关关系.[结论]股骨后髁角测定仪提供了术中测苗股骨后髁角的新方法,为股骨假体旋转对线提供依据;股骨后髁角和股骨髁外翻角、胫骨平台内翻角之间存在正相关关系,术前测量股骨髁外翻角和胫骨平台内翻角,可为股骨假体旋转角度提供参考.     

标准型股骨髁、胫骨托与高切迹胫骨聚乙烯垫组合TKA治疗严重膝关节骨性关节炎并膝内、外翻畸形

目的探讨采用标准型股骨髁、胫骨托与高切迹胫骨聚乙烯垫组合全膝关节置换术（TKA）治疗严重膝关节骨性关节炎并膝内、外翻畸形的临床疗效。方法采用标准型股骨髁、胫骨托与高切迹胫骨聚乙烯垫组合TKA治疗20例（25膝）严重膝关节骨性关节炎并膝内、外翻畸形,其中2例保留后交叉韧带,18例不保留后交叉韧带。结果本组20例术后获得平均12（5~60）个月随访。术前膝关节活动范围15°~85°,术后0°~130°。膝内、外翻畸形得到矫正。术前KSS评分（11.50±1.61）分,术后（91.35±1.23）分。结论采用标准型股骨髁、胫骨托与高切迹胫骨聚乙烯垫组合TKA治疗严重膝关节骨性关节炎并膝内、外翻畸形术中通过软组织平衡技术的应用,操作方便,假体稳定性及关节活动度好。早期临床疗效满意,远期疗效有待进一步随访观察。     

全膝关节置换术中胫骨近端骨缺损的处理

目的探讨初次人工全膝关节置换术中胫骨近端骨缺损的植骨方法和疗效。方法2001年10月至2006年3月，在23例（42膝）初次人工全膝关节置换术中采用自体或异体骨移植修复胫骨近端骨缺损，男5例（9膝），女18例（33膝）。骨关节炎19例（35膝），类风湿性关节炎2例（4膝），大骨节病1例（2膝），关节结核1例（1膝）。非包容型骨缺损22例40膝，包容型骨缺损1例2膝。参照Engh ＆ Parks分类法，T1级5膝，T2级33膝，B级4膝。自体髂骨2例3膝，1例2膝为类风湿性关节炎，包容型，为T2级，骨移植起填充作用；另1例1膝为左膝骨关节炎，非包容型，为T3级。异体冷冻骨1例1膝为膝关节结核，同时股骨外髁和胫骨内侧平台骨缺损，为T3级，行大块骨移植，螺钉固定。自体股骨内髁加异体冻于骨移植修复胫骨内侧平台骨缺损1例1膝，为T3级。其余19例37膝均为自体股骨内髁或胫骨外侧平台修整后移植，修复胫骨内侧平台骨缺损，其中螺钉固定14膝。结果术后随访38．2（3-56）个月。所有患者术前均有内或外翻畸形和屈曲挛缩畸形，术后畸形得到矫正，疼痛消失；3个月后均可弃拐行走，生活可以自理。膝关节HSS评分由术前15.3（10-26）分提高到术后86（79-95）分。膝关节活动范围由术前74．4°（0°--90°）提高到术后109．4°80°-135°）。1例于术后3年死于心肺功能衰竭。术后X线复查1年以上者20例（39膝），胫股角为5°-7°，平均6．4°。结论骨移植尤其是自体骨移植在初次人工全膝关节置换术中可以恢复胫骨近端的完整性，为胫骨假体提供初始稳定性，具有简便、实用、经济实惠等优点；可以保留足够的骨量，为以后的翻修提供良好的基础。     

