膝關(guān)節(jié)冠狀面對(duì)線CPAK分類系統(tǒng)_不是所有的膝關(guān)節(jié)、全膝關(guān)節(jié)置換都是一樣的（2024）Notallkneesarethesame?MacDessiSJ,vandeGraafVA,WoodJA,Griffiths-JonesW,BellemansJ,ChenDB.Notallkneesarethesame[J].BoneJointJ,2024,106-B(6):525-531.?轉(zhuǎn)載文章的原鏈接1：https://pubmed-ncbi-nlm-nih-gov-443.vpnm.ccmu.edu.cn/38821506/?轉(zhuǎn)載文章的原鏈接2：https://boneandjoint.org.uk/Article/10.1302/0301-620X.106B6.BJJ-2023-1292.R1?AbstractTheaimofmechanicalalignmentintotalkneearthroplastyistoalignallkneesintoafixedneutralposition,eventhoughnotallkneesarethesame.Asaresult,mechanicalalignmentoftenaltersapatient’sconstitutionalalignmentandjointlineobliquity,resultinginsoft-tissueimbalance.ThisannotationprovidesanoverviewofhowtheCoronalPlaneAlignmentoftheKnee(CPAK)classificationcanbeusedtopredictimbalancewithmechanicalalignment,andthenofferspracticalguidanceforbonebalancing,minimizingtheneedforsoft-tissuereleases.全膝關(guān)節(jié)置換術(shù)中的機(jī)械對(duì)線的目的是將所有膝關(guān)節(jié)對(duì)線到一個(gè)固定的中立位置，盡管并非所有膝關(guān)節(jié)都相同。因此，機(jī)械對(duì)線通常會(huì)改變患者的固有對(duì)線和關(guān)節(jié)線傾斜度，導(dǎo)致軟組織失衡。本文概述了如何使用“膝關(guān)節(jié)冠狀面對(duì)線（CPAK）”分類來(lái)預(yù)測(cè)機(jī)械對(duì)線引起的失衡，并提供了實(shí)用的指導(dǎo)，以平衡骨骼，減少對(duì)軟組織釋放的需要。?IntroductionIrrespectiveofthealignmentstrategyusedwhenundertakingtotalkneearthroplasty(TKA),surgeonsmustcontendwiththefactthatnotallkneesarethesame.InmechanicallyalignedTKA,balancingisusuallyperformedfollowingcompletionofthebonycutsandassessmentofthelaxityofthesoft-tissues.1Thelong-standingapproachforachievingbalanced“gaps”hasbeenbyreleasingorlengtheningligamentousandcapsularstructures,therebyalteringtheirinherentphysiologicalfunction.1,2Withagreateracceptancethatligamentsdonotcontract,3andthatimbalanceresultsfromsurgicalalterationstothepatient’sconstitutionalalignment,4amorenuancedapproachwith“bonebalancing”hasbeensuggested.5Bonebalancingmodifiesthealignmentbybiasingbonyresectionstowardsamoreconstitutionalorientation,therebymaintainingtheirfunctionandreducingthenecessityforsoft-tissuereleases.BonebalancingusinganinitialmechanicalalignmentplanrepresentsoneendofthespectrumofTKAalignmentstrategies,withunrestrictedkinematicalignmentattheother.6-10Subtlechangesofalignmentupto3°fromaneutralmechanicalaxisareoftenenoughtoimproveimbalance,andstillconsideredsafeforsurgeonswhowanttomaintainalignmentwithinthismoretraditionalwindow.11,12Restoringtheknee’sconstitutionalalignmentismorelikelytoachievesoft-tissuebalancecomparedwithusingmechanicalalignmentforallpatients.13,14TheCoronalPlaneAlignmentoftheKnee(CPAK)classificationisawidelyadoptedandpragmaticsystemthatoffersaframeworktounderstandtherelationshipbetweenthenativelowerlimbalignmentandjointlineobliquity(JLO)tothesoft-tissuebalance.14CPAKdefinesninekneephenotypesbasedonconstitutionalalignmentoftheknee,incorporatingthearithmetichip-knee-ankleangle(aHKA)andthejointlineobliquity.Inthisinstructionalreview