180° rotatory dislocation of the rotating platform of a posterior-stabilized mobile-bearing knee prosthesis; possible complication after closed reduction of a posterior dislocation – a case report –

Dislocation of the rotating platform is a significant early complication of mobile-bearing total knee arthroplasty. The authors report an unusual case of acute 180° rotatory dislocation of the rotating platform after closed reduction of a posterior dislocation of a posterior-stabilized mobile-bearing total knee prosthesis. A 71-year-old male with knee osteoarthritis underwent TKRA using a posterior-stabilized mobile-bearing prosthesis. Posterior dislocation of the prosthesis occurred at 5 weeks postoperatively, and closed reduction of the posterior dislocation resulted in complete 180° rotatory dislocation of the rotating platform. The patient was treated by open exploration and polyethylene exchange for a larger component. This case illustrates that dislocation of a posterior-stabilized mobile-bearing total knee prosthesis can occur given valgus laxity and causes a 90° spin-out of the polyethylene insert, and that closed reduction attempts may contribute to complete 180° rotatory dislocation of the rotating platform. Special attention should be given to both AP and lateral views to ensure that the platform is truly reduced and not rotated by 180°. Plain digital radiography, which enhances the density of polyethylene, or arthrography is helpful for diagnosing this complication.     

兔用金属对金属表面人工膝关节假体置入的可行性

背景：目前抗磨损方面的研究主要集中在关节摩擦副的改进和选择,其中金属对金属摩擦副是重要的革新与探索方向之一。 目的：观察兔用金属对金属表面人工膝关节假体置入动物体内的可行性及置入后12个月的使用情况,并探讨其生物力学性能。 方法：自行设计完成兔膝关节假体,人工股骨和人工胫骨假体表面均为不锈钢材料,使其摩擦表面配对成为金属对金属。10 只成年新西兰大白兔随机分成两组,每组5只,实验组和对照组分别行左侧人工膝关节置换,髌骨不置换,分别置入生物型网孔假体和骨水泥固定的非网孔假体。 结果与结论：置换后12个月,实验组标本大体观察可见大量骨质重建现象;两组膝关节功能差异无显著性意义;X射线检测示两组均固定良好,无脱位及松动发生;生物力学测试假体骨界面最大剪切强度实验组明显高于对照组(P < 0.05);扫描电镜观察实验组假体固定界面可见新骨形成,对照组假体与骨固定界面无新骨形成。提示金属对金属表面人工膝关节,无论是骨水泥假体还是生物型假体,均适合于在动物体内使用,置换后12个月动物实验观察见生物型假体及骨水泥假体在动物体内生存良好,多层网孔表面兔用生物型人工膝关节假体置入动物体内的固定强度要优于骨水泥假体。     

胫骨假体放置位置与人工膝关节置换后的稳定性

背景：目前关于在全膝置换中针对选择何种参照方法和技术来确定胫骨假体放置位置或参数尚报道较少。 目的：分析人工膝关节置换过程中胫骨假体放置的位置对其置换后稳定性及相容性的的影响。 方法：通过检索选择文章内容与人工膝关节置换过程中胫骨假体或角度相关的文章,同一领域文献则选择近期发表或发表在权威杂志文章。 结果和结论：初检得到132篇文献,根据纳入标准选择关于胫骨假体放置的27篇文章进行综合分析。由于胫骨上端几何结构的个体差异以及手术操作等原因,假体与胫骨上端切面有时不能良好匹配。全膝关节置换中,胫骨假体各面的角度、对线、对位对置换后膝关节的稳定性、屈伸功能和假体使用寿命均有重要影响;胫骨假体的放置直接关系到人工膝关节置换后假体的松动、下沉及术后关节感等。因此选用适合患者型号的假体,使假体与胫骨上端切面能良好匹配的同时,还要提高假体植入技巧,以增强假体的稳定性。     

