膝关节内翻屈曲畸形的软组织平衡

膝关节内翻屈曲畸形的软组织平衡 Neural Regeneration Research Dear Liwen Bianji editor, after editing please take a brief moment to complete the following evaluation intended to help raise the language quality of NRR manuscripts. For Question #9 please provide any comments which you feel might help improve the manuscript scientifically.Please contact us with any questions. 1. Manuscript No:08-s-9-1077 2. Date sent: 2008-11-21 3. Research area of manuscript: ? NRR ? ? Internal document 4. Word count: 2878 5. Your name: 6. Your research area as it pertains to the article: Physiology 7. Academic evaluation of manuscript: ? Good ? Average ? ? Poor 8. Language and expression: ? Good ? Average ? ? Poor 9. Other suggestions: Some detail linking study results to points made in the Discussion might be useful.Soft tissue balance in total knee arthroplasty for patients with varus deformity and flexion contracture knees Abstract OBJECTIVE: To explore the technique of soft tissue balance in total knee Neural Regeneration Research arthroplasty (TKA) for patients with varus deformity knees and flexion contractures. METHODS: A total of 86 (104 knees) primary TKA patients suffering from varus deformity and flexion contractures in the knee were reviewed. All patients suffered from osteoarthritis. The technique of soft tissue balance in TKA was discussed. RESULTS: In this study, the average flexion contracture of the included patients was 18.9? before operation. There were four cases with 5? residual flexion contractures but all other deformities were corrected completely by surgery. All patients were followed up for an average of 37 months (range 6–72 months). Six cases had 5–10? residual flexion contractures and the othershad full knee extension. The average varus angle was 12.3? (range 6–34?) before operation. The average tibiofemoral angle was 174.7? postoperatively. The residual varus angle exceeded 3? in two cases. CONCLUSION: Soft tissue balance is very important for TKA. It is a major means of correcting varus deformity and flexion contracture. Individual good soft tissue balance is indicated with different diseases and deformities. Good soft tissue balance improves the knee’s range of motion and corrects deformity after operation in high deformity cases. Accurate soft tissue balance can be achieved by careful preoperative evaluation and skilled operative technique. It can provide consummate biological stabilization. Accurate soft tissue balance depends on Neural Regeneration Research improvement of operative techniques, clinical research and empirical summary.Key Words: arthroplasty; replacement; knee; contracture; knee joint Total knee arthroplasty (TKA) is the main indication for advanced-stage osteoarthritis patients, who have characteristics of varus deformity and flexion contracture in the knees. Inappropriate operative management and residual varus, medial collateral ligament contracture or lateral laxity may result in excessive load on the medial compartment and medial subluxation of the knee joint, thus causing the polyethylene prosthesis to wear and loosen. The main causes of these lesions are osteotomy and soft tissue imbalance. Although people are focusing on soft tissue balance research, accurate soft tissue balance is difficult to obtain. This study aims to review 86 osteoarthritis patients (104 knees) suffering from varus deformity and flexion contracture in the knees who have received TKA, to discuss the technique of soft tissue balance in TKA, and to improve the efficacy of TKA. CLINICAL DATA General data A total of 86 patients (104 knees), comprising 19 men and 67 women, underwent primary TKA. The patients were aged 57–78 years (median 66 years). There were 68 patients who had received unilateral surgery and 18 who had received bilateral Neural Regeneration Research surgery. All patients included suffered from osteoarthritis, and had the complications of varus deformity and flexion contractures of the knee joint to differing extents. The standardized levels were defined as a femorotibial angle of 6? and a tibial plateau-tibial shaft angle of 90?. The average varus angle of patients in the study was 12.3? (6–34?) before the operation. Soft tissue varus cases accounted for 56.7% of total varus cases, while osteogenic varus accounted for 43.3%. Before surgery, the varus deformity and flexion contracture of all patients were measured. The average angle was 18.9?. There were 21 cases with an angle of less than 10?, 45 cases with an angle of 10–19?, 22 cases with an angle of 20–29?, and 16 cases with an angle of over 30?. Prosthesis type The knee prostheses included posterior cruciate ligament-retaining implants from the Jinghang Incorporation (n = 12), posterior stabilized implants from the Aikang Incorporation (n = 17), IB-II posterior stabilized implants (n = 5), hi- flexion and posterior stabilized implants from the Zimmer Incorporation (n = 11), Depuy-PFC (n = 44), Depuy-PFC-RP (n = 8) and Depuy-LCS (n = 7). Surgical approach All patients had a routine tourniquet applied. Knee joints were treated by the standard install approach and exposed by making a medial parapatellar incision, cutting the anterior cruciate ligament, removing the marginal osteophyte and resecting the residual