全膝股骨假体矢状面位置与术后膝前痛及功能的关系

doi:10.3877/cma.j.issn.1674-134X.2023.04.004

目的

本研究旨在回顾性研究股骨矢状面位置与人工全膝关节置换术后膝前痛及关节功能的相关性。

方法

本研究纳入广州医科大学附属第六医院保守治疗无效的终末期膝骨关节炎接受人工全膝关节表面置换的患者99例(共99膝)，排除感染性、炎症性关节炎及合并脊柱、髋或踝关节病变患者，随访时间节点为术后1年。本研究分别采用患者报告结局(PROMs)包括美国膝关节协会评分(KSS)，西大略和麦克马斯特大学骨关节炎指数评分(WOMAC)，膝关节置换术后遗忘评分(FKS)及患者满意度评分，医师报告临床结局(CROMs)，包括膝关节活动度(ROM)、股骨前髁偏心距及股骨远端前皮质线与股骨假体纵轴线的夹角(α角)。根据α角分为股骨假体屈曲组(α角>0°)及股骨假体过伸组(α角<0°)，并利用t检验及一元二次方程分别统计分析α角与PROMs及CROMs的相关性。

结果

股骨假体屈曲组的术后PROMs优于股骨假体过伸组(KSS关节评分t＝2.764、功能评分t＝2.215、FKS t＝4.012、满意度t＝2.492，均为P<0.05)，而假体屈曲组患者术后膝前痛的发生率10.0%明显低于假体过伸组28.6%(χ²＝5.504，P＝0.019)，一元二次方程分析显示α角与术后股骨前髁偏心距比值(ACO)存在凸面向上的弧形相关性，其中顶点的α角为2.411°，相应的ACO比值为20.5%(P＝0.006)。

结论

相对于股骨假体过伸的患者，股骨假体屈曲的患者术后膝前痛发生率较低，且术后关节功能恢复较好，可能与术后股骨前髁偏心距降低从而对股骨假体矢状面位置影响较小有关。

关键词: 骨关节炎, 关节成形术，置换, 人工膝关节, 髌股疼痛综合征

Objective

To retrospectively analyse the correlations between sagittal position of the femoral prothesis and patellofemoral pain as well as joint function after total knee arthroplasty(TKA).

Methods

A total of 99 patients with end-stage knee osteoarthritis who failed to respond to conservative treatment and underwent total knee arthroplasty in the Sixth Affiliated Hospital of Guangzhou Medical University were enrolled. Patients with infectious, inflammatory arthritis and spinal, hip or ankle joint lesions were excluded, and the follow-up time was one year after surgery. In this study, patient-reported outcome measures (PROMs) included Knee Society score (KSS), the Western Ontario and McMaster (WOMAC), forgotten knee score (FKS)and patient satisfaction scores, clinician-reported outcome measures (CROMs), including range of motion (ROM), anterior condylar offset (ACO) and the angle between the flange of the femoral component (FC) and the distal femur anterior cortex line (α angle). According to the α angle, the patients were divided into two groups, the FC flexion group (α angle>0°) and the FC extension group (α angle<0°). The correlations between PROMs and CROMS were analyzed by t test and secondary regression.

Results

Postoperative PROMs in the FC flexion group were better than those in the FC extension group (KSS joint score t=2.764, functional score t=2.215, FKS t=4.012, satisfaction scores t=2.492, P<0.05), while the incidence of postoperative anterior knee pain in the FC flexion group (10.0%) was significantly lower than that in the FC extension group (28.6%)(χ²=5.504, P=0.019), secondary regression analysis indicated that there was a convex upward correlation between the α angle and the postoperative ACO ratio. The α angle at the vertex was 2.411°, corresponding to the ACO ratio was 20.5% (P=0.006).

Conclusion

Compared with patients with FC extension, patients with FC flexion have a lower incidence of anterior knee pain and better recovery of joint function, which may be associated with the reduction of postoperative ACO having less effect on the sagittal plane position of FC.

