单纯内固定或假体翻修治疗全膝关节置换术后假体周围骨折

Internal fixation or revision total knee arthroplasty for the treatment of periprosthetic fracture after primary total knee arthroplasty

目的分析单纯内固定和假体翻修治疗全膝关节置换术后假体周围骨折的临床疗效。方法回顾性分析2008年1月至2022年1月就诊于四川大学华西医院骨科的全膝关节置换术后发生假体周围骨折患者35例(35膝),男13例、女22例,年龄(71.4±4.1)岁(范围62~81岁)。左膝19例,右膝16例。RorabeckⅡ型20例、RorabeckⅢ型15例。初次置换均使用固定平台后稳定型膝关节假体,以骨水泥固定。RorabeckⅡ型患者接受单纯内固定治疗(内固定组),RorabeckⅢ型患者接受更换假体翻修术(翻修组)。比较两组患者术后美国特种外科医院(Hospital for Special Surgery,HSS)评分、膝关节活动度范围(range of motion,ROM)、下肢力线矫正情况及术后并发症的发生率。结果所有患者均顺利完成手术并获得随访,随访时间为(5.2±3.6)年(范围1~12年)。术中失血量为(680±102)ml(范围420~1100ml)。内固定组手术时间为(105±17)min,小于翻修组的(140±21)min,差异有统计学意义(t=-5.450,P<0.001)。术中无一例出现神经、血管损伤等并发症。内固定组术后5例下肢力线不满意(与正常值偏差>3°),翻修组下肢力线均满意,两组下肢力线满意率的差异无统计学意义(P=0.057)。内固定组骨折愈合时间、末次随访时膝关节ROM及HSS评分分别为(5.1±1.3)个月、86°±5°、(84±5)分,翻修组为(4.8±1.5)个月、83°±6°、(82±4)分,差异均无统计学意义(P>0.05)。翻修组1例术后确诊为假体周围感染,病原菌培养提示为白色念珠菌,反复出现膝前窦道和髌骨外露,进而发展为骨髓炎,于翻修后1年行大腿中段截肢术。结论假体稳定性是决定全膝关节置换术后假体周围骨折治疗方案的重要参考,对假体未松动患者行坚强的内固定术、对假体松动的患者采取更换假体的翻修术,均可获得良好的膝关节功能。

Objective To analyze the clinical efficacy of internal fixation and prosthesis revision in the treatment of periprosthesis fracture after total knee arthroplasty.Methods A total of 35 patients(35 knees)with periprosthetic fractures after total knee arthroplasty were retrospectively analyzed from January 2008 to January 2022 in the Department of Orthopaedics,West China Hospital,Sichuan University,including 13 males and 22 females,aged 71.4±4.1 years(range,62-81 years).Left knee 19 cases,right knee 16 cases.There were 20 cases of Rorabeck type II and 15 cases of Rorabeck type III.The initial replacement was performed using a fixed platform post-stabilized knee prosthesis,which was fixed with bone cement.Patients with Rorabeck type II were treated with internal fixation alone(internal fixation group)and patients with Rorabeck type III underwent revision with replacement prosthesis(revision group).The Hospital for Special Surgery(HSS)score,range of motion(ROM)of knee joint,alignment of lower extremity and incidence of postoperative complications were compared between the two groups.Results All patients successfully completed the operation and were followed up for 5.2±3.6 years(range,1-12 years).Intraoperative blood loss was 680±102 ml(range,420-1100 ml).The operative time in the internal fixation group was 105±17 min,which was less than 140±21 min in the revision group,and the difference was statistically significant(t=-5.450,P<0.001).There was no complication of nerve or blood vessel injury during the operation.Five cases in the internal fixation group had unsatisfactory lower extremity force lines(>3°deviation from normal)after surgery,and all lower extremity force lines in the revision group were satisfied,and the difference in the satisfaction rate of lower extremity force lines between the two groups was not statistically significant(P=0.057).The fracture healing time,knee ROM and HSS scores at the last follow-up were 5.1±1.3 months,86°±5°and 84±5 in the internal fixation group and 4.8±1.5 months,83°±6°and 82±4 in the revision group.One case in the revision group was diagnosed postoperatively with periprosthetic infection with pathogen culture suggestive of Candida albicans,recurrent anterior knee sinus tracts and patellar ectasia,which progressed to osteomyelitis,and mid-thigh amputation was performed 1 year after revision.Conclusion The stability of prosthesis is an important reference for the treatment of periprosthetic fractures after total knee arthroplasty.Strong internal fixation in patients with unloosened prosthesis and revision with replacement of prosthesis in patients with loose prosthesis can achieve good knee joint function.