ObjectiveTo discuss the feasibility and accuracy of distal femoral patient-specific cutting guide in total knee arthroplasty (TKA) based on knee CT and full-length X-ray film of lower extremities. MethodsBetween July 2016 and February 2017, 20 patients with severe knee joint osteoarthritis planned to undergo primary TKA were selected as the research object. There were 9 males and 11 females; aged 53-84 years, with an average of 69.4 years. The body mass index was 22.1-31.0 kg/m2, with an average of 24.8 kg/m2. The preoperative range of motion (ROM) of the knee joint was (103.0±19.4)°, the pain visual analogue scale (VAS) score was 5.4±1.3, and the American Hospital of Special Surgery (HSS) score was 58.1±11.3. Before operation, a three-dimensional model of the knee joint was constructed based on the full-length X-ray film of lower extremities and CT of the knee joint. The distal femoral patient-specific cutting guide was designed and fabricated, and the thickness of the distal femoral osteotomy was determined by digital simulation. The thickness of the internal and external condyle of the distal femur osteotomy before operation and the actual thickness of the intraoperative osteotomy were compared. The intraoperative blood loss, postoperative drainage loss, and hidden blood loss were recorded. The ROM of knee joint, VAS score, and HSS score at 3 months after operation were recorded to evaluate effectiveness. The position of the coronal and sagittal plane of the distal femoral prosthesis were assessed by comparing the femoral mechanical-anatomical angle (FMAA), anatomical lateral distal femoral angle (aLDFA), mechanical femoral tibial angle (mFTA), distal femoral flexion angle (DFFA), femoral prosthesis flexion angle (FPFA), anatomical lateral femoral component angle (aLFC), and the angle of the femoral component and femoral shaft (α angle) between pre- and post-operation.ResultsTKA was successfully completed with the aid of the distal femoral patient-specific cutting guide. There was no significant difference between the thickness of the internal and lateral condyle of the distal femur osteotomy before operation and the actual thickness of the intraoperative osteotomy (P>0.05). All patients were followed up 3 months. All incisions healed by first intention, and there was no complications such as periarticular infection and deep vein thrombosis. Except for 1 patient who was not treated with tranexamic acid, the intraoperative blood loss of the rest 19 patients ranged from 30 to 150 mL, with an average of 73.2 mL; the postoperative drainage loss ranged from 20 to 500 mL, with an average of 154.5 mL; and the hidden blood loss ranged from 169.2 to 1 400.0 mL, with an average of 643.8 mL. At 3 months after operation, the ROM of the knee was (111.5±11.5)°, and there was no significant difference when compared with the preoperative one (t=–1.962, P=0.065). The VAS score was 2.4±0.9 and HSS score was 88.2±7.5, showing significant differences when compared with the preoperative ones (t=7.248, P=0.000; t=–11.442, P=0.000). Compared with the preoperative measurements, there was a significant difference in mFTA (P<0.05), and there was no significant difference in aLDFA, FMAA, or DFFA; compared with the preoperative plan, there was no significant difference in FPFA, aLFC, or α angle (P>0.05). ConclusionThe use of distal femoral patient-specific cutting guide based on knee CT and full-length X-ray film of lower extremity can achieve precise osteotomy, improve coronal and sagittal limb alignment, reduce intraoperative blood loss, and obtain satisfactory short-term effectiveness.
Objective To make a retrospective analysis on an early clinical outcome of total knee arthroplasty (TKA) for the knees with different degrees of flexion-contracture deformities. Methods Ninety-seven knees of 65 patients undergoing total knee arthroplasty with the Scorpio posterior-stabilized knee prosthesis from January 2000 to December 2003 were reviewed, including 51 osteoarthritis patients (74 knees) and 14 rheumatoid arthritis patients (23 knees). Thirtythree patients underwent unilateral TKA, and 32 patients underwent bilateral TKA. The average range of motion (ROM) before operation was 82.8°(range, 5-140°).According to the preoperative flexion-contracture degrees of the knees, these patients were divided into 2 groups, group A and group B. Group A consisted of the patients with flexioncontracture less than 20° (range, 0-15°), and group B consisted of the patients with flexion-contracture not less than 20° (range, 20-60°). In group A, the average flexion-contracture degree, ROM, KSS (knee society score), and function score were 10.7±8.0°, 104.6±20.0°, 29.1±18.0, and 32.6±20.7, respectively. But the corresponding data were much worse ingroup B than in group A, which were 28.2±7.8°, 60.8±26.6°, 12.1±13.2, and 26.8±18.1. All the operations were primary total knee arthroplasty, and they were performed by the same group of surgeons. The time for the prosthesis installed lasted for 25.6 minutes, and the average tourniquet time was 34.7 minutes. Three or four days after operation, the patients began the continuous passive motion (CPM) and active functional exercise of the knee.Results The patients were followed up for an average of 2 years and 7 months(range, 8 mon-3.5 yr). During the follow-up period, the average flexion-contracture degree, ROM, KSS, and function score in group A were 0.4±2.1°, 108.6±19.0°, 82.1±13.8, and 72.3±29.1, respectively; and the corresponding data in group B were 1.3±3.2°, 986±16.4°, 75.9±8.2, and 81.4±26.9, respectively. There was no significant difference between the 2 groups. No revision or deep infection was found. Conclusion The curative effect is mainly determined by the surgeon’s good operational skills, rich clinical experience, and familiarity with the prosthesis, and it is not influenced by severity of the knee flexioncontracture deformity. The knee ROM after TKA, which has a “toward middle ROM”phenomenon, is influenced by many clinical factors. It is very important for the patientto perform a functional exercise of the knee as early as possible after operation.
