Total diz artroplastisi cerrahisi sonrası patellar klunk sendromu insidansı
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Dosyalar
Tarih
2020
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Düzce Üniversitesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Amaç: Patellar klunk sendromu (PKS), total diz artroplasti (TDA) ameliyatları sonrasında oluşan eklem içi ile ilgili mekanik problemlerden biridir. Özellikle arka çapraz bağ kesen implantların kullanımı sonrası görülme sıklığı artan bu patoloji, kuadriseps tendonunun distal kısmının patella üst kutbu birleşim yeri çevresinde oluşan patolojik fibroz doku sebebiyle ortaya çıkan bir klinik tablodur. Fleksiyondaki dizin ekstansiyona getirilmesi esnasında 30° ve 45 ° fleksiyon açıları aralığında oluşan ağrı, sendroma adını veren klunk sesi ile karakterizedir. Semptomlar genel olarak TDA ameliyatları sonrası 3-8. aylarda ortaya çıksa da, tanı için geçen süre 2 yıla kadar uzayabilmektedir. Görülme sıklığı kullanılan implantlara bağlı olarak % 0-7.5 arasında değişen bu sendromun etiyolojisi preoperatif, implant ilişkili, cerrahi yaklaşıma bağlı etmenler olmak üzere 3 ana başlık altında özetlenebilir. Ağır semptom veren hastaların tedavisinde artroskopik veya açık cerrahi yöntem ile fibroz doku rezeke edilerek klinik tabloda dramatik bir iyileşme ortaya çıkar. Total Diz Artroplastisi cerrahisi çok sık uygulanan ve hastaların klinik olarak çok fayda gördüğü bir operasyondur. Görece nadir olan bu sendrom cerrahi sonuçları olumsuz olarak etkileyen bir komplikasyondur. Literatürde az miktarda geniş kapsamlı, tanımlayıcı çalışmalar mevcuttur. Amacımız kliniğimiz vaka serileri içinde PKS klinik tanı, etyoloji, insidans oranlarını tespit ederek tanımlayıcı bir çalışma ortaya koymaktır. Gereç ve Yöntemler: Çalışmamızda Düzce Üniversitesi Sağlık Uygulama ve Araştırma Hastanesi Ortopedi ve Travmatoloji Anabilim Dalı'nda 2016-2018 yılları arasında primer gonartroz tanısıyla total diz artroplastisi uygulanan 330 hasta incelendi. Daha sonrasında revizyon TDA ameliyatı olan, mental durumu sağlıklı olmayan ve TDA ameliyatı sonrası aynı dizden ikinci bir cerrahi geçirmiş olan hastaları çalışmanın dışında tuttuk. Hastaların ameliyat öncesi ve sonrası direkt grafilerindeki dizilim, insall-salvati (IS) oranı, patellar tendon uzunluğu (PTU), patella kalınlığı, tibial slope açısı 2 ayrı ortopedi doktoru tarafından incelendi, ölçümleri yapıldı ve aritmetik ortalaması alınarak kayıt altına alındı. Hastaların demografik özellikleri, ameliyatlarda kullanılan implantların markaları, kesen veya koruyan türde olmaları açısından, ve cerrahi tekniklere göre gruplandırıldı. Postoperatif 2., 4., 6. 8. haftalarda, 3., 4., 5., 6., 9., 12., 18. ve 24. aylardaki poliklinik takiplerinde hastaların diz eklemi hareket açıklıkları, röntgen üzerinden dizilimleri ve ölçümleri, muayene bulguları, Knee Society Score, Knee Society Score Function, Visual Analog Scale (VAS) açısından değerlendirildi. Ekstansiyon esnasında "klunk" hissi veya sesi alınan hastalar kaydedildi. Çalışmaya dahil edilen tüm hastalara yüzeyel doku ultrasonu yapıldı. Ultrason (USG) görüntülerinde patella üst kutbunda fibröz doku oluşumu olup olmaması değerlendirildi. Patellar klunk tanısı alan ve almayan tüm hastaların verileri incelenerek PKS ile ilişkileri değerlendirildi. İstatistiksel Analiz: Verilerin dağılımı Kolomogorov-Simirnov ve Shapiro-Wilk testleriyle incelenmiş, normal dağılım gösteren değişkenler bakımından grup karşılaştırmalarında Independent samples t test, normal dağılım göstermeyen değişkenler için Mann-Whitney U test kullanılmıştır. Kategorik değişkenlerin karşılaştırılmasında beklenen değer kuralına bağlı olarak Pearson chi-square, Fisher's-Exact veya Fisher-Freeman-Halton testleri kullanılmıştır. İstatistiksel analizler SPSS v.22 paket programı ile yapılmış ve anlamlılık düzeyi 0,05 olarak dikkate alınmıştır. Sonuçlar: Çalışmamızda, Düzce Üniversitesi Ortopedi Kliniği'nde 2016-2018 yılları arasında yapılan TDA cerrahisi sonrasında gelişen patellar klunk sendromu insidansı % 7,49'dur. Patellar klunk sendromu