,weusetheCPAKclassificationtounderstandwhynotallkneesarethesameintermsofimbalancewhenperformingmechanicallyalignedTKA.EachCPAKtypewillbeintroducedbasedonitsprimaryradiologicalandmorphologicalcharacteristics.AlterationstoconstitutionalalignmentthatresultwhenperformingmechanicallyalignedTKAwillbepresentedforeachCPAKtype,alongwiththeanticipatedchallengeswithbalance.Formostsurgeonswhousemechanicalalignment,andforthosewhohavenowadoptedanindividualizedapproach,understandingtheseconceptsisimportantforappreciatingwhyalignmentmatters.?RadiologicalassessmentPreoperativelonglegimagingthatallowsforassessmentofthemechanicalaxisisobtainedusingplainradiographswithdigitalstitching,biplanarimagingorwhole-legCTimaging.Thelateraldistalfemoralangle(LDFA)ismeasuredasthelateralanglesubtendedbythemechanicalaxisofthefemurandthearticularlinetangentialtothedistalfemoralarticularsurface.Themedialproximaltibialangle(MPTA)ismeasuredasthemedialanglesubtendedbythemechanicalaxisofthetibiaandthearticularlinetangentialtotheproximaltibialarticularsurface(Figure1).Apartfromhighlightinglossofjointspace,shortradiographsofthekneeareofnovalueintheassessmentofconstitutionalalignment,andthereforeoftheindividual’skneephenotype.15,16??Fig.1Longlegstandingradiographsshowingthemechanicalaxesofthefemurandtibia.Therightkneeshowsmeasurementofconstitutionalalignmentinanarthritickneeusingthearithmetichip-knee-ankleangle(aHKA)algorithm.Theleftnormalkneeshowsmeasurementofthethemechanicalhip-knee-ankleangle(mHKA).LDFA,lateraldistalfemoralangle;MA,mechanicalaxis;MPTA,medialproximaltibialangle.??TheconstitutionalcoronalalignmentiscalculatedusingtheequationaHKA=MPTA–LDFA,andtheconstitutionaljointlineobliquity(JLO)usingtheequationJLO=MPTA+LDFA.TheboundariesforconstitutionalalignmentofthelowerlimbusingtheaHKAarevarus<-2°,neutral-2°to+2°inclusive,andvalgus>2°.TheboundariesforconstitutionalJLOareapexdistal<177°,neutral177°to183°,andapexproximal>183°.TheCPAKtypeisthendeterminedbasedontheseboundaries(Figure2).??Fig.2TheCoronalPlaneAlignmentoftheKnee(CPAK)classificationwithboundaries.aHKA,arithmetichip-knee-ankle;JLO,jointlineobliquity.??DatafrompreviousstudiessupportthedescriptionsofeachCPAKtypediscussedhere.Alignmentcharacteristicsarederivedfromasampleof500kneesin250healthyadults,agedbetween20and27years(SupplementaryTablei);13soft-tissuelaxitydataarederivedfromasampleof137kneescomparingbalancebetweendifferentalignmentstrategies(SupplementaryTableii);17andloadsensordataarederivedfromasampleof138kneescomparingcompartmentalloadsbetweenalignmentstrategies(SupplementaryTableiii).4Inthisannotation,onlyCPAKTypesItoVIarediscussed,asmanyauthorshaveshownthatTypesVIItoIXarerareinthegeneralpopulation.14,18-23FortheLDFAandMPTA,wecharacterizeorientationas“neutral”if≤1°from90°;“mild”if>1°and≤2°from90°;“moderate”if>2°and≤4°from90°;and“significant”if>4°from90°.DescriptiveradiologicalmeasurementsandschematicphenotypictraitsarepresentedforeachCPAKtypeandforchangestoJLO.Alterationsinconstitutionalalignment,nativefemoraljointlineanatomy,lateralfemoralcolumnlength,andtheirsequelaearesummarizedinTableI.??TableI.TheimplicationsofmechanicalalignmentbasedonCoronalPlaneAlignmentoftheKneetype.CPAK,CoronalPlaneAlignmentoftheKnee;MA,mechanicalalignment;N/A,notapplicable.??CPAKTypeIThekneesin133ofthesampleofhealthyindividuals(26.6%)wereCPAKTypeI.ThisisthemostprevalentphenotypeinAsianandIndianpatientsundergoingTKA,andisthemostcommonvarusphenotypeglobally.18,19,23Thistypeischaracterizedbysignificantproximaltibialvarusandmilddistalfemoralvalgus,resultinginavarusaHKAandanapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3a.MehanicalalignmentwithCPAKTypeIkneesresultsinconsiderabletightnessoftheMCLduetotheshiftinaHKAfromvarustoneutral.Asthemagnitudeofchangeincreases,sodoesthelikelihoodoflateralcondylarlift-off,asignalofmajorimbalance.TheMCListightinbothextensionandflexion.Commonly,surgeonspartiallyorcompletelyreleasetheMCLinanattempttoachievebalance,butsecondaryincompetenceoftheMCLmayresultfromreleasingthiscriticalstructure.Alterationofconstitutionalvarustoneutralwillincreasethelengthoftheleg,andincreasetheneedforathickerpolyethyleneinserttocompensatefortheartificialincreaseinmedialgapheight.24AstheprimarycharacteristicofTypeIistibialvarus,avarustibialrecutwithmechanicalalignmentmayberequiredtoachievebalanceinbothextensionandflexion.??Fig.3Illustrationofsoft-tissueimbalanceinCoronalPlaneAlignmentoftheKnee(CPAK)TypesItoVI,showinghowmechanicalalignment(MA)altersconstitutionalalignmentandjointlineobliquity.a)MAwithCPAKTypeI.Theredwedgehighlightssignificanttibialvarus,andtheredarrowindicateselevationofthemedialjointline.b)MAwithCPAKTypeII.Thegreenwedgeshighlightmoderatefemoralvalgusandmoderatetibialvarus.Theredarrowindicateselevationofthemedialjointline,andtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.c)MAwithCPAKTypeIII.Theredwedgeshighlightssignificantfemoralvalgus,andtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.d)MAwithCPAKTypeIV.Thegreenwedgeindicatesmoderatetibialvarus.Theredarrowhighlightselevationofthemedialjointline.e)MAwithCPAKTypeV.f)MAwithCPAKTypeVI.Thegreenwedgehighlightsmoderatefemoralvalgusandtheorangearrowindicatesdistalizationofthelateralfemoralcolumn.aHKA,arithmetichip-knee-ankleangle;JLO,jointlineobliquity.??CPAKTypeIIThekneesof205ofthehealthyindividuals(41.0%)wereCPAKTypeII.Thisisthemostcommonkneephenotypeglobally.14,22Thistypeischaracterizedbymoderateproximaltibialvarusandmoderatedistalfemoralvalgus,resultinginaneutralaHKAandanapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3b.MechanicallyalignedTKAspecificallyaddressesCPAKTypeIIphenotypiccharacteristics.Asneutralconstitutionalalignmentismaintained,soft-tissuebalanceinextensionisusuallynotaltered.Furthermore,byapplyingexternalrotationtothefemoralcomponent,imbalanceinflexionisunlikely.The“anatomicalalignment”methodattemptedtoreplicateTypeIIbyrecreatinganapexdistalJLO,25butimprecisecuttingguidesresultedinthistechniquebeingabandoned.ThefollowingkinematicalterationsrequireconsiderationinCPAKTypeII.Thenativefemoraljointlineisraisedmediallythroughoutthearcofmotion,apotentialcauseofmid-flexioninstability.26Thelateralfemoralcolumnislengthened(distalized)inextensionandflexion.Ithasbeensuggestedthatthismayleadtoincreasedpatellofemoralretinaculartightnessinflexionbylateraldistalfemoralprostheticoverstuffing,27particularlyinkneeswithveryobliquejointlinessuchasthoseof≤170°.Theneedforsoft-tissuebalancingwithCPAKTypeIIisminimal.?CPAKTypeIIIThekneesof47ofthehealthyindividuals(9.4%)wereCPAKTypeIII.Thistypeisthemostcommonvalgusphenotypeandischaracterizedbyconsiderabledistalfemoralvalgusandmildproximaltibialvarus,resultinginavalgusaHKAandapexdistalJLO.TheimplicationsformechanicalalignmentareshowninFigure3c.Imbalancewithmechanicalalignmentoccursinextensionandtoalesserextentinflexion,astheaHKAisshiftedfromvalgustoneutral.Thedegreeoflateraltightnessisdependentontwovariables:themagnitudeofaHKArelativetothechangeprescribedbymechanicalalignment;andthevariabilityinconstitutionallaxityofthelateralsiderelativetomediallaxity.Inmanyknees,increasedconstitutionallaterallaxity,whichisfurtherincreasedafterresectionofthecruciateligaments,28–30cancompensateforthisshiftinaHKAandreducetheneedforlateralbalancing.However,inourexperience,whenpatientshaveanaHKAof≥5°,soft-tissueimbalanceinevitablyresults.AstheprimarycharacteristicofCPAKTypeIIIissignificantfemoralvalgus,adistalfemoralvalgusrecutmayberequiredtoachievebalanceinextension.?CPAKTypeIVThekneesof21ofthehealthyindividuals(4.2%)wereCPAKTypeIV,whichisararervarusphenotype,characterizedbymoderateproximaltibialvarusandmilddistalfemoralvarus,resultinginavarusaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3d.AswithTypeI,therewillbeMCLtightnessinCPAKTypeIVwithmechanicallyalignedTKA.However,thistightnessismoreprominentinextensionthanflexion.14AsthemajoranatomicalcharacteristicinCPAKTypeIVistibialvarus,avarustibialrecutmayberequiredtorestorebalanceinbothextensionandflexion,althoughanadditionalvarusfemoralrecutcanbeconsidered.?CPAKTypeVThekneesof77ofthehealthyindividuals(15.4%)wereCPAKTypeV,whichisthetargetinmechanicallyalignedTKA.Thistypeischaracterizedbyneutraldistalfemoralandneutralproximaltibialanatomy,resultinginaneutralaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3e.NobalancinginterventionsareusuallynecessaryforCPAKTypeVwithmechanicalalignment.However,unlikeCPAKTypeIIknees,thetibialjointlineisnotchanged,andsurgeonsshouldevaluatewhethertheroutine3°externalrotationofthefemoralcomponentisneeded.?CPAKTypeVIThekneesof16ofthehealthyindividuals(3.2%)wereCPAKTypeVI.Thistypemakesupapproximatelyone-quarterofallvalgusknees,andischaracterizedbymoderatedistalfemoralvalgusandmildproximaltibialvalgus,resultinginavalgusaHKAandneutralJLO.TheimplicationsformechanicalalignmentareshowninFigure3f.ComparedwithCPAKTypeIII,constitutionalvalgusiscontributedtobyfemoralvalgusand,toalesserextent,tibialvalgus.Thisresultsinaneutraljointlineobliquity.Soft-tissueimbalanceismostpronouncedinextension.14AsthemaincharacteristicofTypeVIisfemoralvalgus,avalgusfemoralrecutmayberequiredifthereismarkedlateraltightnessinextension.Ifthereremainssomeimbalance,orwhenfemoralrecutsarepreferablyavoided,areleaseoftheposterolateralcapsular(arcuate)complex,withorwithouttheposteriorbandoftheiliotibialband,maybeconsidered.31?DiscussionThisinstructionalannotationpresentsamethod,basedonconstitutionalalignment,forunderstandingandpredictingthesoft-tissueimbalancethatoftenresultswhenundertakingmechanicallyalignedTKA.Itprovidesclear,alignment-drivenreasoningbasedondeviationstocommonCPAKphenotypes.Imbalancesaremostprofoundinconstitutionalvarusknees,TypesIandIV.However,constitutionalvalgusknees,TypesIIIandVI,alsopresentintraoperativechallenges.Theabilitytounderstandthelikelihoodofencounteringimbalancepriorto,andduring,surgeryisempowering.Theconceptscanalsobeusedbythosewhouseagap-balancingapproachwithconventionalcuttingguides,astheystreamlinetheworkflowofbothtibial-andfemoral-basedtechniques.Mostimportantly,notallkneesarethesame,andtherewillbemuchvariationbetweenindividuals,evenwithineachCPAKtype.Thus,onepatientwithaTypeIIkneemayhaveaLDFAof88°andMPTAof88°,anothermayhaveaLDFAof84°andMPTAof83°.Treatingbothkneeswiththesamemechanicallyalignedresectionsislikelytobringaboutdifferentkinematicresults.Or,whenapatientwithaTypeIkneewithanaHKAof-3°mayonlyrequirea2°varusrecutinordertoobtainabalancedknee,another,alsowithaTypeIknee,butanaHKAof-7°,isunlikelytobebalancedwithasmallvaruscorrectionfrommechanicalalignment.Furthermore,CPAKisaclassificationsystemtodescribephenotypesandisnotgranularenoughtoprovideacomprehensivebreakdownofhowbalancingshouldbeexecutedwhenperformingmechanicallyalignedTKA.Furthermore,itisnotonlytheconstitutionalalignmentbutalsotheconstitutionallaxitythatdeterminesthebalanceofaTKA.Nativelaxitiesarehighlyvariableinboththecoronal(extensionandflexion)andsagittalplanes.32-35Thus,akneecanhaveitsconstitutionalalignmentperfectlyrestored,asinunrestrictedkinematicalignment,butstillhaveunbalancedgaps.17,36TargetingbalancedcoronalandsagittalgapsremainsamajorgoalinTKAandisthecornerstoneofthefunctionalalignmenttechnique.17,36,37However,theoptimalbalance,includingwhetherrectangularortrapezoidalconstitutionalgapsshouldbethenewtarget,remainspoorlydefined.Surgeonsmustcontinuetousetheirclinicalacumentoassesseachkneeonitsmerits,applyingtheknowledgeofoutcomesdeterminedbyphenotype,tooptimizealignmentandbalance.Conventionalcuttingguideswithmechanicalalignmenthavealsobeenreportedtohaveprecisionerrorsof>3°in30%ofcases,38withhalfofthosecasespotentiallydeviatingintomorethan3°varus(15%)andhalfintomorethan3°valgus(another15%).Forexample,ifasurgeonaimingformechanicalalignmentusingconventionalinstrumentsunintentionallyalterstheHKAofakneethathas5°ofconstitutionalvarusto≥4°ofmechanicalvalgus,thiscouldresultinaprofoundchangeinalignmentof9°,thetypeofsituationthatcouldoccurin1in6(15%)ofmechanicallyalignedTKAsundertakenusingconventionalcuttingguides.SeveretightnessoftheMCLwillresultinlateralcondylarlift-off.TheonlywaytocorrectthisimbalanceistoreleasetheMCLfromitstibialinsertion.Thiswillresultinanincreaseinbothmedialflexionandextensiongaps,thesubsequentneedforathickerpolyethyleneinsert,andaneteffectoflengtheningthelimb.24CorrectiontowardsamorevarusphenotypeispreferredtoacompletereleaseoftheMCL.Theinherentlimitationsofconventionalcuttingguidesarethattheydonotallowquantificationorvalidationoftheanglesofresectionorthefinalalignmentofthelimb.Aswegraduallyshifttowardsmorepersonalizedoperationsforourpatients,itishopedthatthisannotationwillencouragesurgeonstoconsidereachpatient’suniqueCPAKtype.This,inpart,maymaketheoutcomesofTKAmorepredictable,reducingtheneedforsoft-tissuereleaseswhileusingadjustmentsinalignmenttorestorethenativebalanceoftheknee.?Takehomemessage-Inthisreview,theCoronalPlaneAlignmentoftheKnee(CPAK)classificationisusedtoenhanceourunderstandingofwhynotallkneesarethesamewhenconsideringsoft-tissueimbalanceinmechanicallyalignedtotalkneearthroplasty.-Bonebalancinginterventionsbasedonanunderstandingofeachpatient’suniqueCPAKtypecanbeusedtoavoidunnecessarysoft-tissuereleases.-Theseconceptsmaybeconsideredbysurgeonsinterestedinamoreindividualizedalignmentstrategy,insteadofafixedmechanicalalignmenttargetforallpatients.在本綜述中，采用“膝關(guān)節(jié)冠狀面排列（CPAK）”分類來(lái)增強(qiáng)我們對(duì)在機(jī)械對(duì)線全膝關(guān)節(jié)置換術(shù)中考慮軟組織失衡時(shí)為何并非所有膝關(guān)節(jié)都相同的理解。基于對(duì)每位患者獨(dú)特CPAK類型的理解，可以實(shí)施骨平衡干預(yù)措施，以避免不必要的軟組織釋放。這些概念可能對(duì)有興趣采用更個(gè)性化對(duì)齊策略的外科醫(yī)生有所幫助，而不是為所有患者設(shè)定固定的機(jī)械對(duì)線目標(biāo)。

單髁置換UKA的適應(yīng)癥從初級(jí)階段的UKA到現(xiàn)在，UKA的適應(yīng)癥一直在擴(kuò)大，禁忌癥越來(lái)越少。以前認(rèn)為年齡、肥胖、髕股關(guān)節(jié)損傷等都屬于UKA的禁忌癥。隨著科學(xué)技術(shù)的發(fā)展，UKA材料和設(shè)計(jì)不斷改進(jìn)，目前公認(rèn)的UKA最佳適應(yīng)癥包括：1、前內(nèi)側(cè)骨關(guān)節(jié)炎（AMOA），股骨內(nèi)側(cè)髁或脛骨內(nèi)側(cè)平臺(tái)骨壞死2、前交叉韌帶ACL完好、內(nèi)側(cè)副韌帶MCL功能完好3、外側(cè)軟骨正?；蜉p微退4、內(nèi)翻畸形<15°，屈膝畸形<15°，膝關(guān)節(jié)可主動(dòng)屈曲≥90°UKA的禁忌癥目前對(duì)于UKA的禁忌癥，多數(shù)并沒有科學(xué)試驗(yàn)數(shù)據(jù)的直接依據(jù)，而只是絕大多數(shù)專家學(xué)者根據(jù)臨床經(jīng)驗(yàn)做出的符合一般規(guī)律的推斷。主要包括：1、ACL、MCL缺失或嚴(yán)重?fù)p傷2、關(guān)節(jié)內(nèi)畸形不能被手動(dòng)矯正3、屈膝畸形>15°，麻醉下膝關(guān)節(jié)被動(dòng)屈曲<100°4、外側(cè)間室軟骨缺損5、炎癥性關(guān)節(jié)炎（類風(fēng)濕性關(guān)節(jié)炎、化膿性關(guān)節(jié)炎、色絨炎等）

