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关节置换术中理想的手术位置和植入物的放置对于假体长期生存、患肢最佳功能恢复至关重要。临床传统人工全膝关节置换术(TKA)因术中复杂的髓内定位装置和过度依赖术者经验来确定所需截骨厚度和角度,容易产生一定的偏差,导致手术失败[1]。有研究[2]表明,传统手术装置对截骨角度的精确率仅为实际解剖的75%。病人膝关节重度畸形和有严重的骨量不足或缺损时,传统的TKA手术精确率又会大大降低,以致无法满足临床疗效的要求[3]。
目前,3D打印是一项日益成熟的技术,具有个性化的模型优势,已广泛应用于骨科实验模型的制作、辅助材料打印、植入物打印和关节手术打印等领域[4-5],它可以为关节置换术的病人提供个性化的专属器械和植入物,并能充分考虑到解剖变异和缺陷对疗效的影响[6],弥补了传统TKA定位不准、截骨偏差诸多方面的不足,从而显著提高手术截骨的准确性、假体的机械强度和重建后膝关节的稳定性[7-9]。本次研究旨在进一步探析3D打印个性化截骨导板辅助TKA和传统TKA应用效果差异,为临床诊治复杂膝内翻畸形骨关节疾病提供理论参考。
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2组病人的年龄、性别和膝内翻患侧差异均无统计学意义(P>0.05)(见表 1),具有可比性。
分组 n 年龄(x±s)/岁 男 女 患侧 左 右 3D打印导板组 23 63.70±4.00 8 13 13 10 传统手术组 21 63.80±4.56 9 12 10 11 χ2 — 0.19* 0.10 0.35 P — >0.05 >0.05 >0.05 *示t值 表 1 2组病人一般资料的比较
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所有病均人成功实施手术,术后24 h拔除引流管,术后1周能自主功能锻炼并在辅助器下行走锻炼,切口甲级愈合,均未发生感染、神经血管损伤及假体松动移位等并发症,术后6个月顺利随访。
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与传统手术组病人比较,3D打印导板组手术时间显著缩短,术中失血量显著减少,术后24 h引流量显著减少,差异均有统计学意义(P<0.01)(见表 2)。
分组 n 手术时间/min 术中失血量/mL 术后24 h引流量/mL aMFTA/(°) 3D打印导板组 23 75.52±6.39 150.70±8.54 232.61±10.43 2.33±0.28 传统手术组 21 94.90±4.33 207.33±9.48 303.05±12.05 1.81±0.21 t — 11.66 20.85 20.78 7.03 P — < 0.01 < 0.01 < 0.01 < 0.01 表 2 2组围手术期相关指标比较(x±s)
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术后,3D打印导板组与传统手术组相比,aMFTA明显减小(P<0.01)(见表 2)。
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2组病人术后6个月KSS临床及功能评分均明显高于术前(P<0.01)。术前, 2组病人KSS临床评分及功能评分比较,差异均无统计学意义(P>0.05);术后6个月,2组病人KSS临床评分比较,差异无统计学意义(P>0.05),3D打印导板组功能评分高于传统手术组(P<0.05)(见表 3)。
分组 n KSS临床评分 KSS功能评分 术前 3D打印导板组 23 53.17±3.07 52.96±3.20 传统手术组 21 53.43±3.11 53.14±2.87 t — 0.27 0.20 P — >0.05 >0.05 术后 3D打印导板组 23 86.30±2.12** 88.00±1.73** 传统手术组 21 86.05±1.36** 86.71±1.82** t — 0.47 2.40 P — >0.05 < 0.05 注:与术前比较**P<0.01 表 3 2组病人术前及术后6个月KSS评分比较(x±s;分)
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2组病人术后3个月和术后6个月WOMAC评分较术前均随着时间的增加而降低(P<0.01);组间比较显示,术前、术后6个月2组间WOMAC评分差异均无统计学意义(P>0.05),术后3个月时3D打印导板组评分低于传统手术组(P<0.05)(见表 4)。
分组 术前 术后3个月 术后6个月 F P MS组内 3D打印导板组 74.48±6.09 18.00±2.07** 11.61±1.47**△△ 1 268.15 < 0.01 14.502 传统手术组 73.29±6.57 20.10±3.21** 11.57±1.43**△△ 1 898.58 < 0.01 18.522 t 0.63 2.55 0.09 — — — P >0.05 < 0.05 >0.05 — — — q检验:与术前比较**P<0.01;与术后3个月比较△△P<0.01 表 4 2组病人WOMAC评分比较(x±s;分)
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病人,女,63岁,双膝关节肿痛、畸形伴功能障碍20年。左膝屈曲5°~85°,内翻30°;右膝屈曲5°~90°,内翻25°。X线片示:双膝关节边缘骨质增生,内侧关节间隙显著变窄,关节面硬化破碎不平,内见低密度囊区,膝关节内缘见游离体,双膝关节对应欠佳,呈半脱位征象。右股骨远端类圆形高密度影,左胫骨近端低密度囊区。术前讨论认为病人膝关节内翻畸形严重,胫骨平台内侧缺损大,外侧副韧带松弛,内侧副韧带紧缩,常规膝关节假体软组织平衡困难,需要在3D打印截骨导板技术辅助下行TKA,考虑左侧膝关节内翻畸形程度更大,先行左侧TKA,11个月后行右侧TKA(见图 1~8)。
3D打印截骨导板辅助人工全膝关节置换术在重度膝内翻畸形中的应用观察
Application value of 3D printed osteotomy guide plate assisted artificial total knee arthroplasty in severe genu varus deformity
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摘要:
目的探析3D打印截骨导板技术辅助人工全膝关节置换术(TKA)在重度膝内翻畸形骨性关节炎中的应用,提高临床TKA的精准性。 方法收集42名重度膝关节内翻畸形病人的临床资料进行分析。将病人采取随机数字表法分为2组,其中3D打印导板组21例(23膝)在3D打印截骨导板辅助下行TKA,传统手术组21例(21膝)接受传统TKA手术治疗。记录2组病人的手术时间、术中失血量、术后24 h引流量、术后股骨与胫骨机械轴夹角(aMFTA)以及膝关节KSS、WOMAC评分并进行统计分析。 结果所有病人均成功实施手术并进行6个月随访。与传统手术组比较,3D打印导板组手术时间显著缩短(P<0.01),术中失血量、术后24 h引流量均明显减少(P<0.01);术后aMFTA低于传统手术组(P<0.01)。2组病人术后6个月KSS临床及功能评分均明显高于术前(P<0.01), 术后6个月3D打印导板组KSS功能评分高于传统手术组(P<0.05), 而2组KSS临床评分差异无统计学意义(P>0.05)。2组病人术后3个月和术后6个月WOMAC评分较术前均随着时间的增加而降低(P<0.01);术后3个月,3D打印导板组评分低于传统手术组(P<0.05)。2组病人术后均未出现感染、神经损伤、深静脉血栓形成、假体松动脱位等并发症。 结论3D打印截骨导板技术辅助TKA治疗膝关节重度内翻畸形较传统TKA手术兼备时间短、失血量少、手术截骨精准度提高和术后功能恢复快的优点,临床疗效更佳。 