肿瘤膝关节置换术后患者下楼时的生物力学特征及临床意义
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摘要
目的:旨在通过研究肿瘤膝关节置换术后患者下楼时的生物力学特征,为患者提供下楼时安全、有效的靶向康复指导。方法:采集研究对象下楼时的三维步态数据。通过下肢运动学与动力学功能参数来综合评估其下楼梯时双下肢的生物力学特征。结果:肿瘤膝关节置换术后(实验组)下楼时健侧髋与膝关节屈伸角度峰值均大于患侧,实验组健侧、患侧下肢髋关节内收外展角度活动范围分别为-12°～7°、-5°～17°;膝骨性关节炎(knee osteoarthritis,KOA)组健侧、患侧髋关节屈伸角度范围分别为14°～30°、17°～82°; KOA组健侧、患侧膝关节屈伸角度范围分别为4°～59°、3°～102°,KOA患者健侧、患侧髋关节内收外展角度范围分别为-2°～27°、-9°～38°。对照组关节力曲线出现两个波峰。实验组患者健侧关节力波峰出现在60%步态周期时刻,患侧关节力有两个波峰; KOA组患者健侧下肢关节力较小,患侧下肢关节力个体差异较大。结论:实验组术后下楼梯时以健侧补偿为主,术后良好的镇痛与超早期肌肉力量训练、神经肌肉适应性训练、户外运动、辅助个性化矫形器和手扶栏杆、改变步态等方式能提高下楼时的安全性,提升靶向康复质量。
Objective: In order to investigate biomechanics and clinical significance after tumor-type knee arthroplasty during stair descent,and to explore the safety and effective rehabilitation strategies. Methods: The three-dimensional gaits were collected during stair descent. The biomechanical characteristics of the lower extremities during stair descent were comprehensively evaluated by the kinematic and dynamic parameters of the lower limbs. Results:The flexion-extension of the hip and knee joints of the healthy lower limb was higher in the experimental group during stair descent than that of the affected side. The range of adduction and outreach of hip joints in the healthy and affected side of the experimental group was-12° ～ 7°,-5° ～ 17°,respectively. The flexion-extension of the hip joints in the healthy and affected side of the knee osteoarthritis( KOA) group was 14° ～ 30°,17° ～ 82°,respectively. The flexion-extension of the knee joints in the healthy and affected side of the KOA group was 4° ～ 59°,3° ～ 102°,respectively. The range of adduction and outreach of hip joints in the healthy and affected side of the KOA group was-2° ～ 27°,-9° ～ 38°,respectively. Two peaks appeared in the control group force curve. In the experimental group,the peak of the joint force of the healthy side appeared at the moment of the 60% gait cycle. Two peaks appeared in the affected side of the experimental group. In the KOA group,the joint force of the healthy lower limb was smaller,and the joint forces of the affected lower limb have greater individual differences. Conclusion: The healthy side still was the mainstay during stair descent after tumor-type knee arthroplasty. Good analgesia,ultra-early muscle strength training,supporting with personalized orthotics and handrails,and changing gait in the postoperative period may increase the safety of downstairs and improve the quality of targeted rehabilitation.
Objective: In order to investigate biomechanics and clinical significance after tumor-type knee arthroplasty during stair descent,and to explore the safety and effective rehabilitation strategies. Methods: The three-dimensional gaits were collected during stair descent. The biomechanical characteristics of the lower extremities during stair descent were comprehensively evaluated by the kinematic and dynamic parameters of the lower limbs. Results:The flexion-extension of the hip and knee joints of the healthy lower limb was higher in the experimental group during stair descent than that of the affected side. The range of adduction and outreach of hip joints in the healthy and affected side of the experimental group was-12° ～ 7°,-5° ～ 17°,respectively. The flexion-extension of the hip joints in the healthy and affected side of the knee osteoarthritis( KOA) group was 14° ～ 30°,17° ～ 82°,respectively. The flexion-extension of the knee joints in the healthy and affected side of the KOA group was 4° ～ 59°,3° ～ 102°,respectively. The range of adduction and outreach of hip joints in the healthy and affected side of the KOA group was-2° ～ 27°,-9° ～ 38°,respectively. Two peaks appeared in the control group force curve. In the experimental group,the peak of the joint force of the healthy side appeared at the moment of the 60% gait cycle. Two peaks appeared in the affected side of the experimental group. In the KOA group,the joint force of the healthy lower limb was smaller,and the joint forces of the affected lower limb have greater individual differences. Conclusion: The healthy side still was the mainstay during stair descent after tumor-type knee arthroplasty. Good analgesia,ultra-early muscle strength training,supporting with personalized orthotics and handrails,and changing gait in the postoperative period may increase the safety of downstairs and improve the quality of targeted rehabilitation.
