活动平台膝关节单髁置换术后蹲起活动的运动生物力学

doi:10.3877/cma.j.issn.1674-134X.2021.05.003

目的

对活动平台膝关节单髁置换术(UKA)后中远期患者膝关节的高载荷高屈曲度活动进行运动学特性和力矩分析，以评估UKA疗效、指导术后康复进程和预期并发症。

方法

本研究是临床队列研究。选取2016年6月至2018年6月收入西安交通大学第二附属医院行初次单侧内侧间室膝关节单髁置换手术患者，纳入经影像学诊断Kellgren & Lawrence分级1或2级)，排除下肢创伤、肿瘤、身体质量指数(BMI)≥26及有并发症(假体松动、感染、对侧骨关节炎进展)等病例，术后定期(12、18、24个月)随访复查并筛选功能康复状态稳定患者26例入组。应用VICON T40三维运动分析系统和AMTI压力反馈系统测量UKA患者自然下蹲动作模式下的运动学和力矩参数。同时入组健康人群22例作为对照组，双尾t检验比较UKA术后与健康肢体的蹲起模式差异。

结果

术后平均随访时间为(24.4±1.5)个月。术后一年期UKA患肢膝关节最大内翻角度(21.20±2.30)°，最大胫骨内旋角度(16.90±1.80)°，伸膝力矩峰值(0.310±0.040)N/kg，内旋力矩峰值(0.020±0.008)N/kg，均较健侧肢体和健康人群有明显降低(t＝2.6，P<0.05)，而内翻力矩峰值(1.220±0.050)N/kg较健侧肢体和健康人群有明显升高( t＝7.9，P<0.05)。

结论

活动平台UKA在改善患侧膝关节最大屈曲角度和伸膝力矩的同时对健侧肢体的生物力学指标无明显影响。术后早期患肢深度屈曲时伸肌力矩减少，内收肌力矩增加。随康复时间增加UKA患膝的活动度和伸肌力矩趋近于健康肢体，对中、长期理想的康复结果有积极的预测意义。

关键词: 关节成形术，置换，膝, 生物力学现象, 动力学, 功能恢复

Objective

To analyze knee kinematic and kinetic parameters after mobile bearing unicompartmental knee arthroplasty (UKA) during postoperative squatting-standing activity, so as to evaluate the efficacy of UKA, guide the process of postoperative rehabilitation and predict complications.

Methods

This study was a clinical cohort study. Thirty-one patients were admitted to the Second Affiliated Hospital of Xi’an Jiaotong University from June 2016 to June 2018 diagnosed with medial knee OA with primary UKA were followed up. After case screening, Kellgren & Lawrence stage one or two, lower limb trauma, tumor, excessive body mass index (BMI), and other complications were excluded, then 26 patients were recruited to take gait tests. Squatting-standing activities were performed under the test of Vicon T40 10-Camera Motion Analysis System and Advanced Medical Technology Incorporated (AMTI) force plates preoperatively at different stages after UKA (12, 18, 24 months). Twenty-two healthy subjects were enrolled as the control group, and the difference of squatting pattern between the healthy group and the UKA patients was compared by double-tail t test.

Results

The average duration of follow-up was (24.4±1.5)months. At one year follow-up, the peak values of varus angle (21.20±2.30) °, internal rotation angle (16.90±1.80) °, the torques of knee extension (0.310±0.040) N/kg and internal rotation (0.020±0.008) N/kg of the UKA knees were inferior to contralateral knees. The peak adductor moment (1.220±0.050) N/kg was superior to the contralateral knees.

Conclusions

Mobile UKA can improve the ROM and torques of the involved knee and don’t affect the biomechanical indicators of healthy limbs. OA knees show decreased torque of knee extension and increased torque of knee adduction during active deep flexion activity in early postoperative period. With rehabilitation time elongation, the patients can achieve better range of motion and more natural torques of knee extension and adduction, which may predict ideal functional outcome in medium and long terms.

