From 1984 to 1993, 49 cases with varioussoft tissue defects around the knee were treated with pedicled calf myocutaneous flap, lateral sural cutaneous artery island skin flap, saphenous neurovascularskin flap and fasciocutaneous flap. The postoperation results were sucessful in 47 cases, and failure 2 cases, in one case with flap infection and theother with scar formation surrounding the knee. Both the failure cases were cured with split skin graft. The patient were followed up for an average of three and a halfyears, the knee function was almost completely regained, and the blood supply of the flaps, the elasticity and colour of the flaps were similiar to that of the normal skin, without being cumbersome. The sensation of the saphenous neurovascular flaps and the lateral suralcutaneous artery island flaps was preserved, except partial numbness was presented at the distal part of the flaps. Operative indications and selection of cases were discussed.
Effective postoperative pain management in patients undergoing total knee arthroplasty is an important part of the realization of enhanced recovery after surgery. Peripheral nerve block is of great significance to the control of postoperative pain, and clinicians are committed to finding a nerve block that has little impact on muscle strength and is conducive to the early recovery of motor function after total knee arthroplasty. Infiltration between the popliteal artery and capsule of the knee block can selectively block the sensory branch of the posterior end of the knee joint without affecting the motor branch of the common peroneal nerve, so that the muscle strength can be minimally affected under the condition of adequate analgesia. This article reviews the proposal of infiltration between the popliteal artery and capsule of the knee block, the approach and method of the block, and the advantages of combining with different nerve blocks for analgesia after total knee arthroplasty.
Objective To investigate the effectiveness of free latissimus dorsi myocutaneous flap transplantation combined with external fixation in the treatment of bone and soft tissue defects around the knee joint. Methods A retrospective analysis was conducted on the clinical data of 13 patients with high-energy trauma-induced bone and soft tissue defects around the knee joint admitted between January 2016 and July 2023. Among them, 11 were male and 2 were female, the age ranged from 23 to 61 years, with an average of 35.7 years. The causes of injury included 10 cases of traffic accident, 2 cases of machine entanglement injury, and 1 case of heavy object crush injury. According to the Gustilo-Anderson classification, 11 cases were type Ⅲ B and 2 cases were type Ⅲ C. Post-injury, 2 cases had wound infection and 2 cases had popliteal artery injury. The time from injury to flap repair was 40-49 days, with an average of 27.5 days. The wound size was 18 cm×13 cm to 32 cm×20 cm, all accompanied by distal femoral bone defects and quadriceps muscle defects. After primary debridement, vacuum sealing drainage combined with external fixation was used for treatment. In the second stage, free latissimus dorsi myocutaneous flaps were transplanted to repair soft tissue defects, with the flap size ranging from 20 cm×15 cm to 34 cm×22 cm. The donor sites of 9 flaps were directly sutured, and 4 cases with large tension were repaired with a keystone flap based on the posterior intercostal artery perforator. At 6-15 months postoperatively, with an average of 10.5 months, 11 patients underwent knee arthrodesis surgery; 2 patients with large bone defects at the distal femur and proximal tibia underwent multi-segment bone transport reconstruction of the bone defect. At last follow-up, the recovery of the flap and the donor site was recorded, and the function of the shoulder joint was evaluated by the American Shoulder and Elbow Surgeons (ASES) score, and the function of the affected knee joint was evaluated by the Knee Society Score (KSS). ResultsAll the flaps survived after operation, the wounds and donor site incisions healed by first intention. All 13 patients were followed up 15-55 months, with an average of 21.6 months. Four patients who underwent the restoration of the donor site with the thoracodorsal keystone perforator flap had obvious scar hyperplasia around the wound, but no contracture or symmetrical breasts on both sides. At last follow-up, the appearance and texture of the flaps were good; the bony fusion of the knee joint was good, and the range of motion and function recovered well; the shoulder joint function on the flap-harvested side was not significantly affected, and the range of motion was satisfactory. The ASES shoulder joint score of the latissimus dorsi muscle-harvested side was 85-95, with an average of 89.5. The knee joint function KSS score was 75-90, with an average of 81.2. ConclusionFree latissimus dorsi myocutaneous flap transplantation combined with external fixation for the treatment of bone and soft tissue defects around the knee joint caused by high-energy trauma can repair bone and soft tissue defects and reconstruct the stability of the knee joint, effectively preserve the integrity of the limb and soft tissues, and improve the patient’s ability of self-care.