tanısı koyulan hastalar arasında implant tipi açısından bağ kesen total diz protezi (n=20), bağ koruyan total diz protezine (n=3) kıyasla anlamlı düzeyde çoğunluktadır (p<0,05). Femoral implant ölçüleri dikkate alındığında, Zimmer Biomet Vanguard® marka implantın 60 ve 62,5 numara boyutlarının (tüm ölçüler: 60, 62,5, 65, 67,5, 70), Pasifik PMG Motion® marka implantların 4, 5 ve 6 numara boyutlarının (tüm ölçüler: 4, 5, 6, 7, 8, 9, 10), Smith&Nephew Anthem® marka implantın 3 ve 4 numaralı boyutlarının (tüm ölçüler: 3, 4, 5, 6, 7, 8), Stryker Energy® marka implantın 4, 5, ve 6 numaralı boyutlarının (tüm ölçüler: 4, 5, 6, 7, 8, 9) kullanıldığı, yani küçük femoral implant kullanılan vakalarda PKS daha sık izlenmektedir (p<0,001). Cerrahide kullanılan insert ölçüleri açısından incelendiğinde ise insert kalınlığı >12mm olan hastaların PKS tanısı alanlar arasında yoğunlaştığı izlenmiştir. Patella değişimi yapılan hastalar arasında preoperatif patella kalınlığı ve postoperatif patella kalınlığı açısından incelendiğinde, patella kalınlığının PKS tanısı alan hastalarda daha az değiştiği, PKS olmayanlarda ise patella kalınlık değişiminin daha fazla olduğu izlenmiştir. Bilateral total diz artroplastisi yapılan hastalarda PKS görülme sıklığı (n=7, %30,4), unilateral total diz artroplastisi yapılan hastalardan (n=16, %5,21) anlamlı düzeyde sık izlenmiştir (p<0,001). Post-operatif takiplerde muayenesi sırasında "klunk" sesinin alınması, ultrasonografide de yüksek oranda suprapatellar bölgede fibröz dokunun tespiti ile ilişkilidir, fakat muayenesinde "klunk" olmamasına rağmen patellofemoral ağrı nedeniyle ultrasonografi yapılan hastalarda da nadir de olsa suprapatellar fibröz doku izlenebilmektedir. Hasta popülasyonu açısından incelendiğinde "aktif çalışma hayatı" olan hastalarda PKS (n=2, %8,7), "aktif çalışma hayatı" olmayanlardan (n=2, %0,7) anlamlı düzeyde sık izlenmektedir (p=0,026). Çıkarımlar: Patellar Klunk Sendromu, yaptığımız araştırmaya göre TDA ameliyatı sonrasındaki poliklinik takiplerde 6. ay ile 40. ay aralarında tanı alabilen, çoğu hastanın konservatif tedavi ile takip edilebildiği, artroskopik veya açık cerrehi ile debritman yapıldıktan sonra çok iyi sonuç alınabilinen bir hastalıktır. PKS için risk faktörleri arasında arka çapraz bağı kesen tip implant, eklem çizgisinin yukarı kaymasına sebep olabilecek kalınlıklarda insert, tercih edilen herhangi bir marka femoral implantının küçük boyutlu olanları, patellar rezeksiyon yapılan hastalarda rezeksiyonun yetersiz (<3mm) yapılması, cerrahi yapılan hastanın aktif bir çalışma hayatının olması ve işe dönüş süresinin <6 ay olması yer almaktadır. Hastalar total diz artroplastisi operasyonuna hazırlanırken dikkatli bir şekilde radyografileri üzerinden ölçümleri yapmak, kullanılacak implant seçimine karar vermek, daha sonra karşılaşabilinecek PKS riskinin önceden analizinin yapılmasına olanak tanır. Bunun yanında postoperatif takiplerde "klunk" sesinin veya hissinin olması, ileri tetkik gereksinimini artırır, hatta klinik bulgular ile birlikte ise, gelecek bir cerrahinin habercisi olabilir. Anahtar Kelimeler, Patellar Klunk Sendromu, Total Diz Artroplastisi, Komplikasyon, Ultrason, Suprapatellar Fibröz Doku
Objective: Patellar clunk syndrome (PCS) is one of the mechanical problems related to the intra-articular area that occurs after total knee arthroplasty (TKA) surgeries. This pathology, whose incidence increases especially after the use of posterior cruciate ligament cutting implants (posterior stabilized TKA), is a clinical course caused by the pathological fibrous tissue formed around the junction of the upper pole of the patella of the distal part of the quadriceps tendon. The pain occurring between 30 ° and 45 ° flexion angles during the extension of the flexed knee is characterized by the "clunk" sound that gives the name of the syndrome. Although symptoms generally occur between 3-8 months after TKA operations, the time taken for diagnosis may take up to 2 years. The etiology of this syndrome, whose incidence varies between 0-7.5% depending on the implants used, can