中国人TKA中保留PCL可行性的分析研究

发布时间：2018-05-10 17:50

本文选题：TKA + PS型TKA　；参考：《第三军医大学》2017年硕士论文

【摘要】：背景我国已步入老龄化社会,膝关节骨性关节炎患者呈逐年增多趋势,已将近5000万人。随着生物医学、材料工程学、手术技术的不断发展,全膝关节置换术(Total knee arthroplasty,TKA)已成为治疗中、晚期膝关节骨性关节炎重要手段。后交叉韧带为膝关节重要结构,对膝关节屈伸、旋转等功能起到重要稳定作用。随着现代膝关节置换技术的发展,后交叉韧带保留型膝关节假体(CR型假体)和后稳定型膝关节假体(PS型假体)已成为主要的两种假体设计使用类型,在长期的临床治疗及学术探讨过程中,如何选择假体始终是学者长期争论的问题。术中能否完整保留后交叉韧带,是术后发挥CR假体功能的重要前提。国内骨科医生大多选择PS型TKA治疗膝关节骨性关节炎,近几年来,CR型TKA术式逐渐增多,CR型TKA是否适合国人膝关节生理解剖特点以及国人TKA术中保留PCL可行性成为本研究探讨的重点。目的1、研究国人PS型TKA中,采取胫骨平台0°后倾、9mm厚度截骨后,是否仍残留部分PCL及其残留量,探讨国人PS型TKA中,影响PCL残留量的影响因素;2、探讨国人行CR型TKA的可行性、术中技术要领,并比较CR型TKA与PS型TKA术后临床疗效。方法1、选取2015年5月—2016年8月在第三军医大学附属新桥医院骨科进行的全膝关节置换术患者共36例,均为单膝患者,年龄范围为52岁-75岁,身高145cm-173cm,男性、女性各18名。以上患者均签署本研究知情同意书及手术同意书,对患者身高、性别、PCL保留比例、胫骨平台截骨前后径、内外径、胫骨长度进行数据收集,仔细收集术中截取胫骨平台标本予以测量处理。PCL保留比例测量:将胫骨平台截骨及残余后交叉韧带标本固定、脱钙,取腱骨界面部位切片、染色,通过Auto CAD2014软件分析PCL保留比例。2、选择2015年5月-2016年5月,在接受单侧PS型全膝关节置换的患者16例,共16膝,其中女性9例,男性7例,患者年龄55-75岁,平均65.1岁。接受单侧CR型全膝关节置换的患者16例,共16膝,其中女性11例,男性5例,患者年龄58-73岁,平均65.0岁。以上患者均签署本研究知情同意书及手术同意书。PS型TKA采取常规手术操作。本研究CR型TKA手术操作要领:经过前期对PS型TKA胫骨平台截骨术后PCL残留量的研究,发现绝大部分患者在CR型TKA术中,胫骨平台采取0°后倾、9mm截骨,PCL无法完整保留。故在施行CR型TKA中,本研究采取预留PCL骨岛(采取克氏针行骨岛周边保护)、分次截骨(对骨岛内外侧及前侧分次截骨),在此过程中,始终保持PCL处于松弛状态,避免产生骨岛骨折,胫骨平台截骨后,常规行股骨髁截骨,采用自制工具检测膝关节屈伸间隙平衡后,安装假体,可有效降低反复使用试模测量屈伸间隙导致的骨岛骨折发生率。采取VAS评分、AKS评分、WOMAC评分、膝关节活动度(ROM)、股骨髁后滚距离比较PS型TKA与CR型TKA术后临床疗效。结果1、身高是影响胫骨平台内外径、前后径大小、后交叉韧带保留比例、胫骨长度大小主要因素,而性别对胫骨平台内外径、前后径、后交叉韧带保留比例、胫骨长度无影响或者影响很小。身高、胫骨平台前后径、内外径、胫骨长度与PCL残留比例存在着线性关系,呈正相关变化。本研究显示,国人行TKA中,采取胫骨平台0°后倾、9mm截骨时,身高低于171cm时,PCL保留比例在50%以下,普遍偏低。2、在本研究CR型TKA术中,采取预留PCL骨岛(采取克氏针行骨岛周边保护)、分次截骨(对骨岛内外侧及前侧分次截骨)的方法实行胫骨平台0°后倾、9mm截骨,术中2例患者出现骨岛撕脱性骨折,改为PS型假体,其余14例患者完整保留PCL。术后3天CR型TKA患者在ROM、股骨髁后滚距离、VAS评分明显优于PS型TKA患者,患者满意率提高,康复周期、平均住院日明显缩短。术后3个月,CR型TKA与PS型TKA患者在AKS评分、WOMAC评分、VAS评分、ROM方面无明显差异。结论身高是影响胫骨平台内外径、前后径大小、后交叉韧带保留比例、胫骨长度大小主要因素,而性别对胫骨平台内外径、前后径、后交叉韧带保留比例、胫骨长度无影响或者影响很小。身高、胫骨平台前后径、内外径、胫骨长度与PCL残留比例存在着线性关系,呈正相关变化。本研究显示,身高低于171cm的患者,当采取胫骨平台0°后倾、9mm截骨时,PCL保留比例在50%以下,普遍偏低,术后残留PCL不能发挥其正常生理功能。对于大部分拟行TKA的国人,身高普遍在170cm以下,若采取后交叉韧带保留型TKA假体,手术难度、技术及时间要求增加,术中发生骨岛撕脱骨折风险增加,后交叉韧带保留成功率降低,临时更改手术方案,改用PS型假体,本研究中采取预留PCL骨岛(采取克氏针行骨岛周边保护)、分次截骨(对骨岛内外侧及前侧分次截骨),手术过程中,始终保持PCL处于松弛状态,使用自制工具检测膝关节屈伸间隙平衡可有效降低反复使用试模测量屈伸间隙导致的骨岛骨折发生率。虽然术后3天CR型TKA患者在ROM、股骨髁后滚距离、VAS评分明显优于PS型TKA患者(P0.05),患者满意率提高、康复周期、平均住院日明显缩短。然而术后3个月,CR型TKA与PS型TKA患者在AKS评分、WOMAC评分、VAS评分、ROM方面无明显差异(P0.05)。故鉴于行TKA的大部分国人的身高普遍在170cm以下,术中采取胫骨平台0°后倾、9mm截骨时,成功保留PCL,手术难度及技术要求高,增加手术时间,易发生骨岛撕脱骨折,导致后交叉韧带保留失败,并且两种类型假体行TKA后,远期疗效并无显著差异(P0.05),大多数国人OA患者不宜行CR型TKA,需更加严格把握手术适应症。
[Abstract]:Background our country has entered an aging society. The patients with osteoarthritis of the knee joint are increasing year by year, and nearly 50 million people. With the continuous development of biomedicine, material engineering and surgical technique, Total knee arthroplasty (TKA) has become an important means of advanced knee osteoarthritis in the treatment of advanced knee joint. As an important structure of the knee joint, it plays an important and stable role in the flexion, extension and rotation of the knee joint. With the development of modern knee replacement technology, the reserved knee prosthesis (CR type prosthesis) and the post stable knee joint prosthesis (PS type prosthesis) have become the main two types of prosthesis design and use in the long term clinical treatment and the development of the knee joint replacement technique. In the course of academic discussion, how to choose the prosthesis has always been a long argument for the scholars. Whether the posterior cruciate ligament is retained completely during the operation is an important prerequisite for the function of the CR prosthesis after the operation. Most of the doctors in the domestic Department of orthopedics choose PS TKA for the treatment of osteoarthritis of the knee joint. In recent years, the CR type TKA has gradually increased, and the CR TKA is suitable for the people of the country. The physiological and anatomical characteristics of the knee joint and the feasibility of retaining the PCL in Chinese TKA have become the focus of this study. 