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ENGLISH ABSTRACT
限制性运动学对线在全膝关节置换中的应用
邵志强
吴登先
蔡宖钢
刘政
宋凯
张晓峰
徐志宏
蒋青
作者及单位信息
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DOI： 10.3760/cma.j.cn121113-20230209-00046
The application of restricted kinematic alignment in total knee arthroplasty
Shao Zhiqiang
Wu Dengxian
Cai Honggang
Liu Zheng
Song Kai
Zhang Xiaofeng
Xu Zhihong
Jiang Qing
Authors Info & Affiliations
Shao Zhiqiang
Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation), Nanjing 210008, China
Wu Dengxian
Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation), Nanjing 210008, China
Cai Honggang
Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation), Nanjing 210008, China
Liu Zheng
Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation), Nanjing 210008, China
Song Kai
Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation), Nanjing 210008, China
Zhang Xiaofeng
Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation), Nanjing 210008, China
Xu Zhihong
Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation), Nanjing 210008, China
Jiang Qing
Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation), Nanjing 210008, China
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DOI： 10.3760/cma.j.cn121113-20230209-00046
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摘要

目的探讨根据限制性运动学对线（restricted kinematic alignment，rKA）原理使用髓外定位工具进行后十字韧带保留型（cruciate-retaining，CR）假体的全膝关节置换术的可行性和治疗效果。

方法回顾性收集2019年11月至2020年12月于南京鼓楼医院采用FEM-X1股骨髓外定位工具行rKA对线CR假体全膝关节置换的膝关节骨关节炎患者35例，男7例、女28例，年龄（71±8）岁（范围55~85岁）。术前第3天摄站立位下肢全长正侧位X线片测量rKA规划术前股骨远端外侧角（the lateral distal femoral angle，LDFA）与胫骨近端内侧角（the medial proximal tibial angle，MPTA）及髋膝踝角（hip-knee-ankle angle，HKA）。行全膝关节置换术，分别用胫骨、股骨髓外定位架依次对胫骨近端和股骨远端截骨，参考胫骨平台及内外侧软组织张力指导股骨后髁截骨，截骨完成后置入假体。记录术中侧副韧带松解情况、后十字韧带功能及松解情况、髌股轨迹情况、髌股支持带松解情况。术后第3天测量LDFA、MPTA、HKA、胫骨假体后倾角；功能评价采用膝关节学会评分（Knee Society score，KSS）。

结果35例髓外rKA对线CR假体的全膝关节置换术均顺利完成，手术时间为100（90，110） min，术中出血量为100（100，200） ml。手术前后的LDFA分别为1.0°（-2.0°，4.0°）、0°（-2.0°，2.0°），MPTA分别为-4.0°（- 5.0°，-1.0°）、-2.0°（-3.0°，-1.0°），HKA分别为-3.0°（-3.0°，-1.0°）、-2.0°（-3.0°，-1.0°），各指标手术前后测量比较的差异均无统计学意义（Z=-0.89，P=0.372；Z=1.87，P=0.061；Z=1.03，P=0.302）；胫骨后倾角为5°（3°，7°）。30例获得随访，随访时间（12.5±0.7）个月（范围12~14个月），术后1年KSS临床评分为94（92，97）分、功能评分为80（70，90）分。术中发现后十字韧带张力过大1例，行后十字韧带松解；术中发现髌股轨迹不良1例，行外侧支持带松解。

结论采用髓外定位工具rKA对线进行CR假体全膝关节置换术具有可行性、操作简便、手术效果确切、软组织平衡良好。

关节成形术，置换，膝;定位标记;限制性运动力学对线
ABSTRACT

ObjectiveTo investigate the feasibility and therapeutic effect of total knee arthroplasty (TKA) with cruciate-retaining (CR) prosthesis by using FEM-X1 femoral extramedullary positioning instrument based on the theory of restricted kinematic alignment (rKA).

MethodsThirty five cases who underwent total knee arthroplasty in Nanjing Drum Tower Hospital from November 2019 to December 2020 were retrospectively analyzed, including 7 males and 28 females with an average age of 71± 8 years (ranging from 55 to 85 years) Following the guidance of rKA alignment, the FEM-X1 femoral extramedullary positioning instrument was used for TKA with CR prosthesis. Before the operation, the full-length lower limb radiographs of both anteroposterior and lateral views were taken in a standing position for preoperative assessment of lateral distal femoral angle (LDFA), the medial proximal tibial angle (MPTA) and hip-knee-ankle angle (HKA). According to the principle of rKA alignment, the target LDFA, MPTA and HKA were calculated. The proximal end of tibia and distal end of femur were cut using extramedullary positioning instrument respectively. The posterior femoral condyle was cut according to the tibial plateau and mediolateral soft tissue tension. The prosthesis was installed after osteotomy. The release of collateral ligaments, PCL function, release of PCL, patellofemoral trajectory, release of patellofemoral support band, the amount of blood loss and time of operation were recorded. Postoperative LDFA, MPTA, HKA, and posterior slope angle of tibial prosthesis were measured on X-ray images. The Knee Society Score (KSS) was used for functional evaluation.

