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中华关节外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (03) : 287 -294. doi: 10.3877/cma.j.issn.1674-134X.2022.03.005

临床论著

两种关节假体在双膝置换术后中期步态分析
高兴华1,†(), 刘永轶1, 陈霖1, 陈祥1, 林泽枫2   
  1. 1. 510180　广州市第一人民医院关节外科，华南理工大学
    2. 510010　广州，广东省骨科矫形技术及植入材料重点实验室，解放军南部战区总医院
  • 收稿日期:2021-08-01 出版日期:2022-06-01
  • 通信作者: 高兴华

Gait difference of two different prostheses in mid-term follow-up following bilateral knee replacements

Xinghua Gao1,†(), Yongyi Liu1, Lin Chen1, Xiang Chen1, Zefeng Lin2   

  1. 1. Department of Orthopaedics, Guangzhou First People's Hospital, South China University of Technology, Guangzhou 510180, China
    2. Guangdong Key Lab of Orthopedic Technology and Implant Materials, General Hospital of Southern Theater Command of PLA, Guangzhou 510010, China
  • Received:2021-08-01 Published:2022-06-01
  • Corresponding author: Xinghua Gao
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引用本文：

高兴华, 刘永轶, 陈霖, 陈祥, 林泽枫. 两种关节假体在双膝置换术后中期步态分析[J]. 中华关节外科杂志(电子版), 2022, 16(03): 287-294.

Xinghua Gao, Yongyi Liu, Lin Chen, Xiang Chen, Zefeng Lin. Gait difference of two different prostheses in mid-term follow-up following bilateral knee replacements[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2022, 16(03): 287-294.

目的

评价后稳定型假体(PS)/后交叉韧带保留型假体(CR)在双侧膝关节置换术后中期的三维运动步态特征。

方法

病例组纳入广州市第一人民医院双侧膝关节置换术后约5年的膝骨关节炎患者，Kellgren-Lawrence分级为Ⅲ级或Ⅳ级，排除单侧膝关节置换、身体质量指数>30 kg/m2等的患者。根据假体类型不同分为两组：后稳定型假体(PS)组和保留后交叉韧带型假体(CR)组，各30人，共60例，120膝。对照组选取同龄健康老年人，共15人，30膝。随访膝关节协会评分(KSS评分)、视觉模拟评分法(VAS评分)及西大略湖和麦克马斯特大学膝关节评分(WOMAC评分)。运用Opti-Knee膝关节三维运动系统测试步态，选取支撑相(初、中、末期)及摆动相的相关数据分析。所有数据采用单因素方差分析，组间两两比较采用Bonferroni检验。

结果

KSS评分、VAS评分三组间差异无统计学意义(均为P>0.05)。WOMAC评分三组比较差异有统计学意义(F＝5.491，P<0.05)，其中PS组高于对照组(P<0.05)。支撑相初期，内外移三组比较差异有统计学意义(F＝84.720，P<0.05)，CR组与对照组、PS组比较，CR组大于其它两组，差异均有统计学意义(均为P<0.05)；支撑相中期，伸展角三组比较差异有统计学意义(F＝7.779，P<0.05)，PS组小于对照组(P<0.05)；支撑相末期，伸展角及内外移三组比较差异有统计学意义(F＝5.836、3.185，均为P<0.05)。PS组比对照组小，且差异均有统计学意义(P <0.05)。摆动相时，内旋角、屈曲角、胫骨外移三组比较差异有统计学意义(F＝10.93、9.089、4.645，均为P<0.05)，CR组内旋角小于对照组(P <0.05)，CR组屈曲角比PS组大(P<0.05)；胫骨外移PS组明显小于对照组(P<0.05)。

结论

在双侧TKA术后PS假体与CR假体患者的中期步态结果中许多指标仍不如同龄健康人，其中CR假体患者三维运动步态结果比PS假体患者更接近同龄成年人。

关键词: 关节成形术，置换，膝, 人工膝关节, 假体和植入物, 步态
Objective

To evaluate and compare the three-dimensional gait parameters of posterior stabilized prosthesis(PS)/cruciate retention ligament(CR)prosthesis after bilateral knee replacement.

