全膝关节置换治疗膝关节夏科氏关节病的中长期疗效（2024）

全膝关节置换治疗膝关节夏科氏关节病的中长期疗效（2024）Mid- to Long-Term Results of Total Knee Arthroplasty for Charcot Arthropathy of the Knee

Onoi Y, Matsumoto T, Nakano N, Tsubosaka M, Kamenaga T, Kuroda Y, Ishida K, Hayashi S, Kuroda R. Mid- to Long-Term Results of Total Knee Arthroplasty for Charcot Arthropathy of the Knee[J]. Indian J Orthop, 2024,58(3): 308-315.

转载文章的原链接1：

https://pubmed.ncbi.nlm.nih.gov/38425826/

转载文章的原链接2：

https://link.springer.com/article/10.1007/s43465-023-01094-z

Abstract

Background:

Total knee arthroplasty (TKA) for Charcot arthropathy of the knee is considered controversial because of its higher complication rate compared with that of TKA for osteoarthritis. In this study, we investigated the clinical outcomes, survival rates, and complications of primary TKA for Charcot arthropathy.

全膝关节置换术(TKA)治疗膝关节Charcot关节病被认为是有争议的，因为与骨关节炎的TKA相比，其并发症发生率更高。在这项研究中，我们调查了初次TKA治疗Charcot关节病的临床结果、生存率和并发症。

Methods:

We conducted a retrospective analysis of nine patients (12 knees) with Charcot arthropathy who underwent TKA. The mean age of the patients was 63.9 ± 9.4 years (range, 52-83 years). The most frequent causative disease was diabetes mellitus (three patients). Patients‘ clinical outcomes, including the 2011 Knee Society Score and the range of motion, were compared between preoperative and the most recent postoperative data. The 5- and 10-year survival rates for aseptic revision, revision due to infection, and complications were examined. The mean follow-up period was 7.3 ± 3.9 years (range, 3-14 years).

我们对9例Charcot关节病患者(12个膝关节)进行了全膝关节置换术的回顾性分析。患者平均年龄为63.9±9.4岁(52 ~ 83岁)。最常见的病因是糖尿病(3例)。患者的临床结果，包括2011年膝关节社会评分和活动范围，在术前和术后的最新数据之间进行比较。检查无菌翻修、感染翻修和并发症翻修的5年和10年生存率。平均随访时间7.3±3.9年(范围3 ~ 14年)。

Results:

The 2011 Knee Society Score and the knee flexion angle significantly improved after TKA surgery (P ＜ 0.05). The 5-year survival rates for aseptic revision, revision due to infection, and complications were 100%, 91.7%, and 83.3%, respectively; the 10-year survival rates for these parameters were the same. One patient underwent revision for insert replacement due to periprosthetic infection, and the other patient had varus/valgus instability due to soft tissue loosening.

TKA术后膝关节社会评分和膝关节屈曲角度均显著提高(P ＜ 0.05)。无菌翻修、感染翻修和并发症翻修的5年生存率分别为100%、91.7%和83.3%;这些参数的10年生存率是相同的。一名患者因假体周围感染接受假体置换翻修，另一名患者因软组织松动出现内翻/外翻不稳定。

Conclusions:

The mid- to long-term results of TKA for Charcot arthropathy were generally favorable. Our findings indicate that TKA may be a viable treatment option for Charcot arthropathy.

TKA治疗Charcot关节病的中长期结果通常是有利的。我们的研究结果表明TKA可能是治疗Charcot关节病的可行选择。

Keywords:

Charcot arthropathy; Constrained condylar prosthesis; Neuropathic arthropathy; Rotating hinge prosthesis; Survival rates; Total knee arthroplasty.

Introduction

Charcot arthropathy is a degenerative neuropathic arthropathy that leads to severe joint destruction and instability, caused by repetitive asymptomatic microtrauma due to decreased or absent joint nociception [1]. The global increase in the incidence of diabetes mellitus (DM), the main causative disease of Charcot arthropathy, is expected to lead to a higher prevalence of Charcot arthropathy [2, 3]. Because of the nature of Charcot arthropathy, patients rarely complain of pain during the early deformity stages and typically seek treatment only after severe deformity, instability, and gait disturbance have occurred [4]. This makes Charcot arthropathy one of the most difficult conditions for orthopaedic surgeons to treat.

