| Objectives:In total knee arthroplasty for valgus knee,the main problem to be considered is how to achieve good internal and external soft tissue balance.For Ranawat II valgus knee(10≤HKA<20),there must be lateral tension and medial relaxation after the extension osteotomy.After initial lateral release(including cutting the posterolateral articular capsule,posterior articular capsule and releasing the lateral patellar retinaculum,etc.),the conventional method is to further thoroughly release the lateral collateral ligament(using Pie-crusting technique),but this theoretically destroys the lateral stability.Other balancing techniques,such as lateral condylar slip osteotomy,medial condylar slip osteotomy,MCL folding and shortening,either require additional internal fixations or destroy the integrity of MCL and increase the risk of postoperative complications.Therefore,we propose an innovative soft tissue balance technique to tighten the medial collateral ligament,preserving the integrity of LCL and MCL without additional fixation.The proportion of patients with valgus knee in total knee arthroplasty is about 15%,and the proportion of patients with normal preoperative alignment is about 50-60%.About 20% of patients after knee arthroplasty are not satisfied with the results of surgery,and there are 10-30% of patients with persistent pain after surgery,and whether there is the same high rate of dissatisfaction after valgus knee surgery,there is no relevant research.Therefore,the main purpose of our mid-term follow-up study was to observe the complications,incidence of persistent pain and satisfaction after valgus knee surgery.Methods:1.Novel Soft Tissue Balance Technique and Early Follow-up Study in Total Knee Arthroplasty for Knee Valgus DeformityThis is a prospective cohort study.From July 2014 to February 2018,a total of 40 cases(43 knees)of knee valgus deformity were observed.According to Ranawat classification,all of them belong to type II genu valgus.Twenty patients(22 knees)were treated with medial collateral ligament tightening(MCL tightening group)and 20 patients(21 knees)with lateral collateral ligament loosening(LCL loosening group).Our innovative technique of medial collateral ligament tightening refers to that after the initial release of the lateral structure,the medial collateral ligament is splitted longitudinally on the medial platform,the splitting cracks are widened by bone knife,and then the osteotomy blocks of the platform are pressed in,so that the medial platform is relatively widened,the tibial insertion of the medial collateral ligament moves inward,and the medial collateral ligament is tightened and tightened.Shrinkage,so as to achieve internal and external soft tissue balance.All operations were performed by the same surgeon,using posterior stabilized prostheses.We mainly observed the stability of knee joint,residual valgus and pain score after operation in the two groups.The secondary indexes were knee joint function score,flexion and extension activity,and average thickness of polyethylene insert.2.Mid-term follow-up study of valgus deformity after total knee arthroplastyThis is a retrospective case-control study.From June 2010 to October 2017,166 patients in the valgus group and 170 patients in the normal alignment group were enrolled in the hospital medical record retrieval system.The main inclusion criteria are: primary knee arthroplasty,adequate cognitive and expressive ability.The main exclusion criteria were knee varus deformity,extraarticular deformity,tumor knee replacement,revision surgery and so on.Patients were screened strictly according to inclusion and exclusion criteria.The normal alignment was defined as Hip-Knee-Ankle angle(HKA)of 0±3°,not absolute 0°.The definition of persistent pain is that the pain time after knee replacement is more than 3 months,and the VAS score of pain is more than 4 points.Postoperative satisfaction was rated by Likert as five grades: very satisfied,satisfied,general,unsatisfactory and very unsatisfactory.The latter two showed that the patients were not satisfied with the effect of the operation.Visual analogue scale(VAS): 0 is the most unsatisfactory,100 is completely satisfactory.The main outcome measures were reoperation rate(endpoint for surgical treatment for various reasons),incidence of persistent pain after operation,and satisfaction after operation(VAS score of satisfaction,Likert score of satisfaction).Secondary indexes were ROM of knee joint,VAS score of knee joint pain,HSS,KSS and HKA after operation.Results:1.Novel Soft Tissue Balance Technique and Early Follow-up Study in Total Knee Arthroplasty for Knee Valgus DeformityThere was no significant difference in age,sex,body mass index and other general data between the two groups.The average follow-up period was 32 months(12-49 months).The average preoperative HKA in MCL group was 13.8°±3.6,and postoperatively HKA was 1.9° ±1.1°.In the LCL release group,the preoperative HKA was 14.2°±4.1°,and the postoperative HKA was 1.4°±1.1°.The average thickness of polyethylene gaskets in MCL group was 9.7±1 mm,12.3±1.3 mm in LCL group,and thicker in LCL group(P<0.05).In LCL group,common peroneal nerve palsy occurred in 2 cases,and recovered spontaneously 4 and 7 months after operation.At the last follow-up,there was no significant difference in pain score,functional score and knee flexion and extension activity between the two groups.2.Mid-term follow-up study of valgus deformity after total knee arthroplastyAmong the patients included in the statistics,95 cases(117 knees)in valgus group and 92 cases(120 knees)in normal alignment group were followed up for an average of 5.2(1-8)years.HKA of knee joint in valgus group was 11.2°±5.8° before operation and 1.9°±0.6° after operation.Among the two groups,the main cases were osteoarthritis,rheumatoid arthritis and post-traumatic arthritis.The proportion of rheumatoid arthritis patients in valgus group was higher,accounting for 35 cases(42 knees),accounting for 36.8%.There was no significant clinical significance in knee joint range of motion,pain score,functional score and alignment HKA after operation in both groups.In the valgus group,1 case underwent reoperation(0.9%).The type II valgus deformity occurred supracondylar fracture 3 months after lateral femoral condylar slip osteotomy.The fracture was cured by internal and external double plate fixation plus bone grafting.X-ray showed that the fracture was healed 6 months after operation.In the normal alignment group,there were 2 cases(1.7%)of knee joint reoperation,one case of femoral supracondylar periprosthetic fracture occurred one year after operation,fixed with bilateral internal and external plates,and one case of persistent knee joint pain occurred two years after operation,the prosthesis position was normal,seriously affecting the patient’s life,and was cured after knee revision surgery.There were 7 patients(7/117,6%)with persistent pain in valgus group and 11 patients(11/120,9.2%)with persistent pain in normal alignment group.The patients in valgus group had a lower incidence of persistent pain during the mid-term follow-up(P < 0.05).According to Likert’s grade 5 classification,dissatisfaction and very dissatisfaction were classified as dissatisfaction after operation.There were 10 unsatisfactory knees(8.5%)in valgus group and 16 unsatisfactory knees(13.3%)in normal alignment group.According to the VAS score of satisfaction,the patients with valgus had higher satisfaction after operation,which was 83.4±11.1(65-100),while those with normal alignment were 76.3±13.8(60-100),P < 0.05.According to the classification of diseases,the VAS score of patients with rheumatoid arthritis was as high as 95.5±6.3(90-100),which was much higher than that of patients with osteoarthritis 74.9±12.3(60-100),P < 0.001.Conclusions:1.MCL tightening technology can use thinner insert,less risk of common peroneal nerve paralysis,and does not destroy the lateral collateral ligament,lateral stability is better.2 Patients with valgus knee and normal alignment were treated with TKA.The mid-term follow-up results of both groups were similar,including the range of motion and functional score of knee joint after TKA.3.The satisfaction of patients with rheumatoid arthritis after TKA is higher than that of patients with osteoarthritis.4.The incidence of persistent pain after TKA for valgus knee is lower and the degree of satisfaction after TKA is higher,which may be related to the higher proportion of rheumatoid arthritis in valgus knee group. |
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