Objective To investigate the effect of lateral retinacular release on the clinical outcomes after total knee arthroplasty (TKA) without resurfacing of the patella. Methods A prospective randomized controlled study was performed on 132 patients with unilateral degenerative knee arthritis undergoing TKA bewteen October 2012 and October 2014, who met the selection criteria. During TKA, lateral retinacular release was used in 66 cases (trial group) and was not used in 66 cases (control group). Two patients were excluded from the study due to missing the follow-up in trial group. Four patients were excluded from the study due to lateral retinacular release in control group. Finally, 64 patients and 62 patients were included in the trial group and in the control group. There was no significant difference in gender, age, body mass index, side, disease duration, preoperative patellar morphology, grading of patellofemoral arthritis, grade of patellar cartilage degeneration, patellar malposition, patellar maltracking, patellar score, and Knee Society Score (KSS) between 2 groups (P>0.05). The operation time, postoperative drainage volume, hospitalization time, postoperative complications, and patient satisfaction were recorded. Postoperative anterior knee pain was assessed by visual analogue scale (VAS), and the knee joint function was evaluated by KSS score and patellar score. The femoral angle, tibial angle, femoral flexion angle, and tibial posterior slope angle were measured on the X-ray film for postoperative prosthetic alignment. The postoperative patellar tracking and patellar position, as well as the presence of osteolysis, prosthesis loosening, patellar fracture and patellar necrosis were observed. Results All patients were followed up for 24 months. There was no significant difference in operation time, postoperative drainage volume, hospitalization time, and patient satisfaction between 2 groups (P>0.05). The incidence of anterior knee pain in the trial group was better than that in the control group (P=0.033). KSS score and patellar score were significantly improved in both groups at 24 months after operation when compared with preoperative scores (P<0.05), but no significant difference was found between 2 groups (P>0.05). Complications included hematoma (2 cases in the trial group, and 1 case in the control group), mild wound dehiscence (2 cases in each group respectively), skin-edge necrosis (1 case in the trial group), and superficial wound infection (1 case in each group respectively), which were cured by conservative treatment. No patellar necrosis, patella fracture, or knee lateral pain occurred in 2 groups. There was no significant difference in complication rate between groups (P=0.392). Satisfactory implant alignment was observed in both groups during follow-up. There was no significant difference in femoral angle, tibial angle, femoral flexion angle, and tibial posterior slope angle between 2 groups (P>0.05). No radiolucent line at the bone-implant interface was seen around the tibial components and femoral components in both groups. The patellar maltracking was observed in 3 patients of the trial group and 5 patients of the control group, showing no significant difference (P=0.488). However, the incidence of patellar malposition in the trial group (18.8%) was significantly lower than that in the control group (35.5%) (χ2=0.173,P=0.034). Conclusion Lateral retinacular release during primary TKA without resurfacing of the patella can reduce postoperative knee pain without increasing complications.
ObjectiveTo evaluate the effect of the surgeon’s handedness on the distribution of prosthesis during primary total knee arthroplasty (TKA).MethodsA retrospective analysis was performed on 86 patients (100 knees) with primary TKA completed by the same right-handed surgeon between December 2016 and December 2018, including 72 cases of single knee and 14 of bilateral knees. The patients were divided into dominant group (right side) and non-dominant group (left side) according to the operating position of the surgeon and each group had 50 knees. There was no significant difference in gender, age, body mass index, disease duration, clinical diagnosis, preoperative Hospital for Special Surgery (HSS) score, and other general data between the two groups (P>0.05). The operation time and complications were recorded in both groups. The function of knee was evaluated by HSS score. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured by using X-ray film of full-length lower extremity before TKA and at 2 weeks after TKA that were used to evaluate the coronal position of the prosthesis. Posterior distal femoral angle (PDFA) and posterior proximal tibial angle (PPTA) were measured by using lateral X-ray films at 3 months after operation that were used to evaluate the sagittal position of the prosthesis.ResultsThere was no significant difference in operation time between the two groups (t=−1.128, P=0.262). One case of posterior tibial artery thrombosis occurred in the dominant group, and 1 case of poor healing of the incision occurred in each of the dominant group and the non-dominant group. Patients in both groups were followed up 12-34 months with an average of 22.0 months. The HSS scores at last follow-up were 87.2±4.3 in the dominant group and 86.8±5.0 in the non-dominant group. There was no significant difference between the two groups (t=0.471, P=0.639). No complications such as periprosthetic infection, prosthetic loosening, or periprosthetic fracture occurred during follow-up. There was no significant difference in the HKA, mLDFA, and mMPTA between the two groups before and after operation (P>0.05). The differences in the incidence of sagittal femoral prosthesis malposition and PDFA between the two groups were significant (P<0.05); however, there was no significant difference in the PPTA, the rate of femoral prosthesis distributed in the neutral position, the incidence of over-flexed femoral prosthesis, and the incidence of anterior femoral notch (P>0.05).ConclusionThe surgeon’s handedness is one of the factors affecting the placement of the sagittal femoral prosthesis in primary TKA. The incidence of sagittal femoral prosthesis malposition could increase when the surgeon performs on the non-dominant side.
