Measurements And Clinical Analyses Of Osteotomical Parameters For Knee Arthroplasty In South China

The concept of 'Knee arthroplasty' was brought forward by Verneil in 1860. In early time, knee arthroplasty (KA) had bad outcome because appropriate materials for prostheses were scarce. Hard exploration went on for nearly a century until Walldius invented and developed the hinged knee prosthesis-the first kind of knee prosthesis with practical value-in the fifties of the twentieth century (1951). Because of the mechanic and kinematical differences and contradictions with human knee joint, the hinged knee prosthesis, which had a poor follow-up result couldn't get to the expectation of the surgeons and patients. Since 70th of the twentieth century, on account of the highly effective work not only in theory research, but also in clinic practices which done by the orthopedic surgeons and engineers, such as Gunston, Townly, Freeman, Swonson, Insall, etc, the knee prostheses with more biomechanical adaptability to the human knee were designed and manufactured successfully. Then the modern knee replacement came into being. During this period, the total condylar prosthesis series, together with the relating theory about total knee replacement (TKR), which put forward by John N. Insall (1973), made knee arthroplasty surgery to become a worldwide and quickly developing subject, then 'total knee arthroplasty (TKA)' got the same meaning as 'TKR'. Now, TKA is a safe and effective technology that used as a means to relieve pain and reconstruct function for pathological knees which cannot get good results from a period of time of conservative treatments and other therapies. Totally, TKA is a kind of technology with low risk and high achievement ratio even if the outcome may be influenced by mentation and health status of patients, experiences and technique of surgeons, apparatus and equipments for operations, etc. Modern TKA has been developing for more than 30 years and received great success in clinic practice. However, there are still many questions in basic theory and surgical technique, in which some have been come to agreements but some more will be debated for quite a long time. In our country, some orthopaedic surgeons commenced on TKA in late of eighties in the twentieth century. In the nineties of the twentieth century, TKA got prevalence in China and Chinese orthopaedic surgeons found they were always puzzled by many questions. It is same that the problem is that orthopaedic surgeons in our country haven't got a good command of the new concept and new surgical techniques of modern TKA as Western orthopedists. Commonly, domestic orthopaedists find they cannot get the same perfect outcome as the orthopaedic surgeons aboard, even all the time they performed TKA when guided by alignment guides and rotary blades provided by Western countries, carry out according to the guidebooks published by the instrument companies. Insall said: TKA is a highly difficult technique, for it is relating to many complicated problems. So, lack of systemic training for orthopaedic surgeon is the great obstacle to TKA's development in our country. Another problem is that the knee prostheses and alignment guides were designed and manufactured by the Western, according to the Western's anatomy data. The differences in anatomy data and life style between Eastern and Western maybe lead to deviations in TKA when Eastern surgeons copying Western's data and principle. Locations of prosthesis components and joint lines are pivotal to TKA's success or failure. So it is always a highly important subject to find reliable reference points and analyze the clinical significances of the parameters of osteotomy in TKA surgery. Domestic traditional anatomic research ignores the data of these reference points and baselines. We cannot find particular data closely relating to prosthetic design, osteotomy and location of TKA in the book and its continuation edited by Constitution Survey Committee of China Anatomic Association. There are nothing in these books about the most important reference points and parameters such as posterior condylar line (PCL), surgical transepicondylar axis (STEA), clinical transepicondylar axis (CTEA), posterior condylar angle (PCA), condylar twist angle (CTA), posterior slope angle (PSA) of tibial plateau, etc.Hereby, the author was trying to measure and analyse these parameters in the past two years and this paper consists of five sections