全膝关节置换术中髌骨置换及髌骨高度对术后疗效的影响

Effects of patellar replacement and height on treatment outcomes of total knee arthroplasty

目的探讨全膝关节置换术(total knee arthroplasty,TKA)中行髌骨置换与否及术前髌骨高度对疗效的影响。方法回顾性分析2020年7月至2021年12月山东第一医科大学第一附属医院采用TKA治疗的膝关节严重骨关节炎患者429例,男92例、女337例;年龄(66.81±7.05)岁,左侧226例、右侧203例,体质指数(27.60±4.22)kg/m^(2),Kellgren-Lawrence分级均为Ⅲ级,Insall-Salvati(IS)比值>0.8。按是否行髌骨置换及术前IS比值(IS为0.8~1.2为正常高度髌骨、>1.2为高位髌骨)将患者分为四个组:髌骨置换+正常高度髌骨组(263例)、髌骨置换+高位髌骨组(66例)、髌骨未置换+正常高度髌骨组(68例)、髌骨未置换+高位髌骨组(32例)。比较组间术后IS比值、美国膝关节协会评分(Knee Society Score,KSS)、美国特种外科医院(Hospital for Special Surgery,HSS)膝关节评分、牛津膝关节评分(Oxford Knee Score,OKS)、膝关节活动度、并发症和满意度。结果所有患者均获得随访,随访时间为(1.15±0.16)年(范围1~2年);术后膝关节疼痛、肿胀、活动受限等症状均较术前明显改善。四组患者KSS疼痛评分、膝关节活动度、HSS评分、OKS评分的组间差异均有统计学意义(F=9.49,P<0.001;F=11.09,P<0.001;F=6.74,P<0.001;F=3.24,P=0.022),但KSS功能评分的差异无统计学意义(F=1.84,P=0.140)。髌骨置换+正常高度髌骨组的KSS疼痛评分、HSS评分、OKS评分、膝关节活动度[(41.84±5.25)分、(80.43±6.99)分、(14.27±5.39)分、122.33°±4.93°]均优于髌骨未置换+正常高度髌骨组[(38.31±7.31)分、(77.00±7.81)分、(16.05±5.81)分、120.99°±4.90°]和髌骨未置换+高位髌骨组[(37.97±7.28)分、(75.62±11.02)分、(16.63±6.67)分、116.25°±13.08°],差异均有统计学意义(P<0.05)。髌骨置换+高位髌骨组仅KSS疼痛评分优于髌骨未置换+正常高度髌骨组和髌骨未置换+高位髌骨组[(41.74±6.35)分、(38.31±7.31)分、(37.97±7.28)分],差异均有统计学意义(P<0.05)。髌骨置换+高位髌骨组(121.68°±2.88°)和髌骨未置换+正常高度髌骨组(120.99°±4.90°)的膝关节活动度优于髌骨未置换+高位髌骨组(116.25°±13.08°),差异均有统计学意义(P<0.05)。四组患者术前、术后1天及术后1年IS比值差异均有统计学意义(P<0.05),术后1天较术前均降低且差异有统计学意义(P<0.05),但术后1年时与术前比较差异无统计学意义(P>0.05)。术前不同髌骨高度患者膝前疼痛、髌骨弹响发生率及满意率的差异均无统计学意义(P>0.05)。髌骨置换组较髌骨未置换有更低的膝前疼痛发生率(正常高度髌骨:7.6%比16.2%,χ^(2)=4.68,P=0.031;高位髌骨:9.1%比25.0%,χ^(2)=4.46,P=0.035)及髌骨弹响发生率(正常高度髌骨:9.1%比17.6%,χ^(2)=4.05,P=0.044;高位髌骨:13.6%比31.2%,χ^(2)=4.28,P=0.039);术后四组患者满意率的差异无统计学意义(P>0.05)。结论TKA术中行髌骨置换患者的术后疗效优于髌骨未置换患者,术前正常高度髌骨患者膝关节活动度优于高位髌骨患者,TKA术对髌骨的高度不造成影响。

