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通讯作者:

刘锋,E-mail:njliuf@163.com

中图分类号:R687.4

文献标识码:A

文章编号:1007-4368(2022)09-1294-06

DOI:10.7655/NYDXBNS20220915

参考文献 1
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参考文献 8
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参考文献 9
STEINBRÜCK A,SCHRÖDER C,WOICZINSKI M,et al.Mediolateral femoral component position in TKA signifi⁃ cantly alters Patella shift and femoral roll⁃back[J].Knee Surg Sports Traumatol Arthrosc,2017,25(11):3561-3568
参考文献 10
YOUNG S W,SAFFI M,SPANGEHL M J,et al.Unex⁃ plained pain following total knee arthroplasty:is rotation⁃ al malalignment the problem?[J].Knee,2018,25(2):329-334
参考文献 11
JANG E S,CONNORS⁃EHLERT R,LIARNO S,et al.Accuracy of reference axes for femoral component rota⁃ tion in total knee arthroplasty:computed tomography ⁃ based study of 2,128 femora[J].J Bone Joint Surg Am,2019,101(23):e125
参考文献 12
MAHRAN M A,KHALIFA A A,AHMED M A,et al.Evalu⁃ ating distal femoral torsion and posterior condylar line re⁃ liability for adjusting femoral component rotation in TKA,Egyptian population radiographic study[J].J Clin Orthop Trauma,2021,13:99-105
参考文献 13
ASANO T,AKAGI M,NAKAMURA T.The functional flexion⁃extension axis of the knee corresponds to the surgi⁃ cal epicondylar axis:in vivo analysis using a biplanar im⁃ age⁃matching technique[J].J Arthroplasty,2005,20(8):1060-1067
参考文献 14
BERGER R A,RUBASH H E,SEEL M J,et al.Determin⁃ ing the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis[J].Clin Orthop Relat Res,1993,286):40-47
参考文献 15
VICTOR J,VAN DONINCK D,LABEY L,et al.A com⁃ mon reference frame for describing rotation of the distal femur:a ct ⁃ based kinematic study using cadavers[J].J Bone Jo Surg Br Vol,2009,91(5):683-690
参考文献 16
FITZ D W,JOHNSON D J,HARTWELL M J,et al.Rela⁃ tionship of the posterior condylar line and the transepicon⁃ dylar axis:a CT⁃based evaluation[J].J Knee Surg,2020,33(7):673-677
参考文献 17
NEWMAN C R,WALTER W L,TALBOT S.Femoral rota⁃ tional asymmetry is a common anatomical variant[J].Clin Anat N Y N Y,2018,31(4):551-559
参考文献 18
FRANCESCHINI V,NODZO S R,GONZALEZ DELLA VALLE A.Femoral component rotation in total knee ar⁃ throplasty:a comparison between transepicondylar axis and posterior condylar line referencing[J].J Arthroplas⁃ ty,2016,31(12):2917-2921
参考文献 19
CORONA K,CERCIELLO S,VASSO M,et al.Femoral component malrotation is not correlated with poor clinical outcomes after total knee arthroplasty[J].Knee Surg Sports Traumatol Arthrosc,2020,28(12):3879-3887
参考文献 20
邵禹棋,王瑞,陈哲峰,等.TKA术中股骨内侧后髁软骨磨损对股骨假体旋转对线的影响[J].南京医科大学学报(自然科学版),2021,41(5):718-724
目录contents

