膝关节置换中的屈曲挛缩与软组织松解

doi:10.3969/j.issn.2095-4344.2013.48.004

摘要/Abstract

摘要：

背景：软组织松解是矫正膝关节屈曲挛缩的主要手段，对不同的膝关节疾病和畸形程度其全膝关节置换中软组织松解方法各不相同。良好合理的软组织平衡使高度屈曲挛缩的膝关节在全膝关节置换后获得明显的功能恢复和畸形矫正。
目的：探讨膝关节置换中膝关节的屈曲挛缩与软组织松解的处理。
方法：对26例屈膝畸形在20°-60°的初次全膝置换病例进行回顾性研究，记录其全膝关节置换中软组织松解步骤及每步松解后畸形残留情况。全膝关节置换后平均随访12个月。
结果与结论：26例膝关节的屈曲畸形在软组织松解后得到纠正。所有病例均进行了不同程度的后关节囊松解，屈曲畸挛缩畸形得到了纠正，活动范围也得到了很大的提高，提示充分的后关节囊及侧副韧带松解可以矫正绝大部分屈曲畸形，增加股骨远端截骨并非必须。

关键词: 骨关节植入物, 人工假体, 膝关节置换, 屈曲畸形, 后关节囊, 副韧带, 松解, 软组织, 截骨, 后交叉韧带, 省级基金

Abstract:

BACKGROUND: Soft tissue releasing is a major means of correcting knee flexion contracture, and the soft tissue releasing methods are different for different knee joint diseases and degrees of deformity. Ideal soft tissue balance can gain a clear functional recovery and deformity correction from severe knee flexion contracture after total knee arthroplasty.
OBJECTIVE: To study the proper handling of knee flexion contracture and soft tissue releasing in total knee arthroplasty.
METHODS: Twenty-six cases of knee deformity in 20 ° to 60 ° receiving primary total knee arthroplasty were retrospectively studies. Steps of soft tissue releasing and residue deformity after each step were recorded. Postoperative follow-up was 12 months on average.
RESULTS AND CONCLUSION: The 26 cases were recovered from knee flexion deformity after soft tissue release. Posterior capsular release was carried out in all cases to different extents, and the flexion deformity and postoperative range were corrected and greatly improved, respectively. These indicate that the posterior capsular release and lateral collateral ligament release can correct most of the flexion deformity, but increasing the distal femoral osteotomy is not necessary.

Key words: arthroplasty, replacement, knee, contracture, joint capsule, joint capsule release

中图分类号:

R318

钱科军，姜宇. 膝关节置换中的屈曲挛缩与软组织松解[J]. 中国组织工程研究, 2013, 17(48): 8319-8324.

Qian Ke-jun, Jiang Yu. Soft tissue release processing in knee flexion contracture during knee replacement[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(48): 8319-8324.

图/表（结果） 2

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引言

材料方法

设计：回顾性研究。

时间及地点：实验于2009年6月至2012年6月在无锡市第二人民医院骨科完成。

对象：选取无锡市第二人民医院骨科屈曲畸形进行膝关节置换的患者。

诊断标准：屈曲畸形的诊断标准为膝关节正常活动的活动范围是0°-140°的弯曲^[29]。

纳入标准：①初次全膝关节置换的患者。②屈曲畸形的患者。③屈曲畸形范围从20°-60°。

排除标准：①年龄大于80岁。②严重骨质疏松的患者。③合并有严重心肺合并症的患者。

最终共26例屈曲畸形进行膝关节置换的患者，其中男12例，女14例；平均年龄为62岁；膝关节的膝关节功能评分平均(36.5±4.9)分，全膝关节置换前屈曲畸形(30.1±3.3)°，膝关节的活动范围(63.0±8.3)°。类风湿合并外翻畸形7例，平均外翻(7.8±2.8)°，骨性关节炎合并内翻畸形6例，平均内翻(7.2±3.8)°，查体膝关节内外翻应力实验均阴性，证实不存在侧副韧带松弛，并全膝关节置换前常规行膝关节MRI检查。