人工全膝关节置换术中髌股关节轨迹不良的处理策略及疗效

目的　总结人工全膝关节置换（total knee arthroplasty,TKA）术中,纠正髌股关节轨迹不良的方法及效果。 方法　2012年6月-2014 年12 月,对52例58膝TKA术中出现髌骨向外侧脱位倾向髌股关节轨迹不良的患者,针对发生原因,通过单纯调整髌骨内、外侧支持带张力,髌骨修整成形或调整胫骨假体位置等方法,或者联合应用上述两种或两种以上方法进行纠正。 结果 术中无拇指试验髌股关节轨迹恢复正常,术后髌骨未出现向外脱位倾向。术后切口均Ⅰ期愈合,2例因外翻明显,术中外侧支持带松解范围较大,术后出现关节积血,经对症处理后好转,无其他并发症发生。所有患者术后均获随访,随访时间 17-47个月,平均32个月。膝关节内、外翻畸形均获得矫正,4例残留 5-10°(平均8°）左右的屈曲畸形。随访末期KSS评分78-89分,平均84分,膝关节KSS功能评分为82-91分,平均86分。术后至随访期末X线片均显示人工关节位置正常,无松动及感染迹象。 结论 TKA术中出现髌股关节轨迹不良时,通过单纯调整髌骨内、外侧支持带张力,髌骨修整成形或调整胫骨假体等方法,或者联合应用上述两种或两种以上方法等进行调整,是处理髌股轨迹不良的有效方法,有利于术后膝关节的功能恢复。     

个体化术前模拟截骨在全膝关节置换胫骨平台假体选择中的应用

BACKGROUND: Inappropriate size of tibia prosthesis will affect the stability and long term curative effect of knee joint. Raising the tibia prosthesis bone coverage through preoperative analysis may further reduce the incidence of loosing and sinking of tibia prosthesis. OBJECTIVE: To select the appropriate prosthesis and maximize the tibia prosthesis bone coverage rate through the three dimensional reconstruction of CT and preoperative tibia osteotomy simulation among the patients preliminarily treated with total knee arthroplasty.  METHODS: Totally 76 (84 knees) patients treated with total knee arthroplasty were enrolled and randomly divided into test group (38 cases, 41 knees) and control group (38 cases, 43 knees). All the patients in the test group were underwent CT scan and three-dimensional reconstruction of CT before operation. Preoperative tibia osteotomy was stimulated. The most appropriate tibia prosthesis was selected by comparatively analyzing the data of tibia osteotomy, and maximizing the tibial plateau prosthesis bone coverage. Three-dimensional reconstruction of CT was absence in the control group by contrast. Tibia plateau bone coverage of patients in these two groups after replacement was evaluated. The repair effect was evaluated during the follow-up. RESULTS AND CONCLUSION: Totally 75 patients were followed up for 13 to 56 months. One patient in the test group withdrew from the study because of periprosthetic fractures. Analyzing from the follow-up after replacement, tibia plateau prosthesis coverage rates of test group and control group were (89.87±4.14)%, (83.15±5.21)% respectively; New York Hospital for Special Surgery scores were respectively (87.48±8.69) points and (82.37±10.14) points, the difference was statistically significant (P < 0.05). However, there were no significant differences in the range of motion and postoperative complications between test and control groups (P > 0.05). These results suggest that choosing the most appropriate type of tibia prosthesis by applying three-dimensional reconstruction of CT and preoperative tibia osteotomy on patients treated with total knee arthroplasty can improve tibial plateau prosthesis bone coverage rate and is conductive to achieve a satisfactory repair effect.      

