初次全膝关节置换术后下肢力线对内翻型膝关节骨性关节炎患者早期临床疗效的影响

Effect of lower extremity force lines after initial total knee arthroplasty on early clinical outcomes in patients with varus knee osteoarthritis

目的探讨初次全膝关节置换术(TKA)后不同下肢力线对内翻型膝关节骨性关节炎(KOA)患者早期临床疗效的影响。方法选择2018年10月至2022年3月于新乡医学院第一附属医院行TKA治疗的55例(73膝)KOA患者为研究对象,根据患者术后髋膝踝角(HKA)大小分为外翻组(HKA<-3°,4膝)、中立位组(-3°≤HKA≤3°,32膝)、轻度内翻组(3°<HKA<6°,30膝)、重度内翻组(HKA≥6°,7膝)。术前及术后1周,测量4组患者的股骨远端外侧角(mLDFA)、胫骨近端内侧角(mMPTA)、膝关节活动度(ROM)、关节线相交角(JLCA)。记录4组患者术前及术后6个月的膝关节美国特种外科医院膝关节评分(HSS)、美国西安大略和麦克马斯特大学骨关节炎指数(WOMAC)评分及数字评分法(NRS)评分。结果55例(73膝)患者术后mLDFA、mMPTA、ROM及HSS评分显著大于术前,JLCA及WOMAC、NRS评分显著小于术前(P<0.01)。4组患者术前mLDFA、mMPTA、JLCA、ROM比较差异无统计学意义(F=2.689、0.692、0.476、0.892,P>0.05)。中立位组、轻度内翻组和重度内翻组患者术后mLDFA、mMPTA、ROM显著大于术前,JLCA显著小于术前(P<0.05)。外翻组患者术后mMPTA、ROM显著大于术前,JLCA显著小于术前(P<0.05);外翻组患者手术前后mLDFA比较差异无统计学意义(P>0.05)。4组患者术后JLCA、ROM比较差异无统计学意义(F=1.164、1.045,P>0.05)。4组患者术后mLDFA、mMPTA比较差异有统计学意义(F=21.068、4.551,P<0.05);其中中立位组、轻度内翻组、重度内翻组患者的mLDFA显著大于外翻组,轻度内翻组、重度内翻组患者的mLDFA显著大于中立位组,重度内翻组患者的mLDFA显著大于轻度内翻组(P<0.05);中立位组、轻度内翻组和重度内翻组患者的mMPTA显著小于外翻组(P<0.05);中立位组、轻度内翻组和重度内翻组患者的mMPTA比较差异无统计学意义(P>0.05)。4组患者术前HSS、WOMAC、NRS评分比较差异无统计学意义(F/χ^(2)=0.141、1.587、3.811,P>0.05)。4组患者术后HSS评分显著高于术前,WOMAC、NRS评分显著低于术前(P<0.05)。4组患者术后HSS、WOMAC评分比较差异有统计学意义(F=6.216、7.632,P<0.05)。中立位组、轻度内翻组患者术后HSS评分显著高于外翻组和重度内翻组(P<0.05);中立位组与轻度内翻组患者术后HSS评分比较差异无统计学意义(P>0.05);外翻组与重度内翻组患者术后HSS评分比较差异无统计学意义(P>0.05)。外翻组、轻度内翻组和重度内翻组患者术后WOMAC评分显著高于中立位组,外翻组和重度内翻组患者术后WOMAC评分显著高于轻度内翻组患者(P<0.05);外翻组与重度内翻组患者术后WOMAC评分比较差异无统计学意义(P>0.05)。4组患者术后NRS评分比较差异无统计学意义(P>0.05)。结论TKA术后下肢力线处于中立位对于术前内翻型KOA患者的早期临床效果最好,在TKA手术中应将下肢力线重建至中立位水平。