引文
[1]Lei P,Sun R,Liu H,et al.Prognosis of advanced tenosynovial giant cell tumor of the knee diagnosed during total knee arthroplasty[J].J Arthroplasty,2017,32(6):1850-1855.
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[9]Novak AC,Brouwer B.Sagittal and frontal lower limb joint moments during stair ascent and descent in young and older adults[J].Gait Posture,2011,33(1):54-60.
[10]Ren ZB,Han GG,Du XL,et al.Biomechanical analysis of the elderly during stair descent[J].Journal of Chengdu Sport University,2016,42(2):93-97.[任占兵,韩格格,杜兴兰,等.老年人下楼梯行走的生物力学分析[J].成都体育学院学报,2016,42(2):93-97.]
[11]Zhao Chang,Lin Chuangxin,Wang Wenhao,et al.Kinematics of anterior cruciate ligament-deficient knees in a Chinese population during stair ascent[J].J Orthop Surg Res,2016,11(1):89.
[12]Michael E Zabala,Julien Favre,Sean F Scanlan,et al.Three-dimensional knee moments of ACL Reconstructed and control subjects during gait,stair ascent,and stair descent[J].J Biomech,2013,46(3):515-520.
[13]Mizner RL,Petterson SC,Stevens JE,et al.Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty[J].J Rheumatol,2005,32(8):1533-1539.
[14]G Kuntze,V von Tscharner,Hutchison,et al.Ronsky alterations in lower limb multimuscle activation patterns during stair climbing in female total knee arthroplasty patients[J].J Neurophysiol,2015,114(5):2718-2725.
[15]Metcalfe AJ,Stewart CJ,Postans NJ,et al.Abnormal loading and functional deficits are present in both limbs before and after unilateral knee arthroplasty[J].Gait Posture,2017,55:109-115.
[16]Jessica W Smith,Robin L Marcus,Brian L Tracy,et al.Stance time variability during stair stepping before and after total knee arthroplasty:A pilot study[J].Hum Mov Sci,2016,45:53-62.
[17]Ava ST Storey,Ainslie M Myrah,Robyn A Bauck,et al.Indoor and outdoor mobility following total Knee arthroplasty[J].Physiother Can,2013,65(3):279-288.
[18]Bennell KL,Hunt MA,Wrigley TV,et al.Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment:A randomised controlled trial[J].Osteoarthritis Cartilage,2010,18(5):621-628.
[19]Whitchelo T,Mc Clelland JA,Webster KE.Factors associated with stair climbing ability in patients with knee osteoarthritis and knee arthroplasty:A systematic review[J].Disabil Rehabil,2014,36(13):1051-1060.
[20]Li R,Wang YZ,Yan F,et al.Customized rehabilitation for tumor-based knee prosthesis replacement[J].Practical Journal of Clinical Medicine,2015,12(6):44-47.[李蕊,王耀州,严芳,等.定制肿瘤型膝关节假体置换术后的整体康复治疗[J].实用医院临床杂志,2015,12(6):44-47.]
[21]Medina-Mirapeix F,Vivo-Fernández I,López-Caňizares J.Five times sit-to-stand test in subjects with total knee replacement:Reliability and relationship with functional mobility tests[J].Gait Posture,2018,59:258-260.
[22]Suter E,Herzog W.Does muscle inhibition after knee injury increase the risk of osteoarthritis[J]?Exercise and Sport Science Reviews,2000,28(1):15-18.
[2]Karam JA,Huang RC,Abraham JA,et al.Total joint arthroplasty in cancer patients[J].J Arthroplasty,2015,30(5):758-761.
[3]Ethgen O,Bruyere O,Richy F,et al.Health-related quality of life in total hip and total knee arthroplasty.A qualitative and systematic review of the literature[J].J Bone Joint Surg Am,2004,86-A(5):963-974.