ObjectiveTo evaluate the effect of the surgeon’s handedness on the distribution of prosthesis during primary total knee arthroplasty (TKA).MethodsA retrospective analysis was performed on 86 patients (100 knees) with primary TKA completed by the same right-handed surgeon between December 2016 and December 2018, including 72 cases of single knee and 14 of bilateral knees. The patients were divided into dominant group (right side) and non-dominant group (left side) according to the operating position of the surgeon and each group had 50 knees. There was no significant difference in gender, age, body mass index, disease duration, clinical diagnosis, preoperative Hospital for Special Surgery (HSS) score, and other general data between the two groups (P>0.05). The operation time and complications were recorded in both groups. The function of knee was evaluated by HSS score. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured by using X-ray film of full-length lower extremity before TKA and at 2 weeks after TKA that were used to evaluate the coronal position of the prosthesis. Posterior distal femoral angle (PDFA) and posterior proximal tibial angle (PPTA) were measured by using lateral X-ray films at 3 months after operation that were used to evaluate the sagittal position of the prosthesis.ResultsThere was no significant difference in operation time between the two groups (t=−1.128, P=0.262). One case of posterior tibial artery thrombosis occurred in the dominant group, and 1 case of poor healing of the incision occurred in each of the dominant group and the non-dominant group. Patients in both groups were followed up 12-34 months with an average of 22.0 months. The HSS scores at last follow-up were 87.2±4.3 in the dominant group and 86.8±5.0 in the non-dominant group. There was no significant difference between the two groups (t=0.471, P=0.639). No complications such as periprosthetic infection, prosthetic loosening, or periprosthetic fracture occurred during follow-up. There was no significant difference in the HKA, mLDFA, and mMPTA between the two groups before and after operation (P>0.05). The differences in the incidence of sagittal femoral prosthesis malposition and PDFA between the two groups were significant (P<0.05); however, there was no significant difference in the PPTA, the rate of femoral prosthesis distributed in the neutral position, the incidence of over-flexed femoral prosthesis, and the incidence of anterior femoral notch (P>0.05).ConclusionThe surgeon’s handedness is one of the factors affecting the placement of the sagittal femoral prosthesis in primary TKA. The incidence of sagittal femoral prosthesis malposition could increase when the surgeon performs on the non-dominant side.
Objective To evaluate the efficacy and safety of the midvastus approach in total knee arthroplasty. Methods We searched The Cochrane Library, EMBASE, PubMed, and CBM to identify clinical controlled trials comparing the midvastus approach with the medial parapatellar approach in total knee arthroplasty. The quality of the included studies was critically assessed and the data analyses were performed by the Cochrane Collaboration’s RevMan 5.0. Results Eight studies were included, involving 4 randomized controlled trials (RCTs), 2 quasi-RCTs and 2 non-RCTs. Meta-analyses showed that rate of lateral retinacular release (RR=0.75, 95%CI 0.52 to 1.08, P=0.12), range of motion at 6 week postoperation (MD=2.65, 95%CI –1.20 to 6.50, P=0.18), operation time (MD=1.04, 95%CI –3.50 to 5.58), and adverse events postoperation (OR=1.04, 95%CI 0.43 to 2.52, P=0.94) were similar between the midvastus approach and the medial parapatellar approach in total knee arthroplasty. One study showed that there was no significant difference in blood loss interoperation between the two approaches, and two showed that the midvastus approach had less blood loss interoperation than the medial parapatellar approach. There was no statistical analysis about the blood loss interoperation in one study. For the time of straight leg raise, there was no significant difference in two studies. But in one study, it showed that patients needed longer time for straight leg raise. Conclusion Based on the current evidence, the midvastus approach for total knee arthroplasty is as safe and effective as the medial parapatellar approach, but blood loss interoperation and time of straight leg raise are not decided. Due to the poor quality of the included trials, more high-quality RCTs are needed.