    摘要

    目的:通过下肢CT图像测量股骨髁通髁轴与股骨后髁轴的旋转度数,为人工全膝关节置换术(total knee arthroplasty, TKA)术中股骨假体旋转定位提供参考。方法:回顾性分析2018年10月—2022年3月在南京医科大学第一附属医院骨关节外科行TKA手术的283例患者的膝关节X线及下肢CT影像学资料。1名关节外科住院医师及1名资深关节外科主任医师分别通过影像系统测量股骨外科通髁轴(surgical transepicondylar axis,sTEA)及股骨后髁轴(posterior condylar axis,PCA)间夹角的度数。计算sTEA与PCA夹角及常规按照PCA外旋3°放置股骨假体TKA术后与sTEA的夹角。结果:sTEA相对于PCA平均外旋1.63°(内旋3.79°至外旋7.87°)。常规将股骨假体参照PCA外旋3°放置时,只有163例(57.6%)患者TKA术后股骨假体旋转在sTEA的±2°范围内,其中68例(24.0%)的患者股骨假体相对于sTEA内旋。结论:膝骨关节炎患者股骨远端旋转存在广泛的差异性,常规参照PCA外旋3°放置股骨假体将会造成显著位置误差,影响TKA预后。应根据术前影像资料个性化制定TKA术中股骨假体旋转力线。

    Abstract

    Objective:This study aims to provide references on the rotation of the femoral component during total knee arthroplasty (TKA)by measuring the rotation degree of the surgical transepicondylar axis and the posterior condylar axis of the femoral condyles on CT images. Methods:The X - ray and lower extremity CT imaging data of 283 patients who underwent TKA in the Department of Bone and Joint Surgery,the First Affiliated Hospital of Nanjing Medical University from October 2018 to March 2022 were retrospected in our study. One resident and one senior chief physician of joint surgery measured the angle between the surgical transepicondylar axis (sTEA)and the posterior condylar axis(PCA)by the imaging system,respectively. The angle between sTEA and PCA and the angle between femoral component and sTEA after routine placement of the femoral component with reference to 3° external to the PCA was calculated. Results:The sTEA was on average 1.63° externally rotated to the PCA(range 3.79° internal to 7.87° external). When the femoral component was routinely placed at 3°external to PCA,only 163(57.6%)patients had femoral component rotation within ± 2 ° of sTEA after TKA,of which 68(24.0%)patients had femoral component internal rotation to sTEA. Conclusion:There were extensive differences in the rotation of the distal femur in patients with osteoarthritis. Routinely setting femoral rotation 3° external to the PCA would cause significant position errors in femoral component,affecting the prognosis of TKA. Joint surgeons should individualize the rotational alignment of the femoral component during TKA based on preoperative imaging data.

  • 骨关节炎是一种常见的关节退行性疾病,最常见的发病部位是膝关节[1]。膝骨关节炎多见于中老年人,可以引起关节疼痛肿胀、活动受限、畸形等问题,严重影响患者的生活质量,给患者家庭及社会造成严重负担[1-4]。目前临床上对于膝骨关节炎的治疗方法包括减少活动、减轻负重、物理治疗、药物治疗、手术治疗等[15-6]。人工全膝关节置换术 (total knee arthroplasty,TKA)是治疗中晚期骨关节炎的有效方法[7]。而股骨假体正确的旋转力线是TKA术后减轻膝关节疼痛、功能恢复的重要条件。据报道,不恰当的股骨假体旋转会导致TKA术后膝关节屈曲间隙的不平衡、髌股关节轨迹异常、膝前疼痛发生率高、影响假体使用寿命等不良反应[8-10]。目前临床有多种TKA术中确定股骨假体旋转力线的方法,诸如参照股骨后髁轴(posterior condylar axis,PCA)、股骨滑车前后轴(anterior⁃posterior axis,AP axis)、股骨外科通髁轴(surgical transepicondylar axis,sTEA)、间隙平衡及机器人辅助导航技术等[11-12],然而以上方法均存在不同的局限性。

  • sTEA被公认为确定股骨假体旋转力线的金标准[13-15],但因内外侧髁表面覆盖软组织及退变关节中骨质异常增生导致术中难以确定sTEA的确切位置,进而导致不可预估的误差[11]。在TKA术中,一种常用的确定股骨假体旋转力线的方法是参照PCA外旋3°放置股骨假体[716-17]。这种传统方法在如今TKA术中仍是确定股骨假体旋转力线及尺寸的基础。但因畸形、解剖异常及股骨后髁的磨损状况各异,按照传统方法将股骨假体参照PCA外旋3° 放置受到质疑。