材料：膝关节假体为德国LINK提供的后稳定型、骨水泥固定型的膝关节假体。

方法：

全膝关节置换：患者全身麻醉后，采用膝关节正中入路，切开关节囊，切除部分髌下脂肪垫，切除内外侧半月板及前交叉韧带。检查伸屈间隙，按标准程序截骨行股骨、胫骨截骨后，完成及髁间窝骨质处理后，充分清除股骨后髁增生骨赘，伸直膝关节，用2把板状撑开器撑开胫股间隙，使得后关节囊保持高张力，用血管钳挑起关节囊后予以松解关节囊，如松解不彻底，则切除局部的后关节囊，直至整个后关节完全松解。所有手术均由同一组医师完成。

膝关节功能评分：膝关节置换1年后采用膝关节功能评分系统进行评价^[30]。

膝关节功能评分标准：

膝关节恢复情况评价：记录置换后畸形情况和活动范围^[31]。

主要观察指标：膝关节置换前后患者活动能力的差异。

统计学分析：数据以x(_)±s表示，应用SPSS 13.0软件分析。

讨论

膝关节屈曲挛缩患者由于膝关节失稳，轻者可以引起步态异常；当屈曲挛缩超过30°时，须在扶助下行走；当双膝屈曲畸形超过40°，患者难以直立，通常需要坐轮椅或蹲移。合并滑膜、关节病变者还会出现膝关节疼痛。引起膝关节屈曲挛缩的病因主要有以下几种：①先天性疾病(包括先天性多发性关节挛缩症、多发性翼蹼关节、脊柱裂后遗症、肢骨纹状肥大病、先天性髌骨脱位、先天性胫骨缺如、先天性腓骨缺如等)。②炎症性疾病(包括青少年类风湿性关节炎、成人类风湿性关节炎、强直性脊柱炎、化脓性膝关节炎、血友病性膝关节积血、其它类型的膝关节滑膜炎等)。③脊髓灰质炎后遗症。④膝关节及下肢创伤。⑤膝关节周围烧伤。⑥膝关节固定。⑦畸形性侏儒症。⑧脑性瘫痪。⑨下肢延长的并发症等。传统上，从股骨远端额外的骨切除一直用于全膝关节置换中治疗膝关节的屈曲挛缩。但实验表明这个历程是没有必要的。后交叉韧带的松解治疗这些挛缩畸形也是值得注意的，大多数的膝关节置换治疗中骨赘切除和各自的内侧或外侧软组织释放取决于存在内翻或外翻畸形，剩下治疗包括后关节囊的畸形的松解。实验回顾性分析一些文献，拟分析膝关节置换中挛缩畸形骨与韧带之间处理，见表3。

软组织平衡是全膝关节置换中的重要环节，其处理的好坏直接影响到全膝关节置换后膝关节的功能，朱国兴等^[45-46]认为选择应先行软组织松解再截骨。而Bäthis等^[47]认为早先的截骨对于软组织松解更有力，作者发现早期的松解，可以松解挛缩的组织，使得空间得以开放，避免二次截骨的风险，因为过多的股骨远端截骨虽可顺利安装假体，但减弱了股四头肌的张力，使患者全膝关节置换后主动伸膝肌力下降，卢世璧等^[46]认为屈曲畸形膝关节软组织松解中如畸形严重可将后关节囊横行切开。也有人提出对于中到重度的挛缩畸形可以行后关节囊切除^[48]。

后交叉韧带的正确处理也是相当重要的，目前对于是否切除后交叉韧带，选用何种类型的假体仍有争议。Whiteside等^[49]认为后交叉韧带主要在膝关节屈曲时起作用，切除后对伸直间隙影响较小。然而最新的研究表明，切断该韧带主要增加屈曲间隙，而且有可能造成新的伸屈间隙不平衡^[50]。后交叉韧带松解的目的并非纠正屈曲畸形而是增加较小的屈曲间隙和增加股骨假体后的移动^[51]。实验并没有切除后交叉韧带，保留它的一份生理作用，对于挛缩畸形的膝关节置换也获得了比较好的影响。

实验应用同一专家，使用统一的标准，消除信息偏倚，在纳入研究的患者26例中无一例脱落，无失访偏倚。实验也存在一定的不足，首先是病例数量可以更大，这样结果更具有普遍性。其次是随访时间不够长，如果平均随访时间能够延长至全膝关节置换后2年，将使得实验结果更有意义。

总之，对于膝关节置换中屈曲畸形，没有进行充分软组织松解而贸然增加股骨远端截骨是错误的，充分的后关节囊及侧副韧带松解就可以矫正绝大部分畸形。