Charcot关节病是一种退行性神经性关节病，可导致严重的关节破坏和不稳定，由关节痛觉减少或缺失引起的重复性无症状微创伤引起[1]。糖尿病(DM)是Charcot关节病的主要致病疾病，随着全球糖尿病发病率的增加，预计将导致Charcot关节病的患病率升高[2,3]。由于Charcot关节病的性质，患者在早期畸形阶段很少主诉疼痛，通常只有在发生严重畸形、不稳定和步态障碍后才寻求治疗[4]。这使得Charcot关节病成为骨科医生最难治疗的疾病之一。

Although total knee arthroplasty (TKA) for Charcot arthropathy was previously not recommended because of its high rate of complications, such as periprosthetic infection, fracture, and dislocation [5, 6], several recent studies have shown good short-term clinical outcomes with TKA [2, 7]. However, there is limited literature on the mid- to long-term results of TKA for Charcot arthropathy [8, 9], and important questions regarding survival rates, potential complications, and clinical outcomes of TKA remain unresolved. This lack of information may prevent proper management of Charcot arthropathy. Therefore, we aimed to report the mid- to long-term results of primary TKA for patients with Charcot arthropathy.

尽管全膝关节置换术(TKA)治疗Charcot关节病之前不被推荐，因为其并发症发生率高，如假体周围感染、骨折和脱位[5,6]，但最近的几项研究表明，TKA的短期临床效果良好[2,7]。然而，关于TKA治疗Charcot关节病的中长期结果的文献有限[8,9]，TKA的生存率、潜在并发症和临床结果等重要问题仍未解决。这种信息的缺乏可能会妨碍对Charcot关节病的适当治疗。因此，我们的目的是报道原发性全膝关节置换术治疗Charcot关节病患者的中长期结果。

Materials and Methods

Patients

The study was approved by the Institutional Review Board of our institution (Permission No; 1510), and written informed consent was obtained from the patients. We conducted a retrospective analysis of 11 consecutive patients with Charcot arthropathy of the knee who underwent primary TKA at our institution between August 2008 and March 2020. Two patients were excluded from the study because they died within one year for reasons unrelated to TKA. The remaining nine patients (12 knees), consisting of four men and five women with a mean age of 63.9 ± 9.4 years (range, 52–83 years) at the time of TKA, were enrolled in the study. None of the patients had undergone arthroscopic debridement or other knee surgeries prior to the TKAs. Prior to TKA, three patients had ipsilateral ankle joint fractures and underwent open reduction and internal fixation.

The Charcot arthropathy-causative neuropathy was diagnosed by neurologists using nerve conduction studies, electromyography, and clinical evaluations. Orthopaedic surgeons verified the diagnoses by physical examination and radiographic studies, revealing features characteristic of Charcot arthropathy, including severe deformity, instability, and restricted range of motion. The nine patients included in the study had a variety of causative diseases. Of these, DM was the most common (three patients), with a mean HbA1c of 5.9 ± 0.2% (range, 5.6–6.1%). Two patients had neurosyphilis, one had Charcot-Marie-Tooth disease, one had Guillain–Barre syndrome, one had cervical ossification of the posterior longitudinal ligament, and one had meningeal aneurysm (Table 1). None of the patients were lost to follow-up, and the mean follow-up period was 7.3 ± 3.9 years (range, 3–14 years).

Table 1 Patients’ characteristics

Operative Procedures

All surgeries were performed by senior surgeons with ＞ 15 years of experience in TKA procedures. All patients received general anesthesia and femoral/sciatic nerve block with 0.75% ropivacaine (40 mL). After inflating the air tourniquet to 250 mmHg, the knees were exposed by medial parapatellar arthrotomy; osteotomy was performed using the measured resection technique. A Legacy constrained condylar knee prosthesis (LCCK; Zimmer Biomet, Warsaw, IN, USA) was inserted in ten knees and a rotating hinge knee prosthesis (RHK; Zimmer Biomet) was inserted in two knees presenting hyperextension. Stems were used in both the femur and tibia for seven knees; in four knees, the stems were used in the tibia only; in one knee, no stems were used, following a protocol to use stems in fragile bones. Augmentation was applied to replace tibial bone defects of ＞ 5 mm in eight knees. All the femoral and tibial prostheses were fixed with cement after pulsed lavage, drying, and pressurization of the cement. Patellar resurfacing was conducted in seven knees with patellar deformity. After all the prostheses were implanted, lateral retinacular release was needed in four cases of knees based on the assessment of patellar tracking. During surgery, no cases had soft tissue injuries such as medial or lateral collateral ligaments or patellar tendons (Table 1).