Methods

All the patients after bilateral knee replacement in Guangzhou First People′s Hospital for about five years were followed up, and the Kellgren-Lawrence classification was Ⅲ to Ⅳ grade. The patients of unilateral knee replacement and body mass index over 30 kg/m2 and so on were excluded. According to the different types of implant, the patients were divided into two groups, the posterior stabilized prosthesis (PS) group and the cruciate retention ligament (CR) group, 30 cases in each group. The control group were 15 healthy adults of the same age(30 knees). Knee Society score (KSS), visual analogue scale (VAS) and the Western Ontario and Mcmaster Universities (WOMAC) osteoarthritis index were evaluated. The gait was recorded and analyzed by the Opti-Knee three-dimensional motion analysis system. The parameters were recorded in supporting phase and swing phase. The repeated measurement ANOVA was used for comparison, and Bonferroni test was used for comparison between two groups.

Results

There was no significant difference in KSS, VAS in PS group, CR group and control group(both P>0.05). The differences of WOMAC score among the three groups were statistically significant(F=5.491, P<0.05), and the PS group was higher than the control group(P<0.05). At initial stage of the supporting phase, the differences of the medial and lateral displacements were statistically significant among the three groups (F=84.720, P<0.05); the data of the CR group were larger than the other groups(both P<0.05). During the middle supporting phase, the extension angles were different among the three groups(F=7.779, P<0.05); the data of the PS group were smaller than the control group(P<0.05). At the end of the supporting phase, the extension angles and medial/lateral displacements were different among the three groups (F=5.836, 3.185, both P<0.05); the data of the PS group were smaller than the control group (P <0.05). At the swing phase, the differences of the internal rotation, flexion angle and external displacement were statistically significant among the three groups (F=10.93, 9.089, 4.645, all P<0.05). The internal rotation of the CR group was smaller than the control group (P<0.05). The flexion angle of CR group was larger than that of the PS group (P<0.05). The external displacement of the PS group was smaller than the control group (P<0.05).

Conclusions

At mid term follow-up after bilateral TKA, most of the gait parameters of the patients with PS/CR implants may still inferior to the healthy people of the same age. The three-dimentional gait of the patients with CR prosthesis are more similar to the healthy adults, which are better than the patients with PS prosthesis.

