全膝关节置换后下肢力线及假体力线与疗效和假体松动率的关系
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摘要
背景:对于全膝关节置换后最佳下肢力线的争议仍然较多,而国内对于下肢力线与临床疗效关系的研究较少。目的:分析膝骨性关节炎患者全膝关节置换后下肢力线(髋-膝-踝角)、股骨假体力线(股骨假体角)、胫骨假体力线(胫骨假体角)与临床疗效、假体松动率的关系。方法:回顾性分析2015年3月至2016年12月初次行全膝关节置换的膝关节骨性关节炎患者118例(139膝),所有患者对治疗方案均知情同意,且得到医院伦理委员会批准。摄患肢下肢全长X射线片、测量置换前后股骨胫骨机械轴夹角(髋-膝-踝角)、股骨假体远端内侧角(股骨假体角)、胫骨假体近端内侧角(胫骨假体角)。术后定期随访膝关节活动度、美国特种外科医院评分评价全膝关节置换后临床疗效。随后根据最新随访复查X射线片,采用EWALD标准查找假体松动、骨溶解、断裂的迹象。分析全膝关节置换后下肢力线(髋-膝-踝角)、股骨假体力线(股骨假体角)、胫骨假体力线(胫骨假体角)与临床疗效、假体松动率的关系。结果与结论:①118例(139膝)均获得随访,随访时间(35.8±6.2)个月,未发现假体松动、骨溶解、断裂的迹象;②对于下肢力线,中立组与内翻组、外翻组置换后美国特种外科医院评分差异有显著性意义(P<0.05),且中立组评分最高;③对于股骨假体力线,只有中立组与外翻组之间置换后美国特种外科医院评分差异有显著性意义(P <0.05),且中立组评分更高;④胫骨假体力线3组间置换后美国特种外科医院评分差异无显著性意义(P>0.05);⑤提示传统全膝关节置换后中性力线[下肢力线中立组髋-膝-踝角=(180±3)°]依然为全膝关节置换后推荐的恢复力线,应当尽量避免术后内、外翻力线。短期随访中,全膝关节置换后下肢力线及假体力线对假体松动无影响。
BACKGROUND: There is still much controversy about the lower limb alignment after total knee arthroplasty. There are few studies on the relationship between lower limb alignment and clinical outcome in Chinese patients.OBJECTIVE: To analyze the relationship of limb alignment(angle of femoral and tibial mechanical alignment), coronal alignment of the femoral component(distal medial angle of femoral prosthesis) and coronal alignment of the tibial component(proximal medial angle of tibial prosthesis) with clinical outcome and implant loosening rate after total knee arthroplasty in patients with knee osteoarthritis.METHODS: Data of 118 patients(139 knees) with knee osteoarthritis after first total knee arthroplasty from March 2015 to December 2016 were retrospectively analyzed. All patients signed the informed consent. The study was approved by the Hospital Ethics Committee. The long-leg weight-bearing radiographs were taken and the angle of femoral and tibial mechanical alignment(angle of femoral and tibial mechanical alignment), distal medial angle of femoral prosthesis(distal medial angle of femoral prosthesis), proximal medial angle of tibial prosthesis(proximal medial angle of tibial prosthesis) were measured before and after surgery. The postoperative follow-up of the knee range of motion and Hospital for Special Surgery scores were used to evaluate the clinical outcome after total knee arthroplasty. Standard radiographs were subsequently obtained at follow-up in order to look for signs of wear and or lucency using the EWALD classification. The relationship of limb alignment(angle of femoral and tibial mechanical alignment), femoral alignment(distal medial angle of femoral prosthesis), and tibial alignment(proximal medial angle of tibial prosthesis) with clinical outcome and implant loosening rate after total knee arthroplasty was analyzed.RESULTS AND CONCLUSION:(1) All the 118 patients(139 knees) were followed up for 35.8 ± 6.2 months. No complications such as osteolysis, loosening of the prosthesis and prosthesis fracture were found.(2) For the limb alignment, there were significant differences in the Hospital for Special Surgery scores between the neutral group and the varus group and the valgus group(P < 0.05), and the neutral group score was highest.(3) As for femoral component alignment, the difference of the Hospital for Special Surgery scores was statistically significant between the neutral group and the valgus group(P < 0.05), and the score in the neutral group was higher.(4) As for tibial component alignment, there were no significant differences in postoperative Hospital for Special Surgery scores among the three groups(P >0.05).(5) The traditional neutral alignment [angle of femoral and tibial mechanical alignment =(180±3)°] was still recommended for the recovery alignment after total knee arthroplasty. The residual postoperative varus and valgus alignment should be avoided as much as possible. In the short-term follow-up, the postoperative limb alignment had no effect on the loosening of the prosthesis.
