股神经阻滞下手法松解术治疗全膝关节置换术后僵硬

目的探讨股神经神经阻滞镇痛下手法松解术治疗全膝关节置换术后僵硬的临床疗效。 方法自2013年1月至2017年12月,山东大学齐鲁医院(青岛)关节外科32例全膝关节置换术后僵硬的患者纳入本研究。在B超引导下连续股神经阻滞镇痛后行手法松解术,松解完毕后患者行主被动功能康复锻炼。记录术前及术后膝关节的屈曲度、美国膝关节学会评分(KSS)及功能锻炼时的视觉模拟评分法(VAS)评分。所得计量资料采用配对t检验。 结果32例患者平均随访(20.4±3.1)周。松解前膝关节主动屈曲度平均(70.0±10. 8)°,松解后末次随访主动屈曲度平均(106.4±7.9)°,平均改善(36.9±7.5)°(t＝-28.5,P<0.05)。松解前KSS评分平均(78.3±2.3)分,松解后末次随访KSS评分平均(88.3±2.7)分,差异具有统计学意义(t＝-27.1,P<0.05)。功能锻炼时VAS评分平均(4.5±1.1)分,为中度疼痛。随访无假体周围骨折、伸膝装置损伤、异位骨化等并发症。 结论股神经神经阻滞镇痛下手法松解术能有效改善全膝关节置换术后僵硬,缓解患者功能锻炼时的疼痛,具有良好的临床效果和较低的并发症。     

个体化导板辅助全膝关节置换运动学对线技术

大部分自然人群膝关节存在不同程度的生理内翻或外翻,而目前广泛应用的全膝关节置换机械学对线技术并没有充分尊重这种生理变异,而把下肢中立位对线作为对线目标。有学者认为这可能与膝关节置换较低的术后满意率相关。在此背景下出现了一种更为尊重自然膝关节解剖形态的对线方式——运动学对线,由于该方法可能有助于减少术中软组织松解,改善膝关节术后功能并提高病人的满意率,所以近年来受到广泛关注。作者医院是国内最早使用个体化截骨导板进行运动学对线膝关节置换的单位之一。本文总结了该技术的术前规划、手术技巧和陷阱、相关理论以及临床和实验室证据等方面内容,以帮助读者全面理解运动学对线技术。     

腓骨近端截骨术治疗内侧间室膝骨关节炎的短期效果

目的观察分析腓骨近端截骨术与人工全膝关节置换术治疗内侧间室膝骨关节炎的短期效果差异。 方法回顾2018年1月至2019年12月间于赤峰宝山中医医院骨科接受腓骨近端截骨术(PFO)和人工全膝关节置换术(TKA)治疗的患者,符合内侧间室膝骨关节炎的诊断且Kellgren-Lawrence分级为Ⅲ、Ⅳ级,排除膝关节内畸形及其他影响关节功能的疾病,排除严重内科疾病及外翻畸形,临床资料完整者。其中接受PFO共55例,纳入观察组,同期接受TKA的55例纳入对照组,统计两组的手术时间、切口长度、术中出血量、住院时间、住院费用,采用t检验进行比较;统计术前及术后3个月的疼痛视觉模拟评分(VAS评分)、美国特种外科医院膝关节评分(HSS评分)、西安大略和麦克马斯特大学膝关节炎评分(WOMAC评分)、生活质量问卷评分(SF-36评分),组内及组间比较采用t检验。 结果观察组手术时间、切口长度、术中出血量、住院时间、住院费用均明显低于对照组,差异具有统计学意义(t＝8.712、9.251、9.435、8.987、9.296,均为P<0.01);两组患者术后3个月的VAS、HSS、WOMAC、SF-36评分较术前明显改善,差异具有统计学意义(观察组：t＝7.692、7.802、8.453、7.622,均为P<0.01;对照组：t＝7.639、7.787、8.441、7.619,均为P<0.01),各评分组间比较差异均无统计学意义(t＝0.258、0.401、0.250、0.542,均为P>0.05)。 结论腓骨近端截骨术与人工全膝关节置换术治疗内侧间室膝骨关节炎,均可获得较好的早期效果;前者手术简单、创伤小、费用低,临床中可以选择性使用。     

社区医疗中运动疗法治疗膝骨关节炎的疗效分析

目的评价运动疗法治疗膝骨关节炎患者的疗效。 方法北京市东城区第一人民医院从2019年1月至10月纳入76例膝骨关节炎患者(114膝),进行为期6周的运动疗法,训练地点为社区居委会或社区养老驿站。该研究纳入标准为确诊为膝关节骨关节炎且可配合完成6周运动疗法课程的患者;排除标准为膝关节屈伸肌肌力2级及以下或存在炎症性膝关节炎或重要脏器功能衰竭者。分别于治疗开始前、6周和12周后对患者进行疗效评定,评定内容包括膝关节主动活动度(AROM)、40 m步行试验、30 s椅子坐起试验;并利用量表对膝关节功能(HSS)、欧洲5维健康量表(EQ-5D)评分、疼痛视觉模拟评分(VAS)进行评价,使用单因素重复测量方差分析比较基线与6周、12周随访的结果变化,组间比较则采用Bonferroni检验。此外在治疗结束时询问患者对治疗课程的满意度,并使用秩和检验进行统计学分析。 结果在76例患者中,71例患者(109膝)完成了12周随访。109膝不同时点膝关节AROM(F＝137.55,P<0.001)、HSS评分(F＝108.81,P<0.001)及VAS评分(F＝179.72,P<0.001)治疗后均比治疗前有改善;71例患者不同时点的EQ-5D生活质量评分(F＝99.53,P<0.001)、40 m步行试验(F＝199.54,P<0.001)、30 s椅子坐起试验(F＝170.62,P<0.001)治疗后均比治疗前有改善,差异有统计学意义。患者总体满意率达100%,K/L分级为Ⅰ、Ⅱ级患者与Ⅲ、Ⅳ级患者相比,对该项目的满意度更高(U＝401.5,P＝0.044)。 结论运动疗法可缓解膝关节疼痛,改善膝关节功能,提高患者的生活质量,且在社区训练中取得良好效果,利于在社区的推广普及。     

