全膝置换术后的髌腱短缩及其临床影响

目的研究全膝置换(totalkneearthroplasty,TKA)术后的髌腱长度变化,置换髌骨对髌腱长度的影响,髌腱长度变化与术后膝关节活动度的关系。方法2002年5月~2003年12月对49例55个关节行初次全膝置换手术。包括48例骨关节炎、7例类风湿性关节炎,其中7例做了外侧支持带松解,测量术前的髌腱长度及术后1年的髌腱长度和膝关节活动度,按是否置换髌骨分成两组,对数据进行组间和组内统计学分析。结果术后1年,髌腱发生有统计学意义的短缩(P<0·01)。在短缩大于10%的发生率上,换与不换髌骨组没有统计学意义的差别(P>0·05)。髌腱短缩和关节活动度呈负相关(P<0·01)。结论全膝置换术后存在髌腱短缩的并发症。置换髌骨对髌腱短缩没有影响。髌腱短缩可能是导致术后活动度损失的原因之一。     

A Meta-Analysis of Patellar Replacement in Total Knee Arthroplasty for Patients With Knee Osteoarthritis

Background

This meta-analysis (MA) aims at comparing the clinical outcomes of resurfacing and nonresurfacing the patella in patients undergoing total knee arthroplasty in the treatment of knee osteoarthritis.

全膝置换术后髌骨髌腱角的变化

目的 研究全膝置换术后相同屈膝角度下矢状位髌骨和髌腱之间的角度变化,及其与术后活动度的关系.方法 材料为2002年5月～2003年12月期间做了初次全膝置换的33个关节(30例),诊断包括29个膝骨关节炎、4个类风湿性关节炎,其中20个关节置换了髌骨.男5例,女25例;年龄平均67.3岁.术前和术后1年摄0°、45°、90°侧位X线片,记录术后1年的活动度,测量术前术后不同屈膝度下的髌骨纵轴和髌韧带的夹角,并进行分析.结果 术后1年在屈膝90°时,髌骨与髌腱的角度较术前增大(P＜0.01).更换髌骨和保留髌骨组术后都发生了相似的角度变化(P＜0.01).术后屈膝90°的髌骨髌腱角和术后活动度呈负相关(r=-0.506,P=0.003).结论 全膝置换术后在屈膝活动时的髌骨髌腱角变化规律发生改变,与置换髌骨无关;术后屈膝90°时髌骨髌腱角的改变幅度与术后活动度限制有关.     

Patellar Resurfacing in Total Knee Arthroplasty: A Cost-Effectiveness Analysis

Background

This study estimates the cost-effectiveness of patellar resurfacing in total knee arthroplasty (TKA).

Patellar Resurfacing in Primary Total Knee Arthroplasty: A Meta‐analysis and Trial Sequential Analysis of 50 Randomized Controlled Trials

ObjectiveDuring total knee arthroplasty, femur and tibia parts are regularly replaced, while resurfacing the patellar or not is an ongoing discussion. To compare revision rate, anterior knee pain rate, patient‐reported outcome measures, complication, radiographic, and clinical outcomes after patellar resurfacing versus non‐resurfacing in total knee arthroplasty.MethodsPubMed, Medline, EMBASE, CENTRAL, and CINAHL databases were searched on 25 April 2021 to enroll randomized controlled trials that compared patellar resurfacing versus non‐resurfacing. We used the grading of recommendations assessment, development and evaluation (GRADE) framework to assess the certainty of evidence. Our primary outcome was revision rate and secondary outcomes was anterior knee pain rate. Outcomes were pooled using the random‐effect model and presented as risk ratio (RR), or mean difference (MD), with 95% confidence interval (CI).ResultsFifty studies (5586 knees) were included. Significant reductions in patellar revision rate (RR 0.41, 95% CI [0.19, 0.88]; P = 0.02; I ² = 24.20%) and non‐patellar revision rate (RR 0.64, 95% CI [0.55, 0.75]; P < 0.001; I ² = 0%) were seen after patellar resurfacing. Patellar resurfacing significantly reduced the anterior knee pain rate than nonresurfacing (RR 0.72, 95% CI [0.57, 0.91]; P = 0.006; I ² = 69.5%). Significant differences in patient‐reported outcome measures were found. However, these differences were inconsistent and lacked clinical importance. Patellar resurfacing resulted in a significant lower rate of patellar clunk (RR 0.58, 95% CI [0.38, 0.88]; P = 0.01; I ² = 0%), a higher patellar score (MD 1.24, 95% CI [0.67, 0.81]; P < 0.001; I ² = 73.8%), but prolonged surgical time (MD 8.59, 95% CI [5.27, 11.91]; P < 0.001; I ² = 88.8%).ConclusionsThe clear relationship is that patellar resurfacing reduces revisions, anterior knee pain, and patellar clunk. It will be interesting to compare the initial cost with the revision cost when required and cost‐utility analysis with long‐term results in future studies.     

Onlay Patellar Resurfacing in a Posterior-Stabilized Total Knee Arthroplasty Increases Patellar Crepitus Complication: A Randomized,Controlled Trial

BackgroundPatellar crepitus (PC) is a potentially problematic complication after total knee arthroplasty (TKA) more commonly occurring with a posterior-stabilized (PS) prosthesis. Patellar resurfacing has been reported to reduce PC complications; however, no study has compared the PC complication rates between 2 different resurfacing techniques, namely inlay and onlay.MethodsA prospective, randomized controlled trial was conducted to compare the PC complication between inlay and onlay patellar resurfacing techniques. A total of 222 patients who underwent unilateral TKA using a Legion PS Total Knee System were randomized into 2 groups. PC incidence, time of PC presentation, radiographic parameters associated with PC development, and clinical outcomes were evaluated at 3, 6, 9, 12, 18, and 24 months postoperatively.ResultsPC occurred significantly more in the onlay group (17.9% vs 6.5%, P = .009). Time of PC presentation in both groups was not different. Anterior knee pain was found in 11.5% of PC patients, and none required any surgical procedure. Postoperative radiographic parameters, range of motion, Knee Society score, Oxford score, patellar score, incidence and intensity of anterior knee pain, and visual analog scale of overall knee pain were not significantly different between the 2 groups during the follow-up period.ConclusionTo reduce the chance of PC development, we suggest an inlay patellar resurfacing technique during PS-TKA with this knee system.     

Patellar Resurfacing in Total Knee Arthroplasty: Systematic Review and Meta-Analysis

Background

Patellar resurfacing in total knee arthroplasty remains controversial. The aim of this study is to evaluate this technique through an analysis of comparative studies in the current literature.

Comparison of Gap Balancing vs Measured Resection Technique in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty: One Technique per Knee

BackgroundTotal knee arthroplasty requires careful surgical technique to attain the goal of a well-aligned and symmetrically balanced knee. Soft tissue balance and correct femoral component rotation are paramount in achieving these goals. The two competing techniques to select femoral component rotation and soft tissue balance are the gap balance technique and the measured resection technique.MethodsWe performed a randomized, prospective study to compare the two techniques in patients undergoing simultaneous bilateral total knee arthroplasty, whereby one technique was performed in each knee. Fifty (50) subjects were enrolled into the study. The inclusion criteria were osteoarthritic varus knee deformities with similar deformities in both knees. Subjects were followed up for a minimum of two years.ResultsThe knees balanced via the gap balance technique had significantly more posterior medial bone removed from the femur than those knees balanced via the measured resection technique (P < .001). Knees in the gap balance group tended to require more medial knee releases in extension and tended to have smaller sized femoral components as a result of cutting more bone from the femur in flexion. The modular tibial polyethylene bearing tended to be thicker in the gap balance group. Despite these differences, average knee flexion and functional revised Oxford Knee Scores at 2-year follow-up were not statistically different.ConclusionAt 2-year follow-up, there were no differences between the function and scores using the two techniques. Long-term follow-up will be necessary to evaluate any differences in long-term durability.     

