TKA术中上移膝关节线获得膝屈伸间隙平衡的临床应用
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摘要
目的探讨人工全膝关节置换(TKA)术中后交叉韧带切除后通过增加股骨远端截骨量上移膝关节线以获得屈伸间隙平衡的临床应用效果。方法回顾性分析自2015-01—2016-01完成的32例TKA手术,均置入后稳定型假体,术中发现后交叉韧带切除后屈曲间隙增加大于伸直间隙,通过增加股骨远端截骨、增加垫片厚度后重新达到屈伸间隙平衡。结果 32例均获得随访,随访时间29.3(24～35)个月。术后膝关节功能恢复,疼痛明显减轻,膝关节内外翻畸形得到改善。所有患者术后均获得了屈伸间隙及内外侧间隙平衡,无屈膝中期不稳。术后下肢力线为(180±3)°,膝关节线均出现不同程度上移(上移均在4 mm以内),上移距离1.2～3.6(1.9±1.0)mm。末次随访时膝关节HSS评分、KSS功能评分、Oxford评分及疼痛VAS评分、膝关节活动度均较术前明显改善,差异有统计学意义(P <0.05)。结论 TKA术中采用间隙平衡法在获得膝关节屈伸间隙及内外侧间隙平衡中优于测量截骨法,选用后稳定型假体需要切除后交叉韧带,会引起屈曲间隙增加大于伸直间隙,而术中通过增加股骨远端截骨量、增加垫片厚度上移关节线重新获得屈伸间隙平衡,可获得满意的疗效。
Objective To evaluate the clinical effectiveness of re-cutting distal femur and raising joint line position to achieve flexion and extension gap balancing after a posterior cruciate ligament resection in the total knee arthroplasty.Methods Thirty-two cases of total knee arthroplasty between January 2015 and January 2016 were retrospectively studied.The posterior stabilized prosthesis was used in all cases and the flexion gap increased more than the extension gap after the posterior cruciate ligament was resected, but a new flexion and extension gap balancing was achieved by enlarging thicker tibial polyethylene component and re-cutting more distal femur. Results All 32 patients were followed up for an average of29.3(24-35) months. The joint function was recovered, the pain was reduced and the valgus/varus deformity was corrected. A new gap balancing was achieved not only in medial and lateral side but also in the flexion and extension gap, no mid-flexion instability case was reported. The postoperative mechanical limb axis was within(180 ±3)° and the postoperative joint line position was raised up from 1.2 to 3.6(less than 4 mm), the mean was(1.9 ±1.0) mm. In the last follow-up, the knee has obvious improvement in the HSS, the KSS, oxford, VAS and the range of motion of the knee after operation( P <0.05).Conclusion The gap balancing in total knee arthroplasty is superior to the measured resection in the recovery of the gap balancing in not only medial and lateral gap but also in the flexion and extension gap. The posterior cruciate ligament is resected to use the posterior stabilized prosthesis, resulting in the flexion gap increased more than extension, but a new flexion and extension gap balancing is achieved by enlarging thicker tibial polyethylene component and re-cutting more distal femur.
Objective To evaluate the clinical effectiveness of re-cutting distal femur and raising joint line position to achieve flexion and extension gap balancing after a posterior cruciate ligament resection in the total knee arthroplasty.Methods Thirty-two cases of total knee arthroplasty between January 2015 and January 2016 were retrospectively studied.The posterior stabilized prosthesis was used in all cases and the flexion gap increased more than the extension gap after the posterior cruciate ligament was resected, but a new flexion and extension gap balancing was achieved by enlarging thicker tibial polyethylene component and re-cutting more distal femur. Results All 32 patients were followed up for an average of29.3(24-35) months. The joint function was recovered, the pain was reduced and the valgus/varus deformity was corrected. A new gap balancing was achieved not only in medial and lateral side but also in the flexion and extension gap, no mid-flexion instability case was reported. The postoperative mechanical limb axis was within(180 ±3)° and the postoperative joint line position was raised up from 1.2 to 3.6(less than 4 mm), the mean was(1.9 ±1.0) mm. In the last follow-up, the knee has obvious improvement in the HSS, the KSS, oxford, VAS and the range of motion of the knee after operation( P <0.05).Conclusion The gap balancing in total knee arthroplasty is superior to the measured resection in the recovery of the gap balancing in not only medial and lateral gap but also in the flexion and extension gap. The posterior cruciate ligament is resected to use the posterior stabilized prosthesis, resulting in the flexion gap increased more than extension, but a new flexion and extension gap balancing is achieved by enlarging thicker tibial polyethylene component and re-cutting more distal femur.
引文
[1]Moon YW,Kim HJ,Ahn HS,et al.Comparison of soft tissue balancing,femoral component rotation,and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty:a meta-analysis[J].Medicine(Baltimore),2016,95(39):e5006.
[2]Konigsberg B,Hess R,Hartman C,et al.Inter-and intraobserver reliability of two-dimensional CT scan for total knee arthroplasty com ponent malrotation[J].Clin Orthop Relat Res,2014,472(1):212-217.
[3]Springer BD,Parratte S,Abdel MP.Measured resection versus gap balancing for total knee arthroplasty[J].Clin Orthop Relat Res,2014,472(7):2016-2022.
[4]Maderbacher G,Keshmiri A,Schaumburger J,et al.Accuracy of bony landmarks for restoring the natural joint line in revision knee surgery:an MRI study[J].Int Orthop,2014,38(6):1173-1181.
[5]Kadoya Y,Kobayashi A,Komatsu T,et al.Effects of posterior cruciate ligament resection on the tibiofemoral joint gap[J].Clin Orthop Relat Res,2001,391:210-217.