生物型与水泥型单髁置换术治疗膝关节病的Meta分析

目的比较生物型与水泥型人工膝关节单髁置换术治疗内侧间室膝骨关节病的临床疗效。 方法检索Pubmed、荷兰医学文摘数据库(Embase)、循证医学数据库(Cochrane Library)、Web of science、中国期刊全文数据库(CNKI)和万方数据库2000年1月至2019年10月所有关于生物型与水泥型人工膝关节单髁置换术治疗内侧间室膝关节病的临床随机对照研究(RCT)和非随机对照研究(CCT)。排除重复文献,低质量文献,观察指标不符文献以及无法获得全文的文献。采用Cochrane风险评估工具及纽卡斯尔-渥太华量表(NOS)对纳入研究的文献进行质量评价。使用Revman 5.3进行Meta分析,比较两种固定方式在假体周围透亮线,5年假体生存率,牛津大学膝关节评分(OKS),并发症,手术时间等方面的差异。 结果共纳入文献9篇,累计病例18 702例,其中生物组8 735例,水泥组9 967例。Meta分析结果显示：生物型单髁组与水泥型单髁组比较,生物型单髁组假体周围完全透亮线的发生率更低[比值比(OR)＝0.08,95%置信区间(CI)(0.01,0.42),P＝0.003],膝关节OKS功能评分更高[均数差(MD)＝2.08,95%CI(0.51,3.65),P＝0.009],5年假体生存率更高[OR＝1.39,95% CI(1.20,1.60),P<0.0001],手术时间更短[MD＝-9.23,95% CI(-13.72,-4.74),P<0.0001],在并发症的发生率方面,两组间差异无统计学意义[OR＝0.43,95% CI(0.17,1.09),P＝0.07]。 结论与水泥型单髁相比,生物型单髁可以降低假体周围完全透亮线的发生率,提高膝关节功能及5年假体生存率,缩短手术时间,且不会增加并发症的发生,在临床值得推广应用。     

The use of polyvinyl alcohol hydrogel implants in the lesser metatarsal heads. Is it safely doable? A cadaveric study

BackgroundThe use of synthetic polyvinyl alcohol hydrogel (PVAH) implants for treatment of lesser toe metatarsophalangeal joint (MTPJ) arthritis is promising and currently limited by the size of implants available. The primary objective of this cadaveric study was to investigate the maximum drilling size and largest PVAH implant dimension that could be safely introduced while still preserving an intact bone rim of the lesser metatarsal heads.MethodsHeight and width of all lesser metatarsals were measured on CT and during anatomic dissection. Sequential reaming of the second to fourth metatarsals was performed. Maximum reaming size, largest implant inserted, and failure of the metatarsal head were recorded. Metatarsal head sizes were compared and a multiple regression analysis evaluated measurements that influenced maximum drilling and implant size.ResultsCT and anatomical measurements demonstrated significant correlation (ICC range, 0.–0.85). Mean values for height and width of the metatarsal heads were respectively: second (14.9 mm and 9.9 mm), third (14.8 mm and 8.8 mm), fourth (14.0 mm and 8.7 mm) and fifth (12.3 mm and 9.3 mm). All the second, third and fourth metatarsal heads could be safely drilled up to 7.5 mm, preserving an intact bone rim. At 80% of the time, the heads could be safely drilled up to 8.0 mm. Height of the metatarsal heads was the only factor to significantly influence the size of maximum reaming and implant introduced. In respectively 20%, 40% and 50% of the second, third, and fourth metatarsal heads, neither 8 mm nor 10 mm PVAH implants could be used.ConclusionsOur cadaveric study found that the even though the majority of the lesser metatarsal heads could be safely drilled up to 8 mm, the smallest PVAH implant size currently available in most countries (8 mm) could be inserted in most of the second, but only in about half of the third and fourth metatarsal heads. The remaining bone rim around inserted implants was considerably thin, usually measuring less than 1 mm. In order to optimize the use PVAH in lesser metatarsal heads, smaller implant options are needed.     

Flexibility does not affect the dorsiflexion of foot and the popliteal angle in young adults

BackgroundThe aim of the study was to assess how flexibility affects the dorsiflexion of foot and the popliteal angle test results in junior high school students.MethodsThe subjects were 142 students from the 2nd, and 3rd year of Poznań junior high schools (age between 13 and 15).Each subject was examined 6 times: there were 3 raters, a specialist in orthopaedics, a resident doctor and a physical therapy student, and each of them performed 2 measurements. Flexibility was also measured using the Beighton scale (score from 0 to 9).ResultsSince the Beighton scale is ordinal in order to evaluate the relationship between flexibility and the range of motion Spearman's rank correlation coefficient was calculated. The statistical analysis showed no correlation between flexibility measured on the Beighton scale and the range of passive foot dorsiflexion and the popliteal angle.ConclusionsThe degree of flexibility does not affect the dorsiflexion of the foot and the popliteal angle in junior high students. At this age the range of dorsiflexion is determined by the length of the triceps surae muscle while the popliteal angle depends on the length of the muscles on the back of the thigh.