1, in the study of Chinese human PS TKA, the influence factors of the residual amount of PCL and its residual amount remained after the tibial plateau was 0 degrees and the thickness of 9mm was cut, and the influence factors of the PCL residues in the PS type TKA of the Chinese people were discussed. 2, to explore the TKA CR TKA. The feasibility, technical essentials in the operation, and comparison of the clinical effect of CR type TKA and PS type TKA. Method 1, 36 cases of total knee arthroplasty in the Department of orthopedics, Xinqiao Hospital Affiliated to Third Military Medical University from May 2015 to August 2016 were selected, all were single knee patients, the age range was 52 years old -75 years, height 145cm-173cm, male and female 18. All the patients signed this research agreement and the surgical consent. The patient's height, sex, PCL retention ratio, the tibial plateau anterior and posterior diameter, the internal and external diameter, the length of the tibia were collected, and the tibial plateau specimens were collected carefully to measure the.PCL retention ratio: the tibial plateau osteotomy and the residual posterior cruciate ligament The specimens were fixed, decalcified, and the tendon bone interface was sliced and stained, and the PCL retention ratio was analyzed by Auto CAD2014 software. In May 2015 -2016 May, 16 patients received unilateral PS total knee replacement, including 16 knees, 9 women, 7 men, 55-75 years old and 65.1 years old. 16 cases, including 16 knees, 11 women, 5 men, 58-73 years old, average 65 years old. All the patients signed this study and the operation consent book.PS TKA to take routine operation. This study of CR type TKA operation essentials: after the early stage of the PS TKA tibial plateau osteotomy after the study of PCL residues, found the vast part In the patients with type CR TKA, the tibial plateau was tilting 0 degrees, 9mm osteotomy, and PCL could not be retained completely. Therefore, in the CR TKA, this study adopted the reservation of PCL bone island (with Kirschner needle on the periphery of the bone island) and the sub osteotomy (the osteotomy of the bone and the anterior and outer sides of the bone island). During this process, the PCL was kept in a relaxed state to avoid producing bone. After the island fracture and the tibial plateau osteotomy, the femoral condyle osteotomy was routinely carried out. After using the self-made tool to detect the balance of the knee joint and extension space, the prosthesis was installed, which could effectively reduce the incidence of bone island fracture caused by the flexion and extension clearance. The VAS score, the AKS score, the WOMAC score, the knee joint activity (ROM), and the femoral condyle roll distance were compared with PS The clinical efficacy of type TKA and type CR TKA after operation. Results 1, height is the influence of the internal and external diameter of tibial plateau, the size of the anterior and posterior diameter, the retention ratio of the posterior cruciate ligament, the main factor of the length of the tibia, and the proportion of the internal and external diameter of the tibial plateau, the back and back diameter, the posterior cruciate ligament, the length of the tibia, and the small influence of the tibia length, the height, and the tibial plateau diameter, the tibial plateau, and the diameter of the tibial plateau. There is a linear relationship between the diameter of the internal and external diameter, the length of tibia and the ratio of PCL residue, which shows a positive correlation. This study shows that in TKA, when the tibial plateau is 0 degrees back, and when the 9mm osteotomy is lower than 171cm, the retention ratio of PCL is below 50%, and it is generally low.2. In this study, the PCL bone island (Kirschner pin is used to take the bone island around the bone island). 