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摘要：目的综述内轴型膝关节假体行人工全膝关节置换的研究进展。方法广泛查阅近年国内外相关文献，分析总结内轴型膝关节假体的特点及与传统假体行人工全膝关节置换的对比观察。结果目前用于行全膝关节置换术的假体主要有两种：即后稳定型假体及交叉韧带保留型假体。随着新的假体—内轴型膝关节假体的诞生，可供选择的假体愈来愈多。结论相比于传统假体，内轴型膝关节假体的优势与否并不确定，这需要更多的对比性研究加以证明。
关键词：内轴型膝关节假体；人工全膝关节置换
本文引用格式：胡海波,郑志永.应用内轴型膝关节假体行人工全膝关节置换的研究进展[J].世界最新医学信息文摘,2019,19(71):161-162.
Research Progress of Total Knee Arthroplasty Using Medial Pivot Knee Prosthesis
HU Hai-bo1,ZHENG Zhi-yong2*
(1.Shandong University of Traditional Chinese Medicine,Jinan Shandong;2.Department of Joint Orthopedics,Affiliated Hospital of Shandong University of Traditional Chinese Medicine,Jinan Shandong)
ABSTRACT:Objective To summarize the research progress of total knee arthroplasty with internal axial knee prosthesis is reviewed.Methods The related literature on surgical procedures to analyze and summarize the characteristics of internal axial knee prosthesis and the comparative observation of total knee arthroplasty with traditional prosthesis.Results Currently,there are two main types of prostheses used for total knee replacement:posterior stabilization prosthesis and cruciate ligament retention prosthesis.With the advent of a new type of knee prosthesis,the number of prostheses available is increasing.Conclusion The advantage of internal axial knee prosthesis over traditional prosthesis is uncertain,which needs more comparative studies.
KEY WORDS:Medial pivot knee prosthesis;Total knee arthroplasty
0引言
人全工膝关节置换术（total knee arthroplasty，TKA）是治疗晚期膝关节炎的重要手术治疗方法，能非常有效地根除病痛，极大地提高了病人的生活质量。目前临床上应用于行初次膝关节置换的假体主要有两种，即后稳定型假体(posterior stabilizing，PS)及交叉韧带保留型假体(cruciate-retaining，CR)[1]。美国Wright公司在1998年推出了1款全新设计的假体-Advance内轴膝关节假体(medial pivot，MP)，新的假体自诞生以来便一直受到广泛关注。本文通过广泛阅读国内外相关文献报道，现就MP假体的理论基础、特点、临床应用及最新进展作一综述。
1MP假体理论基础及特点
相关文献表明：在膝关节屈曲过程中，内侧胫股关节面接触点保持相对静止，而外侧胫股关节面接触点随膝关节屈曲而出现大幅度后移改变[2-5]。这直接提示，在膝关节屈曲过程中以内侧胫股关节面接触点为中心股骨远端相对胫骨平台发生了外旋运动，即膝关节屈曲过程中以内侧胫股关节面接触点为中心胫骨相对股骨远端内旋，故此理论被称为内侧轴心理论[6]。Advance内轴膝关节假体遵从“Ball in Socket”的理念，即聚乙烯垫片的非对称设计—内侧形成部分“球窝”界面而控制了股骨内侧髁的前后滚动，而外侧半等面弓形界面对外侧髁无限制[7]。在膝关节屈伸过程中，由于股骨侧假体的内侧髁部分设计为球形，使得其在聚乙烯垫片上的运动像球一样在球窝中滚动，而股骨侧假体的外侧髁部分在屈曲的过程中则可以出现正常膝关节的后滚运动，所以此假体被称为MP假体，这种假体也被认为是运动学上最符合膝关节自然状态的假体[8]。