Key words: Arthroplasty, replacement, knee, Knee prosthesis, Prostheses and implants, Gait
图1 PS(后稳定型)组术前术后双膝关节正侧位X线片。图A为双膝关节术前正位X线片，示内侧间隙变窄；图B为右膝关节术前侧位X线片；图C为左膝关节术前侧位X线片；图D为双膝关节PS假体术后正位X线片，示假体大小合适、间隙对称；图E为右膝关节PS假体术后侧位X线片，示假体位置正常、髌骨置换术后改变；图F为左膝关节PS假体术后侧位X线片，示假体大小合适、髌股间隙好注：假体为Depuy Attune PS系统
图2 CR(保留后交叉韧带型)组术前术后双膝关节正侧位X线片。图A为双膝关节术前正位X线片，示内侧间隙变窄；图B为右膝关节术前侧位X线片；图C为左膝关节术前侧位X线片；图D为双膝关节CR假体术后正位X线片，示假体位置良好；图E为右膝关节CR假体术后侧位X线片，是假体位置正常；图F为左膝关节CR假体术后侧位X线片，示假体大小合适注：假体为Depuy Attune CR系统
表1 研究对象末次随访基线资料(±s)
分组 例数 年龄(岁) 身高(cm) 体重(kg) BMI(kg/m2)
PS组 30 67±7 156±5 67±11 27±5
CR组 30 64±5 154±6 63±7 24±7
对照组 15 64±6 158±3 65±8 24±6
F值   1.546 3.086 1.358 1.601
P值   >0.05 >0.05 >0.05 >0.05
表2 末次随访患者膝关节功能及疼痛评分(±s)
分组 例数 KSS评分 VAS评分 WOMAC评分
PS组 30 88.1±7.5 2.3±0.9 25.7±10.9
CR组 30 85.3±8.7 87.0±4.2 20.6±3.9
对照组 15 87.0±4.2 2.0±0.6 18.6±0.6*
F值   0.994 2.023 5.491
P值   >0.05 >0.05 0.006
表3 三组运动步态图支撑相参数结果(±s)
脚跟着地时 例数 内翻(-)/外翻(+)(°) 内旋(-)/外旋(+)(°) 屈曲(-)/伸展(+)(°) 前移(-)/后移(+)(mm) 上移(-)/下移(+)(mm) 内移(-)/外移(+)(mm)
PS组 30 1.9±1.8 -1.7±2.3 14.7±7.1 -4.8±5.9 8.2±2.5 -1.6±3.4a
CR组 30 2.4±2.5 -1.3±3.9 12.0±9.7 -5.3±4.9 8.4±1.6 7.5±2.0b
对照组 15 2.7±2.4 -1.3±3.4 15.9±7.9 -4.4±2.9 7.5±5.4 -1.1±3.0
F值   0.591 0.196 1.327 0.200 0.451 87.420
P值   >0.05 >0.05 >0.05 >0.05 >0.05 <0.001
50%站立中期 例数 内翻(-)/外翻(+)(°) 内旋(-)/外旋(+)(°) 屈曲(-)/伸展(+)(°) 前移(-)/后移(+)(mm) 上移(-)/下移(+)(mm) 内移(-)/外移(+)(mm)
PS组 30 0.9±1.7 -1.5±2.1 2.9±2.4 -3.8±6.1 8.4±2.2 -0.9±3.0
CR组 30 1.1±2.2 -0.8±2.1 5.7±4.9 -1.6±5.3 8.6±2.5 0.5±3.5
对照组 15 0.8±1.9 -2.3±3.9 7.8±4.8c -1.9±2.7 7.1±6.7 0.9±3.9
F值   0.166 1.623 7.799 1.397 0.928 1.949
P值   >0.05 >0.05 0.001 >0.05 >0.05 >0.05
脚跟离地(站立期末相) 例数 内翻(-)/外翻(+)(°) 内旋(-)/外旋(+)(°) 屈曲(-)/伸展(+)(°) 前移(-)/后移(+)(mm) 上移(-)/下移(+)(mm) 内移(-)/外移(+)(mm)
PS组 30 0.5±1.8 -2.4±1.9 4.6±2.9a -4.6±5.2 12.3±1.7 -0.5±2.5
CR组 30 0.5±2.5 -0.9±2.1 7.2±4.1 -3.1±4.8 12.8±2.7 -0.1±2.5
对照组 15 0.6±1.5 1.0±0.4 8.3±4.7c -1.4±2.0 11.8±6.4 1.9±4.7c
F值   0.040 2.734 5.836 2.521 0.458 3.185
P值   >0.05 >0.05 0.005 >0.05 >0.05 0.047
表4 三组运动步态图摆动相参数最大值及运动过程中活动范围(±s)
摆动相最大值 例数 外翻(°) 胫骨内旋(°) 屈曲(°) 胫骨后移(mm) 胫骨上移(mm) 胫骨外移(mm)
PS组 30 5.9±2.6 6.9±1.9 45.9±7.6a 12.8±5.2 15.6±2.4 1.7±2.8
CR组 30 6.1±2.4 8.2±2.6b 54.7±9.3 13.6±3.8 15.9±3.3 3.5±2.8
对照组 15 7.6±2.0 10.9±4.2c 51.8±5.9 14.5±1.9 15.4±4.8 4.3±3.9c
F值   2.791 10.93 9.089 0.891 0.117 4.645
P值   >0.05 <0.001 <0.001 >0.05 >0.05 0.013
运动步态活动范围 例数 内外翻(°) 内外旋(°) 屈曲/伸展(°) 前后位移(mm) 上下位移(mm) 内外位移(mm)
PS组 30 7.0±2.4 7.7±2.8a 44.8±7.4a 11.3±3.7a 9.2±3.3 6.7±2.3
CR组 30 6.6±2.7 10.7±3.3 51.1±11.4 14.4±5.7 9.7±3.2b 7.5±2.0
对照组 15 8.3±2.3 11.7±4.1c 46.6±7.6 14.8±2.0c 12.5±4.8c 7.9±3.0
F值   2.369 9.843 3.592 5.105 4.402 1.525
P值   >0.05 <0.001 0.032 0.008 0.015 >0.05
图3 PS(后稳定型假体)组、CR(后交叉保留型假体)组对照组步态周期的各曲线参数。图A为胫骨内外翻曲线，示支撑相时PS组与CR组基本接近对照组，摆动相时两组均小于对照组；图B为胫骨内外旋曲线，呈内旋状态，PS组与CR组均位于对照组上方；图C为屈曲伸展曲线，示支撑相时为伸展，摆动相为屈曲，CR组与对照组均位于PS组上方；图D为胫骨前后位移曲线，示PS组与CR组摆动相后移均小于对照组；图E为胫骨上下位移曲线，示CR组与对照组曲线均位于PS组上方；图F为胫骨内外位移曲线，示PS组与CR组胫骨内外位移均比小于对照组
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