BACKGROUND: There is still much controversy about the lower limb alignment after total knee arthroplasty. There are few studies on the relationship between lower limb alignment and clinical outcome in Chinese patients.OBJECTIVE: To analyze the relationship of limb alignment(angle of femoral and tibial mechanical alignment), coronal alignment of the femoral component(distal medial angle of femoral prosthesis) and coronal alignment of the tibial component(proximal medial angle of tibial prosthesis) with clinical outcome and implant loosening rate after total knee arthroplasty in patients with knee osteoarthritis.METHODS: Data of 118 patients(139 knees) with knee osteoarthritis after first total knee arthroplasty from March 2015 to December 2016 were retrospectively analyzed. All patients signed the informed consent. The study was approved by the Hospital Ethics Committee. The long-leg weight-bearing radiographs were taken and the angle of femoral and tibial mechanical alignment(angle of femoral and tibial mechanical alignment), distal medial angle of femoral prosthesis(distal medial angle of femoral prosthesis), proximal medial angle of tibial prosthesis(proximal medial angle of tibial prosthesis) were measured before and after surgery. The postoperative follow-up of the knee range of motion and Hospital for Special Surgery scores were used to evaluate the clinical outcome after total knee arthroplasty. Standard radiographs were subsequently obtained at follow-up in order to look for signs of wear and or lucency using the EWALD classification. The relationship of limb alignment(angle of femoral and tibial mechanical alignment), femoral alignment(distal medial angle of femoral prosthesis), and tibial alignment(proximal medial angle of tibial prosthesis) with clinical outcome and implant loosening rate after total knee arthroplasty was analyzed.RESULTS AND CONCLUSION:(1) All the 118 patients(139 knees) were followed up for 35.8 ± 6.2 months. No complications such as osteolysis, loosening of the prosthesis and prosthesis fracture were found.(2) For the limb alignment, there were significant differences in the Hospital for Special Surgery scores between the neutral group and the varus group and the valgus group(P < 0.05), and the neutral group score was highest.(3) As for femoral component alignment, the difference of the Hospital for Special Surgery scores was statistically significant between the neutral group and the valgus group(P < 0.05), and the score in the neutral group was higher.(4) As for tibial component alignment, there were no significant differences in postoperative Hospital for Special Surgery scores among the three groups(P >0.05).(5) The traditional neutral alignment [angle of femoral and tibial mechanical alignment =(180±3)°] was still recommended for the recovery alignment after total knee arthroplasty. The residual postoperative varus and valgus alignment should be avoided as much as possible. In the short-term follow-up, the postoperative limb alignment had no effect on the loosening of the prosthesis.
引文
[1]吕厚山.人工膝关节置换术的进展和现状[J].中华外科杂志,2004,42(1):30-33.
[2]Ritter MA,Davis KE,Meding JB,et al.The effect of alignment and bmi on failure of total knee replacement.J Bone Joint Surg Am.2011;93(17):1588-1596.
[3]Hungerford DS.Alignment in total knee replacement.Instr Course Lect.1995;44:455-68.
