股骨内侧髁切迹对内侧单间室置换手术的意义

发布时间：2018-05-15 05:27

本文选题：膝关节骨性关节炎 + 膝关节内侧单间室置换手术　；参考：《河北医科大学》2017年硕士论文

【摘要】：背景:膝关节骨性关节炎是骨科常见疾病,骨性关节炎表现为关节软骨磨损退变,骨质增生导致骨赘形成。患者行走疼痛,关节间隙压痛,对患者的生活及工作有极大的影响。在膝关节骨性关节炎的患者中,有大约30%的患者是膝关节前内侧间室骨性关节炎,针对这一类患者的治疗手段较多,其中膝关节内侧单间室置换手术经过长期的临床随访,被证实是有效可靠的手术方式。但是术后部分患者会出现髌骨与股骨假体撞击的问题,以及出现髌股关节炎的进展,有研究显示是术中对于股骨内侧髁切迹的错误判断,导致选择了型号偏大的股骨假体,术后股骨假体的前缘与髌骨发生撞击。膝关节单间室置换的长期并发症还包括对侧间室的骨关节炎进展及假体无菌性松动,有学者提出膝关节内翻的矫正角度应控制在1°左右为佳,后倾的理想角度为7°,目前关于膝关节内侧单间室置换的文献较多,但是关于股骨内侧髁切迹对股骨截骨及假体型号选择的研究还为数较少。本研究通过使用三维重建成像技术模拟手术使用的股骨假体型号,来实现每位患者的个体化截骨,达到准确的选择假体型号及安放假体位置,减少了髌骨撞击等并发症的发生。目的:本实验是选择诊断为膝关节前内侧间室骨性关节炎的患者,术前常规做双膝关节CT平扫+三维重建及膝关节正侧位X线片。利用膝关节单髁假体模板模拟股骨假体放置位置,评估选择合适的假体型号,根据术前测量结果进行精确的胫骨及股骨截骨,为临床进行单间室置换手术提供进一步的手术操作依据及优化手术技巧。方法:选取河北医科大学第三医院自2014年9月至2016年5月初次行膝关节内侧间室置换术的患者102例102膝(女性67例,男性35例,年龄50~73岁)。随机分为两组,常规手术组及个体化截骨组(CT测量组)。手术均由同一位主任医师完成,个体化截骨组术前通过RadiAnt DICOM软件在CT片及三维重建中测量,确定确切截骨方案及评估术中可能使用假体型号完成手术;常规手术组没有术前测量。术前所有患者常规扫描膝关节CT,然后对股骨进行三维重建,在合适的CT矢状位层面上,确定股骨远端骨性标志点:股骨内侧髁切迹最低点(A点),后髁最远点(B点)。确定股骨长轴中轴线(f),经过A、B两点分别做f的平行线定义为a线和b线。a线与b线的最短距离定义为H。将每位患者使用的相应假体前后径(AP值)分别减去其测得的H值,得到相应的数值定义为h值,h0的数据不计入统计分析,h≥0进行统计分析。h≥0,意味着假体前缘超过了股骨内侧髁切迹,有可能造成术后髌骨与股骨假体撞击。将单髁的股骨假体与三维重建图像进行模拟放置,评估假体的位置。两组所有病例术前及术后均拍摄患者负重位双下肢全长片及膝关节正侧位。对X线片的胫骨后倾角度及膝关节内翻角度进行测量。评估两组术后8周的膝关节活动度、膝关节协会评分及视觉模拟评分的情况并进行统计学分析。结果:所有患者中有髌骨撞击的患者共5例,均出现在常规手术组,并且h≥3mm。髌股关节有症状(这些症状包括髌骨撞击、膝前疼痛及上下楼疼痛或不适,Table 1、2)的患者15例,其中h≥0mm,常规手术组有7例,个体化截骨组有2例;h0的一共有6例,常规手术组及个体化截骨组个体化截骨组各3例。常规手术组与个体化截骨组术后的胫骨假体后倾角及膝关节内翻角度无统计学差异;两组术后的膝关节活动度、膝关节协会评分及视觉模拟评分均存在统计学差异。结论:股骨假体前缘超过股骨内侧髁切迹3mm会产生髌骨与股骨假体撞击的症状。术前进行三维重建模拟假体型号的大小及假体放置的位置,有效的避免了因股骨假体型号选择过大、股骨假体的过度旋前导致的假体前移和后髁截骨量过多所导致的髌骨撞击的发生;避免了因股骨假体型号选择过小,股骨假体的过度旋后所导致的股骨假体与聚乙烯衬垫撞击的发生。因此在CT及三维重建影像下模拟手术截骨方案是非常重要的。股骨内侧髁切迹对于单髁置换术中假体的位置判断有重要意义。
[Abstract]:Background: osteoarthritis of the knee is a common disease in the Department of orthopedics. Osteoarthritis is manifested by osteoarthritis of the articular cartilage and osteophyte formation caused by hyperosteogeny. The patient's walking pain and joint space pressure pain have a great influence on the life and work of the patients. In the patients with osteoarthritis of the knee, about 30% of the patients are the anterior medial knee joint. There are many methods of treatment for this type of patients. The medial single compartment replacement of the knee is proved to be an effective and reliable operation after a long period of clinical follow-up. However, some patients will have the problem of patellar and femoral prosthesis and the progress of patellofemoral arthritis. It is a misjudgement of the medial condyle notch of the femur during the operation, resulting in the selection of a large femoral prosthesis. The anterior margin of the femoral prosthesis is impacted by the patella. The long-term complications of the single compartment replacement of the knee include the progress of the osteoarthritis of the lateral compartment and the aseptic loosening of the prosthesis, and some scholars have proposed the correction angle of the knee varus. The best angle of control is about 1 degrees, and the ideal angle of posterior inclination is 7 degrees. There are many literatures about the replacement of the medial single compartment of the knee joint, but the study of the selection of the femoral osteotomy and the type of prosthesis of the femoral medial condyle is still less. The individualized osteotomy of each patient has achieved an accurate selection of the type of prosthesis and the position of the prosthesis to reduce the occurrence of the patellar impact. Objective: this experiment was to select the patients who were diagnosed as the medial anterior chamber osteoarthritis of the knee joint with CT plain and three-dimensional reconstruction of the knee joint and the lateral X-ray of the knee joint before operation. A single condyle prosthesis template was used to simulate the placement of the femoral prosthesis. The appropriate model of the prosthesis was selected. The precise tibial and femur osteotomy was carried out according to the preoperative measurement results. The surgical technique was provided for the clinical single room replacement and the surgical technique