meniscus. The medial collateral ligament was released to Neural Regeneration Research achieve a flexion angle of 90?. The tibial plateau was resected by extramedullary guide; all resection specimens had a measured thickness of 1–2 mm at the distal end of the minimal tibial plateau or 8–10 mm at the distal end of the light lesion side. A femoral intramedullary system was recommended. Lower extremities were measured usingthrough the radiography of the entire whole lower extremitiesy radiography ir whole long X-ray films and the angle between the line of the femoral axis and the line of the mechanical axis of the lower extremity served as the valgus angle. The extorsion angle could be controlled. The femur was resected in a sequence, starting at the distal femur, then the anterior and posterior condyle, and finishing at the anterior and posterior slope. The posterior stabilized prosthesis required secondary intercondylar osteotomy. Routine patellar replacement is unnecessary, which only allows a replacement at a thickness of less than 21 mm. Testing models adopted an exact pattern, then the force line of low extremities, range of motion (flexion 125? and extension 5?), varus and valgus balances were all measured. The joint cavity was rinsed and fixed with the prosthesis on the tibia, femur and patella until the bone cement solidified. A drainage tube was then placed and the incision was sutured and covered with a pressure dressing. In the present study, 17 knees underwent patellar replacement, while others received patellar osteoplasty due to the insufficiency of patellar thickness and slight wearing of patellar cartilage. One hour before the operation and for 3 days after the operation, patients Neural Regeneration Research received prophylactic treatment consisting of antibiotics and an anticoagulant. From postoperative day 1, patients performed active and passive flexion and extension of the knee joint and functional exercises of the quadriceps femoris with the assistance of a CPM instrument. From day 7 after surgery, patients were encouraged to walk with a walking device. Results In this study, the average flexion contracture of the included patients was 18.9? before surgery. Except for four cases where 5? residual flexion contractures were present, the others’ deformities were corrected completely by surgery. All patients were followed up for an average of 37 months (range 6–72 months). Six patients had 5–10? residual flexion contractures while the othershad full knee extension. The average varus angle was 12.3? (range 6–34?) before the operation. The average tibiofemoral angle was 174.7? postoperatively. A residual varus angle exceeding 3? was observed in 2 cases. Six cases presented with complications during or after the operation. Two cases received an injury to the medial collateral ligament – namely a cortical shell-like avulsion fracture of the medial epicondyle of the femur. They were treated with absorbable screw fixation and filament suture and broken parts of the femur were stabilized. These patients achieved good recovery using a brace. Two cases presented with patellar clunk when they performed functional exercise following the operation and this syndrome remained at 47 months follow-up. Knee pain Neural Regeneration Research after long walks was experienced. One case had a cerebral infarction and one case a lacunar infarction; both these patients had undergone bilateral TKA. Facial distortion was visible during the operation, and no neurological symptoms were observed after treatment. There was no skin necrosis, incision infection or deep infection. DISCUSSION Pathological factors and classification of varus deformity and flexion contractures of the knee joint Varus deformity and flexion contractures of the knee joint have an obvious correlation with knee joint disease [1]Whiteside et al demonstrated that flexion contracture of the knee joint is associated with varus deformity in osteoarthritis patients. The severity of varus and the incidence of flexion contracture indicate a higher probability of medial collateral ligament and articular capsule laxity, namely the corrected flexion contracture. Consequently the osteoarthritis-induced flexion contracture is closely related to the collateral ligaments and posterior joint capsule in the contracted lesion. The osteoarthritis-induced varus deformity may change the force line of the lower extremity and a long-term malalignment results in wear of the medial compartment, destruction of the tibial plateau and severing of the genu varum.Reasons for, and classification of, genu varum Neural Regeneration Research The causes of genu varum deformity include: ? bone wear, especially at the tibial posterior plateau.; ? Ffemoral and tibial osteophytes inducing soft tissue tension.; ? Kknee joint medial structure, such as the medial collateral ligament, the semimembranosus in the posterior medial angle, the joint capsule and the pes [2–3]anserinus dead center contracture. The medial angle can be complicated by semimembranosus contracture, which results in the genu varum. When a flexion deformity is also present, advanced stage genu varum may cause a secondary laxity of the lateral structure. Varus knee is caused by two factors: ? Tthe varus