膝骨关节炎的活动衬垫型单髁置换疗效与假体生存率

doi:10.3877/cma.j.issn.1674-134X.2024.03.006

目的

探讨活动衬垫型单髁置换在膝骨关节炎治疗中的临床疗效与长期假体生存率。

方法

回顾性分析2007年4月至2022年6月在解放军联勤保障部队第九六〇医院骨病科应用活动衬垫型人工单髁关节置换手术治疗膝骨关节炎患者共1 084例，纳入患者均为初发膝内侧间室骨关节炎，且交叉韧带及内侧副韧带功能完整。排除其他膝关节疾病、合并膝关节严重畸形、同侧膝关节截骨或关节置换术史、严重疾病不能耐受手术、随访资料不全者。通过西安大略和麦克马斯特大学（WOMAC）骨关节炎指数、牛津膝关节评分（OKS）、膝关节活动度（ROM）评估临床疗效，比较传统器械与新型器械、不同年龄之间对临床疗效及假体生存率的影响，采用寿命表法分析单髁关节假体生存率，术前与术后疗效比较采用配对样本t检验、新老器械分组间比较采用两独立样本t检验，不同年龄组间比较采用单因素方差分析。

结果

末次随访时间2022年12月，平均随访（62±40）个月，随访时间超过10年以上114例，5～10年435例，5年以下535例。平均年龄（62±8）岁。WOMAC由术前（58.9±5.0）分，降至术后（26.7±7.2）分（t=121.570，P<0.05）；OKS由术前（36.7±4.3）分，提高至术后（55.4±2.7）分（t=-121.317，P<0.05）；膝关节ROM术前（102.7±6.1）°、术后（116.7±5.1）°（t=-58.904，P<0.05）。共有41例术后并发症发生，其中聚乙烯活动半月板衬垫脱位发生率最高。人工单髁关节假体生存率为95.9%，其中随访时间超过10年以上患者长期假体生存率为93.9%。传统器械与新型器械手术患者假体生存率均为96.1%，两者差异无统计学意义（P>0.05）。年龄≤55岁的假体生存率为91.8%，55～75岁为97.3%，年龄>75岁为96.8%，组间差异有统计学意义（P=0.02）。

结论

活动衬垫型UKA治疗膝内侧骨关节炎临床疗效可靠，长期假体生存率高，伴随手术技术的进步和假体设计的改良，该手术方式能够得到越来越广泛的临床应用。准确的适应证选择以及精确的手术操作，是取得良好临床疗效及避免并发症发生的根本保障。

关键词: 骨关节炎, 关节成形术，置换，膝, 存活率分析

Objective

To explore the clinical efficacy and long-term prosthesis survival rate of mobile bearing unicompartmental knee arthroplasty in the treatment of knee osteoarthritis.

Methods

A retrospective analysis was performed in 1084 patients with primary medial compartment osteoarthritis of the knee who were treated by mobile bearing unicompartmental knee arthroplasty between April 2007 and June 2022. The patients with other knee diseases, severe knee deformity, history of knee osteotomy or arthroplasty, intolerance for surgery, and invalid follow-up information were excluded. All the patients were treated in orthopetic department of the 960th Hospital. The clinical treatment was evaluated by Western Ontario and Mcmaster University osteoarthritis index (WOMAC),Oxford University knee score (OKS) and knee range of motion (ROM). The changes between old and new instruments, and between different ages on the clinical efficacy and survival rate were compared. The long-term survival rate of prosthesis was evaluated by life-table survival analysis. Paired sample t test was used to compare the efficacy between preoperative and final follow-up, two independent sample t test was used for postoperative comparison between new and old device groups, and univariate analysis of variance was used for comparison between different age groups.

