摘要
目的:对膝关节单髁置换术早中期疗效进行评估,并探讨其手术适应症、禁忌症及手术要点。方法:回访2004年5月至2008年10月期间在我院骨科行膝关节单髁置换术的55例患者(65膝)。结果7例失访、1例死亡,回访率86.2%(56膝)。其中男性8例(10膝),女性39例(46膝);患者平均年龄63.9岁(47～79岁),其中47～60岁11例(14膝),60～79岁36例(42膝);平均体重67.4kg(40-90kg),其中40～80kg 41例(49膝),81～90kg 6例(7膝);回访患者术前均诊断为退行性骨关节炎;内侧间室置换52膝,外侧间室置换4膝;双膝置换的9例(18膝):采用牛津活动衬垫型假体(oxford)7膝,捷迈解剖型假体(zimmer)49膝。术后平均随访27.7个月(5～30个月)。分别测量患者膝关节术前及术后的最大屈曲度和胫股角(FTA),对患者膝关节行KSS评分。并对患者膝关节术前及术后最大屈曲度和KSS评分及术前术后影像学表现进行评估。结果:随访的47例(56膝)患者,KSS临床评分由术前平均40.3分提高至术后平均95.4分,KSS功能评分由术前50.4分提高至术后平均94.1分。KSS评分包括临床和功能评分在统计学上均具有显著性差异(两者P值均小于0.05)。膝关节最大屈曲度术前平均为102.2°,术后为129.4°。统计学分析显示最近一次随访和术前关节最大屈曲度有显著性差异(P＜0.05)。膝关节内侧单髁置换术后患者股胫角平均为175.7°,外侧术后平均为172.8°。X线检查显示假体位置良好、无松动、无假体周围骨溶解及其他各个间室的继发性退变等并发症。
结论:1膝关节单髁置换术是治疗膝关节单间室骨性关节炎的有效方法。2患者年龄小于60岁、体重超过80Kg、髌股关节轻度疼痛、内外翻畸形大于5°、屈曲挛缩大于5°、最大屈曲度小于90°并非膝关节单髁置换的禁忌症。3对于使用解剖型假体的患者术中可通过松解髌腱到内后角的胫骨平台下方2 cm范围内的软组织来矫正内外翻,但使用牛津膝假体的患者术中禁止对周围软组织行松解。另外矫枉过正的原则不适用于膝关节单髁置换术。
objective To report the medium-term results of UKA for osteoarthritis,and to discuss the indication and the key points of surgical technique.Methods A total of 55 unicompartmental knee arthroplasty patients(65 knees),8 males(10knees),39 females(46 knees)were performed from May 2005 to May 2008.The follow-up is well done except 7 lose follow-up and 1 death.The rate of fellow-up was 86.2%,mean periods was 27.7 months.The patients aged from 47-79 years old,the mean age was 63.9 years old,including 11 cases(14 knees) aged from 47-60 years old,36 cases(42 knees) aged from 60-79 years old.The mean weight was 67.4kg(40-90kg),including 40-80kg in 41 cases(49 knees),81-90kg in 6cases (7 knees).All patients are OA.There were 52 knees in medial compartment knee athroplasty,4 knees in lateral,9cases(18knees) in bilateral,73 oxford prothesis and 49 zimmer prothesis.The observation includes KSS knee score criterion of the preoperation and latest follow-up,the statistical analysis of ROM,the measurement of the angle of the posterior slope of the tibial implants and FTA,the radiology ofthe preoperation and postoperation.Results The mean clinical KSS knee score was from 40.3scores in preoperation to 95.4in postoperation,the mean function KSS knee score was from 44.6 to 94.1scores.The Statistical Analysis was significant (P＜0.05).The mean maximum flexion angle was from 102.2°in preoperation to 129.4°in postoperation.The Statistical Analysis was significant(P＜0.05) too.The mean FAT angle was 175.7°in medial UKA and 172.8°inlateral after operation.Prosthesis loosening,osteolysis surrounding prosthesis,secondary degeneration in other compartments were not observed after radiological follow-up.Conclutions 1 The UKA is a good way of therapy on knee compartment OA.2 The patients aged lower than 60 years old,weighted lower than 80kg, moderate pain in Patellofemoral joint,varus or valgus deformity larger than 5°,flexion contracture larger than 5°is not the contraindication of the UKA.3 For the anatomic prosthesis,release Patellar tendon to soft tissue below 2cm of media-posterior horn of tibial plateau is the way of correcting varus or valgus deformity.It is fobbiden to release soft tissue in oxford prothesis cases.In addition,the principle of over-correction does not apply to unicompartmental knee arthroplasty.