angle in the bone structure, including the proximal tibia varum. Varus knee is then caused by medial plateau collapse resulting from medial articular surface wear and tibial plateau destruction.; ? Vvarus angles caused by an imbalance of the collateral ligaments [4–5]and the soft tissue around the knee. Varus knee induced by an imbalance of soft tissue is a chief pathological change in the osteoarthritis varus angle. When performing varus knee replacement, it is important to note that correction by increasing the osteotomy volume only may result in an alteration in the joint line and articular instability. Ligament laxity and soft tissue balance are the key steps in surgical correction. Preoperative evaluation of TKA Preoperative evaluation is performed by a systemic and general review of case history, a health examination, gaining an understanding of the deformity of the Neural Regeneration Research diseased knee and examining soft tissue function. A series of factors have to be considered before performing surgery and these include whether the medial collateral ligament, the lateral collateral ligament and the posterior cruciate ligament are intact; whether the knee extension device is intact; the size of the applied prosthesis and limitations of the prosthesis. When formulating the surgical proposal, the surgical approach, the soft tissue releasing method, and whether or not to reach a precise soft tissue balance as well as the size and type of prosthesis to be used must all be taken into account. The balance of soft tissue during the operation is closely related to the limitations of the prosthesis. Joint stability depends on the geometry and limitations of the articular surface, joint capsule, ligament and surrounding muscular tissues. When the articular surface is flatter, there are fewer limitations on the joint. Greater joint stability depends on [6–7]the surrounding soft tissue and soft tissue balance. Therefore, good soft tissue balance plays an important role in controlling the stability of knee joint following TKA. Limitations of a prosthesis are that it only offers mechanical stability, while reconstruction of the lower extremity force line and soft tissue balance can provide biological stability. Biological stability is important for maintaining joint function and long-term effects of surgery. The design pattern of the prosthesis used can decrease its limitations so as to reduce the prosthesis loosening rate, [8]while the stability of a low-restricted prosthesis depends on soft tissue balance. A good total knee replacement will include the following features: ? Tthe force Neural Regeneration Research lines of the lower extremity are accurate on three planes.; ? Lligament tension is balanced when the knee joints flex and extend.; ? Tthe joint lines are normal.; ? Tthe patella is in the middle position and at normal height.; ? Tthe range of [2–3]motion in the knee joint is satisfactory. Therefore, the osteotomy direction, and the probability of retaining posterior cruciate ligament and medial collateral ligament laxity should be taken into consideration during varus knee treatment. Obtaining an accurate soft tissue balance depends on the balance and equalization in both the flexion and extension gaps. The stability and motion range of the joints should be adjusted to the optimal state, and the loosened joint should show a better function than the tight joint. Soft tissue balance technique of varus deformity and flexion contractures of knee joint Laxity of soft tissue is a key feature in varus deformity of the knee joint. The following conclusions regarding surgical technique can be drawn: ? Tthe deep medial collateral ligament is isolated 1 cm below the articular surface, and the osteophyte is removed.; ? Tthe superficial medial collateral ligament is released in the subperiosteum.; ? Tthe posterior medial articular surface is released in flexion contracture patients.; ? Tthe superficial layer of the medial collateral ligament and pes anserinus can be fully released if necessary.; ? Fflexion contractures can be corrected following lateral equilibration.; ? Ssoft tissue should be considered when making decisions about the osteotomy direction, Neural Regeneration Research retention of the posterior collateral ligament, and the resection site.; ? Mmedial soft tissue release in the tibia and the superficial layer of medial collateral ligament is a key structure in the joint capsule and posterior collateral ligament. Only the deformity can be released and the releasing process only occurs in subperiosteum. ? Iinsufficient release causes a high level of medial stress and increases the risk of polyethylene prosthesis wearing and tibial prosthesis [9]loosening;. ? Eexcessive release may induce valgus laxity and joint instability [10]in the flexion position. TKA in flexion contracture patients is more challenging than in patients without flexion contracture. The extension of knee joint requires a wide release of soft tissue and some patients need secondary osteotomy at the distal femur level. Release of soft tissue is a chief method of correcting flexion contractures. [11]Mihalko et al have reported that secondary osteotomy at the distal femur level is not suitable for flexion contracture