Postoperative Therapy

The operated knee did not wear any brace from the day of surgery. From the day after surgery, all patients were allowed full weight-bearing and began active knee motion exercises, along with quadriceps-strengthening exercises and standing at the bedside or walking with crutches or a walker under the supervision of a physical therapist. On the 14th postoperative day, the wound stitches were removed. No patient had any infection or wound dehiscence at this point. Two to four weeks after surgery, patients were discharged from the hospital, and physical therapy at the outpatient clinic was conducted once a week for three months after surgery. In addition to the inpatient rehabilitation program, outpatient rehabilitation focused on activities of daily living exercises such as bathing, hill walking, and stair climbing, tailored to each patient‘s condition. For postoperative analgesia, NSAIDs were administered up to 1 month postoperatively and acetaminophen from 1 to 3 months postoperatively. After diagnosis of osteoporosis by dual energy X-ray absorptiometry, patients received oral administration of 35 mg alendronate once a week and 0.75 µg eldecalcitol daily.

Clinical and Radiographic Evaluations

Clinical and radiographic evaluations were performed for each patient preoperatively, and at 3-, 6-, and 12-months postoperatively, and annually thereafter.

The 2011 Knee Society Score (KSS) [10] was recorded and assessed. The range of motion (ROM) was measured three times each using a goniometer in the supine position by several senior physiotherapists with ＞ 5 years of clinical experience.

During radiographic evaluation, the femorotibial angle (FTA) was measured in full-length views of the lower extremities, in the standing position. The stage of Charcot arthropathy was classified according to the Koshino classification [11]. Prosthesis loosening was assessed by component subsidence ＞2 mm or by a complete radiolucent line around the component [12]. All radiographic evaluations were independently analyzed by two investigators, who had ＞ 10 years of clinical experience and were not involved in the operations.

11. Koshino, T. (1991). Stage classifications, types of joint destruction, and bone scintigraphy in Charcot joint disease. Bulletin of the Hospital for Joint Diseases Orthopaedic Institute, 51(2), 205–217.

12. Ewald, F. C. (1989). The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clinical Orthopaedics and Related Research, 248, 9–12.

Statistical Analysis

All values were normally distributed and were expressed as mean ± standard deviation (SD). All statistical analyses were performed using the statistical software EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan) [13]. Paired t tests were used to compare the 2011 KSS and ROM between preoperative and the most recent data. For patients who died or experienced revision surgery, the values at the pre-event visit were considered the most recent data. The Kaplan–Meier method was used to create survival curves for revision and complications [14]. Statistical significance was set at P ＜ 0.05.

Results

Clinical Outcomes

The average pre- and postoperative 2011 KSS and their subscales, ROMs, and mobility are presented in Table 2. The 2011 KKS, all its subscales, and knee flexion angles were significantly improved following surgery (P ＜ 0.05) (Table 2). Preoperatively, none of the patients could walk independently and only three patients could walk with a single cane; however, postoperatively, three patients were able to walk independently and five patients could walk with a single cane (Table 2).

Table 2 Clinical outcomes pre- and post-operatively

Radiographic Results

According to the Koshino classification, two knees had stage II, and 10 knees had stage III Charcot arthropathy (Table 1). Preoperatively, the FTA of eight varus knees was 199.8 ± 11.1° (range, 186–223°) and the FTA of four valgus knees was 155.1 ± 5.4° (range, 148–163°); postoperatively, the FTA improved to 176.6 ± 3.7° (range, 170–183°). No cases showed component subsidence ＞ 2 mm or progressive radiolucent lines around the femoral, tibial, or patellar components (Figs. 1, 2).

Fig. 1 Radiographs of a 61-year-old male with Koshino classification stage III Charcot arthropathy (No. 2 in Table 1) preoperatively (A, B), immediately postoperatively (C, D), and most recently, 14 years postoperatively (E, F)

Fig. 2 Radiographs of a 74-year-old female with Koshino classification stage III Charcot arthropathy (No. 4.1 in Table 1) preoperatively (A, B), immediately postoperatively (C, D), and most recently, 5 years postoperatively (E, F)

Implant Survival, Revisions, and Complications

The survival rates for aseptic revision, revision due to infection, and complications are presented in Fig. 3. The 5-year survival rates were 100% (12/12) for aseptic revision, 91.7% (11/12) for revision due to infection, and 83.3% (10/12) for complications. The 10-year survival rates were the same. Only 2 out of 12 patients had complications during follow-up period.

