运动学及机械对线全膝关节置换术早期临床结果对比

doi:10.3877/cma.j.issn.1674-134X.2021.02.006

目的

探讨传统器械行运动学对线(KA)和机械对线(MA)全膝关节置换术(TKA)的差异和早期临床结果。

方法

回顾分析2020年4月至2020年7月因膝骨关节炎在首都医科大学附属北京朝阳医院行TKA手术患者，排除既往下肢骨折病史及下肢严重畸形患者，其中男6例，女30例，平均年龄(68.4±6.0)岁。根据手术方式分为KA-TKA组17例，MA-TKA组19例。比较两组的手术时间，术后第3天血红蛋白(Hb)值，术后第5天膝关节主动活动度(AROM)，术后3月髋-膝-踝角(HKA)，膝关节临床评分(KS-C)和膝关节功能评分(KS-F)。手术前后同组数据采用配对t检验，两组间数据采用独立样本t检验。

结果

KA-TKA和MA-TKA两组手术时间分别为(76.9±11.8)min和(78.3±12.7)min，差异无统计学意义(t＝0.35，P>0.05)。两组术后HKA分别为(2.7±1.2)°和(2.1±1.5)°，差异无统计学意义(t＝1.60，P>0.05)。两组术后第3天Hb值分别为(113.3±9.1)和(111.3±8.2)g/L，差异无统计学意义(t＝0.70，P>0.05)。两组术后第5天AROM值分别为(105.6±8.3)°和(95.4±14.9)°，差异有统计学意义(t＝2.50，P<0.05)。两组术后3月KS-C评分分别为(82.8±6.2)和(78.1±7.3)，差异有统计学意义(t＝2.05，P<0.05)。两组术后3月KS-F评分分别为(80.3±10.9)和(71.3±14.3)，差异有统计学意义(t＝2.09，P<0.05)。

结论

传统器械KA-TKA早期临床结果较MA-TKA存在一定优势，且不会额外增加手术难度和手术风险。

关键词: 骨关节炎, 膝, 关节成形术, 置换

Objective

To explore the difference and early clinical results of kinematic alignment (KA) and mechanical alignment (MA) total knee arthroplasty (TKA) with conventional instruments.

Methods

A retrospective analysis of patients undergoing TKAs at Beijing Chaoyang Hospital, Capital Medical University from April 2020 to July 2020 due to knee osteoarthritis.Patients with a history of lower extremity fractures and severe deformities of the lower extremities were excluded, including six males and 30 females, with an average age of (68.4±6.0)years. There were 17 cases in the KA-TKA group and 19 cases in the MA-TKA group. The time of the surgical procedure, the value of hemoglobin (Hb) on the third day after the surgery, the active rang of motion (AROM) on the fifth day after the surgery, the hip-knee-ankle angle (HKA) three months after surgery, the knee joint clinical score(KS-C) and the knee joint functional score (KS-F) three months after the surgery in both groups, were recorded and analyzed statistically. The data of the same group before and after the surgery were analyzed by paired t test, and the data between the two groups was analyzed by independent t test.

Results

The surgical procedure durations of the KA-TKA and MA-TKA groups were (76.9±11.8) and (78.3±12.7) min, respectively, and the difference was not statistically significant(t=0.35, P>0.05). The HKA of the two groups after the surgery were (2.7±1.2) and (2.1±1.5) respectively, and the difference was not statistically significant (t=1.60, P>0.05). The Hb values of the two groups on the third day after the surgery were (113.3±9.1) and (111.3±8.2) g/L, respectively, and the difference was not statistically significant(t=0.70, P>0.05). The AROM values of the two groups on the fifth day after the surgery were (105.6±8.3) ° and (95.4±14.9)° respectively, the difference was statistically significant(t=2.50, P<0.05). The KS-C of the two groups three months after the surgery were (82.8±6.2) and (78.1±7.3) respectively, the difference was statistically significant(t=2.05, P<0.05). The KS-F of the two groups 3 months after the surgery were (80.3±10.9) and (71.3±14.3) respectively, the difference was statistically significant(t=2.09, P<0.05).

Conclusion

The KA-TKA can achieve better results than MA-TKA with conventional instruments, and will not increase the difficulty and risk of the operation.

Key words: Osteoarthritis, knee, Arthroplasty, replacement

图1 KA-TKA(运动学对线全膝关节置换术)术前计划及术后冠状位对线。图A为术前双下肢负重位全长X线，测量股骨及胫骨畸形角度，依照参照角度，拟术后下肢力线残留2°内翻；图B为胫骨冠状位截骨的体表标志点的确定(该病例指向外踝尖)；图C为术中依照术前计划的体表标志点行冠状位对线；图D为术后双下肢负重位全长X线，示恢复了患者原有的下肢力线

图2 KA-TKA(运动学对线全膝关节置换术)的胫骨侧对线。图A为胫骨旋转对线参考轴，确定外侧胫骨平台椭圆形关节面的长轴，并将该轴线平行移动到PCL止点中点处；图B为胫骨后倾，后倾角度的设定参考内侧胫骨平台的自然后倾；图C为胫骨内外翻对线，保持髓外定位杆近端旋转对线不变，定位杆远端移至术前规划的体表标志点

