全膝关节置换术行股骨远端髓外与髓内定位截骨的影像学评估

目的比较全膝关节置换术行股骨远端髓外定位与髓内定位截骨术后X线影像学评估。方法回顾性分析大理大学第一附属医院关节外科收治的12例行双侧人工全膝关节置换术的患者病例资料。膝骨关节炎并其手术由同一组医生完成的患者纳入本研究,膝关节重度内、外翻和重度屈曲畸形,膝关节外畸形患者均未纳入研究。每位患者一侧用股骨远端髓内定位截骨,另一侧用股骨远端髓外定位截骨,按定位方式将其分为:髓内定位组与髓外定位组。术后,利用X线影像上测量的髋-膝-踝角(HKA),股骨力线角、股骨屈曲角作为评价依据,比较两种方法的术后结果,用配对t检验作数据的统计分析。结果髓外定位组与髓内定位组在术后影像学评估中的HKA角(179.5±0.8)°vs(179.0±1.2)°(t=-0.995),股骨力线角(89.5±0.8)°vs(89.0±1.2)°(t=-0.980),股骨屈曲角(3.2±0.7)°vs(2.8±0.8)°(t=-2.019),差异均无统计学意义(P0.05)。结论利用股骨远端髓外定位截骨与股骨远端髓内定位截骨行全膝关节置换术,术后测量其HKA角、股骨力线角、股骨屈曲角的X线影像学评估无显著差异。     

股骨髁前后径与内外径比值对膝关节置换的影响

[目的]测量股骨髁的前后径、内外径,分析两者的比值对全膝关节置换的影响。[方法]选取2015年10月～2017年12月行全膝关节置换的170例患者,手术前利用X线片在膝关节上对股骨髁的前后径、内外径进行测量,算出两者比值,对比假体数据,将比值>0.9的60例患者分为两组,对照组:采取髓内长定位杆截骨;研究组:采取髓内短定位杆截骨,均为30例,对两组临床效果进行比较。[结果]两组患者术后均未出现感染、假体周围骨折及假体松动;两组患者术后KSS评分、伸直角度和伸膝障碍所占比例差异均无统计学意义(P>0.05);两组膝关节屈曲角度、股骨假体屈曲角度和股骨前端切迹差异均有统计学意义(P<0.05)。[结论]针对股骨髁前后径、内外径比值较大者,采取髓内短定位杆截骨能够维持伸屈稳定,降低截骨切迹和假体周边骨折发生概率,临床应用效果良好。     

股骨髓内定位通道嵌压植骨减少全膝置换术后出血的前瞻性研究

[目的]探讨股骨髓内定位通道采用截骨块嵌压植骨减少全膝置换术后出血的临床效果。[方法]采用前瞻性研究方法,对2009年1月~2015年5月在本院接受单侧初次膝关节置换的60例膝关节骨性关节炎患者,随机分成两组,30例术中股骨侧髓腔定位通道用截骨块植入封闭(植骨组),另30例髓腔通道不做处理(对照组)。随访6~68个月,平均32个月。观察指标包括手术时间、术中出血量、术后引流量、手术后并发症,末次随访时采用HSS评分评价患膝功能。[结果]植骨组的术后引流量明显比对照组减少,两组比较差异具有统计学意义。两组患者的手术时间、术中出血量和末次随访时患膝HSS评分差异无统计学意义。对照组有6例患者术后两个月患膝关节内反复出现血性积液。[结论]股骨髓内定位通道采用截骨块嵌压植骨能够有效减少全膝置换术后失血量,并能取得较好的临床效果,值得临床推广应用。     

