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中华关节外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (02) : 201 -208. doi: 10.3877/cma.j.issn.1674-134X.2023.02.008

临床论著

全膝关节置换术行髌骨置换的疗效及其影响因素
刘亚茹, 毛彦杰, 张仁波, 何阿祥, 张先龙, 刘万军†()   
  1. 201306　上海海洋大学食品学院；201306　上海市第六人民医院骨科
    201306　上海市第六人民医院骨科
  • 收稿日期:2022-06-23 出版日期:2023-04-01
  • 通信作者: 刘万军
  • 基金资助:
    民生科研专项资金医疗卫生项目(PKJ2018-Y54); 上海市卫健委健康老龄化项目(2020YJZX0120); 上海市2021年度"科技创新行动计划"自然科学基金面项目(21ZR1448900)

Efficacy of patellar replacement on total knee arthroplasty and influencing factors

Yaru Liu, Yanjie Mao, Renbo Zhang, Axiang He, Xianlong Zhang, Wanjun Liu†()   

  1. College of Food Science &Technology, Shanghai Ocean University, Shanghai 201306, China; Department of Orthopedics, Shanghai Sixth People's Hospital, Shanghai 201306, China
    Department of Orthopedics, Shanghai Sixth People's Hospital, Shanghai 201306, China
  • Received:2022-06-23 Published:2023-04-01
  • Corresponding author: Wanjun Liu
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引用本文：

刘亚茹, 毛彦杰, 张仁波, 何阿祥, 张先龙, 刘万军. 全膝关节置换术行髌骨置换的疗效及其影响因素[J]. 中华关节外科杂志(电子版), 2023, 17(02): 201-208.

Yaru Liu, Yanjie Mao, Renbo Zhang, Axiang He, Xianlong Zhang, Wanjun Liu. Efficacy of patellar replacement on total knee arthroplasty and influencing factors[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2023, 17(02): 201-208.

目的

本研究旨在探讨髌骨置换对于全膝关节置换术(TKA)的疗效及其影响因素。

方法

回顾性纳入并分析2020年3月至2021年3月在上海市第六人民医院骨科行TKA治疗，随访时间超过1年且资料完整的170例患者，排除有关节感染病史、髌骨厚度<20 mm、严重的骨质疏松患者及翻修患者。按手术方式分为3组，髌骨保留组(75例78膝行TKA未置换髌骨)、普通髌骨组(65例65膝行TKA并置换普通髌骨)和解剖髌骨组(30例30膝行TKA并置换解剖髌骨)。随访期间记录收集美国膝关节外科协会(KSS)临床及功能评分、西安大略和麦克马斯特大学(WOMAC)骨关节炎指数、髌骨评分(PS)结果，并观察膝前痛、髌骨弹响及下蹲的情况。影像学检查假体位置。通过logistic回归分析术后评分高低、有无膝前痛、有无异响、能否下蹲的影响因素。

结果

三组术前PS评分、KSS功能评分、术前和术后1年KSS临床评分、WOMAC评分以及术后1年膝前痛、异响发生率及下蹲困难率比较，差异均无统计学意义(均为P>0.05)。术后1年普通髌骨组(74±10)及解剖髌骨组(75±9)的KSS功能评分显著高于髌骨保留组(70±12)(t＝-2.487，P＝0.014；t＝-2.120，P＝0.036)。此外，普通髌骨组术后1年PS评分(21.7±4.9)显著高于髌骨保留组(19.5±3.9)(t＝-2.862，P＝0.005)。身体质量指数(BMI)每增加1 kg/m2，术后可能出现髌骨评分低的概率是出现评分高概率的1.186倍[优势比(OR)＝1.186，95%置信区间(CI)＝(1.017，1.384)]，其余未观察到独立影响因素。影像学结果显示，随访期间无假体骨折、松动，感染情况的发生。

结论

TKA术后早期髌骨置换较髌骨保留能显著改善临床功能评分，但解剖髌骨与普通髌骨相比其没有明显优势。

关键词: 关节成形术，置换，膝, 骨关节炎, 髌骨
Objective

To investigate the efficacy of patellar replacement for total knee arthroplasty(TKA) and its influencing factors.