comprising some anatomic problems relating to KA about the distal femur, the proximal tibia and the patella, all of adults living in South of China. Some of them are paradoxical issues that we surely will dispute for quite a long time. Maybe no other than these are worth of our attention.SectionⅠand SectionⅡcomprise something about the anatomical rotary landmarks of the distal femur on which the author discussed the osteotomy of the distal femur and rotary alignment of the femoral prosthesis. In SectionⅢand SectionⅣ, the author discussed the problem of proximal tibia's osteotomy and design of the tibial prosthesis, according to the measurement of the posterior slope angle of medial tibial plateau and the altitude difference between meidal tibial plateau and fibular head. In SectionⅤ, an epidemiological research about Wiberg's and Baumgartl's morphological classification of patella in normal southern Chinese adults was carried out. After that, patellofemoral arthroplasty (PFA) and design of the patellofemoral joint prosthesis were discussed.My research work is still in the elementary grade while my ultimate objective is to set up a parameter data bank of southern Chinaman, rely on which surgeons can select proper prosthesis and organize ideal alignment in primary TKA, reconstruct original joint line in revised TKA. As well, it will provide data support for the design and manufacture of proper knee prosthesis for southern Chinaman.Abstract of each section is introduced respectively as follows:SectionⅠMesurments of the Posterior Condylar Angle and Condylar Twist Angle of Normal Southern Chinese Adults by means of MRObjective To investigate the posterior condylar angle (PCA) and condylar twist angle (CTA) of normal southern Chinese adults by a mean of MR scan, to provide anatomic parameters for the osteotomy of distal femur and rotational location of the femoral prosthesis in total knee arthroplasty.Methods 100 adults who born in and long living in south of China were chose at random, in which, 100 knees (25 male right, 25 male left, 25 female right and 25 female left) were examined with an axial MR scan of the distal femur. All the photoes were inputed in personal computer, PCA and CTA of each femur were measured in Photoshop 7.0.1 software. Data were summarized as means±standard deviations. The SPSS for windows 10.0 program was used for statistical analysis. 2×2 Factorial Univariate was applied to analyze the main effects (gender/side). Independent-Samples t-Test was applied to compare male-female and fight-left measurements. To determine the relationships between PCA and CTA in males and femals respectively, Linear Regression was calculated and analyzed. Statistical significance was set at P≦0.05.Results 1) Male PCA was 3.86°±0.28°(right 3.83°±0.28°, left 3.92°±0.28°), female PCA was 3.19°±0.33°(right 3.17°±0.34°, left 3.20°±0.33°). There was singnificant difference between male and female (P＜0.001, right P＜0.001, left P＜0.001), there were no singnificant differences between rightside and leftside in both male (P=-0.335) and female (P=0.266). 2) Male CTA was 5.97°±0.43°(right 5.91°±0.38°, left 6.03°±0.47), female CTA was 5.03°±0.47°(right 4.95°±0.56°, left 5.10°±0.37°). There was singnificant difference between male CTA and female CTA (P＜0.001, right P＜0.001, left P＜0.001), there were no singnificant differences between rightside and leftside in both female (P=0.231) and female (P=-0.719). 3) There were moderate correlations between CTA and PCA in male (R~2=0.323, F=22.878, P＜0.001), and in female (R~2=0.206, F=12.435, P=0.001).Conclusions 1) There was no side-difference in PCA and CTA in normal southern Chinese adults. However, both PCA and CTA of male's were greater than female's. The gender difference must be noticed in TKA, when osteotomy of the distal femur and placement of the femoral prosthesis be operated. 2) There were moderate correlations between CTA and PCA of southern Chinese adults, both in male and female, respectively. 