[4]Zhu W,Ma Q,Bian Y,et al.Total hip/knee arthroplasty in the treatment of tumor-induced osteomalacia patients:More than 1year follow-up[J].PLo S One,2017,12(5):e0177835.
[5]Walsh M,Woodhouse LJ,Thomas SG,et al.Physical impairments and functional limitations:A comparison of individuals 1 year after total knee arthroplasty with control subjects[J].Phys Ther,1998,78:248-258.
[6]Jacobs JV.A review of stairway falls and stair negotiation:Lessons learned and future needs to reduce injury[J].Gait Posture,2016,49:159-167.
[7]Startzell JK,Owens DA,Mulfinger LM,et al.Stair negotiation in older people:A review[J].J Am Geriatr Soc,2000,48:567-580.
[8]Joseph A Zeni,Jr Lynn Snyder-Mackler.Preoperative predictors of persistent impairments during stair ascent and descent after total knee arthroplasty[J].J Bone Joint Surg Am,2010,92(5):1130-1136.
[9]Novak AC,Brouwer B.Sagittal and frontal lower limb joint moments during stair ascent and descent in young and older adults[J].Gait Posture,2011,33(1):54-60.
[10]Ren ZB,Han GG,Du XL,et al.Biomechanical analysis of the elderly during stair descent[J].Journal of Chengdu Sport University,2016,42(2):93-97.[任占兵,韩格格,杜兴兰,等.老年人下楼梯行走的生物力学分析[J].成都体育学院学报,2016,42(2):93-97.]
[11]Zhao Chang,Lin Chuangxin,Wang Wenhao,et al.Kinematics of anterior cruciate ligament-deficient knees in a Chinese population during stair ascent[J].J Orthop Surg Res,2016,11(1):89.
[12]Michael E Zabala,Julien Favre,Sean F Scanlan,et al.Three-dimensional knee moments of ACL Reconstructed and control subjects during gait,stair ascent,and stair descent[J].J Biomech,2013,46(3):515-520.
[13]Mizner RL,Petterson SC,Stevens JE,et al.Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty[J].J Rheumatol,2005,32(8):1533-1539.
[14]G Kuntze,V von Tscharner,Hutchison,et al.Ronsky alterations in lower limb multimuscle activation patterns during stair climbing in female total knee arthroplasty patients[J].J Neurophysiol,2015,114(5):2718-2725.
[15]Metcalfe AJ,Stewart CJ,Postans NJ,et al.Abnormal loading and functional deficits are present in both limbs before and after unilateral knee arthroplasty[J].Gait Posture,2017,55:109-115.
[16]Jessica W Smith,Robin L Marcus,Brian L Tracy,et al.Stance time variability during stair stepping before and after total knee arthroplasty:A pilot study[J].Hum Mov Sci,2016,45:53-62.
[17]Ava ST Storey,Ainslie M Myrah,Robyn A Bauck,et al.Indoor and outdoor mobility following total Knee arthroplasty[J].Physiother Can,2013,65(3):279-288.
[18]Bennell KL,Hunt MA,Wrigley TV,et al.Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment:A randomised controlled trial[J].Osteoarthritis Cartilage,2010,18(5):621-628.
[19]Whitchelo T,Mc Clelland JA,Webster KE.Factors associated with stair climbing ability in patients with knee osteoarthritis and knee arthroplasty:A systematic review[J].Disabil Rehabil,2014,36(13):1051-1060.
[20]Li R,Wang YZ,Yan F,et al.Customized rehabilitation for tumor-based knee prosthesis replacement[J].Practical Journal of Clinical Medicine,2015,12(6):44-47.[李蕊,王耀州,严芳,等.定制肿瘤型膝关节假体置换术后的整体康复治疗[J].实用医院临床杂志,2015,12(6):44-47.]
[21]Medina-Mirapeix F,Vivo-Fernández I,López-Caňizares J.Five times sit-to-stand test in subjects with total knee replacement:Reliability and relationship with functional mobility tests[J].Gait Posture,2018,59:258-260.
[22]Suter E,Herzog W.Does muscle inhibition after knee injury increase the risk of osteoarthritis[J]?Exercise and Sport Science Reviews,2000,28(1):15-18.