單間室膝關(guān)節(jié)置換出現(xiàn)于20世紀(jì)50年代，在當(dāng)時(shí)處于初級(jí)階段的UKA，因假體材料、設(shè)計(jì)、技術(shù)等客觀原因的制約，UKA適應(yīng)癥很窄而禁忌癥很廣。目前臨床臨床上應(yīng)用的UKA假體主要有活動(dòng)平臺(tái)（MB）和固定平臺(tái)（FB）兩種。1、MB-UKAMB-UKA?可使膝關(guān)節(jié)的運(yùn)動(dòng)更接近自然生物力學(xué)且磨損率低，但易發(fā)生墊片脫位及假體撞擊等并發(fā)癥。襯墊脫位與內(nèi)側(cè)副韌帶碰撞目前MB-UKA的主要代表是Oxford牛津單髁假體，MB-UKA可以使膝關(guān)節(jié)的運(yùn)動(dòng)更近似于正常的人體膝關(guān)節(jié)，減少脛股關(guān)節(jié)面的接觸應(yīng)力，降低墊片的磨損。實(shí)現(xiàn)MB-UKA更佳生物力學(xué)表現(xiàn)的前提是假體的精準(zhǔn)置入，故對(duì)術(shù)者的手術(shù)技術(shù)要求更高，學(xué)習(xí)曲線更長(zhǎng)，且存在一定的墊片脫位發(fā)生率。2、FB-UKAFB-UKA較穩(wěn)定，無(wú)脫位風(fēng)險(xiǎn)，并發(fā)癥少但磨損率高。FB-UKA主要有ZUK假體和LinkSled假體，手術(shù)技術(shù)相對(duì)簡(jiǎn)單，精準(zhǔn)度要求相對(duì)低，但由于固定平臺(tái)的假體設(shè)計(jì)限制了負(fù)荷分散效能，活動(dòng)時(shí)關(guān)節(jié)面的受力不能完全均勻分配，導(dǎo)致假體邊緣負(fù)荷過(guò)重，可能會(huì)增加聚乙烯墊片下表面磨損的發(fā)生，故更適合于一些韌帶松弛及活動(dòng)量要求低的患肢。目前國(guó)內(nèi)外文獻(xiàn)對(duì)兩者的孰優(yōu)孰劣尚未形成統(tǒng)一標(biāo)準(zhǔn)。

很多親愛的患者咨詢我，膝關(guān)節(jié)退變，藥物治療效果不理想，已經(jīng)到了關(guān)節(jié)置換的程度，但是不知道做單髁置換術(shù)（UKA）還是全膝關(guān)節(jié)置換（TKA）。其實(shí)，能回答這個(gè)問題的專業(yè)醫(yī)師都很少，患者來(lái)說(shuō)，不清楚怎么選擇是很正常的。膝關(guān)節(jié)外傷、感染、老化等原因?qū)е玛P(guān)節(jié)疼痛，正規(guī)的治療需要進(jìn)行以下幾個(gè)階梯，一般不能馬上選擇開刀。以下四個(gè)步驟是目前最權(quán)威的治療方案：基礎(chǔ)治療，藥物治療，修復(fù)性治療，重建治療，分別對(duì)應(yīng)不同病情階段的關(guān)節(jié)炎患者。也就是說(shuō)，癥狀輕中度的，都不需要置換關(guān)節(jié)，到了終末期的膝關(guān)節(jié)炎，可以選擇關(guān)節(jié)鏡或者關(guān)節(jié)置換的治療方案。其中關(guān)節(jié)置換針對(duì)的是所有其他方法都不奏效的患者。那么，什么是單髁置換術(shù)呢。單髁是對(duì)應(yīng)全膝置換而言的“相對(duì)微創(chuàng)”的手術(shù)，對(duì)于膝關(guān)節(jié)單側(cè)癥狀的，且符合適應(yīng)證的患者，推薦選擇單髁置換術(shù)（具體適應(yīng)癥比較專業(yè)，患者有興趣的可以咨詢您的醫(yī)生，不再贅述）。單髁置換術(shù)相對(duì)來(lái)說(shuō)，可以保留更多的骨量（手術(shù)截取的骨頭少），所以，中年左右的、活動(dòng)量大的患者可以考慮單髁置換術(shù)。單髁置換術(shù)涉及的專業(yè)知識(shí)較多，選擇合適的假體、選擇固定平臺(tái)還是活動(dòng)平臺(tái)，都是需要仔細(xì)考慮的問題。作為一種保膝的手段，單髁置換術(shù)的并發(fā)癥發(fā)生率和病死率相對(duì)全膝置換低。但是需要注意的是，單髁置換術(shù)不宜擴(kuò)大適應(yīng)癥，否則會(huì)帶來(lái)災(zāi)難性的后果，不僅不能緩解患者的疼痛，反而增加了費(fèi)用和翻修的風(fēng)險(xiǎn)。全膝關(guān)節(jié)置換術(shù)幾乎是關(guān)節(jié)炎的最終治療方法。對(duì)其他干預(yù)措施都無(wú)效的患者，無(wú)奈之下只能選擇做全膝關(guān)節(jié)置換術(shù)。糾結(jié)于選擇單髁還是全膝置換，不能建立在是不是微創(chuàng)的角度上片面解釋，解決問題才是最重要的，各種手術(shù)都有自己的優(yōu)點(diǎn)和局限性。絕不能搜點(diǎn)資料就對(duì)號(hào)入座。術(shù)式的選擇，這中間的評(píng)估過(guò)程比較復(fù)雜，建議咨詢關(guān)節(jié)外科的專業(yè)醫(yī)師。本人熱忱歡迎廣大患者來(lái)咨詢關(guān)于關(guān)節(jié)置換的選擇問題，希望為您解答疑惑。

女性，68歲，因?yàn)殛P(guān)節(jié)磨損變形走路困難就診。給予行膝關(guān)節(jié)置換，爭(zhēng)得病人的同意，愿意作為科普給大家做示教。術(shù)后8個(gè)月走路樣子術(shù)后8個(gè)月晨練術(shù)后八個(gè)月晨練。良好的適應(yīng)癥，熟練的手術(shù)技術(shù)，樂觀積極的心態(tài)，努力的康復(fù)鍛煉，造就良好的手術(shù)效果。

單間室膝關(guān)節(jié)置換出現(xiàn)于20世紀(jì)50年代，在當(dāng)時(shí)處于初級(jí)階段的UKA，因假體材料、設(shè)計(jì)、技術(shù)等客觀原因的制約，UKA適應(yīng)癥很窄而禁忌癥很廣。近年來(lái)，隨著微創(chuàng)外科技術(shù)的發(fā)展和保膝理念的盛行，單髁置換術(shù)（UKA）在國(guó)內(nèi)逐漸開始流行。?隨著科學(xué)技術(shù)的發(fā)展，UKA假體材料及設(shè)計(jì)得到不斷改進(jìn)，更多優(yōu)質(zhì)的假體類型不斷涌現(xiàn)。?目前臨床臨床上應(yīng)用的UKA假體主要有活動(dòng)平臺(tái)（MB）和固定平臺(tái)（FB）兩種。1、MB-UKAMB-UKA?可使膝關(guān)節(jié)的運(yùn)動(dòng)更接近自然生物力學(xué)且磨損率低，但易發(fā)生墊片脫位及假體撞擊等并發(fā)癥。