ResultsThirty five cases of TKA with CR prosthesis following rKA alignment were successfully completed. The operation time was 100 (90, 110) min, and the blood loss was 100 (100, 200) ml. 30 of them were followed up for 12.5±0.7 months (ranging from 12 to 14 months). The pre-operative and post-operative LDFA were 1.0°(-2.0°, 4.0°), 0°(-2.0°, 2.0°), MPTA were -4.0°(-5.0°, -1.0°), -2.0°(-3.0°, -1.0°), HKA were -3.0°(-3.0°, -1.0°), -2.0°(-3.0°, -1.0°). There was no significant difference between the three angles before and after operation (Z=-0.89, P=0.372; Z=1.87, P=0.061; Z=1.03, P=0.302). The average posterior tibial slope was 5°(3°, 7°). At the follow-up of one year, the KSS clinical score was 94(92, 97) and functional score was 80(70, 90) in 30 cases. During the operation, PCL was released in 1 case because of excessive tension; and lateral retinacular release was performed in 1 case because of poor patellofemoral track.

ConclusionITKA with CR prosthesis by using the extramedullary positioning instrument on the theory of rKA alignment showed a good clinical outcome at a short follow up.

Arthroplasty, replacement, knee;Fiducial markers;Restricted kinematic alignment
Xu Zhihong, Email: mocdef.yabylgjngnohihzux
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引用本文

邵志强,吴登先,蔡宖钢,等. 限制性运动学对线在全膝关节置换中的应用[J]. 中华骨科杂志,2023,43(16)：1076-1084.

DOI:10.3760/cma.j.cn121113-20230209-00046

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膝关节人工关节置换术已日趋普及，但据文献报道全膝关节置换术后患者的不满意度可高达约20%[ 1 , 2 ]。越来越多的医生关注并致力于改善患者手术满意度，因而精准化术前评估、规划及手术操作技术受到重视[ 2 ]。如机器人辅助、导航辅助、患者个性化工具（patient-specific instruments，PSI）等技术均可提升手术规划、术中操作的准确度，应运而生的限制性运动学对线（restricted kinematic alignment，rKA）技术关注于在不影响假体生存期的前提下提高患者手术满意度，即通过适当放弃机械轴力线对线，仅恢复至术前的力线、关节线，减少对软组织的调整[ 3 , 4 , 5 , 6 ]，实现术后运动步态更接近于正常步态[ 7 , 8 , 9 ]。目前已有部分早中期疗效相关研究报道证实了rKA技术相较于机械轴力线对线（mechanical alignment，MA）技术的临床功能更优[ 5 , 8 , 10 , 11 , 12 ]，也更容易获得软组织平衡。
目前运动学对线技术的相关研究已有很多[ 5 , 7 , 13 , 14 ]，但利用传统手术工具难以精确地判断力线，尤其很多病例冠状面下肢原始力线偏差>3°，更增加了判断难度。由于传统股骨髓内定位工具的髓内杆与机械轴并不在同一平面，很难做到同时对冠状面和矢状面的精确控制[ 15 , 16 , 17 , 18 ]。此外，髓内定位时并不能确保达到预定位置[ 19 , 20 , 21 ]，可能原因包括术前规划的准确度[ 22 ]、冠状面中髓内杆插入点的位置、股骨直径、股骨弯曲程度及髓内杆的样式等[ 15 , 18 , 23 ]。再者，髓内定位需在股骨上开骨髓孔，可能增加术后失血、血栓相关并发症和术中骨折的风险[ 24 , 25 ]。因此，有学者开始尝试利用导航技术进行rKA对线[ 4 , 11 , 26 ]，在恢复关节线的同时尽可能通过调整截骨使股骨及胫骨关节线偏差5°以内，总体力线偏差3°以内[ 26 ]。但手术时间和手术费用增加、学习曲线长等缺点影响了导航技术的广泛使用。
股骨髓外定位工具综合了定位的准确性及使用的便利性，较传统股骨髓内定位工具更易广泛使用于临床。本研究使用自制FEM-X1股骨髓外定位架（专利号：ZL20142029-5979.5[ 27 ]）由江苏科润玺公司（中国）生产（ 图1 ），已在临床应用5年以上、累计使用于数百台全膝关节置换术。FEM-X1股骨髓外定位架参考导航原理进行设计，通过术前双髋关节CT准确定位股骨头中心与髂前上棘，于术中可同时调整股骨冠状面及矢状面，较髓内定位工具准确性更高[ 28 ]。
FEM-X1髓外定位器示意图。定位器由髂前上棘固定弓、弧形连接杆、限位器及截骨板连接组成；髂前上棘固定弓两足定位在两侧髂前上棘（anterior superior iliac spine，ASIS），远端限位器与股骨远端接触，上面可放置截骨板。HDFA，股骨头中心与患侧髂前上棘的水平距离；VDFA，股骨头中心与患侧髂前上棘的垂直距离；X值，限位器与膝关节水平面的垂直距离
本研究回顾性根据rKA对线原理采用FEM-X1髓外定位工具辅助全膝关节置换术的患者资料，观察手术前后的力线、关节线影像学参数及术后功能，目的在于：（1）检验FEM-X1髓外定位工具在运用rKA原理上的准确性；（2）总结FEM-X1髓外定位工具在全膝关节置换术中的操作经验；（3）分析rKA对线全膝关节置换术后的疗效。
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徐志宏，Email: mocdef.yabylgjngnohihzux
B

邵志强：课题设计、实施和论文写作；邵志强、吴登先：采集分析和解释数据；蔡弘鋼、刘政：患者管理；邵志强、蔡弘鋼：统计分析；张晓峰：起早文案；徐志宏、宋凯：写作指导和论文修改；徐志宏、蒋青：提供行政、材料和手术技术支持

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