全膝关节置换术中测量截骨与间隙平衡技术对股骨外旋截骨参数及膝关节功能的影响

目的探讨全膝关节置换术中股骨外旋截骨时测量截骨技术与间隙平衡技术对截骨参数及膝关节功能的影响。方法纳入自2014-01—2016-12行全膝关节置换术治疗的64例膝关节骨性关节炎,34例术中采用间隙平衡技术进行股骨截骨(间隙平衡组),30例术中进行股骨测量截骨(测量截骨组)。比较2组手术时间、截骨参数(股骨假体旋转角、截骨板相对后髁线旋转角、膝关节内翻角、股骨后内髁截骨量、股骨后外髁截骨量),以及术后膝关节功能KSS评分、WOMAC评分、疼痛VAS评分。结果 64例均获得随访,随访时间36~60(40.8±4.7)个月。与测量截骨组比较,间隙平衡组手术时间较短,股骨后内髁截骨量更大,股骨假体旋转角更小,截骨板相对后髁线旋转角更大,术后1个月膝关节功能KSS评分更高,差异有统计学意义(P0.05)。间隙平衡组与测量截骨组术后6个月、1年、3年膝关节功能KSS评分差异无统计学意义(P0.05)。间隙平衡组与测量截骨组膝关节内翻角、股骨后外髁截骨量、术后MOMAC评分及疼痛VAS评分差异无统计学意义(P0.05)。结论全膝关节置换术中股骨外旋截骨时采用间隙平衡技术的截骨量比测量截骨技术的截骨量更大,但手术时间缩短,术后短期内膝关节功能恢复效果更好。     

胫骨内侧高位截骨术与单髁置换术治疗膝关节内侧间室骨性关节炎的比较

目的比较胫骨内侧高位截骨术与单髁置换术治疗单纯膝关节内侧间室骨性关节炎的临床疗效,为临床选择恰当的治疗方法提供参考。方法回顾性分析自2015-01—2019-10诊治的47例单纯膝关节内侧间室骨性关节炎,其中22例采用胫骨内侧高位截骨术治疗(截骨组),25例采用单髁置换术治疗(置换组)。结果 47例均获得随访,随访时间平均11.2(11～15)个月。截骨组术后1例膝关节疼痛缓解不明显,1例膝内翻复发,行全膝关节置换术。置换组术后1例屈膝时髌骨弹响,末次随访时弹响消失;1例对侧间室不明原因疼痛,1年后行全膝关节置换术。截骨组与置换组手术时间、术中出血量、末次随访时股胫角差异无统计学意义(P0.05);置换组术后住院时间、术后至下床负重时间较截骨组短,术后2周疼痛VAS评分较截骨组低,末次随访时膝关节活动度较截骨组大,差异有统计学意义(P0.05)。置换组与截骨组术后3个月、末次随访时疼痛VAS评分差异无统计学意义(P0.05)。结论胫骨内侧高位截骨术与单髁置换术治疗单纯膝关节内侧单间室骨性关节炎各具有优缺点,临床医师应根据患者膝关节退行性改变程度、类型、患者年龄以及患者对术后运动功能的期望值等因素进行综合考虑,制定个性化的治疗方案。     

我国川南人群胫骨干骺角与胫骨后倾角的测量及临床应用

目的研究我国川南人群胫骨干骺角与胫骨后倾角的相关性,为全膝关节置换术中行合理的胫骨截骨提供参考。方法 1在106例无膝关节疼痛、畸形和膝部手术史的成人膝关节侧位X线片上,分为10~29岁组、30~49岁组、50~69岁组、70岁以上组测量胫骨干骺角及胫骨后倾角,并以此数据为依据分析两者是否存在相关性。2对28例30~49岁年龄段的患者行全膝关节置换术,其中16例采用髓内定位进行胫骨截骨(A组),12例采用髓外定位进行胫骨截骨(B组),记录术前、术后2周的膝关节活动度,测量术前、术后的胫骨后倾角。结果 1 30~49岁组的胫骨干骺角与胫骨后倾角存在中度直线正相关关系。2 28例手术患者均获得随访,时间12~18个月,A组术后胫骨后倾角和术后2周膝关节活动度均优于B组,差异有统计学意义(P0.05)。结论 1确立我国川南人群中30~49岁组的胫骨干骺角与胫骨后倾角呈正相关关系。2在30~49岁人群中行全膝关节置换术时采用髓内定位法行胫骨截骨,可恢复患者胫骨平台的生理后倾角度,获得满意的关节活动度。     