Lateral Patellar Facetectomy and Medial Reefing in Patients With Lateral Facet Syndrome After Patellar-Retaining Total Knee Arthroplasty

We analyzed clinical outcomes of partial lateral patellar facetectomy and medial reefing in patients with lateral patellar facet syndrome with painful patellar-retaining total knee arthroplasty. 34 patients were followed for a mean of 40 months. All 34 patients were matched with those having secondary patellar resurfacing without facetectomy. Both groups experienced significant pain relief and range of motion improvement. The facetectomy group had higher Kujala scores than those in patellar resurfacing group. Patients with facetectomy had significantly less pain postoperatively. There were significant differences in postoperative lateral patellar tilt and congruency angle in both groups. The mid-term results for LPF with medial reefing are promising to resolve pain in patients with lateral patellar facet syndrome in patellar-retaining TKA. Therapeutic level III (retrospective comparative study).     

The Outcome of Total Knee Arthroplasty With and Without Patellar Resurfacing up to 17 Years: A Report From the Australian Orthopaedic Association National Joint Replacement Registry

BackgroundPatellar resurfacing in total knee arthroplasty (TKA) remains a controversial issue after more than 4 decades of TKA. Despite a growing body of evidence from registry data, resurfacing is still based largely on a surgeon’s preference and training. The purpose of this study is to provide long-term outcomes for patellar resurfaced compared to when the patella is not resurfaced.MethodsData from the Australian Orthopaedic Association National Joint Replacement Registry (1999-2017) were used for this study. The analysis included 570,735 primary TKAs undertaken for osteoarthritis. Hazard ratios (HRs) and 17-year cumulative percent revision rates were used to compare revision rates between 4 subgroups: minimally stabilized (MS) patellar resurfacing, posterior stabilized (PS) patellar resurfacing, MS unresurfaced, and PS unresurfaced patella. Additional analyses of the patellar implant type and a comparison of inlay and onlay patellar resurfacing were also performed.ResultsFor all primary TKA, procedures where the patella was not resurfaced have a higher rate of revision compared to procedures where the patella was resurfaced (HR, 1.31; confidence interval, 1.28-1.35; P < .001). Unresurfaced PS knees have the highest cumulative percent revision at 17 years (11.1%), followed by MS unresurfaced (8.8%), PS resurfaced (7.9%), and MS resurfaced (7.1%). Inlay patellar resurfacing has a higher rate of revision compared to onlay patellar resurfacing (HR, 1.27; confidence interval, 1.17-1.37; P < .001).ConclusionResurfacing the patella reduces the rate of revision for both MS and PS knees. MS knees with patellar resurfacing have the lowest rate of revision. Onlay patella designs are associated with a lower revision rate compared to inlay patella designs.     

Patella Resurfacing in Total Knee Arthroplasty: A Series of 1280 Patients at Midterm Follow-Up

Background

The management of patella in total knee arthroplasty (TKA) is a controversial topic. The elevated risk of patellofemoral complications seems to support those who are not eager to perform such procedure. The aim of this study is to carry out a retrospective assessment of patients who underwent patellar resurfacing during TKA from 2004 to 2009.

The Combination of Inlay Patellofemoral Arthroplasty and Medial Unicompartmental Knee Arthroplasty Versus Total Knee Arthroplasty for Mediopatellofemoral Osteoarthritis: A Comparison of Mid-Term Outcomes

