调整限制性运动学对线在导航辅助全膝关节置换术中的初步应用

Preliminary application of navigation-assisted total knee arthroplasty using adjusted restricted kinematic alignment

目的探讨导航辅助全膝关节置换术(total knee arthroplasty,TKA)中应用调整限制性运动学对线(adjusted restricted kinematic alignment,arKA)的可行性及其临床疗效。方法回顾性分析2019年10月至2021年9月连续14例行OrthoPilot导航辅助TKA中应用arKA对线的患者资料,男3例、女9例;年龄为(67.71±8.96)岁;体质指数为(25.94±3.12)kg/m2。选取同期同一手术团队行导航辅助TKA调整机械轴对线(adjusted mechanical alignment,aMA)的27例连续病例作为对照,两组患者性别、年龄、体质指数的差异无统计学意义。主要观察指标为手术时间、胫骨侧截骨角度、胫骨平台截骨量、股骨侧截骨角度、股骨远端、后方及前方截骨量、关节线移动情况、屈曲和伸直间隙及内外侧松弛度、髋-膝-踝角、冠状面和矢状面股骨组件角、冠状面和矢状面胫骨组件角、西安大略和麦克马斯特大学(Western Ontario and McMaster Universities,WOMAC)骨关节炎指数评分及美国特种外科医院(Hospital for Special Surgery,HSS)评分。结果所有患者均获得随访,arKA组随访时间(18.57±6.98)个月,aMA组(22.15±4.91)个月。术中arKA组与aMA组胫骨平台截骨角度分别为3.07°±1.00°和0.67°±0.56°、平台外侧截骨量为(9.07±1.82)mm和(6.89±2.94)mm、屈曲间隙外侧松弛度为(1.71±0.83)mm和(1.04±0.71)mm、屈曲间隙内外松弛度差为(1.14±0.86)mm和(0.41±0.75)mm,组间差异均有统计学意义(P<0.05);术后两组髋-膝-踝角分别为174.10°±1.63°和177.12°±2.07°、冠状面胫骨组件角为87.58°±0.85°和89.14°±1.23°、冠状面股骨组件角为93.10°±1.75°和90.41°±3.01°,组间差异均有统计学意义(P<0.05);两组矢状面股骨组件角(1.30°±0.82°vs.1.56°±1.19°)、矢状面胫骨组件角(87.16°±0.95°vs.87.79°±1.04°)及股骨切迹发生率(7.1%vs.11.1%)的差异均无统计学意义(P>0.05)。术前arKA组HSS评分(46.07±4.68)分,术后1个月(73.86±3.48)分;aMA组术前HSS评分(47.04±4.52)分,术后1个月(74.04±3.57)分,组间差异有统计学意义(P<0.05);两组术后6个月WOMAC评分为(12.93±2.37)分与(12.63±2.34)分,HSS评分分别为(86.86±2.74)分与(86.11±2.95)分,组间差异均无统计学意义(P>0.05)。arKA组2例(14.3%)发生下肢深静脉血栓,aMA组5例(18.5%),差异无统计学意义(χ^(2)=0.12,P=0.733)。结论导航辅助TKA应用arKA对线为术者处理严重膝关节畸形提供了一种新的力线对线选择,与aMA对线相比,arKA对线在保护膝关节周围软组织和调控间隙平衡方面更具优势。

Objective To evaluate the feasibility and clinical outcomes of navigation-assisted total knee arthroplasty(TKA)using adjusted restricted kinematic alignment(arKA).Methods Data of 14 consecutive cases of OrthoPilot navigation-assisted TKA using arKA from October 2019 to September 2021 were retrospectively analyzed,including 3 males and 9 females.The average age was 67.71±8.96 years with mean body mass index(BMI)25.94±3.12 kg/m2.27 consecutive patients who underwent navigation-assisted TKA using aMA during the same period were assessed as the control group.There were no significant differences in gender,age or BMI between the two groups.Intraoperative parameters including operative duration,tibia resection angle,frontal femoral angle,axial femoral angle,joint line translation,medial and lateral gap in extension and flexion position were recorded.Radiographic parameters including hip-knee-ankle(HKA)angle,coronal femoral component angle(cFCA),coronal tibial component angle(cTCA),sagittal femoral component angle(sFCA)and sagittal tibial component angle(sTCA)were measured.Functional outcomes were assessed by Western Ontario and McMaster Universities Osteoarthritis Index(WOMAC)and Hospital for Special Surgery(HSS)score.Surgery-related complications were recorded.Results All cases were followed up.The mean follow-up of arKA group was 18.57±6.98 months and follow-up of aMA group was 22.15±4.91 months.The intraoperative tibial resection was 3.07°±1.00°in arKA group versus 0.67°±0.56°in aMA group(P<0.05).The lateral cutting height of tibia was 9.07±1.82 mm in arKA group versus 6.89±2.94 mm in aMA group(P<0.05).The lateral gap in flexion was 1.71±0.83 mm in arKA group versus 1.04±0.71 mm in aMA group(P<0.05).The difference of medial-lateral flexion laxity was 1.14±0.86 mm in arKA group versus 0.41±0.75 mm in aMA group(P<0.05).The postoperative HKA angle was 174.10°±1.63°in arKA group versus 177.12°±2.07°in aMA group(P<0.05).The cTCA was 87.58°±0.85°in arKA group versus 89.14°±1.23°in aMA group(P<0.05).The cFCA was 93.10°±1.75°in arKA group versus 90.41°±3.01°in aMA group(P<0.05).There was no statistical difference between the two groups in sFCA(1.30°±0.82°vs.1.56°±1.19°),sTCA(87.16°±0.95°vs.87.79°±1.04°)and femoral notching(7.1%vs.11.1%).The preoperative HSS score in arKA group was 46.07±4.68 and HSS score at 1 month postoperatively was 73.86±3.48(P<0.05).The preoperative HSS score in aMA group was 47.04±4.52 and HSS score at 1 month postoperatively was 74.04±3.57(P<0.05).There was no statistical difference between the two groups in WOMAC score(12.93±2.37 vs.12.63±2.34)and HSS score(86.86±2.74 vs.86.11±2.95)at 6 months postoperatively.2 cases(14.3%)in arKA group and 5 cases(18.5%)in aMA group had deep venous thrombosis(χ^(2)=0.12,P=0.733).Conclusion Navigation-assisted TKA using arKA offers the surgeons a new alignment option for severe knee deformity with satisfactory clinical outcomes,the arKA technique has advantages in soft tissue protection and gap balance regulation compared to aMA technique.