3) MR scan is a good means to measure PCA and CTA of the femur. It is better to measure PCA and CTA, make the rotational alignment of the distal femur certain before TKA. It is necessary that we locate the femoral rotational alignment based on the measurement in TKA. SectionⅡThe Value of Whiteside's Line in Deciding the Rotational Alignment of the Distal FemurObjective To measure the angle between the perpendicular line of the Whiteside's line and the posterior condylar line (PCL), discuss the value of the Whiteside's line as a rotational alignment landmark of the distal femur.Methods 15 nomal femurs of Chinese adult cadavers were selected at random. Axial photo of every femur gotten with a digital camera was inputed in the personal computer. All the photos were disposed with Photoshop 7.0.1 software. The angles between the Whiteside perpendicular line and PCL, noted as WPCA, were measured and compared with the posterior condylar angles (PCA) between surgical transepicondylar axis (STEA) and PCL. All the computation data were noted as means±standard deviations and Paired-Samples t-Test was done for statistical analysis with the SPSS for windows 10.0 program. P≦0.05 was regarded as a significant difference.Results PCA: 3.67°±0.40°(2.74°～4.10°); WPCA: 3.50°±0.62°(2.34°～4.25°). There was no significant difference between these two angles (t=-0.949, P=0.359).Conclusion It was feasible that use Whiteside's line as one of the reliable rotational landmarks of the distal femur in TKA.SectionⅢThe Measurement of the Medial Tibial Plateau Posterior Slope Angle of Southern Chinese Adults and its Clinical Meaning in Total Knee ArthroplastyObjective To measure the meidal tibial plateau posterior slope angle (PSA) of the nomal and osteoarthritic knees of adults in South China, obtain relating morphological parameters of tibia in order that suitable resecting of tibia plateau can be obtained in TKA.Methods In this research, there were two groups designed: the case group and the cadaver group. The case group including two secondary groups: the nomal group and the osteoarthritic group. 25 osteoarthritic knees (8 sides of male, 17 sides of female, HSS Scores 50～70 points) of 25 southem Chinese adults were selected randomly for the osteoarthritic group. 25 normal knees (15 sides of male, 10 sides of female) of 25 southern Chinese adults without osteoarthritis were selected at random for the normal group. Each knee was gotten an X-ray of lateral view, which disposed with Photoshop 7.0.1 software and the meidal tibia plateau PSA was measured with ectomarrow reference (referencing the anterior tibial cortical plate tangent line) and endomarrow reference (referencing the axis of middle-upper tibia). Selected 20 non-osteoarthritic cadaveric dry tibias of Chinese adults (gender, age and living area not known) in a random manner as the cadaver group. The medial tibial plateau PSA of each sample was measured by means of visual means and X-ray means, both with ectomarrow reference and endomarrow reference as well. Data were summarized as means±standard deviations. The SPSS for windows 10.0 program was used for statistical analysis. 2×2 Factorial Univariate was applied to analyze the main effects of the case group and the cadaver group, respectively. Independent-Samples t-Test was applied to compare the individual effect. Linear regression/curve estimation were calculated and analyzed to approach the correlation of the ectomarrow reference and the endomarrow reference. Statistical significance was set at P≦0.05.Results 1) In case group, with ectomarrow reference, the meidal tibial plateau PSA was 14.00°±3.64°, normal group was 14.06°±3.28°, arthritic group was 15.27°±3.66°, there was no significant difference between these two group (t=-1.223, P=0.225). However, with endomarrow reference, the meidal tibial plateau PSA was 11.80°±3.02°, normal group was 10.86°±2.55°, arthritic group was 12.74°±3.21, there was significant difference between these two group (t=-2.299, P=-0.026). There was strong correlation between eetomarrow reference and endomarrow reference (R~2=0.870, F=153.481, P＜0.001) in normal group and there was no significant correlation between these two references in arthritic group (R~2=0.017, F=0.394, P=0.536). 2) In cadaver group, there were no significant difference between the visual group and the X-ray group (ectomarrow reference: t=-0.958, P=0.344; endomarrow reference: t=-0.674, P=0.504). Tow references had significant differences in these two groups (visual group: t=3.126, P＜0.001; X-ray group: t=4.161, P＜0.001) and there were strong correlation (visual group: R~2=0.721, F=46.554, P＜0.001; X-ray group: R2~=0.709, F=43.772, P＜0.001) between these two references. 