BackgroundTo the best of our knowledge, there have been no studies in the literature related to the use of second-generation inlay patellofemoral arthroplasty and unicompartmental knee arthroplasty combination (inlay PFA/UKA) in the treatment of mediopatellofemoral osteoarthritis (MPFOA). The aim of this study is to evaluate the efficacy of inlay PFA/UKA in MPFOA.MethodsThe study included 49 patients applied with inlay PFA/UKA because of MPFOA and 49 patients applied with TKA, matched one-to-one according to age, gender, body mass index, follow-up period, preoperative Knee Society Score, and range of motion. All the patients were evaluated clinically using the Knee Society Score, Knee Injury Osteoarthritis Outcome Score, and range of motion, and were also evaluated radiologically. Complication rates and length of hospital stay were compared.ResultsThe mean follow-up period was 54 ± 4 and 54.4 ± 3.9 months in inlay PFA/UKA and TKA groups, respectively. (P = .841). No statistically significant difference was determined between the 2 groups in respect of the mean clinical scores at the final follow-up examination (P ≥ .129). Total complications were fewer and length of hospital stay was shorter in the inlay PFA/UKA group than in the TKA group (P = .037 and P = .002). There was no radiographic evidence of progression of lateral compartment osteoarthritis according to Kellgren-Lawrence in any patient in the inlay PFA/UKA group.ConclusionIn selected patient groups, inlay PFA/UKA is an alternative to TKA, with lower complication rates, shorter length of hospital stay, and clinical and functional results similar to those of TKA without osteoarthritis progression in the unresurfaced lateral compartment in the mid-term.Level of EvidenceIII.     

Comparison of Expectations and Outcomes in Rheumatoid Arthritis Versus Osteoarthritis Patients Undergoing Total Knee Arthroplasty

BackgroundWe hypothesized that patients undergoing primary total knee arthroplasty (TKA) for rheumatoid arthritis (RA) would have different preoperative expectations compared to osteoarthritis (OA) patients, and that postoperative satisfaction would correlate with specific postoperative pain and functional domains.MethodsThis is a retrospective cohort study of RA patients matched based on age, gender, American Society of Anesthesiologists score, and Charlson Comorbidity Index score 1:2 with OA patients (76 RA, 152 OA) who underwent primary TKA. The Hospital for Special Surgery Knee Replacement Expectations Survey, Visual Analogue Scale for Pain (VAS), Knee injury and Osteoarthritis Outcome Score (KOOS), and the Short Form-12 (SF-12) were compared at baseline and at 2 years postoperatively. Minimum clinically important differences (MCIDs) were calculated for KOOS and SF-12 subdomains.ResultsPreoperatively, RA patients had lower expectations, worse VAS Pain, and worse KOOS Pain, Symptoms, and Activities of Daily Living (P < .05). However, at 2 years, RA patients had significantly larger improvements in VAS (P = .01) and these 3 KOOS subdomains (P < .05), achieving comparable absolute scores to OA patients. Overall, 86.1% of RA and 87.1% of OA patients were either somewhat or very satisfied with their TKA. Patient satisfaction correlated with VAS Pain and KOOS outcome scores in both groups. RA and OA patients had high rates of achieving MCID in SF-12 physical component scores and all 5 KOOS subdomains. A higher proportion of RA patients achieved MCID in KOOS Symptoms (98.4% vs 77.2%, P < .001).ConclusionRA patients had lower baseline expectations compared to OA patients. However, RA patients had greater improvements in KOOS and SF-12 subdomains, and there was no difference in satisfaction compared to OA patients after TKA.     

Comparison of Anterior-Posterior Axis Versus Transepicondylar Axis in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty: One Technique per Knee

BackgroundIn primary total knee arthroplasty (TKA), the preferred reference line for setting femoral component rotation is debatable. This study compared the anterior-posterior axis line (APAL) versus the transepicondylar axis line (TEAL) in patients undergoing simultaneous bilateral TKA using a measured resection technique where one reference line was randomized to each knee.MethodsThis prospective study compared the two reference lines using posterior knee referencing with a cemented posterior stabilized knee. The study included 32 patients with osteoarthritis with both knees having similar varus knee deformities. All patients had the same surgical procedure with the only change being the selected femoral rotation axis line. Patients were followed up for a minimum of two years.ResultsThere was no significant difference in any of the measured radiographic, operative, and clinical parameters, except for a postoperative radiographic limb alignment (APAL 179.7° vs TEAL 180.1° P = .04). The mean femoral external rotation relative to the posterior condylar axis line (PCAL) was 3.0 degrees (0-7 degrees) using the APAL and 3.3 degrees (2-7 degrees) using the TEAL (P = .46). Two-year knee flexion and revised Oxford Knee Scores showed no difference. Seventy-five percent of patients stated no preference for either knee technique.ConclusionWhen using a measured resection, a posterior referencing technique, we found no difference in knee function and scores when setting femoral component rotation using the APAL versus TEAL.Level of Evidence2, Randomized prospective study.     