股骨远端内翻截骨加交锁髓内钉固定治疗膝外翻畸形

目的　探讨股骨远端内翻截骨加交锁髓内钉固定 ,治疗伴有膝外翻畸形的膝关节骨性关节炎的疗效。方法　 1996年 5月～ 2 0 0 0年 8月 ,采用股骨远端内翻截骨加交锁髓内钉固定治疗 16例 (16膝 )伴膝外翻畸形的膝关节骨性关节炎 ,病程 1～ 2 1年 ,平均 5 .2年。按 Ahlback分类 度 10例 , 度 6例。股骨髁上截骨 11例 ,股骨干远端截骨 5例。术前、术后 8周和 2年均行患肢全长 X线片检查 ,以测量股胫角、胫骨角、股骨角及胫股关节面切线夹角及胫股外侧间距大小。按膝关节功能评定标准 ,评定术后膝关节功能恢复情况。　结果　 16例术后获随访 2 5～ 4 6个月 ,平均 31个月。术后 2年随访骨愈合满意 ,1例延迟愈合 ,为股骨干远端截骨患者。皮肤感染 1例。膝关节功能自 5 0 .4± 15 .9分增至 78.5± 12 .9分 ,胫股关节面切线夹角自 5 .6± 2 .9°减少至 1.6± 3.4°,胫股外侧关节间距自 2 .1± 1.8mm增至 4 .7±1.7m m。　结论　股骨远端内翻截骨加交锁髓内钉内固定 ,可作为治疗伴有膝外翻畸形的膝关节骨性关节炎的有效方法之一。     

固定与旋转平台膝关节假体治疗重度膝外翻骨性关节炎的疗效比较

目的比较固定与旋转平台膝关节假体治疗重度膝外翻骨性关节炎的临床疗效。方法对76例接受治疗的重度膝外翻骨性关节炎患者按照膝关节假体类型分为观察组(应用旋转平台假体,36例)和对照组(应用固定平台假体,40例)。比较术后两组患者解剖学参数(股骨角、胫骨角、平台后倾角、髌骨高度、膝外翻角)、膝关节屈曲角度和KSS评分情况。结果患者均获得随访,时间6～36个月。两组患者术后股骨角、胫骨角、平台后倾角、髌骨高度以及膝外翻角指标比较差异无统计学意义(P 0. 05)。术后膝关节屈曲角度观察组高于对照组,差异有统计学意义(P 0. 05)。术后KSS评分两组比较差异无统计学意义(P 0. 05)。结论旋转平台假体能够有效恢复膝关节屈曲角度,纠正膝关节外翻畸形。     

人工全膝关节置换术中胫股关节旋转对线不良的影像学分析

目的分析和探究造成全膝置换术中胫股关节旋转对线不良的可能原因,指导术中选择正确的确定假体部件旋转的方法,以减少术后并发症。方法选择40例正常人的膝关节作为研究对象,男、女各20例,年龄18～42岁。应用螺旋CT扫描(层厚0.5mm)获取膝关节的横断面图像,采用Autocad2004软件测量股骨假体的旋转轴与胫骨假体的旋转轴之间的关系,运用统计学方法分析临床上选择临床上髁轴、外科上髁轴、股骨后髁轴等方法可能存在的潜在的胫股旋转对线不良及其影响程度。结果术中胫骨假体旋转以胫骨结节内、中1/3交界处来确定,而股骨假体旋转分别以临床上髁轴、外科上髁轴、股骨后髁轴外旋3°来确定,可能产生的胫股旋转对线不良的交角平均值分别为2.94°、6.50°、6.83°。结论全膝置换术中利用骨性解剖标志各自独立地确定胫骨假体、股骨假体的旋转对线必然会产生胫股旋转对线不良,而临床上髁轴产生的影响较小。     

胫骨假体旋转参考轴的MR测量研究

目的在磁共振图像上研究胫骨假体旋转排列的骨性标志。方法对68例正常膝关节行磁共振横断面扫描,在胫骨近端横断面上测量胫骨前后轴与髌腱交点内侧宽度比例（AB％）,与股骨外科上髁轴中点与髌腱中内1／3连线的夹角（角α）及后交叉韧带中点与膑腱内侧缘连线夹角（角β）。测量髌骨轴、股骨外科上髁轴、胫骨后髁轴之间的旋转关系。结果AB％为（18．12％±6．17％）,角d为（5．41°±2．52°）,角B为（3．05°±1．38°）。胫骨后髁轴相对股骨外科上髁轴内旋（9．59°±2．73°）、髌骨轴内旋（11．47°±3．27°）。结论将股骨外科上髁轴作为股骨假体旋转参考轴,使用胫骨后髁轴作为胫骨假体参考轴会引起胫骨假体相对股骨假体内旋放置。后交叉韧带中点与髌腱内侧缘连线与胫骨前后轴变异较髌腱中内1／3小,作为术中参考标志相对可靠。     