Results

The last follow-up time point was December 2022. The follow-up time were (62±40) months on average, 114 patients were followed up for more than 10 years, 435 for five to 10 years, and 535 for less than five years. The average age were (62±8) years. WOMAC score improved from (58.9±5.0) before operation to (26.7±7.2) after operation (t=121.570, P<0.05); OKS score increased from (36.7±4.3) before operation to (55.4±2.7) after operation (t =-121.317, P<0.05); ROM of knee joint was (102.7±6.1) before operation and (116.7±5.1) after operation (t=-58.904, P<0.05). A total of 41 postoperative complications occurred, among which the dislocation of bearing was the highest . The over-all survival rate of prosthesis was 95.9%, and the long-term prosthesis survival rate was 93.9% in patients followed for more than 10 years. The survival rate was 96.1% in both traditional and new instrument groups, there was no statistically significant difference (P>0.05). The survival rate in different age groups was 91.8% in group of age ≤55 years, 97.3% in group of 55 to 75 years old, 96.8% in group of age >75 years. The difference between groups was statistically significant (P=0.02).

Conclusions

OUKA has a reliable clinical effect in the treatment of medial knee osteoarthritis, and has a high long-term prosthesis survival rate. With the progress of surgical techniques and the improvement of prosthesis design, this surgical method can be applied more and more widely in clinic. Accurate indication selection and accurate operation are essential to obtain good clinical efficacy and avoid complications.

Key words: Osteoarthritis, Arthroplasty, replacement, knee, Survival analysis

图1 传统手动器械与新型手术定位器械（Bioment公司，英国）。图A为传统手动器械，图B为新型手术定位器械

Figure 1 Traditional manual instrument and new type instrument(Biomet Ltd，UK) . A is traditional manual instrument; B is new type instrument

表1 OUKA术前与末次随访时患肢功能评分［n=1 084，（

）］

Table 1 Functional scores of the involved limb before and after OUKA

时间 Time	WOMAC	OKS	膝关节ROM Knee ROM
术前 Before surgery	58.9±5.0	36.7±4.3	102.7±6.1
末次随访 Last follow-up	26.7±7.2	55.4±2.7	116.7±5.1
t值	121.570	-121.317	-58.904
P值	<0.05	<0.05	<0.05

表1 OUKA术前与末次随访时患肢功能评分［n=1 084，（

）］

Table 1 Functional scores of the involved limb before and after OUKA

时间 Time	WOMAC	OKS	膝关节ROM Knee ROM
术前 Before surgery	58.9±5.0	36.7±4.3	102.7±6.1
末次随访 Last follow-up	26.7±7.2	55.4±2.7	116.7±5.1
t值	121.570	-121.317	-58.904
P值	<0.05	<0.05	<0.05

表2 采用传统与新型器械OUKA手术的患肢功能评分（

）

Table 2 Functional scores of the involved limb using traditional and new instruments in OUKA

器械分组 Groups	例数 Number of cases	WOMAC	OKS	膝关节ROM Knee ROM
传统器械组 Traditional group	422	26.4±7.2	55.1±3.0	116.5±5.3
新型器械组 New type group	662	27.0±7.2	55.6±2.4	116.8±5.0
t值		-1.334	-2.699	-0.870
P值		> 0.05	0.007	> 0.05

表2 采用传统与新型器械OUKA手术的患肢功能评分（

）

Table 2 Functional scores of the involved limb using traditional and new instruments in OUKA

器械分组 Groups	例数 Number of cases	WOMAC	OKS	膝关节ROM Knee ROM
传统器械组 Traditional group	422	26.4±7.2	55.1±3.0	116.5±5.3
新型器械组 New type group	662	27.0±7.2	55.6±2.4	116.8±5.0
t值		-1.334	-2.699	-0.870
P值		> 0.05	0.007	> 0.05

表3 OUKA术后不同年龄分组间患肢功能评分（

）

Table 3 Functional scores of the involved limb in different age groups after OUKA

分组 Groups	例数 Number of cases	WOMAC	OKS	膝关节ROM Knee ROM
年龄≤55岁 ≤55 years Age	245	27.2±7.2	55.3±3.0	116.3±5.6
55～75岁 55 to 75 years old	794	26.7±7.2	55.5±2.6	116.8±4.9
年龄>75岁 >75 years Age	45	25.9±6.8	55.7±2.4	116.8±5.7
F值		0.888	0.885	1.066
P值		> 0.05	> 0.05	> 0.05