Key words: Osteoarthritis, Arthroplasty, replacement, Knee prosthesis, Patellofemoral pain syndrome

图1 ACO(股骨前髁偏心距)及α角的测量方法。图A示术前ACO的测量，ACO比值＝ACO /股骨直径；图B示术后ACO的测量，ACO比值＝ACO /股骨直径；图C示术后股骨假体过伸时α角的测量；图D示术后股骨假体屈曲时α角的测量注：Anterior Condylar Offset-股骨前髁偏心距(ACO)；Femoral Diameter-股骨直径

Figure 1 The measuring methods of anterior condylar offset (ACO) and the α angle. A shows ACO measurement before operation, ACO ratio＝ACO / femoral diameter; B shows ACO measurement after operation, ACO ratio＝ACO / femoral diameter; C shows α angle measurement at extension position of femoral component after operation; D shows α angle measurement at flexion position of femoral component after operation

表1 患者一般情况

Table 1 General information of the patients

组别Groups	例数Number of cases	性别Gender(例)		年龄[岁，(±s)] Age	BMI[kg/m²，(±s)]	骨密度^*(±s) Bone mass density
组别Groups	例数Number of cases	Male	Female	年龄[岁，(±s)] Age	BMI[kg/m²，(±s)]	骨密度^*(±s) Bone mass density
假体屈曲组Prosthesis flexion group	50	9	41	70.9±5.3	25.2±3.8	－2.3±1.6
假体过伸组Prosthesis extension group	49	8	41	70.2±5.4	25.6±3.9	－2.1±1.6
统计值		χ²＝0.049		t＝0.630	t＝－0.563	t＝－0.554
P值		>0.05		>0.05	>0.05	>0.05
组别Groups	例数Number of cases	畸形类型(例) Deformity		住院天数Hospitalization[d，(±s)]	病变程度(例) (K-L level)
组别Groups	例数Number of cases	内翻Varus	外翻Valyum	住院天数Hospitalization[d，(±s)]	Ⅲ级	Ⅳ级
假体屈曲组Prosthesis flexion group	50	37	13	16.6±6.2	16	34
假体过伸组Prosthesis extension group	49	38	11	17.0±6.0	17	32
统计值		χ²＝0.170		t＝－0.310	χ²＝0.081
P值		>0.05		>0.05	>0.05

表1 患者一般情况

Table 1 General information of the patients

组别Groups	例数Number of cases	性别Gender(例)		年龄[岁，(±s)] Age	BMI[kg/m²，(±s)]	骨密度^*(±s) Bone mass density
组别Groups	例数Number of cases	Male	Female	年龄[岁，(±s)] Age	BMI[kg/m²，(±s)]	骨密度^*(±s) Bone mass density
假体屈曲组Prosthesis flexion group	50	9	41	70.9±5.3	25.2±3.8	－2.3±1.6
假体过伸组Prosthesis extension group	49	8	41	70.2±5.4	25.6±3.9	－2.1±1.6
统计值		χ²＝0.049		t＝0.630	t＝－0.563	t＝－0.554
P值		>0.05		>0.05	>0.05	>0.05
组别Groups	例数Number of cases	畸形类型(例) Deformity		住院天数Hospitalization[d，(±s)]	病变程度(例) (K-L level)
组别Groups	例数Number of cases	内翻Varus	外翻Valyum	住院天数Hospitalization[d，(±s)]	Ⅲ级	Ⅳ级
假体屈曲组Prosthesis flexion group	50	37	13	16.6±6.2	16	34
假体过伸组Prosthesis extension group	49	38	11	17.0±6.0	17	32
统计值		χ²＝0.170		t＝－0.310	χ²＝0.081
P值		>0.05		>0.05	>0.05

表2 假体屈曲组及过伸组的医师报告临床结局相关情况(±s)

Table 2 Clinician-reported outcomes of the prosthesis flexion group and the prosthesis extension group