Patellar Denervation in Total Knee Arthroplasty Without Patellar Resurfacing and Postoperative Anterior Knee Pain: A Meta-Analysis of Randomized Controlled Trials

The aim of this meta-analysis was to investigate whether patellar denervation with electrocautery (PD) after total knee arthroplasty (TKA) could reduce the postoperative anterior knee pain (AKP). Five randomized controlled trials (RCTs) with 572 patients and 657 knees were eligible for this meta-analysis. Our results showed that PD was associated with less AKP, lower visual analogue scale (VAS), higher patellar scores and better knee function compared with no patellar denervation (NPD). Complications did not differ significantly between the two groups. The existing evidence indicates that PD may be a better approach, as it improves both anterior knee pain and knee function after TKA. Future multi-center randomized controlled studies with large sample sizes are required to verify the current findings.     

Effect of Patellar Thickness on Knee Flexion in Total Knee Arthroplasty: A Biomechanical and Experimental Study

A biomechanical computer-based model was developed to simulate the influence of patellar thickness on passive knee flexion after arthroplasty. Using the computer model of a single-radius, PCL-sacrificing knee prosthesis, a range of patella–implant composite thicknesses was simulated. The biomechanical model was then replicated using two cadaveric knees. A patellar-thickness range of 15 mm was applied to each of the knees. Knee flexion was found to decrease exponentially with increased patellar thickness in both the biomechanical and experimental studies. Importantly, this flexion loss followed an exponential pattern with higher patellar thicknesses in both studies. In order to avoid adverse biomechanical and functional consequences, it is recommended to restore patellar thickness to that of the native knee during total knee arthroplasty.     

三维手术模拟系统在肝癌患者精准肝切除中的应用

目的评价一种新研发的三维手术模拟系统在精准肝切除中的应用价值。方法回顾性分析2009年5~11月期间在中山大学附属第一医院肝胆外科因肝癌接受精准肝切除术的85例患者的临床资料。对所有患者术前行CT检查,应用三维手术模拟系统进行术前评估,分别计算模拟切除的肝脏体积、剩余肝脏体积和手术切缘,并与术后实际切除肝脏体积和实际手术切缘进行比较,最后通过软件虚拟肝切除功能优化手术方案。结果 三维手术模拟系统可以清晰地显示和三维重建正常肝脏组织、肿瘤组织和肝内血管。所有患者均行精准肝切除术,3例患者术后2 d出现腹水,2例患者术后2 d出现中量胸水,4例术后5 d发现漏胆,均经保守治疗后好转。85例患者住院时间为6~88 d(平均23 d),术后30 d内无复发,住院期间无死亡病例。患者模拟切除肝脏体积与实际切除肝脏体积统计学上具有相关性(r=0.960,P<0.001),两者均值的差异无统计学意义(896.7 ml比819.1 ml,t=1.851,P=0.068)。模拟手术切缘与实际手术切缘统计学上也具有相关性(r=0.972,P<0.001),两者均值的差异也无统计学意义(12.2 mm比11.9 mm,t=1.143,P=0.256)。结论 三维手术模拟系统可准确评估和模拟肝脏手术情况,在精准肝切除的开展中具有一定的辅助作用。     

A Comparison of Walking Gait Following Mechanical and Kinematic Alignment in Total Knee Joint Replacement

Background

Although previous studies have compared radiological, pain, and function scores in kinematically aligned (KA) and mechanically aligned (MA) total knee arthroplasty (TKA), no previous studies have undertaken a three-dimensional (3D) gait analysis in these groups. This study compared kinematic and kinetic variables recorded during level walking in patients at least 2 years post-surgery who underwent an MA or KA procedure.