内翻型弓形股骨对膝骨性关节炎下肢力线的影响

目的 探讨股骨弓形形态与股骨远端关节线方向的相关性。方法 纳入2018年至2019年因膝骨性关节炎在我院行初次全膝关节置换的病例共126例（187膝）,其中男39例（47膝）,女87例（140膝）,年龄为（68.1±3.7）岁（61~79岁）。术前均拍摄下肢全长片。收集术前胫股机械轴内侧角（HKA）、股骨弓形角（FBA）、股骨下段外翻角（dAMA）、股骨远端关节线外侧机械角（mLDFA）、胫骨近端关节线内侧机械角（mMPTA）以及胫股关节线夹角（JLCA）,依据FBA大小分为显著弓形组（FBA＞4°）、轻度弓形组（4°≥FBA＞2°）、非弓形组（2°≥FBA≥0°）。比较上述形态学参数的组间差异,并分析显著弓形组内各参数相关性。结果 显著弓形组内股骨弓形、股骨下段外翻、股骨侧关节线内翻以及膝内翻最显著（FBA=5.1°±0.6°,dAMA=7.0°±1.6°,mLDFA=94.5°±1.0°,HKA=171.4°±4.3°,P＜0.001）;而非弓形组内胫骨侧关节线内翻和胫股关节面内翻最显著（mMPTA=86.7°±1.6°,P＜0.05;JLCA=-4.4°±2.5°,P＜0.001）。显著弓形组内FBA与mLDFA存在较强相关性（r=0.607,P＜0.01）。结论 弓形股骨与膝骨性关节炎的股骨关节线内翻显著相关,并使下肢整体内翻增加。     

膝内、外翻畸形对膝关节影响的三维有限元计算分析

目的　通过对膝内、外翻畸形的三维模型进行有限元分析 ,了解膝内、外翻畸形对膝关节生物力学影响。方法　利用膝关节影像学资料 ,通过Super-Sap软件建立三维有限元模型 ,在内翻 30°至外翻 30°之间 ,按每 2°加载 ,计算各节点的应力应变情况。结果　①正常膝关节内、外侧均表现为压应力。②膝内翻在 1 2°～ 1 8°之间应力显著集中于内侧胫骨平台。③膝外翻2 0°后应力集中于外侧胫骨平台。结论　膝内翻 1 0°、膝外翻 2 0°为应力集中的临界角度。     

Bony landmarks and rotational alignment in total knee arthroplasty for Chinese osteoarthritic knees with varus or valgus deformities

The purpose of this study was to investigate the rotational mismatch of total knee arthroplasty when taking the medial one third of the tibial tuberosity as a rotational landmark in Chinese osteoarthritic knees. Computed tomographic images of 49 osteoarthritic knees (42 with varus and 7 with valgus deformities) and 10 healthy knees were analyzed. The angle (alpha) between the 2 baselines for the anteroposterior axis of the femoral and tibial components was measured. The mean value of alpha in healthy knees was +6.45 degrees, which increased significantly to +11.53 degrees in varus knees (P = .002) and +12.17 degrees in valgus knees (P = .04). It showed that there is a tendency for the tibial component to be externally rotated when the medial one third of the tibial tuberosity is defined as a rotational landmark. This finding is particularly prominent in Chinese osteoarthritic knees with varus or valgus deformities.     

Bone anatomy and rotational alignment in total knee arthroplasty

The purpose of the current study was to investigate the bone anatomy in determining the rotational alignment in total knee arthroplasty using computed tomography. Axial images of 109 knees in 83 patients with varus osteoarthritis who had total knee arthroplasty were analyzed. On the images of the distal femur and the proximal tibia, a baseline for the anteroposterior axis of each component was drawn based on the epicondylar axis for the femur and the medial (1/3) of the tibial tuberosity for the tibia. The angle between these two lines was analyzed as the rotational mismatch between the components when they were aligned to the anatomic landmarks of each bone. Fifty-four knees (49.5%) had an angle of 5 degrees or greater and 13 knees (11.9%) had an angle of 10 degrees or greater. There was a tendency to align the tibial component in external rotation relative to the femoral component. The results indicated that the landmarks of each bone were the intrinsic cause of the rotational mismatch in knees with varus osteoarthritis. Surgeons doing total knee arthroplasties should be aware of this and check the rotational mismatch between the components. When it is present, the tibial component should be realigned to match the femoral component rotation to minimize problems caused by the mismatch.     