[6]Schnurr C,Eysel P,Konig DP.Is the effect of a posterior cruciate ligament resection in total knee arthroplasty predictable?[J].Int Orthop,2012,36(1):83-88.
[7]Chaiyakit P,Meknavin S,Hongku N.Effects of posterior cruciate ligament resection in total knee arthroplasty using computer assisted surgery[J].J Med Assoc Thai,2009,92 Suppl 6:S80-84.
[8]Babazadeh S,Dowsey MM,Stoney JD,et al.Gap balancing sacrifices joint-line maintenance to improve gap symmetry:a randomized controlled trial comparing gap balancing and measured resection[J].J Arthroplasty,2014,29(5):950-954.
[9]Matsumoto T,Muratsu H,Kawakami Y,et al.Soft-tissue balancing in total knee arthroplasty:cruciate-retaining versus posterior-stabilised,and measured-resection versus gap technique[J].Int Orthop,2014,38(3):531-537.
[10]Griffin FM,Insall JN,Scuderi GR.Accuracy of soft tissue balancing in total knee arthroplasty[J].J Arthroplasty,2000,15(8):970-973.
[11]Daines BK,Dennis DA.Gap balancing vs.measured resection technique in total knee arthroplasty[J].Clin Orthop Surg,2014,6(1):1-8.
[12]Dennis DA,Komistek RD,Kim RH,et al.Gap balancing versus measured resection technique for total knee arthroplasty[J].Clin Orthop Relat Res,2010,468(1):102-127.
[13]符得红,戴祝.全膝关节置换术中间隙平衡技术的应用进展[J].中国骨与关节损伤杂志,2018,33(4):446-448.
[14]Castelli CC,Falvo DA,Iapicca ML,et al.Rotational alignment of the femoral component in total knee arthroplasty[J].Ann Transl Med,2016,4(1):4.
[15]Cross MB,Nam D,Plaskos C,et al.Recutting the distal femur to increase maximal knee extension during TKA causes coronal plane laxity in mid-flexion[J].Knee,2012,19(6):875-879.
[16]Kreuzer SW,Pourmoghaddam A,Leffers KJ,et al.Computed tomography analysis of postsurgery femoral component rotation based on a force sensing device method versus hypothetical rotational alignment based on anatomical landmark methods:a pilot study[J].Adv Orthop,2016,2016:4961846.
[2]Konigsberg B,Hess R,Hartman C,et al.Inter-and intraobserver reliability of two-dimensional CT scan for total knee arthroplasty com ponent malrotation[J].Clin Orthop Relat Res,2014,472(1):212-217.
[3]Springer BD,Parratte S,Abdel MP.Measured resection versus gap balancing for total knee arthroplasty[J].Clin Orthop Relat Res,2014,472(7):2016-2022.
[4]Maderbacher G,Keshmiri A,Schaumburger J,et al.Accuracy of bony landmarks for restoring the natural joint line in revision knee surgery:an MRI study[J].Int Orthop,2014,38(6):1173-1181.
[5]Kadoya Y,Kobayashi A,Komatsu T,et al.Effects of posterior cruciate ligament resection on the tibiofemoral joint gap[J].Clin Orthop Relat Res,2001,391:210-217.
[6]Schnurr C,Eysel P,Konig DP.Is the effect of a posterior cruciate ligament resection in total knee arthroplasty predictable?[J].Int Orthop,2012,36(1):83-88.
[7]Chaiyakit P,Meknavin S,Hongku N.Effects of posterior cruciate ligament resection in total knee arthroplasty using computer assisted surgery[J].J Med Assoc Thai,2009,92 Suppl 6:S80-84.
[8]Babazadeh S,Dowsey MM,Stoney JD,et al.Gap balancing sacrifices joint-line maintenance to improve gap symmetry:a randomized controlled trial comparing gap balancing and measured resection[J].J Arthroplasty,2014,29(5):950-954.
[9]Matsumoto T,Muratsu H,Kawakami Y,et al.Soft-tissue balancing in total knee arthroplasty:cruciate-retaining versus posterior-stabilised,and measured-resection versus gap technique[J].Int Orthop,2014,38(3):531-537.
[10]Griffin FM,Insall JN,Scuderi GR.Accuracy of soft tissue balancing in total knee arthroplasty[J].J Arthroplasty,2000,15(8):970-973.
[11]Daines BK,Dennis DA.Gap balancing vs.measured resection technique in total knee arthroplasty[J].Clin Orthop Surg,2014,6(1):1-8.
[12]Dennis DA,Komistek RD,Kim RH,et al.Gap balancing versus measured resection technique for total knee arthroplasty[J].Clin Orthop Relat Res,2010,468(1):102-127.
[13]符得红,戴祝.全膝关节置换术中间隙平衡技术的应用进展[J].中国骨与关节损伤杂志,2018,33(4):446-448.
[14]Castelli CC,Falvo DA,Iapicca ML,et al.Rotational alignment of the femoral component in total knee arthroplasty[J].Ann Transl Med,2016,4(1):4.
[15]Cross MB,Nam D,Plaskos C,et al.Recutting the distal femur to increase maximal knee extension during TKA causes coronal plane laxity in mid-flexion[J].Knee,2012,19(6):875-879.
[16]Kreuzer SW,Pourmoghaddam A,Leffers KJ,et al.Computed tomography analysis of postsurgery femoral component rotation based on a force sensing device method versus hypothetical rotational alignment based on anatomical landmark methods:a pilot study[J].Adv Orthop,2016,2016:4961846.