图3 KA-TKA(运动学对线全膝关节置换术)股骨侧对线。图A为股骨远端对线，使用髓内定位杆控制截骨导板矢状位定位，2 mm钕磁片补偿内侧股骨远端软骨磨损，外翻截骨导向器内外侧均与股骨髁紧密接触，以复制患者原有的生理外翻；图B为股骨后髁对线，0°旋转定位，优先使用后参考定位(如有)，或保守的后髁截骨(前参考定位器械)，先截后髁，再截其他各面

表1 KA-TKA与MA-TKA两组患者术前资料比较(±s)

分组	例数	年龄(岁)	术前HKA(°)	术前Hb(g/L)	术前AROM(°)	术前KS-C	术前KS-F
KA-TKA组	17	69±7	8±3	135±13	107±10	51±71	46±7
MA-TKA组	19	68±5	7±3	130±11	101±15	56±19	43±8
t值		0.63	1.50	1.08	1.55	1.09	1.17
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表1 KA-TKA与MA-TKA两组患者术前资料比较(±s)

分组	例数	年龄(岁)	术前HKA(°)	术前Hb(g/L)	术前AROM(°)	术前KS-C	术前KS-F
KA-TKA组	17	69±7	8±3	135±13	107±10	51±71	46±7
MA-TKA组	19	68±5	7±3	130±11	101±15	56±19	43±8
t值		0.63	1.50	1.08	1.55	1.09	1.17
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表2 KA-TKA组患者手术前后指标比较[n＝17，(±s)]

时间点	HKA(°)	KS-C评分	KS-F评分	Hb(g/L)	AROM(°)
术前	8.2±3.1	50.5±7.3	45.8±7.5	134.6±13.5	107.3±10.3
术后	2.7±1.2	82.8±6.2^a	80.3±10.9^a	113.3±9.1^b	105.6±8.3^c
t值	9.91	16.15	16.42	6.15	1.16
P值	<0.001	<0.001	<0.001	<0.001	>0.05

表2 KA-TKA组患者手术前后指标比较[n＝17，(±s)]

时间点	HKA(°)	KS-C评分	KS-F评分	Hb(g/L)	AROM(°)
术前	8.2±3.1	50.5±7.3	45.8±7.5	134.6±13.5	107.3±10.3
术后	2.7±1.2	82.8±6.2^a	80.3±10.9^a	113.3±9.1^b	105.6±8.3^c
t值	9.91	16.15	16.42	6.15	1.16
P值	<0.001	<0.001	<0.001	<0.001	>0.05

表3 MA-TKA组患者手术前后指标比较[n＝19，(±s)]

时间点	HKA(°)	KS-C评分	KS-F评分	Hb(g/L)	AROM(°)
术前	6.5±3.5	55.7±19.2	42.9±7.7	130.1±11.1	100.5±15.2
术后	2.1±1.5	78.1±7.3^a	71.3±14.3^a	111.3±8.2^b	95.4±14.9^c
t值	6.43	3.28	8.26	5.02	1.22
P值	<0.001	<0.01	<0.001	<0.001	>0.05

表3 MA-TKA组患者手术前后指标比较[n＝19，(±s)]

时间点	HKA(°)	KS-C评分	KS-F评分	Hb(g/L)	AROM(°)
术前	6.5±3.5	55.7±19.2	42.9±7.7	130.1±11.1	100.5±15.2
术后	2.1±1.5	78.1±7.3^a	71.3±14.3^a	111.3±8.2^b	95.4±14.9^c
t值	6.43	3.28	8.26	5.02	1.22
P值	<0.001	<0.01	<0.001	<0.001	>0.05

表4 KA-TKA与MA-TKA两组术后指标及手术时间比较(±s)

分组	例数	手术时间(min)	术后HKA(°)	术后第3天Hb(g/L)	术后第5天AROM(°)	术后3个月KS-C	术后3个月KS-F
KA-TKA组	17	76.9±11.8	2.7±1.2	113.3±9.1	105.6±8.3	82.8±6.2	80.3±10.9
MA-TKA组	19	78.3±12.7	2.1±1.5	111.3±8.2	95.4±14.9	78.1±7.3	71.3±14.3
t值		0.35	1.60	0.70	2.50	2.05	2.09
P值		>0.05	>0.05	>0.05	0.018	0.048	0.044

表4 KA-TKA与MA-TKA两组术后指标及手术时间比较(±s)

分组	例数	手术时间(min)	术后HKA(°)	术后第3天Hb(g/L)	术后第5天AROM(°)	术后3个月KS-C	术后3个月KS-F
KA-TKA组	17	76.9±11.8	2.7±1.2	113.3±9.1	105.6±8.3	82.8±6.2	80.3±10.9
MA-TKA组	19	78.3±12.7	2.1±1.5	111.3±8.2	95.4±14.9	78.1±7.3	71.3±14.3
t值		0.35	1.60	0.70	2.50	2.05	2.09
P值		>0.05	>0.05	>0.05	0.018	0.048	0.044

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Comparison of early clinical outcomes of kinematic and mechanical alignments in total knee arthroplasty

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Comparison of early clinical outcomes of kinematic and mechanical alignments in total knee arthroplasty