组别Groups	例数Number of cases	ACO比值(%) ACD ratio	膝关节活动度(°) Range of invtion of knee
组别Groups	例数Number of cases	ACO比值(%) ACD ratio	伸直Extension	屈曲Flexion
假体屈曲组Prosthesis flexion group	50	20.3±4.0	－2.8±3.4	118.4±16.2
假体过伸组Prosthesis extension group	49	22.4±5.7	－1.8±3.6	111.5±14.3
t值		2.165	1.477	2.253
P值		0.033	>0.05	0.027

表2 假体屈曲组及过伸组的医师报告临床结局相关情况(±s)

Table 2 Clinician-reported outcomes of the prosthesis flexion group and the prosthesis extension group

组别Groups	例数Number of cases	ACO比值(%) ACD ratio	膝关节活动度(°) Range of invtion of knee
组别Groups	例数Number of cases	ACO比值(%) ACD ratio	伸直Extension	屈曲Flexion
假体屈曲组Prosthesis flexion group	50	20.3±4.0	－2.8±3.4	118.4±16.2
假体过伸组Prosthesis extension group	49	22.4±5.7	－1.8±3.6	111.5±14.3
t值		2.165	1.477	2.253
P值		0.033	>0.05	0.027

表3 假体屈曲组及过伸组的患者报告临床结局相关情况

Table 3 Patient-reported outcomes were measured among the femoral component flexion group and the femoral component extension group

组别Groups	例数Number of cases	KSS(±s)		WOMAC (±s)
组别Groups	例数Number of cases	关节评分Joint score	功能评分Functional score	WOMAC (±s)
假体屈曲组Prosthesis flexion group	50	90.2±5.9	65.8±17.3	26.9±4.8
假体过伸组Prosthesis extension group	49	87.2±5.0	59.0±12.9	27.6±4.3
t值		2.764	2.215	－0.683
P值		0.007	0.029	>0.05
组别Groups	例数Number of cases	FKS (±s)	满意度(±s) Satisfaction score	膝前痛[例(%)] Patellofemoral pain
假体屈曲组Prosthesis flexion group	50	71.5±19.9	8.2±1.3	5/50 (10.0)
假体过伸组Prosthesis extension group	49	55.6±19.7	7.6±1.3	14/49(28.6)
统计值		t＝4.012	t＝2.492	χ²＝5.504
P值		<0.001	0.014	0.019

表3 假体屈曲组及过伸组的患者报告临床结局相关情况

Table 3 Patient-reported outcomes were measured among the femoral component flexion group and the femoral component extension group

组别Groups	例数Number of cases	KSS(±s)		WOMAC (±s)
组别Groups	例数Number of cases	关节评分Joint score	功能评分Functional score	WOMAC (±s)
假体屈曲组Prosthesis flexion group	50	90.2±5.9	65.8±17.3	26.9±4.8
假体过伸组Prosthesis extension group	49	87.2±5.0	59.0±12.9	27.6±4.3
t值		2.764	2.215	－0.683
P值		0.007	0.029	>0.05
组别Groups	例数Number of cases	FKS (±s)	满意度(±s) Satisfaction score	膝前痛[例(%)] Patellofemoral pain
假体屈曲组Prosthesis flexion group	50	71.5±19.9	8.2±1.3	5/50 (10.0)
假体过伸组Prosthesis extension group	49	55.6±19.7	7.6±1.3	14/49(28.6)
统计值		t＝4.012	t＝2.492	χ²＝5.504
P值		<0.001	0.014	0.019

图2 ACO(股骨前髁偏心距)比值及α角相关性的拟合方程分析注： y＝－0.038χ² +1.557x－13.538；顶点值：ACO比值＝20.5%，α角＝2.411°；(r² ＝0.102，P ＝0.006)

Figure 2 Secondary regression analysis of the correlation between the postoperative anterior condylar offset ratio and α angle

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Correlations in sagittal position of femoral componenet of knee arthroplasty and postoperative patellofemoral pain and joint function

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Correlations in sagittal position of femoral componenet of knee arthroplasty and postoperative patellofemoral pain and joint function