Stuchin S A, Ruoff M, Matarese W
Hospital for Joint Diseases Orthopaedic Institute, New York, New York 10003.
Clin Orthop Relat Res. 1991 Dec(273):42-51.
Patients with bone compromised by inflammatory arthritis and medications are often excluded from cementless total knee arthroplasty (TKA) because of concerns regarding implant fixation and ingrowth. However, many such patients are young and at long-term risk for implant failure no matter what the fixation technique. Improved implant designs and technique may improve results. Cementless arthroplasty was performed in 45 patients with inflammatory arthritis. There were 38 patients with 53 implants available for follow-up evaluation during a 2- to 6.4-year period (average, 3.3 years). Medications included steroids (16 patients), nonsteroidal antiinflammatory drugs (36 patients), and cytotoxic agents (12 patients). Twenty-nine patients were using at least two types of medication. Prostheses included the Tricon P, Tricon M, Miller-Galante, and Anatomic Modular Knee (AMK) prosthesis. The procedures were performed using standard ligament-balancing techniques. Tibial resections were within 1 cm of the tibial plateau, thereby necessitating extensive bone grafts in ten patients. Tibial components were chosen for maximal cortical rim contact. Roentgenograms were reviewed for alignment, tibial rim contact, radiolucencies, gaps, sclerosis, and subsidence. Patients with no evidence of gap or lucency had spot films under image control. Hospital for Special Surgery knee scores averaged 47 preoperatively and 88 at follow-up examination. Alignment was from 3 degrees valgus to 9 degrees valgus (average, 6 degrees valgus), with a tibial axis of 0 degrees +/- 2 degrees. Plateau coverage was within 2.4 mm (average) of the cortical rim in all planes in the anteroposterior (AP) and lateral views. Tibial sclerosis occurred with equal frequency in all AP zones and was present equally in anterior and posterolateral zones. Gaps and lucencies were more common laterally. Fifteen femoral components showed a disturbing, localized osteopenia. Sclerosis, gap, and lucency were most common anteriorly. Cementless TKA with appropriate technique can produce results comparable to cemented surgery in patients with bone quality compromised by inflammatory arthritis, steroids, and nonsteroidal and cytotoxic agents. The femoral bone response suggests an intimate bone implant relationship. The tibia shows little direct coupling of prosthesis to bone. These responses are similar to reports from other studies. Fixation is sufficient to allow for continued analysis over time and results are encouraging.
因炎性关节炎和药物治疗导致骨质受损的患者，常因担心植入物固定和骨长入问题而被排除在非骨水泥全膝关节置换术（TKA）之外。然而，许多此类患者较为年轻，无论采用何种固定技术，都面临植入物长期失败的风险。改进的植入物设计和技术可能会改善手术效果。对45例炎性关节炎患者实施了非骨水泥关节置换术。在2至6.4年（平均3.3年）的随访期内，有38例患者的53枚植入物可供评估。所用药物包括类固醇（16例患者）、非甾体抗炎药（36例患者）和细胞毒性药物（12例患者）。29例患者至少使用两种药物。假体包括Tricon P、Tricon M、Miller-Galante和解剖型模块化膝关节（AMK）假体。手术采用标准的韧带平衡技术。胫骨截骨在距胫骨平台1厘米范围内，因此10例患者需要进行广泛的骨移植。选择胫骨假体以实现最大程度的皮质边缘接触。复查X线片以评估对线、胫骨边缘接触、透射线、间隙、硬化和下沉情况。无间隙或透射线证据的患者在影像控制下拍摄点片。特种外科医院膝关节评分术前平均为47分，随访时为88分。对线从外翻3度到外翻9度（平均外翻6度），胫骨轴线为0度±2度。在前后位（AP）和侧位片的所有平面上，平台覆盖范围在皮质边缘平均2.4毫米以内。胫骨硬化在所有AP区域出现频率相同，在前侧和后外侧区域出现情况相同。间隙和透射线在外侧更常见。15个股骨假体出现令人不安的局限性骨质减少。硬化、间隙和透射线在前侧最为常见。对于因炎性关节炎、类固醇、非甾体和细胞毒性药物导致骨质受损的患者，采用适当技术的非骨水泥TKA可产生与骨水泥手术相当的效果。股骨的骨质反应表明骨与植入物关系密切。胫骨显示假体与骨之间几乎没有直接耦合。这些反应与其他研究报告相似。固定足以允许进行长期分析，结果令人鼓舞。
