| Objective: To observe the short-term clinical effect of total knee arthroplasty(TKA)in the treatment of stiff or ankylosed knee.At the same time,21 patients with 27 knees and more than 90 degrees of ROM(range of motion)were randomly selected as the control group.The curative effect(ROM,the score of HSS,KSS and WOMAC)of two groups were compared and correlation analysis.To analyze the influencing factors of ROM after total knee arthroplasty of the stiff or ankylosed knee,and to explore the surgical indications and their advantages and disadvantages of the legacy posterior stabilized prosthesis(LPS)and legacy constrained condylar knee(LCCK)prosthesis,to sum up the surgery experience and skills of the TKA treatment.Methods: Twenty patients(25 knees)with stiff knee or ankylosed knee underwent TKA surgery from January 2011 to March 2017 in Rizhao People’s Hospital were enrolled.They were selected as the experimental group and twenty-one patients(27 knees)were selected as the control group and for retrospective analysis.The experimental group included three men(4 knees)and 17 women(21 knees).Their age are varied from 55 to 80 years with an average of(64.5±4.9)years.The duration is from 5 to 21 years with an average of 8.3 years.All patients with the ROM of flexion and extension do not exceed 50 °,and confirmed by X-ray examination.In the flexion deformity knees,5 cases(5 knees)showed ankylosis knee,rigidity angle was greater than 50 °,less than 90 °,11 cases(16 knees)showed knee-bent fibrous stiffness knee.In the straight deformity,2 cases showed ankylosis knee,2 cases showed fibrous stiffness knee,5 cases(6 knees)showed varus deformity with 5 °-15 °,3 cases(3 knees)showed valgus deformity with 5 °-15 °.All patients had the pain and deformity(or deformity)of the knee,and had increased pain while walking and could not walk more than 300 meters.They need to lean on the railing while climbing up and down the stairs,and some patients need someone else to help.They can not squat to wear shoes or go to the toilet alone.Their daily life is extremely inconvenient.Physical examination: some patients’ ipsilateral knees had mild swelling and hurt when pressed.Most patients had joint line tenderness around the knee joint.Both the anterior and posterior drawer test were negative.Some patients’ test on inside stress test and lateral stress test were suspicious positive.The X-ray of the AP and lateral position of knee joint showed: Various degrees of bone hyperplasia and osteoporosis around the knee,narrow joint space in the lateral and medial knees,and even had partial fusion.All patients showed different degrees of flexion,straight deformity.Some also had varus deformity or valgus deformity.Reasons of knee stiffness: rheumatoid arthritis in 12cases(15 knees),osteoarthritis in 5 cases(6 knees),post-traumatic arthritis in 2cases(2 knees),ankylosing spondylitis in 1 case(2 knees).Complications: diabetes in 11 cases,hypertension in 13 cases,coronary heart disease in 15 cases,chronic obstructive pulmonary in 7 cases.25 knees were performed with median incision of the knee and patallar medical approach.The control group included four men(7 knees)and 17 women(20 knees).Their age are varied from 57 to 82 years with an average of(66.3 ± 5.1)years.The duration is from 4 to 20 years with an average of 7.9 years.All patients with the ROM of flexion and extension exceed 90 °,and confirmed by X-ray examination.8 cases(9 knees)showed varus deformity with 5 °-15 °,5 cases(7 knees)showed valgus deformity with 5 °-15 °.All patients had knee pain and a history of aggravated pain during walking.Causes of knee disease: rheumatoid arthritis in 11 cases(15 knees),osteoarthritis in 7 cases(8 knees),post-traumatic arthritis in 2cases(3 knees),ankylosing spondylitis in 1 case(1 knees).Complications: diabetes in 9 cases,hypertension in 15 cases,coronary heart disease in 17 cases,chronic obstructive pulmonary in 7 cases.In the experimental group,used LCCK prosthesis in 7 knees,LPS prosthesis in 18 knees,LPS prosthesis with lengthened handle in 3 knees.Among them,Plus prosthesis in 7 knees,Zimmer prosthesis in 5 knees,Depuy prosthesis in 13 knees.In the control group,used Plus prosthesis in 10 knees,Zimmer prosthesis in 8 knees,Depuy prosthesis in 9 knees.All patients were performed patella angioplasty,wihout patella resurfacing.All the prostheses were fixed with bone cement.All 41 patients were