活动型牛津膝单髁置换在膝关节自发性骨坏死治疗中的应用价值

目的探讨活动型牛津膝单髁置换术在膝关节自发性骨坏死(SONK)治疗中的应用价值。 方法回顾性分析上海交通大学医学院附属松江医院骨科2015年1月至2022年8月收治的采用活动型牛津膝单髁置换术治疗的32例(32膝)SONK患者,其中单柱活动型牛津膝单髁置换14例,双柱活动型牛津膝单髁置换18例。术中患者麻醉成功后取仰卧位,屈膝90°取髌骨旁内侧至胫骨结节内侧入路,彻底清除股骨内髁病变坏死病变组织,根据病灶周围硬化骨完整度和强度选择截骨深度。小缺损以骨水泥填塞,较大缺损建议采用已清除的骨赘块制作细小碎骨柱填塞。安装单柱/双柱双柱活动型牛津膝假体。再次检查膝关节活动范围及稳定性,彻底止血,充分冲洗切口,关节周围注射鸡尾酒镇痛混合剂,常规放置引流管,逐层缝合,弹力绷带包扎固定。术后24 h内预防性应用抗生素,术后1~2 d拔除引流管,术后常规给予抗凝、镇痛等对症治疗,麻醉结束后主动进行股四头肌训练和踝泵练习。记录患者的手术时间及住院时间;记录患者术后1、3、6、12、24、36个月患膝并发症发生情况;分别于术前及末次随访时,收集并比较患者的膝关节功能情况[特种外科医院(HSS)评分、膝关节协会评分(KSS)、膝关节活动度];测量并比较患者术前及末次随访时下肢力线情况[膝关节股胫角、胫骨内髁后倾角及胫骨平台角];比较2种假体患者末次随访时的膝关节功能情况及下肢力线情况。数据比较采用t检验。 结果所有患者均顺利完成手术,手术切口均Ⅰ期愈合。32例患者的手术时间为35.0~70.0 min,平均手术时间(45.5±6.9) min;住院时间5.0~8.0 d,平均6.5 d。32例患者中,1例双柱活动型牛津膝单髁置换患者于术后1个月出现半月板垫片脱位,予以翻修后好转;1例行单柱活动型牛津膝单髁置换后,于术后24个月出现下肢力线改变和假体松动,翻修为全膝关节置换术后好转。其他患者均无血管神经损伤、围手术期感染、假体松动、半月板垫片脱位、下肢深静脉血栓形成等相关并发症发生。末次随访时患者膝关节HSS评分、KSS和膝关节活动度分别为(85.6±4.4)分、(88.4±5.2)分、(108.8±8.2)°,均显著高于术前[(66.8±5.2)分、(61.3±9.8)分、(97.5±7.6)°],比较差异均有统计学意义(t＝15.61、13.81、5.71,P<0.05);末次随访时患者膝关节股胫角、胫骨平台角分别为(174.4±5.6)°、(84.6±3.6)°,均显著低于术前[(179.5±3.8)°、(88.1±2.0)°],比较差异均有统计学意义(t＝4.26、4.80,P<0.05);膝关节胫骨内髁后倾角末次随访时为(82.8±3.4)°,较术前[(84.2±3.9)°]差异无统计学意义(t＝1.53,P＝0.131)。末次随访时,单柱活动型牛津膝单髁置换患者HSS评分、KSS、膝关节活动度、股胫角、胫骨内髁后倾角、胫骨平台角分别为(84.8±4.2)分、(89.2±6.0)分、(107.6±9.0)°、(175.8±6.0)°、(82.0±4.1)°、(83.8±3.2)°,与双柱活动型牛津膝单髁置换患者[(86.3±4.6)分、(87.8±4.5)分、(109.8±7.9)°、(173.4±5.4)°、(83.5±3.6)°、(85.3±4.0)°]比较,差异均无统计学意义(P>0.05)。 结论活动型牛津膝单髁置换在SONK患者的治疗中取得满意效果,并发症发生少,能明显改善患膝功能和部分纠正下肢力线,值得临床推广应用。     

The use of a reconstructed three-dimensional solid model from CT to aid the surgical management of a total knee arthroplasty: a case study

The use of a rapid prototyping method was utilised to produce a pre-operative solid model of the proximal tibia in a patient with a massive defect of the medial tibial plateau. The solid model was reconstructed from aligned sequential CT images of the knee. This was then used to determine the level of bone resection of the proximal tibia for the optimum placement of the tibial component of a total knee replacement. This technique gives the surgeon both the three-dimensional anatomical information needed to ascertain whether there is adequate bony support after cutting for the prosthesis, as well as a solid model on which to carry out the proposed surgery, before undertaking the procedure on the patient.     