  • 因此,本研究目的在于探究TKA术中常规将股骨假体参照PCA外旋3°放置的准确性并为TKA术中股骨假体放置提供参考性意见。具体来说,首先通过患者CT影像图像测量股骨髁各解剖轴间旋转夹角,然后计算常规参照PCA将股骨假体外旋3°放置TKA术后股骨假体与sTEA之间的旋转夹角。

  • 1 对象和方法

  • 1.1 对象

  • 本研究纳入2018年10月—2022年3月因单纯膝骨关节炎于南京医科大学第一附属医院骨关节外科行TKA手术的283例患者影像学资料,回顾性分析股骨髁各解剖轴间的旋转关系。纳入标准:① 具有临床症状的中重度膝骨关节炎患者;②术前术后膝关节正侧位X线及全下肢CT扫描影像学资料健全患者。排除标准:①术前术后影像学资料不健全患者;②因类风湿性关节炎、强直性脊柱炎、创伤性膝骨关节炎等非单纯性骨关节炎行TKA手术患者; ③既往曾有股骨髁骨折或手术史患者。

  • 本研究纳入283例行TKA手术患者,其中男64例,女219例,平均年龄为(68.48±6.66)岁,平均体重指数(body mass index,BMI)为(27.19±3.67)kg/m2。患者的一般资料信息及各角度测量结果详见表1。

  • 本研究已获得南京医科大学第一附属医院伦理委员会批准(伦理号:2022⁃SR⁃216)。

  • 1.2 方法

  • 1.2.1 通过膝关节正侧位X线及全下肢CT测量股骨髁各解剖轴的旋转

  • 患者膝关节正侧位X线由荷兰Philips DR扫描设备拍摄,全下肢CT由德国Siemens CT扫描设备拍摄。所有X线及CT影像数据均导入影像归档和通信系统(picture achieving and communication system, PACS,上海Carestream Health公司)进行测量分析。关节线交角(joint line convergency angle,JLCA)为股骨髁远端切线与胫骨平台切线的交角,正常范围为0°~2°(图1A)。本研究纳入病例JLCA平均为 (5.49±3.84)°。全下肢CT拍摄时要求患者下肢伸直平行于检查床,通过CT图像及3D重建后测量下肢冠状面力线、股骨远端外侧角(mechanical lateral distal femur angle,mLDFA)及胫骨近端内侧角 (medial proximal tibia angle,MPTA)排除关节外畸形 (图1B、C)。测量结果显示,本研究纳入病例mLDFA平均为(88.34±1.83)°,MPTA平均为(86.28±1.56)° (表1)。sTEA为股骨髁内侧沟最深部分至外上髁最突出部分的连线。PCA为股骨内外侧后髁间连线。通过CT轴位测量sTEA与PCA间的夹角(sTEA ⁃PCA角)(图1D)。

  • 表1 患者一般基本信息及各角度测量结果

  • Table1 Basic information of patients and measurement results of angles

  • JLCA:关节线交角;mLDFA:股骨远端外侧角;MPTA:胫骨近端内侧角。

  • 1.2.2 TKA术后股骨假体旋转满意度

  • 计算参照PCA将股骨假体外旋3°放置,TKA术后测量股骨假体与sTEA之间的旋转夹角(图1E、F)。

  • 1.3 统计学方法

  • 测量结果均以均值±标准差(x-±s)表示。患膝冠状面力线中,膝关节内翻为正值,外翻为负值。 sTEA⁃PCA角中sTEA相对PCA外旋为正值,sTEA相对PCA内旋为负值。TKA术后股骨假体相对sTEA内旋为正值,相对sTEA外旋为负值。所有数据采用IBM SPSS 26.0统计学软件进行统计分析,P < 0.05为差异有统计学意义。

  • 图1 膝关节各角度测量及常规TKA

  • Fig.1 Measurement of knee joint angles and conventional TKA

  • 采用组内相关系数(intraclass correlation coeffi⁃ cient,ICC)证明观察者内部及观察者间的一致性,计算ICC的95%可信区间(95%CI)。1名关节外科住院医师及1名资深关节外科主任医师分别测量2次,检验观察者内部及观察者间一致性。