引文
[1]lnsall J,Aglietti P,A five to seven-year follow-up of unicondylar arthroplasty.J Bone Joint Surg Am,1980,62(8);1329-1337
[2]Jamali AA,Scott RD,Rubash HE,et al.Unicompartmental knee arthroplasty:past,present,and future.Am J Orthop,2009,38(1):17-23
[3]Berger RA,Meneghini RM,Jacobs JJ,et al.Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up.J Bone Joint Surg Am,2006,88(11):2533;author reply 2533-4.
[4]Lustig S,Paillot JL,Servien E,et al.Cemented all polyethylene tibial insert unicompartimental knee arthroplasty:a long term follow-up study.Orthop Traumatol Surg Res,2009,95(1):12-21.Epub 2009 Feb 4.
[5]Price AJ,Dodd CA,Svard UG,et al.Oxford medial unicompartmental knee arthroplasty in patients younger and older than 60 years of age.J Bone Joint Surg Br,2005,87(11):1488-92.50
[6]李德明,张伟兵,张世安.膝内外翻得体表测量.骨与关节杂志,1995,10(6):333-335.
[7]Berend KR,Lombardi AV Jr,Mallory TH.Early failure of minimally invasive unicompartmental knee arthroplasty is associated with obesity.Clin Orthop Relat Res.,2005Nov;440:60-6.
[8]Heck DA,Marmor L,Gibson A,et al.Unicompartmental knee arthroplasty.A multicenter investigation with long-term follow-up evaluation.Clin Orthop Relat Res.,1993Jan;(286):154-9.
[9]Naal FD,Neuerburg C,Salzmann GM,et al.Association of body mass index and clinical outcome 2 years after unicompartmental knee arthroplasty.Arch Orthop Trauma Surg,2009;129(4):463-8.Epub 2008 Apr 15
[10]Hemigou P,Deschamps G.Patellar impingement following unicompartmental arthroplasty.J Bone Joint Surg Am,2002,84(7);1132-1137
[11]Beard DJ,Pandit H,Ostlere S.Pre-operative clinical and radiological assessment of the patellofemoral joint in unicompartmental knee replacement and its influence on outcome.J Bone Joint Surg Br.,2007;89(12):1602-7
[12]Emerson RH Jr,Higgins LL.Unicompartmental knee arthroplasty with the oxford prosthesis in patients with medial compartment arthritis.J Bone Joint Surg Am.,2008;90(1):118-22.
[13]Argenson JA,Flecher X Minimally invasive unicompartmental knee arthroplasty[J],The Knee,2004,11;341-347.
[1]Insall J,Aglietti P,A five to seven-year follow-up of unicondylar arthroplasty.J Bone Joint Surg Am,1980;62(8);1329-1337
[2]Jamali AA,Scott RD,Rubash HE,et al.Unicompartmental knee arthroplasty:past,present,and future.Am J Orthop,2009 Jan;38(1):17-23
[3]Scott RD,Cobb AG,McQueary FG,et al.Unicompartmental knee arthroplasty:Eight to twelve-year follow-up with survivorship analysis.Clin Orthop,271:96,1991
[4]吕厚山.膝关节外科学.北京:人民卫生出版社,2006.
[5]吕厚山.现代人工关节外科学.北京:人民卫生出版社,2006.
[6]Berend KR,Lombardi AV Jr,Adams JB.Obesity,young age,patellofemoral disease,and anterior knee pain:identifying the unicondylar arthroplasty patient in the United States.Orthopedics,2007;30(5 Suppl):19-23
[7]Price AJ,Dodd CA,Svard UG,et al.Oxford medial unicompartmental knee arthroplasty in patients younger and older than 60 years of age.J Bone Joint Surg Br,2005;87(11):1488-92.50
[8]Berend KR,Lombardi AV Jr,Mallory TH.Early failure of minimally invasive unicompartmental knee arthroplasty is associated with obesity.Clin Orthop Relat Res,2005;440:60-6.
[9]Heck DA,Marmor L,Gibson A,et al.Unicompartmental knee arthroplasty.A multicenter investigation with long-term follow-up evaluation.Clin Orthop Relat Res,1993J;(286):154-9.