全膝关节置换中的改良截骨

背景：近年来全膝关节置换在临床应用普遍,置换技术及假体设计理念均获得极大改善和提高,但尚无截骨顺序方面的研究。 目的：探讨改良截骨方法在全膝关节置换过程中应用的临床效果。 方法：对60例患者的60膝行全膝关节置换,原发疾病包括骨关节炎52例,类风湿性关节炎6例,创伤性关节炎2例,均为后稳定型膝关节,应用强生PFC-Sigma PS型假体或LINK Gemini PS型假体。在极度屈膝下,先行股骨截骨,包括股骨远端前方后方斜面截骨(某些类型还包括股骨髁间截骨)。髌骨不常规置换,再行胫骨平台截骨。记录手术时间,置换后引流量,置换前及置换后6,12周膝关节活动度及美国特种外科医院膝关节评分,并进行统计学分析。 结果与结论：60例患者均获得随访,随访时间3-14个月。手术时间平均(51.3±12.5) min,置换后引流量平均(302±39) mL。置换后6,12周患者膝关节活动度及美国特种外科医院膝关节评分均较置换前明显改善(P < 0.01)。2例患者置换后1个月出现低度感染,经抗感染治疗后好转,未出现假体排异反应。提示全膝关节置换过程中先行股骨截骨可以为胫骨的操作获得更大的空间,方便切除半月板,并可安全地进一步松解周围软组织。操作简便,可以缩短手术时间,减少术中失血,具有良好的修复效果。     

The use of unicondylar osteoarticular allografts in reconstructions around the knee

Unicondylar osteoarticular allografts (UOA) of the knee are mainly used after bone tumour resections for benign aggressive tumours or small malignant tumours with clearly defined margins. They are also used less often in large posttraumatic condylar defects. Between 1989 and 2004, 12 deep-frozen UOA reconstructions (in 11 patients) were performed at our Institute. The diagnosis was chondrosarcoma in four cases, giant cell tumour in three, osteosarcoma in three, posttraumatic defect in one, and one failed UOA. The involved site was the medial femoral condyle in six cases, the lateral femoral condyle in three, the medial side of the tibial plateau in two, and the lateral in one case. One allograft was removed after 29 months because of an intra-articular displaced fracture, and substituted with a new UOA. One patient died of metastatic disease at 24 months. We report the functional and radiographical outcome of the remaining 10 UOAs with a minimum follow-up of 4 years (average 11 years). Two of the 10 patients had excellent results, five were good and three were fair. Radiographically, five patients had "mild" and five had "severe" degenerative changes. One patient with severe degenerative changes had pain and stiffness, therefore the UOA was converted into a prosthesis allograft composite, using a conventional total knee prosthesis. In selected cases of distal femoral and proximal tibial tumours, UOA reconstructions give good functional outcomes with relatively few major complications.     

Spontaneous dislocation of a mobile-bearing polyethylene insert after posterior-stabilized rotating platform total knee arthroplasty: a case report

We describe a dislocation after Scorpio mobile-bearing total knee arthroplasty. This system is a rotating platform posterior-stabilized design and utilizes a single post as part of the metal tibial tray. Only one locking ring inside the socket of the polyethylene insert secures a tight connection with the post. Spontaneous dislocation between the polyethylene insert and the metal tray occurred at 22 months post surgery while rising from the supine position with slight knee flexion. Operative findings revealed failure of the locking ring and the original insert was replaced with a thicker insert. Our case and a duplicated saw bone model demonstrated that failure of the locking system resulted in the dislocation of the insert.     

人工全膝关节置换修复晚期膝关节病变的短期随访

背景：在最近的数十年,人工全膝关节置换被广泛地应用于晚期膝关节病变,如骨关节炎、类风湿关节炎和创伤性骨关节炎等疾病的治疗。全膝关节置换过程中的截骨方法、软组织平衡以及假体旋转定位一直是争论和探讨的问题。 目的：探讨晚期膝关节病变行全膝关节置换的修复效果。 方法：采用人工全膝关节置换修复31例(31膝)晚期膝关节病变,其中骨关节炎26例26膝,类风湿关节炎5例5膝。所有病例均伴有不同程度屈曲挛缩畸形,最大屈曲畸形角度均小于25°。分别对患者在置换前和置换后进行膝关节美国特种外科医院评分,所有31膝均使用固定平台后稳定型人工全膝关节假体。 结果与结论：置换后无早期感染,无假体脱位并发症发生。置换后关节疼痛症状明显缓解、屈曲和内翻畸形均得到明显改善。置换后X射线片显示假体位置良好,下肢力线良好。所有患者均获随访,随访时间6-12个月。膝关节美国特种外科医院评分置换前为(46.4±5.3)分,置换后6个月为(84.6±10.5)分,优良率为84%。提示人工全膝关节置换修复晚期膝关节病变效果确切,但操作较复杂,技术要求精确。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