自制组配式截骨工具行微创膝关节置换术的早期随访结果

目的评价自制组配式截骨工具行微创全膝关节置换术的临床及早期随访效果。 方法对95例中山大学附属第一医院关节外科行全膝关节置换的重度膝关节骨关节炎的患者随机分组,分别使用自制组配式截骨工具行微创全膝关节置换术或常规全膝关节置换术。对患者术前、术后的膝关节评分法(KSS)、视觉模拟评分法(VAS)、X线影像学(下肢力线、股骨角、胫骨角和胫骨平台后倾角)进行随访对比研究,微创组和传统组之间的差异采用独立样本t检验进行比较。 结果成功随访2年以上的手术患者87例,其中微创组42例,传统组45例。微创组手术时间比传统组长(t＝9.275,P<0.05),但两组在术中出血量、输血量、引流量的比较无统计学差异(P>0.05)。两组患者均未出现皮肤坏死,深部感染和神经血管损伤的并发症。下肢力线、股骨角、胫骨角和胫骨平台后倾角比较无统计学差异(P>0.05)。术后2周内,KSS评分、VAS评分微创组要优于传统组(t＝1.518,P<0.05)(除外术后第2周KSS临床评分),但术后3月后两组比较无统计学差异(P>0.05)。 结论自制组配式截骨工具行微创全膝关节置换手术早期的临床效果要优于常规人工全膝关节置换术,两组的影像学结果相当,但尚需更长时间的随访以全面评价其临床疗效。     

胫骨后倾角在膝关节置换术后的改变及意义

[目的]对因骨性关节炎行全膝关节置换术(total knee arthroplasty,TKA)术后膝关节功能恢复优良的患者,测量评价术前、术后胫骨(假体)平台后倾角(PSA),为TKA中胫骨平台截骨提供参考数据.[方法]采用回顾性研究,对本院2007年1月～2009年3月因骨性关节炎行TKA治疗的30膝24例术后HSS评分70分以上的患者,收集术前、术后X线侧位片的医学数字影像通信标准DICOM格式的相片,测量髓内、髓外胫骨(假体)平台后倾角.[结果]髓内参照法,术前胫骨内、外侧平台及术后假体后倾角分别为13.1°±3.3°,9.8°±3.5°,5.1°±2.3°,三者两两之间均有显著性差异(P<0.05).髓内、髓外参照法之间也有显著性差异(P<0.05).髓内参照法,术后假体后倾角和5°后倾截骨标准无显著性差异(P>0.05).[结论]术前、术后胫骨平台后倾角不同,术中胫骨截骨应符合髓内参照法5°或髓外参照法8°后倾截骨标准,以恢复包括关节软骨、半月板在内的后倾角度,获得更好的术后功能.     

滑移截骨在严重膝外翻人工膝关节置换中的应用

目的 总结人工全膝关节表面置换术中滑移截骨在软组织平衡中应用的手术方法和经验.方法 对7例(8膝)严重膝外翻行全膝关节表面置换,术中均通过股骨髁的滑移截骨达到膝关节周嗣的软组织平衡.结果 所有病例均得到随访.采用HSS膝关节评分标准:优5例(6膝),良1例,可1例.术后膝关节力线正常,均无残留外翻畸形.结论 膝关节表面置换术软组织平衡的处理中,股骨髁滑移截骨具有操作简单易行、损伤小、手术效果好、疗效满意等优点,是可行的办法.     

髓外定位与关节内代偿截骨在膝内翻合并股骨畸形TKA术中的应用

正临床上股骨畸形很常见,部分膝内翻患者同时存在股骨畸形,术前对股骨干或股骨髁畸形认识不足可能导致人工全膝关节置换术(TKA)操作失误。笔者于2012-09及2015-06对2例(3膝)膝内翻合并股骨畸形行TKA,术中采用髓外定位及关节内代偿截骨,术后下肢力线正常,报道如下。1病例报道例1,女,60岁。因双膝内翻疼痛加重2年入院治疗,40年前曾因双膝内翻行双侧胫骨截骨矫形术。摄     

踝间线足背动脉在全膝关节置换术髓外定位中的临床应用

目的探讨踝关节力学中心体表标志点,为全膝关节置换术(TKA)下肢力线的准确定位提供依据。方法对64例膝骨关节炎(OA)终末期患者实施初次TKA治疗,股骨侧采用髓内定位,胫骨侧采用髓外定位,实验组(34例)踝关节力学中心位于踝间线足背动脉处,对照组(30例)定位则按传统方法进行。术后测量患者胫骨假体胫骨角及后倾角。结果患者均获得随访,时间4~6年。胫骨假体胫骨角平均度数:实验组为(2.1±0.2)°,对照组为(2.6±0.1)°,差异有统计学意义(P0.05);胫骨假体后倾角:实验组为(3.1±0.2)°,对照组为(3.3±0.1)°,差异无统计学意义(P0.05)。实验组胫骨假体力线优于对照组。结论踝间线足背动脉定位可靠,其标示简单易行,能提高胫骨假体力线的精确度,不失为TKA术中踝关节力学中心定位的理想参考。     