followed up.The experimental group was followed up for(12-69)months with an average of 35.3 months.The control group was followed up for(12-72)months(average 35.5 months).The postoperative efficacy of total knee arthroplasty for the treatment of stiff or ankylosed knee and non-stiff knees was evaluated by the knee surgery scoring system of the Hospital for Special Surgery(HSS),the American knee society score(KSS)and the Western Ontario and McMaster Universities(WOMAC)Osteoarthritis Index)according to before surgery and the final follow up.The preoperative and postoperative ROM of the knee,individual scores and the score of HSS,KSS and WOMAC were recorded,and the corresponding improvement rate was recorded.The intraoperative and postoperative complications were recorded and compare the effect of complications on the patients.Preoperative and postoperative ROM,individual score and the score of HSS,KSS and WOMAC were compared with those of age,sex,body mass index,course of disease,etiology,combined deformity and medical complications by Pearson correlation analysis.Results: In the experimental group the average operation time was(125±24)min,the total blood loss(750±145)ml and the average operation time was(67±11)min and the total blood loss(430 ± 102)ml in the control group.They were statistically significant(P <0.05).ROM in the experimental group increased from 0 °-50 °(39.4 °±5.3 °)before surgery to 70 °-125 °(92.5 °±11.2 °)at the last follow-up.The last follow-up The change of ROM was 70 °-90 °(60.3 °±15.4 °),ROM of the control group increased from 95 °-115 °(93.5 °± 15.7 °)before operation to 85 °-125 °(105.4% °±13.5 °).The change of ROM in the last follow-up was-15 °-22 °(11.7 °± 16.2 °).The HSS score of the experimental group increased from(32.36±12.31)points(22-45)points to(80.70±18.52)points(60-87)points at the final follow-up,the change of HSS at the final follow up was(44.87±15.61)points(13-69)points,the final follow-up improvement rate was(71.45±15.48)%.The HSS score of the contral group increased from(35-57)points(40.18 ± 4.94)points to(83-96)points(89.17 ± 3.26)points at the last follow-up,the change of HSS at the last follow-up was(24-53)Points(36.35±4.52)points,the last follow-up improvement rate(81.89±14.67)%;The function score of KSS in the experimental group was increased from(27.9±8.3)points(17-32)points before surgery to(86.2±7.1)points(75-91)points at the last follow-up.The change of the function score of KSS was(54.8±15.3)points(38-62)points,the final follow-up improvement rate was(80.85±19.17)%,and the clinical score increased from(18.2±2.7)points(12-23)points before surgery to(87.3±9.2)points(70-87)points.The change of KSS clinical score at the last follow-up was(60.7±7.2)points(45-68)points,the final follow-up improvement rate was(83.39±14.32)%,the function score of KSS in the control group was increased from(22-46)points(35.2±11.3)points before surgery to(85-92)points(89.9±9.3)points at the last follow-up,and The change of the function score of KSS was(42-65)points(51.3±8.8)points,the final follow-up improvement rate was(84.81±13.58)%,the clinical scores increased from(21-45)points(34.1 ± 10.2)to(80-97)points(91.5 ± 7.8)Points at the last follow-up.The change of the clinical score of KSS was(34-54)points(51.6±15.4)points,the final follow-up improvement rate was(87.16 ± 16.61)%,The score of WOMAC in the experimental group was decreased from(52-85)points(72.56±10.17)points to(11-25)points(18.43±5.12)points at the last follow-up,The change of WOMAC was(33-70)points(50.12±7.24)points.The score of WOMAC in the control group was decreased from(46-80)points(64.62±14.47 points)to(13-27)points(16.98±7.93)points at the last follow-up,.The change of WOMAC was(22-67)points(41.36 ± 8.71)points.The comparison within the group between the preoperative and the final follow-up group in the experimental group and the control group: the score of HSS: the individual scores and the total score were significantly different(P <0.05),the comparison between groups before operation: There was significant difference in pain,function,ROM and flexion deformity(P <0.05).There was no significant difference in muscle strength and stability(P> 0.05).The comparison between groups at the last follow-up:There was no significant difference in pain,function,muscle strength,flexion deformity and stability(P> 0.05),but there was significant difference in ROM and the total