Methods

A retrospective study was carried out on 170 patients who underwent TKA for severe knee osteoarthritis at the Department of Orthopaedics, Shanghai Sixth People's Hospital from March 2020 to March 2021. Complete data were collected from the patients at one year after surgery. The exclusion criteria: those with a history of joint infection, patellar thickness <20 mm, severe osteoporosis and revision surgery. According to the operation procedures, patients were divided into three groups: the patellar preservation group (TKA only, no patellar resurfacing, 78 knees of 75 patients), the traditional patellar resurfacing group (TKA plus a patellar resurfacing with regular patella prosthesis, 65 knees of 65 patients), and the anatomical patellar resurfacing group (TKA plus a patellar resurfacing with anatomical patella prosthesis). American Knee Surgery Society (KSS) clinical and functional scores, West Ontario and McMaster Universities (WOMAC) osteoarthritis index, and patellar score (PS) were employed in the patient assessment. Pain in anterior knee, patellar crepitus and ability to squat during follow-up were observed and recorded. X-rays were taken to check the component position. Factors influencing postoperative scores, presence or absence of anterior knee pain, patellar crepitus and ability to squat were analysed by logistic regression.

Results

It was found that there were no statistically significant differences in the preoperative PS scores, preoperative and one-year postoperative KSS clinical scores and WOMAC scores, as well as in the incidences of anterior knee pain, crepitus and difficulty in squatting one year after surgery among the three groups (all P>0.05). The KSS functional score at one year after surgery in both of the traditional patellar resurfacing group (74±10) and the anatomical patellar resurfacing group (75±9) was found higher than that in the patellar preservation group (70±12) (t=-2.487, P=0.014; t=-2.120, P=0.036). As for the PS score, the traditional patellar resurfacing group (21.7±4.9) was significantly higher than the patellar preservation group (19.5±3.9) (t=-2.862, P=0.005) at one year after surgery. It was also noticed that for every 1 kg/m2 increase in body mass index (BMI), the probability of having a low patella score was 1.186 times higher than the probability of having a high patella score [odd ratio (OR)=1.186, 95% confidence interval (CI)= (1.017, 1.384)]. No independent influence factor was observed for the other factors. X-rays showed neither fracture, loosening of the prosthesis nor infection during the follow-up.

Conclusion

A patellar resurfacing in early postoperative TKA significantly improves clinical function scores in comparison with a patellar preservation. However, an anatomical patellar prosthesis shows no significant advantage compared with a traditional patellar prosthesis.