3) Measured with X-ray, the meidial tibial plateau PSA of normal Chinese cadavers was 13.91°±2.75°in ectomarrow reference group and 10.73°±2.02°in endomarrow reference group. There were no significant differences between case group and cadaver group (ectomarrow reference: t=0.169, P=0.867; endomarrow reference: t=0.187, P=0.852).Conclusion There was no significant difference of the medial tibial plateau PSA between the normal knees and the arthritic knees of adults in South China. There was no significant difference between southern Chinese adults and Chinese cadavers as well.SetcionⅣAltitude Difference between Medial Tibial Plateau and Fibular Head of Adults in South ChinaObjective Altitude differences between medial tibial plateau and fibular head of healthy and arthritic knees of adults in South China were measured to provide parameters for tibial osteotomy and tibial prosthesis' design.Methods 60 normal knees (30 males, 30 females) of southern Chinese adults who suffered from soft organize trauma were selected randomly as the normal group. 60 arthritic knees (30 males, 30 females) of southern Chinese adults were selected randomly as well, as the arthritic group. All the knees were taken the radiograph of anterioposterior view on which the altitude differences between the medial tibial plateaus and the fibular heads were measured. The date were noted as means±stardand deviations and processed with the SPSS for windows 10.0 program for statistical analysis. 2×2 Factorial Univariate was applied to analyze the main effects (group/gender). Independent-Samples t-Test was applied to compare the single effcct. Statistical significance was set at P≦0.05.Results The mean altitude difference between the medial tibial plateau and the fibular head of the normal knees was 8.29±0.93mm (male: 8.67±0.92mm; female: 7.90±0.79mm). In arthritic group, the values were 7.40±0.94mm (male: 8.05±0.82mm, female: 6.75±0.51mm). There was singnificant difference between male and femal on the mean altitude difference between the medial tibial plateau and the fibular head. The values of P were＜0.001, =0.001 and＜0.001 in total group, normal group, arthritic group, respectively. Still, there was singnificant difference between normal knees and arthritic knees on the mean altitude difference between the medial tibial plateau and the fibular head. The values of P were＜0.001, =0.008 and＜0.001 in total group, male group, female group respectively.Conclusions Proper thickness of the tibial prosthesis was 6mm～9mm for most of the people in South China considering the altitude difference between the medial tibial plateau and the fibular head. For male, the proper thickness of the tibial prosthesis was 7～9mm. For female, it should be 6mm～8mm. We should routinely measure the altitude difference between tibial plateau and fibular head before TKA and pay enough attention to protect the lateral collateral ligament when performing proximal tibial resection in TKA.SectionⅤAn Epidemiologicai Research about Wiberg's and Baumgartl's Types of Patella in Normal Southern Chinese AdultsObjective An epidemiological research about Wiberg's and Baumgartl's types of patella in normal southern Chinese adults was carried out, to approach patellar morphologic meaning in patellofemoral arthroplasty (PFA) as well as the prosthesis design of the patellofemoral joint.Methods 200 normal knees of 200 adults (100 males, 100 females) who born in and long living in south of China were chosen at random. Each knee was taken an axial raidograph of the patella on which the Wiberg's and Baumgartl's type classification was discerned. Then, the numeration data was processed with SPSS 10.0 for windows, in that, a R×C Crosstabs Chi-square test was applied to compare the difference of patella types' distribution in male and female, a Nonparametric Chi-Square Test was made use of to check the uinformity of the types' distribution in southern Chinese people. Statistical significance was set at P≦0.05.Results In 100 male patellae, there were 8 cases of Wiberg's typeⅠ, 87 cases of typeⅡ, and 5 cases of typeⅢ. The corresponding numbers in female were 4,91,5. There were not other types of patella in male as well as in female. There was not significant difference of the appearanced three types of patella between male and female (x~2=1.449, v=2, P=0.491), and the different types' distribution was not even in the normal crowed in this area (x~2=278.920, v=2, P＜0.001).Conclusion There were much more Wiberg's typeⅡpatellae which occupying about 90% of the total in normal southern Chinese adults. This proportion was large than date on abroad documents. In PFA and prosthesis design of patellofemoral joint, this character must be taken into account.