目前MB-UKA的主要代表是Oxford牛津單髁假體，MB-UKA可以使膝關(guān)節(jié)的運(yùn)動(dòng)更近似于正常的人體膝關(guān)節(jié)，減少脛股關(guān)節(jié)面的接觸應(yīng)力，降低墊片的磨損。?實(shí)現(xiàn)MB-UKA更佳生物力學(xué)表現(xiàn)的前提是假體的精準(zhǔn)置入，故對(duì)術(shù)者的手術(shù)技術(shù)要求更高，學(xué)習(xí)曲線更長(zhǎng)，且存在一定的墊片脫位發(fā)生率。2、FB-UKAFB-UKA較穩(wěn)定，無(wú)脫位風(fēng)險(xiǎn)，并發(fā)癥少但磨損率高。FB-UKA主要有ZUK假體和LinkSled假體，手術(shù)技術(shù)相對(duì)簡(jiǎn)單，精準(zhǔn)度要求相對(duì)低，但由于固定平臺(tái)的假體設(shè)計(jì)限制了負(fù)荷分散效能，活動(dòng)時(shí)關(guān)節(jié)面的受力不能完全均勻分配，導(dǎo)致假體邊緣負(fù)荷過(guò)重，可能會(huì)增加聚乙烯墊片下表面磨損的發(fā)生，故更適合于一些韌帶松弛及活動(dòng)量要求低的患肢。目前國(guó)內(nèi)外文獻(xiàn)對(duì)兩者的孰優(yōu)孰劣尚未形成統(tǒng)一標(biāo)準(zhǔn)。UKA的適應(yīng)癥從初級(jí)階段的UKA到現(xiàn)在，UKA的適應(yīng)癥一直在擴(kuò)大，禁忌癥越來(lái)越少。以前認(rèn)為年齡、肥胖、髕股關(guān)節(jié)損傷等都屬于UKA的禁忌癥。隨著科學(xué)技術(shù)的發(fā)展，UKA材料和設(shè)計(jì)不斷改進(jìn)，UKA經(jīng)歷了從實(shí)踐到認(rèn)識(shí)、認(rèn)識(shí)又反作用于實(shí)踐的前進(jìn)的、上升的發(fā)展后，社會(huì)存在決定社會(huì)意識(shí)，目前公認(rèn)的UKA最佳適應(yīng)癥包括：1、前內(nèi)側(cè)骨關(guān)節(jié)炎（AMOA），股骨內(nèi)側(cè)髁或脛骨內(nèi)側(cè)平臺(tái)骨壞死2、ACL?完好、MCL功能完好3、外側(cè)軟骨正?；蜉p微退變4、內(nèi)翻畸形<15°，屈膝畸形<15°，膝關(guān)節(jié)可主動(dòng)屈曲≥90°UKA的禁忌癥?目前對(duì)于UKA的禁忌癥，多數(shù)并沒有科學(xué)試驗(yàn)數(shù)據(jù)的直接依據(jù)，而只是絕大多數(shù)專家學(xué)者根據(jù)臨床經(jīng)驗(yàn)做出的符合一般規(guī)律的推斷。主要包括：1、ACL、MCL?缺失或嚴(yán)重?fù)p傷2、關(guān)節(jié)內(nèi)畸形不能被手動(dòng)矯正3、屈膝畸形>15°，麻醉下膝關(guān)節(jié)被動(dòng)屈曲<100°4、外側(cè)間室軟骨缺損5、炎癥性關(guān)節(jié)炎（類風(fēng)濕性關(guān)節(jié)炎、化膿性關(guān)節(jié)炎、色絨炎等）?特殊情況在一些文獻(xiàn)中，還可以看到涉及單髁置換術(shù)的聯(lián)合或復(fù)雜手術(shù)的病例：1、UKA+ACL重建2、UKA+HTO3、髕股關(guān)節(jié)和內(nèi)側(cè)單髁置換術(shù)4、雙室置換小結(jié)?這些病例提醒著我們，適應(yīng)癥與禁忌癥在某些條件下可以轉(zhuǎn)變。針對(duì)不同病人，具體問題具體分析，為患者提供更具個(gè)性化的治療方案。

選擇膝關(guān)節(jié)鏡、膝關(guān)節(jié)置換手術(shù)的患者術(shù)前一般都是因?yàn)楦鞣N疾病造成了在關(guān)節(jié)活動(dòng)時(shí)出現(xiàn)嚴(yán)重的疼痛。而為了避免疼痛的發(fā)生，只能減少關(guān)節(jié)的活動(dòng)。久而久之，造成膝關(guān)節(jié)周圍肌肉組織力量減弱、肌肉萎縮、周圍韌帶組織粘連，整個(gè)關(guān)節(jié)就像一部銹住的機(jī)器，失去了正常運(yùn)動(dòng)的能力。為了恢復(fù)正常的活動(dòng)能力，術(shù)后正確的康復(fù)鍛煉來(lái)恢復(fù)膝關(guān)節(jié)的活動(dòng)度和力量是十分重要的。①股四頭肌+踝泵運(yùn)動(dòng)練習(xí)-增加您的大腿肌肉力量。盡量伸直您的膝關(guān)節(jié)勾住腳踝，每次持續(xù)30到60秒。在30分鐘內(nèi)重復(fù)左右腿交叉各15次，這樣的動(dòng)作，然后休息30分鐘，一直重復(fù)練習(xí)直到您感覺大腿肌肉很疲憊。建議每天早中晚3組，每組30次。

靠墻靜蹲和金雞獨(dú)立：本視頻前半部分為靠墻靜蹲，后半部分為金雞獨(dú)立。動(dòng)作要點(diǎn)見視頻解說(shuō)。靠墻靜蹲可以練雙下肢的肌肉力量，我們很多術(shù)后患者練靠墻靜蹲后發(fā)現(xiàn)，對(duì)側(cè)腿越來(lái)越粗而手術(shù)那一側(cè)腿越來(lái)越細(xì)，那是因?yàn)榭繅o蹲的時(shí)候主要用力用在對(duì)側(cè)腿上了，而如果要練單側(cè)可以用金雞獨(dú)立。

??髖關(guān)節(jié)置換術(shù)中時(shí)間大約1小時(shí)，膝關(guān)節(jié)置換術(shù)中時(shí)間大約1小時(shí)多一點(diǎn)。??手術(shù)全麻，術(shù)中一般都不需要插尿管，術(shù)前血紅蛋白在120g/L及以上的患者，一般都不需要輸血。??對(duì)于95%以上的病人，都是今天做手術(shù)，第二天就可以在助行器輔助下完全負(fù)重下地行走，建議助行器用4周。??目前國(guó)家對(duì)髖膝關(guān)節(jié)置換的假體進(jìn)行了帶量采購(gòu)(集采)，髖膝關(guān)節(jié)總費(fèi)用均是3萬(wàn)5左右(老年患者，合并癥多的患者，圍術(shù)期長(zhǎng)了大血栓的患者，復(fù)雜病例等，住院總費(fèi)用可能增加)，患者入院時(shí)墊付2萬(wàn)，入院后第二天到一樓醫(yī)保辦刷社?？?，出院辦理結(jié)算時(shí)多退少補(bǔ)。??與髖關(guān)節(jié)置換相比，膝關(guān)節(jié)置換術(shù)后的鍛煉更加辛苦，病人及家屬要提前有思想建設(shè)。