0 degree posterior tibial plateau tilting, 9mm osteotomy, 2 cases of bone island avulsion fracture, changed into PS type prosthesis, and the remaining 14 cases of CR TKA patients at ROM and femoral condyle roll distance, VAS score was obviously superior to PS type TKA patients in the other 14 cases. 3 months after operation, there was no significant difference in AKS score, WOMAC score, VAS score and ROM in the patients with type CR TKA and PS TKA. Conclusion the height of the tibial plateau is influenced by the internal and external diameter of the tibial plateau, the size of the posterior cruciate ligament, the main factor of the length of the tibia, and the gender of the tibial plateau. Internal and external diameter, front and back diameter, posterior cruciate ligament retention ratio, tibial length has no influence or small impact. Height, tibial plateau diameter, internal and external diameter, the length of tibia and PCL residual ratio has a linear relationship, and there is a positive correlation. This study shows that people with height below 171cm, when the tibial plateau is 0 degrees back, 9mm osteotomy, PCL retention ratio The cases are below 50%, generally low and the residual PCL can not perform normal physiological function after operation. For most of the people who do TKA, the height is generally below 170cm. If the posterior cruciate ligament is reserved for the reserved TKA prosthesis, the operation difficulty, the technical and time requirements are increased, the risk of bone island avulsion fracture is increased in the operation, and the posterior cruciate ligament has a successful rate drop. In this study, the PCL bone island was reserved (with Kirschner's needle on the periphery of bone island) and sub osteotomy (partial osteotomy of the lateral and anterior side of the bone island). During the operation, the PCL was kept in a relaxed state, and the balance of the flexion and extension gap of the knee joint could be effectively reduced repeatedly by using the self-made tool in this study. The incidence of bone island fracture caused by the flexion and extension gap was measured with a test model. Although the CR TKA patients were at ROM and the femoral condyle roll distance on the 3 day after operation, the VAS score was obviously better than that of the PS TKA patients (P0.05). The satisfaction rate of the patients was improved, the recovery cycle was significantly shortened. However, 3 months after the operation, CR type TKA and PS TKA were scored in AKS score There is no significant difference in ROM (P0.05). Therefore, in view of the height of the majority of the people in TKA is generally below 170cm, the tibial plateau is 0 degrees behind, and when the 9mm osteotomy is taken, the PCL is successfully retained, the operation difficulty and the technical requirement are high, the operation time is increased, the bone island avulsion is easy to take place, the posterior cruciate ligament is failed, and the two types of prosthesis are made. After TKA, there was no significant difference in long-term efficacy (P0.05). Most Chinese OA patients were not suitable for CR TKA.

【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.4

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