Dislocation of posterior-stabilized mobile-bearing knee prosthesis. A case report

Spin-out of mobile-bearing knees is a significant early complication of mobile-bearing total knee arthroplasty. Dislocation of the cam-post mechanism of fixed-bearing posterior-stabilized knees occurs more rarely. We have observed an unusual case of dislocation of posterior-stabilized rotating-platform total knee arthroplasty, which has both a cam-post mechanism and rotating platform. A 65-year-old man with knee osteoarthritis and cervical spondylotic myelopathy underwent total knee arthroplasty using a mobile-bearing prosthesis. The dislocation, which occurred 4 days postoperatively, could not be reduced by closed manipulation. However, spontaneous reduction occurred 6 days after the dislocation, which did not recur. A gap mismatch or trapezoidal-shaped gaps may lead to dislocation or spin-out of the bearing insert. This case illustrates that dislocation of a posterior-stabilized mobile-bearing total knee arthroplasty can occur, and both quadriceps deficiency and ligament laxity may contribute to the risk of dislocation.     

膝关节单髁置换界面应力失效分析

目的 分析骨水泥型胫骨假体平台界面应力,确定界面应力损伤区域,为临床单髁置换胫骨平台的应力失效问题提供参考。方法 通过人体动力学软件模拟完整周期的步态,获得膝关节的承力条件;利用医学影像及三维重建软件建立完整的膝关节模型并进行单髁置换;通过有限元法分析单髁置换后胫骨假体平台界面应力的分布规律。结果 步态下膝关节的力和角度随时间呈周期性变化,1.3 s为1个周期,膝关节合力峰值为760 N;界面最大剪切应力为11.82 MPa、最大拉应力6.849 MPa,均发生在假体-骨水泥界面的内侧前端拐角处;对于界面的最大应力,钛合金假体低于不锈钢假体。结论 假体的弹性模量减小可以降低界面最大主应力,从界面应力考虑,钛合金假体优于不锈钢假体;胫骨假体平台界面损伤区域主要在内侧前、后端拐角和外侧中端处,故提高该区域假体-骨水泥结合能力能防止单髁膝关节胫骨假体平台松动。研究结果对临床中单髁术后胫骨假体平台松动预防具有实际意义。     

如何实现Oxford单髁置换的准确截骨和术后稳定

Oxford单髁置换(UKA)准确截骨、间隙平衡、获得稳定及良好运动轨迹是手术成功的关键.UKA首先建立的是屈曲间隙,然后根据屈曲间隙大小再建立伸直间隙.其间隙平衡是指,在完成内侧胫骨平台截骨后,通过对股骨髁远端研磨调整股骨假体相对于股骨放置的高度,获得相等的屈伸间隙.UKA截骨一环扣一环,不能失误.胫骨截骨量不能过多...     

全膝关节置换过程中的假体旋转对位

背景：在全膝关节置换过程中对假体旋转对位争论的焦点目前仍集中在旋转对位的参照地标如何设定。 目的：综述全膝关节置换手术中假体旋转对位的相关临床和基础研究进展。 方法：广泛查阅全膝关节置换手术中假体旋转对位的解剖定位标志、定位方法、旋转对位的匹配、手术精确度等临床上遇到的相关文献。 结果与结论：许多研究表明,旋转对位不良,会导致膝前痛,胫股骨和髌股关节间的稳定性失衡,髌骨的运动轨迹失调,步态异常,胫骨侧聚乙烯平台的磨损加速,假体过早松动,出现关节半脱位和脱位,甚至需进一步手术翻修等问题。术中胫股骨侧假体的旋转对位时要综合利用所获得的各种信息,个别校正,必要时结合置换前的CT扫描来进行,以改善全膝关节置换疗效和远期生存率。     

Medium-term results of the Scorpio total knee replacement

We performed a medium-term clinical and radiological analysis of 160 patients (173 knees) who underwent Scorpio total knee arthroplasty between August 1997 and September 2000. Seventeen patients (19 knees) were lost to follow-up and 29 patients (29 knees) died before completing a minimum 5 year follow-up. The mean age of the patients at the time of the operation was 73.5 years and the mean duration of follow-up was 5 years and ten months. At the time of latest follow-up, the mean knee score was 92 and the mean functional score was 65. Overall, 104 knees were rated as excellent, 12 knees as good, 8 knees as fair, and one knee as poor. Thin, incomplete, non-progressive radiolucent lines were noted around eight tibial components and one femoral component. Massive osteolysis in the tibia was observed in one case. Only one patient needed revision of the prosthesis. Our findings suggest that the prosthesis design with a single flexion extension radius is associated with a good medium-term outcome.     