was optimized. Method: the Third Hospital of Hebei Medical University was selected from 2014. From September to early May 2016, 102 patients with 102 knees (67 females, 35 males, 50~73 years old) were randomly divided into two groups, the routine operation group and the individual osteotomy group (CT measurement group). The operation was performed by the same chief physician. The individual osteotomy group was performed by RadiAnt DICOM software in CT and 3 D before the operation. In the reconstruction, the exact osteotomy scheme and the possible use of the prosthesis were evaluated during the operation. There was no preoperative measurement in the routine operation group. All the patients before the operation were routinely scanned on the knee joint CT, then the three-dimensional reconstruction of the femur, and the distal femur condyle notch point was determined at the appropriate CT sagittal level: the lowest point of the medial femoral condyle. (A point), the farthest point of the posterior condyle (B point). Determine the axis axis (f) of the long axis of the femur. After A, the parallel lines of F are defined as the shortest distance between the a line and the B line.A line and the B line. The corresponding values of the corresponding prosthesis diameter (AP value) used by each patient are subtracted, and the corresponding values are defined as the values. The data are not included in the statistics. Analysis, H > 0, the statistical analysis of.H > 0, means that the anterior margin of the prosthesis exceeds the medial femoral condyle incisor, which may result in the impact of the patellar and femoral prosthesis. The femoral prosthesis of the single condyle and the three-dimensional reconstruction image are simulated and the position of the prosthesis is evaluated. All cases of all cases in the two groups are taken to take the full length of the lower limbs before and after the operation. The knee joint lateral position. The tibial posterior angle of the X-ray and the angle of the knee joint were measured. The knee joint activity, the knee association score and the visual analogue score of the two groups were evaluated at 8 weeks after operation, and the results were statistically analyzed. Results: all the patients with patellar impact were 5 cases in the routine operation group, and H The symptoms of the patellar joint (including the patellar joint, including the patellar impact, the pain of the knee and the pain or discomfort of the upper and lower floors, and discomfort, Table 1,2) were 15 cases, of which h was more than 0mm, 7 in the routine operation group, 2 in the individual osteotomy group, 6 in the total of H0 and 3 in the individual osteotomy group of the routine operation group and the individualized osteotomy group, and the routine operation group and the individualized section. There was no statistical difference between the tibial prosthesis and the knee varus angle after the operation of the bone group. There were statistical differences between the two groups of the knee joint activity, the knee association score and the visual analogue score. Conclusion: the 3mm of the femoral prosthesis ahead of the femoral medial condyle can produce the symptoms of the patellar and femoral prosthesis. The reconstruction of the size of the simulated prosthesis and the position of the prosthesis can effectively avoid the occurrence of the patellar impact caused by the excessive selection of the femoral prosthesis, the overrotation of the femoral prosthesis and the excessive posterior condyle osteotomy, and the avoidance of the excessive selection of the femoral prosthesis caused by the excessive rotation of the femoral prosthesis. The femoral prosthesis is impacted by the polyethylene liner. Therefore, it is very important to simulate the surgical osteotomy scheme under the CT and 3D reconstruction images. The medial femoral condyle notch is of great significance to the position of the prosthesis during the single condylar replacement.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.4

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