全膝关节置换术后下肢绝对长度的变化模式

目的探讨全膝关节置换术(total knee arthroplasty,TKA)术后下肢绝对长度的变化模式。方法前瞻性分析2014年1月至2017年12月56例行全膝关节置换术治疗终末期骨关节炎患者的临床资料,其中男14例,女42例;年龄为56-82岁,平均为(71.6±2.4)岁。根据术前内翻的程度将患者分为两组,内翻畸形<5°为A组,10°≥内翻畸形≥5°为B组,每组28例。术中在股骨前侧和胫骨前侧分别做标记,记录截骨前膝关节完全伸直位和安装假体后膝关节完全伸直位,分别测量截骨前及假体安装后两标记点之间的距离,两次距离的差值就是下肢绝对长度的变化值。术前及术后记录两组的下肢负重位全长X线的机械力线、膝关节活动范围、美国膝关节协会评分(knee society score,KSS)和功能评分,同时记录术后患者的满意率和对肢体长度变化的感知率。TKA术前A组膝关节活动范围(78.5±30.2)°,KSS评分(64.8±11.6)分,功能评分(62.8±9.8)分,机械轴线平均内翻(3.8±1.2)°;B组膝关节活动范围(76.4±31.4)°,KSS评分(63.4±10.4)分,功能评分(60.6±9.6)分,机械轴线平均内翻(7.4±2.3)°。结果 56例患者均获随访,随访时间6-40个月,平均(18.4±4.6)个月。所有患者未出现感染及假体松动。术后6个月时,A组膝关节活动范围(96.4±28.4)°,KSS评分(86.2±10.4)分,功能评分(83.6±9.6)分,机械轴线平均内翻(1.6±1.1)°;B组膝关节活动范围(94.6±26.6)°,KSS评分(84.8±10.2)分,功能评分(86.2±9.2)分,机械轴线平均内翻(1.8±1.2)°。两组均较术前明显改善,差异有统计学意义(P<0.05)。两组术后KSS及功能评分比较,差异无统计学意义(P>0.05)。总体来说,82.1%(46/56)的患者术后肢体绝对长度增加,其中A组为71.4%(20/28),B组为92.9%(26/28),差异有统计学意义(P<0.05)。术后能感知肢体长度有变化的患者约50.0%(28/56),其中A组为35.7%(10/28),B组为64.3%(18/28),差异有统计学意义(P<0.05)。因感觉肢体长度变化而不满意的患者约为24.2%。术后半年,感知肢体长度有变化的患者下降为14.3%(8/56),其中A组为10.7%(3/28),B组为17.9%(5/28),差异无统计学意义(P>0.05)。因感觉肢体长度有变化而不满意的患者下降为3.6%(2/56)。结论应用TKA治疗晚期骨关节炎,可明显改善功能,缓解疼痛,恢复肢体的下肢力线。但是,大多数患者置换术后肢体绝对长度会发生变化,而且这种变化的幅度和术前膝关节内翻的程度相关。术后部分患者会对这种变化有明显的感知,进而可能影响治疗总体的满意率。     