Key words: Arthroplasty, replacement, knee, Osteoarthritis, Patella
表1 患者一般资料
Table 1 Basic information of patients
组别Group 例数Case number 年龄Age [岁，(±s)] 性别(男/女) Gender (male/female) 身高Height [cm，(±s)] 体重Weight [kg，(±s)] BMI [kg/m2，(±s)]
髌骨保留组Patellar preservation group 75 67.4±8.1 11/64 156.9±7.9 64.2±7.8 25.7±3.9
普通髌骨组Traditional patellar resurfacing group 65 67.5±9.0 5/60 158.8±6.3 65.1±7.3 25.5±2.8
解剖髌骨组Anatomic patellar resurfacing group 30 70.7±8.4 5/25 158.8±7.9 62.1±7.7 27.1±3.4
统计值   F＝1.806 χ2＝2.190 F＝1.436 F＝1.507 F＝2.199
P值   >0.05 >0.05 >0.05 >0.05 >0.05
表2 三组患者KSS临床和功能评分比较(±s)
Table 2 Comparison of KSS clinical and functional scores between the groups
组别Group 例数Case number KSS临床评分KSS clinical score KSS功能评分KSS functionality score
术前Before surgery 术后1年One year after surgery 术前Before surgery 术后1年One year after surgery
髌骨保留组Patellar preservation group 75 18±7 77±10 14±6 70±12
普通髌骨组Traditional patellar resurfacing group 65 17±7 77±9 144±74 74±10*
解剖髌骨组Anatomic patellar resurfacing group 30 16±7 76±8 144±64 75±9*
F值   1.055 0.105 0.115 4.164
P值   >0.05 >0.05 >0.05 0.017
表3 三组患者WOMAC评分和PS比较(±s)
Table 3 Comparison of WOMAC score and PS between the groups
组别Group 例数Case number WOMAC PS
术前Before surgery 术后1年One year afger surgery 术前Before surgery 术后1年One year afger surgery
髌骨保留组Patellar preservation group 75 36.4±3.8 8.5±2.3 8.2±2.4 19.5±3.9
普通髌骨组Traditional patellar resurfacing group 65 36.7±4.4 7.9±2.0 8.9±2.9 21.7±4.9*
解剖髌骨组Anatomic patellar resurfacing group 30 35.6±4.0 7.8±2.4 8.2±2.3 20.9±5.4
F值   0.795 2.114 1.536 3.983
P值   >0.05 >0.05 >0.05 0.020
表4 膝前痛、异响发生率和下蹲困难率比较[例(%)]
Table 4 Comparison of anterior knee pain、crepitus and difficulty in squatting between the groups
组别Group 例数Case number 膝前痛Anterior knee pain 异响率Crepitus 下蹲困难率Difficulty in squatting
髌骨保留组Patellar preservation group 75 28(37.3) 32(42.7) 41(54.7)
普通髌骨组Traditional patellar resurfacing group 65 19(29.2) 24(35.8) 32(49.2)
解剖髌骨组Anatomic patellar resurfacing group 30 10(33.3) 12(40.0) 14(46.7)
χ2值   1.026 0.479 0.708
P值   >0.05 >0.05 >0.05
表5 影响术后PS评分高低的因素
Table 5 Factors affecting postoperative PS scores
变量Variables   回归系数Regression coefficient SE OR值 P值 95% CI
年龄Age   0.030 0.030 1.031 0.320 (0.971，1.094)
BMI   0.171 0.079 1.186 0.030 (1.017，1.384)
聚乙烯垫片厚度对比5 mm Thickness of polyethylene comparing to 5mm -0.007 0.734 0.993 0.993 (0.235，4.190)
胫骨平台假体型号对比2# Tibial component size comparing to 2 # 3# 1.428 1.202 4.170 0.235 (0.395，43.979)
  4# 1.602 1.329 4.963 0.228 (0.367，67.102)
  5# 1.726 1.452 5.616 0.235 (0.326，96.681)
  6# 1.877 1.71 6.535 0.272 (0.229，186.530)
股骨平台假体型号对比3# Femoral component size comparing to 3 # 4# -0.692 0.808 0.501 0.392 (0.103，2.441)
  5# -0.282 0.775 0.754 0.716 (0.165，3.445)
  6# -0.156 1.136 0.856 0.891 (0.092，7.936)
髌骨假体大小对比29 mm Patella component size comparing to 29 mm 32 mm 0.013 0.525 1.013 0.980 (0.362，2.836)
  35 mm -1.096 0.869 0.334 0.207 (0.061，1.835)
图1 典型病例左侧TKA(膝关节置换)术中及术后情况。图A为术前测量髌骨厚度20 mm；图B为使用截骨导向器截7.5 mm厚度；图C为骨床准备完毕；图D为髌骨和股骨假体试模安装后测试髌骨轨迹满意；图E为髌骨假体置换后厚度19 mm；图F为解剖型假体和普通型假体的对比；图G为术后左膝正侧位X线片，示假体位置良好；图H为术后1年随访时患者下蹲情况
Figure 1 Intra-operative process and postoperative results of a left knee TKA. A is measurement of the patellar thickness which was 20 mm; B is a 7.5 mm thickness of the patellar removed using an osteotomy guide; C is preparing bony base for patella prosthesis; D shows that after installation of patellar prosthesis and femoral trial implants, the patellar trajectory was tested and the results were satisfactory; E shows the overall patellar thickness at 19 mm after patellar resurfacing; F is the comparison of anatomical and traditional patellar prostheses; G is anterior-posterior and lateral views of postoperative X rays, showing good position of the implants; H shows that the patient is able to squat at one year after the surgery
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