patients as it can alter the joint line at the extension position and reduce the contact area between the femoral posterior condyle and bone surface. An excessive osteotomy volume has an impact on the length of extremities and decreases the tension of the quadriceps femoris if it is more than 6 mm. The active tension of the extended knee can be reduced and secondary flexion contracture can develop if quadriceps femoris rehabilitation exercises are not performed. After the excision of the bilateral meniscus and cruciate ligament, the knee joint flexes, and the posterior joint capsule is Neural Regeneration Research dissected along with the femoral condyle and intercondylar fossa. To avoid enlarging the flexion gap too much, the knee posterior ligament and popliteal tendon should not be injured during surgery. During surgery, release should be thorough enough to extend the knee joint and even an excessive 5–10? extension is allowed. It is not possible to correct the residual flexion contracture through postoperative functional exercise. Under anesthesia, residual flexion contracture still occurs. Once the patient is no longer under anesthesia, it is difficult to correct the tension of soft tissue surrounding the knee joint and some patients who should achieve full extension are likely to present with secondary flexion contracture. Therefore, excessive correction is acceptable. The advisability of excising the posterior cruciate ligament and applying a posterior stabilized prosthesis is still in dispute. The difference between the flexion gap and the extension gap increases with the severity of the deformity in patients with flexion contracture. Secondary osteotomy is necessary at the distal femur level if the angle is more than 30?, the joint line is higher than the normal level, and the posterior cruciate ligament fails to function. So a posterior stabilized prosthesis is a good choice. Balance of flexion and extension joint gaps The balance of flexion and extension joint gaps can be achieved by the release of contractured soft tissues, and the severity of soft tissue laxity should increase gradually. Subsequent to the recovery of the distal femur and proximal tibia in the Neural Regeneration Research anatomical axis after osteotomy, the ligament of the side under tension gradually releases until the extension joint gap is rectangular. The balance of flexion and extension joint gaps can be achieved by various means, such as regulation of the resection plane on the proximal tibia and distal femur. The femoral posterior [12]resection plane has an impact on the flexion knee gap. In the present study, the joint gaps of flexed and extended knees were measured, and the soft tissue balance was evaluated. When knee joints are fully extended and the joint gaps are the same between the flexed knee and the extended knee, or when the joint gap is less than 4 mm greater with flexed knee than with the extended knee, there is a good soft tissue balance and routine osteotomy of both femur and tibia can be carried out. If the joint gap of the flexed knee is 4–6 mm greater than that of the extended knee, this also shows an approximation to soft tissue balance and indicates the feasibility of tibial osteotomy. In this instance the distal femur should be resected 2–4 mm more than in routine osteotomy. If the residual flexion contracture angle is less than 10? and the joint gap of the flexed knee is more than 6 mm greater than that of the extended knee, there is a soft tissue imbalance. The optimal balance of flexion and extension joints can be achieved by producing a joint gap of less 2 mm in the tibia and more than 4 mm in the [13]femur during osteotomy . In conclusion, soft tissue balance plays an important role in TKA and it is a chief means of correcting varus deformity and flexion contracture. Individual good soft Neural Regeneration Research tissue balance is indicated with different diseases and deformities. Good soft tissue balance improves the knee’s range of motion and allows correction of deformity after surgery in high deformity cases. Accurate soft tissue balance can be achieved by careful preoperative evaluation and skilled operative technique. It can provide consummate biological stabilization. Accurate soft tissue balance depends on improvement of the operative technique, clinical research and empirical summary. REFERENCES 1 Whiteside LA,Mihalko WM.Surgical procedure for flexion contracture and recurvation in total knee arthroplasty. Clin Orthop,2002,(404):189–195. ’ éé2 Huten D.Libration ligamentaire dans le genu varum[A].In:Duparc F ed.Confrence dEnseignement de la Sofcot[M].Paris:Elsevier,2002:85–101. è3 Neyret P,Guyen O,Selmi AS. Prothse total du genou sur genu varum important[A].In:Bonin Med.La Gonarthrose[M].Paris:Springer,2002:366–375. ’4 Deschamps G. Léquilibrage ligamentaire des prothése totales du genou [A].In:Bonin Med.La Gonarthrose[M].Paris:Springer,2002:454–471. 5 Zanone X,Ait-Si-Selmi T,Neyret P.Rev Chir Orthop Reparatrice Appar Mot, 1999,85(7):749–756.6 Yagishita K,Muneta T,Shinomiya K. Quantitative evaluation of the effect of soft tissue release on soft Neural Regeneration Research tissue balance in total knee arthroplasty. 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