胫骨假体旋转对线技术影响髌股关节生物力学的作用机制

BACKGROUND: At present, the placement of tibial anatomic landmarks has no gold standard during total knee arthroplasty. In order to achieve the most ideal rotation function of the tibial prosthesis, we should do the preparation before surgery, understand tibial rotational alignment to rationally select and apply the prosthesis.     

制型肿瘤膝关节假体在膝关节周定围肿瘤中的应用体会

目的探讨采用国产定制型肿瘤膝关节假体治疗膝关节周围肿瘤的临床疗效.方法对2004年6月~2011年10月应用定制肿瘤型铰链膝关节假体置换膝关节周围肿瘤的15例病人进行回顾性分析,男6例,女9例;年龄27~76岁,平均51.4岁.骨肉瘤4例,骨巨细胞瘤6例,非典型性纤维组织细胞瘤2例,软骨肉瘤3例,均为股骨远端肿瘤.均行瘤段广泛切除国产骨水泥定制肿瘤型铰链膝关节假体重建.结果全部15例随访14~96个月,平均32个月.术后切口均一期愈合,未出现感染、免疫排斥、皮肤会死等近期并发症.1骨肉瘤患者术后10个月出现局部复发,拒绝手术,术后16个月死亡,1例骨肉瘤患者18个月肺转移死亡,1例骨肉瘤患者术后3年局部复发截肢.所有患者无关节脱位、假体松动、断裂、肢体短缩.术后膝关节主动屈曲活动度70~120°,平均89.4°,末次随访ISLOS影像评分24~31分,平均28.6分;骨肿瘤术后MSTS功能评分21~25分,平均22.8分.结论对膝关节周围恶性与侵袭性骨肿瘤切除后骨缺损采用国产定制肿瘤型人工假体重建是有效的保肢方法.     

胫骨近端的形态学测量与膝关节置换

背景：胫骨近端为膝关节假体构成的下半部分,胫骨近端是膝关节假体放置的底部位。 目的：评价胫骨近端的形态测量在临床上膝关节置换中的重要性。 方法：以 “膝关节;假体;置换”为中文关键词,以“Knee; Prosthesis; replacement” 为英文关键词。采用计算机检索1995-01/2011-10有关磁共振图像测量在临床上膝关节置换中假体旋转对线中应用的文章。 结果与结论：胫骨近端的形态测量即胫骨近端的三维有限元模型、相关参数及角度、生物力学研究与膝关节假体选择及设计有着重要相关性。胫骨近端的形态测量有二维和三维测量,以三维测量法精确,测量胫骨平台宽和倾斜角度、胫骨内外侧平台前后径,所测量的数据在临床上均有应用意义。胫骨近端是膝关节假体放置的底位置,而胫骨近端的三维模型与假体模型底部行模拟对接,提高手术的成功。     

膝关节假体周围胫骨骨折研究进展

全膝关节置换术后,由于胫骨周围软组织的特殊性和假体松动,膝关节假体周围骨折已成为一个具有挑战性的难题。因此,合理治疗膝关节假体周围骨折对于恢复膝关节功能至关重要。这种骨折的合理处理要求术前仔细参阅影像学资料和了解完整的临床病史,同时需排除假体周围感染。膝关节假体周围胫骨骨折最常见的类型是胫骨平台周围骨折。对于稳定的膝关节假体周围胫骨骨折可保守治疗,但需定期复查。不稳定的膝关节假体周围胫骨骨折应立即手术治疗,但具体手术方式应视骨折分型而定。本文就膝关节假体周围胫骨骨折近年的研究进展作一综述,旨在为膝关节假体周围胫骨骨折的临床治疗提供参考。