Objective To analyze the relationship between the collateral ligament attachment and the epicondylar axis with rotational alignment of the femoral component in the total knee arthroplasty(TKA).Methods Twenty normal cadaver knee joints were anatomized and 2 holes were drilled on the distal femur from the deep and superficial insertions of the medial collateral ligaments to the lateral condylar part, respectively. Then, all the knees were scanned by MRI on the sagittal plane, making the drilled hole located relatively to the posterior condylar joint surface on the axial plane, and the posterior condylar angle (PCA) and thecondylar twist angle (CTA) were measured.Results The colateral ligament had the deep and superficial parts, and the deep part was strained during the knee flexing. PCA and CTA were 4.50±1.26° and 7.10±0.30° respectively, and there was a significant difference between them(P＜0.05), which were significantly greater than those reported abroad. On the sagittal plane, there wasno significant difference between the radiuses of the posterior medial and lateral condylar circles (Pgt;0.05). The distance from the center of the posterior condylar circle to the deep insertion of the medial collateral ligament (MCL) (d1) was 4.22±0.20 mm, and the distance to the superficial insertionof MCL (d2) was 7.36±0.13 mm. The difference between d1 and d2 was significant(Plt;0.05). Conclusion The center of the posterior condylar circle passes from the deep insertion of the collateral ligament, which can be regarded as a fixed flexionextension axis of the knee. By releasing the different parts of the collateral ligaments, the balance of the flexion and extension gap canbe obtained, and then varus, valgus or flexed contracture deformity of the kneecan be realigned. Besides, the rotational orientation of the femoral prothesis can be made by a reference to the epicondylar insertion of the collateral ligament.
Objective To analyze the effect of the posterior cruciate ligament (PCL) retaining or not on knee-joint proprioception by comparing the proprioceptive difference between PCL retaining and no PCL retaining in total knee arthroplasty (TKA). Methods Between June 2009 and June 2010, 38 osteoarthritis patients meeting the inclusion criteria were divided into PCL retaining group (group A, n=19) and PCL-substituting group (group B, n=19) according to the random number table. There was no significant difference in gender, age, disease duration, the range of motion of the knee between 2 groups (P gt; 0.05). The effectiveness and the knee-joint proprioception were separately assessed by the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score and the passive angle reproduction test (30, 60, and 90° of knee flexion) preoperatively and 12 months postoperatively. Results All incisons healed by first intention, without complications of infection, fracture, and deep vein thrombosis of lower limb. The patients were followed up 12-17 months (mean, 14.1 months). The knee function after operation was obviously improved when compared with preoperative one; significant differences were observed in the WOMAC scores and the results of passive angle reproduction test between at preoperation and at 12 months after operation (P lt; 0.05), but no significant difference was found between group A and group B (P gt; 0.05). Conclusion Whether PCL retaining or not in TKA both can improve knee-joint proprioception, and no obvious difference between them.
目的 探讨髋或膝关节置换术（THR/TKR）并存甲状腺功能减退症（甲减）患者围手术期的处理策略。方法 2009年1月－2011年12月收治30例行THR/TKR并存甲减患者，其中男8例，女22例，平均年龄62.4岁。处理要点包括术前纠正甲状腺激素水平；术中缩短手术时间，减少出血量，选择性应用糖皮质激素；术后补充甲状腺激素，预防感染及深静脉血栓形成，改善胃肠功能。评价指标包括围手术期血压、心率变化，胃肠功能状况，切口愈合时间，甲状腺功能水平，黏液性水肿昏迷等并发症发生率；术前及术后Harris及特种外科医院评分系统（HSS）评分等。 结果 术后心率变化大，非致命性心律失常者20例；血压控制平稳；术后甲状腺功能变化不明显，无黏液性水肿昏迷、心包积液及呼吸窘迫等严重并发症发生。随访1个月，术前HSS评分平均28分，术后86分；术前Harris评分平均32分，术后87分。 结论 术前控制血清促甲状腺素在0.5～3.0 mU/L以内，总甲状腺素、游离甲状腺素至正常水平，是有效预防甲减患者THR/TKR围手术期并发症的关键；综合应用左甲状腺素片、糖皮质激素和抗凝治疗是安全渡过围手术期的重要保证。
ObjectiveTo simulate and validate the performance, accuracy, and safety of the Yuanhua robotic-assisted total knee arthroplasty system (YUANHUA-TKA) through cadaver-based experiment, thus optimizing the robotic system for the future human clinical application.MethodsSix unilateral adult cadaver specimens of the lower limbs were scanned by three-dimensional CT before the experiment, and then the three-dimensional models of femur and tibia were obtained by using the preoperative software of YUANHUA-TKA system, so as to plan the type of prosthesis implant, the osteotomy volume and osteotomy angles [hip-knee-ankle angle (HKA), coronal frontal femoral component (FFC) and frontal tibial component (FTC)], the ideal value of HKA was set to 180°, and of FFC and FTC were set to 90°, respectively. The operator could further confirm the osteotomy plan according to the intraoperative situation before osteotomy, and then install the prosthesis after completing the osteotomy in each plane with the assistance of YUANHUA-TKA system. At last, the X-ray films of hip joint, knee joint, and ankle joint were taken and stitched into the full length X-ray film of the lower limb, and HKA, coronal FFC and FTC were measured.ResultsDuring the experiment, YUANHUA-TKA system ran stably. All sections of femur and tibia were smooth and no ligament injury was found. After operation, the HKA was 177.1°-179.7°, FFC was 87.9°-91.4°, and FTC was 87.3°-91.4°, which were within ±3° from the ideal values of preoperative planning.ConclusionThe YUANHUA-TKA system can assist the surgeon to carry out precise osteotomy according to the preoperative planned value, which has a good auxiliary effect for total knee arthroplasty. It is expected to assist joint surgeons to improve the surgical accuracy in clinical application.