Key words: Arthroplasty, replacement, knee, Biomechanical phenomena, Kinetics, Recovery of function

图1 入组患者全身外挂式步态标记(plug-in gait marker)

图2 完整蹲起动作周期模式示意图

表1 入组对象基本临床资料统计表

分组	例数	男/女(例)	患肢(左/右)	年龄[岁，(±s)]	身高(m)	体重[kg，(±s)]	BMI[kg/m²，(±s)]
UKA	26	10/16	9/17	66.00±4.00	1.63±0.11	66.40±10.10	24.70±0.80
正常组	22	10/12	-	32.00±7.00	1.68±0.12	68.20±10.60	24.30±0.90
统计值		χ²＝0.315	-	t＝21.50	t＝-1.57	t＝-0.63	t＝1.69
P值		>0.05	-	<0.05	>0.05	>0.05	>0.05
分组	例数	下肢长度[cm，(±s]		膝宽[cm，(±s)]		有支撑蹲起动作完成时间[s，(±s)]	无支撑蹲起动作完成时间[s，(±s)]
分组	例数	健侧	患侧	健侧	患侧	有支撑蹲起动作完成时间[s，(±s)]	无支撑蹲起动作完成时间[s，(±s)]
UKA	26	78.40±2.90	77.80±3.20	10.50±4.00	10.40±5.00	4.30±0.25	4.00±0.28
正常组	22	79.60±2.40	-	10.50±5.00	-	3.20±0.18	3.90±0.22
统计值		F＝2.68	-	F＝0.39	-	t＝-17.2	t＝0.39
P值		>0.05	-	>0.05	-	<0.05	>0.05

表1 入组对象基本临床资料统计表

分组	例数	男/女(例)	患肢(左/右)	年龄[岁，(±s)]	身高(m)	体重[kg，(±s)]	BMI[kg/m²，(±s)]
UKA	26	10/16	9/17	66.00±4.00	1.63±0.11	66.40±10.10	24.70±0.80
正常组	22	10/12	-	32.00±7.00	1.68±0.12	68.20±10.60	24.30±0.90
统计值		χ²＝0.315	-	t＝21.50	t＝-1.57	t＝-0.63	t＝1.69
P值		>0.05	-	<0.05	>0.05	>0.05	>0.05
分组	例数	下肢长度[cm，(±s]		膝宽[cm，(±s)]		有支撑蹲起动作完成时间[s，(±s)]	无支撑蹲起动作完成时间[s，(±s)]
分组	例数	健侧	患侧	健侧	患侧	有支撑蹲起动作完成时间[s，(±s)]	无支撑蹲起动作完成时间[s，(±s)]
UKA	26	78.40±2.90	77.80±3.20	10.50±4.00	10.40±5.00	4.30±0.25	4.00±0.28
正常组	22	79.60±2.40	-	10.50±5.00	-	3.20±0.18	3.90±0.22
统计值		F＝2.68	-	F＝0.39	-	t＝-17.2	t＝0.39
P值		>0.05	-	>0.05	-	<0.05	>0.05

表2 术后一年期随访各组角度峰值及达峰时间比较(±s)

组别	例数	角度峰值(°)			角度达峰值时间(s)
组别	例数	屈曲角度	内翻角度	内旋角度	屈曲峰时	内翻峰时	内旋峰时
健康人群	22	135.80±3.20	24.80±3.70	18.30±1.90	2.05±0.22	2.01±0.21	1.52±0.19
UKA患肢	26	118.60±2.70^a	21.20±2.30^a	16.90±1.80^a	1.48±0.18^a	1.75±0.20^a	1.14±0.17^a
UKA健肢	26	119.10±2.90^b	25.30±3.10^c	18.80±2.00^c	1.46±0.19^b	1.71±0.22^b	1.12±0.18^b
t值		20.2^a, 19.0^b	4.1^a，5.4^c	2.6^a，3.6^c	9.9^a，10.0^b	4.4^a，4.8^b	7.3^a，7.5^b
P值		<0.01^ab	<0.01^ac	0.012^a，<0.01^c	<0.01^ab	<0.01^ab	<0.01^ab