TKA after clamshell osteotomy for femoral diaphyseal malunion

Proper component positioning is essential for successful total knee arthroplasty (TKA). Femoral component positioning presents a technical challenge when significant femoral deformity is present. Most commonly, an intramedullary guide is used to make an accurate distal femoral cut. However, in the presence of a significant femoral deformity, this is not a viable option.The use of clamshell osteotomy to restore anatomic alignment in patients with complex femoral diaphyseal deformity is described in the literature. This article describes a case of a patient who underwent staged TKA after clamshell osteotomy and retrograde femoral nailing to correct femoral diaphyseal malunion. The retrograde intramedullary nail was retained and used as an intramedullary guide, allowing for TKA in a routine manner. Using an intramedullary nail as an alignment guide may be more accurate than using extramedullary alignment and may avoid the increased surgical time and potential pin-site stress risers of navigation. It is a simple, effective way to treat complicated diaphyseal femoral deformities in the face of posttraumatic knee arthritis. Further study of this technique with longer follow-up and multiple surgeons is necessary to validate this treatment algorithm.     

Extramedullary versus intramedullary tibial alignment guides for total knee arthroplasty

This retrospective study evaluated whether intramedullary or extramedullary tibial alignment guides are more accurate in assuring correct tibial component positioning in total knee arthroplasties (TKAs). Fifty-five TKAs were performed with the only difference being whether an intramedullary (31) or extramedullary (24) cutting guide was used. Pre- and postoperative tibiofemoral angle, tibial component alignment angle, and femoral component alignment angles were measured and the results were statistically analyzed. We also performed a subgroup analysis on the preoperative varus knees to determine if the presence of a varus deformity would have better results with either the intramedullary or extramedullary cutting guide. The 2-sample t test was used to compare the results of the two groups. The results showed no statistical difference in alignment of the tibial component when using the intramedullary or extramedullary guides.     

Extramedullary versus intramedullary tibial cutting guides in megaprosthetic total knee replacement

Background

In a standard total knee replacement, tibial component alignment is a key factor for the long term success of the surgery. The purpose of this study is to compare the accuracy of extramedullary and intramedullary tibial cutting guides used in indigenous and imported implants respectively, in positioning of the tibial components in megaprosthetic knee replacements.

Methods

A comparative study of the accuracy of extramedullary and intramedullary tibial cutting guides was carried out in 92 megaprosthetic knee replacements for distal femoral tumors. For the proximal tibia cut for tibial component placement, an extramedullary guide was used in 65 patients and an intramedullary guide was used in 27 patients. Tibial component alignment angles were measured in postoperative X-rays with the help of CAD software.

Results

There was more varus placement in coronal plane with extramedullary cutting guide (?1.18 +/? 2.4 degrees) than the intramedullary guide (?0.34 +/? 2.31 degrees) but this did not reach statistical significance. The goal of 90 +/? 2 degrees alignment of tibial component was achieved in 54% of patients in the extramedullary group versus 67% in the intramedullary group. In terms of sagittal plane alignment, extramedullary guide showed less accurate results (2.09 +/? 2.4 degrees) than intramedullary guide (0.50 +/? 3.80 degrees) for tibial component alignment, though 78% of patients were aligned within the goal of 0–5 degrees of tibial slope angle in extramedullary group versus 63% in intramedullary group. The mean error in the measurements due to rotation of the knee during taking the X-rays was less than 0.1 degrees and distribution of the X-rays with the rotation of knee was similar in both the groups.

Conclusions

Overall, in megaprosthetic knee replacement intramedullary guides gave more accurate results in sagittal plane and exhibited similar variability as of extramedullary guides in coronal plane.     

Influence of intramedullary versus extramedullary alignment guides on final total knee arthroplasty component position: A radiographic analysis