be summarized under three main headings: preoperative, implant-related, and surgical approach-related factors. In the treatment of patients with severe symptoms, the fibrous tissue is resected by arthroscopic or open surgical methods, resulting in a dramatic improvement in the clinical course. Total Knee Arthroplasty surgery is an operation that is performed very often and patients benefit greatly from clinical practice. This relatively rare syndrome is a complication that negatively affects surgical results. There are few comprehensive descriptive studies in the literature. Our aim is to present a descriptive study by determining the clinical diagnosis, etiology and incidence rates of PCS in our clinic case series. Materials and Methods: In our study, 330 patients who underwent total knee arthroplasty with the diagnosis of primary gonarthrosis in Düzce University Health Practice and Research Hospital, Department of Orthopedics and Traumatology between 2016-2018 were examined. The alignment, insall-salvati ratio, patellar tendon length, patella thickness, tibial slope angle on pre- and postoperative plain radiographs of the patients were examined by 2 different orthopedic doctors, their measurements were made and their arithmetic mean was taken and recorded. Patients were grouped according to their demographic characteristics, brands of implants used in surgeries, cutting or protecting types, and surgical techniques. Knee joint range of motion, x-ray alignment and measurements, examination findings, Knee Society Score, Knee Society Score Function, Visual Analog Scale (VAS) was evaluated in the outpatient clinic follow-ups at postoperative 2nd, 4rd, 6th, 8th weeks and 3rd, 4th, 5th, 6th, 9th, 12th, 18th and 24th months. Superficial tissue ultrasound was performed on patients who had a "clunk" feeling or sound during extension. The presence or absence of fibrous tissue formation in the upper pole of the patella was evaluated in the ultrasound images. The data of all patients with and without patellar clunk were examined and their relationship with PCS was evaluated. Results: In our study, the incidence of patellar clunk syndrome that developed after TKA surgery performed in Düzce University Orthopedics Clinic between 2016-2018 was 7.49%. In terms of implant type, total knee prosthesis cutting ligament (n = 20) was significantly more common than ligament preserving total knee prosthesis (n = 3) among patients diagnosed with patellar clunk syndrome (p <0.05). When femoral implant dimensions are taken into consideration, the dimensions of the size 60 and 62.5 of the Zimmer Biomet Vanguard® brand implant (all sizes: 60, 62.5, 65, 67.5, 70), the size 4, 5 and 6 of the Pasifik PMG Motion® brand implants (all sizes 4, 5, 6, 7, 8, 9, 10), Smith&Nephew Anthem® brand implant size 3 and 4 (all dimensions: 3, 4, 5, 6, 7, 8), Stryker Energy® brand implant 4, 5, PCS is observed more frequently in cases where the size and number 6 (all dimensions: 4, 5, 6, 7, 8, 9) are used, that is, small femoral implants are used (p <0.001). When examined in terms of insert sizes used in surgery, it was observed that patients with an insert thickness >12mm concentrated among those diagnosed with PCS. When examined in terms of preoperative patella thickness and postoperative patella thickness among patients who underwent patella change, it was observed that patella thickness changed less in patients with a diagnosis of PCS, and that patella thickness change was greater in patients without PCS. The incidence of PCS in patients who underwent bilateral total knee arthroplasty (n = 7, 30,4%) was significantly higher than patients who underwent unilateral total knee arthroplasty (n = 16, 5.21%) (p <0.001). In post-operative follow-up, the detection of the "Clunk" sound during the examination is associated with the detection of fibrous tissue in the suprapatellar area in ultrasonography, but although there is no "Clunk" in the examination, suprapatellar fibrous tissue can be observed rarely in patients who have undergone ultrasonography for patellofemoral