表3 OUKA术后不同年龄分组间患肢功能评分（

）

Table 3 Functional scores of the involved limb in different age groups after OUKA

分组 Groups	例数 Number of cases	WOMAC	OKS	膝关节ROM Knee ROM
年龄≤55岁 ≤55 years Age	245	27.2±7.2	55.3±3.0	116.3±5.6
55～75岁 55 to 75 years old	794	26.7±7.2	55.5±2.6	116.8±4.9
年龄>75岁 >75 years Age	45	25.9±6.8	55.7±2.4	116.8±5.7
F值		0.888	0.885	1.066
P值		> 0.05	> 0.05	> 0.05

图2 寿命表法分析1 084例患者总体假体生存曲线注：总假体生存率为95.9%

Figure 2 The overall prosthetic survival curve of 1 084 patients analyzed by life-table Note: the overall prosthetic survival rate was 95.9%

图3 寿命表法分析114例随访时间10年以上患者长期假体生存曲线注：10年假体生存率为93.9%

Figure 3 The long-term prosthesis survival curve of 114 patients (follow-up for more than 10 years) analyzed by life-table Note: the 10-year prosthetic survival rate was 93.9%

图4 寿命表法分析传统器械与新型器械假体生存曲线注：两组假体生存率均为96.1%, 两组差异无统计学意义（P=0.974）

Figure 4 The prosthetic survival curve of traditional and new instruments analyzed by life-table Note: the prosthetic survival rate in both groups was 96.1%, showing no statistically significant difference between the two groups (P=0.974)

图5 寿命表法分析不同年龄分组假体生存曲线注：年龄≤55岁生存率为91.8%，55～75岁为97.3%，年龄>75岁为96.8%，组间差异有统计学意义（P=0.02）

Figure 5 The survival curves of prostheses in different age groups analyzed by life-table Note: survival rate of age≤55 years was 91.8%，55 to 75 years was 97.3%，ate>75 years was 96.8%，the difference was statistically significant （P=0.02）

图6 41例活动衬垫型OUKA（Oxford第三代活动衬垫型人工单髁置换系统）手术治疗膝OA（骨关节炎）并发症种类、发生时间及处理策略

Figure 6 Complications, occurrence time and management strategy of 41 knee OA cases treated by OUKA

图7 左侧OUKA（牛津第三代活动衬垫型人工单髁置换系统）术后4年平台侧假体松动翻修病例。图A为术前左膝负重正侧位片，示膝关节内侧间室骨对骨改变；图B为初次术中所见，示膝内侧OA且前交叉韧带正常；图C为术后2周复查，示假体位置良好；图D为术后2年复查，示胫骨平台假体下方疑似透亮带形成；图E为术后4年复查，示平台侧假体松动并平台骨质塌陷；图F为翻修术中所见，选择髁限制性假体（CCK）假体翻修，内侧平台骨质缺损区加垫块填充，平台假体加用延长杆；图G为翻修术后1年复查X线片，示假体位置良好

Figure 7 Case of prosthesis loosening four years after left OUKA. A is the anteroposterior and lateral radioimagedata views of left knee at weight-bearing positions, showing bone on bone in the medial compartmental knee; B is the intraoperative observation at primary surgery，showing medial compartmental knee OA with normal anterior cruciate ligment; C is the anteroposterior and lateral radioimagedata views of left knee at two weeks after surgery，showing normal position of the prosthesis；D is the anteroposterior and lateral radioimagedata views of left knee two years after surgery，showing the bright band formed below the tibial plateau prosthesis；E is the anteroposterior and lateral radioimagedata views of left knee four years after surgery，showing the loosening prosthesis with bone collapsed；F is the findings during revision, constrained condylar knee（CCK）prosthesis was selected for revision, the bone defect area was filled with a pad, and the tibial prosthesis was supplemented with an extension rod；G is the anteroposterior and lateral radioimagedata views of left knee one year after revision, showing normal position of the revision prosthesis

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Survival analysis and therapeutic effect of mobile bearing unicompartmental arthroplasty for knee osteoarthritis

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Survival analysis and therapeutic effect of mobile bearing unicompartmental arthroplasty for knee osteoarthritis