Fig. 3 Kaplan–Meier curves of survival rates for aseptic revision, revision due to infection, and complications

One patient experienced a periprosthetic infection 4 years postoperatively. Under general anesthesia, the polyethylene insert was removed, and the knee joint was thoroughly debridement and washed with 9 L of saline solution. The femoral and tibial components showed no septic loosening and were not replaced. A new polyethylene was inserted and the wound was closed. The drain placed in the knee joint was removed the day after surgery. The pathogenic bacteria was E. coli, and the patient was treated with ceftriaxone intravenously for 6 weeks postoperatively, followed by cefditoren pivoxil orally for 6 weeks. No additional revision surgery was required in this case.

The other patient had coronal plane instability due to soft tissue loosening 1 year postoperatively. Lateral loosening was significant, and a lateral thrust was observed. No lateral collateral ligament injury was observed during surgery, however, the soft tissue fragility was apparent, probably due to increased postoperative activity and stress. The patient needed to wear a hinged knee brace when walking.

None of the patients developed patellar dislocation, periprosthetic fracture, deep vein thrombosis, or patellar crank syndrome.

Discussion

The most important finding of this study is that TKA was generally a safe treatment option for Charcot arthropathy of the knee. Clinical outcomes including 2011 KSS and ROM were significantly improved at the last follow-up, similar to previous reports [7, 8], and the mid- to long-term survival rate for aseptic revision in this study was 100%. However, several postoperative complications were observed.

本研究最重要的发现是TKA通常是膝关节Charcot关节病的安全治疗选择。最后一次随访时，包括2011年KSS和ROM在内的临床结果均有显著改善，与既往报道相似[7,8]，本研究无菌翻修的中长期生存率为100%。然而，观察到一些术后并发症。

Survival rates for aseptic revision of TKA for Charcot arthropathy have been reported to be excellent, with 100% at five years and 88% at ten years [8], and our data support that result. However, the previous report showed a high incidence (16%) of periprosthetic infections, which occurred at an average of 3 years postoperatively (range, 1–6 years) [8]. In our study, the incidence of periprosthetic infection was slightly lower, affecting 1 in 12 knees (8%). Charcot arthropathy patients are often frail due to their underlying disease, and the frailty increases the incidence of infection after TKA [15]. DM, the most common disease causative of Charcot arthropathy, is also related to a high incidence of periprosthetic infection [16]. In this study, one case experienced postoperative varus/valgus instability, which was similarly reported in previous reports and required revision surgery in some cases [6, 9]. However, the patient did not need revision surgery because of no symptoms related to the instability with a brace. Joint instability is one of the most important complications in Charcot arthropathy because ligamentous laxity often occurs due to advanced joint deformity. Remaining hyperextension of the knee after TKA increases the risk of neurovascular injury and residual knee pain. In such cases, it is important to choose RHK to restrict the extensor mechanism and avoid revision surgery [17, 18], and this hinged prosthesis was applied for 2 cases in the series of the study.

据报道，无菌改良TKA治疗Charcot关节病的生存率非常好，5年生存率为100%，10年生存率为88%[8]，我们的数据支持这一结果。然而，先前的报道显示假体周围感染的发生率很高(16%)，平均发生在术后3年(范围1-6年)[8]。在我们的研究中，假体周围感染的发生率略低，影响12个膝关节中的1个(8%)。Charcot关节病患者往往因其基础疾病而身体虚弱，这种虚弱增加了TKA后感染的发生率[15]。DM是Charcot关节病最常见的病因，也与假体周围感染的高发有关[16]。在本研究中，1例患者出现了术后内翻/外翻不稳，这在之前的报道中也有类似的报道，在一些病例中需要进行翻修手术[6,9]。然而，由于没有与支具不稳定相关的症状，患者不需要翻修手术。关节不稳定是Charcot关节病最重要的并发症之一，因为晚期关节畸形常导致韧带松弛。全膝关节置换术后膝关节持续过伸会增加神经血管损伤和膝关节疼痛的风险。在这种情况下，选择RHK来限制伸肌机制，避免翻修手术是很重要的[17,18]，本系列研究中有2例使用了这种铰链式假体。