关节镜下AR缝合枪缝合外侧半月板撕裂的临床疗效观察

目的探讨分析外侧半月板体部层裂或纵向撕裂在关节镜下使用AR缝合枪全内垂直褥式缝合的临床疗效。方法本研究回顾性分析2017年1月至2017年12月,我科收治膝关节单纯外侧半月板体部撕裂(层裂或纵向撕裂)36例患者的临床资料,男13例,女23例;年龄16-41岁,平均(26.50±2.50)岁。36例患者中盘状半月板损伤7例。术中将撕裂外侧半月板修切白区内缘,保留红白区交界,体部层裂或纵裂新鲜化处理后行AR缝合枪全内垂直褥式缝合。术后根据Barrett标准门诊随访判断半月板的体部缝合临床愈合情况,采用重复测量方差分析比较不同时间视觉模拟评分(visual analogue scale,VAS)、膝关节主观功能评分(IKDC 2000评分)、膝关节功能评分(Lysholm评分)的差异来评估手术缝合疗效。术后12个月行膝关节MRI检查观察缝合部位恢复情况。结果本组36例患者均获随访,随访时间12-18个月,平均(15.0±2.3)个月。术后未出现感染、神经血管损伤、二次手术等并发症。根据Barrett标准评价,本组患者均获得半月板临床愈合。术后3个月、6个月、12个月的VAS评分为(1.10±0.12)分、(1.00±0.21)分、(0.90±0.32)分低于术前的(5.20±1.80)分,IKDC2000评分为(82.34±3.15)分、(85.34±5.17)分、(87.34±4.18)分高于术前的(40.51±5.54)分,Lysholm评分为(87.38±6.18)分、(88.52±4.19)分、(90.34±4.22)分高于术前的(42.11±6.82)分,差异具有统计学意义(P<0.05)。术后12个月复查MRI结果,34例(94.44%)甲级愈合,1例(2.78%)乙级愈合,1例(2.78%)未愈合。结论关节镜下采用AR缝合枪行全内垂直褥式缝合膝关节外侧半月板体部撕裂(层裂或纵裂),能有效缓解疼痛、提高患肢功能活动、促进半月板愈合,同时具有操作简单、并发症少等优势,经中短期临床随访其临床疗效显著,远期疗效需进一步随访追踪。     

Combined Injury to the ACL and Lateral Meniscus Alters the Geometry of Articular Cartilage and Meniscus Soon After Initial Trauma

Combined injury to the anterior cruciate ligament (ACL) and meniscus is associated with earlier onset and increased rates of post-traumatic osteoarthritis compared with isolated ACL injury. However, little is known about the initial changes in joint structure associated with these different types of trauma. We hypothesized that trauma to the ACL and lateral meniscus has an immediate effect on morphometry of the articular cartilage and meniscus about the entire tibial plateau that is more pronounced than an ACL tear without meniscus injury. Subjects underwent magnetic resonance imaging scanning soon after injury and prior to surgery. Those that suffered injury to the ACL and lateral meniscus underwent changes in the lateral compartment (increases in the posterior–inferior directed slopes of the articular cartilage surface, and the wedge angle of the posterior horn of the meniscus) and medial compartment (the cartilage-to-bone height decreased in the region located under the posterior horn of the meniscus, and the thickness of cartilage increased and decreased in the mid and posterior regions of the plateau, respectively). Subjects that suffered an isolated ACL tear did not undergo the same magnitude of change to these articular structures. A majority of the changes in morphometry occurred in the lateral compartment of the knee; however, change in the medial compartment of the knee with a normal appearing meniscus also occurred. Statement of clinical significance: Knee injuries that involve combined trauma to the ACL and meniscus directly affect both compartments of the knee, even if the meniscus and articular cartilage appears normal upon arthroscopic examination. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:759-767, 2020     

The relationship of three-dimensional joint space width on weight-bearing CT with pain and physical function

Limitations of plain radiographs may contribute to poor sensitivity in the detection of knee osteoarthritis and poor correlation with pain and physical function. Three-dimensional (3D) joint space width (JSW), measured from weight-bearing computed tomography (CT) images, may yield a more accurate correlation with patients’ symptoms. We assessed the cross-sectional association between 3D JSW and self-reported pain and physical function. Five hundred twenty eight knees (57% women) were analyzed from Multicenter Osteoarthritis Study participants. An upright weight-bearing CT scanner was used to acquire bilateral, weight-bearing, fixed-flexion images of the knees. A 3D dataset was reconstructed from cone beam projections and JSW was calculated across the joint surface. The percentages of the apposed medial tibiofemoral joint surface with JSW less than 2.0 and 2.5 mm, respectively, were calculated. Pain and physical function were measured using Western Ontario and McMaster Universities Osteoarthritis Index. Participants who reported greater pain severity tended to have a greater joint area with JSW less than 2.0 mm (P = .07 for the highest vs the lowest tertile). Participants who reported greater functional limitations had a greater joint area with JSW less than 2.0 mm (P = .02 for the highest vs the lowest tertile). There appears to be an association between the medial tibiofemoral area with JSW less than 2.0 mm and pain and physical function.     