Objective To investigate the effect of patellar replacement and patellar height on the therapeutic effect of total knee arthroplasty(TKA).Methods A retrospective analysis was conducted on 429 patients(92 males,337 females;aged 66.81±7.05 years;left=226,right=203)with severe knee osteoarthritis who underwent TKA in the First Affiliated Hospital of Shandong First Medical University from July 2020 to December 2021,with the body mass index of 27.60±4.22 kg/m^(2),Grade-ⅢKell gren-Lawrence,and Insall-Salvati(IS)ratio>0.8.Afterward,the patients were divided into 4 groups according to whether patellar replacement was performed or not and the preoperative IS ratio(IS of 0.8-1.2 for normal patellar and>1.2 for high patellar):the patellar replacement+normal height patellar group(263 cases),the patellar replacement+high height patellar group(66 cases),the patellar non-replacement+normal height patellar group(68 cases),and the patellar non-replacement+high height patellar group(32 cases).Moreover,postoperative intergroup IS ratio,Knee Society Score(KSS),Hospital for Special Surgery(HSS)knee score,Oxford Knee Score(OKS),knee range of motion,complications,and satisfaction were analyzed.Results All patients were followed up,and the time was 1.15±0.16 years(range,1-2 years).Postoperative symptoms such as knee pain,swelling,and limitation of movement were significantly improved compared with the preoperative period.Additionally,KsS pain score,knee range of motion,HSS score and 0KS score were significantly different among the four groups(F=9.49,P<0.001;F=11.09,P<0.001;F=6.74,P<0.001;F=3.24,P=0.022),but the difference in KSS functional scores was not statistically significant(F=1.84,P=0.140).At the same time,the KSS pain score,HSS score,OKS score,and knee range of motion(41.84±5.25,80.43±6.99,14.27±5.39,and 122.33°±4.93°)in the patellar replacement+normal height patella group were all better than those in the patellar non-replacement+normal height patella group(38.31±7.31,77.00±7.81,16.05±5.81,120.99°±4.90°)and patella non-replaced+high height patella group(37.97±7.28,75.62±11.02,16.63±6.67,116.25°±13.08°),with statistically significant differences(P<0.05).The patella replacement+high height patella group only had better KSS pain scores than the patella non-replaced+normal height patella group and the patella non-replaced+high height patella group(41.74±6.35,38.31±7.31,37.97±7.28),with statistically significant differences(P<0.05).Moreover,Knee mobility was better in the patellar replacement+high height patella group(121.68°±2.88°)and the patellar non-replacement+normal height patella group(120.99°±4.90°)than in the patellar non-replacement+high height patella group(116.25°±13.08°),and the differences were statistically significant(P<0.05).There were statistically significant differences in the IS ratio before surgery,1 day after surgery and 1 year after surgery among the four groups(P<0.05),and the IS ratio at 1 day after surgery was lower than that before surgery with statistically significant differences(P<0.05),but there was no statistically significant difference between the IS ratio at 1 year after surgery and that before surgery(P>0.05).Furthermore,the preoperative differences in the incidence of anterior knee pain,patellar clicking and satisfaction rates in patients with different patellar heights were not statistically significant(P>0.05).Finally,the patellar replacement group possessed a lower incidence of anterior knee pain(normal height patella:7.6%us.16.2%,χ^(2)=4.68,P=0.031;high height patella:9.1%us.25.0%,χ^(2)=4.46,P=0.035)and patellar clicking(normal height patella:9.1%us.17.6%,χ^(2)=4.05,P=0.044;high patella:13.6%us.31.2%,χ^(2)=4.28,P=0.039);there was no significant difference in satisfaction rate among the four groups after operation(P>0.05).Conclusion Postoperative outcomes were better in patients with patellar replacement during TKA than in patients with no patellar replacement,and knee range of motion was better in patients with normal-height patellas than in patients with high patellas preoperatively,with no effect of TKA on patellar height.