[4]Sharkey PF,Hozack WJ,Rothman RH,et al.Insall Award paper.Why are total knee arthroplasties failing today?Clin Orthop Relat Res.2002;404(404):7-13.
[5]Bellemans J,Colyn W,Vandenneucker H,et al.The chitranjan ranawat award:is neutral mechanical alignment normal for all patients?:the concept of constitutional varus.Clin Orthop Relat Res.2012;470(1):45.
[6]Vanlommel L,Vanlommel J,Claes S,et al.Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees.Knee Sur Sports Traumatol Arthrosc.2013;21(10):2325-2330.
[7]Ritter MA,Faris PM,Keating EM,et al.Postoperative alignment of total knee replacement.Its effect on survival.Clin Orthop Relat Res.1994;299(299):153.
[8]Parratte S,Pagnano MW,Trousdale RT,et al.Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern,cemented total knee replacements.J Bone Joint Surg Am.2010;92(12):2143.
[9]Howell SM,Kuznik K,Hull ML,et al.Results of an initial experience with custom-fit positioning total knee arthroplasty in a series of 48patients.Orthopedics.2008;31(9):857-863.
[10]Howell SM,Hodapp EE,Vernace JV,et al.Are undesirable contact kinematics minimized after kinematically aligned total knee arthroplasty?An intersurgeon analysis of consecutive patients.Knee Surg Sports Traumatol Arthrosc.2013;21(10):2281-2287.
[11]Ramadier JO,Buard JE,Lortatjacob A,et al.Radiological assessment of knee deformity in the frontal plane(author's transl).Rev Chir Orthop Reparatrice Appar Mot.1982;68(1):75-78.
[12]Ewald FC.The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system.Clin Orthop Relat Res.1989;248(248):9-12.
[13]Longstaff LM,Sloan K,Stamp N,et al.Good alignment after total knee arthroplasty leads to faster rehabilitation and better function.JArthroplasty.2009;24(4):570-578.
[14]Puliero B,Favreau H,Eichler D,et al.Total knee arthroplasty in patients with varus deformities greater than ten degrees:survival analysis at a mean ten year follow-up.Int Orthop.2019;43(2):333-341.
[15]Matziolis G,Adam J,Perka C.Varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement.Arch Orthop Trauma Surg.2010;130(12):1487-1491.
[16]Magnussen RA,Weppe F,Demey G,et al.Residual varus alignment does not compromise results of tkas in patients with preoperative varus.Clin Orthop Relat Res.2011;469(12):3443-3450.
[17]Shetty GM,Mullaji A,Bhayde S,et al.Factors contributing to inherent varus alignment of lower limb in normal Asian adults:role of tibial plateau inclination.Knee.2014;21(2):544-548.
[18]Delport H,Labey L,Innocenti B,et al.Restoration of constitutional alignment in TKA leads to more physiological strains in the collateral ligaments.Knee Surg Sports Traumatol Arthrosc.2015;23(8):2159-2169.
[19]Slevin O,Amsler F,Hirschmann MT.No correlation between coronal alignment of total knee arthroplasty and clinical outcomes:a prospective clinical study using 3D-CT.Knee Surg Sports Traumatol Arthrosc.2016;25(12):1-9.
[20]Fang DM,Ritter MA,Davis KE.Coronal alignment in total knee arthroplasty:just how important is it?J Arthroplasty.2009;24(6-supp-S):39-43.
[21]Saragaglia D,Sigwalt L,Refaie R,et al.Influence of the post-operative axis on the clinical results of total knee replacement for severe varus deformities:does a slight residual varus improve the results?Int Orthop.2018.doi:10.1007/s00264-018-4092-7.
[22]Huang TW,Lee CY,Lin SJ,et al.The influence of alignment on midterm outcome after total knee arthroplasty in patients with marked coronal femoral bowing.J Arthroplasty.2015;30(9):1531-1536.