In TKA for Charcot arthropathy, various prostheses have been used, including cruciate-retaining (CR), posterior-stabilized (PS), LCCK, and RHK. The choice of implants is still a matter of debate [19, 20]. Unrestrained components (e.g., CR, PS) are often inappropriate for Charcot arthropathy, because they can lead to postoperative joint instability due to severe deformity and soft-tissue imbalance [4, 19]. RHK should be selected carefully, because excessive restraint can increase the risk of aseptic loosening and periprosthetic fractures [18, 20]. Therefore, some surgeons consider that LCCK, which provides good stability with minimal restriction, is the optimal prosthesis for Charcot arthropathy [7, 8]. In our study, LCCK was the preferred prothesis, with RHK used only in patients presenting with knee hyperextension. Moreover, when using constrained components, the use of long stems is important to distribute the increased stress on the bone [21, 22]. In a previous report, 16% of Charcot arthropathy patients treated without stems developed aseptic loosening within 5 years [4]. Conversely, another study reported no cases of aseptic loosening after five years and only 6% after 10 years in patients treated with stems [8]. Of the patients included in our study, stems were used in 92% of cases, with none of the patients showing aseptic loosening during the follow-up period.

在Charcot关节病的TKA中，使用了各种假体，包括交叉关节保留(CR)、后稳定(PS)、LCCK和RHK。植入物的选择仍然是一个有争议的问题[19,20]。无约束假体(如CR、PS)通常不适合用于Charcot关节病，因为它们可能导致严重畸形和软组织失衡导致术后关节不稳定[4,19]。应谨慎选择RHK，因为过度约束会增加无菌性松动和假体周围骨折的风险[18,20]。因此，一些外科医生认为LCCK具有良好的稳定性和最小的限制，是治疗Charcot关节病的最佳假体[7,8]。在我们的研究中，LCCK是首选的假体，RHK仅用于出现膝关节过伸的患者。此外，当使用受限组件时，使用长柄对于分配骨上增加的应力很重要[21,22]。在先前的报道中，16%的Charcot关节病患者在5年内发生无菌性松动[4]。相反，另一项研究报告5年后没有无菌性松动病例，10年后只有6%的患者接受了茎干治疗[8]。在我们的研究中，92%的患者使用了支架，在随访期间没有患者出现无菌性松动。

Management of large bone defects in Charcot arthropathy is a major concern. Treatment strategies for bone defects include autografts, allografts, metal augmentation, and tantalum implants [6, 23]. However, the bone structure of Charcot arthropathy is very weak, and even if autologous or allogeneic bone is grafted into the defect, a bone union is difficult to achieve [9, 24]. Therefore, in our cases, metal augmentation was used to fill the bone defect. Immediately after surgery, full weight bearing was allowed; however, no cases resulted in loosening or periprosthetic fractures.

Charcot关节病大骨缺损的处理是一个主要问题。骨缺损的治疗策略包括自体移植物、同种异体移植物、金属隆胸和钽植入物[6,23]。然而，Charcot关节病的骨结构非常薄弱，即使将自体或异体骨移植到缺损处，也难以实现骨愈合[9,24]。因此，在我们的病例中，我们使用金属隆胸来填充骨缺损。手术后立即允许完全负重;然而，没有病例导致松动或假体周围骨折。

This study had some limitations. First, it was a retrospective case series with a limited number of patients. This limited the ability to perform subgroup analysis based on causative disease, Charcot stage, or implant type. To perform subgroup analysis, a larger number of patients is needed. Second, a longer follow-up period is desirable to accurately evaluate the efficacy of the TKA procedure in Charcot arthropathy.

这项研究有一些局限性。首先，这是一个回顾性病例系列，患者数量有限。这限制了基于病因、Charcot分期或植入物类型进行亚组分析的能力。为了进行亚组分析，需要更多的患者。其次，为了准确评估TKA手术治疗Charcot关节病的疗效，需要更长的随访期。

In conclusion, our mid- to long-term results of TKA for Charcot arthropathy were generally favorable. Patients in this study achieved definite improvement in knee pain, function, and mobility, and the 5- and 10-year survival rates for aseptic revision were excellent. Therefore, TKA may be a viable treatment option for Charcot arthropathy while the complications such as periprosthetic infection and instability should be kept in mind.

总之，TKA治疗Charcot关节病的中长期结果总体上是有利的。在这项研究中，患者在膝关节疼痛、功能和活动方面得到了明确的改善，无菌翻修术的5年和10年生存率非常好。因此，TKA可能是Charcot关节病的一种可行的治疗选择，但应注意假体周围感染和不稳定等并发症。