个性化截骨工具辅助下运动学对线全膝关节置换的早期临床结果

Early clinical effects of total knee arthroplasty with kinematic alignment assisted by patient-specific instrumentation

目的探讨个性化截骨工具(PSI)辅助下运动学对线全膝关节置换(KA-TKA)治疗膝关节骨关节炎患者的临床效果。方法回顾性分析2018年5月至2019年8月首都医科大学附属北京朝阳医院骨科收治的行PSI辅助下单侧KA-TKA的14例膝关节骨关节炎患者的临床资料。男性6例,女性8例,年龄66.6岁(范围:56~79岁),左膝9例,右膝5例。记录患者的手术时间,术中软组织松解情况,术中有无增加内翻或外翻截骨及截骨量。测量术中截骨块数据并与所用假体对应位置进行对比。分别测量患者术前、术后3个月的髋-膝-踝角(HKA)、机械股骨远端外侧角(mLDFA)和胫骨近端内侧角(MPTA),记录膝关节功能评分(KS-F)、膝关节临床评分(KS-C)、西安大略和麦克马斯特大学(WOMAC)骨关节炎指数。手术前后测量指标和评分的比较采用配对样本t检验或Wilcoxon非参数检验。结果所有患者手术过程顺利,手术时间为(81.8±16.9)min(范围:60~115 min)。2例患者手动增加内翻截骨2 mm,1例患者行髌外侧支持带松解,所有病例均未行内外侧软组织松解。术中测量股骨侧截骨误差<2 mm,内外髁远端、内外后髁分别相对多截0.50、0.21、0.93、0.71 mm;胫骨侧截骨误差<1.5 mm,内外侧平台分别相对少截0.43 mm和0.32 mm。HKA由术前的(8.8±5.6)°纠正到术后的(1.6±4.3)°(t=20.723,P=0.000),KS-C由术前的(28.2±13.5)分升至术后的(78.1±8.0)分(t=-16.570,P=0.000),KS-F由术前的(41.0±15.3)分升至术后的(85.0±10.9)分(t=-14.675,P=0.000),WOMAC骨关节炎指数由术前的53.5(25.75)[M(QR)]分升至术后的5.5(5.25)分(Z=-3.297,P=0.001)。术后mLDFA和MPTA较术前均无差异。随访期间无髌股关节并发症发生。结论PSI辅助TKA截骨具有较高的精准度,KA-TKA技术注重保持膝关节原有的解剖形态,只矫正软骨磨损导致的下肢力线改变,对软组织干扰少,易于获得满意的膝关节松弛度。

Objective To examine the clinical effects of the treatment of knee osteoarthritis patients with kinematic alignment technique of total knee replacement(KA-TKA)assisted by patient-specific instrumentation(PSI).Methods The clinical data of 14 patients with knee osteoarthritis treated with unilateral KA-TKA assisted by PSI at Department of Orthopaedic Surgery,Beijing Chaoyang Hospital Affiliated to Capital Medical University from May 2018 to August 2019 were analyzed retrospectively.There were 6 males and 8 females,aged 66.6 years(range:56 to 79 years),9 left knees and 5 right knees.The operation time,soft tissue release and extra varus or valgus osteotomy were recorded.The data of osteotomy blocks were measured and compared with the corresponding position of the prostheses.The hip knee ankle angle(HKA),the mechanical distal femoral lateral angle(mLDFA)and the proximal tibial medial angle(MPTA)were measured before and 3 months after the operation.The knee joint functional score(KS-F),knee joint clinical score(KS-C)and the Western Ontario McMaster(WOMAC)Osteoarthritis Index were recorded and compared by paired t test or Wilcoxon non-parametric test.Results The operation time was(81.8±16.9)minutes(range:60 to 115 minutes),2 cases were manually increased varus osteotomy by 2 mm and 1 patient received lateral retinaculum release.There was no extra medial or lateral soft tissue release.Intraoperative measurement of the resection showed that the femoral side mismatch was within 2 mm.The medial and lateral condyle,the medial and lateral posterior condyles were relatively overcut by 0.50 mm,0.21 mm,0.93 mm,and 0.71 mm,respectively.The tibial side mismatch was within 1.5 mm,the medial and lateral plateau were relatively undercut by 0.43 mm and 0.32 mm.HKA was corrected from(8.8±5.6)°to(1.6±4.3)°(t=20.723,P=0.000).KS-C improved from 28.21±13.47 preoperative to 78.07±8.01 postoperative(t=-16.570,P=0.000);KS-F improved from 41.00±15.25 preoperative to 84.93±10.85 postoperative(t=-14.675,P=0.000).WOMAC Osteoarthritis Index decreased from 53.5(25.75)(M(QR))preoperative to 5.5(5.25)postoperative(Z=-3.297,P=0.001).No statistically significant difference was found in mLDFA and MPTA before and after surgery.No significant patellofemoral complication was recorded during follow-up time.Conclusions PSI assisted TKA resection has high accuracy.KA-TKA aims to restore the native anatomy of the knee joint,only corrects the malalignment of lower extremities caused by articular cartilage wear,with less interference to soft tissues,easy to obtain satisfactory knee joint laxity and has a promising early clinical effect.