  • 2 结果

  • 2.1 股骨髁解剖轴旋转测量结果

  • 本研究测量结果显示sTEA相对PCA平均外旋1.63°(内旋3.79°至外旋7.87°)(图2A、B)。其中,男性患者sTEA相对PCA平均外旋1.66°(内旋2.52°至外旋5.42°),女性患者sTEA相对PCA平均外旋1.63°(内旋3.79°至外旋7.87°)(图2C、D、E)。

  • 相关性分析显示,患者冠状面力线与sTEA ⁃ PCA角无显著相关(r=-0.115,P> 0.05)(图2B、E)。男性sTEA ⁃PCA角(1.66±1.92)°,女性sTEA ⁃ PCA角(1.63±2.14)°,t 检验结果显示性别与sTEA⁃ PCA角无显著相关(t=0.105,r=0.916)。

  • 2.2 观察者内部可靠性及观察者间可靠性

  • sTEA⁃PCA角观察者内部ICC分别为0.88(95%CI:0.86~0.91)及0.87(95%CI:0.85~0.90)。sTEA ⁃ PCA角观察者间ICC为0.87(95%CI:0.84~0.90)。

  • 2.3 常规外旋3°放置股骨假体TKA术后股骨假体旋转满意度

  • 在常规参照PCA外旋3°放置股骨假体的TKA术后,股骨假体相对sTEA平均外旋1.37°(内旋4.87°至外旋6.79°)(图3A)。其中只有57.6%的患者术后股骨假体与sTEA旋转夹角在±2°以内(股骨假体相对sTEA内旋4.87°至外旋6.79°),24.0%出现股骨假体相对sTEA内旋(图3B)。

  • 3 讨论

  • 在TKA术中,参照PCA外旋3°放置股骨假体作为一种传统的确定股骨假体旋转力线方法在临床上广泛应用[1618]。然而本研究发现,因单纯膝骨关节炎而行TKA手术患者股骨远端各解剖轴间存在广泛的旋转差异性,sTEA相对于PCA内旋3.79°至外旋7.87°。通过计算常规将股骨假体参照PCA外旋3°放置,TKA术后的膝关节中近43%的病例存在股骨假体与sTEA显著的旋转差异,因此,按照传统方法将股骨假体参照PCA外旋3°放置遭受挑战。作为TKA术后预后良好的关键,正确建立股骨假体旋转力线仍是一项重要工作。因此亟需寻找在TKA术中更好定位股骨假体旋转力线的方法,包括机器人辅助导航、术中综合参考股骨髁多个解剖标志、术前影像学规划截骨等,以达到更好、更准确的股骨假体旋转力线。

  • 图2 sTEA⁃PCA角测量结果

  • Fig.2 Measurement results of sTEA⁃PCA angle

  • 图3 常规TKA术后股骨假体与sTEA旋转的关系

  • Fig.3 Rotational relationship between femoral component and sTEA after conventional TKA

  • 本研究发现sTEA相对PCA平均外旋1.63°(内旋3.79°至外旋7.87°)。既往文献报道sTEA相对PCA外旋2°~3°,这为现在广为应用的TKA术中股骨假体参照PCA外旋3°放置提供理论基础[1116]。本研究发现一系列股骨髁解剖轴变异,存在sTEA相对PCA外旋7.87°患者,该患者若常规将股骨假体外旋3°放置将会导致股骨假体相对sTEA内旋,造成不良预后。本研究结果显示患者膝关节冠状面力线及性别与股骨髁解剖轴旋转关系之间无显著相关性。