Abstract:ObjectiveTo investigate the application value of 3D printing osteotomy technology assisted artificial total knee arthroplasty(TKA) in severe genu varus deformity to improve the accuracy of clinical TKA. MethodsThe clinical data of 42 patients with severe genu varus deformity were collected and analyzed.The patients were divided into two groups by random number table method.The 3D printing guide group(21 cases, 23 knees) were treated with 3D printed osteotomy guide plate assisted TKA, and the traditional surgical group were treated with traditional TKA.The operative time, intraoperative blood loss, 24 hours postoperative drainage, postoperative femoral and tibial mechanical shaft clamping angle(aMFTA) and knee joint KSS and WOMAC scores were recorded and statistically analyzed. ResultsAll patients were successfully operated and followed up for 6 months.Compared with the traditional surgery group, the operation time was significantly shortened(P<0.01), and the intraoperative blood loss and 24 hours postoperative drainage volume were significantly reduced in the 3D printing guide group(P<0.01).The postoperative aMFTA in 3D printing guide group was lower than that in traditional surgery group(P<0.01).After 6 months of surgery, the clinical and functional scores of KSS in two groups were significantly higher than those before surgery(P<0.01), the functional score of KSS in 3D printing guide group was higher than that in traditional surgery group(P<0.05), but there was no statistical significance in the clinical score of KSS between two groups(P>0.05).Compared with that before surgery, the WOMAC scores in two groups after 3 and 6 months of surgery decreased with the increase of time(P<0.01).After 3 months of surgery, the score of 3D printing guide group was lower than that of the traditional surgery group (P<0.05).No postoperative complications such as infection, nerve injury, deep vein thrombosis, prosthesis loosening and dislocation occurred in two groups. ConclusionsCompared with the traditional TKA surgery, the 3D printed osteotomy guide plate technology in the treatment of severe genu varus deformity has the advantages of shorter operation time, less blood loss, effective improving the surgical osteotomy accuracy, quick recovering the postoperative function and better clinical effects. -
Key words:
- total knee arthroplasty /
- 3D printing /
- knee genu varus /
- osteoarthritis
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表 1 2组病人一般资料的比较
分组 n 年龄(x±s)/岁 男 女 患侧 左 右 3D打印导板组 23 63.70±4.00 8 13 13 10 传统手术组 21 63.80±4.56 9 12 10 11 χ2 — 0.19* 0.10 0.35 P — >0.05 >0.05 >0.05 *示t值 表 2 2组围手术期相关指标比较(x±s)
分组 n 手术时间/min 术中失血量/mL 术后24 h引流量/mL aMFTA/(°) 3D打印导板组 23 75.52±6.39 150.70±8.54 232.61±10.43 2.33±0.28 传统手术组 21 94.90±4.33 207.33±9.48 303.05±12.05 1.81±0.21 t — 11.66 20.85 20.78 7.03 P — < 0.01 < 0.01 < 0.01 < 0.01 表 3 2组病人术前及术后6个月KSS评分比较(x±s;分)
分组 n KSS临床评分 KSS功能评分 术前 3D打印导板组 23 53.17±3.07 52.96±3.20 传统手术组 21 53.43±3.11 53.14±2.87 t — 0.27 0.20 P — >0.05 >0.05 术后 3D打印导板组 23 86.30±2.12** 88.00±1.73** 传统手术组 21 86.05±1.36** 86.71±1.82** t — 0.47 2.40 P — >0.05 < 0.05 注:与术前比较**P<0.01 表 4 2组病人WOMAC评分比较(x±s;分)
分组 术前 术后3个月 术后6个月 F P MS组内 3D打印导板组 74.48±6.09 18.00±2.07** 11.61±1.47**△△ 1 268.15 < 0.01 14.502 传统手术组 73.29±6.57 20.10±3.21** 11.57±1.43**△△ 1 898.58 < 0.01 18.522 t 0.63 2.55 0.09 — — — P >0.05 < 0.05 >0.05 — — — q检验:与术前比较**P<0.01;与术后3个月比较△△P<0.01 -
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