[10]Berend KR,Lombardi AV Jr,Mallory TH,et al.Early failure of minimally invasive unicompartmental knee arthroplasty is associated with obesity.Clin Orthop,2005;440;60-66
[11]Naal FD,Neuerburg C,Salzmann GM,et al.Association of body mass index and clinical outcome 2 years after unicompartmental knee arthroplasty.Arch Orthop Trauma Surg,2009;129(4):463-8.Epub 2008 Apr 15
[12]Hemigou P,Deschamps G.Patellar impingement following unicompartmental arthroplasty.J Bone Joint Surg Am,2002,84(7);1132-1137
[13]Beard DJ,Pandit H,Ostlere S.Pre-operative clinical and radiological assessment of the patellofemoral joint in unicompartmental knee replacement and its influence on outcome.J Bone Joint Surg Br.2007 Dec;89(12):1602-7Lustig S,Paillot JL,Servien E,et al.Cemented all polyethylene tibial insert unicompartimental knee arthroplasty:a long term follow-up study.Orthop Traumatol Surg Res,2009,95(1):12-21.Epub 2009 Feb 4.
[14]Lustig S,Paillot JL,Servien E,et al.Cemented all polyethylene tibial insert unicompartimental knee arthroplasty:a long term follow-up study.Orthop Traumatol Surg Res,2009;95(1):12-21.
[15]Christensen No.Unicompartmental prosthesis for gonarthrosis;anine-year series of 575 knees from a swedish hospital.Clin Orthop,1991,273;165
[16]Pandit H,Van Duren BH,Gallagher JA,et al.Combined anterior cruciate reconstruction and Oxford unicompartmental knee arthroplasty:in vivo kinematics.Knee,2008;15(2):101-6.Epub 2008 Jan 14.
[17]Seon JK,Song EK,Park SJ,et al.Comparison of minimally invasive unicompartmental knee arthroplasty with or without a navigation system.J Arthroplasty.2009 Apr;24(3):351-7.Epub 2008 Apr 3.
[18]Hopgood P,Martin CP,Rae PJ.The effect of tibial implant size on post-operative alignment following medial unicompartmental knee replacement[J].Knee,2004,11(5);385-388
[19]Luombardi AV Jr,Berend KR,Walter CA,et al.Is Recovery Faster for Mobile-bearing Unicompartmental than Total Knee Arthroplasty?Clin Orthop Relat Res,2009 Feb 19.
[20]Amendola A,Panarella L,Hightibial osteotomy for the treatment of unicompartmental arthritis of the knee.Orthop Clin North Am,2005,36(4);497-504
[21]Dowd GS,Somayaji HS,Uthukuri M.High tibial osteotomy formedial compartment osteoarthritis[J].Kneedn't,2006,13(2);87-92
[22]Scotton RD,Cobb AG,Mcqueary FG,et al.Unicompartmental knee arthroplasty,8to12-year follow-up evaluation with survivorship analysis.Clin Orthop,1991,271;96-100
[23]李众利,刘玉杰,王岩。人工单髁置换治疗膝单间室严重骨关节炎。Journal of Clinical Onhopaedics,2008,Apr,11(2);107-109
[24]Monk AP,Keys GW,Murray DW.Loosening of the femoral component after unicompartmental knee replacement.J Bone Joint Surg Br,2009;91(3):405-7.
[25]Clarius M,Hauck C,Seeger JB,et al.Pulsed lavage reduces the incidence of radiolucent lines under the tibial tray of Oxford unicompartmental knee arthroplasty:Pulsed lavage versus syringe lavage.Int Orthop.2009 Feb 14.
[26]Parratte S,Argenson JN,Pearce O,et al.Medial unicompartmental knee replacement in the under-50s.J Bone Joint Surg Br,2009;91(3):351-6
[27]Simpson DJ,Gray H,D'Lima D,et al.The effect of bearing congruency,thickness and alignment on the stresses in unicompartmental knee replacements.Clin Biomech(Bristol,Avon),2008;23(9):1148-57.Epub 2008 Jul 18.
[28]Argenson JA,Flecher X Minimally invasive unicompartmental knee arthroplasty[J].The Knee,2004,11;341-347.
[29]Hannaoui S,Lustig S,Servien E,et al.Arthroscopy of the knee after unicompartmental arthroplasty.Rev Chir Orthop Reparatrice Appar Mot,2008;94(7):678-84.Epub 2008 Jul 11.
[30]Riddle DL,Jiranek WA,McGlynn FJ.Yearly incidence of unicompartmental knee arthroplasty in the United States.J Arthroplasty,2008;23(3):408-12.Epub 2007 Nov 26.