[23]Konan S,Howell S,Oussedik S.Alignment Targets in Total Knee Arthroplasty//Total Knee Arthroplasty.2015.
[24]Saragaglia D,Sigwalt L,Gaillot J,et al.Results with eight and a half years average follow-up on two hundred and eight e-Motion FP?knee prostheses,fitted using computer navigation for knee osteoarthritis in patients with over ten degrees genu varum.Int Orthop.2018;42(4):799-804.
[25]Vandekerckhove PJ,Lanting B,Bellemans J,et al.The current role of coronal plane alignment in Total Knee Arthroplasty in a preoperative varus aligned population:an evidence based review.Acta Orthopaedica Belgica.2016;82(1):129.
[26]Abdel MP,Ollivier M,Parratte S,et al.Effect of postoperative mechanical axis alignment on survival and functional outcomes of modern total knee arthroplasties with cement.J Bone Joint Surg.2018;100(6):472-478.
[27]Kim YH,Park JW,Kim JS,et al.The relationship between the survival of total knee arthroplasty and postoperative coronal,sagittal and rotational alignment of knee prosthesis.Int Orthop.2014;38(2):379-385.
[28]Gromov K,Korchi M,Thomsen MG,et al.What is the optimal alignment of the tibial and femoral components in knee arthroplasty?Acta Orthopaedica.2014;85(5):480-487.
[29]Howell SM,Papadopoulos S,Kuznik K,et al.Does varus alignment adversely affect implant survival and function six years after kinematically aligned total knee arthroplasty?Int Orthop.2015;39(11):2117-2124.
[30]Ishikawa M,Kuriyama S,Ito H,et al.Kinematic alignment produces near-normal knee motion but increases contact stress after total knee arthroplasty:A case study on a single implant design.Knee.2015;22(3):206-212.
[2]Ritter MA,Davis KE,Meding JB,et al.The effect of alignment and bmi on failure of total knee replacement.J Bone Joint Surg Am.2011;93(17):1588-1596.
[3]Hungerford DS.Alignment in total knee replacement.Instr Course Lect.1995;44:455-68.
[4]Sharkey PF,Hozack WJ,Rothman RH,et al.Insall Award paper.Why are total knee arthroplasties failing today?Clin Orthop Relat Res.2002;404(404):7-13.
[5]Bellemans J,Colyn W,Vandenneucker H,et al.The chitranjan ranawat award:is neutral mechanical alignment normal for all patients?:the concept of constitutional varus.Clin Orthop Relat Res.2012;470(1):45.
[6]Vanlommel L,Vanlommel J,Claes S,et al.Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees.Knee Sur Sports Traumatol Arthrosc.2013;21(10):2325-2330.
[7]Ritter MA,Faris PM,Keating EM,et al.Postoperative alignment of total knee replacement.Its effect on survival.Clin Orthop Relat Res.1994;299(299):153.
[8]Parratte S,Pagnano MW,Trousdale RT,et al.Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern,cemented total knee replacements.J Bone Joint Surg Am.2010;92(12):2143.
[9]Howell SM,Kuznik K,Hull ML,et al.Results of an initial experience with custom-fit positioning total knee arthroplasty in a series of 48patients.Orthopedics.2008;31(9):857-863.
[10]Howell SM,Hodapp EE,Vernace JV,et al.Are undesirable contact kinematics minimized after kinematically aligned total knee arthroplasty?An intersurgeon analysis of consecutive patients.Knee Surg Sports Traumatol Arthrosc.2013;21(10):2281-2287.
[11]Ramadier JO,Buard JE,Lortatjacob A,et al.Radiological assessment of knee deformity in the frontal plane(author's transl).Rev Chir Orthop Reparatrice Appar Mot.1982;68(1):75-78.
[12]Ewald FC.The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system.Clin Orthop Relat Res.1989;248(248):9-12.