pain. When examined in terms of the patient population, PCS (n = 2, 8.7%) was observed more frequently in patients with an "active working life" than those without an "active working life" (n = 2, 0.7%) (p = 0.026). Conclusions: Patellar Clunk Syndrome is a disease that can be diagnosed between the 6th and 40th months in outpatient clinic follow-ups after TKA surgery, most patients can be followed up with conservative treatment, and very good results can be obtained after arthroscopic or open surgery debridement. Risk factors for PCS include the type of implant that cuts the posterior cruciate ligament, the insert with thicknesses that may cause the joint line to slide up, the smaller femoral implants of any brand, insufficient resection (<3mm) in patients with patellar resection, the patient who underwent surgery had an active working life and a return to work time of <6 months. While the patients are preparing for the total knee arthroplasty operation, it is possible to make measurements on the radiographs carefully, to decide on the choice of the implant to be used, and to make a pre-analysis of the PCS risk that may be encountered later. In addition, the presence of a "clunk" sound or sensation in postoperative follow-up increases the need for further examination, and even if it is with clinical findings, it may be a harbinger of a future surgery. KEY WORDS, Patellar Clunk Syndrome, Total Knee Arthroplasty, Complication, Ultrasound, Suprapatellar Fibrous Tissue
Objective: Patellar clunk syndrome (PCS) is one of the mechanical problems related to the intra-articular area that occurs after total knee arthroplasty (TKA) surgeries. This pathology, whose incidence increases especially after the use of posterior cruciate ligament cutting implants (posterior stabilized TKA), is a clinical course caused by the pathological fibrous tissue formed around the junction of the upper pole of the patella of the distal part of the quadriceps tendon. The pain occurring between 30 ° and 45 ° flexion angles during the extension of the flexed knee is characterized by the "clunk" sound that gives the name of the syndrome. Although symptoms generally occur between 3-8 months after TKA operations, the time taken for diagnosis may take up to 2 years. The etiology of this syndrome, whose incidence varies between 0-7.5% depending on the implants used, can be summarized under three main headings: preoperative, implant-related, and surgical approach-related factors. In the treatment of patients with severe symptoms, the fibrous tissue is resected by arthroscopic or open surgical methods, resulting in a dramatic improvement in the clinical course. Total Knee Arthroplasty surgery is an operation that is performed very often and patients benefit greatly from clinical practice. This relatively rare syndrome is a complication that negatively affects surgical results. There are few comprehensive descriptive studies in the literature. Our aim is to present a descriptive study by determining the clinical diagnosis, etiology and incidence rates of PCS in our clinic case series. Materials and Methods: In our study, 330 patients who underwent total knee arthroplasty with the diagnosis of primary gonarthrosis in Düzce University Health Practice and Research Hospital, Department of Orthopedics and Traumatology between 2016-2018 were examined. The alignment, insall-salvati ratio, patellar tendon length, patella thickness, tibial slope angle on pre- and postoperative plain radiographs of the patients were examined by 2 different orthopedic doctors, their measurements were made and their arithmetic mean was taken and recorded. Patients were grouped according to their demographic characteristics, brands of implants used in surgeries, cutting or protecting types, and surgical techniques. Knee joint range of motion, x-ray alignment and measurements, examination findings, Knee Society Score, Knee Society Score Function, Visual Analog Scale (VAS) was evaluated in the outpatient clinic follow-ups at postoperative 2nd, 4rd, 6th, 8th weeks and 3rd, 4th, 