老年性骨关节炎行人工膝关节置换术后 假体旋转对线的定量分析

目的根据不同解剖标志利用CT扫描定量测量人工膝关节置换术后股骨和胫骨假体的旋转对线。方法 2004年对21位合并膝内翻畸形(35个膝)老年性骨关节炎患者(平均年龄73.3岁,范围:60～81岁)行人工膝关节置换手术,术中采用后稳定型固定平台膝关节假体,以股骨后髁轴外旋截骨确定股骨假体旋转定位,综合参考胫骨平台最大覆盖率和胫骨后髁轴确定胫骨假体旋转定位。术后7年进行随访,内容包括病史采集、物理检查,KSS评分和功能评分,负重位膝关节正侧位X光片、髌骨轴位片以及膝关节CT扫描。在CT扫描图像上,根据股骨内外上髁轴(SEA)测量股骨假体旋转角度,分别根据股骨内外上髁轴和胫骨结节内侧1/3测量胫骨假体旋转角度,并以此测算假体的联合旋转角度和旋转不匹配程度。结果对35个膝关节随访7年结果显示,未出现感染、假体透亮带、髌骨脱位或半脱位、髌骨骨折、假体松动等,KSS临床评分平均91分,功能评分平均83分。股骨假体、胫骨假体旋转角度、联合假体旋转角度均呈正态分布;股骨假体平均旋转角度为(3.02±3.88)°;胫骨假体相对于胫骨结节内侧1/3明显处于内旋位(平均17°),相对于SEA旋转角度平均0°,参考两个标志测量的胫骨假体旋转角度之间有显著差异(P=0.000);相对于SEA确定的假体联合旋转角度平均(2.99±7.90)°,相对于胫骨结节内侧1/3确定的假体联合旋转角度平均(-2.64±8.39)°,参考两个参考标志测定假体联合旋转角度之间有显著差异(P=0.005),股骨和胫骨假体旋转不匹配最大程度在10°度左右。结论与胫骨结节内侧1/3做比较,股骨内外上髁轴(SEA)更适合作为CT定量测量人工膝关节置换术后股骨和胫骨假体旋转对线的标志;胫骨平台最大覆盖率和胫骨后髁轴可以作为胫骨假体旋转定位的参考轴线,但具有较大的个体差异性。     

Anatomical analysis of the femoral condyle in normal and osteoarthritic knees.

It is important to understand anatomical feature of the distal femoral condyle for treatment of osteoarthritic knees. Detailed measurement of the femoral condyle geometry, however, has not been available in osteoarthritic knees including valgus deformity. This study evaluated femoral condyle geometry in 30 normal knees, 30 osteoarthritic knees with varus deformity, and 30 osteoarthritic knees with valgus deformity using radiographs and magnetic resonance imaging (MRI). In radiographic analysis in the coronal plane, the femoral joint angle (lateral angle between the femoral anatomic axis and a tangent to femoral condyles) was 83.3 degrees in the normal knees, 83.8 degrees in the varus knees, and 80.7 degrees in the valgus knees. In MRI analysis in the axial plane, the posterior condylar tangent showed 6.4 degrees of internal rotation relative to the transepicondylar axis in the normal knees, 6.1 degrees in the varus knees, and 11.5 degrees in the valgus knees. These results suggested that there was no hypoplasia of the medial condyle in the varus knees, but the lateral condyle in the valgus knees was severely distorted. Surgeons should take this deformity of the lateral femoral condyle into account when total knee arthroplasty is performed for a valgus knee.     

Varus tibial joint line obliquity: a potential cause of femoral component malrotation.

In 60 consecutive total knee arthroplasties done in 52 patients with primary osteoarthritis and varus or neutral tibiofemoral alignment, the posterior condylar angle was calculated intraoperatively and averaged 3.98 degrees (range, 0 degrees-9 degrees). Eighteen knees had a posterior condylar angle value less than 3 degrees whereas 27 knees had a posterior condylar angle value of 5 degrees or greater. Final rotational alignment of the femoral component was set parallel to the transepicondylar axis. Only one of these 60 knees required a lateral retinacular release for proper patellar tracking during the knee arthroplasty. When compared with three previously defined angles measured on the radiographs taken preoperatively, only the tibial plateau-tibial shaft angle values were correlated significantly with the value of the posterior condylar angle. As the tibial varus joint line obliquity increased, there was a distinct tendency for the transepicondylar axis to be rotated more externally relative to the posterior condylar axis. This variance suggests that the use of the posterior condylar axis as a rotational reference is inappropriate in many knees with arthritis with varus or neutral tibiofemoral alignment. In particular, varus tibial joint line obliquity of more than 4 degrees increases the likelihood of femoral component malrotation when the posterior femoral condyles are used to reference femoral component rotation.     