  • 既往有关个体解剖差异导致的初次TKA术中股骨假体旋转力线异常的报道较少,因此本研究按照常规确定股骨假体旋转力线的方法,计算参照PCA将股骨假体外旋3°放置,TKA术后测量股骨假体与sTEA之间的旋转夹角,测量结果显示约43%的患者股骨假体相对sTEA旋转超过±2°。许多研究表明,股骨假体旋转不良,尤其是内旋,会导致TKA术后膝关节功能恢复差、股四头肌无力及假体磨损严重等不良后果[8-9]。然而,另一些研究也表示股骨假体旋转对于TKA术后结局无显著差异[19]。尽管将股骨假体放置到正常解剖旋转对线位置的理想TKA手术较难实现,但外科医生应该有一个力求股骨假体与sTEA对齐的目标,并能够在术中可靠地实现这一目标。本研究结果表明,常规参照PCA将股骨假体外旋3°放置的技术,即使在没有任何失误的情况下完美执行,也会在约43%的患者中造成股骨假体的异常旋转对线,并在24%的患者中导致内旋。

  • 测量结果观察者内部及观察者间ICC的高度一致性说明股骨远端各解剖轴的变异具有意义,而非测量误差造成的。此外,这说明可以通过患者术前影像学资料的测量预知患者股骨远端各解剖轴间变异情况,结合术中情况对股骨假体的旋转力线提供参考性意见。

  • 本研究尚存在一定局限性。首先,仅测量了轴面的sTEA⁃PCA夹角,没有考虑患者术前患膝屈曲挛缩的可能性。再者,仅计算常规TKA术后股骨假体相对sTEA的旋转夹角,未进行股骨假体旋转与患者术后功能恢复及预后的分析。此外,本研究中将sTEA作为股骨假体精准旋转对线的标准,但现在尚无文献明确表明此法术后膝关节功能恢复、假体寿命延长。由于本次测量仅纳入南京医科大学第一附属医院就诊的患者,存在一定的地域局限性,类推到更广阔区域时需考虑地域因素对股骨远端解剖的影响。最后,由于股骨后髁软骨的磨损情况因人而异,CT扫描无法显示股骨后髁上的软骨,与术中股骨假体旋转放置存在一定差异性[20],这可能增加测量的变异性。

  • 总之,因单纯膝骨关节炎行初次TKA手术患者股骨远端各解剖轴间旋转对线具有高度解剖变异性,sTEA相对于PCA平均外旋1.63°,旋转范围为内旋3.79°至外旋7.87°。即使常规TKA术中准确参照PCA外旋3°放置股骨假体,仍有约43%的膝关节术后股骨假体与sTEA旋转存在较大误差,其中约24%的股骨假体相对sTEA内旋。因此在TKA术中,应该寻找其他更加准确放置股骨假体的方法,譬如术前个性化测量截骨技术、间隙平衡截骨技术、计算机或机器人辅助技术等,使TKA术后更好地恢复膝关节功能,延长假体寿命。

  • 参考文献

    • [1] HUNTER D J,BIERMA⁃ZEINSTRA S.Osteoarthritis[J].Lancet,2019,393(10182):1745-1759

    • [2] LONG H,ZENG X,LIU Q,et al.Burden of osteoarthritis in China,1990⁃2017:findings from the Global Burden of Disease Study 2017[J].Lancet Rheumatol,2020,2(3):e164-e172

    • [3] VAN DEN BOSCH M H J.Osteoarthritis year in review 2020:biology[J].Osteoarthr Cartil,2021,29(2):143-150

    • [4] LIU Q,WANG S,LIN J,et al.The burden for knee osteo⁃ arthritis among Chinese elderly:estimates from a nationally representative study[J].Osteoarthritis Cartilage,2018,26(12):1636-1642

    • [5] DEYLE G D,ALLEN C S,ALLISON S C,et al.Physical therapy versus glucocorticoid injection for osteoarthritis of the knee[J].N Engl J Med,2020,382(15):1420-1429

    • [6] KNOOP J,DEKKER J,VAN DER LEEDEN M,et al.Knee joint stabilization therapy in patients with osteoar⁃ thritis of the knee:a randomized,controlled trial[J].Os⁃ teoarthritis Cartilage,2013,21(8):1025-1034

    • [7] ROSSI R,COTTINO U,BRUZZONE M,et al.Total knee arthroplasty in the varus knee:tips and tricks[J].Int Or⁃ thop,2019,43(1):151-158