Objective To investigate the effect of different lower extremity force lines after initial total knee arthroplasty(TKA)on the early clinical outcomes of patients with varus knee osteoarthritis(KOA).Methods Fifty-five patients(73 knees)with KOA who underwent TKA at the First Affiliated Hospital of Xinxiang Medical University from October 2018 to March 2022 were selected as research subjects.According to the postoperative hip-knee-ankle angle(HKA),the patients were divided into the valgus alignment group(HKA<-3°,4 knees),neutral alignment group(-3°≤HKA≤3°,32 knees),mild varus alignment group(3°<HKA<6°,30 knees),and severe varus alignment group(HKA≥6°,7 knees).The mechanical lateral distal femoral angle(mLDFA),mechanical medial proximal tibial angle(mMPTA),range of motion(ROM)of knees,and joint line convergence angle(JLCA)of the four groups of patients were measured before and 1 week after surgery.The Hospital for Special Surgery Knee Scores(HSS),The Western Ontario and McMaster Universities Osteoarthritis Index(WOMAC)scores,and numeric rating scale(NRS)scores of the knee joints of patients in the four groups were also recorded preoperatively and 6 months postoperatively.Results The overall postoperative mLDFA,mMPTA,ROM and HSS scores were significantly greater than the preoperative values and the JLCA,WOMAC and NRS scores were significantly less than the preoperative values in 55 patients(73 knees)(P<0.01).There was no statistically significant difference in the preoperative mLDFA,mMPTA,JLCA and ROM among the patients in the four groups(F=2.689,0.692,0.476,0.892;P>0.05).Postoperative mLDFA,mMPTA,and ROM were significantly greater than preoperative values and JLCA was significantly less than preoperative value in patients in the neutral alignment,mild varus alignment,and severe varus groups(P<0.05).Postoperative mMPTA and ROM were significantly greater than preoperative values and JLCA was significantly less than preoperative value in patients in the valgus group(P<0.05);the difference was not statistically significant when compared with preoperative and postoperative mLDFA in patients in the valgus group(P>0.05).There was no statistically significant difference in the postoperative JLCA and ROM among the four groups(F=1.164,1.045;P>0.05).The difference in postoperative mLDFA and mMPTA was statistically significant among the four groups(F=21.068,4.551;P<0.05);the mLDFA of patients in the neutral alignment,mild varus alignment,and severe varus alignment groups was significantly greater than that of the valgus alignment group,and patients in the mild varus alignment and severe varus alignment groups had greater mLDFA than those in the neutral alignment group,patients in the severe varus alignment group had greater mLDFA than those in the mild varus alignment group(P<0.05);the mMPTA of patients in the neutral alignment,mild varus alignment,and severe varus alignment groups was less than that of patients in the valgus alignment group(P<0.05);there was no statistically significant difference in the mMPTA among patients in the neutral alignment,mild varus alignment and severe varus alignment groups(P>0.05).There was no statistically significant difference in the preoperative HSS,WOMAC and NRS scores among the four groups(F/χ^(2)=0.141,1.587,3.811;P>0.05).Postoperative HSS scores were significantly higher and WOMAC and NRS scores were significantly lower than preoperative scores in all groups(P<0.05).The difference between the postoperative HSS and WOMAC scores of patients in the four groups was statistically significant(F=6.216,7.632;P<0.05).The postoperative HSS scores of patients in the neutral alignment group and the mild varus alignment group were significantly higher than those of the valgus alignment group and the severe varus alignment group(P<0.05);the difference in the postoperative HSS scores of patients in the neutral alignment group compared with those of patients in the mild varus alignment group was not statistically significant(P>0.05);and the difference in the postoperative HSS scores of patients in the valgus alignment group compared with those of patients in the severe varus alignment group was not statistically significant(P>0.05).The postoperative WOMAC scores of patients in the valgus alignment,mild varus alignment and severe varus alignment groups were significantly higher than those in the neutral alignment group,and the postoperative WOMAC scores of patients in the valgus alignment and severe varus alignment groups were significantly higher than those of patients in the mild varus alignment group(P<0.05);the difference in postoperative WOMAC scores of patients in the valgus alignment group compared with those in the severe varus alignment group was not statistically significant(P>0.05).There was no statistically significant difference in the postoperative NRS scores among the four groups(P>0.05).Conclusion The lower extremity force line in a neutral position after TKA has the best early clinical outcome for patients with preoperative varus KOA,and the lower extremity force line should be reconstructed to a neutral level during TKA.