表2 术后一年期随访各组角度峰值及达峰时间比较(±s)

组别	例数	角度峰值(°)			角度达峰值时间(s)
组别	例数	屈曲角度	内翻角度	内旋角度	屈曲峰时	内翻峰时	内旋峰时
健康人群	22	135.80±3.20	24.80±3.70	18.30±1.90	2.05±0.22	2.01±0.21	1.52±0.19
UKA患肢	26	118.60±2.70^a	21.20±2.30^a	16.90±1.80^a	1.48±0.18^a	1.75±0.20^a	1.14±0.17^a
UKA健肢	26	119.10±2.90^b	25.30±3.10^c	18.80±2.00^c	1.46±0.19^b	1.71±0.22^b	1.12±0.18^b
t值		20.2^a, 19.0^b	4.1^a，5.4^c	2.6^a，3.6^c	9.9^a，10.0^b	4.4^a，4.8^b	7.3^a，7.5^b
P值		<0.01^ab	<0.01^ac	0.012^a，<0.01^c	<0.01^ab	<0.01^ab	<0.01^ab

表3 术后1年期随访各组力矩峰值及达峰时间比较(±s)

组别	例数	标准化力矩峰值(N/kg)			力矩达峰值时间(s)
组别	例数	伸膝力矩	内翻力矩	内旋力矩	伸膝力矩	内翻力矩	内旋力矩
健康人群	22	0.450±0.040	1.160±0.040	0.100±0.009	2.480±0.290	2.100±0.250	1.740±0.230
UKA患肢	26	0.310±0.040^a	1.220±0.050	0.020±0.008	2.720±0.300	1.780±0.240	1.110±0.200
UKA健肢	26	0.360±0.050^b	1.130±0.030^bc	0.070±0.010^bc	3.180±0.270^bc	1.750±0.290^b	1.300±0.180^bc
t值		12.1^a，6.8^b	3.0^b，7.9^c	10.8^b，19.9^c	8.7^b，5.8^c	4.4^b	7.4^b，3.8^c
P值		<0.01^ab	<0.01^bc	<0.01^bc	<0.01^ab	<0.01^b	<0.01^bc

表3 术后1年期随访各组力矩峰值及达峰时间比较(±s)

组别	例数	标准化力矩峰值(N/kg)			力矩达峰值时间(s)
组别	例数	伸膝力矩	内翻力矩	内旋力矩	伸膝力矩	内翻力矩	内旋力矩
健康人群	22	0.450±0.040	1.160±0.040	0.100±0.009	2.480±0.290	2.100±0.250	1.740±0.230
UKA患肢	26	0.310±0.040^a	1.220±0.050	0.020±0.008	2.720±0.300	1.780±0.240	1.110±0.200
UKA健肢	26	0.360±0.050^b	1.130±0.030^bc	0.070±0.010^bc	3.180±0.270^bc	1.750±0.290^b	1.300±0.180^bc
t值		12.1^a，6.8^b	3.0^b，7.9^c	10.8^b，19.9^c	8.7^b，5.8^c	4.4^b	7.4^b，3.8^c
P值		<0.01^ab	<0.01^bc	<0.01^bc	<0.01^ab	<0.01^b	<0.01^bc

图3 各组角度和力矩的蹲起动作时相图。图A~C分别为屈曲、内翻、内旋角度的蹲起动作时相图；图D~F分别为屈曲、内翻、内旋力矩的蹲起动作时相图

图4 术后各阶段无支撑下蹲膝关节屈曲角度和伸膝力矩变化。图A为屈伸力矩随康复时间变化箱形图；图B为屈伸力矩随康复时间变化相关分析；图C为屈曲角度随康复时间变化的箱形图；图D为屈曲角度随康复时间变化的相关分析

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Biomechanical properties of knee after unicompartmental knee arthroplasty during squatting and standing up

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Biomechanical properties of knee after unicompartmental knee arthroplasty during squatting and standing up