Relationship between frontal knee alignment and reference axes in the distal femur.

The two transepicondylar axes (the clinical and surgical epicondylar axes), the posterior condylar axis, and the anteroposterior axis were constructed using computed tomography scans in 111 (66 patients) knees with symptomatic arthritis. The relationships between angles made by these reference axes and two angles indicating frontal knee alignment (the tibiofemoral valgus angle and the femoral valgus angle) were investigated. In Y of the knees, the surgical epicondylar axis could not be constructed because the sulcus of the medial epicondyle was not recognizable. The condylar twist angle was almost constant and averaged 6 degrees when the femoral valgus angle was 9 degrees or less, but increased gradually when the angle was greater than 9 degrees. The difference between the condylar twist angle and the posterior condylar angle was constantly 3 degrees. The anteroposterior axis was almost at right angles to the clinical epicondylar axis, and the relationship between these axes was constant, independent of the femoral valgus angle. With 3 degrees to 6 degrees external rotation relative to the posterior condylar axis, the femoral component could be set parallel to the transepicondylar axis in common varus or neutral knees. In cases with a larger femoral valgus angle, the anteroposterior axis would be a more reliable reference axis. Preoperative computed tomography scans are recommended for patients with knees with severe valgus deformity or severe hypertrophic osteoarthritis.     

Rotational Position of Femoral and Tibial Components in TKA Using the Femoral Transepicondylar Axis

Proper femoral and tibial component rotational positioning in TKA is critical for outcomes. Several rotational landmarks are frequently used with different advantages and limitations. We wondered whether coronal axes in the tibia and femur based on the transepicondylar axis in the femur would correlate with anteroposterior deformity. We obtained computed tomography scans of 100 patients with arthritis before they underwent TKA. We measured the posterior condylar angle on the femoral side and the angle between Akagi’s line and perpendicular to the projection of the femoral transepicondylar axis on the tibial side. On the femoral side, we found a linear relationship between the posterior condylar angle and coronal deformity with valgus knees having a larger angle than varus knees, ie, gradual external rotation increased with increased coronal deformity from varus to valgus. On the tibial side, the angle between Akagi’s line and the perpendicular line to the femoral transepicondylar axis was on average approximately 0°, but we observed substantial interindividual variability without any relationship to gender or deformity. A preoperative computed tomography scan was a useful, simple, and relatively inexpensive tool to identify relevant anatomy and to adjust rotational positioning. We do not, however, recommend routine use because on the femoral side, we found a relationship between rotational landmarks and coronal deformity. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.     

The posterior condylar angle in osteoarthritic knees

The posterior condylar angle is formed by the transepicondylar axis and the tangent line to the posterior condyles. It is an important relationship to determine rotational alignment of the femoral component in total knee arthroplasty. We measured this angle directly in 107 osteoarthritic knees undergoing total knee arthroplasty. The posterior condylar angle was significantly greater in valgus knees than in other osteoarthritic knees. Given the standard deviations and ranges of values noted, the posterior condyles are potentially unreliable references for femoral component rotation in some knees.     

Medial torsion of the tibia in Japanese patients with osteoarthritis of the knee

To assess the reliability of the landmarks for the rotationally neutral alignment of the tibial component in total knee arthroplasty for Japanese patients, the rotational position of the medial (1/3) of the tibial tuberosity relative to the femoral epicondylar line (Angle TT) and that relative to the center of the ankle (Angle TT-AA) were measured in 24 knees with medial femorotibial osteoarthritis and in 28 normal knees by computed tomography. Angle TT-AA shows the degree of medial torsion of the tibia. The range of Angle TT and that of Angle TT-AA each was greater than 40 degrees. The position of the tibial tuberosity and degree of medial torsion of the tibia varied by individual. In patients with severe medial torsion, the internal rotation of the foot is extreme if the medial (1/3) of the tibial tuberosity is used for the rotationally neutral alignment of the partially constrained tibial component. In the treatment specifically of patients from East Asian countries, medial torsion of the tibia should be taken into account in total knee arthroplasty to ensure proper patellar tracking and proper rotation of the foot in knees with medial femorotibial osteoarthritis.