Characterization of synovial fluid from periprosthetic infection in revision total joint arthroplasty by single-molecule microscopy

Periprosthetic joint infection is among the most common and severe complications in total joint arthroplasty. Today, a combination of different methods is used for diagnosis because no single method with sufficient sensitivity and specificity is available. In this study, we explored the usability of single-molecule microscopy to characterize synovial fluid samples from periprosthetic joint infections. Patients (n = 27) that needed revision arthroplasty underwent the routine diagnostic procedures for periprosthetic joint infection of the University Hospital in Bonn. Additionally, the diffusion rate of two probes, dextran and hyaluronan, was measured in small volumes of periprosthetic synovial fluid samples using single-molecule microscopy. To evaluate the suitability of single-molecule microscopy to detect PJI the AUC for both markers was calculated. The diffusion rate of hyaluronan in periprosthetic synovial fluid from patients with septic loosening was faster than in samples from patients with aseptic loosening. Single-molecule microscopy showed excellent diagnostic performance, with an area under the receiver operating characteristic curve of 0.93, and allowed the detection of periprosthetic joint infection in patients that would be challenging to diagnose with current methods. For the first time, single-molecule microscopy was used to detect periprosthetic joint infection. Our results are encouraging to study the value of single-molecule microscopy in a larger patient cohort. The speed and accuracy of single-molecule microscopy can be used to further characterize synovial fluid, potentially allowing intraoperative diagnosis of periprosthetic joint infections in the future.     

Initiating factors for the onset of OA: A systematic review of animal bone and cartilage pathology in OA

There is controversy over whether bone or cartilage is primarily involved in osteoarthritis (OA) pathogenesis; this is important for targeting early interventions. We explored evidence from animal models of knee OA by preforming a systematic review of PubMed, Scopus, and Web of Science for original articles reporting subchondral bone and cartilage pathology in animal models with epiphyseal closure. Extracted data included: method of induction; animal model; cartilage and bone assessment and method; meniscal assessment; skeletal maturity; controls; and time points assessed. Quality scoring was performed. The best evidence was synthesized from high-quality skeletally mature models, without direct trauma to tissues of interest and with multiple time points. Altogether, 2849 abstracts were reviewed. Forty-seven papers were included reporting eight different methods of inducing OA, six different species, six different methods of assessing cartilage, five different bone structural parameters, and four assessed meniscus as a potential initiator. Overall, the simultaneous onset of OA in cartilage and bone was reported in 82% of datasets, 16% reported bone onset, and 2% reported cartilage onset. No dataset containing meniscal data reported meniscal onset. However, using the best evidence synthesis (n = 8), five reported simultaneous onset when OA was induced, while three reported bone onset when OA occurred spontaneously; none reported cartilage onset. In summary, there is a paucity of well-designed studies in this area which makes the conclusions drawn conjectures rather than proven certainties. However, within the limitation of data quality, this review suggests that in animal models, the structural onset of knee OA occurs either in bone prior to cartilage pathology or simultaneously.     

Reduction of arthrofibrosis utilizing a collagen membrane drug-eluting scaffold with celecoxib and subcutaneous injections with ketotifen

The dense formation of abnormal scar tissue after total knee arthroplasty results in arthrofibrosis, an unfortunate sequela of inflammation. The purpose of this study was to use a validated rabbit model to assess the effects on surgically-induced knee joint contractures of two combined pharmacological interventions: celecoxib (CXB) loaded on an implanted collagen membrane, and subcutaneously (SQ) injected ketotifen. Thirty rabbits were randomly divided into five groups. The first group received no intervention after the index surgery. The remaining four groups underwent intra-articular implantation of collagen membranes loaded with or without CXB at the time of the index surgery; two of which were also treated with SQ ketotifen. Biomechanical joint contracture data were collected at 8, 10, 16, and 24 weeks. At the time of necropsy (24 weeks), posterior capsule tissue was collected for messenger RNA and histopathologic analyses. At 24 weeks, there was a statistically significant increase in passive extension among rabbits in all groups treated with CXB and/or ketotifen compared to those in the contracture control group. There was a statistically significant decrease in COL3A1, COL6A1, and ACTA2 gene expression in the treatment groups compared to the contracture control group (P < .001). Histopathologic data also demonstrated a trend towards decreased fibrous tissue density in the CXB membrane group compared to the vehicle membrane group. The present data suggest that intra-articular placement of a treated collagen membrane blunts the severity of contracture development in a rabbit model of arthrofibrosis, and that ketotifen and CXB may independently contribute to the prevention of arthrofibrosis. Statement of clinical significance: Current literature has demonstrated that arthrofibrosis may affect up to 5% of primary total knee arthroplasty patients. For that reason, novel pharmacologic prophylaxis and treatment modalities are critical to mitigating reoperations and revisions while improving the quality of life for patients with this debilitating condition.     