[13]Longstaff LM,Sloan K,Stamp N,et al.Good alignment after total knee arthroplasty leads to faster rehabilitation and better function.JArthroplasty.2009;24(4):570-578.
[14]Puliero B,Favreau H,Eichler D,et al.Total knee arthroplasty in patients with varus deformities greater than ten degrees:survival analysis at a mean ten year follow-up.Int Orthop.2019;43(2):333-341.
[15]Matziolis G,Adam J,Perka C.Varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement.Arch Orthop Trauma Surg.2010;130(12):1487-1491.
[16]Magnussen RA,Weppe F,Demey G,et al.Residual varus alignment does not compromise results of tkas in patients with preoperative varus.Clin Orthop Relat Res.2011;469(12):3443-3450.
[17]Shetty GM,Mullaji A,Bhayde S,et al.Factors contributing to inherent varus alignment of lower limb in normal Asian adults:role of tibial plateau inclination.Knee.2014;21(2):544-548.
[18]Delport H,Labey L,Innocenti B,et al.Restoration of constitutional alignment in TKA leads to more physiological strains in the collateral ligaments.Knee Surg Sports Traumatol Arthrosc.2015;23(8):2159-2169.
[19]Slevin O,Amsler F,Hirschmann MT.No correlation between coronal alignment of total knee arthroplasty and clinical outcomes:a prospective clinical study using 3D-CT.Knee Surg Sports Traumatol Arthrosc.2016;25(12):1-9.
[20]Fang DM,Ritter MA,Davis KE.Coronal alignment in total knee arthroplasty:just how important is it?J Arthroplasty.2009;24(6-supp-S):39-43.
[21]Saragaglia D,Sigwalt L,Refaie R,et al.Influence of the post-operative axis on the clinical results of total knee replacement for severe varus deformities:does a slight residual varus improve the results?Int Orthop.2018.doi:10.1007/s00264-018-4092-7.
[22]Huang TW,Lee CY,Lin SJ,et al.The influence of alignment on midterm outcome after total knee arthroplasty in patients with marked coronal femoral bowing.J Arthroplasty.2015;30(9):1531-1536.
[23]Konan S,Howell S,Oussedik S.Alignment Targets in Total Knee Arthroplasty//Total Knee Arthroplasty.2015.
[24]Saragaglia D,Sigwalt L,Gaillot J,et al.Results with eight and a half years average follow-up on two hundred and eight e-Motion FP?knee prostheses,fitted using computer navigation for knee osteoarthritis in patients with over ten degrees genu varum.Int Orthop.2018;42(4):799-804.
[25]Vandekerckhove PJ,Lanting B,Bellemans J,et al.The current role of coronal plane alignment in Total Knee Arthroplasty in a preoperative varus aligned population:an evidence based review.Acta Orthopaedica Belgica.2016;82(1):129.
[26]Abdel MP,Ollivier M,Parratte S,et al.Effect of postoperative mechanical axis alignment on survival and functional outcomes of modern total knee arthroplasties with cement.J Bone Joint Surg.2018;100(6):472-478.
[27]Kim YH,Park JW,Kim JS,et al.The relationship between the survival of total knee arthroplasty and postoperative coronal,sagittal and rotational alignment of knee prosthesis.Int Orthop.2014;38(2):379-385.
[28]Gromov K,Korchi M,Thomsen MG,et al.What is the optimal alignment of the tibial and femoral components in knee arthroplasty?Acta Orthopaedica.2014;85(5):480-487.
[29]Howell SM,Papadopoulos S,Kuznik K,et al.Does varus alignment adversely affect implant survival and function six years after kinematically aligned total knee arthroplasty?Int Orthop.2015;39(11):2117-2124.
[30]Ishikawa M,Kuriyama S,Ito H,et al.Kinematic alignment produces near-normal knee motion but increases contact stress after total knee arthroplasty:A case study on a single implant design.Knee.2015;22(3):206-212.