2MP假体的临床运用研究现状
MP假体自1999年上市以来，国内外相关学者对其做了多个术后的随访研究。Youm等[9]随访了80例患者共计置换120个MP假体，Kaplan-Meier生存分析结果表明：伸直畸形度数平均值较术前减小了6.1°，最大屈膝度数平均值较术前增加了5.4°，7年假体生存率为98.1%。Ｒobert等[10]随访了320例患者共计置换365例MP假体，最终随访结果显示KSS评分平均95.5分，优良率达98%，关节活动度平均值较术前增加了4°，5年假体生存率为96.6%。Fitch等[7]运用系统评价及Meta分析研究了共计1146例膝关节置换患者，结果显示假体的5、8年生存率分别为99.2%和97.6%，术后的加权KSS平均分为87.9分。王煜城[11]随访了25例患者共置换33例MP假体，结果显示：术后KSS平均分为86.9分；Womac平均分降至23.2分；膝关节活动度度数较术前平均提高10.2°。Macheras[12]随访了325位患者发现，术后膝关节功能均得到了明显的改善，膝关节屈伸活动度平均为120°。Karachalios[13]随访了225位患者，所有患者的膝关节功能都得到了改善，膝关节活动度平均117°，15年假体累积生存率为97.7%。Martucci[14]和Kitagawa[15]等发现使用MP假体用于外翻膝关节置换后，膝关节的运动学得到了一定的恢复，膝关节功能也得到了较大的改善。不少文献也都证明了MP假体TKA术后膝关节功能评分较术前有明显提升[16-22]。
3MP假体与传统假体（PS假体及CR假体）的比较
运动学：不同的假体设计会导致膝关节置换术后膝关节运动学的不同[23]。传统假体的设计建立在几个基础概念上，包括膝关节的“三轴运动”，股骨髁上的J形曲线，股骨的后滚。膝关节置换术后膝关节运动学常出现与膝关节自然运动轨迹不相符的前滚或“反向前移”现象[7,21]，这一现象已被Dennis[24]等所证实。这种现象将导致膝关节不稳[25]并使得患者产生多种不适，如屈膝时髌骨撞击导致的撞击痛等。而MP假体运动学更接近自然膝关节运动学，符合正常解剖结构的运动。
聚乙烯衬垫的磨损：聚乙烯磨损是人工膝关节置换术失败的最常见原因[26]。股骨和胫骨之间传递的高剪切应力是影响磨损的直接因素[27]。MP假体系统使股骨假体可以在膝关节屈曲过程中与聚乙烯胫骨垫片保持较大的接触面积，有利于减少接触应力，因此可以降低长期垫片磨损率[2，3，28]，因此延长假体寿命。在许多股骨假体设计中[29]，其半径都在屈曲过程中逐渐减小，即随着屈曲度数的增加，后髁曲面半径减小，从而使得接触面积也常常减小，而内轴型假体系统股骨假体的单一曲率半径可以使在屈曲过程中假体接触面积一直保持较高的水平[30]。
相关临床研究：Pritchett等人[31-32]研究发现相比PS和CR假体，分别有77%和79%的患者对MP假体更满意。有报道对比了不同膝关节假体产生声音相关症状的比例，结果提示患者对前-后交叉韧带保留型假体及内轴膝的满意度更高[33]。张珂[34]对142例行TKA患者（MP组67例，PS组75例）近中期疗效做了对比研究，结果显示：MP假体与PS假体大致相同，两种假体并未体现出明显的疗效差异。夏长所等[35]对111例TKA患者（MP组49例，PS组62例）对比分析两者中期临床效果，结果显示：PS组的膝关节活动度和KSS评分高于MP组；MP组的WOMAC评分和Kujala评分要高于PS组。袁丁[36]对101名行TKA患者（MP组49人，PS组52人）假体置换术后中期效果做了对比研究，结果显示：（1）MP组与PS组中期随访无显著差异，两者在置换术后均能取得了良好的康复效果；（2）内轴型膝关节假体系统较后稳定型假体更为稳定，髁间截骨明显少于后者，可大幅度降低后期翻修所致骨缺损量，对于翻修较为有利。
综上所述，从设计理念来说MP假体相比传统假体更符合正常解剖结构要求，更贴近于自然膝关节运动学。用MP假体行TKA后膝关节活动度及膝关节功能评分都较术前都有较大的提高和改善。相比于传统假体，MP假体的优势与否并不确定，这需要更多的对比性研究加以证明。MP假体为TKA提供更多的选择，在未来随着MP假体的普及和使用率的提升，其一定能够获得令人满意的结果。
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