5th, 6th, 9th, 12th, 18th and 24th months. Superficial tissue ultrasound was performed on patients who had a "clunk" feeling or sound during extension. The presence or absence of fibrous tissue formation in the upper pole of the patella was evaluated in the ultrasound images. The data of all patients with and without patellar clunk were examined and their relationship with PCS was evaluated. Results: In our study, the incidence of patellar clunk syndrome that developed after TKA surgery performed in Düzce University Orthopedics Clinic between 2016-2018 was 7.49%. In terms of implant type, total knee prosthesis cutting ligament (n = 20) was significantly more common than ligament preserving total knee prosthesis (n = 3) among patients diagnosed with patellar clunk syndrome (p <0.05). When femoral implant dimensions are taken into consideration, the dimensions of the size 60 and 62.5 of the Zimmer Biomet Vanguard® brand implant (all sizes: 60, 62.5, 65, 67.5, 70), the size 4, 5 and 6 of the Pasifik PMG Motion® brand implants (all sizes 4, 5, 6, 7, 8, 9, 10), Smith&Nephew Anthem® brand implant size 3 and 4 (all dimensions: 3, 4, 5, 6, 7, 8), Stryker Energy® brand implant 4, 5, PCS is observed more frequently in cases where the size and number 6 (all dimensions: 4, 5, 6, 7, 8, 9) are used, that is, small femoral implants are used (p <0.001). When examined in terms of insert sizes used in surgery, it was observed that patients with an insert thickness >12mm concentrated among those diagnosed with PCS. When examined in terms of preoperative patella thickness and postoperative patella thickness among patients who underwent patella change, it was observed that patella thickness changed less in patients with a diagnosis of PCS, and that patella thickness change was greater in patients without PCS. The incidence of PCS in patients who underwent bilateral total knee arthroplasty (n = 7, 30,4%) was significantly higher than patients who underwent unilateral total knee arthroplasty (n = 16, 5.21%) (p <0.001). In post-operative follow-up, the detection of the "Clunk" sound during the examination is associated with the detection of fibrous tissue in the suprapatellar area in ultrasonography, but although there is no "Clunk" in the examination, suprapatellar fibrous tissue can be observed rarely in patients who have undergone ultrasonography for patellofemoral pain. When examined in terms of the patient population, PCS (n = 2, 8.7%) was observed more frequently in patients with an "active working life" than those without an "active working life" (n = 2, 0.7%) (p = 0.026). Conclusions: Patellar Clunk Syndrome is a disease that can be diagnosed between the 6th and 40th months in outpatient clinic follow-ups after TKA surgery, most patients can be followed up with conservative treatment, and very good results can be obtained after arthroscopic or open surgery debridement. Risk factors for PCS include the type of implant that cuts the posterior cruciate ligament, the insert with thicknesses that may cause the joint line to slide up, the smaller femoral implants of any brand, insufficient resection (<3mm) in patients with patellar resection, the patient who underwent surgery had an active working life and a return to work time of <6 months. While the patients are preparing for the total knee arthroplasty operation, it is possible to make measurements on the radiographs carefully, to decide on the choice of the implant to be used, and to make a pre-analysis of the PCS risk that may be encountered later. In addition, the presence of a "clunk" sound or sensation in postoperative follow-up increases the need for further examination, and even if it is with clinical findings, it may be a harbinger of a future surgery. KEY WORDS, Patellar Clunk Syndrome, Total Knee Arthroplasty, Complication, Ultrasound, Suprapatellar Fibrous Tissue
Açıklama
YÖK Tez No: 648060
Anahtar Kelimeler
Ortopedi ve Travmatoloji, Orthopedics and Traumatology, Diz eklemi, Knee joint, Diz protezi, Knee prosthesis, Postoperatif komplikasyonlar, Postoperative complications
