单侧全膝关节置换后对侧膝关节置换的风险评估

Risk assessment of contralateral knee arthroplasty after unilateral total knee arthroplasty

背景:单侧全膝关节置换后部分患者会再次行对侧全膝关节置换治疗,但目前对于对侧膝手术的影响因素尚不明确。目的:评估双膝骨关节炎患者在初次全膝关节置换后对侧膝再行全膝关节置换的风险,并通过临床及影像学指标分析对侧全膝关节置换的危险因素。方法:回顾性分析徐州医科大学附属医院2013至2015年因双膝骨关节炎入院并行单侧全膝关节置换的患者193例(随访时间1-66个月),根据对侧膝关节是否置换,分为双侧置换组和单侧置换组。采用K-M生存分析法评估对侧膝全膝关节置换的风险比例;评估年龄、性别、体质量指数、初次手术侧、非术侧膝关节美国特种外科医院评分、疼痛、机械轴垂线角、内外侧关节间隙、股胫角、髋膝踝角和初次手术时的Kellgren-Lawrence(K-L)分级因素对于对侧膝全膝关节置换的风险。结果与结论:①有58例患者(30.1%)接受了对侧全膝关节置换治疗,1年的非术侧膝手术风险为8%,5年的非术侧膝手术风险为32%;②K-L分级与将来对侧膝行全膝关节置换的风险高度相关(P<0.001);K-L分级为4级的非术侧膝关节平均生存时间为45.7个月,5年的手术风险为44.3%;③年龄、性别、初次手术侧、体质量指数、内外侧关节间隙、髋膝踝角都不是进展为对侧全膝关节置换的危险因素;非术侧膝关节的机械轴垂线角(风险比=1.437,P<0.001)、股胫角(风险比=1.232,P<0.001)以及K-L分级(风险比=2.110,P=0.005)是独立的危险因素;股胫角≥185.8°、机械轴垂线角≥2.75°的患者有更高的风险行对侧全膝关节置换(P<0.001);④术前双侧置换组对侧膝美国特种外科医院评分明显低于单侧置换组(P=0.039),目测类比疼痛评分明显高于单侧置换组(P=0.013);术后6个月2组患者的美国特种外科医院评分均较术前有所改善,但双侧置换组仍然低于单侧置换组(P=0.003);⑤并非所有的双膝骨关节炎患者在单侧全膝关节置换后均需要再进行对侧全膝关节置换治疗,而对于膝骨关节炎较重的患者(K-L分级4级)有较高的风险需要行对侧全膝关节置换;术前对侧膝机械轴垂线角、股胫角、美国特种外科医院评分及疼痛程度可作为建议患者或安排再次手术计划的重要因素。

BACKGROUND:After total knee arthroplasty,some patients will receive the contralateral total knee arthroplasty again,but the influencing factors of contralateral knee surgery are not clear at present.OBJECTIVE:To evaluate the risk ratio of contralateral knee to total knee arthroplasty in patients with osteoarthritis of both knees after total knee arthroplasty,and to analyze the risk factors of contralateral total knee arthroplasty by clinical and radiographic indicators.METHODS:Data of 193 patients admitted to Affiliated Hospital of Xuzhou Medical University from 2013 to 2015 with bilateral knee osteoarthritis and undergoing unilateral total knee arthroplasty(follow-up time of 1-66 months)were retrospectively analyzed.The patients were divided into bilateral arthroplasty and unilateral arthroplasty groups based on whether the contralateral knee joint was replaced.K-M survival analysis was used to evaluate the risk ratio of contralateral knee total knee arthroplasty.Age,gender,body mass index,primary surgical side,non-operative knee Hospital for Special Surgery score,pain,mechanical axis perpendicular angle,medial and lateral joint space,femoral tibial angle,hip knee ankle angle,and Kellgren-Lawrence grade at initial surgery were used to assess the risk of contralateral total knee arthroplasty.RESULTS AND CONCLUSION:(1)Fifty-eight patients(30.1%)received contralateral total knee arthroplasty.The risk of nonoperative knee surgery at 1 year was 8%,and the risk of nonoperative knee surgery at 5 years was 32%.(2)The K-L grade was highly correlated with the risk of future nonoperative total knee arthroplasty(P<0.001).The mean survival time of the nonoperative knee with K-L grade 4 was 45.7 months,and the 5-year surgical risk was 44.3%.(3)Age,gender,initial surgery side and body mass index,medial and lateral joint space,and hip knee ankle angle were not risk factors for progression to contralateral total knee arthroplasty.Nonoperative knee mechanical axis perpendicular angle(risk ratio=1.437,P<0.001),femoral tibial angle(risk ratio=1.232,P<0.001)and K-L classification(risk ratio=2.110,P=0.005)were independent risk factors.Patients with femoral tibial angle≥185.8°and mechanical axis perpendicular angle≥2.75°had a higher risk of contralateral total knee arthroplasty(P<0.001).(4)The preoperative Hospital for Special Surgery score of the bilateral arthroplasty group was significantly lower than that of the unilateral arthroplasty group(P=0.039).Visual analogue scale pain score in the preoperative bilateral arthroplasty group was significantly higher than that in the unilateral arthroplasty group(P=0.013).At 6 months postoperatively,Hospital for Special Surgery score was improved in both groups,but still lower in the bilateral arthroplasty group than that in the unilateral arthroplasty group(P=0.003).(5)Not all patients with bilateral knee osteoarthritis need to receive contralateral total knee arthroplasty after unilateral total knee arthroplasty,and patients with severe knee osteoarthritis(K-L grade 4)are at high risk of needing contralateral total knee arthroplasty.Preoperative contralateral knee mechanical axis perpendicular angle,femoral tibial angle,Hospital for Special Surgery score and pain degree can be used as important factors to recommend patients or arrange a reoperation plan.