Is the Patient-Reported Outcome Measurement Information System Feasible in Bundled Payment for Care Improvement in Total Hip Arthroplasty Patients?

BackgroundThe Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly used to assess patient health. The Bundled Payment for Care Improvement (BPCI) initiative for total hip arthroplasty (THA) was introduced to decrease costs and improve clinical care. We investigated differences between BPCI and non-BPCI THA patients and their PROMIS scores, along with its feasibility and responsiveness in these populations.MethodsWe included all consecutive patients receiving unilateral primary THA who also had preoperative and one-year postoperative PROMIS physical function (PF), PROMIS pain interference (PI), and PROMIS depression (DEP) scores. Demographics and PROMIS scores were compared. Test burden was assessed using the number of questions and time required for PROMIS completion. The minimum clinically important difference was defined as 5. Floor and ceiling effects were noted if more than 15% of patients responded with the lowest or highest possible score, respectively. Wilcoxon rank-sum test was used to compare categorical data. ANOVA was used for PROMIS comparisons.Results290 hips (86 BPCI, 30%) were included. The BPCI cohort was older (P < .001) with a higher American Society of Anesthesiologists physical status classification system (P = .0045). There were significant differences in baseline scores of PF and DEP between BPCI and non-BPCI (P = .046 and P = .048, respectively). Both groups showed significant improvement at follow-up in all scores (all P < .001). Significantly more non-BPCI patients achieved minimum clinically important difference at follow-up in PI and PF (P = .047 and P = .023, respectively). Floor effects were identified for DEP at baseline and follow-up and for PI at follow-up only.ConclusionPROMIS is feasible and time-efficient in BPCI patients undergoing primary THA. There were significant differences between BPCI and non-BPCI hips.Level of EvidenceLevel III.     

Association of the Intensive Lifestyle Intervention With Total Knee Replacement in the Look AHEAD (Action for Health in Diabetes) Clinical Trial

BackgroundEvidence has established obesity as a risk factor for total knee replacement (TKR) due to osteoarthritis. Obesity is a risk factor for TKR. Randomized trials such as Look AHEAD (Action for Health in Diabetes) have shown long-term successful weight loss with an intensive lifestyle intervention (ILI). It is unknown, however, if intentional weight loss can reduce the risk of TKR.MethodsLook AHEAD randomized persons aged 45-76 with type 2 diabetes who had overweight or obesity to either an ILI to achieve/maintain 7% weight loss or to standard diabetes support and education (DSE). Reported knee pain was assessed using the Visual Analog Scale and Western Ontario McMaster University Osteoarthritis Index questionnaire in 5125 participants without previous TKR. Cox proportional hazard regression was used to model differences in risk of TKR in relation to randomization group assignment (ILI vs DSE) along with baseline body mass index category and baseline knee pain as potential confounders from baseline through Look AHEAD-Extension.ResultsBaseline mean ± SD Western Ontario McMaster University Osteoarthritis Index knee pain scores did not differ by treatment assignment (ILI: 3.6 ± 2.9, DSE: 3.9 ± 3.0, P = .08); as expected due to randomization. During follow up, the 631 (12%) participants who reported having a TKR were more likely to have been heavier (P < .001) and older (P < .001) at enrollment, but risk of TKR did not differ by treatment group assignment (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.91-1.25, P = .43). Heterogeneity of treatment effect was observed according to baseline knee pain (interaction P = .02). In persons without knee pain at baseline, there was a 29% reduced risk of TKR in ILI compared to DSE (HR 0.71, 95% CI 0.52-0.96). However, in persons with knee pain at baseline, there was no statistically significant association of treatment assignment with respect to subsequent TKR incidence (HR 1.11, 95% CI 0.92-1.33).ConclusionFindings suggest that intensive lifestyle change including physical activity, dietary restriction and behavioral changes to achieve weight loss for prevention of TKR may be most effective in preventing TKR prior to the development of knee pain.