score(P <0.05).The score of KSS : the individual scores and the total score were significantly different(P <0.05),the comparison between groups before operation: There was significant difference in the pain,range of motion,clinical scores,walking ability,ability to go downstairs and functional score(P <0.05),but no significant difference in stability(P> 0.05).The comparison between groups at the last follow-up:There was no significant difference in the pain,stability,walking ability,ability to go up and down,and score of functional score(P> 0.05).There was significant difference in the range of motion and the total clinical score(P <0.05).The score of WOMAC: There was significant difference in the individual scores and the total score(P <0.05),the comparison between groups before operation: There was significant difference in the pain,stiffness,function and the total score(P <0.05).The comparison between groups at the last follow-up: There was no significant difference in pain(P> 0.05),but there was significant difference in stiffness,function and the total score(P <0.05).There was excellent in 7,good in 15,fair in 3 in the experimental group and the excellent and good rate was 88%.,and excellent in 12,good in 13,fair in 2 in the control group and the excellent and good rate was 92.59%.All patients did not appear instability,there was no periprosthetic fractures and patella fracture and other complications.Dislocation,prosthesis loosening and infection did not appear in them.Except 2 patients with extensor laxity,the rest were completely straight,adverse patellar tracking did not appear.In radiographically,the postoperational X-ray film showed that prosthesis was in a proper position without loosening,subsiding,displacement and the bone dissolution and bone resorption,the force line of lower limbs was corrected.No dissolution and resorption of bone around the prosthesis,no noticeable translucent lines,The translucent band of radiation betweeen the bone cement and bone interface was <1mm,and the band of radiation transmission was not increased with several follow-up.The overall postoperative satisfaction rate was 92% in the experimental group and 96.30% in the control group.The incidence of complication in the experimental group was 36%(9/25),while that in the control group was 3.7%(1/27).The postoperative efficacy was related to ROM,stiffness,pain,function,muscle strength,the score of HSS,KSS and WOMAC(P <0.05).There was no correlation with flexion deformity,stability,age,gender,body mass index,course of disease,etiology,combined deformity and medical complications(P> 0.05).Conclusion:According to our study,Although the ultimate outcome of stiff or ankylosing knee at the last follow-up was worse than that of non-stiff knee,The total knee arthroplasty is a kind of effective treatment method in the treatment of stiff or ankylosed knee.Although there are high complications in operation,the operation is difficult,as long as the surgical approach,soft tissue releasing,osteotomy,prosthesis selection,postoperative rehabilitation exercise and other aspects of the design are good,Postoperation satisfactory range of motion and functionality of the knee could be obtained.The postoperative curative effect was positively correlated with ROM,stiffness,pain,function,muscle strength,the score of HSS,KSS and WOMAC of knee joint before operation.The postoperative curative effect had no correlation with flexion deformity,stability,age,gender,body mass index,Deformity,with or without medical complications.Postoperative range of motion is determined by the surgical technique,the type of prosthesis and postoperative rehabilitation training and other factors.Legacy posterior stabilized prosthesis or legacy constrained condylar prosthesis is a good choice according to the situation during the operation.However,stiff or ankylosed knee is the end-stage disease of knee joint,such cases are rare.For the present,the recent reports were a few cases,retrospectively,the bulk of cases of long-term prospective studies have not been reported,TKA in the treatment of stiff or ankylosed knee is still at the exploratory stage.As a doctor,efforts should be made to improve the surgical technique,improve the design of the prosthesis,improve the postoperative rehabilitation exercise,and make the best efforts to restore the function of the knee. |
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