    • [8] NETTROUR J F,RAZU S S,KEENEY J A,et al.Femoral component malrotation produces quadriceps weakness and impaired ambulatory function following total knee ar⁃ throplasty:results of a forward ⁃ dynamic computer model [J].J Knee Surg,2019,33(11):1121-1127

    • [9] STEINBRÜCK A,SCHRÖDER C,WOICZINSKI M,et al.Mediolateral femoral component position in TKA signifi⁃ cantly alters Patella shift and femoral roll⁃back[J].Knee Surg Sports Traumatol Arthrosc,2017,25(11):3561-3568

    • [10] YOUNG S W,SAFFI M,SPANGEHL M J,et al.Unex⁃ plained pain following total knee arthroplasty:is rotation⁃ al malalignment the problem?[J].Knee,2018,25(2):329-334

    • [11] JANG E S,CONNORS⁃EHLERT R,LIARNO S,et al.Accuracy of reference axes for femoral component rota⁃ tion in total knee arthroplasty:computed tomography ⁃ based study of 2,128 femora[J].J Bone Joint Surg Am,2019,101(23):e125

    • [12] MAHRAN M A,KHALIFA A A,AHMED M A,et al.Evalu⁃ ating distal femoral torsion and posterior condylar line re⁃ liability for adjusting femoral component rotation in TKA,Egyptian population radiographic study[J].J Clin Orthop Trauma,2021,13:99-105

    • [13] ASANO T,AKAGI M,NAKAMURA T.The functional flexion⁃extension axis of the knee corresponds to the surgi⁃ cal epicondylar axis:in vivo analysis using a biplanar im⁃ age⁃matching technique[J].J Arthroplasty,2005,20(8):1060-1067

    • [14] BERGER R A,RUBASH H E,SEEL M J,et al.Determin⁃ ing the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis[J].Clin Orthop Relat Res,1993,286):40-47

    • [15] VICTOR J,VAN DONINCK D,LABEY L,et al.A com⁃ mon reference frame for describing rotation of the distal femur:a ct ⁃ based kinematic study using cadavers[J].J Bone Jo Surg Br Vol,2009,91(5):683-690

    • [16] FITZ D W,JOHNSON D J,HARTWELL M J,et al.Rela⁃ tionship of the posterior condylar line and the transepicon⁃ dylar axis:a CT⁃based evaluation[J].J Knee Surg,2020,33(7):673-677

    • [17] NEWMAN C R,WALTER W L,TALBOT S.Femoral rota⁃ tional asymmetry is a common anatomical variant[J].Clin Anat N Y N Y,2018,31(4):551-559

    • [18] FRANCESCHINI V,NODZO S R,GONZALEZ DELLA VALLE A.Femoral component rotation in total knee ar⁃ throplasty:a comparison between transepicondylar axis and posterior condylar line referencing[J].J Arthroplas⁃ ty,2016,31(12):2917-2921

    • [19] CORONA K,CERCIELLO S,VASSO M,et al.Femoral component malrotation is not correlated with poor clinical outcomes after total knee arthroplasty[J].Knee Surg Sports Traumatol Arthrosc,2020,28(12):3879-3887

    • [20] 邵禹棋,王瑞,陈哲峰,等.TKA术中股骨内侧后髁软骨磨损对股骨假体旋转对线的影响[J].南京医科大学学报(自然科学版),2021,41(5):718-724

  • 参考文献

    • [1] HUNTER D J,BIERMA⁃ZEINSTRA S.Osteoarthritis[J].Lancet,2019,393(10182):1745-1759

    • [2] LONG H,ZENG X,LIU Q,et al.Burden of osteoarthritis in China,1990⁃2017:findings from the Global Burden of Disease Study 2017[J].Lancet Rheumatol,2020,2(3):e164-e172

    • [3] VAN DEN BOSCH M H J.Osteoarthritis year in review 2020:biology[J].Osteoarthr Cartil,2021,29(2):143-150

    • [4] LIU Q,WANG S,LIN J,et al.The burden for knee osteo⁃ arthritis among Chinese elderly:estimates from a nationally representative study[J].Osteoarthritis Cartilage,2018,26(12):1636-1642

