膝关节后交叉韧带保留型假体置换术15年远期疗效研究

Long-term clinical result of posterior cruciate ligament retaining total knee arthroplasty： 15 years follow-up study

目的针对后交叉韧带（posterior cruciate ligament，PCL）保留型膝关节假体置换术进行15年以上临床随访研究，分析其临床疗效及失败原因。方法对Medico-Chirurgical du Cedre中心1990年9月至1992年3月行PCL保留型全膝关节假体初次置换术获得随访的153例（178膝）患者的临床资料进行回顾性研究。对其采用术后X线测量结合随访时国际膝关节协会临床评分评估手术疗效，X线测量包括髋膝踝角（HKA）平均值、HKA绝对偏差、α角、β角、髌骨指数（AP／AT）、胫骨后倾角（PTA）等。以翻修率作为假体生存率最终评定标准。结果153例患者随访时31例（49膝）死亡，4例（4膝）失访，获访118例（125膝）。翻修11膝，15年以上假体生存率93．7％。翻修11膝原因分别为：9膝为假体界面无菌性松动（其中7膝伴严重骨溶解，2膝为胫骨假体周围透亮线伴疼痛），1膝反曲畸形，1膝内侧胫骨平台塌陷。术后随访时膝关节协会评分达173分，优良率95．9％。对比翻修患者与未翻修患者临床资料：对侧未手术膝关节内外翻角、术前正位X线片B角、两组手术前后膝关节协会评分差异均有统计学意义（P〈0．05）。结论PCL保留型假体可以较好地恢复膝关节生物力学特性，15年以上生存率优良。仅个别病例失败与PCL失效有关，聚乙烯衬垫后部过度磨损和髌股关节并发症少见。未手术侧膝关节畸形程度和术侧膝关节胫骨侧内翻畸形程度可能是影响假体翻修率的重要因素。

Objective To evaluate the long-term clinical result and reason of failure of posterior cruciate ligament（PCL） preserved prosthesis in a 15 years of follow-up study. Methods A case series of 153 patients （178 knees） undergoing total knee arthroplasty （TKA） with PCL preserved prosthesis between September 1990 and March 1992 in Center Medico-Chirurgical du Cedre was reported. All cases were evaluated with postoperative roentgenogram and Keen Society Clinical Scale. Measurement of X-ray included average hip knee ankle angle （HKA）, deviation of HKA, α angle, β angle, index of patella （AP/AT）, proximal tibia angle （PTA）, et al. Results Thirty-one patients died and 4 patients were lost at the time follow-up. And 118 patients（ 125 knees） out of 153 patients were successfully followed-up. Fifteen years survival rate was 93.7%. And 11 knees were revised and the reasons were as follow： 9 aseptic loosening （7 knees with severe osteolysis, 2 knees with radiolucent line around tibial prosthesis） ; 1 recurvatum, 1 medial tibial plateau collapse. Postoperative score was 173 points. And 95. 9% patients got good or excellent result. Comparing the clinical data of revised patients and unrevised patients, there were obvious difference between the following clinical data： varus and valgus angel of contralateral knee, β angle of preoperative AP roentgenogram, preoperative and postoperative Knee Society Clinical Scale （P 〈0.05 ）. Conclusions PCL preserved prosthesis could recover the knee function to good or excellent result. Survival rate over 15 years is good. The way to sterilize the prosthesis could be the main reason for surgery failure. Few failures are related to PCL rupture. High wear rate and patellofemoral syndrome could be avoided by correct PCL and soft tissue balancing. Varus and valgus deformity of unsurgeried knee and tibial varus deformity of snrgefied knee could be important factors for prosthesis failure.