ObjectiveTo compare the clinical efficacy between medial collateral ligament (MCL) repair and MCL reconstruction in multi-ligament injury. MethodsThirty-one patients with MCL rupture and multi-ligament injury of knee joint were treated between August 2008 and August 2012, and the clinical data were retrospectively analyzed. Of 31 patients, 11 cases underwent MCL repair (repair group), and 20 cases underwent MCL reconstruction (reconstruction group). There was no significant difference in gender, age, body mass, injury side, injury cause, and preoperative knee Lyshlom score, International Knee Documentation Committee (IKDC) subjective score, range of motion, and medial joint opening between 2 groups (P > 0.05). The postoperative knee subjective function and stability were compared between 2 groups. ResultsAll incisions healed by first intention, and no postoperative complication occurred. All patients were followed up 2-4 years (mean, 3.2 years). At 2 years after operation, the IKDC subjective score, Lyshlom score, and range of motion were significantly increased in 2 groups when compared with preoperative ones (P < 0.05). The range of motion of reconstruction group was significantly better than that of repair group (P < 0.05). No significant difference was found in IKDC subjective score and Lyshlom score between 2 groups (P > 0.05). The medial joint opening was significantly improved in 2 groups at 2 years after operation when compared with preoperative one (P < 0.05), but no significant difference was found between 2 groups (P > 0.05). ConclusionBoth the MCL reconstruction and MCL repair can restore medial stability in multi-ligament injury, but MCL reconstruction is better than MCL repair in range of motion.
ObjectiveTo evaluate the effect of bone cement filling on articular cartilage injury after curettage of giant cell tumor around the knee. MethodsFifty-three patients with giant cell tumor who accorded with the inclusion criteria were treated between January 2000 and December 2011, and the cl inical data were retrospectively analyzed. There were 30 males and 23 females, aged 16-69 years (mean, 34.2 years). The lesion located at the distal femur in 28 cases and at the proximal tibia in 25 cases. According to Campanacci grade, there were 6 patients at grade I, 38 at grade Ⅱ, and 9 at grade Ⅲ. Of 53 patients, 42 underwent curettage followed by bone cement fill ing, and 11 received curettage followed by bone grafts in the subchondral bony area and bone cement fill ing. Two groups were divided according to whether secondary osteoarthritis occurred or not during postoperative follow-up. The gender, age, lesion site, the subchondral residual bone thickness, tumor cross section, preoperative Campanacci grade, subchondral bone graft, and Enneking function score were compared between 2 groups, and multivariate logistic regression analysis was done. ResultsAll incisions healed by first intention. The average follow-up time was 65 months (range, 23-158 months). Of 53 cases, 37 (69.8%) had no osteoarthritis, and 16 (30.2%) had secondary osteoarthritis. Three cases (5.7%) recurred during the follow-up period. Univariate logistic regression analysis showed no significant difference in gender, age, lesion site, and Campanacci grade between 2 groups (P>0.1); difference was significant in the subchondral residual bone thickness, tumor cross section, Enneking function score, and subchondral bone graft (P<0.1). The multivariate logistic regression analysis showed that the decreased subchondral residual bone thickness, the increased tumor cross section, and no subchondral bone graft are the risk factors of postoperative secondary osteoarthritis (P<0.05). ConclusionCurettage of giant cell tumor around the knee followed by bone cement filling can increase the damage of cartilage, and subchondral bone graft can delay or reduce cartilage injury.
ObjectiveTo evaluate the early effectiveness of one-stage total knee arthroplasty (TKA) with tibial stem extender for knee arthritis complicated with tibial stress fractures. MethodsBetween January 2014 and November 2016, 12 patients (12 knees) with knee arthritis and tibial stress fractures underwent one-stage TKA with tibial stem extender. There were 5 males and 7 females with an average age of 71.5 years (range, 60-77 years). There were 8 cases with osteoarthritis and 4 cases with rheumatoid arthritis. The radiographic examination showed the 6 cases of intra-articular fractures and 6 of extra-articular fractures (including transverse fractures in 4 cases and short oblique fractures in 2 cases); 2 cases complicated with middle and upper fibular fractures; 12 cases of varus deformities. Preoperative Knee Society Score (KSS) clinical score was 31.5±8.4 and functional score was 33.3±9.0. The preoperative range of motion (ROM) of the knee was (65.6±9.6)°. ResultsAll incisions healed primarily and no wound infection or skin necrosis occurred. All patients were followed up 36.5 months on average (range, 6-52 months). X-ray films showed that all fractures healed at 3-7 months (mean, 4 months); the position of the prosthesis was good, and no loosening or signs of infection occurred. At last follow-up, the KSS clinical score was 90.5±8.9 and functional score was 92.1±7.8; the ROM of the knee was (115.0±9.8)°. All indexes were significantly improved than those before operation (t=40.340, P=0.000; t=32.120, P= 0.000; t=8.728, P=0.000). ConclusionOne-stage TKA with tibial stem extender for patients with knee arthritis and tibial stress fractures can restore limb alignment, facilitate fracture healing, and obtain the satisfactory early effectiveness.