    • [5] DEYLE G D,ALLEN C S,ALLISON S C,et al.Physical therapy versus glucocorticoid injection for osteoarthritis of the knee[J].N Engl J Med,2020,382(15):1420-1429

    • [6] KNOOP J,DEKKER J,VAN DER LEEDEN M,et al.Knee joint stabilization therapy in patients with osteoar⁃ thritis of the knee:a randomized,controlled trial[J].Os⁃ teoarthritis Cartilage,2013,21(8):1025-1034

    • [7] ROSSI R,COTTINO U,BRUZZONE M,et al.Total knee arthroplasty in the varus knee:tips and tricks[J].Int Or⁃ thop,2019,43(1):151-158

    • [8] NETTROUR J F,RAZU S S,KEENEY J A,et al.Femoral component malrotation produces quadriceps weakness and impaired ambulatory function following total knee ar⁃ throplasty:results of a forward ⁃ dynamic computer model [J].J Knee Surg,2019,33(11):1121-1127

    • [9] STEINBRÜCK A,SCHRÖDER C,WOICZINSKI M,et al.Mediolateral femoral component position in TKA signifi⁃ cantly alters Patella shift and femoral roll⁃back[J].Knee Surg Sports Traumatol Arthrosc,2017,25(11):3561-3568

    • [10] YOUNG S W,SAFFI M,SPANGEHL M J,et al.Unex⁃ plained pain following total knee arthroplasty:is rotation⁃ al malalignment the problem?[J].Knee,2018,25(2):329-334

    • [11] JANG E S,CONNORS⁃EHLERT R,LIARNO S,et al.Accuracy of reference axes for femoral component rota⁃ tion in total knee arthroplasty:computed tomography ⁃ based study of 2,128 femora[J].J Bone Joint Surg Am,2019,101(23):e125

    • [12] MAHRAN M A,KHALIFA A A,AHMED M A,et al.Evalu⁃ ating distal femoral torsion and posterior condylar line re⁃ liability for adjusting femoral component rotation in TKA,Egyptian population radiographic study[J].J Clin Orthop Trauma,2021,13:99-105

    • [13] ASANO T,AKAGI M,NAKAMURA T.The functional flexion⁃extension axis of the knee corresponds to the surgi⁃ cal epicondylar axis:in vivo analysis using a biplanar im⁃ age⁃matching technique[J].J Arthroplasty,2005,20(8):1060-1067

    • [14] BERGER R A,RUBASH H E,SEEL M J,et al.Determin⁃ ing the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis[J].Clin Orthop Relat Res,1993,286):40-47

    • [15] VICTOR J,VAN DONINCK D,LABEY L,et al.A com⁃ mon reference frame for describing rotation of the distal femur:a ct ⁃ based kinematic study using cadavers[J].J Bone Jo Surg Br Vol,2009,91(5):683-690

    • [16] FITZ D W,JOHNSON D J,HARTWELL M J,et al.Rela⁃ tionship of the posterior condylar line and the transepicon⁃ dylar axis:a CT⁃based evaluation[J].J Knee Surg,2020,33(7):673-677

    • [17] NEWMAN C R,WALTER W L,TALBOT S.Femoral rota⁃ tional asymmetry is a common anatomical variant[J].Clin Anat N Y N Y,2018,31(4):551-559

    • [18] FRANCESCHINI V,NODZO S R,GONZALEZ DELLA VALLE A.Femoral component rotation in total knee ar⁃ throplasty:a comparison between transepicondylar axis and posterior condylar line referencing[J].J Arthroplas⁃ ty,2016,31(12):2917-2921

    • [19] CORONA K,CERCIELLO S,VASSO M,et al.Femoral component malrotation is not correlated with poor clinical outcomes after total knee arthroplasty[J].Knee Surg Sports Traumatol Arthrosc,2020,28(12):3879-3887

    • [20] 邵禹棋,王瑞,陈哲峰,等.TKA术中股骨内侧后髁软骨磨损对股骨假体旋转对线的影响[J].南京医科大学学报(自然科学版),2021,41(5):718-724

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