A prospective study of 116 consecutive Kinemax cemented posterior cruciate ligament-retaining total knee arthroplasties was carried out. Similar surgical technique was used with a single variable: 61 were implanted using intramedullary guides on the tibia and 55 were implanted using extramedullary guides on the tibia. A radiographic study was performed after at least 1 year of follow-up to evaluate postoperative component position and compare the difference in the accuracy of positioning of the femoral and tibial components. Radiographic analysis showed that satisfactory position was achieved using both types of instrumentation. No statistically significant difference was observed in either the coronal or sagittal plane of the femoral component and the sagittal plane positioning of the tibial component. However, the coronal plane positioning of the tibial component revealed a statistically significant difference (P <.01), with intramedullary guides being superior to extramedullary guides. Also observed, was that using either technique, patients with less accurate postoperative positioning tended to be obese, with wide intramedullary canals. Patients with significant extraarticular deformities, marked bowing, and those with prior surgery or fractures may not be suitable for intramedullary guides, and they may require the use of extramedullary guides and intraoperative radiographic control. The ideal indication for the use of intramedullary instrumentation is in the patient who is not obese, with no extraarticular deformity, and with a well-defined, but not excessively wide, tibial medullary canal. Since tibial component malalignment in general, and coronal plane malalignment in particular, may adversely affect the long-term survival of total knee arthroplasties, the use of intramedullary alignment instrumentation is recommended when possible.     

同期和分期全膝关节置换术治疗双侧膝骨关节炎的比较

目的 探讨和比较同期全膝关节置换术和分期全膝关节置换术分别治疗双侧膝骨关节炎的安全性、经济性和成效性.方法 选取2011年5月至2015年5月于我院接受双侧膝关节初次置换手术的108例双侧膝骨关节炎病人,根据手术方案的不同分为两组:同期全膝关节置换术治疗病人46例(同期组),分期全膝关节置换术治疗病人62例(分期组).收集反应两组病人安全性、经济性和成效性的相关指标进行对比分析.结果 同期组病人和分期组病人在术后病死率、二次手术率、术后30 d再次入院率、并发症发生率等显性安全风险指标比较,差异均无统计学意义(均P>0.05);同期组病人术后血红蛋白含量、白蛋白水平、总住院时间均低于分期组,而出血量、引流量、术后输血量等指标高于分期组,差异均有统计学意义(均P<0.05).同期组病人的平均住院费用(不含假体费用)低于分期组,差异有统计学意义(P<0.05).同期组和分期组在术后3个月、1年的膝关节功能用美国特种外科医院(Hospital for Special Surgery,HSS)膝关节功能评定标准评分、膝关节活动度、屈曲挛缩度、疼痛视觉模拟量表(visual analogue scale,VAS)评分等方面比较,差异均无统计学意义(均P>0.05).结论 对于初次行双侧全膝关节置换的膝骨关节炎病人,在严格的围手术期管理和谨慎评估下,同期双侧置换与分期置换在手术的安全性和成效性上并无显著性差异,但在经济性上前者显著优于后者.     

Extramedullary femoral alignment instrumentation reduces blood loss after uncemented total knee arthroplasty

The influence of different femoral alignment systems on blood loss and the need for blood transfusion after total knee arthroplasty (TKA) was studied. The blood loss was retrospectively recorded in two similar groups of consecutive patients. The first group consisted of 46 patients in whom TKA was performed using the intramedullary femoral alignment system and the second group consisted of 45 patients in whom the procedure was performed with the extramedullary system. In the intramedullary group, the mean volume of drained blood was 758 mL, whereas in the extramedullary group it was 613 mL (P < .05). More patients in the intramedullary. group required blood transfusions, but no significant difference was noted in the number of blood units transfused per patient. Extramedullary femoral alignment instrumentation reduces blood loss after cementless TKA.     

股骨近端防旋髓内钉微创治疗老年股骨粗隆间骨折的疗效观察

[目的]探讨股骨近端防旋髓内钉(PFNA)微创治疗老年股骨粗隆间骨折的近期临床疗效。[方法]分析92例老年股骨粗隆间骨折患者的临床资料,根据不同手术方法分为动力髋螺钉组(DHS组)、股骨近端防旋髓内钉组(PFNA组),分别行动力髋螺钉固定术和股骨近端防旋髓内钉固定术,比较两种手术方法的近期临床疗效及术后并发症的发生情况。同时以成人尸体标本为测试对象,对两种手术后的尸体标本进行生物力学测试并作比较。[结果]92例均获得9～24个月的随访,平均15个月。PFNA组术后并发症发生率比DHS组低,有统计学意义(P<0.05)。PFNA组手术时间、出血量、愈合时间比DHS组低,有统计学意义(P<0.05)。DHS组和PFNA组优良率分别为84.1%、85.5%,组间疗效差异无统计学意义(P>0.05)。[结论]闭合复位小切口股骨近端防旋髓内钉(PFNA)微创治疗老年股骨粗隆间骨折近期疗效与DHS相当,但术后并发症发生率明显低于DHS。